Tertiary Abdominal Compartment Syndrome in the Burn Injured Patient

Abstract

A bdominal compartment syndrome (ACS) has not been commonly reported in burn patients, although it is becoming more frequently recognized. We present a case of secondary ACS that was further complicated by an episode of tertiary ACS in a severely burned patient. CASE REPORTA previously healthy 42-year-old, 80-kg man presented to our regional trauma referral center with direct partial and full thickness flame burns covering 52% of his total body surface area (TBSA). The burns were located on his anterior thorax, abdomen, upper extremities, and buttocks.At presentation the patient was alert and normotensive, but tachycardic at 124 beats per minute. He displayed evidence of significant inhalational injury and was intubated. During the following 24 hours, the patient required vigorous fluid resuscitation with intravenous crystalloid (18.4 L) (4.42 mL/kg/% TBSA), packed red blood cells (8 units) and fresh frozen plasma (4 units) to maintain urine output, normalize his vital signs, and correct his anemia and coagulopathy.Within 12 hours of admission, the patient became profoundly hypoxemic and difficult to ventilate. His peak inspiratory pressures (PIP) rose to greater than 50 cm H 2 O. Initially this was thought to be a result of his constrictive thoracic burns. Escharotomies of his chest and abdomen, however, resulted in only transient improvements in oxygenation and airway pressures. His urine output subsequently decreased to less than 25 mL/hr (0.3 mL/kg/hr) and his intravesicular and pulmonary artery wedge (PAWP) pressures increased to 38 and 40 mm Hg, respectively. Secondary ACS was diagnosed and an urgent midline decompressive celiotomy, extending from the sternum to approximately 10 cm above the pubis, was performed. The viscera were edematous, but well perfused with no other pathology noted. Intraoperative monitoring included standard vital signs, central venous pressure, pH, lactate, base deficit, and urine output. The abdomen was left open, but temporarily sealed using a sterile clear X-ray cassette bag, which was cut to size and inserted (not sutured) deep into the surrounding fascia (Fig. 1). Two overlying Jackson-Pratt drains connected to low continuous suction were then placed along the fascial-plastic interface. This was followed by a large antimicrobial, adherent clear drape applied over the entire closure. Decompression resulted in remarkable improvements in oxygenation, urine output (125 mL/ hr), PIP (32 cm H 2 O), bladder pressure (12 mm Hg), and PAWP (16 mm Hg).During the following days the patient underwent excision of deep burns with split thickness skin grafting. On his third hospital day, he sustained a significant episode of hypovolemic shock after a difficult burn excision that required aggressive fluid resuscitation. A total of 22.9 L (5.50 mL/ kg/% TBSA) of crystalloid fluid had been infused since his decompressive celiotomy. Recurrent ACS was suggested by the onset of oliguria at 30 mL/hr (0.4 mL/kg/hr) and increased PIP (52 cm H 2 O), PAWP (26 mm Hg), and bladder pressure (29 mm Hg). Thes...

Defining Intra-Abdominal Hypertension and Abdominal Compartment Syndrome in Acute Thermal Injury: A Multicenter Survey

“…Some patients that develop IAH may be adequately treated with conservative measures such as nasogastric decompression, sedation, pharmalogical paralysis, or abdominal escharotomies. 1,6,8,12 If these measures are unsuccessful, the standard of care has been to perform a decompressive laporatomy, 3,5,8,17,19 -21 which may increase morbidity and make wound management profoundly difficult in burn patients. 6,8 If IAP is not monitored closely, ACS can quickly develop; even with a decompressive laparotomy, some studies cite a mortality rate of 50 to 55%.…”

Intra-abdominal hypertension and abdominal compartment syndrome in burns, obesity, pregnancy, and general medicine

“…The generalized increase in capillary permeability that occurs in severe burn patients contributes to extensive edema formation and intra-peritoneal accumulation of "third-space" fluid [3]. Bowel edema and fluid translocation is further worsened by venous hypertension caused by elevated IAP [4]. This increasing volume in the abdominal cavity, however, is reduced after capillary permeability improves.…”

“…However, if patients develop sepsis, the risk for IAH/ACS increases again and those not progressing spontaneously to the flow phase may need intervention [11]. Burn patients are also at risk of tertiary or recurrent ACS any time they require aggressive resuscitation as, for instance, after any overly aggressive burn excision [3,4].…”

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

“…Once IAP is elevated, venous hypertension may follow, further aggravating fluid translocation [16]. Furthermore, direct effects of the burn insult, such as eschars, may lead to a decreased abdominal wall and thoracic compliance [17,18].…”