To close or not to close? Treatment of abdominal compartment syndrome by neuromuscular blockade without laparostomy

Abstract

A 67-year-old man with a history of hypertension was referred to hospital with an isolated raised ALT (85 IU/l) on routine blood testing. On subsequent abdominal imaging with ultrasound, CT, and MRI, he was found to have bilateral adrenal masses, the largest on the right, measuring 9 × 6 × 4 cm. Urinary catecholamines were raised, and a provisional diagnosis of bilateral phaeochromocytoma was made. Following stabilisation with alpha and beta blockade, he underwent bilateral adrenalectomy via a large roof-top incision. The surgery was technically difficult due to a combination of body habitus (body mass index 34 kg/m 2 with extensive intra-and extraperitoneal adipose tissue, in a rather protuberant abdomen) extensive retroperitoneal dissection, and multiple adhesions. A concurrent splenectomy was undertaken for an adhesional splenic capsular tear not controlled by conservative methods. His roof-top incision was closed in the usual fashion and he was extubated postoperatively.On the first postoperative day, he complained of increasing amounts of abdominal pain, and was noted to have a tense, distended abdomen. He was hypotensive, oliguric and his intra-abdominal pressure (IAP) was markedly raised at 40 mmHg (normal, < 12 mmHg). A presumptive diagnosis of established ACS was made and the patient was taken back to theatre for an exploratory re-laparotomy through the existing roof-top incision (principally to exclude significant postoperative bleeding as a cause for the ACS) which was opened in its entirety. Apart from a nonischaemic, moderately distended transverse colon, there were no abnormal intraperitoneal findings. After opening the incision, the IAP reduced from 40 mmHg to 28 mmHg.At this time, a decision was made not to leave the rooftop wound open as a laparostomy, but to instead to close the incision in a standard fashion and to undertake prolonged neuromuscular blockade (atracurium) with mandatory ventilation as primary therapy for his ACS for a trial period. The patient was transferred to the ICU and, during this time period, his IAP started to decrease, which was accompanied by improvement in his physiological indices. After 48 h of neuromuscular blockade, his IAP had reduced to 19 mmHg, neuromuscular blockade was stopped and he was extubated. His IAP subsequently fell to normal levels over the following few days. He made a good recovery and was discharged home 12 days after his initial operation. Histology subsequently revealed bilateral phaeochromocytomas in the resected specimens. The patient remains well 18 months following his surgery, with no clinical herniation detectable in his roof-top scar. Abdominal compartment syndrome (ACS) is a recognised postoperative complication seen frequently in the intensive care unit (ICU). Surgical decompression and laparostomy remain the gold standard treatment for established ACS, combined with supportive non-surgical therapy, such as nasogastric decompression. In the following case report, we describe our successful management of a patient with established postop...

Effect of intra-abdominal volume increment on lungs in hemorrhagic shock

“…In our experiment, the CT value indicated that the diaphragm height reached 11 mm relative to the elevated bladder pressure (Fig. 5), which was similar to the result of Ridings et al (20). In addition, we observed that the CT value of the lung increased by 48 HU (Fig.…”

The Use of Neuromuscular Blocking Agents in the ICU

“…NMBAs have been reported to improve elevated IAPs by reducing abdominal muscle tone (110)(111)(112)(113). Neuromuscular blockade may provide clinicians with more time to remove fluid or treat the underlying cause of IAH and avoid surgical decompression (113)(114)(115). Table 6 presents a few studies examining the use of NMBA in the treatment of IAH.…”

“…A small prospective trial suggested that a bolus dose of cisatracurium was effective in significantly decreasing mild elevations in IAP ( 111 ). A recent case report describing a patient undergoing adrenalectomy who had ACS reported that a prolonged NMBA infusion of 48 hours was effective in reducing IAPs and providing a good recovery (114). It has been recommended (Grade 2C) by the International ACS Consensus Definitions Conference Committee that NMBAs can be used in selected patients to reduce mild-to-moderate elevations of IAP (109,110).…”

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

“…A Belgium study that included ten patients showed that bolus administration of cisatracurium at a dose of 0.15 mg/kg can be used to temporarily reduce IAP in patients with intra-abdominal hypertension [96]. One report described successful treatment of ACS with prolonged neuromuscular blockade with atracurium, avoiding a laparostomy [97]. An important role in this stage is represented by an analgesia and an adequate sedation.…”