Medical Management of Abdominal Compartment Syndrome

Medical Management of Abdominal Compartment Syndrome

An elderly man was admitted after a Hartman’s procedure with primary closure for a perforated sigmoid diverticulum with four quadrant peritonitis. Postoperatively, he remained ventilated and noradrenaline dependent. His intra-abdominal pressures gradually rose from 15 to 24mmHg. Urine output was poor, and he required peak pressures of 28cmH2O to achieve 6ml/kg tidal volumes. Vasopressor requirements gradually increased and a diagnosis of abdominal compartment syndrome was made. Medical management was attempted with fluid resuscitation, increased sedation, aspiration of nasogastric tube and neuromuscular blockade. However this did not improve the intra-abdominal pressures so the patient returned to theatre laparostomy and VAC dressing. On return from theatre, intra-abdominal pressures stabilised between 12 and 15mmHg. Noradrenaline requirements fell and urine output improved. The abdomen was closed on day 5 and he was discharged from ICU on day 10.

What non-surgical strategies can be used to reduce intra-abdominal pressure?

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Nutrition in Acute Pancreatitis

Nutrition in Acute Pancreatitis

A 55-year-old previously healthy lady was admitted with pancreatitis secondary to gallstones. Her admission modified Glasgow Score was 4, and CT scan showed approximately 70% necrosis of the pancreas encompassing the neck, body and tail with sparing of the head. She rapidly developed ARDS, AKI and vasoplegia, and subsequently developed abdominal compartment syndrome requiring decompressive laparotomy. Her later complications included intraabdominal collections requiring percutaneous drainage, upper GI bleeding, and staged closure of her laparostomy. She was initially commenced on enteral NG feeding but developed high NG aspirates despite pro-kinetics. Parenteral nutrition (PN) was commenced in combination with a ‘trophic’ enteral feed. Four weeks into her admission her triglyceride level was found to be elevated, necessitating lipid free PN and cessation of propofol. This led to a drop in her triglyceride level.

How should we manage the provision of nutrition in acute pancreatitis?

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Decompressive Laparotomy in Abdominal Compartment Syndrome

Decompressive Laparotomy in Abdominal Compartment Syndrome

A 55 yr old man developed severe necrotizing pancreatitis with multiorgan failure. One week into his illness he had developed multiple intra-abdominal collections and had high intra-abdominal pressures. Initial conservative management failed, percutaneous drainage of his collections failed to reduce the abdominal pressures, and he underwent decompressive laparotomy.

What is the evidence behind the current guidelines for the measurement of intra-abdominal hypertension and the use of decompressive laparotomy in the management of Abdominal Compartment Syndrome?Read More »

Loop Diuretics in Acute Kidney Injury

Loop Diuretics in Acute Kidney Injury

A 65 year old woman underwent an elective mitral valve repair (MVR) and four vessel coronary artery bypass graft (CABG) procedure. Pre-operatively she was diagnosed with chronic kidney disease (CKD) secondary to hypertensive nephropathy, and chronic airway disease secondary to smoking. Her baseline creatinine was 275. Surgery was uneventful but in the post-operatively period she developed pulmonary oedema and worsening acute kidney injury (AKI). On day 2 her creatinine reached 420 and oliguria occurred (urine output < 0.5 ml kg-1 hr-1). Non-invasive respiratory ventilation provided adequate support and maintained a normal blood PaCO2 and pH, although her base excess drifted to -7 mmol l-1.Dopamine was administered at 2–10 μg kg-1 min-1, titrated to MAP ≧ 75 mmHg; pericardial pacing continued to maintain sinus rhythm at 60 bpm; her CVP was 14 mmHg and stable. Furosemide was started and given by a continuous infusion of 10 mg hr-1 after an initial bolus of 100 mg to try and help with diuresis.

Is there any evidence to support the use of loop diuretics in acute kidney injury?

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Necrotising Fasciitis - Advances in diagnosis and management

Necrotising Fasciitis – Advances in diagnosis and management

A 40 year old man underwent a minor elective day case lower limb soft tissue operation. 72 hrs later he began to feel unwell and developed fevers and rigors. He was seen first thing in the morning with increasing pain and inflammation extending up from the foot to the knee. Intravenous antibiotics were started on admission. He was in theatre having a debridement by late morning, by which time the inflammation had spread to the inner thigh. He was in profound septic shock with disseminated intravascular coagulopathy. During the debridement, it was noted that the inflammation had spread to his pelvis. He had a laparotomy and it was determined that the resection he would require was unsurvivable. Treatment was withdrawn and he died on the operating table.

How is necrotising fasciitis diagnosed and how is it managed?

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IV Immunoglobulin for Necrotising Fasciitis

IV Immunoglobulin for Necrotising Fasciitis

A 40 year old woman presented with painful swelling of the right side of the neck. She had previously suffered a haematological malignancy and received a bone marrow transplant. A presumptive diagnosis of necrotising fasciitis was made and the neck, shoulder and chest underwent surgical debridement. Postoperatively, the patient remained ventilated in septic shock. Further debridement was required at 24 hours. Group A streptococcus was grown from the debrided tissue and IV immunoglobulins was commenced. The patient gradually weaned from support and was discharged from ICU several days later.

Does IV immunoglobulin have a role to play in the treatment of necrotising fasciitis?Read More »

Management of the Open Abdomen

Management of the Open Abdomen after Severe Abdominal Sepsis

A middle aged man presented with a week long history of severe abdominal pain and distension. CT scans confirmed free air, fluid and probable large bowel perforation. Laparotomy revealed multiple large bowel perforations and four quadrant peritonitis. He had an extensive washout, a colectomy and a laparostomy with negative pressure dressing applied. He returned to theatre at 24 hrs for further washout, and at 48hrs for stoma formation. He had several further relook laparotomies, and abdominal wall closure was achieved on day 10. During this time he had been treated for septic shock and acute kidney injury and had been commenced on parenteral nutrition. His recovery was further complicated by healthcare associated infections but he left hospital nearly a month later.

How is an open abdomen managed after severe abdominal sepsis?Read More »

Intraabdominal Hypertension & Abdominal Compartment Syndrome

Intraabdominal Hypertension & Abdominal Compartment Syndrome

A 35 year old was admitted following a simultaneous kidney pancreas transplant. The procedure had been complicated and she had received a large volume transfusion and crystalloid infusion.Her initial intraabdominal pressures were elevated at 22cmH2O on admission to the intensive care. It continued to escalate over the next 48 hours peaking at 29. She was managed with sedation, NG tube and abdominal perfusion pressures kept above 60mmHg. The tranplanted pancreas remained functional, but the renal transplant showed delayed graft function. On day 4 there was a reduction in her abdominal pressure and her urine output correspondingly increased.

What is the current evidence for the management of intra abdominal hypertension (IAH)?Read More »

On-Demand Re-Laparotomy for Severe Secondary Peritonitis

On-Demand Re-Laparotomy for Severe Secondary Peritonitis

An elderly man underwent an elective open left hemicolectomy for a splenic flexure tumour. On day 4 he was admitted to the intensive care due to fevers, fast AF and hypotension. He developed respiratory failure and required intubation. CT abdomen revealed free fluid in the abdomen, and emergency laparotomy found anastomotic breakdown and faecal peritonitis. He was washed out, and had further bowel resection and his abdomen was closed. He developed anuria requiring renal replacement therapy and continued to have persistently raised inflammatory markers. On day 9 he had a further deterioration and repeat CT revealed several large collections. He underwent relook laparotomy and washout, but continued to deteriorate and died 48 hours later.

Do patients with severe secondary peritonitis benefit from on-demand relaparotomy or planned relaparotomy?Read More »