Abdominal compartment syndrome in a patient resulting from pneumothorax

Excerpt

Sir: An 18-year-old woman developed acute respiratory distress syndrome after cesarian section. She subsequently developed multiple pneumothoraces manifesting as worsening respiratory acidosis and tachycardia. These were difficult to detect on chest radiograph because of subcutaneous emphysema (Fig. 1), but she responded to tube thoracostomy placement with rapid improvement. With each pneumothorax the patient had a distended abdomen out of proportion to subcutaneous emphysema, and pneumoperitoneum was persistently present on radiography. On ICU day 20 she was improving on pressure control ventilation, receiving tidal volumes of 450 cc on drive pressure 30, positive end-expiratory pressure 5. Bladder pressure was 9 mmHg. She then suffered an acute decompensation with tidal volume decrease to 275 cc. Increasing drive pressure to 40 improved tidal volumes to 400 cc. Her heart rate also acutely increased from 110 to 210–240. Chest tubes placed on suction demonstrated vigorous air leaks without hemodynamic improvement. Physical examination revealed marked worsening in abdominal distension. Bladder pressure was measured at 31 mmHg. The patient was diagnosed with abdominal compartment syndrome (ACS) and received emergency decompression by bedside laparotomy, with an immediate increase in tidal volume to 650 cc upon entering the peritoneal cavity and a decrease in tachycardia to 120 within 1 min. Abdominal exploration revealed only extensive air throughout the mesentery. The ventilator drive pressure was then decreased to 30 with resultant tidal volumes of 500 cc. The patient was discharged after mesh closure and was well at 1-year follow-up.

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