CLINICAL CASE STUDY:ABDOMINAL COMPARTMENT

SYNDROME

Brittney McGetrick

• Abdominal Compartment Syndrome (ACS) occurs when pressure builds up in the abdomen and causes subsequent multi organ failure due to lack of perfusion

• ACS is defined as a sustained intra-abdominal pressure >20 mmHg that is

associated with new organ dysfunction or failure.

WHAT IS ABDOMINAL COMPARTMENT

SYNDROME?

• Diminished abdominal wall complianceMajor trauma, or Major burns

• Increased intraluminal contents

(gastroparesis, distention, or ileus)

• Increased intra-abdominal contents (acute pantreatitis, intra-peritoneal fluid

collections, intra-abdominal infection/abscess, liver dysfunction/cirrhosis with ascites)

• Capillary leak/fluid resuscitation seen in damage control laparotomy or positive fluid balance

RISK FACTORS FOR DEVELOPING ACS

• ACS can be dealt with from a preventative standpoint

For example, if a patient comes in with abdominal trauma, if the surgeon feels that closing the abdominal fascia will lead to ACS, he/she may decide

to leave the abdomen open after performing damage control surgery to prevent ACS from developing

• If a patient in the ICU develops ACS, the definitive treatment is a decompressive laparotomy, which usually results in the

abdomen being left open

TREATMENT

• There are a number of ways the abdomen can be temporarily closed:

Bogota Bag: a sterilized genitourinary irrigation bag sutured over the wound

Towel clips: used to close the skin only, with the fascia remaining open

Wound Vac

Wittman patch: velcro-type dressing sutured to the fascia on either side of t he wound, & the abdomen is essentially velcroed together, allowing the abdomen to open as needed

• Many patients undergo definitive abdominal closure in 5-7 days, but sometimes the abdomen may remain open for up to 2 weeks

THE OPEN ABDOMEN

http://yester.ispub.com/journal/the-internet-journal-of-surgery/volume-4-number-1/the-abdominal-compartment-syndrome-enteric-feeding-may-prolong-closure.article-g03.fs.jpg

• Yes. NG/NJ tubes are indicated for enteral nutrition administration

• Early enteral nutrition (before abdominal closure) has been associated with:

Fewer infections

Lower nutrition supplementation costs

Decreased rates of fistulas

Early closure of the abdomen

Lower overall hospital costs

A decrease in the rate of ventilator associated pneumonia

CAN WE FEED THE OPEN ABDOMEN?

• VE is a 41 year old female who was transferred to UCSD from El Centro after presenting 36-

weeks pregnant with pre-ecclampsia, and having labor induced.

• After giving birth, VE developed uncontrolled bleeding, requiring emergent laparotomy and

hysterectomy• Her baby was transferred to Children’s in SD d/t

being born at 36 weeks gestation• Upon arrival at UCSD, she developed ACS, MOF,

AKI requiring dialysis, HELLP, and ARDS

MY PATIENT: “VE”

Prior to arriving at the El Centro hospital, VE had been compliant in her pre-natal care and

had her BP taken regularly

VE lives in Calexico with her husband and two other children, an 11-year old and a 16-

year old

PATIENT HISTORY

41 year old female5’8’’

Admit Wt: 222 lbsAdmit BMI: 33.8

Admit %IBW: 156%

ANTHROPOMETRICS

• Upon admit on 2/5, VE was started on iHD to correct high potassium levels. She was

transitioned to CRRT shortly after.• She developed ACS that same day and underwent decompressive laparotomy that evening. Her abdomen was left open with a

wound vac in place.• Two days later, on 2/7, she returned to the OR

for complete abdominal closure• VE had been NPO since admit, tube feeds were

started on 2/8, after complete abdominal closure.

MEDICAL PROGRESSION AFTER ADMIT

VE was first seen by an RD on 2/7• VE was first seen by an RD on 2/7• Labs:

• Prealbumin was pending

INITIAL ASSESSMENT

Lab Value

Reference Range

VE’s Value

Creatinine

0.51-0.95 1.53 (high)

GFR >60 37 (low)ALT 0-33 2324

(high)AST <1.2 3171

(high)D Bilirubin

<0.2 1.1 (high)

T Bilirubin

<1.2 2.4 (high)

Albumin 3.5-5.2 1.7 (low)Ionized Ca

1.13-1.32 0.99 (low)

EnergyEST Needs per Penn State equation (100.8kg): 1922 x 70-80%

(accounting for obesity) = 1345-1538 kcal/day (13-15 kcal/kg; 21-24 kcal/63.6kg IBW),  

Protein

Minimum 127g protein/day (2g/63.6kg IBW).

Unable to complete CRRT calculations

Fluids

Maintenance Fluid: deferred to MD given CRRT

ESTIMATED NEEDS

Diagnosis: Inability to manage self care r/t medical course AEB intubated with need for nutrition support.

Goal: (2/7) Pt to receive nutrition support within 48 hours.

NUTRITION DIAGNOSIS AND

GOAL

1. If able to use bowel: Place post-pyloric feeding tube, once placement confirmed initiate TF's of  Pivot 1.5 at 20mL/hr, increasing by 10mL q 4-6 to goal rate of 35mL/hr x 24 hours + 4 prosource/day. Total formula provides 1500 kcal, 139g protein, 840mL total volume, 638mL free water.

2. If unable to use bowel: REC TPN via PICC for nutrition support. TPN (5%AA, 15%D) @ 75mL/hr x 24 hours + IL 20% @ 10mL/hr x 12 hours. Total formula provides 1518 kcal, 90g protein, 1920mL total volume, 80:1 NPC:N ratio, 0.24g/kg/day lipid infusion rate, GIR 1.9mg/kg/min (meets 100% of calorie needs, 71% of protein needs).

*Remove Copper/Mn from PN MVT if t bili > 2.5

3. REC check baseline prealbumin w/ CRP. If plans to initiate PN, check TG q weekly to trend

4. If plans to start trophic feeds, REC MVT w/o minerals.

5. Continue Ca Gluconate to replace ionized Ca.

6. Monitor bowel movements.

7. Weigh pt daily to monitor fluid trends. 

NUTRITION RECOMMENDATIONS

• At her next follow up, VE’s tube feeding was running at goal, and she was meeting her needs

• On 2/15 she was extubated. TF’s were continued, and the SLP saw her on 2/18

• The SLP recommended a mechanical soft diet with nectar thick liquids

• Problems arose on 2/19 when VE was eating some pudding, and started coughing. She progressively

declined until she had to be re-intubated for airway protection d/t a Glascow coma score of 4

• TF’s of Pivot were started again

VE’S PROGRESS

• VE was extubated again on 2/23, and the SLP recommended she continue tube feeds and NPO status

given prolonged aphonia and concern for airway protection

• On 2/28, VE’s CRRT was stopped and she was switched to hemodialysis, her tube feeds were then changed to

Nepro, as she now required renal restrictions• Speech recommended Ears, Nose and Throat (ENT) for

evaluation of vocal cords; per ENT note on 3/2: “vocal cords are fully mobile, thus no intervention required, but

glottic inlet widened s/p prolonged intubation and pharyngeal muscles weak, may improve with time”

• VE was able to advance to a pureed diet on 3/5, but still required nocturnal tube feeds, as she was not eating

enough to meet her needs.

PROGRESS, CONTINUED

• As of the last RD’s note on 4/15, VE progressed to a regular texture diet, and was eating ~50% of meals, which was enough to meet her needs w/out

TF’s

• Her weights fluctuate between 120-130’s, with her lowest weight since

admit at 122# (55.7kg), with a BMI of 22, and 113% of IBW

PROGRESS TO PRESENT

05-F

eb

08-F

eb

11-F

eb

14-F

eb

17-F

eb

20-F

eb

23-F

eb

26-F

eb

01-M

ar

04-M

ar

07-M

ar

10-M

ar

13-M

ar

16-M

ar

19-M

ar

22-M

ar

25-M

ar

28-M

ar

31-M

ar

03-A

pr

06-A

pr

09-A

pr

12-A

pr

15-A

pr0

50

100

150

200

250

222

219

189

174

154 145

154 152

132

121

169

164

123

VE's Weight Trend

Weight (lbs)IBW (140 lbs)

Her labs:

• Prealbumin 13 (4/7) <--7 (3/31) <--13 (3/17) <--8 (3/10) <--5 (3/3)

• 25-OH Vit D3 <8 (3/18) <-- 6 (3/12)

PROGRESS TO PRESENT

Lab Value Reference Range

VE’s Value at admit

VE’s Value at Present

Creatinine 0.51-0.95 1.53 (high) 1.14GFR >60 37 (low) 52 (taken post

HD)ALT 0-33 2324

(high)58 (improved)

AST <1.2 3171 (high)

56 (improved)

D Bilirubin

<0.2 1.1 (high) 3.6 (high)

T Bilirubin

<1.2 2.4 (high) 4.8 (high)

Albumin 3.5-5.2 1.7 (low) 3.5 (improved)Ionized Ca 1.13-1.32 0.99 (low) 1.1 (on 2/27)

GOAL 4/15: continue to meet >75% estimated needs.  

Recommendations:  1. Continue Renal 80g diet (pt changed to regular

texture on 4/11). Change Nepro to once/day2. Continue Nephro-vite, 2000 units cholecalciferol

daily. Start phos binder per Nephrology.3. Continue to weigh pt daily to monitor fluid

trends.  4. Continue megace w/ meals.

PROGRESS TO PRESENT

• Per the latest doctor’s notes, a liver biopsy is recommended because the etiology of her liver

injury is unclear, but it has not been performed d/t concerns for bleeding.

• At this time, she does not currently need evaluation for liver transplant.

• Per Nephrology note, A kidney “biopsy done on 4/3/14 suggestive of tubular damage but minimal fibrosis. This portends favorable renal outcome, barring the possibility of sampling error. But for

now, she remains dialysis dependent (since 2/5/14)”• VE discharged to an LTAC on 4/17

PROGRESS TO PRESENT

QUESTIONS?