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Abdominal Compartment Syndrome in Children: Experience with Five Cases

Hussein Naji¹²³

¹Department of Pediatric Surgery, American Hospital Dubai, Dubai, United Arab Emirates

²Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden

³Department of Women´s and Children´s Health, Karolinska Institutet, Stockholm, Sweden


Correspondence

Hussein Naji

Department of Pediatric Surgery

American Hospital Dubai

PO BOX 5566, Dubai, UAE

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Tel: + 971 56971 4909

 

Abstract

Background

Abdominal compartment syndrome is the adverse physiologic consequence that occurs as a result of a sever increase in intra-abdominal pressure, leading to cardiopulmonary, renal and splanchnic disturbance regardless of the cause. This article highlights our experience with abdominal compartment syndrome in children and focuses on the role of abdominal decompression as its management.

Patients and method

Retrospectively, we reviewed the files of 5 children who were treated in our unit for abdominal compartment syndrome. Two of them were neonates, one infant and the other 2, 7 and 10 years old, respectively. Each child presented in a different way, required massive fluid resuscitation, and had tense abdominal distension. Each clinical scenario will be described and the management will be outlined.

Results

Apart from one child with multiple organ injury, the rest showed immediate improvement in the respiratory, renal, and hemodynamic function, after abdominal decompression. When the measurement of intra-abdominal pressure is not feasible, the clinical signs of tensely distended abdomen, hypoxia and respiratory distress, progressive oliguria and cyanosis of the lower extremities, are sufficient to make the diagnosis of abdominal compartment syndrome and to justify decompression.

Conclusions

Abdominal compartment syndrome is a potentially lethal condition and may be the consequence of a variety of conditions. Increased awareness of abdominal compartment syndrome may prevent its occurrence and its lethal consequences. Intra-abdominal pressure should be monitored closely, when possible, otherwise decompression should be considered depending on the clinical signs.

Keywords: abdominal compartment syndrome, intra-abdominal pressure, hemodynamic parameters, clinical signs

 

Introduction

The Abdominal Compartment Syndrome (ACS) is a clinical entity which refers to organ dysfunction caused by a severe and sustained increase in intraabdominal pressure (IAP). The physiologic consequence of ACS is impairment of nearly every organ system leading to impaired cardiac function, alterations in respiratory mechanics, renal impairment, diminished gut perfusion and elevated intracranial pressure that eventually lead to multiple organ failure [1].

The increased intraabdominal pressure and its adverse effects were first described in the late 19th century. It took long time till its recognition as a significant clinical problem in general surgery by Kron et al. in 1984 [2] who wrote about the measurement of intra-abdominal pressure as a criteria for abdominal re-exploration. Fietsam et al. [3] in 1989 was the first to use the term intraabdominal compartment syndrome.

Pediatric surgeons have been long time pioneers in the use of prosthetic silos for temporary abdominal decompression as well as the measurement of intraabdominal pressure. It is difficult to determine the incidence of ACS in children because of the wide variety of associated illness, the paucity of publications, and the relative lack of consensus on the threshold of IAP used to define ACS in children. Occurrence rates between 0.6 and 9.8% of critically ill children have been reported in different studies [1, 4-6].

In this article, we present our experience with 5 children who developed ACS and focuses on the role of abdominal decompression in its management.

Patients and Method

Retrospectively, we reviewed the files of 5 children who were treated in our unit for abdominal compartment syndrome. Two of them were neonates treated in the intensive care unit which developed ACS and were treated with abdominal decompression at bed site. The third case was an infant presenting to the emergency department with huge abdominal distension and later on developed ACS. The last 2 cases were post traumatic, presented with hypovolemic shock due to hemoperitoneum and were included in this study to demonstrate the importance of IAP measurement and proper timing of surgical intervention to prevent ACS development. The criteria for ACS diagnosis were described and discussed. Each child presented in a different way, required massive fluid resuscitation, and had tense abdominal distension.

Case 1

A 5 days old male patient, delivered by Caesarean section, presented with a 6 cm diameter omphalocele,. Otherwise, the neonate was healthy and in good condition. Under general anaesthesia, reduction of the omphalocele was done. The content of omphalocele included most of the small intestine, transverse colon and the liver left lobe. The abdominal wall was closed in layers. The IAP was monitored through a Foley catheter placed in the urinary bladder. It measured 9 mmHg at the end of operation and the patient was kept under mechanical ventilation. After 4 hours, he developed respiratory distress with a need to increase the ventilatory pressure. The abdomen became tenser, with hypotension, oliguria, and week femoral pulse. The IAP increased to 12 mmHg. Ten hours later, the IAP increased to 15 mmHg. With the diagnosis of ACS, the abdominal wall was opened in the neonatal intensive care unit, to decompress the abdomen and a silo was placed. The IAP was monitored post operatively and it was less than 7 mmHg. There was a rapid improvement in the ventilatory pressure, PaO2, and urine output. The skin was closed after 48 hours, leaving a ventral hernia that was repaired successfully 6 months later.

Case 2

An 8 days old girl neonate, presented with severe abdominal distension, constipation and bile stained vomiting of which started 4 days prior. The child passed stool after rectal stimulation with a thermometer by a midwife. Abdominal X-ray showed distended bowel loops with 6 multiple air-fluid levels. Immediate resuscitation initiated to correct the shock state, but the abdomen was hugely distended with respiratory distress, anuria, cyanosis and absent pulses in the lower limbs. Laparotomy was performed, 12 hours after admission, and showed oedematous and distended bowel loops, necrosis and debris in the pelvis, and a rectal perforation with fibrinous adhesion and necrotic materials. Sigmoid colostomy was performed with debridement and suturing of the rectal perforation. Because of bowel loops oedema and distension, her abdominal wall could not be closed without excessive tension. The IAP was 11 mmHg at the end of the surgery. It increased to 16 mmHg after 3 hours. Re- exploration was done and the skin was closed with creation of a ventral hernia. The IAP was 10 mmHg. Rectal biopsy was normal. She recovered fully with no complications.

Case 3

A 5 months old male infant, presented with huge abdominal distension, after 4 days of constipation, bile stained vomiting (in the last 24 hours), pallor, respiratory distress, and cyanosis of the lower extremities. He was a known case of Hirschsprung’s disease, diagnosed at the age of 4 months by rectal biopsy. A colostomy operation was scheduled for him, but the parents were not able to bring him because of a private family problem. He was admitted to the emergency department, and was vigorously resuscitated. Abdominal X-ray showed distended bowel loops with air under the right hemidiaphragm. Diagnosis of bowel perforation was made and emergency laparotomy was performed 3 hours after admission. Intraoperative, a perforation with small necrotic area in the sigmoid colon was identified. The bowel loops were congested, oedematous and dilated. Sigmoid colostomy was performed, biopsies were taken and the abdominal wall closed in layers. The patient received 100 ml of red cells, 2 units of fresh frozen plasma and 1400 ml of crystalloid solution. In the intensive care unit, the blood pressure started to decline, with a decrease in PaO2, an increase in positive intermittent pressure, oliguria and tense abdominal distension. After 5 hours, the diagnosis of ACS was suspected and the IAP was measured through the existing Foley`s catheter. The IAP increased from 13 mmHg to 18 mmHg. The abdomen was decompressed at bed side, and the bowel loops were covered by sterile soaked gauze. Immediately after decompression, his PIP decreased and PaO2 increased. The abdominal wall was closed 72 hours later, after the abdominal oedema and distension significantly decreased. Two months later, an abdominoperineal pull through operation was performed with a smooth postoperative evolu- tion.

Case 4

A 7 years old girl was involved in a road traffic accident and admitted to the emergency department with mild respiratory distress, abdominal pain and mild abdominal distension. Hemodynamic parameters were stable at admission. Ultrasonography showed fluid in the peritoneal cavity. CT scan demonstrated a laceration at the right lobe of the liver, a right retroperitoneal haematoma extending to the pelvis, and a moderate amount of free fluid in the peritoneal cavity. She received 250 ml of blood and 1600 ml of crystalloid solution. After 8 hours, the general condition started to deteriorate, with hypotension, oliguria, tachypnea and abdominal distension. The IAP increased from 14 mmHg (on admission) to 20 mmHg. With the diagnosis of internal bleeding and raised intra-abdominal pressure, laparotomy was performed, 2250 ml of blood was aspirated, and liver laceration was repaired, while the haematoma left without intervention. There was a noticeable improvement in the cardiopulmonary parameters just after abdominal decompression. The IAP was 13 mmHg. The postoperative period was smooth and she was in a good health at 6 months follow up visit.

Case 5

A 10 years old boy, brought to the emergency department after a car accident, sustained multiple injuries. He was intubated and two chest tubes were inserted for bilateral hemo- pneumothorax. The abdomen was distended and internal bleeding was suspected. The hemodynamic parameters were deteriorated with respiratory distress, oliguria and severe abdominal distension. With the assumption that, the beneficial tamponade effect started to work paradoxically, and had a worse effect on the hemodynamic status, laparotomy was performed. Intraoperative, 2500 ml of blood were aspirated, the spleen was severely injured, right lobe of the liver was lacerated, and the ileum was perforated. Splenectomy was done, liver laceration was sutured and the ileal perforation was closed. After surgery, the patient developed multiple organ failure and died on the 5th postoperative day.

Discussion

Abdominal compartment syndrome is the adverse physiologic consequence of a sustained increase in intraabdominal pressure. It is associated with a wide variety of surgical and medical illnesses. It results in 100% mortality if left untreated [1, 7].

The adult literature is rich in publications regarding ACS while there is a relative paucity of publications in children. The free intra-abdominal space is relatively small due to the normal relative organomegaly. As a result children may be less able to accommodate additional intra-abdominal volume. However, their abdominal wall is thinner and more compliant which may compensate for that. There is no evidence that children are less susceptible to develop ACS than adults [8].

The presentations of ACS in our patients were similar to those reported in the literature and included tense abdominal distension, decreased urine output, hypotension or hemodynamic instability, metabolic acidosis, and decreased thoracic compliance with respiratory distress.

Medical management principles to lower IAP and improve organ perfusion were applied for our patients in accordance with the recommendations of international conference of experts [9]; including but not limited to the following:

- optimize fluid administration by avoiding excessive fluid resuscitation. Hemodynamic monitoring to guide resuscitation, and use of vasoactive medications to maintain adequate abdominal perfusion pressures

- evacuate intraluminal contents via nasogastric or rectal tubes; avoiding enteral feeds; admin- istering enemas

- improve abdominal wall compliance by ensuring adequate sedation, analgesia, and neuro- muscular blockade

- evacuate free intraperitoneal fluid or air, by paracentesis or percutaneous catheter drainage.

If these measures fail to lower the raised IAP, decompresive laparotomy is the treatment of choice for most patients with ACS that is refractory to nonoperative medical management. Decompresive laparotomy is potentially life- saving and is associated with significantly improved patient survival [10].

In the first 2 cases, the diagnosis of ACS was based on the measurements of IAP, clinical signs and the ventilatory pressure, as both patients were ventilated in the intensive care unit. In such cases of omphalocele, gastroschisis and diaphragmatic hernia; the ventilatory pressure can reflect changes in the intra-abdominal pressure as these patients, in most cases, are ventilated. The ventilatory pressure can be a suitable guide for proper management [11]. In both cases, abdominal decompression was performed at bedside, because of rapid deterioration in patients’ condition that was judged to be unstable to transfer to the operating theatre. Bedside laparotomy is an option for abdominal decompression in critical patients when transfer to the operating room may result in delay [8].

The other 3 cases were treated in the emer- gency department, where the clinical signs were the indicators to guide proper manage- ment, particularly in case 5 when the IAP could not be measured. Abdominal decompression was justified depending on the clinical signs of tensely distended abdomen, progressive oliguria, inability to palpate the femoral pulses, cyanosis of the lower extremities and hypoxia due to respiratory distress.

When there is bowel perforation, laparotomy is a standard and life-saving procedure. Laparotomy was performed in case 3 because of severe abdominal distension and bowel loops oedema; the abdomen was closed under ten- sion. The IAP was monitored with high index of suspicion. It showed progressive increment to 18 mmHg. This increment in IAP together with deterioration of patient´s general condition lead to re-exploration of the abdomen and closure of only the skin layer.

In the last 2 cases, the raised IAP was caused by intraabdominal bleeding and abdominal distension. In children with intra-abdominal bleeding after blunt abdominal trauma, the effect of tamponade is well known [12]. In such scenario, the time factor is important and it is crucial to make a correct decision concerning a surgical intervention to prevent irreversible changes that may occur if treatment is delayed. A real challenge that should take into account is the fact that the increased IAP, in some cases, is life saving and can prevent an unnecessary operation, but can in other occasions be life- threatening and cause death if decompression is delayed [11]. Measurement of IAP, when it is feasible, is a valid indicator to help in determining the time of intervention to prevent the irreversible consequences of ACS.

IAP can be measured either by direct or indirect methods. The direct technique is used during laparoscopic procedures. The indirect method is by measuring the urinary bladder pressure which is the standard technique for IAP evaluation [1, 13, 14]. This measurement is done by instilling 1 mL/kg body weight of sterile saline into the Foley catheter. The end of the catheter is connected to a transducer or a manometer via a 3-way stopcock. The symphysis pubis is used as the zero reference point, and the pressure is measured in millimetres of mercury or centimeters of water (1 mm Hg = 1.36 cm H2O). The exact level of IAP at which ACS occurs is not known. Studies showed that the level at which various authors would decompress the abdomen varies from 15 to 25 mm Hg [15]. Other authors stated that abdominal decompression is not only determined by a specific pressure measurement but by the physiological derangement of the increased intraabdominal pressure, like renal impairment and cardiopulmonary insufficiency [16].

We need more studies to determine the normal and critical values of IAP in children, to make a final decision before the development of late irreversible changes. We make our final decision only after carefully weighing the po- tential benefits and the perioperative risks re- lated to the individual patient.

Conclusion

Abdominal compartment syndrome in children carries a high mortality and may be associated with different conditions. It is important to prevent ACS in children by high index of suspicion, careful observation and supportive care. Abdominal decompression should not be delayed until the development of irreversible changes. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

 

 

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