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Clinical Case Study: Abdominal Compartment Syndrome

Brittney McGetrick. Clinical Case Study: Abdominal Compartment Syndrome. What is Abdominal Compartment Syndrome?. Abdominal Compartment Syndrome (ACS) occurs when pressure builds up in the abdomen and causes subsequent multi organ failure due to lack of perfusion

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Clinical Case Study: Abdominal Compartment Syndrome

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  1. Brittney McGetrick Clinical Case Study:Abdominal Compartment Syndrome

  2. What is Abdominal Compartment Syndrome? • 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.

  3. Risk Factors for Developing ACS • Diminished abdominal wall compliance • Major 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

  4. Treatment • 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

  5. The Open Abdomen • 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

  6. Can We Feed the Open Abdomen? • 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

  7. My Patient: “VE” • 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

  8. Patient History • 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

  9. Anthropometrics • 41 year old female • 5’8’’ • Admit Wt: 222 lbs • Admit BMI: 33.8 • Admit %IBW: 156%

  10. Medical Progression after Admit • 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.

  11. Initial Assessment • VE was first seen by an RD on 2/7 • VE was first seen by an RD on 2/7 • Labs: • Prealbumin was pending

  12. Estimated Needs • Energy • EST 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

  13. Nutrition Diagnosis and Goal • 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.

  14. Nutrition Recommendations • 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. • 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 • REC check baseline prealbumin w/ CRP. If plans to initiate PN, check TG q weekly to trend • If plans to start trophic feeds, REC MVT w/o minerals. • Continue Ca Gluconate to replace ionized Ca. • Monitor bowel movements. • Weigh pt daily to monitor fluid trends. 

  15. VE’s Progress • 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

  16. Progress, continued • 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.

  17. Progress to Present • 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

  18. Progress to Present • Her labs: • Prealbumin 13 (4/7) <--7 (3/31) <--13 (3/17) <--8 (3/10) <--5 (3/3) • 25-OH VitD3 <8 (3/18) <-- 6 (3/12)

  19. Progress to Present • GOAL4/15: continue to meet >75% estimated needs. • Recommendations: • Continue Renal 80g diet (pt changed to regular texture on 4/11). Change Nepro to once/day • Continue Nephro-vite, 2000 units cholecalciferol daily. Start phos binder per Nephrology. • Continue to weigh pt daily to monitor fluid trends.   • Continue megace w/ meals.

  20. 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

  21. Questions?

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