Abdominal Compartment Syndrome during Off-pump Coronary Artery Bypass: a Case Report

Abstract

We report a case of intraoperative hemodynamic instability due to abdominal compartment syndrome in a 65-year-old woman who underwent elective off-pump coronary artery bypass graft. She had manifestation of destabilized hemodynamic and respiration, and detected an extremely tense and distended abdomen when the sternum was closed. After excluding hemorrhage and right heart failure, the patient was considered to have ACS. Then a nasogastric tube was inserted to decompress the stomach and 100 ml of 20% mannitol was administered intravenously. With the above treatment, the patient was gradually relieved, and discharged 12 days later. Keywords:Abdominal compartment syndrome; Off-pump coronary artery bypass graft surgery Jeokgeum-ro, Danwon-gu, Ansan-si, Gyunggi-do, 15355, South Korea, Tel: +82-31-412-5316; Fax: +82-31-412-5294; E-mail: yslee4719@gmail.com dropped from 110/70 to 60/30 mmHg and heart rate increased from 80 to 130/min. At a tidal volume of 400 ml and a respiratory rate of l2/min, peak airway pressure concomitantly increased from 18 to 30 cm H 2 O, end tidal CO 2 increased from 29 to 33 mmHg, and SpO 2 in 50% oxygen/air mixture decreased to 96%. Lung sounds were equal and clear. Then, Mean Pulmonary Arterial Pressure (mPAP) increased from 18 to 28 mmHg, and central venous pressure (CVP) increased from 5 to 17 mmHg. Fluid was infused rapidly and inotropic support was provided, including dopamine, dobutamine, and phenylephrine. Phenylephrine (50 µg) was administered intravenously. Phenylephrine (100 µg) was then given repeatedly, which increased blood pressure only slightly to 90/50 mmHg. Dopamine and dobutamine were titrated to maintain systolic blood pressure > 90 mmHg. Blood pressure was maintained at 90-100/50-60 mmHg and heart rate was maintained at 110-130/min. Urinary output was maintained during the operation. An arterial blood gas analysis on 100% oxygen showed pH of 7.25, PaCO 2 of 45.1 mmHg, and PaO 2 of 124 mmHg. Tidal volume and respiratory rate were reset to improve the progressively worsening oxygenation and to increase peak inspiratory pressure. CVP and mPAP did not decrease during fluid resuscitation and inotropic support. Bleeding and right heart failure was suspected. The surgeons were informed that ventilation was becoming more difficult, but no cause for the problem was provided. Hemoglobin was 10.2 g/dl and platelet count was 55,000 cells/ µl. The patient had received about 2000 ml of intravenous crystalloid solution, five units of packed red blood cells, five units of fresh frozen plasma, and eight units of platelet concentrate.An extremely tense and distended abdomen was detected when the sternum was closed. A nasogastric tube was inserted to decompress the stomach and 100 ml of 20% mannitol was administered intravenously. Respiratory and the hemodynamic variables improved gradually 30 min later. Peak inspiratory pressure decreased to 25 cm H 2 O, blood pressure increased to 110/60 mmHg, and heart rate decreased 100/min. Ultrasonography revealed fluid in the abdominal c...

Massive Ascites Causing Presumed Abdominal Compartment Syndrome During Open Heart Surgery With Cardiopulmonary Bypass

“…Although increases in IAP occur more commonly in the post-operative period, increases in IAP are known to occur during cardiopulmonary bypass (CPB) and have been implicated in the development of renal failure and mesenteric vascular dysfunction [1,[3][4][5][6][7][8]. The literature on catastrophic IAH and ACS in cardiac surgery, however, is limited to case reports and small studies [9][10][11][12][13]. In one study, the incidence of ACS in cardiac surgery was determined to be about 1% [13].…”

“…In one study, the incidence of ACS in cardiac surgery was determined to be about 1% [13]. The definitive cause(s) of ACS and catastrophic IAH is not known and remain subject to investigation [2,7,8,[10][11][12]. Dalfino et al attempted to identify the risk factors for secondary IAH in cardiac surgery patients.…”

“…In one study, the incidence of ACS in cardiac surgery was determined to be about 1% [ 13 ]. The definitive cause(s) of ACS and catastrophic IAH is not known and remain subject to investigation [ 2 , 7 , 8 , 10 - 12 ].…”