NM-247
Undiagnosed Abdominal Compartment Syndrome Causing Sudden Cardiac Arrest In a Neonate with Necrotizing Enterocolitis: A Case Report
Khizkiyayeva A, Salam M
SUNY Downstate Medical Center, Brooklyn, NY, USA
Abdominal Compartment Syndrome (ACS) has tremendous relevance in the care of critically ill patients, because increased pressure within the confined space of the abdomen can impair venous return & cause sudden cardiovascular collapse. ACS can encompass many clinical scenarios. ACS can be acute, chronic or even undiagnosed secondary to an acute increase in intra abdominal pressure. We present a case report of a patient with necrotizing enterocolitis (NEC) who a had sudden cardiovascular collapse leading to cardiac arrest from an undiagnosed abdominal compartment syndrome due to massive silent intraperitoneal bleeding.
A 20 day old male, 1.4kg, with pmhx of 28 week prematurity, NEC, adrenal insufficiency, hypothyroidism, RDS, PFO, thrombocytopenia, & sepsis is brought down to the OR for an emergent exploratory laparatomy & colon resection. Patient was brought to OR from NICU in critical conditions, with uncuffed 3.0 ETT in situ & 2 PIV in place.
A few minutes after patient was connected to the ventilator, saturation started going down from high 90’s to 80’s. Patient was taken off the ventilator & manually hand ventilated with no improvement in saturation. End tidal CO2 was not appreciated on the ventilator & at the same time, patient started to become bradycardic to 100’s. Patient was given IVP Atropine 100mcg & the ETT was suctioned. Patient still showed no improvement in saturation & both pulse oximetry & heart rate further kept decreasing.
On auscultations, faint breath sounds were heard & still no etco2 was appreciated, so decision was made to replace the ETT under direction visualization. Again, no etco2 was appreciated on the ventilator & only faint breath sounds were heard. Pneumothorax was suspected & a needle decompression was done with no improvement in saturation. Blood pressure & saturation became unmeasurable. Chest compressions were started for heart rate below 60’s & patient was given epinephrine 20mcg twice. Epinephrine seemed to have little if any effect on patient’s vital signs.
At this point the abdomen was palpated & was found to be very distended. Abdominal compartment syndrome was suspected & the abdomen was cut. Immediately, etco2 started registering on the ventilator as compression against the IVC was lifted & saturation & hear rate started picking up. Surgeon continued with the procedure & found severe intraperitoneal bleeding & hematoma which was evacuated & resected.
Patient was finally stabilized & resuscitated with D10 1/2NS, prbc, ffp, platelets, albumin, calcium & hydrocortisone. Dopamine drip was started. EBL was 100ml. Patient was still oozing during transport to NICU & DIC was suspected. Patient subsequently expired few days later from DIC & sepsis.
While most of the literature details the management of ACS following abdominal trauma, one must keep in mind that ACS can occur in a variety of settings, particularly those associated with coagulopathy, major hemorrhage & massive volume resuscitation such as in NEC. While ACS is usually associated with abdominal wall defects such as gastroschisis or omphalocele, one must be vigilant that silent intraperitoneal bleeding in NEC can also put these patients at risk for the development of increased intraabdominal pressure & cardiovascular collapse.
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