| Abstract: Introduction: Rectus sheath hematoma (RSH) is a well recognised complication of low molecular weight heparin (LMWH). In the past, surgeons were reluctant to operate on RSH. Increased intra-abdominal-pressure (IAP) and abdominal-compartment-syndrome (ACS) have been reported in association to RSH. IAP is usually measured via the bladder (IBP) but can be increased compared to gastric pressure (IGP). We report 2 cases of ACS caused by LMWH-induced RSH were simultaneous IBP-IGP were recorded. We hypothesized that a high bladder-to-gastric-pressure-difference was a marker of localised ACS, whereas a low bladder-to-gastric-pressure-difference was of systemic ACS.
Methods:
IGP was measured via with the Spiegelberg IAP-catheter (Spiegelberg, Hamburg, Germany) while IBP with the FoleyManometer (Holtech Medical, Kopenhagen, Denmark).
Patients:
First case: A 81-year-old woman was admitted with LMWH-induced RSH related cardiorespiratory failure . SAPS II score was 61, APACHE II 28, and SOFA 12. IBP rose from 2 mmHg on day1 to 40mmHg on day3 and IGP from 19 to 38 respectively, this together with organ failure lead to the diagnosis of ACS. Mean bladder-to-gastric-pressure-difference was 1.. She was intubated and ventilated, on high FiO2 and vasopressors. On day3 she deteriorated dramatically and a surgical “rescue” evacuation of the hematoma (3L) was performed. This resulted in a drop of IBP to 18mmHg postoperative and 11mmHg over the following days. She regained spontaneous diuresis a couple of hours after decompression, vasopressors were stopped the next day and she was weaned from the ventilator the day after. She was discharged on day10.
Second case: A 77-year-old man was admitted following respiratory distress, lactic acidosis and (pre)renal insufficiency related to LMWH-induced RSH. SAPS II score was 49, APACHE II 25, and SOFA 4. IBP was 24 mmHg on day1 while the IGP was only 5.5mmHg. She was intubated later that day. The high IBP together with cardiorespiratory failure lead to the diagnosis of localised ACS (normal IGP). Mean bladder-to-gastric-pressure-difference was 6.1. She was treated conservatively with sedation,curarisation,ultrafiltration,gastro- and colonoprokinetics resulting in normalisation of IBP. On day 14 she was extubated and regained diuresis. She was discharged on day24.
Results:
The results are summarized in Figure 1
Conclusion:
IBP can be dramatically increased by RSH. This does not always imply ACS, even in the presence of organ failure. We suggest to use the bladder –to-gastric-pressure-difference to differentiate between a localised or systemic ACS. The latter should be treated with decompressive surgery, whereas the former can be treated conservatively.
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