| Abstract: ABSTRACT: Abdominal compartment syndrome (ACS) in children is usually described in association with abdominal wall defects, trauma, or burns.1,2 We describe an unusual and severe case of ACS in a 9 month-old girl after operation for intussusception. Review of literature regarding ACS in pediatric patients is provided. Children may be predisposed for recurrent ACS.
Case Report: A 9 month-old girl presented with a three-day history of vomiting and feeding intolerance, progressing to lethargy and diminished urine output. Upon arrival to the hospital, she was listless and tachycardic. Her abdomen was distended & firm. Extremities were cool with diminished pulses. Fluid resuscitation began. A marked systemic inflammatory response was evident. At operation an ileocolic intussuception was found, with the remainder of the bowel unremarkable. The intussusceptum was reduced; a segment of necrotic ileum was resected and a primary ileo-ileal anastomosis performed. The abdomen was closed primarily without difficulty.
Post-operatively, acidosis persisted in despite aggressive measures. Hypotension and worsening ventilation required pharmacologic pressor support and high frequency oscillatory ventilation. Oliguria developed. Bladder pressure was 40 cmH2O. Emergent decompressive laparotomy was performed at the bedside. Re-opening the abdomen, immediate improvements were noted in hemodynamic and respiratory performance. The bowel was edematous but otherwise viable. A sterile plastic covering was sutured to the abdominal fascia to protect the viscera (Fig. 1).
Despite initial improvements, within 12 hours the abdomen was again tense, and the viscera appeared taut beneath the plastic cover. Acidosis, hypotension, and ventilatory difficulties recurred. Bladder pressure was re-measured at 35 cmH2O. The abdomen was again re-opened, and the bowel eviscerated. Physiologic improvements identical to those experienced after the first decompressive laparotomy were again seen. A silastic silo was constructed to allow the bowel to remain outside the peritoneal cavity yet still protected (Fig.’s 2&3). Following the second emergent decompression, there was no further evidence of ACS. The patient remained nonetheless critically ill. She required several re-operations for necrotic bowel. She was gradually weaned off pressors and mechanical ventilation. Bowel function returned and enteral feeds were begun. Her abdomen was eventually closed tension-free.
CONCLUSION: We describe a case of severe pediatric abdominal compartment syndrome that recurred despite decompressive laparotomy. ACS in children is infrequently described, much less so in this setting. Nonetheless, similar cases have been reported.3 Review of the literature suggests that recurrent abdominal compartment syndrome in children may be more frequent than is commonly suspected. |
