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Rant: Abdominal Compartment Syndrome

Discussion in 'Surgery and Surgical Subspecialties' started by neb85, 05.05.12.

  1. neb85

    neb85

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    Must vent.

    We had just taken one of the patients whom I was covering overnight to the OR to debride what was left of her pancreas (infected necrotic pancreatitis by cx). 6 hours later around midnight, I got a page from the ICU fellow who was worried that she was developing abdominal compartment syndrome - for some reason the unit team had done a bladder pressure, which was 45. Her belly was distended but still soft, and all other indicators were normal including airway pressures, labs were all stable, and nothing incriminating from any of the bazillion drains. She had gone oliguric sometime during the operation, we assumed as a result of shock, so urine output wasn't a big player at that point.

    I wasn't very concerned for ACS, but hey I'm still an intern for the next two months, what do I know. So I called up my fellow at home, gave him the hard data and my exam and impressions, and he agreed that the bladder pressure was probably off (as they tend to be). I explained this to the ICU fellow and he seemed to understand - besides, the patient was rock stable, or at least as stable as she could be s/p pancreatic debridement.

    Two hours later, with the patient still ridiculously stable, I got a page from the ICU attending (who had been called by the ICU fellow), to discuss the same data which hadn't changed. In the meantime they had done another bladder pressure and it was 50; the patient's belly was still soft. At this point the unit attending is actively trying to run me over to impose his point, so I woke up my fellow again and they had a nice long chat. We finally agreed to paralyze the patient and redo the bladder pressures and behold, they came back in the low 20s. Patient stable, case closed.

    We find out the next day that after all this, the unit attending had attempted to call OUR ATTENDING at 3am to try to convince him to take the pt back to the OR in the middle of the night behind our backs.

    I do appreciate that these guys were trying to do the right thing, but for God sakes that was taking it a bit too far, especially trying to live or die by the bladder pressure. It was one of my last nights on float at the mothership and to add that time sucking charade to all the preexisting BS - the aggravation was overwhelming and it was all I could do to keep things civil (which they were, until we woke my fellow up the second time).

    Sorry for the rant. I've seen more than a few consults this year for r/o abdominal compartment syndrome, and each one has hinged on faulty bladder pressures - is this generally a common theme?

    neb
  2. vhawk

    vhawk 2K Member

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    This is really nothing to do with ACS, and instead about professional relationships, teamwork and collaborative medicine.

    Also, as annoying as it probably was to you (mostly because its a blow to your ego), the ICU doc did the right thing. What would YOU do if you were convinced that a patient needed something and you felt that one of your consult services was mismanaging it or making a mistake? First, you would call them and discuss it with them and try to see why you disagree. If you still disagree, you would move it up the chain, preferably one link at a time.

    Thats exactly what happened. As long as no one got fired and the patient didnt die, this seems like basically exactly how this situation should play out every time.
  3. butterfly0660

    butterfly0660 Junior Member

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    We see this all the time. Pulmonary for whatever reason randomly checks a bladder pressure in a non-paralyzed patient and it comes back high. Otherwise patient isn't clinically worrisome for ACS. The bladder pressure always comes down once you paralyze the patient. In my opinion there isn't any utility whatsoever in checking a bladder pressure if the patient isn't paralyzed.
  4. SLUser11

    SLUser11 CRS

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    What sort of ICU is this? Is it a medical ICU staffed by Pulm/CC doctors? If so, that may be your first problem. In general, you want patients like that in a surgical ICU being managed by doctors of the same cloth....or being managed by you, preferably.

    Anyway, I'm not sure that the bladder pressure was faulty, or that it is an unreliable measurement in general. I will say that bladder pressures are operator-dependent, so you should know how to do them and re-check yourself if there's any question. I think they are an overall reliable way to determine intra-abdominal pressure.

    A pressure of 45 would make anybody nervous, and they did the right thing to call. I certainly wouldn't want a medicine resident NOT telling me about a bladder pressure of 45.

    To be honest, I'm not sure I'd be satisfied once the on-call surgical intern decided it was okay...so you did the right thing by loading the boat. Also, I don't agree with your assessment that "urine output wasn't a big player" since you assumed it was from shock, as you put it. If the patient is oliguric, there's a reason, whether it's acute kidney injury, under-resuscitation, or compartment syndrome...it's not something to be ignored.

    At the end of the day, there's a difference between abdominal compartment syndrome and intra-abdominal hypertension, and it sounds like this patient had the latter. However, this situation, while frustrating, had several learning points:

    1. Placing your sick surgical patients in a medical ICU leads to too many cooks in the kitchen, and overall conflicting interests, especially concerning fluids/resuscitation and vent management.

    2. Learn to accurately check a bladder pressure yourself. That way, you know if it's being done correctly, and if the number is reliable.

    3. Don't get overly-upset when someone goes over your head...it will drive you insane if you do. People routinely go over the intern's head. That being said, you did the right thing by immediately going to see the patient (I assume), then notifying your senior.
  5. ESU_MD

    ESU_MD Old School

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    I would get more mad if the icu staff DIDNT call your attending instead trying to just bully the intern. Communication should stick to resident to resident and staff to staff
  6. Miami_med

    Miami_med Moving Far Away Moderator Emeritus

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    In general, my experience is to not check a bladder pressure unless you are concerned for ACS. I've seen many false positives, and it often just confounds the situation. I remember once have a bladder pressure read as 85 in a patient on a vent with peak pressures of 25. I had it rechecked, and it was still high on the recheck. The patient was making 50cc/hr of urine. I can't even fathom a physiologic condition that could make this set of data all accurate. Usually, I check bladder pressures when I suspect ACS, and I'm looking to confirm the diagnosis.

    That being said, you have exactly the type of patient here who gets ACS. I'll bet he had a huge crystalloid resusciation to go along with the septic shock, and I'll bet he'd been getting an IVF of rate of between 150 to 200 cc/hr for days before, along with third spacing like crazy. He's also oliguric, and you stated that he was in shock, so your assesment of being rock stable seems a little questionable. Perhaps he didn't require pressors or wasn't actively dying, but I've never seen a patient sick enough for a debridement not atleast get tachycardic and exhibit other subtle signs associated with the SIRS response. The oliguria is never just acceptable. You have to explain it. If you're saying he's in shock as an explanation, and he's persistently oliguric, then you need to consider something to improve his renal perfusion.

    Also, if he was a younger guy, they can look "stable," until they go off a cliff. I think it's actually laudible that everyone was appropriately concerned about this guy. Even paralyzed, his bladder pressures are still high. I don't think its at all unreasonable to be worried about ACS in an oliguric patient with necrotizing pancreatitis and elevated bladder pressures.
  7. SLUser11

    SLUser11 CRS

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    I strongly disagree. Paralytics are used to treat ACS, but definitely not necessary to diagnose ACS. If we paralyze everyone before checking bladder pressure, I guess we better re-think what numbers we use to diagnose intra-abdominal hypertension.

    To me, that's masking the problem instead of treating it...like giving lasix to treat low UOP from kidney failure, or giving beta blocker for tachycardia.

    I'm by no means an expert on this subject, though, and I'm basically retired from critical care work. However, there's the World Society of the Abdominal Compartment Syndrome, and their website is worth a look sometime. There are recommendations, definitions, and links to consensus statements.
  8. PMPMD

    PMPMD 4G MD

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    How many CC's were they instilling in the bladder? I've heard that over-filling the bladder can cause detrusor spasm and falsely elevate the bladder pressure. Not sure why they were checking it if there were no other signs of organ dysfunction (high peak pressure, high lactate, etc.)
  9. neb85

    neb85

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    I get what you guys are saying about the chain of command and the way things should be done if people more senior are worried about the patient. In the end I guess I don't mind so much that all these exchanges happened and I think my frustration just stemmed from being the low guy on the pole being squashed in between all of this mess.

    To answer some questions, this was one of our mixed med/surg ICUs (there are pure surgical units in our hospital but the pts from certain ORs go to certain units based on location). There were no other signs of possible ACS other than the renal failure which had begun intraop. My fellow and I went back and pored over this case afterwards to see if we had missed anything that could have been helpful. Other sx such as the lactate had started higher and had been trending down this whole time. I agree that there was most likely IAH since she obviously had gotten tons of fluid during the surgery but the disagreement was about the severity of the problem.

    Anyway, thanks for all the thoughts. Everything ended up fine in the AM when my fellow came in, and we were able to bring the unit attending around to our point of view.
  10. SLUser11

    SLUser11 CRS

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    I have to confess that I'm an eternal devil's advocate, so I would have disagreed with whatever you had said in the initial post. I honestly think it's fine to vent a little bit, and SDN forums are probably the best place to do it since it's semi-anonymous and light-hearted.

    It's difficult being a surgical intern toward the end of the year. You've learned the basics, and your eager for some more responsibility and less bull$#@t. Unfortunately, some of the unpleasant parts about being a resident continue into the senior years, and it's important to shake it off so you won't burn out or go crazy.

    I also believe that PGY-2s are some of the most dangerous residents in the hospital, as they have just enough responsibility to do some serious harm, and they haven't learned to be Socratic yet (they don't know that they don't know). Mid-level and senior residents are less dangerous partially because they have more experience, but also because they have developed a healthy fear of bad outcomes, and they are aware of how little they actually know.

    I bring up the whole PGY-2 rant because I think it will benefit you to stay humble, and continue to be a sponge for knowledge and experience. I think learning more about bladder pressures and visiting the website I mentioned is a good place to start. You don't want to take your senior resident or fellow's teachings at face value, but instead explore why you do the things you do, especially in the ICU.
  11. 45408

    45408 aw buddy

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    Not a fan of bladder pressures. They've never actually helped us make the diagnosis, and they have certainly confounded the issue before.
  12. filter07

    filter07

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    listen to this guy
  13. FaytlND

    FaytlND Senior Member

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    Not to jump in laste, but I don't necessarily agree. I do think that a bladder pressure in isolation and/or in a patient who doesn't have clinical evidence of ACS is fairly useless. And I guess the issue is how heavily do you weigh the bladder pressure in someone who "looks" like they have ACS. Is it something that's going to tip your decision into decompressive laparotomy, or is it something you do just to document even though you've already made the decision to go to the OR.

    For example, if I have a patient who is a setup for ACS, and they start having increasing plateau pressures with a tense abdomen and hypotension requiring increasing pressors, I'm probably going to the OR even if the bladder pressure is 25. And if the bladder pressure was 40 in a patient with no clinical signs, then of course he's not getting an operation. Ultimately, I think it's more useful as a trend than a spot number.

    As for this specific case, I think it's a mischaracterization to say that the paralytics were used to get an "accurate" bladder pressure. Rather that the paralytics successfully treated the patient's IAH and the bladder pressure dropped as you would have expected.

    Second, I agree with everyone else that it's certainly not wrong for the attending to be told about this situation, even if it seemed like it was "going over your head". Now, if it was an ICU resident calling your attending, then that's a bit of a problem. But it's that ICU attending's responsibility to be 100% sure the patient is being treated appropriately. And if he feels the attending surgeon should be aware of the issue, that's his perogative.

    Personally, in a patient like this that just had a necrosectomy and you know is going to be a hot mess, my attendings would likely want to know about something like this, and I would have been the one to tell them just so they were in the loop. Sure, you and the fellow didn't think he needed the OR immediately, but who's to say he wouldn't have fallen off a cliff and needed something done emergently? If I called my attending and said "Hey, this guy needs the OR now." and they found out it was a developing issue all night that they weren't aware of, I'd be crucified. I suppose some of that is institutional/cultural differences, but I still don't think it's a bad thing.
  14. 45408

    45408 aw buddy

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    If it's a patient with a confounding issue, say, a dialysis patient who doesn't make urine anyway, then I could see more utility for it. Otherwise, I feel like it's a clinical diagnosis that doesn't need a bladder pressure. If their peak pressures are climbing and their belly feels like a snare drum, then I feel like you already have your diagnosis. Depending on the type of resuscitation being done, you might end up waiting too long to see the urine output drop off.

    We've had a whole run of these hot messes. I'm really hoping that we don't get any more.
  15. pmapunk66

    pmapunk66

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    Agree. Humble intern here, soon to be PGY2. I have been called for ACS many times, we are one of the busiest trauma centers in the country. Reading and the teachings of my seniors have taught me that ACS is mainly a clinical diagnosis.

    :thumbup: nice piece of advice for us interns.
  16. doc05

    doc05 2K Member

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    The bladder pressure IS important follow; rarely are these cases so cut-and-dry that a tense abdomen means you must go to the OR. Most importantly is the TREND in bladder pressure, and the overall picture.

    As for the question of paralytics, the patient must be paralyzed to measure bladder pressure accurately. Otherwise you have the confounding factor of abdominal wall muscular contraction; this can make a big difference in terms of the measured pressure.

    The other important point is that you should probably leave the abdomen open if the patient is high-risk for ACS. Akin to prophylactic fasciotomies done in vascular cases.
  17. 45408

    45408 aw buddy

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    Agree, although of the two patients I've had that developed ACS, neither one had an abdominal operation in the first place.
  18. FaytlND

    FaytlND Senior Member

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    Intuitively this doesn't make much sense. The abdominal wall musculature is not a confounding factor for intrabdominal pressure, rather a known contributing factor. The intrabdominal pressure in someone who isn't paralyzed isn't "falsely" elevated. The number may certainly be real, and just because someone isn't paralyzed doesn't exclude the diagnosis of ACS if they present with the clinical syndrome. That's why paralytics a treatment, and can help you avoid a decompressive laparotomy in someone with ACS if you remove the musculature from the equation.

    It's akin to saying that the chest wall compliance is a confounding factor for respiratory dynamics. It's not a confounding factor, but rather an important thing to take into consideration in your overall treatment plan.

    Further, while I agree that leaving a belly open in the right situation is not wrong, I think there is a trend to leave too many open. So if you mean "high risk for ACS" as "I can't close the belly without significant tension", then sure. But often in these patients you are only getting one chance to close the belly. If you don't do it early, you certainly aren't going to get it done after they're edematous and their fascia has retracted. I think it's actually better to err on the side of needing to watch them closely than leaving them with a giant ventral hernia.
  19. SLUser11

    SLUser11 CRS

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    Agree 100%.

    During the early 2000's, the pendulum swung too far toward turning all trauma and acute care surgeries into "damage control" when many of those abdominal walls could have been closed safely.

    I don't necessarily disagree with the comparison of decompressive laparotomy to prophylactic fasciotomies, but I do want to point out that there's a very large difference in procedure-related morbidity between the two.

    Anyway, I think this thread has illustrated how diverse opinions are on the subject, which is why I'm glad there is an organization (referenced above) that provides evidence, definitions, recommendations, and consensus statements....
  20. southernIM

    southernIM

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    Agree with this as well. I think we are single-handedly funding KCI with all the abtheras we use...
  21. 45408

    45408 aw buddy

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    Anybody know what an Abthera costs? They're so easy to use....
  22. dpmd

    dpmd Relaxing

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    That one is the blue spider, right. We started using them, then one attending had something bad happen and now we went back to the old style ones (don't get me started on the ridiculousness of changing practice based on one bad event). The old style dressing costs $300 at my hospital. I think they told me before that the Abthera was more expensive.
  23. Miami_med

    Miami_med Moving Far Away Moderator Emeritus

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    I believe at my institution it costs a little more than $300 each use. That is substantially more than a bile bag, towel, kerlex, a JP drain, and some ioban, which I don't believe cost anywhere near $300.
  24. DrDawg

    DrDawg Member

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    There has been a push in Critical Care Medicine to recognize Intraabdominal hypertension, and abdominal compartment syndrome for some time now. So its kind of a hot topic that is old hat for surgeons. Still I would review the information that SLUser noted above. Intra-abdominal hypertension is a concern, and abdominal compartment syndrom is a surgical emergency. If your chief or fellow disagreed from home he should have sauntered into the hospital as several people with more experience that you were concerned enough to check a pressure, call the operating service, and ultimately the attending.
  25. europeman

    europeman

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    While at first glance it seems ridiculous to pay $300 for those spider bags when u can just make a trauma dressing out of lap blue towels and a bowel bag or mayo stand cover.... I have to tell you that they work MUCH better in my experience.

    First... They are quicker. But is 300 really worth 10 minutes in OR I dunno but if is a bonus.

    Second... You can far the sponges into the infradiaphragmagic space, the gutters, and pelvis in a way much much better that you can do with a homemade dressing. Those spiders are much more effective at sucking and I'll tell u anecdotally that when u go back it's night and day. It's do much more efficient that even the bowel is less edematous/ irritated and w/o fibrinous reactive stuff that u see after 48 hours with a homemade one.

    In short... It's just more efficient at sucking all over in an even fashion and you can macroscopically appreciate it when you go back. And as a bonus it's faster AND as a result of its efficienty and even distribution of sucking the bowel is noticeably less edematous and much easier to close.

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