RevBrasAnestesiol.2015;65(6):519---521
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
OfficialPublicationoftheBrazilianSocietyofAnesthesiologywww.sba.com.br
CLINICAL
INFORMATION
Management
of
abdominal
compartment
syndrome
after
transurethral
resection
of
the
prostate
Megan
M.
Gaut,
Jaime
Ortiz
∗DepartmentofAnesthesiology,BaylorCollegeofMedicine,Houston,USA
Received13November2013;accepted12December2013 Availableonline8January2014
KEYWORDS
Transurethral resectionofthe prostate; Bladderrupture; Abdominal compartment syndrome
Abstract Acuteabdominalcompartmentsyndromeismostcommonlyassociatedwithblunt abdominaltrauma,althoughithasbeenseenafterrupturedabdominalaorticaneurysm,liver transplantation,pancreatitis,andmassivevolumeresuscitation.Acuteabdominalcompartment syndromedevelopsoncetheintra-abdominalpressureincreasesto20---25mmHgandis charac-terizedbyanincrease inairwaypressures,inadequateventilationandoxygenation,altered renalfunction,andhemodynamicinstability.Thiscasereportdetailsthedevelopmentofacute abdominalcompartmentsyndromeduringtransurethralresectionoftheprostatewith extra-andintraperitonealbladderruptureundergeneralanesthesia.Thefirstsignsofacuteabdominal compartmentsyndromeinthispatientwerehighpeakairwaypressuresanddifficulty deliver-ingtidalvolumes.Managementofthecompartmentsyndromeincludedre-intubation,emergent exploratorylaparotomy,anddrainageofirrigationfluid.Difficultywithventilationshouldalert theanesthesiologisttoconsiderabdominalcompartmentsyndromehighinthelistofdifferential diagnosesduringanyendoscopicbladderorbowelcase.
© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.
PALAVRAS-CHAVE
Ressecc¸ão transuretralde próstata;
Rupturadebexiga; Síndrome
compartimental abdominal
Manejodasíndromedocompartimentoabdominalpós-ressecc¸ãotransuretralde próstata
Resumo Asíndromecompartimentalabdominalagudaémaiscomumenteassociadaatrauma abdominalfechado,emboratenhasidoobservadaapósrupturadeaneurismadaaorta abdom-inal, transplante de fígado, pancreatite e reanimac¸ão com volume macic¸o. A síndrome compartimental abdominal aguda surge quando a pressão intra-abdominal aumenta para 20-25mmHg e é caracterizada pelo aumento das pressões das vias aéreas, ventilac¸ão e oxigenac¸ãoinadequadas,func¸ãorenalalteradaeinstabilidadehemodinâmica.Esterelatode caso descreve odesenvolvimento da síndrome compartimental abdominal agudadurante a ressecc¸ãotransuretraldepróstatacomrupturadabexigaextraeintraperitonealsobanestesia geral.Osprimeirossinaisdasíndromecompartimentalabdominalagudanessepacienteeram
∗Correspondingauthor.
E-mails:jaimeo@bcm.edu,jaimeo@bcm.tmc.edu(J.Ortiz).
520 M.M.Gaut,J.Ortiz
pressões de pico elevadas das vias aéreas e dificuldade para fornecer volumes correntes. O manejo da síndrome de compartimento inclui reintubac¸ão, laparotomia exploratória de emergênciaedrenagem delíquidosdeirrigac¸ão.Adificuldadenaventilac¸ãodevealertaro anestesiologistaparaqueconsidereasíndromecompartimentalabdominalemprimeirolugar nalistadediagnósticosdiferenciaisdurantequalquercasodeendoscopiadebexigaouintestino. ©2013SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.
Introduction
Intraperitoneal bladder rupture is a rare complication of transurethralresectionoftheprostate(TURP).Bladder per-foration,bothextra-andintraperitoneal,occursinonly1.3% of all patients receiving this procedure. Only 17% of all perforations are intraperitoneal.1 Intraperitoneal bladder
perforationisaseverecomplicationwhichrequires
imme-diate treatment to prevent serious consequences such as
peritonitis,uremia,acidosis,andcompartmentsyndrome.2
Abdominalcompartmentsyndrome(ACS)developsoncethe
intra-abdominalpressure(IAP)increasesto20---25mmHg.3,4
The initial insult from increased IAP is decreased venous
return, leading to hypovolemic shock. A study on dogs
showed a decrease in cardiac output and stroke volume
of 36% after IAP increased to 40mmHg.5 During
hypov-olemicshock, theincreasedsympatheticoutflow causesa
decreasein splanchnic perfusion. Hypoxiaof the
abdomi-naltissuesinitiatesareleaseofinflammatorycytokinesthat
increase capillarypermeability and tissueedema, further
increasingtheIAP.Astudyonrats6showedthatalongwith
decreased mean arterial pressure and pH, increasing IAP
leadstoincreasedlevelsofTNF-␣,IL-1,andIL-6,i.e.
pro-inflammatorycytokineswhichmayserveasasecondinsult
for theinduction of multi-organ failure.Unless diagnosed
andtreatedrapidly,upto36%ofcasesofACSleadto
mul-tiorganfailure.7 The increase in thoracic pressure results
inadecreaseinalllungvolumesexceptresidualvolume.5
Ifa patientis onvolumecontrolledventilation,a
precipi-tousrisein peakairwaypressuresmaybeseen. This case
report details the development of ACS during TURP with
extra- and intraperitoneal bladder rupture under general
anesthesia.
Case
description
A 79-year-old male was scheduled to undergo palliative
TURP for prostate cancer and obstructive uropathy. His
medical comorbidities included hypertension and type II
diabetes. Physical examination wassignificant for a
well-appearingelderlymalewithan indwellingFoley catheter,
heart rate 105 beats/min, blood pressure 168/93mmHg,
bodymassindex26kg/m2,MallampaticlassIIIairway,and
a2---3cmoralaperture.Pertinentlaboratorytestsincluded
ahematocrit of 43.8% andcreatinine 1.1mg/dL. An
elec-trocardiogramrevealedsinustachycardiawithleftanterior
fascicularblock.Hewasdeemedalowcardiacriskforalow
riskprocedure.
Intraoperative monitoring for this patient included
standardAmericanSocietyofAnesthesiologists(ASA)
moni-tors. An 18-gauge peripheral intravenous catheter was
placedpriortoinduction.Anesthesiainductionandtracheal
intubation were uneventfully performed and the surgery
wasbegun.Volumecontrolledventilationwasstartedwith
settingsof: tidalvolume500mL, respiratoryrate10/min,
positiveend-expiratory pressure5cmH2O.Twohoursinto
thesurgery,thepeakairwaypressuresincreasedfrom20to
37cmH2O,tidalvolumesdecreasedfrom450to100mL,and
an audible inspiratoryleak aroundthe endotracheal tube
cuffwasheard.Aftercheckingthecuffforadequate
pres-sure,suctioningtheendotrachealtube,checkingthecircuit,
hand ventilating,andconfirming decreased breath sounds
bilaterally, albuterol anddexamethasone were givenwith
mildimprovementinventilation.
Shortlyafterthisevent,thesurgicalprocedurewas
com-pleted.Thepatientresumedspontaneousrespirationswith
a rate of 20 breaths/min and tidal volumes of 120mL.
Neuromuscular blockade was reversed, and he awakened
andfollowed commands. Whenhedemonstratedhead lift
for five seconds, the patient was extubated. However,
he had minimal respiratory effort right after extubation,
and the drapes were removed toexamine for chest rise.
The abdomen was noted to be severely distended and
tympanic to percussion. A rapid-sequence induction was
performed, but placement of the endotracheal tube was
moredifficultduetoswellingaroundthevocalcords.After
endotrachealintubation,thepatientbecame
hemodynam-ically unstable witharterial blood pressure decreasing to
the70s/40s.Aradialarteriallinewasplacedand
phenyle-phrineandephedrinebolusesweregiventomaintainamean
arterial blood pressure above 60mmHg. The continuous
bladder irrigation, which is customary after TURP
proce-dures,wasdiscontinued.Uponstoppingtheirrigation,tidal
volumesimprovedto350mL.
Due to the lack of space in the cystoscopy suite, the
patient wastransported nextdoor tothe trauma
operat-ingroomforexploratorylaparotomy.An arterialblood gas
at that time showed a combined metabolic and
respira-tory acidosis (pH 7.08, pCO2 66, HCO3− 19, sodium 126,
base excess −10). Upon incision, 3L of clear irrigation
fluid were suctioned out of the peritoneum. Laparotomy
revealedabladderneckrupturewithextraperitonealfluid
collection, with a second tear in the peritoneum leading
to the massive intraperitoneal fluid collection.
Immedi-ately aftertheabdominalfluidwasremoved,airwaypeak
pressuresreturnedtobaseline.However,thepatient
AbdominalcompartmentsyndromeafterTURP 521
to maintain hemodynamic stability. After decompression
of the abdomen, the pH normalized within 1h. The
sur-geons performed a repair of the bladder rupture, open
suprapubic prostatectomy,andplacementof asuprapubic
catheter.
Thepatientremainedintubatedaftertheprocedureand
wastransportedtothesurgicalintensivecareunit.Hewas
extubated thefollowing day andwasdischargedhome on
postoperativeday5withanindwellingFoleycatheter.Athis
follow-upvisitonemonthaftersurgery,theFoleycatheter
wasremovedandthepatientcontinuedwithagood
recov-ery.
Discussion
Ourpatient developed abdominal compartment syndrome
(ACS)causedbyextra-andintraperitonealbladderrupture
duringTURP.ACSafterTURPisarareoccurrencepreviously
describedjustonceintheliterature.7
Anincreaseinpeakairwaypressureswasnoted2hinto
the procedure, which we initially attributed to reactive
airwaydisease.Ofnote,thispatient’sprostatewas
approx-imately 120g, and our urology team does not routinely
performTURPforprostatesizegreaterthan80g.However,
thepurposeofthispatient’ssurgerywastoofferrelieffrom
obstructiveuropathyandtoavoidmajorabdominalsurgery.
Duetotheabnormallylarge prostateandprolonged
dura-tion of the resection (greater than 2½h), aswell as the
pressurizedbladderirrigationusedduringandimmediately
after theprocedure, our patientquicklydeveloped a
dis-tendedabdomenwhichleadtoACSandrespiratorydistress
immediatelyafterextubation.His treatmentincluded
dis-continuationoftheirrigationsolutionandrapidexploratory
laparotomy to evacuate the fluid and repair the bladder
injury.
Opening the abdomenis the most effective methodto
reduce IAP andis the treatment of choice for abdominal
compartmentsyndromewhenIAPisconstantlyhigherthan
30mmHgwithongoingorganfailurerefractorytomedical
therapy.8Duetoourpatient’shemodynamicinstabilityand
quicklyworseningclinicalpicture,hisIAPwasnever
mea-suredbutthereliefafterlaparotomyincisionwasinstant.
Hispre-incisionpHwas7.08anditquicklynormalizedbythe
endofthesurgery.
Anadditionalchallengeourteamfacedwasthatthe
cys-toscopy suite is smalland not suited for an urgent open
abdominal exploration. Therefore, our patient had to be
movednextdoor tothe traumaoperatingroom.We were
fortunatethatthiscomplicationoccurredinatrauma
hos-pital with an immediately available operating room and
in-housetrauma surgeons. TURPcommonly takesplacein
ambulatory surgical centers where emergency assistance
maybelimited.Althoughbladderruptureisarare
compli-cation,appropriatemeasuresforitsmanagementshouldbe
considered.
Sincethis event, the operating room teamin the
cys-toscopysuitehasmadeitapointtomonitortheabdomen
fordistentionduringprolongedcystoscopyprocedures,and
to assess the abdomen visually with the operating room
lightsonbeforeextubation.The irrigationfluidinput and
output are also collected and measured. Another option
wouldbetodoanultrasoundexaminationoftheabdomen
in the cystoscopy suite in cases where symptoms
suspi-ciousfor bladder rupture present. Thiswould avoid doing
anunnecessarylaparotomyinpatientswherethesuspicion
isthere,butwhoremainhemodynamicallystable.Thiscase
hasremindedustohavebladderrupturehighonthelistof
differentialdiagnoseswhenacaseofunexpectedincreased
airwaypressuresoccursduringcystoscopy.
In the presented case, our patient developed acute
abdominal compartment syndrome after extraperitoneal
bladderruptureandsubsequentintraperitonealleakduring
TURP.Hishemodynamicinstabilityanddifficultywith
venti-lationledtothedecisiontoperformemergentexploratory
laparotomyinan adjacentoperatingroom.Quick
recogni-tionandinterventionafterthiscomplicationpreventedlong
termmorbidityforthispatient.
Conflicts
of
interest
Theauthordeclaresnoconflictsofinterest.
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