Abdominal Compartment Syndrome
Case #183
A 43-year-old man was found to have several bladder stones.
He was quadriplegic from an accident many years earlier and had a suprapubic catheter.
He saw his urologist (Dr. C), who recommended a procedure to remove the bladder stones.
During the procedure, Dr. C removed the suprapubic catheter for better visualization.
A cystoscope was introduced through the urethra.
After visualizing the stones, he inserted an 18 Fr trocar through the suprapubic tract.
Dr C then used several different instruments via the cystoscope to remove the stones.
During the process, several liters of fluids were instilled into the bladder.
Dr. C suddenly noted that the patient’s abdomen was extremely distended.
He realized that the trocar had slipped out, and the fluid that was instilled into the bladder had filled the patient’s abdomen.
A general surgeon (Dr. U) was consulted.
The patient’s abdomen was so distended that blood flow to the patient’s lower extremities had been lost.
A laparotomy was performed, releasing a large volume of fluid under high pressure.
The patient was taken to the ICU with a temporary abdominal closure.
Over the next 4 days, his condition continued to worsen.
After a conference with his wife, he was placed on comfort care and died shortly thereafter.
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His wife sued the urologist, his practice, and the hospital.
An expert witness was hired:
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The plaintiff offered to settle with Dr. C and his group for $1,000,000 and with the hospital for $4,000,000.
A confidential settlement was reached.
MedMalReviewer Analysis:
The expert mentions that 2L of fluid were discovered in his abdomen. This seems like a surprisingly small amount of fluid to cause an abdominal compartment syndrome. We routinely take 4-8L of fluid out of the abdomen when doing a paracentesis on liver failure patients. I suspect the key difference here is the rapid accumulation of fluid. Also, the patient may have been thin, and it is unclear if the 2L of fluid was an accurate measurement or simply an underestimation.
I am sympathetic to the urologist as this seems like a very unfortunate accident, and he realized the issue before the end of the case. A similar freak accident could probably happen to even the most careful and diligent surgeons. However, the hospital and doctor did the right thing to settle the case. It would have found a sympathetic jury. Cases like these are why you have malpractice insurance.
Here’s another case of abdominal compartment syndrome:
![Enoxaparin to Warfarin Bridge Fiasco [Abdominal Compartment Syndrome]](https://substackcdn.com/image/fetch/$s_!pekM!,w_140,h_140,c_fill,f_webp,q_auto:good,fl_progressive:steep,g_auto/https%3A%2F%2Fbucketeer-e05bbc84-baa3-437e-9518-adb32be77984.s3.amazonaws.com%2Fpublic%2Fimages%2Fccf3d1e8-ea64-41e6-9b3b-136d2065afcf_876x770.jpeg)
OK...I am about to go off on a completely different direction...but there is a point.
Three years ago, at the age of 11, our 35 pound dog developed right heart failure from a congenital double outlet right ventricle with on obstructive pulmonary outflow tract. At her initial diagnosis, she had four liters of fluid in her abdomen drained by the veterinary cardiologist. A week later, he drained another four liters. Her condition progressively deteriorated and, over the next nine months, my girlfriend (a PICU nurse) and I drained 1.5 liters of fluid via paracentesis three times a week...
And she never developed abdominal compartment syndrome.
Sadly, we had to euthanize her because of the ongoing deterioration of her heart failure and eventual failure to respond to medication.
The point...
I agree completely with Med Mal Reviewer that two liters of fluid seems very small to cause an abdominal compartment syndrome...
No matter how thin the patient was...
Or how acute the buildup.
Perhaps 2L was just the excess, after a much larger amount had been absorbed and distended the tissues? I might have missed what the cystoscopic total fluid deficit was. And he was also likely in much more fragile condition than the typical patient.
For hysteroscopic procedures we are taught to limit the total crystalloid fluid deficit to about 2L, maybe slightly less if the patient is very elderly or otherwise medically fragile. Most of it is expected to be absorbed intravascularly and the idea is to avoid pulmonary edema. If 2L was found in the belly, I’d think a larger amount had already been absorbed…?