Abdominal compartment syndrome: the imp of urinary catheter
The present case has been reported in BMJ. A 27-year-old man with a background of alcohol excess presented to the surgical assessment unit (SAU) with abdominal pain. On clinical examination, he was tender in his epigastric and left-upper quadrant.

The blood results of note were a white cell count of 21×109/L, C reactive protein 332 mg/L and amylase 812 U/L. He deteriorated quite quickly on the SAU with agitation, type 1 respiratory failure and hypotension. He required intubation and ventilation, and to be started on vasopressors.

A CT of his abdomen and pelvis showed features in keeping with necrotising pancreatitis with a collection in the lesser sac. He was managed conservatively in the ICU with vasopressors, intravenous fluids, nasogastric feeds and antimicrobials.

Continue reading about the case here: http://casereports.bmj.com/content/2018/bcr-2018-226786.full

Learning points
• Abdominal compartment syndrome (ACS) is defined as new organ dysfunction in the presence of intra-abdominal hypertension (IAH). It can occur in many conditions including trauma, burns, abdominal sepsis, ascites, postabdominal surgery, intraperitoneal bleeding, ruptured abdominal aortic aneurysm and pancreatitis. Intra-abdominal pressure (IAP) cannot be measured radiologically. The diagnosis of ACS therefore requires indirect IAP measurement via intragastric, intracolonic, intravesical or inferior vena cava catheters. The standard method is intravesical (bladder).

• If an intravesical approach is used to measure IAP, it is important to ensure that the catheter is appropriately sited in the bladder. If it is not, then this can result in a spuriously elevated IAP. Because sedated patients cannot communicate discomfort, a urinary catheter can be displaced even in the presence of high urinary volumes. A bladder scan can help to assess displacement.

• The management of ACS consists of careful observation and supportive care. Because APP=MAP−IAP, patients may benefit by an increased MAP using vasopressors such as norepinephrine to improve perfusion to the abdominal viscera. In some cases, surgical decompression may be required. This occurs after carefully weighing the benefits of decompression with the risks of performing this intervention.
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