Abdominal Pain, Anemia, and Oliguria in a Distressed Woman

Eva Nourbakhsh, MD; Kenneth M. Nugent, MD; Rishi Raj, MD

Disclosures

April 30, 2021

The treatment of ACS is multifactorial and depends on both the severity and the primary cause. Because a wide variety of patients may develop IAH/ACS, no one management strategy can be uniformly applied. Appropriate IAH/ACS management is based on three principles: serial monitoring of IAP, optimization of systemic perfusion and organ function, and prompt surgical decompression for refractory IAH. Most patients with Grade III pressures and all patients with Grade IV pressures should have surgical decompression. Nonsurgical strategies are appropriate, at least initially, for Grades I and II. These modalities may include body positioning, nasogastric and colonic decompression, fluid resuscitation, diuretics and continuous renal replacement therapies, as well as percutaneous catheter decompression.[4]

After reversal of her warfarin-induced coagulopathy with plasma and vitamin K, the patient in this case was taken to the operating room for evacuation of a large abdominal wall hematoma. No active bleeding was found. The wound was packed for hemostasis, and the abdominal cavity was left open to ensure that the IAP remained low. The following day, after improvement of her condition, she was taken back to the operating room for removal of the packing and for closure of the abdominal cavity. Another blood clot was found, but no active arterial or venous bleed was noted. A Jackson-Pratt tube and a wound vacuum-assisted closure (VAC) were placed. The patient's clinical status and multiorgan failure resolved, and she was discharged to a long-term acute care facility with the wound VAC in place.

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