A patient with abdominal compartment syndrome and perforated transverse colon successfully managed with ECMO.

Case Report A 24-year-old male soldier was admitted to the intensive care unit (ICU) for exertional heat stroke. Endotracheal intubation was performed for respiratory and metabolic acidosis (pH, 7.008; PaCO2, 66.6 torr; PaO2, 131.9 torr; HCO3-, 19.7 mmol/L). The patient recovered consciousness, bowel sounds were present, and nasogastric (NG) feeding was begun 17 hours later. The patient’s condition gradually improved; however, 48 hours after admission his fraction of inhaled oxygen decreased from 100% to 40%. He was treated with hydration and dopamine infusion, and his oxygen saturation improved. At the 72 hours after admission, the patient developed a fever of 38.9°C, and his white blood cell count was 1.03×109/L. He became agitated, his abdomen was distended, and cold limbs and marbled skin were noted. Laboratory testing revealed an amylase level of 204 U/L, lipase of 794.6 U/L, and glutamic-oxaloacetic transaminase (GOT) of 279 U/L. Chest X-ray showed bilateral infiltration and arterial blood gas testing revealed a PaO2 of 59.9 torr on ventilator support with 100% oxygen. Abdominal sonography revealed an ileus and bowel dilatation which prevented an adequate study. Transthoracic echocardiography showed borderline of left ventricular (LV) regional wall motion with adequate LV systolic function and preserved right ventricular free wall motion and systolic function. Abdominal computed tomography (CT) showed scattered fluid and free air accumulation over the bilateral subphrenic regions and other peritoneal potential spaces. Collapse of the bilateral lower lungs, positive round-belly sign, bowel wall thickening with enhancement, and collapse of the inferior vena cava (IVC) were also noted (Fig. 1). The impression was high intra-abdominal pressure. The patient became hypotensive (blood pressure 67/49 mm Hg) on the 4th hospital day. His heart rate was 142 beats/minute, SaO2 was 66.1%, and PaO2 was 32.1 torr. Shock was not controlled by hydration and a dopamine infusion (20 μg/kg/min). ECMO (Terumo Capiox SP101; Terumo Co., Japan) was begun in vein-to-vein mode. Venous blood was drained out from the inferior vena cava through right femoral vein cannulation and oxygenated blood was returned into right atrium through right internal jugular vein cannulation. After beginning ECMO, his oxygen saturation improved to 97% and blood pressure increased to 131/62 mm Hg with inotropic support.