Four days after damage control laparotomy for gunshot wounds, a 32-year-old man develops increasing peak inspiratory pressures, worsening oliguria despite fluid boluses, and a tense distended abdomen. Bladder pressure measures 28 mmHg. What is the most appropriate management?

• A Increase sedation and continue conservative management with repeat measurement in six hours
• B Administer furosemide to increase urine output
• C Return to theatre for decompressive laparostomy ✓
• D Start renal replacement therapy and defer abdominal decompression

Explanation

An intravesical pressure above 25 mmHg with new organ dysfunction (respiratory compromise and oliguria) establishes abdominal compartment syndrome. The only definitive treatment is urgent decompression of the abdomen, usually by reopening the laparotomy incision or performing a decompressive laparostomy. Diuretics are harmful in a hypovolaemic, shock state, and renal replacement does not relieve the raised intra-abdominal pressure driving the multiorgan failure.

Reference: Sabiston Textbook of Surgery, 21st ed.

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