Abdominal compartment syndrome – a rare complication of veno-venous extracorporeal membrane oxygenation for primary graft dysfunction following lung transplantation
L. Valeanu, M. Stefan, S. Andrei, P. Augustin
Centre Hospitalier Universitaire Bichat Claude Bernard, Paris, France
Background: Primary graft dysfunction (PGD) is a severe form of ischemia reperfusion syndrome developing after lung transplantation (LT). Extracorporeal membrane oxygenation (ECMO) can be used for hemodynamic failure following PGD, but the massive fluid overload needed for adequate pump flow can lead to development of abdominal compartment syndrome (ACS).
Case Report: A 46 kg, 54 years old female underwent bipulmonary LT for emphysema. Ischemia time for the lungs was 8 hours, with a 4 hours exvivo lung perfusion. There was no need for ECMO assistance during transplantation, but 8 liters of crystalloids and an infusion of 150 µg/kg/min noradrenaline were administered. The transesophageal echocardiography showed normal biventricular function and severe hypovolemia. After ICU admission, the patient developed grade 3 PGD with persistent vasoplegic shock and was assisted with a veno-venous femuro-jugular ECMO 2 hours later. After initial successful hemodynamic resuscitation, impaired venous return and pump flow of less than 1 l/min were noted. Correct cannula position was confirmed. During the first 4 hours, 20 liters of crystalloids were administered and the noradrenaline dose increased to 750 ng/kg/min. Mesenteric ischemia, septic shock and anaphylactic shock were ruled out. After measuring an intra-abdominal pressure of 40 mmHg, decompressive laparotomy for ACS was performed in the ICU, 4 hours after admission. Following decompression, the pump flow increased to 4 l/min. The multiple organ dysfunction progressively ameliorated, the ECMO was explanted on day 3 and the abdominal wall was closed on day 6. Extubation was possible on day 14 and the patient left the ICU after a 5 weeks stay, with no evidence of graft rejection.
Discussion: PGD can develop rapidly after LT and the need for assistance using ECMO is documented1. The massive vasoplegic shock necessitates resuscitation with large doses of fluids and vasoconstrictors for adequate pump flow, which leads to formation of tense ascites and development of ACS, which will then worsen on its own the venous return and pump flow. 
Learning points: Measurement of intra-abdominal pressure should be considered in case of inappropriate venous return and pump flow after massive fluid overload and decompressive laparotomy should be realized as soon as possible. 
References: 1. Augustin P. et al. Abdominal compartment syndrome due to extracorporeal membrane oxygenation in adults. Ann Thorac Surg 2010; 90: e40-41.

Abdominal compartment syndrome – a rare complication of veno-venous extracorporeal membrane oxygenation for primary graft dysfunction following lung transplantation