Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame?
BACKGROUND
Secondary abdominal compartment syndrome (ACS) is the development of ACS in the absence of abdominal injury. The development of secondary ACS has been viewed by some authors as an unavoidable sequela of the aggressive crystalloid resuscitation often employed in the treatment of severe shock. We hypothesized that poor resuscitation techniques, including early and excessive crystalloid administration, places patients with extremity injuries at risk for developing secondary ACS.


METHODS
The Trauma Registry of the American College of Surgeons database was queried for all patients with an extremity Abbreviated Injury Scale (AIS) score of 3 or greater and abdominal AIS score of 0 treated at our institution between January 1, 2001 and December 31, 2005. The study group included those patients who developed secondary ACS, whereas the comparison cohort included those who did not develop secondary ACS.


RESULTS
Forty-eight patients developed secondary ACS and were compared with 48 randomly selected patients who had an extremity AIS score of 3 or greater and an abdomen AIS score of 0. There were no differences between the groups with respect to age, sex, race, or individual AIS scores. However, the secondary ACS group had a slightly higher Injury Severity Score (25.6 vs. 21.4, p = 0.02), significantly higher operating room crystalloid administration (9.9 L vs. 2.7 L, p < 0.001), and more frequent use of a rapid infuser (12.5% vs. 0.0%, p = 0.01). Multiple logistic regression identified prehospital and emergency department crystalloid as predictors of secondary ACS.


CONCLUSIONS
Aggressive resuscitation techniques, often begun in the prehospital setting, appear to increase the likelihood of patients with severe extremity injuries developing secondary ACS. Early, large volume crystalloid administration was the greatest predictor of secondary ACS.
Madigan
Michael C
MC
Department of Surgery, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
Kemp
Clinton D
CD
Johnson
J Chad
JC
Cotton
Bryan A
BA
D015998:Abbreviated Injury Scale; D000005:Abdomen; D000328:Adult; D001134:Arm Injuries / Q000150:complications*; D003161:Compartment Syndromes / Q000209:etiology*; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects*; D006801:Humans; D007552:Isotonic Solutions / Q000008:administration & dosage; D007869:Leg Injuries / Q000150:complications*; D016015:Logistic Models; D008297:Male; D011312:Pressure; D012151:Resuscitation / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D065227:Transfusion Reaction
D000077324:Crystalloid Solutions; D007552:Isotonic Solutions