Unusual complications from amitriptyline intoxication.

Althoughtricyclic antidepressants(TCAs) are frequently prescribed to patients with depression, these drugs can also be misused. A 21-year-old comatose patient was referred to our hospital presenting with ventricular tachycardia. Despite initial treatment including intravascular lipid emulsion, ventricular fibrillation occurred soon after arrival. Venoarterial extracorporeal membrane oxygenation and therapeutic hypothermia were administered. Refractory arrhythmia disappeared on the next day. A high concentration of amitriptyline was identified in his blood samples on arrival. Mechanical bowel obstruction followed after abdominal compartment syndrome caused by anticholinergic effects, and refractory seizure occurred due to TCA intoxication. Although seizure was brought under control with anticonvulsant agents, his Glasgow Coma Scale did not recover to the full score. MRI presented irreversible damage to the bilateral frontal lobe and insula. Amitriptyline has the potential to cause unusual serious complications, such as abdominal compartment syndrome, irreversible central nervous system disability and lethal arrhythmia.

Intra-Abdominal Hypertension Causes Bacterial Growth in Lungs: An Animal Study.

To study the effect of intra-abdominal hypertension (IAH) on the frequency of pneumonia with an experimental study, thirteen Sprague-Dawley rats were included. Eight out of thirteen animals were randomly assigned to receive 10 ml of benzalkonium chloride 0.2% (megacolon group) and five animals received 10 ml NaCl 0.9% (controls). Animals were anaesthetized by intramuscular delivery of ketamine. The incidence of positivity for bacteria lung tissue cultures and mesenteric lymph node cultures was assessed at the 21st day after animals' sacrification, or before in case of death. All megacolon group animals presented progressive increase of the abdomen and increased IAP (≥10 mmHg) whereas the frequency of their evacuations was almost eliminated. Controls presented normal evacuations, no sign of abdominal distention, and normal IAP. In megacolon group animals, there was evidence of significant amount of bacteria in lung cultures. In contrast, no bacteria were found in control animals.

[CORRECTION OF INTRAABDOMINAL PRESSURE IN RATS IN AN ACUTE PANCREATITIS, USING INFUSION OF MYORELAXANT OF A DURABLE ACTION PIPECURONIUM BROMIDE].

Impact of a durable action of myorelaxant pipecuronium bromide on intraabdominal pressure (IAP) in rats in experimentally simulated acute peritonitis was studied. In the rats in purulent pancreatitis, іnduced by L-аrginin, IAP was in 4,5 times high (p < 0.001), than in intact laboratory animals. Pipecuronium bromide have lowered IAP by 33.4%, witnessing efficacy of application of myorelaxants in treatment of intraabdominal hypertension in purulent pancreatitis.

Ileus and Intra-Abdominal Hypertension due to Phosphate- Containing Enema.

The most well known complications of fleet enema solution are cardiac insufficiency, renal failure, water-electrolyte imbalance, and ileus. A 7-y-old girl with phenylketonuria and long-term constipation was admitted to the emergency department with symptoms of seizure, vomiting and abdominal distention. Laboratory results revealed hypocalcemia and hyperphosphatemia. ECG findings showed normal sinus rhythm and prolonged QT interval. At the follow-up, the patient's abdominal distention was markedly increased. She was evaluated for a surgical pathology and, this was considered unlikely. Intra-abdominal pressure (IAP) was 19.5 mmHg. Gastric and colonic decompression, intravenous 10 % calcium gluconate were applied. After 2 d of treatment, the patient's condition became stable, and serum calcium and phosporus normalized to 8.8 mg/dl and 4.0 mg/dl, respectively. Abdominal distention regressed and the last IAP measurement was 3.5 mmHg. Thus, IAP measurements are a useful adjunct in clinical follow-up of patients with progressive abdominal distention due to phosphate enema use.

Abnormal Expression of Urea Transporter Protein in a Rat Model of Hepatorenal Syndrome Induced by Succinylated Gelatin.

BACKGROUND: Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Abdominal compartment syndrome (ACS) occurs with dysfunction of multiple organs when abdominal pressure increases. Here, we report on a novel model of ACS with ascites and a model of HRS in rats to observe the urea transporter protein (UT) expression in the 2 models. MATERIAL AND METHODS: A liver cirrhosis model was induced by CCl4. After changes of liver histopathology were observed, rats were injected intraperitoneally with succinylated gelatin to establish a model of ACS and HRS. Then, changes in BUN, Cr, and renal histopathology were detected. Moreover, the UT in ACS and HRS were also quantified. RESULTS: The surfaces of liver in the cirrhotic group became coarse, with visible small nodules and became yellow and greasy. The normal structure of the hepatic lobules were destroyed, and hyperplasia of fibrotic tissue and pseudo-lobe was observed. The levels of BUN and Cr were significantly increased in rats suffering from ACS and HRS, respectively, compared to their control groups. In addition, the mRNA levels of UT-A2 and UT-A3 decreased in rats with HRS compared to cirrhotic rats. However, there was no significant difference between the mRNA levels of UT-A2, UT-A3, and UT-B in rats with ACS vs. normal rats. CONCLUSIONS: It is feasible to model ACS in rats by injecting succinylated gelatin into the abdominal cavity. Increasing the intra-abdominal pressure by succinylated gelatin is also a novel approach for modeling HRS in cirrhotic rats. Compared with control rats, there is an abnormal mRNA expression of UT in ACS rats and HRS rats.

[IMPACT OF A HEIGHTENED INTRAABDOMINAL PRESSURE ON POLYORGAN INSUFFICIENCY OCCURRENCE IN AN ACUTE PANCREATITIS].

In experiment the impact of intraabdominal hypertension (IAH) on an acute pancreatitis (AP) course was studied up. The procedure of an acute experiment, using intraparenchymatose introduction of 40% solution of ethanol, was proposed. The isolated influence of IAH on target organs was investigated, as well as its impact on the simulated severe AP course. Morphological changes in pancreas, small intestine, kidneys, liver in an AP were studied up. While performing the investigation a negative impact of IAH in AP was noted, such as the polyorgan insufficiency occurence.

Hepatopulmonary syndrome: the role of intra-abdominal hypertension and a novel mouse model.

OBJECTIVE: Hepatopulmonary syndrome (HPS) is considered as a triad of chronic liver disease, pulmonary vascular ectasia and severe hypoxemia. The study aims to investigate the pathological mechanism of intra-abdominal pressure (IAP) in HPS and establish a novel mouse model. METHODS: Fifty male ICR mice were randomly divided into experimental and control group, receiving subcutaneous injection of carbon tetrachloride and water, respectively. Mice in experimental group were then divided into 4 sub-groups with the intraperitoneal injection of different volume of albumin to form different IAP (0, 5, 10 and 20 cmH2O). All the mice were then sacrificed 24 hours later and blood gas analysis was conducted. In addition, liver and lung histopathology was also examined. RESULTS: Blood gas analysis in different IAP suggested the respiratory alkalosis. Arterial partial pressure of oxygen significantly decreased in the IAP=10 cmH2O (68.13 ± 3.56, P<0.01) and 20 cmH2O (66.00 ± 3.78, P<0.01). Alveolar-arterial oxygen pressure difference increased markedly in the IAP=10 cmH2O (54.60 ± 6.80, P<0.001) and 20 cmH2O (57.04 ± 5.60, P<0.001). According to lung histopathology, macrophages were found to accumulate in the alveolar spaces and the widened alveolar walls were detected. In addition, there was visible blood stasis in the alveolar walls and numerous red blood cells extravasated into air space in the IAP=10 and 20 cmH2O. CONCLUSIONS: Our study suggested that intra-abdominal hypertension was a significant pathological mechanism of HPS. Meanwhile, we have established a novel mouse model that will now be optimized with further investigation of the mechanism and therapeutic targets of HPS.

Hepatorenal syndrome: insights into the mechanisms of intra-abdominal hypertension.

OBJECTIVE: Hepatorenal syndrome is one of the serious complications of cirrhosis and closely associated with the increasing intra-abdominal pressure (IAP). The study aims to explore the potential mechanism of intra-abdominal hypertension in the development of hepatorenal syndrome in mouse models. METHODS: Eighty male mice were randomly divided into model group (subcutaneous injection of carbon tetrachloride) and control group (subcutaneous injection of olive oil). After 12 weeks, parts of the mice were sacrificed and liver histopathology was detected. Then, albumin (30 g/L) and normal saline were separately injected into the peritoneal cavity of mice to induce the different IAP levels (0, 5, 10 and 20cmH2O). Blood urea nitrogen, serum creatinine and renal histopathology were examined 24 hours later. RESULTS: Blood urea nitrogen and serum creatinine levels were statistically significant high in the group of IAP= 10 and 20cmH2O as compared with the IAP= 0cmH2O. From results of renal histopathology, the constrictive renal tubular lumen and inflammatory infiltration in the interstitial were observed in groups of IAP= 5 and 10cmH2O. Besides, the formed casts and hyperemia in the renal interstitial could be detected in group of IAP= 20cmH2O. The cellular swelling and edema of renal tubular epithelial cells were found in model group simultaneously. CONCLUSIONS: Our study suggested that intra-abdominal hypertension was a significant pathological mechanism and a potential independent risk factor of hepatorenal syndrome.

Hipertensión intraabdominal y síndrome compartimental / No disponible

La hipertensión intraabdominal (HIA) fue descrita por primera vez hace más de cien años, pero no ha sido hasta los últimos años cuando ha aumentado el interés por esta entidad, disminuyendo así la morbimortalidad asociada a ella. La presión intraabdominal (PIA) normal varía desde menos de 5 mmHg en la mayoría de pacientes, hasta 9-14 mmHg en diversas situaciones (obesidad, gestación, pacientes críticos). Definiciones: Se define hipertensión intraabdominal (HIA) como un aumento sostenido de la PIA mayor o igual a 12 mmHg en dos tomas espaciadas como mínimo 6 horas. El término Síndrome Compartimental Abdominal (SCA) hace referencia a un aumento de la PIA mayor o igual a 20 mmHg registrada en 3 ocasiones entre 1 y 6 horas, asociada al fracaso (no conocido previamente) de uno o más órganos. Existen muchos factores de riesgo asociados a esta patología, aunque tal vez el más importante relacionado con el SCA secundario sea la reanimación masiva con líquidos. El SCA compromete a casi todos los órganos del cuerpo, tanto por la acción directa de la compresión como indirectamente a través de una inadecuada perfusión tisular. Diagnóstico: La vía de elección para medir la PIA es la transvesical, por ser la menos invasiva, mientras que la medición transgástrica se usa cuando la patología de base lo requiere (vejiga neurógena, trauma vesical, etc.) (AU)

Tratamiento: La descompresión quirúrgica vía laparotomía ha sido el tratamiento definitivo durante mucho tiempo; la indicación para un tratamiento quirúrgico (TQ) es el fallo del tratamiento médico (TM). Los pilares del TM se basan en mejorar la distensibilidad de la pared abdominal, evacuación de lesiones ocupantes de espacio intraabdominal, disminución de contenido intraluminal y optimización de la perfusión tisular. En estudios con animales se han empleado nuevos fármacos específicos como la melatonina y el octreótido con buenos resultados, pero aún no se han utilizado en humanos. El TQ consiste en la descompresión mediante laparotomía, manteniendo abierta la pared abdominal hasta mejorar los valores de la PIA y la presión de perfusión abdominal. El abdomen abierto debe ser protegido mediante un cierre abdominal temporal. Para realizarlo se han descrito diversas técnicas: cierre exclusivo de la piel, cobertura plástica tipo bolsa de Bogotá, cierre tipo Wittmannpatch y cierre con vacuum pack (VAC®), siendo este último el método más fisiológico; por esta razón algunos grupos lo consideran el tratamiento de elección (AU)

Although already described more than one hundred years ago, Intra-abdominal hypertension (IAH) has recently raised a renewed interest, allowing a reduction in morbi-mortality. Normal intra-abdominal pressures may vary from less than 5 mmHg in normal conditions to 9 to 14 mmHg in different situations (obesity, pregnancy, critically ill patients).Definitions: Intra-abdominal hypertension is defined as an intra-abdominal pressure ? 12 mmHg in two different measurements separated at least by 6 hours. The term Abdominal Compartment Syndrome is defined as a value of intra-abdominal pressure ? 20 mmHg measured three times during 6 hours and associated to organ failure. There are many risk factors associated with this syndrome, above all intensive fluid resuscitation. This compartment syndrome may affect almost all body organs, by means of direct compression or indirectly for the inadequate tissue perfusion. Diagnosis: Intra-bladder pressure allows to estimate intra-abdominal pressure with minimal complications, thus it represents the chosen path of measurement. Intra-gastric measurements are used only in selected situations (neurogenic bladder, bladder trauma, etc.). Treatment: The pillars of IAH treatment should be: improving the compliance of the abdominal wall, evacuation of the space-occupying lesions, diminishing the intraluminal content, optimization of the tisular perfusion. In animal models new specific drugs have been used, such as melatonin and octreotide, with good results. Studies on humans are being carried on. Surgical decompression via laparotomy is indicated when medical treatments have failed or when patient’s condition are critical. The abdominal wall can be kept open until patient’s condition are improved. The open abdomen must be protected with a temporary surgical closure, such as an exclusive skin closure, plastic coverage such as a Bogotá bag, Wittmannpatch closure, or vacuum assisted closure (VAC®), being the latter the most used (AU)

Abdominal compartment syndrome following opioid-induced postoperative ileus.

A 35 year old woman, 6 days after ileal neobladder construction, reported uncontrolled pain despite 33 mg hydromorphone via patient-controlled analgesia (PCA). Abdominal compartment syndrome was suspected based on worsening tachypnea, oxygen desaturation, and severe, prolonged ileus. Following emergent intubation, peak airway and bladder pressures were elevated. After nasogastric decompression, they returned to normal. Continuous ketamine infusion was used for opioid resensitization and the patient was extubated following return of bowel function. Opioid use contributed to the ileus, caused gastric distension, and displaced the diaphragm cephalad. The patient interpreted the subsequent dyspnea as pain and increased PCA opioid use, thereby worsening the ileus.

Influence of fentanyl on intra-abdominal pressure during laparoscopy in dogs.

OBJECTIVE: To evaluate the influence of fentanyl on intra-abdominal pressures in spontaneously breathing dogs during capnoperitoneum. STUDY DESIGN: Prospective clinical study. ANIMALS: Eleven healthy client-owned and five healthy experimental dogs undergoing laparoscopy. METHODS: Dogs were premedicated with acepromazine (0.03 mg kg(-1) IV) and carprofen (4 mg kg(-1) IV). Anaesthesia was induced with propofol and maintained with isoflurane in oxygen. The abdomen was insufflated with CO(2) (11-16 cm H(2) O). Intra-abdominal pressures were measured with a transducer. Respiratory variables were measured with a spirometry sensor and side-stream capnography. Following preparation, fentanyl (1 µg kg(-1) ) was injected over 30 seconds IV. Data were recorded 5 minutes before, during and 5 minutes after treatment. The following time points were selected for statistical analysis (anova, p < 0.05): -160, -140, -120, -100, -80, -60, -40, -20, 0, 30, 50, 70, 90, 110, 130 and 150 seconds after the start of fentanyl injection. RESULTS: Intra-abdominal pressure increased during inspiration in 15 dogs but decreased in one dog. Fentanyl treatment did not alter these patterns. Peak inspiratory and end-expiratory intra-abdominal pressures continuously decreased over time during the whole experiment and fentanyl exaggerated the decrease in inspiratory pressures but did not affect the rate of decrease in expiratory pressures. Differences between intra-abdominal pressures were stable before, but decreased after fentanyl administration from 4.1 ± 1.4 to 3.3 ± 1.2 cm H(2) O (at 0 and 150 seconds time points). End-tidal CO(2) partial pressures increased from 6.0 ± 0.8 to 6.6 ± 0.9 kPa, respiratory rate decreased from 10.8 ± 2.6 to 7.8 ± 2.2 breaths per minute and tidal volume decreased from 13.7 ± 4.4 to 12.4 ± 2.9 mL kg(-1) after fentanyl but these variables did not change before fentanyl treatment. Airway pressures did not change. CONCLUSIONS AND CLINICAL RELEVANCE: Fentanyl did not increase intra-abdominal pressures in dogs.

Psychiatric drug-induced fatal abdominal compartment syndrome.

Several drugs used in psychiatry may induce constipation, paralytic ileus, or acute megacolon (Ogilvie's syndrome). We report here 2 cases of patients presenting with fatal abdominal compartment syndrome related to the absorption of antidepressants and benzodiazepines. Two patients (a 27-year-old man and a 57-year-old woman) with a previous psychiatric history and treatment with psychiatric drugs were admitted to the emergency department for coma. Both presented hypothermia; a hard, distended abdomen; and ischemia of the lower limbs. In both cases, the abdominal scan showed massive colonic dilatation without mechanical obstruction; there was even aortic compression and ischemia of the abdominal viscera. Emergency laparotomy with bowel decompression was performed in both cases, but multiple organ failure led to death in both patients. Psychiatric drugs may induce acute severe megacolon with life-threatening abdominal compartment syndrome.