A 27-year-old woman who is a recent immigrant of East Indian descent was admitted to our burn center with a 35% total body surface area deep-partial and full-thickness flame burn to her torso, buttocks, and circumferential bilateral upper and lower extremities. The patient underwent staged excisions, integra placement, autografting, and VAC (vacuum-assisted wound closure device) therapy. The patient began experiencing abdominal discomfort and distension on hospital day 17. She failed conservative therapy which included nil per os, intravenous (IV) fluid administration, nasogastric decompression, laxatives, promotility agents, stool softeners, and correction of electrolytes. On hospital day 21, despite having regular bowel movement and flatus, we noted a drastic increase in abdominal girth with associated discomfort and nausea. A plain abdominal radiograph indicated significant colonic distension, with a cecal diameter of 12 cm with associated air extending to the rectosigmoid junction ().
Figure 1 Note the marked dilatation of both the cecum and the transverse colon. Also note the presence of air down to the rectosigmoid junction, with no evidence of obstruction. Also visible in this image are the staples from the multiple skin grafts and the Dobbhoff (more ...)
After consultation with colleagues in trauma surgery and a review of the literature (MeSH/PubMed/NLM), the decision was made to try neostigmine therapy rather than a surgical/procedural option such as colonoscopy.
She was moved to the intensive care unit to monitor potential untoward bradycardia and 2 mg of neostigmine was administered intravenously over 4 minutes. The patient experienced immediate symptomatic relief. Approximately 30 minutes after the IV dose, all abdominal examination findings had returned to baseline. A follow-up abdominal x-ray ordered 3 hours later showed near-normal colonic profile, with a cecal diameter of 5 cm (). No significant adverse effects were noted and she did not redevelop abdominal distension afterward.
Taken a few hours after neostigmine administration. The reduction in colonic dilatation is clearly visible.
Thankfully, over the past 2 years, we have not encountered a second case of ACPO in one of our burn patients. With an N of 1, however, it is difficult to draw any real conclusions about the precise cause of ACPO in this patient but we have identified numerous risk factors. As is common with large surface area burn patients, this patient was in the operating room for debridement and wound VAC changes every 3 days from admission until the time of this event for a total of 7 operations in that time span. All of her major electrolytes (calcium, magnesium, and phosphate) were low and required nearly daily repletion during the month leading up to her ACPO episode (). In addition, she had an extremely low pain tolerance (something we commonly see in our younger patient population) and required multiple pain medications. She also had significant anemia that lasted for most of her stay and required a transfusion of 1 unit of packed red blood cells on hospital day 10, roughly 7 days prior to the onset of her abdominal symptoms. Her Dobhoff feeding tube was suboptimally placed and noted to be curled up into the fundus of the stomach which may have contributed to her abdominal discomfort. Other factors included frequent and sustained tachycardia, indwelling Foley catheter, Escherichia coli urinary tract infection, Pseudomonas aeruginosa wound infection (diagnosed the day following her neostigmine dose), waxing/waning fever over the course of her stay, and the presence of a triple lumen central line.
Figure 3 The red lines in these images represent the generalized normal high and low reference values for our laboratory. Serum albumin levels are not available for this patient. The slight bump in hematocrit, in the middle of the graph, on this patient represents (more ...)
Her initial pain regimen consisted of the following: acetaminophen 650 mg tab by mouth every 4 hours, fentanyl 50-200 mcg IV per in-house pain-scale guidelines every 12 hours, hydromorphone 4 mg by mouth every 4 hours, oxycodone 30 mg sustained-release tab by mouth every 12 hours, morphine 2 mg IV every 4 hours, midazolam 1 mg IV every 4 hours, lorazepam 1 mg IV every 12 hours. Other medications included maintenance IV fluids dextrose 5% in 0.45% NaCl at 30 mL/h, and several nausea medications: prochlorperazine 5 mg IV every 6 hours, and scopolamine 1.5 mg transdermal. For her tachycardia, she was on metoprolol 12.5 mg by mouth every 12 hours.
Because gastrointestinal motility issues are common in our patient population, we start all patients on a standard bowel regimen. This initial conservative therapy consists of metoclopramide 10 mg IV every 8 hours, polyethylene glycol 3350 17 g by mouth every 12 hours, senna 1 tab by mouth daily, simethicone 1.2 mL by mouth daily, docusate 100 mg by mouth daily, esomeprazole 20 mg IV daily. In this patient's case, following the initial complaints of gastrointestinal discomfort and chest pain, a daily Fleets enema was added to her regimen.
The most striking lab abnormalities are presented here, with additional graphs provided in an addendum.