2026 FSA Podium and Poster Abstracts

Introduction: Abdominal compartment syndrome (ACS) is a rare but life-threatening intraoperative emergency characterized by elevated intra-abdominal pressure leading to impaired ventilation, hemodynamic instability, and end-organ dysfunction. In anesthetized patients, early recognition relies heavily on vigilant monitoring, particularly abrupt increases in peak airway pressures and changes in respiratory mechanics. Patients with prior abdominal surgery, complex transplant anatomy, and bladder-drained pancreas grafts are at increased risk of atypical presentations and catastrophic complications, especially during urologic procedures. We report a case of acute intraoperative ACS during cystoscopy in a high-risk kidney-pancreas transplant (KP) recipient, in which anesthetic monitoring and physical exam played a critical role in early diagnosis of bladder perforation with massive intraperitoneal fluid extravasation.

Methods: A 65-year-old male with a history of type 1 diabetes mellitus, hypertension, coronary artery disease status post CABG, end-stage renal disease on hemodialysis, and a KP transplant in 2007 with bladder-drained pancreatic graft presented with severe hematuria, anemia, and clot retention. He was taken emergently to the operating room on for cystoscopy with clot evacuation under general endotracheal anesthesia (ASA IV-E). Invasive arterial monitoring was established, and the patient arrived on minor vasopressor support.

During cystoscopic irrigation, the anesthesia team noted a sudden and significant rise in peak airway pressures, reduced tidal volumes, and worsening hypotension on increasing vasopressor support. Rapidly progressive abdominal distension and rigidity were then noticed, raising immediate concern for ACS. The procedure was halted, and an emergent exploratory laparotomy was initiated by the transplant surgery team.

Results: Upon entering the peritoneal cavity, approximately 2 liters of clear fluid consistent with bladder irrigation fluid were evacuated under pressure, resulting in immediate decompression and normalization of ventilatory mechanics and hemodynamics. Surgical exploration revealed a bladder wall defect with mucosal hemorrhage and a perforation of the donor pancreatic duodenum at the duodenocystostomy site, approximately 2 cm from the ampulla of Vater. The injuries were repaired in a layered fashion with preservation of pancreatic ductal drainage. Estimated blood loss was 500 mL, and the patient received 2 units of packed red blood cells and 1 unit of fresh frozen plasma. Postoperatively, the patient required ICU admission with continued ventilatory and vasopressor support but demonstrated hemodynamic and respiratory stabilization following decompression.

Conclusion/Discussion: This case highlights the critical role of anesthesiologists in the early recognition of acute abdominal compartment syndrome during non-abdominal procedures. Sudden increases in peak airway pressures under general anesthesia may be the earliest and most reliable indicator of catastrophic intra-abdominal pathology. In patients with altered anatomy from bladder-drained pancreas transplants, cystoscopic irrigation carries unique risks, including unrecognized perforation and massive intraperitoneal fluid extravasation. Prompt communication, cessation of the procedure, and immediate surgical decompression were life-saving.