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.