614: Uncommon Utility of Paracentesis: Emergent Decompression of Pneumoperitoneum

Introduction: Pneumoperitoneum is typically associated with gastrointestinal perforation or barotrauma but may rarely result from upper airway instrumentation. In mechanically ventilated patients, air tracking through fascial planes can lead to abdominal compartment syndrome (ACS). We present a case in which a malpositioned tracheostomy led to a false lumen and massive pneumoperitoneum, treated with bedside air evacuation using a Safe-T-Centesis catheter. Description: 63-year-old female, with stage 4 breast cancer with pleural metastases was admitted to the ICU for progressive hypoxemic respiratory failure. Due to ventilator dependence, she underwent percutaneous tracheostomy. 2 days post procedure, the tracheostomy created a false lumen by being malpositioned into the soft tissues of the neck. The patient became acutely unstable with severe ventilatory failure and peak inspiratory pressure >50 cm H2O. Examination revealed a distended, tympanic abdomen, mottled lower extremities with poor capillary refill, and hypotension. Bedside POCUS showed intraperitoneal air without clear anatomy. Intraabdominal pressure (IAP) measured using the intravesicular method was >30 mmHg consistent with ACS. In the setting of rapidly worsening physiology and no immediate surgical availability, emergent bedside decompression was performed using a drainage system. Upon entry into the peritoneal cavity, a large volume of pressurized air was released. Tidal volumes immediately improved, peak inspiratory pressures normalized to the patient’s baseline, and follow-up IAP decreased to < 8 mmHg. Abdominal imaging confirmed extensive pneumoperitoneum. The patient stabilized with conservative management. Discussion: This case illustrates a complication of percutaneous tracheostomy: false lumen creation resulting in tension pneumoperitoneum and ACS. In mechanically ventilated patients, undetected extratracheal placement may lead to insufflation of soft tissue planes. When this air tracks into the peritoneum, it can impair diaphragmatic excursion and venous return, culminating in hemodynamic collapse. The diagnosis was aided by a combination of clinical signs, IAP monitoring, and POCUS. In the absence of immediate surgical access, bedside paracentesis can be a rapid and effective method of decompression of tension pneumoperitoneum.