1 abdominal compartment syndrome cvicu rounds dr. alan sobey
Post on 17-Dec-2015
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ABDOMINAL COMPARTMENT SYNDROME• GI complications affect up to 3% of cardiac
surgery cases.• Depending on the complication rate the
mortality rates can be as high as 64%• Known to occur with massive resuscitation,
liver transplantation, elective surgical procedures, “septic abdomens” and with severe burns
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Abdominal Compartment Syndrome
• OUTLINE– Definition– History– Measurements– Significance– Summary
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Abdominal Compartment Syndrome
• Definition: Elevated intra-abdominal pressure (IAP)– Sustained increase in the intra-abdominal
pressure over normal: > 12mmHg– Multiple etiologies– NB: not the same as ACS– ACS is a late consequence of increased IAP
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Abdominal Compartment Syndrome
• Definition: Compartment Syndrome– Compartment Syndrome:
• An increase in pressure within an enclosed space or cavity that causes physiologic dysfunction of its contents.
• Ex: extremities following fracture or revascularization of a limb
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Abdominal Compartment Syndrome
• Definition: ACS– The adverse physiologic effects due to
increased intra-abdominal pressure.– Prolonged and unrelieved pressure may lead to
respiratory compromise, renal impairment, cardiac failure, shock and death.
– Generally it is measured from the intracystic pressure (bladder pressure).
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Abdominal Compartment Syndrome
• HISTORY:– Fietsam et al (1989) first presented the notion
of the abdominal compartment syndrome (ACS) to describe the collective effects of increased intra-abdominal pressure (IAP) on the body.
– Their description was in the setting of ruptured abdominal aortic aneurysms.
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Abdominal Compartment Syndrome
• HISTORY:– Trauma literature now a major source of
information.– In general, the trauma literature has recognized
that end organ dysfunction occurs in the presence of a grossly distended and tense abdomen.
– Open abdomen concept
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Abdominal Compartment Syndrome
• PATHOPHYSIOLOGY:– Usual intra-abdominal pressure is assumed to
be near atmospheric– Sugerman et al: increased with increasing
abdominal girth– Kron et al: 3 – 15 mmHg (5-7)
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Abdominal Compartment Syndrome
• PATHOPHYSIOLOGY:– As the volume in the abdomen rises so does the
pressure:• the increase in pressure is in proportion to the
abdominal wall compliance
• Increase in pressure is in proportion to the increase in the intra-abdominal pressure.
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Abdominal Compartment Syndrome
• PATHOPHYSIOLOGY:– Corresponding decrease in hepatic /
splanchnic / renal perfusion – presumably due to compression of these vascular beds.
– 20% of the rise in the IAP is transmitted to the thoracic cavity:
• Increase in juxtacardiac pressure.
• Impaired ventricular filling.
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Abdominal Compartment Syndrome
• PATHOPHYSIOLOGY:• Increased left ventricular afterload (with decreased
CO and increased PCWP)
• Increased work of breathing due to decreased diaphragmatic excursion and impairment of chest wall movement.
• Increased intracranial pressure (significant in the head injured trauma patient)
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Abdominal Compartment Syndrome
• CONSEQUENCES: SUMMARY
• Decreased cardiac output• Elevated RAP and PCWP• Reduced hepatic perfusion• Lactic acidosis• Splanchnic hypoperfusion• Raised ICP • Peripheral edema with
tendency to thrombosis
• Increased work of breathing
• Elevated airway pressures during mechanical ventilation
• Abnormal V/Q matching with hypoxemia
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Abdominal Compartment Syndrome
• ETIOLOGY
• Intra-peritoneal or retroperitoneal hemorrhage
• Ascites• Bowel obstruction• Post-op edema
• Pneumoperitoneum
• Laparoscopy
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Acidosis Hyperthermia transfusion
Coagulopathy Sepsis: intra or extra abd
Bacteremia
pancreatitis Liver dysfunction
Mechanical ventilation
Pneumonia Abdominal surgery (DCL)
Massive resuscitation
Gastric or colon dist’n
Hemo-peritoneum
Burns and trauma
BMI Abdominal tumors
Prone ventilation
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Abdominal Compartment Syndrome
• INDEX OF SUSPICION: Setting– Ascites
– Bowel distention: mech obstruction/ileus
– Bowel edema: resuscitation or ischaemia
– Retroperitoneal hematoma
– Hemoperitoneum
– Coagulopathy
– Trauma
– Abdominal packing after damage control surgery
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Abdominal Compartment Syndrome
• DIAGNOSIS: Index of suspicion– When any signs of intra-abdominal
hypertension are present:• Abdominal distention• Refractory oliguria• Hypercarbia• Refractory hypoxemia• Increasing PIPs• Refractory hypotension
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Abdominal Compartment Syndrome
• DIAGNOSIS: Measuring the pressure– Insert a Foley catheter and clamp the tube distal to the
sample port
– Instill 5-1000mL of saline into the bladder so as to leave a continuous column of fluid from the bladder to the sample port on the Foley
– Insert a 18g catheter into the sample port and connect to a CVP transducer
– Level the transducer at the symphysis pubis Fusco et al J
Trauma 2001
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Abdominal Compartment Syndrome
• Measurement: WSACS– Cmpletely supine– Relaxed abdominal wall– mid-axillary line– 25 mL saline into the bladder
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Abdominal Compartment Syndrome
• DIAGNOSIS;– Most papers suggest several measurements
during a 24 hr period: every 4 hrs– Repeat measurements are indicated by the
clinical appearance of the abdomen and on the clinical situation (index of suspicion)
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Abdominal Compartment Syndrome
• INTERPRETATION: NORMAL IAP– 3-15 mmHg– Obesity: higher (8 vs. 5 mmHg)– Age: no definite trend– Surgery: no definite trend– Comorbidities: trend to higher IAP with more
concurrent illnessesSanchez et al Am
Surg Mar 2001
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Abdominal Compartment Syndrome
• INTERPRETATION:– As the pressure rises over 20cm water there will be
some evidence of hypoperfusion– Most will accept surgical decompression if the intra-
abdominal pressure is over 35 cm.– More recent authors are advocating surgical
decompression for IAP of 20-25 mmHg (Cheatham et al)
– WSACS: 20mmHg for treatment
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Abdominal Compartment Syndrome
• INTERPRETATION: evidence– Decreased ACS with earlier decompression– Decreased mortality with earlier
decompression: ?– More pronounced benefit with increasing age
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Abdominal Compartment Syndrome
• Management:– Medical:
• Maintain APP (>60mmHg)• Sedation / Analgesia• NMB• Supine positioning• NG / Colonic decompression• Fluid resuscitation• diuretics
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Abdominal Compartment Syndrome
• Surgical:– Percutaneous tube drainage– Abdominal decompression (DCL)
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Abdominal Compartment Syndrome
• TREATMENT: SURGICAL DECOMPRESSION / DAMAGE CONTROL LAPAROTOMY
– Surgical decompression involves opening the abdominal wound and packing the wound open or closing it with a plastic dressing (Bogata Bag)
– Delayed closure can be done once the edema / bleeding has resolved
– Ascites can be drained percutaneously
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Abdominal Compartment Syndrome
• DAMAGE CONTOL LAPAROTOMY:– Stone et al (1982)– Penetrating injuries to the abdomen– Avoid hypothermia / acidosis / coagulopathy– Involves:
• Rapid control of bleeding and contamination• Abdominal packing instead of involved procedures• Skin closure only or plastic tent closure (3 L
peritoneal / CVVHDF bag)
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Abdominal Compartment Syndrome
• DAMAGE CONTROL LAPAROTOMY– Offner et al (Arch Surg)
• Denver Colo
• Penetrating and blunt traumas
• ACS:– Long hospital stay
– Increased multisystem organ failure
– Increased ARDS
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Abdominal Compartment Syndrome
• Offner et al
– Technique of closure and ARDS/MSOF and ACS
ACS MSOF/ARDS
Primary closure
80% 90%
Skin 24% 36%
Bogota bag 18% 47%
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Abdominal Compartment Syndrome
• SUMMARY:– IAP – measureable / preventable / treatable– ACS – end organ dysfunction from untreated or
undertreated elevated IAP– Measurement: simple technique with an 18 g
needle through the Foley port and a CVP transducer
– Damage control – the standard for avoiding or treating elevated IAP or ACS
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Abdominal Compartment Syndrome
• Deompressive laparotomy: Effects• Most studies show a significant decrease in the
IAP• IAH persists in the majority of patients (De Waele
et al)• MR remained high at 35%• Overall benefit for oxygenation (PaO2/FiO2) and
increased urine output
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Abdominal Compartment Syndrome
• Decompressive Laparotomy: Effects
• The wound:– Messy– Open - risks for colonization or secondary
infection– Delayed closure: how?
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Abdominal Compartment Syndrome
• Decreased renal output:– Harman et al– Dogs– Increased the intra-abdominal pressure to
40mmHg leading to decreased urine output and cardiac output
– Resuscitated the dogs to normal CO yet the renal function remained impaired until the abdomen was decompressed
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Abdominal Compartment Syndrome
• INTRACRANIAL PRESSURE:– Increased
1. Due to increased intrathoracic pressure from the elevated diaphragms
2. Due to decreased cardiac output– Thus, increases cerebral hypoperfusion and
worsens brain injuryCitero
et al CCM
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Abdominal Compartment Syndrome
• Definitions:– IAH: intra-abdominal hypertension
• Sustained increase in IAP of 12 mmHg or more over 3 recordings separated by 4hrs each
– ACS: abdominal compartment syndrome• Sustained increase in IAP of 20mmHg or more
• Single or multiple organ system failure that was not previously present
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Abdominal Compartment Syndrome
• Classification:– Primary:
• Due to injury or disease in the abdomen or pelvis
• Frequently requires surgery or radiological treatment
• Ex: trauma or the septic abdomen
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Abdominal Compartment Syndrome
– Secondary:• ACS due to conditions arising outside of the
abdomen
• Associated with severe capillary leak requiring resuscitation
• Ex: sepsis, burns, retroperitoneal hematoma
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Abdominal Compartment Syndrome
• Recurrent ACS: – Occurs following either prophylactic
decompression or therapeutic surgical decompression of either primary or secondary ACS
– Ex: temporary closure device is too tight, inadequate fascial opening, recurrs after the fascia was closed.
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Abdominal Compartment Syndrome
• APP: abdominal perfusion pressure
• APP = MAP - IAP
• “magic number”: 50-60
• Corresponds to the perfusion gradient across the intra-abdominal visera
• Evidence????
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