dig abdominal compartement syndrome
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1
INTRAABDOMINALHYPERTENTION &
ABDOMINALCOMPARTMENTSYNDROME Aditya Bhayusakti, M.
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important values
Normal intra-abdominal pressure is 0 - 5mmHg. Pressures > 13mmHg may be sufficient to restrict perfusion
to the organs of the gut. If the abdominal compartment pressures is beteen 1!-"5
mmHg# hyper$olemic $olume e%pansion therapy can be usedto maintain the perfusion pressure gradient for the abdominalorgans.
&hen compartment pressures e%ceed "5mmHg#decompression surgery should be considered to pre$ent
organ damage. Pressure may rise rapidly ith acti$ebleeding. 'dema (hich occurs ith any ischemic insult) illgenerally result in a later rise in the pressure ("* hours ormore post insult).
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Classiy IAH i!t" # $%"us'
Hyperacute(sec,min):laughing,strain,coug-
hing,sneez,physical activities)
Acute(couple H):trauma,hge
Subacute (couple days): most medicalcases.
Chronic: morbid obesity,intraabdominal
tumor,pregnancy.
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Pati(!ts at %isk "% ACSi!)lud(' trauma (blunt or open),as a result of the
accumulation of blood# fluid or edema.
gastrointestinal hemorrhage can also lead to
increased pressure in the abdominal compartment as
ischemic cells sell or fluids collect.
pancreatitis
pneumoperitoneum
neoplasm
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syndrome may ollo! a rupturedabdominal aortic aneurysm
intra-abdominal inection Coagulopathies !ith abdominal
bleeding
cirrhosis, or proound hypothermia
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massive intra-abdominalretroperitoneal hemorrhage,
severe gut edema
intestinal obstruction
ascites under pressure.
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"atients !ho have undergone long surgical
procedures !ith intraoperative hypotension andlarge luid re#uirements are at signiicant ris$,particularly i the abdomen has been closedunder pressure in the %&.
'ternal pressure rom circumerential burnsabout the abdomen, application o military anti-shoc$ trousers (AS*), or even tight abdominalrestraint devices can cause tension !ithin theabdomen due to eternal orces and result inACS.+
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&ecently, a!arenesso the ACS has increased or +
primary reasons.
irst, the increased use o laparoscopy among general
surgeons has brought !ith it an appreciation o A" as a
readily #uantiiable entity.
Second, the more re#uent use o planned repeat
laparotomy or trauma has allo!ed both surgeon andintensivist to appreciate the beneicial eects o
abdominal decompression upon removal o pac$ing or
evacuation o hematoma.
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Th( Path"hysi"l"$y " IAH
I+PASC/0A&
C%"&'SS%1
2&'C* %&3A1
C%"&'SS%1
2A"H&A3A*C
'0'A*%1
&" Clo!Cardiac
compression ntrathoracicpressure
Cardiac preloadCardiac contractility Systemic aterload
,+I+, /P&enal ascular
&esistanceSplanchnic
ascular &esistance
&'1A0 A0/&' A42%1A0 5A00SCHA'A6%'2'A &'S"&A*%&7A0/&'
C" S"0A1CH1CSCHA'A
" pressure
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Compartment syndrome occurs !hen
the pressure !ithin a closedanatomic spaceincreases to the
point !here vascular tissue is
compromised !ith subse#uent losso tissue viability and unction. *his
can occur !ithin any closedbody
cavity.
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ncreased A" leads to decreased
4 and to 4acterial translocation
(4*),!hich may contribute to laterseptic complications and organ
ailure.
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AH provo$es the release o pro-inlammatory cyto$ines !hich may
serve as a second insult or the
induction o %. production o interleu$in-8b (0-
8beta), interleu$in-9 (0-9), tumor
necrosis actor (*1-alpha)
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Anaesthetic Implications ofACS:
Renal implications
PulmonaryImplications
CardiovascularImplications
Porto-systemicvisceral
Implications
Centralnervoussystem
Implications
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E*()ts "! C+S
As intraabdominal pressure increases above 8mmHg, cardiac output declines, despite normalarterial pressures.
Additionally, !hole body oygen consumption, pH,and "%+ decrease.
ntraabdominal hypertension aects cardiac
unction by pushing the hemidiaphragms up!ard,thus transmitting the abdominal pressure to theheart and its vessels.
*his decreases preload and increases aterload onthe let ventricle and at the same time creates ahemodynamic picture o lo! cardiac output andhigh illing pressures.8,;
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O! th( ul"!a%y syst(
he most commonly noted effects of I+H on the
pulmonary system are ele$ated pea2 inspiratory
pressures# decreases in Pao" and increases in
Paco" reuiring the use of complete $entilatory
support to maintain adeuate o%ygenation and$entilation.
Hypercarbia# hypo%emia# and acidosis are e$ident
hen arterial blood gases are measured.!
Positi$e end-e%piratory pressure has been shonto e%acerbate the cardiac and respiratory
conseuences of I+H.
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Pul"!a%y (*()ts " i!)%(as(di!t%a-ad"i!al %(ssu%( /0 mechanical ventilation
oten necessary
high pea$ air!ay
pressures
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Pul"!a%y (*()ts " i!)%(as(di!t%a-ad"i!al %(ssu%( /2
"ressure on the C
predisposes to venous
stasis and increased
ris$ o
thromboembolism
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R(!al (*()ts
include decreased renal plasma flo# glomerular filtrationrate# and glucose reabsorption. /liguriaalso occurs# ithanuria noted in animal models hen I+P reaches 30mmHg.1 hese effects occur ithout significantdecreases in blood pressure(mechanical#4#compression of $ein6outflo obstuction64
intraparenchymal pressure6shunting of blood from corte%) . Impro$ement of cardiac output does not impro$e renal
function# nor do renal blood flo and glomerular filtrationrate impro$e.
the placement of ureteral stents failed to impro$e renal
function. Impro$ement in renal function occurred only after
abdominal decompression.*
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*hese indings suggest that the eects o AHon renal unction are related to compression o
the renal parenchyma itsel and tocompression o renal vasculature and are notrelated to decreased cardiac output. %thermechanisms proposed include shunting oblood a!ay rom the renal corte into the
medulla, decreased renal arterial lo! !ith aconcomitant increase in renal vascularresistance, and the presence o high levels orenin, aldosterone, and antidiuretic hormones.8
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=
8
8=
+
= 8 8= + += luids
A
ldosterone
level
(ng6dl)
A" (mmHg above baseline)
'perimental
Control
'ect o increased intra-abdominal pressure on plasma
aldosterone. *he increased levels are reduced by volume
epansion (J Trauma8>>?@;+:>>?-8)
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=
8
8=
+
+=
= 8 8= + += luids
"las
mareninac
tivity
(ng6ml6hr)
A" (mmHg above baseline)
'perimental
Control
'ect o increased intra-abdominal pressure on plasma
renin activity. *he increased levels are reduced by volume
epansion (J Trauma8>>?@;+:>>?-8)
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ncreases in A" have adverse
eect on splanchnic lo!
B8=mmHgSA blood lo!
mar$ed reduction in hepaticartery and portal venous blood
lo!
leads to mucosal acidosis and
oedema
IAH a!d Sla!)h!i) 3l"4
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Cy)l( " (5(!ts )%(at(d yIAH "! sla!)h!i) )i%)ulati"!
AH
Unrelieved
ACS
Splanchnic
hypoperusion
3ut mucosal acidosis
4o!el oedema
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hey measured mucosal and intestinal blood flo
and intramucosal pH (pHi) and found that
mesenteric and mucosal blood flo decreased henI+P reached "0mmHg# ith intestinal mucosal flo
declining to !17of baseline.
+t an I+P of 80mmHg# intestinal flo decreased to
"97of baseline. he intestinal mucosa shoed signs of a se$ere
degree of acidosis# measured by tonometer. hese
changes in splanchnic blood flo occurred despite
maintenance of baseline cardiac output ith $olumeloading.
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pp
+ ; 9 8
8
=4o!el*"%+
Aillary
*"%+
A" +=mmHg or
9 min
A" 8=mmHg or
9 min
4aseline
'ects o increasing A" on bo!el mucosal oygen (tissue
partial pressure, *"%+) compared !ith systemic tissue
oygenation in the ailla (J Trauma 8>>=@>:=8>-=++)
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blood lo! to virtually every abdominal organ
decreased signiicantly. *he only eception
!as the adrenal gland@ the reason this
organ is not aected is un$no!n >>@;? :=>-=88
Current opinion does
not support liberal use
of an open abdomen
technique to preventACS
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An alternative techni#ue is the vacuum-pac$techni#ue. Here the litre bag is opened and placed
into the abdomen to protect the gut contents, underthe sheath. *his has been reerred to as the 4ogotabag, ater the city in Colombia, South America, o itsinception.>
*!o large calibre suction drains are placed overthis, and a large adherent steridrape placed over the!hole abdomen. *he suction catheters areconnected to high-displacement suction to providecontrol o luid losses and create the vacuum-pac$
eect
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*he easiest method to control the open abdomen is
to use a silo-bag closure. A litre plastic irrigationbag is emptied and cut open so it lies lat. *he
edges are trimmed and sutured to the s$in, a!ay
rom the s$in edges, using a continuous 8 sil$
suture. t is useul to place a sterile absorbent drapeinside the abdomen to soa$ up some o the luid and
ease control o the laparostomy.
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Adverse Efects o Surgical
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Adverse Efects o Surgical
Decompression Sudden release o the abdominal compartment
syndrome may lead to an ischaemia-reperusion inEury
*he mechanism !as postulated to be related to !ashout
o anaerobic metabolic products by reperusion o the
previously underperused splanchnic bed causing
acidosis, vasodilatation, cardiac dysunction and arrest.
"rior to release the patient should be pre-loaded !ith
crystalloid solution. annitol and vasodilators such as
dobutamine or the phosphodiesterase inhibitors may
have a place here.
MEDICAL
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MEDICALDECOMPRESSION
*he adverse cardiovascular and
pulmonary eects o intra-
abdominal hypertension IAHJ!ere reversed !ith
pharmacological neuromuscular
bloc$ade (14(
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Management
Prevention
Identicationof patients at ris!
Monitoring
Ade"uate resuscitationAde"uate ventilation
#on-surgicalinterventions
Paracentesis#euromuscular $loc!adeC#AP
%ut emptying
&ctreotide
Prognosis
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Prognosis
he death rate in patients ith +,? is e%tremely high.
?e$eral small series ha$e reported death rates ranging from
8"7 to *17.hese high rates must be considered in the
conte%t of the patientsA underlying disease.
he maority of these patients are critically ill and are
admitted to the intensi$e care unit ith se$ere intra-abdominal sepsis# intra-abdominal inuries or after repair of
a ruptured abdominal aortic aneurysm.
'$en ith prompt recognition and abdominal
decompression# the freuency of multiple organ dysfunction
and death is high because of the se$erity of the initial
physiologic insult.
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Ho!ever, in the ace o elevated A"
and a clinical picture consistent !ith
ACS, the chance o survival isetremely lo! !ithout urgent
abdominal decompression.8
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THAN9 YO: