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Abdominal compartment syndrome

March 13, 2019 by Josh Farkas

CONTENTS

Epidemiology (#epidemiology_&_risk_factors)

Manifestations (#manifestations)

Diagnosis (#diagnosis)

Treatment (#treatment)

Checklist (#checklist)

Podcast (#podcast)

Questions & discussion (#questions_&_discussion)

Pitfalls (#pitfalls)

epidemiology & risk factors(back to contents) (#top)

at-risk patients & types of abdominal compartment syndrome

Primary abdominal compartment syndrome:  Intra-abdominal processSevere pancreatitisTrauma, abdominal surgeryAscitesRetroperitoneal or intraperitoneal hemorrhageSevere ileus, colonic pseudo-obstruction, or obstruction

Secondary abdominal compartment syndrome:  Any critically ill patient who receives large-volume resuscitation:Major burn injuriesSeptic shockHemorrhagic shock (especially with excess crystalloid resuscitation)

Elevated intra-thoracic pressure (e.g. high plateau pressure on ventilator)

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abdominal compartment syndrome is common

Medical ICUSeries vary, reporting frequencies varying between ~2-8%.Likely represents a complication from over-resuscitation of septic shock or pancreatitis.

Surgical ICU:  higher rates than medical ICU.

manifestations(back to contents) (#top)

The initial manifestation may vary depending on the patient's underlying physiology.  For example, a patient with tenuous renal function couldmanifest with renal failure.  Alternatively, a patient with pulmonary comorbidities might present with respiratory distress.

cardiovascular 

Shock and hypotension, due to reduced preload.

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Mesenteric ischemia causes bacterial translocation into the bloodstream, which may cause systemic vasodilation and hypotension.

respiratory

Pressure on the diaphragm reduces thoracic complianceA non-intubated patient may experience increased work of breathing.For an intubated patient, this may manifest as increased peak pressure on the ventilator.

Atelectasis and hypoxemia may occur, due to compression of the lung bases.

renal

Renal failure with reduced urine output is often the �rst sign of abdominal compartment syndrome.Increased pressure may compress the kidney directly and also cause renal congestion (due to impaired drainage of blood out of the kidney).

elevated intracranial pressure

Increased abdominal pressures will translate into increased intrathoracic pressures and increased central venous pressures.   This canactually cause elevated intracranial pressure.

diagnosis(back to contents) (#top)

abdominal compartment pressure 

Estimation by physical examination is insensitive.Abdominal pressures can be elevated despite �nding a soft abdomen.Examination demonstrating tense abdomen is ~80% speci�c.

Measurement using a Foley catheter:Patient must be fully supine and passive (e.g. not coughing or bucking ventilator).Measured at end-expiration.May be inaccurate in the context of pelvic pathology (e.g. hematoma directly compressing the bladder).

interpreting the abdominal pressure

General concepts:2-7 mm:  normal for a non-obese person.>12 cm:  de�ned as intra-abdominal hypertension.> 15-20 mm:  can cause organ failure.> 25-30 mm:  usually causes organ failure, may require emergent decompression.

Technical grading scale is shown here:

diagnostic criteria for abdominal compartment syndrome

Diagnosis requires two components:(1) Sustained intra-abdominal pressure > 20 mm.(2) Organ failure attributable to elevated intra-abdominal pressure.

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Note:  The kidneys are one of the most sensitive organs to increased abdominal pressure.  If the urine output is adequate, it'sconsiderably less likely that the patient has abdominal compartment syndrome.

This diagnosis requires clinical judgement, since critically ill patients invariably have other causes of organ failure.Sorting out whether organ failure is caused by abdominal compartment syndrome versus other causes can be murky and subjective.

treatment(back to contents) (#top)

#1.  defend the abdominal perfusion pressure

Abdominal Perfusion Pressure = MAP – (Abdominal Compartment Pressure)

Abdominal perfusion pressure is the pressure gradient between the MAP and the abdominal compartment.   This is the pressure that drivesperfusion of all intra-abdominal organs (e.g. the kidney).It is probably best to maintain an abdominal perfusion pressure >60mm.  However, there is no strong evidence to support this.

The ideal target MAP could be 60 mm plus the abdominal compartment syndrome.Hemodynamic interventions may be tailored to the particular patient.  This will generally require vasopressors, because additional crystalloidmay merely aggravate matters.

#2.  volume removal if possible

Theoretically, volume removal is bene�cial:In many patients, compartment syndrome may be caused by volume overload.Efforts to remove volume (e.g. diuresis or dialysis) may be helpful.

Unfortunately, in established abdominal compartment syndrome, the patient is often intravascularly volume depleted (despite tissueedema).  This may make it di�cult or impossible to remove �uid without worsening hemodynamics.

A more realistic �uid target might be to achieve a net even �uid balance.Cautions:

(1) Abdominal compartment syndrome may compress the inferior vena cava (IVC), making it look empty!(2) Avoid �uid administration.  This may help temporarily, but �uid will often rapidly transudate into the tissues – which worsensswelling and increases intra-abdominal pressure (futile cycle shown below).

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Shock

Crystalloid

3rd spacing of fluidinto abdominal

soft tissue

Increasingly severecompartment syndrome

The Internet Book of Critical Care, by @PulmCrit

Futile Crystalloid Cycle in abdominal compartment syndrome

Transient benefit,reinforcing ongoing

fluid loading

#3.  decompress the abdominal compartment as able

Ascites may be drained.   An indwelling percutaneous drainage catheter may remove this more completely than intermittent therapeuticparacentesis.Nasogastric or orogastric tube suction may be used to manage gastric distention.Colonic distention may be managed with stimulant laxatives, suppositories, neostigmine, colonoscopy with decompression, and/or rectaltube drainage.

#4.  decompress the thorax

Reduction of PEEP and plateau pressure on the ventilator may decrease intra-abdominal pressure.Permissive hypercapnia may allow for liberalization of ventilator settings.

If a large pleural effusion is present, drainage could be bene�cial.Beware of intubation!

Intubation converts the thorax from a negative-pressure system to a positive-pressure system.  This may acutely increase abdominalpressures and lead to a poly-compartment syndrome, with hemodynamic collapse.

#5.  sedation & paralysis

Agitation (e.g. bucking the ventilator) will increase intra-abdominal pressures.  Adequate analgesia and sedation may be helpful, perhaps to aslightly deeper level than the average ICU patient.Short-term paralysis may be considered, but this doesn't appear to cause persistent improvement.  Paralysis may be used temporarily as abridge to another intervention (e.g. laparotomy).

#6.  surgical decompression

Release of the abdominal fascia is de�nitive treatment, albeit invasive.

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Postoperatively, patients will be left with an open abdomen.  Ideally this may be closed after 1-2 weeks following resolution of primaryprocess.

checklist(back to contents) (#top)

Treatment for abdominal compartment syndrome

HemodynamicsTarget MAP > (60 mm + abdominal compartment pressure)Don’t give additional fluidConsider diuresis/dialysis, if possible

Decompress the abdomenAscites: Drain (indwelling catheter might be ideal approach)NPO, Gastric tube to suctionDecompress the colon (e.g. stimulant laxatives, suppositories, neostigmine for megacolon)

Decompress the thorax (especially if intubated)Large pleural effusion: consider drainageReduce airway pressures as able (e.g. target low PEEP & plateau pressures)Avoid intubation if able

Sedation & paralysis (if intubated)Start with analgesia/sedation to target a passive state on ventilatorParalysis may be used as a short-term therapy

Surgical decompressionFascial release is definitive treatment, but most invasive. Reserve for failure of abovemeasures. The Internet Book of Critical Care, by @PulmCrit

 

podcast(back to contents) (#top)

(https://i1.wp.com/emcrit.org/wp-content/uploads/2016/11/apps.40518.14127333176902609.7be7b901-15fe-4c27-863c-7c0dbfc26c5c.5c278f58-912b-4af9-

88f8-a65fff2da477.jpg)

Follow us on iTunes (https://itunes.apple.com/ca/podcast/the-internet-book-of-critical-care-podcast/id1435679111)

The Podcast Episode

Want to Download the Episode?Right Click Here and Choose Save-As (http://tra�c.libsyn.com/ibccpodcast/IBCC_EP_28_-_Abdominal_Compartment_Syndrome_Final.mp3)

questions & discussion(back to contents) (#top)

To keep this page small and fast, questions & discussion about this post can be found on another page here (https://emcrit.org/pulmcrit/abdominal-

compartment/) .

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Adopting the mindset that the only treatment for abdominal compartment syndrome is laparotomy.  This leads practitioners to ignore thediagnosis (“well, surgery isn't going to operate on them anyway…”).  However, there are numerous non-operative therapies which may be quiteeffective.Failure to consider abdominal compartment syndrome (this is a common phenomenon in all types of critically ill patients, not just surgicalpatients).Over-interpretation of bladder pressure obtained in patients who aren't supine and breathing passively.Abdominal compartment syndrome compresses the inferior vena cava (IVC), making it look empty.  This may lead to erroneous decisionsregarding �uid administration.Avoid intubation of patients with borderline abdominal compartment syndrome if possible (pressurization of the thorax may increase intra-abdominal pressure).

Going further: 

IBCC chapter on pancreatitis (https://emcrit.org/ibcc/pancreatitis/) .Killer resuscitation:  Abdominal hypertension as an occult driver of multiorgan failure (https://emcrit.org/pulmcrit/abdominal-hypertension/)

(PulmCrit)Abdominal Compartment Syndrome (https://lifeinthefastlane.com/ccc/abdominal-compartment-syndrome/) (Chris Nickson, LITFL)Abdominal Compartment Syndrome (http://www.tamingthesru.com/blog/annals-of-b-pod/june-2017/abdominal-compartment-syndrome) (Shaun HartyandJessica Baez, Taming the SRU)Abdominal Compartment Syndrome (https://wikem.org/wiki/Abdominal_compartment_syndrome) (WikiEM)Abdominal Compartment Syndrome: When should it be on your differential? (http://www.emdocs.net/abdominal-compartment-syndrome-when-should-it-

be-on-your-differential/)   (Erica Simon, emDocs)Epic lecture by Thomas Scalea on poly-compartment syndrome:

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References

1. Daugherty E, Hongyan L, Taichman D, Hansen-Flaschen J, Fuchs B. Abdominal compartment syndrome is common in medical intensivecare unit patients receiving large-volume resuscitation. J Intensive Care Med. 2007;22(5):294-299. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/17895487) ]

2. Anvari E, Nantsupawat N, Gard R, Raj R, Nugent K. Bladder Pressure Measurements in Patients Admitted to a Medical Intensive Care Unit.Am J Med Sci. 2015;350(3):181-185. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/26309180) ]

3. Ortiz-Diaz E, Lan C. Intra-abdominal hypertension in medical critically ill patients: a narrative review. Shock. 2014;41(3):175-180. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/24280691) ]

4. Sugrue M, Bauman A, Jones F, et al. Clinical examination is an inaccurate predictor of intraabdominal pressure. World J Surg.2002;26(12):1428-1431. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/12297912) ]

5. Cheatham M, White M, Sagraves S, Johnson J, Block E. Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. J Trauma. 2000;49(4):621-626; discussion 626-7. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/11038078) ]

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( )6. Balogh Z, McKinley B, Cocanour C, et al. Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch

Surg. 2003;138(6):637-642; discussion 642-3. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/12799335) ]

7. Regli A, De K, De L, Roberts D, Dabrowski W, Malbrain M. Fluid therapy and perfusional considerations during resuscitation in critically illpatients with intra-abdominal hypertension. Anaesthesiol Intensive Ther. 2015;47(1):45-53. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/25421925) ]

8. Cheatham M, Safcsak K. Percutaneous catheter decompression in the treatment of elevated intraabdominal pressure. Chest.2011;140(6):1428-1435. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/21903735) ]

9. Maluso P, Olson J, Sarani B. Abdominal Compartment Hypertension and Abdominal Compartment Syndrome. Crit Care Clin. 2016;32(2):213-222. [PubMed (https://www.ncbi.nlm.nih.gov/pubmed/27016163) ]

The Internet Book of Critical Care is an online textbook written by Josh Farkas (@PulmCrit), an associate professor ofPulmonary and Critical Care Medicine at the University of Vermont.

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