abdominal compartmen

ABDOMINAL COMPARTMENT SYNDROMEABDOMINAL COMPARTMENT SYNDROME

Symptomatic organ dysfunction that results from increased intraabdominal Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP)pressure (IAP)

Increased IAP is an under-recognized source of morbidity and mortality.Increased IAP is an under-recognized source of morbidity and mortality.

1-day point-prevalence observational trial conducted in 13 medical ICUs of six 1-day point-prevalence observational trial conducted in 13 medical ICUs of six countries with 97 patients, 8% had IAP > 20mmHg. countries with 97 patients, 8% had IAP > 20mmHg. 11

The incidence of ACS in trauma patients is estimated to be between 2 and 9 The incidence of ACS in trauma patients is estimated to be between 2 and 9 percent.percent.22

11Crit Care Med 2005; 33:315.Crit Care Med 2005; 33:315.

22Am J Surg 2002; 184:538.Am J Surg 2002; 184:538.


Massive volume resuscitation in the leading cause of ACS. Massive volume resuscitation in the leading cause of ACS.

Inflammatory states with capillary leak, fluid sequestration, inadequate tissue Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS. perfusion, and lactic acidosis can develop ACS.

Gastric overdistention following endoscopy has resulted in ACS.Gastric overdistention following endoscopy has resulted in ACS.

ETIOLOGY


The IAP is usually 0 mmHg during spontaneous respiration, and is slightly positive in the patient on The IAP is usually 0 mmHg during spontaneous respiration, and is slightly positive in the patient on mechanical ventilation.mechanical ventilation.

IAP increases in direct relation to body mass index, and in one report, supine hospitalized patients had IAP increases in direct relation to body mass index, and in one report, supine hospitalized patients had a mean baseline value of 6.5 mmHg.a mean baseline value of 6.5 mmHg.

The compliance of the abdominal wall generally limits the rise in IAP but increases rapidly after a The compliance of the abdominal wall generally limits the rise in IAP but increases rapidly after a critical IAP.critical IAP.

Critical IAP varies from patient to patient, based on abdominal wall compliance on perfusion gradient. Critical IAP varies from patient to patient, based on abdominal wall compliance on perfusion gradient.

IAH often defined as IAP > 12mmHg. IAH often defined as IAP > 12mmHg.

Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be protective .protective .

PATHOPHYSIOLOGY

ABDOMINAL COMPARTMENT SYNDROMEABDOMINAL COMPARTMENT SYNDROMECLINICAL MANIFESTATIONS

CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM

Intracranial pressure

Cerebral perfusion pressure

CARDIACCARDIAC

Hypovolemia

Cardiac output

Venous return

PCWP and CVP

SVR

PULMONARYPULMONARY

Intrathoracic pressure

Airway pressures

Compliance

PaO2 PaCO2

Shunt fraction

Vd/Vt

GASTROINTESTINAL GASTROINTESTINAL

Celiac blood flow

SMA blood flow

Mucosal blood flow

pHi

RENAL RENAL

Urinary output

Renal blood flow

GFR

HEPATICHEPATIC

Portal blood flow

Mitochondrial function

Lactate clearance

ABDOMINALABDOMINAL WALLWALL

Compliance

Rectus sheath blood flow

Curr Opin Crit Care 2005; 11:333


50 mL of sterile saline is instilled into the bladder via the aspiration port of the 50 mL of sterile saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped. An 18-gauge needle attached to a Foley catheter with the drainage tube clamped. An 18-gauge needle attached to a pressure transducer is then inserted in the aspiration port, and the pressure is pressure transducer is then inserted in the aspiration port, and the pressure is measured. The transducer should be zeroed at the level of the pubic symphysis.measured. The transducer should be zeroed at the level of the pubic symphysis.

Curr Opin Crit Care 2005; 11:333


MANAGEMENT

PROPOSED GRADING OF ABDOMINAL COMPARTMENT SYNDROME

Grade Pressure (mmHg) Management

I 10-15 Maintenance of normovolemia

II 16-25 Volume administration

III 26-35 Decompression

IV >35 Re-exploration

Surg Clin North Am 1996; 76:833.

Abdominal perfusion pressure (APP):Abdominal perfusion pressure (APP):

APP = MAP - IAPAPP = MAP - IAPIn one retrospective study, the inability to maintain an APP above In one retrospective study, the inability to maintain an APP above 50 mmHg predicted mortality with greater sensitivity and 50 mmHg predicted mortality with greater sensitivity and specificity than either IAP or MAP alone .specificity than either IAP or MAP alone .


OPERATIVE DECOMPRESSION

Vacuum-assisted Vacuum-assisted temporary temporary abdominal closure abdominal closure device:device:

thin plastic sheet, a thin plastic sheet, a sterile towel, closed sterile towel, closed suction drains, and suction drains, and a large adherent a large adherent operative drape. operative drape. This dressing This dressing system permits system permits increases in intra-increases in intra-abdominal volume, abdominal volume, without a dramatic without a dramatic elevation in IAP. elevation in IAP.


ACS is a clinical entity caused by an acute, progressive increase in IAP. ACS is a clinical entity caused by an acute, progressive increase in IAP.

Multiple organ systems are affected, usually in a graded fashion.Multiple organ systems are affected, usually in a graded fashion.

The gut is the organ most sensitive to IAH.The gut is the organ most sensitive to IAH.

Treatment involves expedient decompression of the abdomen.Treatment involves expedient decompression of the abdomen.

Since this syndrome affects patients who are already physiologically Since this syndrome affects patients who are already physiologically compromised, a high degree of suspicion and a low threshold for checking compromised, a high degree of suspicion and a low threshold for checking bladder pressures are required to prevent the mortality associated with this bladder pressures are required to prevent the mortality associated with this complex problem. complex problem.

SUMMARY


Sugrue, M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333.

Bailey, J, Shapiro, MJ. Abdominal compartment syndrome. Crit Care 2000; 4:23.

Malbrain, ML, Chiumello, D, Pelosi, P, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005; 33:315.

Kron, IL, Harman, PK, Nolan, SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 1984; 199:28.

Hong, JJ, Cohn, SM, Perez, JM, et al. Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg 2002; 89:591.

Balogh, Z, McKinley, BA, Cocanour, CS, et al. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation. Am J Surg 2002; 184:538.

Cheatham, ML, White, MW, Sagraves, SG, Johnson, JL. Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. J Trauma 2000; 49:621.

REFERENCES AND READINGS

abdominal compartmen

Documents