sindrome compartimental abdominal
DESCRIPTION
pediatrics intensive care units entityTRANSCRIPT
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Sindrome compartimental Abdominal
Daniel Ulises Torres AriasResidente de tercer añoMedicina pediatrica
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introduccion
Siglo 19 Adultos 1980 Cirujanos pediatras 1940 1989 Fietsam et al
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definiciones
PRESION INTRA ABDOMINAL: Presion que existe en condiciones de
reporso dentro de la cavidad abdominal y que esta determinada por varios factores
Niños sanos cercana a 0 mmHG. Diafragma Posicion del cuerpo y musculatura
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definiciones
Presion arterial que permite perfundir las visceras abdominales
TAM - IAP Indice de perfusion visceral Potencialmente un punto final de
resucitacion con fluidos.
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definiciones
HIPERTENSION INTRABDOMINAL: Aumento sostenido de PIA igual o
superior a 12 mmHg. De acuerdo a duracion: Hiperaguda Aguda (hrs, trauma hemorragia) Subaguda (dias) Cronica (meses a años, embarazo,
obesidad, ascitis cronica o cirrosis)
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Modified Burch et al grading system
Grado I: IAP 12-15 mm Hg. Grado II: IAP 16 – 20 mm Hg. Grado III: IAP 21-25 mm Hg. Grado IV: IAP mayor 25 mm HG.
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Sindrome compartimental abdominal
Progresion natural de la disfuncion de organos diana.
Cuando la PIA supera la TAM las visceras no reciben flujo sanguineo.
Triada clasica: Estado patologico que causa HIA mayor
20 -25 mmHg. Disfuncion organica abdominal
relacionada Mejoria tras la descompresion abdominal
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Sindrome compartimental abdominal
El desarrollo de disfuncion y fallo organico es mas importante para su definicion que el valor de IAP.
Puede ser clasificado como Primario Secundario recurrente
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tac
Estrechez de vena cava inferior Compresion renal directa Engrosamiento transmural Disminucion del calibre de la aorta Aumento relativo del diametro
anteroposterior comparado al diametro transverso
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Factores predisponentes
Resucitacion masiva con fluidos Sindrome de respuesta inflamatoria
sistemica Permeabilidad vascular Secuestro y fuga al tercer espacio. Ascitis Ingurgitacion de vasos mesentericos
y del sistema linfatico Disminuye el retorno venoso
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quemaduras
Quemaduras circunscritas al area abdominal
Edema Formacion de escaras Enterocolitis isquemica Resistencias vasculars mesentericas
elevadas Sustancias vasoactivas Mediadores inflamatorios del tejido
quemado
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Tecnicas para medicion
Examen fisico sensibilidad 40-60% Directas Indirectas: Vesical, gastrica, rectal, uterina,
vena cava inferior y de via aerea Gold standard Otras rutas?
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Presion intravesical
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fisiopatologia
Respiratorio Cardiovascular Renal Gastrointestinal Hepatico Sistema nervioso central Dificil distinguirlos
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fisiopatologia
Aumento de presion intratoracia pleural
Disminucion de complianza Distencion alveolar Liberacion de mediadores
inflamatorios ALI -VALI Hipertension pulmonar
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fisiopatologia
Disminucion del retorno venoso Aumento de las resistencia
vasculares sistemicas Compresion cardiaca Disminucion del volumen al final de
la diastole Disminucion del gasto cardiaco Estasis venosa y tromboembolismo
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fisiopatologia
Aumento de la presion en los atrios Pvc y presion de cuña Altos en hipovolemia severa
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Disfuncion renal Descenso del gasto cardiaco Compresion directa Aumento resistencias vasculares
renales Redistribucion del flujo sanguineo
renal IAP mayores 15-20 mmHg Catecolaminas, angiotensiona II,
aldosterona
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fisiopatologia
Descenso perfusion hepatica y esplacnica
IAP 10mmHg flujo de vena porta IAP 20mmHg flujo mesenterico Translocacion bacteriana Falla multiorganica Disminucion del flujo de la pared
abdominal.
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fisiopatologia
HIC Presion de perfusion cerebral
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prevencion
Reconocimiento a tiempo Resucitacion ¨goal directed¨ Lactato Deficit de base Ph de mucosa gastrica Saturacion de oxigeno venosa
central
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manejo
Monitoreo seriado Optimizar perfusion sistemica y
funcion organica en pacientes con IAP elevada
Institucion de estrategias medicas no invasivas
Pronta descompresion quirurgica para casos refractarios
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Estrategias de manejo medico
Posicion de el cuerpo Vasquez et al Excedente de 20 Posicion prona en sdra
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ESTRATEGIAS DE MANEJO MEDICO
Procineticos Descompresion nasogastrica y
colonica Ileos, aire en viscera hueca, edema
de mucosa, circulo viscioso. Descompresion endoscopica
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Estrategias de manejo medico
Resucitacion con fluidos: Trauma Shock septico individualizado
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Estrategias de manejo medico
Diureticos Terapia de sustitucion renal continua
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Descompresion quirurgica Procedimiento que puede salvar vidas SCA refractario a tratamiento medico Tan pronto como sea posible Evitar daño irreversible isquemico a
organos Paciente inestable - bedside Abdomen abierto Bolsa de bogota, parche de wittmann,
cierre asistido por vacuum.
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prognosis
Mortalidad 80 – 100% Factor independiente de mortalidad Presion de los no sobrevivientes
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MUCHAS GRACIAS
“ Busca siempre la simplicidad de las cosas, y luego desconfía de ella”A. Whitehead.