ABDOMINAL
COMPARTMENT SYNDROME
CVICU Rounds
Dr. Alan Sobey
1
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
2
Abdominal Compartment
Syndrome
• OUTLINE
–
–
–
–
–
Definition
History
Measurements
Significance
Summary
3
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
4
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
5
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).
6
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.
7
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
8
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)
9
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.
10
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.
11
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)
12
Abdominal Compartment
Syndrome
• CONSEQUENCES:
SUMMARY
• Decreased cardiac output
• Increased work of
• Elevated RAP and PCWP
breathing
• Reduced hepatic perfusion • Elevated airway pressures
• Lactic acidosis
during mechanical
• Splanchnic hypoperfusion
ventilation
• Raised ICP
• Abnormal V/Q matching
• Peripheral edema with
with hypoxemia
tendency to thrombosis
13
Abdominal Compartment
Syndrome
• ETIOLOGY
• Intra-peritoneal or
retroperitoneal
hemorrhage
• Ascites
• Bowel obstruction
• Post-op edema
• Pneumoperitoneum
• Laparoscopy
14
Acidosis
Hyperthermia transfusion
Coagulopathy Sepsis: intra
or extra abd
Bacteremia
pancreatitis
Liver
dysfunction
Mechanical
ventilation
Pneumonia
Abdominal
Massive
surgery (DCL) resuscitation
Gastric or
colon dist’n
Hemoperitoneum
Burns and
trauma
BMI
Abdominal
tumors
Prone
ventilation
15
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
16
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
17
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
18
Abdominal Compartment
Syndrome
• Measurement: WSACS
–
–
–
–
Cmpletely supine
Relaxed abdominal wall
mid-axillary line
25 mL saline into the bladder
19
20
21
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)
22
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 illnesses
Sanchez et al Am Surg Mar 2001
23
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 intraabdominal 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
24
Abdominal Compartment
Syndrome
• INTERPRETATION: evidence
– Decreased ACS with earlier decompression
– Decreased mortality with earlier
decompression: ?
– More pronounced benefit with increasing age
25
26
Abdominal Compartment
Syndrome
• Management:
– Medical:
•
•
•
•
•
•
•
Maintain APP (>60mmHg)
Sedation / Analgesia
NMB
Supine positioning
NG / Colonic decompression
Fluid resuscitation
diuretics
27
Abdominal Compartment
Syndrome
• Surgical:
– Percutaneous tube drainage
– Abdominal decompression (DCL)
28
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
29
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)
30
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
31
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%
32
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
33
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
34
Abdominal Compartment
Syndrome
• Decompressive Laparotomy: Effects
• The wound:
– Messy
– Open - risks for colonization or secondary
infection
– Delayed closure: how?
35
36
37
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
38
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 injury
Citero et al CCM
39
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
40
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
41
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
42
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.
43
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????
44
Abdominal Compartment
Syndrome
• Diagnosis: Clinical Suspicion
• Presentation / Suspect with:
– Abdominal distention
– Oliguria
– Increased ventilatory support
45