ABDOMINAL COMPARTMENT SYNDROME

 Symptomatic organ dysfunction that results from increased intraabdominal

pressure (IAP)

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

 1-day point-prevalence observational trial conducted in 13 medical ICUs of six

countries with 97 patients, 8% had IAP > 20mmHg. 1

 The incidence of ACS in trauma patients is estimated to be between 2 and 9

percent.2

1
Crit Care Med 2005; 33:315.

2
Am J Surg 2002; 184:538.
 ABDOMINAL COMPARTMENT SYNDROME

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

 Inflammatory states with capillary leak, fluid sequestration, inadequate tissue

perfusion, and lactic acidosis can develop ACS.

 Gastric overdistention following endoscopy has resulted in ACS.

 ABDOMINAL COMPARTMENT SYNDROME

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

 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.

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

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

 IAH often defined as IAP > 12mmHg.

 Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be
protective .
 ABDOMINAL COMPARTMENT SYNDROME
CLINICAL MANIFESTATIONS
CENTRAL NERVOUS SYSTEM GASTROINTESTINAL
 Intracranial pressure  Celiac blood flow
 Cerebral perfusion pressure  SMA blood flow
CARDIAC  Mucosal blood flow
Hypovolemia  pHi
 Cardiac output RENAL
 Venous return  Urinary output
 PCWP and CVP  Renal blood flow
 SVR  GFR
PULMONARY HEPATIC
 Intrathoracic pressure  Portal blood flow
 Airway pressures  Mitochondrial function
 Compliance  Lactate clearance
 PaO2  PaCO2 ABDOMINAL WALL
 Shunt fraction  Compliance
 Vd/Vt  Rectus sheath blood flow
Curr Opin Crit Care 2005; 11:333
 ABDOMINAL COMPARTMENT SYNDROME

 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
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.

Curr Opin Crit Care 2005; 11:333

 ABDOMINAL COMPARTMENT SYNDROME

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

Abdominal perfusion pressure (APP):

  APP = MAP - IAP

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

Surg Clin North Am 1996; 76:833.

 ABDOMINAL COMPARTMENT SYNDROME

OPERATIVE DECOMPRESSION

Vacuum-assisted
temporary abdominal
closure device:

thin plastic sheet, a

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

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

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

 The gut is the organ most sensitive to IAH.

 Treatment involves expedient decompression of the abdomen.

 Since this syndrome affects patients who are already physiologically

compromised, a high degree of suspicion and a low threshold for checking
bladder pressures are required to prevent the mortality associated with this
complex problem.
 ABDOMINAL COMPARTMENT SYNDROME

REFERENCES AND READINGS

 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.