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Abdominal Compartment

Syndrome in the Critically Ill


Patient

Warko Karnadihardja
Dept. of Surgery, Hasan Sadikin Hospital
Bandung
Intra-Abdominal Hypertension (IAH)
A sustained increase in intra-abdominal
pressure (IAP), can cause hemodynamic,
respiratory, splanchnic and renal dysfunction
(Midwinter MJ, UK, 2004)

Some authors consider that IAH as first hit leading to SIRS


Abdominal Compartment Syndrome (ACS)

Multiple organ dysfunction syndrome


(MODS) attributable to increased
intraabdominal pressures (IAPs), that
improves clinically by decompressive
laparotomy

Some authors consider as Second Hit leading to MODS - MOF


Clinical Findings of ACS

Tensely distended or stone-hard abdomen


Increasing Peak Inspiratory Pressure (PIP)
Hypoxia, hypercarbia, oliguria and anuria
The diagnosis of ACS is verified by measuring
the urinary bladder pressure (UBP)
High index of suspicion must be maintained to
make diagnosis and intervene early in the
course of ACS
Predisposing Factors to Development of ACS
Extensive abdominal and pelvic injury
Damage control surgery
Abdominal packing : over or under packing
Continuing bleeding
Extensive contamination of peritoneal cavity
Massive transfusions and crystaloid infusions
Inadequate resuscitation
The presence of triad of death in trauma patients:
hypothermia-coagulopathy-acidosis
Closure the fascia and skin under tension
Predisposing Factors to Development of ACS
Hemorrhagic pancreatitis
Ileus and intestinal obstruction
Ruptured abdominal aortic aneurysm
Abdominal sepsis especially when associated
with septic shock
Intraabdominal disease processes : massive
ascites, tension pneumoperitoneum, ovarian
masses, etc.
Loss of abdominal wall compliance : abdominal
wall burns, repair of large hernias
ACS
May occur in 5%-15% critically ill
patients
Mortality can be as high as 63% to
72% in most tertiary level hospitals
Measuring Intraabdominal Pressure (IAP)

Direct Method
Directly placed a catheter into the peritoneal
cavity, attaching to a saline manometer or
pressure transducer
Indirect Method
Measurement of
Bladder pressure most popular
Gastric pressure
IVC pressure
Grading System of ACS

Grade Badder pressure (mmHg)


I 10 15
II 16 25
III 26 35
IV > 35

Meldrum DR, Moore FA, Moore FE, et al. Am J Surg 174: 667; 1997.
1 mmHg = 1,26 cmH2O
Percentage of Patients with Respective Organ Dysfunction per
Grade of Abdominal Compartment Syndrome

Grade UO < 0.5PAP > 45SVR > 1000 DO2I < 600
ml/kg/hr

I 0%0% 0%0%

II 0%40% 20%20%

III 65%78% 65%57%

IV 100%100% 100%100%

PAP: Peak Airway Pressure (cmH2O), DO2I: Oxygen Delivery Index (ml O2/min/m2), SVR: Systemic
Vascular Resistance (dyne/sec/cm-5), UO: Urine Output (ml/min)

Meldrum DR, Moore FA, Moore FE, et al. Am J Surg 174: 667; 1997 .
Grading of AIP as determined by intravesical
pressure, & summary of clinical effects
(Midwinter, 2004)
Grade IAP (mmHg/ cmH2O) Clinical
I 7.3 11.0 (10-15) None
IIa 11.7 18.3 (16-25) Oliguria, splancnic
hypoperfusion
IIIb 19.1 25.7 (26-35) Anuria, ventilation
pressure
IVb >25.7 (>35) As above & pO2
a
= initial th/ aims to restore splanchnic & renal hypoperfusion by
hypervolemic resuscitation
b
= these pts will probably require urgent abdominal decompression
Measurement of urinary bladder pressure

Steven L.Lee et al, The Journal of Trauma, Injury, Infection and Critical Care,
Vol 52, No.52, June 2002
The Vicious Circle created by IAH
Splanchnic hypoperfusion

Hepatic ischemia Gut mucosal acidosis


Bowel edema

Coagulopathy
Hypothermia

IAH
Acidosis

unrelieved
Free oxygen radicals
Distant organ damage
Intra-abdominal
bleeding
ACS

Ivatury RR et al. Surg Clin North Am 1997; 77: 796.


IAH : Intraabdominal hypertension, ACS : Abdominal Compartment Syndrome
Adverse Physiologic Effects of ACS
A. Respiratory
Elevated diaphragm : thoracic pressure and
compliance
PIP, ventilation-perfusion abnormality
Increasing PEEP
Hypercarbia
Acidosis

PIP : Peak Inspiratory Pressure


Adverse Physiologic Effects of ACS
B. Cardiovascular
CVP, PCWP, SVR
cardiac output

C. Renal
Direct compression and diminished renal blood
flow
Oliguria is often the earliest sign of ACS
Adverse Physiologic Effects of ACS

D. Decreased abdominal wall blood flow


Increased wound infection and fascial
dehiscence
E. Decreased splanchnic bloodflow
Promotes gut mucosal acidosis, bowel edema
and production of oxygen free radicals
F. Increase intracranial pressure (ICP)
will decrease cerebral perfusion pressure, may
potentially aggravate neuronal disease
Decompressive Laparotomy to treat
intractable intracranial hypertension after
traumatic brain injury

Decompressive laparotomy can be useful adjunct


in the treatment of ICH failing maximal therapy
following TBI

Joseph D.K., et.al. : Journal Trauma 2004, 57:687-695


Effect of increasing IAP on bowel mucosal oxygen (tissue
oxygen partial pressure TPO2) compared with systemic
tissue oxygenation in the axilla (Data from Bongard et al,
1995)
Effect of increasing IAP on Cardiac Output CO, superior
mesenteric artery SMA, and laser-doppler flow LDF in
the intestinal mucosa (Data from Diebel et al, 1992)
Diagnosis of ACS

High index of suspicion


Clinical syndrome
Abdominal distension, stone-hard abdomen
peak inspiratory pressure
CVP ( if the patient euvolemic)
Oliguria
Hypercapnia
Diagnosis of ACS

Measuring IAP

IAP > 25 mmHg correlates with renal


dysfunction
IAP > 25 mmHg in post-op patient with
adequate blood volume and oliguria
indication for decompression laparotomy
Management of increased IAP

Increased IAP is detrimental to organ function, it


should be anticipated and prevented
Increased IAP should be monitored frequently, if
persistently high, treated promptly
Patients treated by DCS are particularly prone to
IAP, consideration should be given to
prevention of IAP
Urine Bag Abdominal Closure
using Sterile Urine Bag
STAR Staged Abdominal Relaparotomies
22yr old male, acute
necrotizing pancreatitis
Indication of surgery:
Sepsis & MOF
Needs 4 laparotomies
until recovery
Original article:
Does re-operation for abdominal sepsis
enhance the inflammatory host response?
Sautner et al. Archive of Surg, Vol 132, Mar 1997

Re-operation for abdominal sepsis frequently causes


substantial hypotention, thus potentially harmful to the
patient
Re-operative trauma may induce an early post-op increase
in IL-6 levels
Because this increase occurs before development of
hypotention, a relationship between the kinetics of this
cytokine & the observed hemodynamic instability may be
present
28 yr old male, perforated
DU for 3 days with abdominal
compartment syndrome
Decompression by
percutaneous Drainage
Needed STAR 8x to
recover
STAR
Damage Control Surgery
Severe abdominal trauma with ACS
Damage Control Surgery
Severe abdominal trauma with ACS
Damage Control Surgery
Pelvic fracture with ACS
Appropriate Nursing Care:
Avoiding secondary infection
Vacuum-assisted Fascial Closure for Patients with
Abdominal Trauma
The Problems of Open Abdomen (1)
Primary abdominal closure restores the normal
preoperative physiologic state
Under certain condition such as:
Damage control Life saving
Planned reoperation sepsis control
Significant visceral edema avoiding ACS
Retroperitoneal hematoma avoiding ACS

Primary closure of the abdomen is not possible and all can lead
to ACS
Stone PA et.al, J.Trauma 2004; 57:1082-1086
The Problems of Open Abdomen (2)
Have a high in-hospital mortality:

20%-30% in most series


Usually are heralded by a high ISS:25 9
And high serum lactate levels indicative of
severe ischemia

Stone PA et.al.; J.Trauma 2004; 57:1082-1086


How to solve the Problem of Open Abdomen?
By implementation of
Vacuum-assisted Fascial Closure (VAC)
Objectives:
1. Containment & protection of the viscera
2. Containment of the fluid loss
3. Prevention of wound contamination
4. Prevention of IAP elevation
5. Procedural ease
6. Avoidance of repeated suture damage
7. Maintenance of constant medial tension of the fascial
edges
Management of increased IAP

UBP Clinical status Treatment

< 10-15mmHg No organ dysfunction Closely monitored


1525mmHg urine, cardiac output Volume expansion
20-30mmHg partial organ response Volume expansion
to fluid administration, Possible
stable decompression for
head injury
> 30mmHg MODS Decompression
mandatory
Prophylaxis & Treatment of IAH

Temporary closure of fascia to patients at high risk


for IAH
ICU/SICU management
monitor gastric mucosal pH (pHi) and use this variable
as an end-point of resuscitation
IAP is measured every 4-6 hours
or more frequently
persistent elevation > 20-25 mmHg
is an indication for re-exploration
Abdominal Perfusion Pressure (APP)

APP = MAP IAP (mmHg)

MAP = SP + (DPx2) (mmHg)


3

APP = Abdominal Perfusion Pressure


MAP = Mean Arterial Pressure
SP = Systolic Pressure
DP = Diastolic Pressure
Abdominal Perfusion Pressure (APP)

A superior parameter in the assessment of intra-


abdominal hypertension
Appears to be clinically useful resuscitation end-point
and predictor of patient survial during treatment for IAH
and ACS
APP > 50 mmHg should be considered a potential
resuscitation endpoint in the patient with elevated IAP

Cheatham ML, White MW, sagraves SG et al. J Trauma 2000; 49(10): 621-627
More and more research on ACS
A simplified approach to the diagnosis of elevated intraabdominal
pressure
Steve L.Lee et al : J Trauma, 2002:52:1169-1172
Systemic Inflammatory Response Secondary to Abdominal
Compartment Syndrome : Stage for Multiple Organ Failure
Joao B. Rezende-Neto et al : J. Trauma 2002;53:1121- 1128
Release of Abdominal Compartment Syndrome Improves Survival
in Patients with Burn Injury
Christina G. Hobson et al : J. Trauma 2002;53:1129- 1134
More and more research on ACS
Abdominal Compartment Syndrome in the Pediatric
Blunt Trauma Patient Treated with Paracentesis :
Report of Two Cases
Richard P. Sharpe et al : J.Trauma 2002;53:1121-
1128
Abdominal Compartment Syndrome in the Open
Abdomen : Original Article
Vincente H. Gracias et al : Arch Surg vol 113 Nov
2002
Abdominal Compartment Syndrome : Panel Discussion
New England Surgical Society
Moderator : Rocco Orlando III; Arch Surg, vol 139,
Apr 2004
More and more research on ACS

The Abdominal Compartment Syndrome Complicating


Nonoperative Management of Major Blunt Liver Injuries:
Recognition and Treatment Using Multimodality Therapy
Edmund Y.Yang et al : J Trauma 2002;52:982-986
Avoidance of Abdominal Compartment Syndrome in
Damage Control Laparotomy After Trauma.
Patrick J.Offner et al : Arch Surg. Vol 136, June
2001
Summary

ACS refers to the renal, pulmonary,


cardiovascular, splanchnic, abdominal wall, and
intracranial disturbances resulting from IAP
regardless of the cause
Although ACS most commonly observed in
trauma patients with severe abdominal injuries, it
is also observed in post-op patients, abdominal
sepsis, hemorrhagic pancreatitis and other
disease processes
Summary

High index of suspicion leading to an early


diagnosis is critical
The reopening of an abdominal incision or the
early decompressive laparotomy has proven life
saving in many critical series
Thank You