Abdominal Compartment Syndrome

1
Abdominal Compartment Syndrome

• Gus Mealor, M3
• November 10, 2006

2
Definitions

• Intraabdominal pressure (IAP)
• normal 5 mmHg
• varies with respiration
• Measurement
• Direct transduction of pressure via direct
  needle or trochar
• Indirect bladder transduction, balloon tipped
  catheter in stomach
• measured at end-expiration, with patient supine
  and abdominal muscles relaxed
• Abdominal Perfusion Pressure (APP) Mean
  Arterial Pressure - IAP
• Intraabdominal Hypertension (IAH)
• 1. IAP of 12 mmHG, x3, 4-6 hours apart or
• 2. APP 60 mm Hg, x2, 1-6 hours apart
• Abdominal Compartment Syndrome (IAP)
• 1. IAP of 20 mm Hg, regardless of APP, x3, 1-6
  hrs apart or
• 2. symptomatic organ dysfunction that results
  from an increase in intraabdominal pressure

Abdominal compartment syndrome. Sugrue M. Curr
Opin Crit Care. 2005 Aug11(4)333-8.
3
Prevalence and Incidence

• Best Trial
• 265 ICU pts, 14 clinical centers, 6 countries
• 50 medicine, 28 elective surgery, 17
  emergency surgery 9 trauma patients
• At admission
• 32.1 had IAH
• 4.2 had ACS
• Development of IAH during the stay was an
  independent predictor of outcome (RR 1.85, p
  0.01)

4
Pathophysiology

• Cardiovascular
• compression of the heart, decreased compliance
  and contractility
• compression IVC
• decreased preload (?)
• pedal edema
• dvt risk
• Pulmonary
• pulmonary edema, atelectesis, ?d dead space
  ratio, ?d shunting
• hypercarbia, hypoxia
• Renal
• ?d venous resistance
• RAA axis elevated (?d urine NaCl)
• oliguria IAP 15 mmHg anuria IAP 30 mmHg
• GI
• low as 10 mmHg
• compression of mesenteric veins ? venous htn ?
  bowel ischemia and edema ? ?d perfusion ? ?d
  ischemia

5
Presentation

• - Very Inconsistent
• Physical Exam suspect ACS with tense, distended
  abdomen and progressively worsening pulmonary
  function.
• sensitivity 40, specificity 94

Is clinical examination an accurate indicator of
raised intra-abdominal pressure in critically
injured patients? Kirkpatrick AW Brenneman FD
McLean RF Rapanos T Boulanger BR. Can J Surg.
2000 Jun43(3)207-11.
6
Work Up

• Indications for IAP Monitoring
• Abdominal post-op patients
• Open or blunt abdominal trauma patients
• Patients with a distended abdomen and
  signs/symptoms consistent with abdominal
  compartment syndrome oliguria, hypoxia,
  hypotension, unexplained acidosis, mesenteric
  ischemia, ?d ICP

Bladder Pressure Transducer system
7
Treatment

• No level I studies
• Non-Surgical Options for IAH
• Paracentesis
• Gastric suctioning and/or rectal enemas and
  suctioning
• Gastroprokinetics (cisapride, metoclopramide),
  Colonoprokinetics (prostigmine)
• Furosemide
• Sedation
• Botulinum toxin into the internal anal sphincter
• Surgery when to decompress
• I normal post-op pressures
• II Monitor carefully, decide clinically
• III Most will require decompression
• IV Decompression manditory
• Post-op care and closure evidence lacking

Burch et.al. The abdominal compartment syndrome.
Surg Clin North Am 1996 76833-842. Andrews et
al. Scientific evaluation of the level of
evidence of publications relating to abdominal
compartment syndrome. ANZ J Surg 2005 75A15.
8
Complications

• Certain death

9
Prevention and Follow-Up

• Good question

10

• 1. Intensive Care Med 2004 May30(5)822-9. Epub
  2004 Feb 3