Abdominal Compartment Syndrome

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Abdominal Compartment Syndrome
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Increased Intra-abdominal Pressure IAP Abd.
Compartment Synd ACS

• Case
• Definition prevalence
• Measurement techniques
• Etiology
• Consequences
• Treatment

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Definition

• Compartment syndrome exists when increased
  pressure in a closed anatomic space threaten the
  viability of enclosed surrounding tissues
• ACS ?organ dysfunction as a result of
• increased IAP

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Definition

• 77 patients prospectively studied
• IAP by measuring bladder pressure
• Mean IAP 6.5 mm Hg ( 0.2-16.2 mm Hg).
• BMI previous abd Sx were the only factors
  associated with high IAP
• 
  Am Surg 2001 Mar

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Definition

• A lot of literature but no consistent criteria
  for has been used for diagnosis
• What measurement should be used ?maximum Vs mean
  Vs median?
• What is the gold standard method of diagnosis?

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Etiology

• Surgical primary
• Large volume resuscitation in abdominal trauma
  or emergency operations
• Tight surgical suture or burn scars
• Non surgical secondary
• peritonitis , pancreatitis , massive ascites
• bowel obstruction , EGD NPPV

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Etiology

• One day prevalence in 13 ICU over 6 countries
• 97 patients with admission gt 24h
• IAP measured with bladder pressure
• q 6 h for 24 hours
• Intraabdominal hypertension IAH
• when IAP or gt 12 mm Hg
• ACS when IAP or gt 20 mm Hg
• Intensive
  Care Med. 2004 May

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Etiology

• IAH incidence 50.8 ACS 8.5
• Only BMI gt27 was strongly associated with ACS in
  multivariate analysis
• Amount of fluid given
• renal coagulation dysfunction have a trend
  of important only on univariate analysis
• Intensive Care
  Med. 2004 May

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Measurement of IVP

• Bladder pressure is the most commonly used method
  
• gastric, rectal uterine has been
  described
• Patient supine, measurement during expiration
  bladder is empty Foley catheter is clamped
• 18 gauge needle attached to transducer is
  inserted into the aspiration port 50 ml NS is
  injected

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Bladder Pressure

• 37 patient undergoing laparoscopy
• Bladder pressure at different volume 0-200 ml
• Moderate correlation R 0.62
• Bias 3.2 mm Hg
• Lowest bias in patient with N IAP ?50 ml
• in patients with high IAP ?0 ml
• J
  Trauma 2001 Feb

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Bladder Pressure

• Possible source of errors in measurement
• Body position , zeroing
• over or under damping
• Baseline IAP
• ? Empty bladder
• Fluctuation in IAP

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Measurement Of IAP

• Continuous fully automated system
• NGT like tube with air pouch at the tip
• The pressure transducer is integrated in the
  monitor
• Excellent correlation with insufflatory pressure
  R .99 with bias .5-2.5 mm Hg
• Intensive
  Care Med. 2004 Mar

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Consequences

• Critical IAP ?IAP at which ACS will develop
• Variable from patient to patient
• Likely critical IAP is lower in morbid obesity ,
  pregnancy CLD with ascites ,previous abdominal
  surgeries

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Consequences

• CNS
• Increase in IAP will increase ICP
• 15 patients with moderate to severe head injury
  after resolution of initial elevated ICP.
• IAP was increased by 15 liter water bag over the
  abdomen
• IAP 4.7?15.5 ICP 12 ?15 mm Hg
• This effect was mediated through increase in the
  intrathoracic pressure
• 
  Crit Care Med 2001

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Consequences

• CVS
• studies in animals mainly
• Rt ward flattening of Frank-Starling curve
• Decrease in compliance contractility
• Decrease in VR
• Elevated CVP PCWP
• not reflector of true intravascular volume
• ?use of volumetric parameters in resuscitation

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Consequences

• Respiratory
• Animal studies
• Decrease in chest wall compliance
• Increase in VQ mismatch dead space
• Hypoxia hypercapnia
• Best PEEP IAP
• Pplt Pplt IAP

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Consequences

• GI
• In animal studies
• ?decrease in blood flow
• increase risk of bacterial translocation
• decrease hepatic lactate clearance
• In human study
• Increase IAP induced in 14 cirrhosis with varices
  ?elevation in varices pressure size wall
  tension
• 
  Hepatology 2002

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Consequences

• Renal
• Decrease in venous drainage because of increased
  venous pressure
• Decrease renal perfusion 2ry to arterial
  vasoconstriction Renin mediated by the fall in
  cardiac output
• Decrease in GFR UOP with pre renal picture

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Consequences

• Renal
• Increase IAP was one risk factor in developing
  hernias leak in 142 peritoneal dialysis
  patients
• Other factors BMI age
• Peritoneal Dialysis
  International 2004

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Diagnosis

• 21/42 trauma patient who had developed IAH
  diagnosed by bladder pressure were examined
  clinically
• Clinical exam sensitivity 56 PPV 35
• specificity 87 NPV
  64
• accuracy 84
• 
  Can J Surg 2000 Jun

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Management

• Surgical
• Decompression with maintenance of open abdomen
  (vacuum pack dressing)
• ? When to operate
• Abdominal perfusion pressure APP was shown in
  retrospective study of 144 pt with IAH to be the
  best predictor of survival
• 
  J Trauma 2000 Oct

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Management

• Volume resuscitation
• Higher filling pressure
• Mechanical ventilation
• Lung protective ventilation?aim Pplt IAP
• Best PEEP IAP

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Summary

• IAH ACS is infrequent but serious complication
  of multiple surgical medical diseases
• Clinical examination had low sensitivity
• Till now bladder pressure is the most commonly
  used method to screen for ACS

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Summary

• The effect of IAH is on all other systems
• With the development of continuous intraabdominal
  pressure monitors IAP may become part of the
  vitals
• Surgical decompression is the main stay of Rx

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Thanks