1 ABDOMINAL COMPARTMENT SYNDROME CVICU Rounds Dr. Alan Sobey.

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ABDOMINAL COMPARTMENT SYNDROME

CVICU Rounds

Dr. Alan Sobey

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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

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Abdominal Compartment Syndrome

• OUTLINE– Definition– History– Measurements– Significance– Summary

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• 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

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• 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

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• 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).

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• 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.

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• 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

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• 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)

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• 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.

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• 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.

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• 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)

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• CONSEQUENCES: SUMMARY

• Decreased cardiac output• Elevated RAP and PCWP• Reduced hepatic perfusion• Lactic acidosis• Splanchnic hypoperfusion• Raised ICP • Peripheral edema with

tendency to thrombosis

• Increased work of breathing

• Elevated airway pressures during mechanical ventilation

• Abnormal V/Q matching with hypoxemia

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• ETIOLOGY

• Intra-peritoneal or retroperitoneal hemorrhage

• Ascites• Bowel obstruction• Post-op edema

• Pneumoperitoneum

• Laparoscopy

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Acidosis Hyperthermia transfusion

Coagulopathy Sepsis: intra or extra abd

Bacteremia

pancreatitis Liver dysfunction

Mechanical ventilation

Pneumonia Abdominal surgery (DCL)

Massive resuscitation

Gastric or colon dist’n

Hemo-peritoneum

Burns and trauma

BMI Abdominal tumors

Prone ventilation

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• 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

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• DIAGNOSIS: Index of suspicion– When any signs of intra-abdominal

hypertension are present:• Abdominal distention• Refractory oliguria• Hypercarbia• Refractory hypoxemia• Increasing PIPs• Refractory hypotension

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• 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

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• Measurement: WSACS– Cmpletely supine– Relaxed abdominal wall– mid-axillary line– 25 mL saline into the bladder

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• 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)

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• 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 illnessesSanchez et al Am

Surg Mar 2001

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• INTERPRETATION:– As the pressure rises over 20cm water there will be

some evidence of hypoperfusion– Most will accept surgical decompression if the intra-

abdominal 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

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• INTERPRETATION: evidence– Decreased ACS with earlier decompression– Decreased mortality with earlier

decompression: ?– More pronounced benefit with increasing age

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• Management:– Medical:

• Maintain APP (>60mmHg)• Sedation / Analgesia• NMB• Supine positioning• NG / Colonic decompression• Fluid resuscitation• diuretics

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• Surgical:– Percutaneous tube drainage– Abdominal decompression (DCL)

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• 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

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• 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)

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• DAMAGE CONTROL LAPAROTOMY– Offner et al (Arch Surg)

• Denver Colo

• Penetrating and blunt traumas

• ACS:– Long hospital stay

– Increased multisystem organ failure

– Increased ARDS

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• 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%

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• 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

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• 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

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• Decompressive Laparotomy: Effects

• The wound:– Messy– Open - risks for colonization or secondary

infection– Delayed closure: how?

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• 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

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• 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 injuryCitero

et al CCM

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• 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

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• Classification:– Primary:

• Due to injury or disease in the abdomen or pelvis

• Frequently requires surgery or radiological treatment

• Ex: trauma or the septic abdomen

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– Secondary:• ACS due to conditions arising outside of the

abdomen

• Associated with severe capillary leak requiring resuscitation

• Ex: sepsis, burns, retroperitoneal hematoma

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• 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.

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• APP: abdominal perfusion pressure

• APP = MAP - IAP

• “magic number”: 50-60

• Corresponds to the perfusion gradient across the intra-abdominal visera

• Evidence????

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• Diagnosis: Clinical Suspicion

• Presentation / Suspect with:– Abdominal distention– Oliguria– Increased ventilatory support

1 ABDOMINAL COMPARTMENT SYNDROME CVICU Rounds Dr. Alan Sobey.

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