Abdominal Abdominal Compartment Compartment

Syndrome Syndrome Vijith VijayasekaranVijith Vijayasekaran

Advanced Trainee Plastic and Advanced Trainee Plastic and Reconstructive Surgery Reconstructive Surgery

Royal Perth HospitalRoyal Perth Hospital

Abdominal Compartment Abdominal Compartment Syndrome (ACS)Syndrome (ACS)

70 yo 33% TBSA flame Burns 70 yo 33% TBSA flame Burns Face, upper and lower limbs Face, upper and lower limbs Co morbidity – epilepsy Co morbidity – epilepsy Day four deterioration in general Day four deterioration in general

condition condition ↑ ↑ HR HR Abdominal distention and pain Abdominal distention and pain ↓ ↓ Sats Sats ↓ ↓ Urine output Urine output ↑ ↑ urea(11 urea(11 → → 18)18) and creatinine ( 88 and creatinine ( 88 → → 140)140) Pulmonary edema Pulmonary edema ICU admissionICU admission

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Continued abdominal distension Continued abdominal distension Acute renal failure Acute renal failure Respiratory failure with increased airway Respiratory failure with increased airway

pressures pressures Exploratory laparotomy Exploratory laparotomy

Dilated, dusky small bowel and colonDilated, dusky small bowel and colon Global ischemiaGlobal ischemia Small bowel mesentery – pulsatile bleedingSmall bowel mesentery – pulsatile bleeding Abdomen not closed due to poor ventilation Abdomen not closed due to poor ventilation IV bag used to close defect IV bag used to close defect

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Day Six closure of laparotomy Day Six closure of laparotomy following general Improvement following general Improvement

Day 14 burns debridementDay 14 burns debridement Prolonged hospital stay Prolonged hospital stay

Abdominal Compartment Abdominal Compartment SyndromeSyndrome

““Intra-abdominal hypertension (IAH) Intra-abdominal hypertension (IAH) associated with organ dysfunctionassociated with organ dysfunction’’ - ’’ - Khron et al Khron et al

Adversely impacts pulmonary , Adversely impacts pulmonary , cardiovascular , renal , splanchnic, cardiovascular , renal , splanchnic, Musculo/skeletal and integumentary Musculo/skeletal and integumentary systems systems

Significant morbidity and Mortality Significant morbidity and Mortality Baseline IAP 2-6 mm HgBaseline IAP 2-6 mm Hg

Abdominal Compartment Abdominal Compartment Syndrome -PathophysiologySyndrome -Pathophysiology

Respiratory (IAP>15 mm HG)Respiratory (IAP>15 mm HG) Reduced Compliance Reduced Compliance ↓↓Total Lung Capacity Total Lung Capacity ↓↓functional residual capacity and residual functional residual capacity and residual

VolumeVolume ↑ ↑ Pulmonary Vascular resistance due to Pulmonary Vascular resistance due to

increased intra thoracic pressure increased intra thoracic pressure Pulmonary organ dysfunction manifests by Pulmonary organ dysfunction manifests by

Hypoxia, Hypercapnia and increased Hypoxia, Hypercapnia and increased ventilatory pressures ventilatory pressures

Abdominal decompression Abdominal decompression → → early reversal of early reversal of pulmonary respiratory failure pulmonary respiratory failure

Abdominal Compartment Abdominal Compartment Syndrome -PathophysiologySyndrome -Pathophysiology

Cardiovascular Dysfunction Cardiovascular Dysfunction (IAP>20mmHg)(IAP>20mmHg) Reduced cardiac output progressively Reduced cardiac output progressively

falls with increased IAPfalls with increased IAP Decreased venous return from direct Decreased venous return from direct

compression of SVC, IVC and Portal Vein compression of SVC, IVC and Portal Vein Cardiac Compression and reduced end Cardiac Compression and reduced end

diastolic Volume diastolic Volume Reduced stroke volume Reduced stroke volume

Abdominal Compartment Abdominal Compartment Syndrome -PathophysiologySyndrome -Pathophysiology

Renal Dysfunction Renal Dysfunction Pre Renal dysfunctionPre Renal dysfunction -decreased renal perfusion secondary to -decreased renal perfusion secondary to

altered cardiac outputaltered cardiac output Renal DysfunctionRenal Dysfunction Increased renal vascular resistance as a Increased renal vascular resistance as a

result of direct renal compression of the result of direct renal compression of the renal arterioles and veins renal arterioles and veins

Oliguria at IAP > 15-20mmHGOliguria at IAP > 15-20mmHG Anuria at IAP > 30 mmHGAnuria at IAP > 30 mmHG

Abdominal Compartment Abdominal Compartment Syndrome -PathophysiologySyndrome -Pathophysiology

Reduced splanchnic circulation with Reduced splanchnic circulation with impaired portal and mesenteric perfusion impaired portal and mesenteric perfusion

Impaired bowel perfusion linked to Impaired bowel perfusion linked to abnormalities in gut mucosal Barrier late abnormalities in gut mucosal Barrier late septic complications septic complications →→ ↑late septic ↑late septic complicationscomplications

Impaired blood flow to the abdominal Impaired blood flow to the abdominal wall musculature wall musculature

Elevated ICP - elevated CVPElevated ICP - elevated CVP

Abdominal Compartment Abdominal Compartment Syndrome – Measurement Syndrome – Measurement

Many techniques available Many techniques available Transduction of pressure from Transduction of pressure from

indwelling cathetersindwelling catheters Urinary bladder and gastric catheters Urinary bladder and gastric catheters

are the most commonly used are the most commonly used ACS – IAP > 20 -25 mmHg and ACS – IAP > 20 -25 mmHg and

accompanied by manifestation of accompanied by manifestation of organ dysfunction organ dysfunction

Abdominal Compartment Abdominal Compartment Syndrome – diagnosis Syndrome – diagnosis

IAH(>20mmhg) associated with IAH(>20mmhg) associated with Physiological changesPhysiological changes

Respiratory failure with elevated Respiratory failure with elevated ventilatory pressures – elevated hemi ventilatory pressures – elevated hemi diaphragms with loss of lung volume diaphragms with loss of lung volume (early)(early)

Hemodynamic abnormalities of - Hemodynamic abnormalities of - ↑HR, ↑SVR and PVR, ↓CO ↑HR, ↑SVR and PVR, ↓CO

Renal Dysfunction progressing from Renal Dysfunction progressing from oliguria to anuria oliguria to anuria

Abdominal Compartment Abdominal Compartment Syndrome – Management Syndrome – Management

Supportive RXSupportive RX Early abdominal decompression of at Early abdominal decompression of at

risk patients risk patients LaparotomyLaparotomy Percutaneous decompression with Percutaneous decompression with

peritoneal lavage catheterperitoneal lavage catheter Abdominal decompression with Abdominal decompression with

temporary cover eg plastic or temporary cover eg plastic or silicone coverage, skin only closure, silicone coverage, skin only closure, mesh grafts etc mesh grafts etc

Abdominal Compartment Abdominal Compartment Syndrome – Outcomes Syndrome – Outcomes

High mortality and morbidity ( 10 – High mortality and morbidity ( 10 – 70 %)70 %)

Mortality when associated with Mortality when associated with burns – up to 100 % in untreated burns – up to 100 % in untreated cases cases

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injury Syndrome – and Thermal injury Few studies Few studies Incidence Incidence

UnknownUnknown Hobson et al (1014 pts Burns ICU admissions), Latensar et Hobson et al (1014 pts Burns ICU admissions), Latensar et

al , Ivy et al al , Ivy et al Diagnosis was suspected high peak inspiratory pressure or Diagnosis was suspected high peak inspiratory pressure or

oliguria despite aggressive fluid resuscitation oliguria despite aggressive fluid resuscitation 1% overall incidence1% overall incidence 30 % of pts TBSA> 40%30 % of pts TBSA> 40% Mean TBSA 70%Mean TBSA 70% 60% cases in Pediatric population60% cases in Pediatric population 60% developed ACS within 24 hours of admission 60% developed ACS within 24 hours of admission

(3.1ml/kg /%TBSA)(3.1ml/kg /%TBSA) 40 % late presentation 11 D to several months after acute 40 % late presentation 11 D to several months after acute

burn burn

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injurySyndrome – and Thermal injury Pathophysiology Pathophysiology Massive fluid resuscitation and Massive fluid resuscitation and

accumulation of tissue edema accumulation of tissue edema Late onset due to sepsis Late onset due to sepsis

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injurySyndrome – and Thermal injury Risk Factors Risk Factors

Inhalation injuryInhalation injury Large TBSA burns Large TBSA burns Extensive full thickness torso burns Extensive full thickness torso burns

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injurySyndrome – and Thermal injury Parameters that improved after Parameters that improved after

decompression decompression Bladder pressure – 40 mm Hg Bladder pressure – 40 mm Hg → → 26 26

mm Hgmm Hg Peak inspiratory pressure – 37 cm Peak inspiratory pressure – 37 cm

HH22O O → → 32 cm H32 cm H22O O Fluid requirements 78 ml / 1 ml Fluid requirements 78 ml / 1 ml

Urine output to 26 ml Urine output to 26 ml

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injurySyndrome – and Thermal injury Methods of decompression Methods of decompression

Laparotomy Laparotomy Bed side percutaneous catheter Bed side percutaneous catheter

placement at early stage 15 -20 mm Hg placement at early stage 15 -20 mm Hg ( Latensar et al) ( Latensar et al)

Abdominal Compartment Abdominal Compartment Syndrome – and Thermal injurySyndrome – and Thermal injury Outcome Outcome 40 % survived to discharge40 % survived to discharge Method of decompression – no Method of decompression – no

impact on survival impact on survival 50 % survival rate in pediatric 50 % survival rate in pediatric

population and 33 % in adult population and 33 % in adult population population