Download Abdominal Compartment Syndrome

Abdominal
Compartment
Syndrome (ACS)
Dr Emily Lai
Princess Margaret Hospital
Joint Hospital Surgical Grand Round 17 Apr 2010
World Congress on Abdominal
Compartment Syndrome 2004
• Intra-abdominal pressure (IAP):
– steady-state pressure concealed within the
abdominal cavity;
– increases with inspiration and decreases with
expiration
– affected by the volume of solid organs and the
intestines, space-occupying lesions, and the
extensibility of the abdominal wall
• Abdominal perfusion pressure = MAP – IAP
World Congress on Abdominal
Compartment Syndrome 2004
• Normal IAP ~ 5-7mmHg
• Intra-abdominal hypertension (IAH)
– Sustained or repeated pathological elevation in IAP >=
12mmHg
• Abdominal compartment syndrome (ACS)
– a sustained IAP > 20mmHg that is associated with a new
organ dysfunction/ failure
Classification of ACS
• Primary
– Associated with injury or disease in the
abdominopelvic region or a condition that
develops after abdominal surgery
– Frequently requires early surgical and radiological
intervention
– e.g. # pelvis, massive retroperitoneal haematoma,
ruptured AAA, ileus, post-liver transplantation
Classification of ACS
• Secondary (medical or extra-abdominal)
– Include conditions that do not originate from the
abdomen
– e.g. major burns, sepsis or other condition requiring
massive fluid resuscitation
Classification of ACS
• Recurrent (tertiary)
– ACS redevelops following previous surgical or
medical treatment of primary or secondary ACS
– Associated with significant morbidity and mortality
Causes of ACS
• Intraperitoneal or retroperitoneal haematoma
– Trauma, # pelvis, ruptured AAA…
• Sepsis
– Intra-abdominal sepsis, pancreatitis, major burns…
•
•
•
•
Excessive fluid resuscitation > 5L within 24 hours
Pneumoperitoneum
Ileus/ intestinal obstruction
Iatrogenic
– Post incisional hernia repair, post abdominal packing…
** Patient with ascites, large abdominal tumors, pregnancy and
morbid obesity have lower thresholds to develop ACS
Pathophysiology
Physiological Insult/ critical illness
(e.g. Haemorrhage, sepsis)
Systemic inflammatory response
Capillary endothelial damage
Interstitial edema (including
bowel wall and mesentery)
Fluid accumulates, stretching the abdominal
wall until it becomes less compliant
Intra-abdominal pressure increases
Multisystem effects of ACS
• Cardiovascular
– Compression of IVC diminishes venous return to
the heart (preload)
– Increased afterload due to raised systemic
vascular resistance and raised intra-thoracic
pressure
– Reduces cardiac output
– Venous stasis in the legs
Multisystem effects of ACS
• Respiratory
– Diaphragm is forced into the thorax, reducing the
intra-thoracic volume, increasing the intrathoracic pressure and compressing lung
parenchyma
– Hypoventilation and VQ mismatch causing
hypoxia and respiratory acidosis
– Compensatory increase in positive end expiratory
pressure may further impede venous return and
raised jugular pressure, which can result in raised
ICP and cerebral edema
Multisystem effects of ACS
• Renal
– Reduction in GFR and renal plasma flow, with
increase in renal vascular resistance
– Leads to oliguric renal failure
– Raised ADH, renin and aldosterone leads to
retention of sodium and water
Multisystem effects of ACS
• Gastrointestinal
– marked reduction in hepatic, splanchnic and
mesenteric blood flow when IAP > 15
– Mucosal ischemia and translocation of bacteria or
inflammatory mediators into the circulation
– Provokes systemic inflammatory response,
prolonged ileus or leads to anastomotic
dehiscence post-operatively
• Central nervous system
– Raised intracranial pressure
Symptoms/ signs
• No characteristic clinical signs are indicative
of ACS
• Clinical judgment fails to detect significant
IAH over 40% of the time
–
–
Kirkpatrick, A.W., et al., Is clinical examination an accurate indicator of raised intraabdominal pressure in critically injured patients? Can J Surg, 2000. 43(3): p. 207-11.
Sugrue, M., et al., Clinical examination is an inaccurate predictor of intraabdominal pressure.
World J Surg, 2002. 26(12): p. 1428-31.
Measurement of IAP
• Direct
– Catheter in the peritoneum
• Indirect
– Intravesical pressure (Gold standard)
– Stomach pressure
– Rectal pressure
– Uterine pressure
– Inferior vena cava pressure
Bladder Technique
• Foley catheter tubing clamped
• 50ml saline instilled into the bladder
• A 16G needle inserted via the aspiration
port proximal to the clamp and
attached to a pressure transducer/
manometer
• The level of pubic symphysis is used as
zero
• Measured at end-expiration and in
supine position
• Contraindication: patient with
suspected or confirmed bladder trauma
Management
• Medical
• Operative
Medical Management
•
•
•
•
•
•
•
•
•
Close monitoring in ICU
Sedation and paralysis
Optimization of ventilation and oxygenation
Optimal fluid resuscitation
Administration of inotropes
Gastric suctioning
Correction of coagulopathy
Correction of hypothermia
CVVH for aggressive correction of metabolic acidosis
associated with acute renal failure despite medical
therapy
Operative Treatment
• Decompressive
laparotomy
– immediate
improvement of
haemodynamic status
– Variety of techniques
• e.g. Bogota bag,
Wittmann patch,
vacuum-pack closure
• Temporary abdominal
closure
http://www.mdconsult.com/
Bogota bag
http://bestpractice.bmj.com/best-practice/monograph/1125/resources/images.html
Decompressive laparotomy
(DL)
• Detailed effects of DL on organ function are only
rarely reported.
• IAP threshold levels for DL reported in the literature
vary considerable.
• DL decreases IAP to < 20 mmHg in most studies
• A positive effect on organ function is reported in most
studies, but the effect is inconsistent, and the duration
of this effect is not clear.
• Reported mortality after DL for ACS is high.
Jan J De Waele et al. Decompressive laparotomy for abdominal compartment syndrome – a
critical analysis Critical Care 2006, 10:R51
Decompression-reperfusion
Syndrome
• Haemodynamic instability
• Release of lactic acid, potassium and
adenosine that accumulate during
anaerobic metabolism
• Result in arrhythmias, metabolic acidosis and
cardiac depression
Conclusion
• Abdominal compartment syndrome is fatal
• Early recognition of patients at risk, frequent
monitoring of IAP, and early initiation of
treatment are important in preventing
irreversible multiorgan failure.
References
•
World Society of the Abdominal Compartment Syndrome
www.wsacs.org
• Results from the International Conference of Experts on Intraabdominal hypertension and Abdominal Compartment
Syndrome Intensive Care Med (2006) 32:1722–1732
• Narendra Nath Basu, Simon Cottam Abdominal Compartment
Syndrome Surgery 2006 260-262
• Scheppach et al. Abdominal Compartment syndrome Best
practice & Research Clinical Gastroenterology 23 (2009) 25-33
•
•
Kirkpatrick, A.W., et al., Is clinical examination an accurate
indicator of raised intra-abdominal pressure in critically injured
patients? Can J Surg, 2000. 43(3): p. 207-11.
Sugrue, M., et al., Clinical examination is an inaccurate predictor of
intraabdominal pressure. World J Surg, 2002. 26(12): p. 1428-31.
• Jan J De Waele et al. Decompressive laparotomy for
abdominal compartment syndrome – a critical analysis Critical
Care 2006, 10:R51
• Guideline for management of abdominal compartment
syndrome (ACS) in trauma patients in PMH ICU