Abdominal compartmental Syndrom


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Abdominal compartmental Syndrom

  1. 1. Abdominal Compartment Syndrome M.A.Elmoneim IABFH-ICU
  2. 2. Case Summary <ul><li>A 26-year-old previously fit and well man was a pedestrian involved in a road traffic accident. His injuries included rib fractures, a ruptured spleen and an unstable pelvic fracture. He was admitted to the intensive care unit following external fixation of his pelvis, laparotomy and splenectomy. Estimated blood loss was over 4 litres, which was replaced with a combination of blood, fresh frozen plasma and platelets. At the end of the case the patient had a metabolic acidosis, a mild coagulopathy, mild anaemia and was hypothermic </li></ul><ul><li>In view of these findings the patient remained ventilated and was admitted to the ICU </li></ul><ul><li>Overnight the coagulopathy, anaemia and hypothermia were corrected. However his ventilatory requirements increased, with peak inspiratory pressure rising from 22cmH20 to 38cmH20 in order to maintain acceptable tidal volumes. In addition his base excess remained greater than 8mmol/l and his urine output remained less than 0.5ml/kg/hr despite fluid resuscitation. His abdomen was noted to be tense and distended and at this stage </li></ul><ul><li>A clinical diagnosis of abdominal compartment syndrome was suggested </li></ul><ul><li>To be contineued </li></ul>
  3. 3. Introduction <ul><li>Compartment syndrome (CS) : is a condition in which the perfusion pressure falls below the tissue pressure in a closed anatomic space, with subsequent compromise of tissue circulation and function </li></ul><ul><li>Compartment syndromes: </li></ul><ul><ul><li>Cerebral </li></ul></ul><ul><ul><li>Orbital </li></ul></ul><ul><ul><li>3. Abdominal </li></ul></ul><ul><ul><li>Extremity </li></ul></ul><ul><ul><li>thoracic </li></ul></ul>
  4. 4. Flexible structures Abdominal Cavity Rigid structures <ul><ul><li>Coastal </li></ul></ul><ul><ul><li>arches </li></ul></ul>Spine <ul><ul><li>Pelvis </li></ul></ul>Diaphragm Musculoaponeurotic
  5. 5. Definitions <ul><li>Normal Intraabdominal Pressure </li></ul><ul><ul><li>IAP varies between subatmospheric to a mean of 6.5 mm Hg </li></ul></ul><ul><ul><li>It is affected by </li></ul></ul><ul><ul><ul><li>Body habitus (chronically elevated in morbid obesity) </li></ul></ul></ul><ul><ul><ul><li>Phase of respiration (higher during inspiration) </li></ul></ul></ul><ul><ul><ul><li>Body position (elevated in the erect position) </li></ul></ul></ul><ul><ul><li>IAP to be considered normal should be measured in the supine position , at end expiration and should have a value less than 10 mm Hg </li></ul></ul><ul><ul><li>Consensus definition of the World </li></ul></ul><ul><ul><li>Society of Abdominal Compartment Syndrome </li></ul></ul>
  6. 6. <ul><li>Intraabdominal Hypertension </li></ul><ul><ul><li>Brief elevations of IAP are fairly common and seen during sneezing, coughing, and so forth and are of little clinical significance </li></ul></ul><ul><ul><li>Even in critically ill patients, brief elevations may be observed during changes in body positions and are likewise clinically unimportant </li></ul></ul><ul><ul><li>For IAP to be considered elevated in a clinically significant fashion, the elevation has to be sustained </li></ul></ul><ul><ul><li>The value at which IAP is considered elevated is a matter of debate, however, since alterations in physiology may be observed even at relatively mild elevations to about 12 mm Hg, the value supported by consensus ), an APP of 60 mm Hg or less, recorded by a minimum of two standardized measurements conducted 1 to 6 hours apart. </li></ul></ul><ul><ul><li>Consensus definition of the World </li></ul></ul><ul><ul><li>Society of Abdominal Compartment Syndrome </li></ul></ul>Definitions
  7. 7. Abdominal Compartment Syndrome <ul><li>ACS should be diagnosed in the presence of peak IAP of 20 mm Hg or more with or without APP below 50 mm Hg on two measurements 1 to 6 hours apart, and one or more organ-system failures that was not previously present as defined by sequential organ failure assessment (SOFA) score of 3 or more (or an equivalent scoring system </li></ul><ul><li>For clinical purposes, ACS is better defined as IAH-induced new organ dysfunction without a strict intraabdominal pressure threshold, since no intraabdominal pressure can predictably diagnose ACS in all patients  </li></ul><ul><ul><li>Consensus definition of the World </li></ul></ul><ul><ul><li>Society of Abdominal Compartment Syndrome </li></ul></ul>Definitions
  8. 8. Types of ACS <ul><li>Primary Abdominal Compartment Syndrome </li></ul><ul><ul><li>ACS developing in a person where the proximate cause of the ACS is intraabdominal/pelvic pathology that usually requires abdominal surgery and/or angio-radiologic intervention. The pathology may be traumatic and/or inflammatory in nature </li></ul></ul><ul><li>Secondary Abdominal Compartment Syndrome </li></ul><ul><ul><li>ACS developing due to increased volume of intraabdominal contents from accumulation of fluid and/or visceral swelling, and where the proximate cause of the increase in volume is not any intraabdominal/pelvic pathology requiring abdominal surgery and/or angio-radiologic therapy. Secondary ACS is usually observed during massive volume resuscitation for major nonabdomino/pelvic injuries, burns, severe acute pancreatitis, septic shock from a nonabdomino/pelvic infective source, and so forth </li></ul></ul>
  9. 9. <ul><li>Tertiary Abdominal Compartment Syndrome </li></ul><ul><ul><li>ACS that develops or persists despite previous attempts to prevent or treat primary or secondary ACS </li></ul></ul><ul><li>Hyperacute Abdominal Compartment Syndrome </li></ul><ul><ul><li>A very early form of secondary ACS that develops while surgical and/or angio-radiologic control of an injury is being carried out simultaneous with massive volume resuscitation for the shock caused by the same injury </li></ul></ul>Types of ACS
  10. 10. How to measure IAP <ul><li>Methods </li></ul><ul><li>IAP can be measured directly by accessing the peritoneal cavity. This method has been used during laparoscopic procedures but is impractical due to the invasiveness and risk of infection outside the operating room </li></ul><ul><li>Intraabdominal pressure can be measured indirectly using intragastric, intracolonic, intravesical (bladder) , or inferior vena cava catheters </li></ul><ul><li>Measurement of bladder pressure has become the standard method to screen for IAH and ACS </li></ul>
  11. 11. <ul><li>The drainage tube of the patient's Foley (bladder) catheter is clamped. </li></ul><ul><li>The transducer should be zeroed at the level of the midaxillary line </li></ul><ul><li>Sterile saline (50-100 mL) is instilled into the bladder via the aspiration port of the Foley catheter. </li></ul><ul><li>An 18-gauge needle attached to a pressure transducer is inserted into the aspiration port. </li></ul><ul><li>The pressure is measured at end-expiration in the supine position after ensuring that abdominal muscle contractions are absent. </li></ul>
  12. 13. <ul><li>Patients who have severe systemic sepsis from any source, especially those where the source is within the abdomen </li></ul><ul><li>Patients undergoing massive fluid resuscitation for shock, usually septic or traumatic, especially where the source of hemorrhage is within the abdomen </li></ul><ul><li>Patients undergoing abdominal damage control surgery </li></ul><ul><li>Patients who have an intraabdominal catastrophe such as severe pancreatitis, bowel necrosis, and so forth </li></ul><ul><li>Patients undergoing large-volume resuscitation for major burn injuries </li></ul><ul><li>All such patients should be monitored for the development of ACS usually by intermittent bladder pressure measurements </li></ul><ul><li>In addition any critically ill patient with acute cardio-respiratory deterioration should be evaluated for the development of ACS </li></ul>Risk Factors
  13. 14. Pathophysiology IAH and ACS have numerous implications on end-organ function within and far outside the abdominal cavity ORGAN FAILURE Progressive Cellular Injury Cellular Death Metabolic Acidosis Anaerobic Metabolism Inadequate O2 delivery Edema
  14. 15. Cardiac Pathophysiology Preload Contractility Afterload Compression of the inferior vena cava Decreasing venous return from the lower half of the body Raises the diaphragm, leading to increased intrathoracic pressure IAP <ul><li>Venous return </li></ul><ul><li>Systemic and pulmonary </li></ul><ul><li>vascular resistance </li></ul>Cardiac Output Stroke volume CVP PCWP
  15. 16. Pulmonary Reduction in minute ventilation Lung compression Pathophysiology IAP Elevation Of diaphragm Intrathoracic Pressure Tidal Volume Atelectasis Hypoxia Hypercarbia Cardiac manifestations
  16. 17. Gastointestinal Animal studies have demonstrated profound reductions in mesenteric and hepatic blood flow occurring with ACS The mucosa seems to be the most sensitive to these reductions Pathophysiology Gut Perfusion mucosal hypoxia and acidosis Ischemia Necrosis bacterial translocation SIRS IAP
  17. 18. Renal Pathophysiology IAP Renal Veins & Arteries Compression Renal Perfusion GFR Urine output Renal Failure + CO If untreated
  18. 19. CNS Pathophysiology IAP Intrathoracic Pressure Sup. VC Preassure Drainage Of SVC CVP IJ Pressure ICP Cerebral Edema Brain Anoxia & Injury
  19. 21. Prevalence of intra-abdominal hypertension in critically ill patients <ul><li>Malbrain et al, Intensive Care Med 2004 </li></ul><ul><li>Prospective multicenter trial: 13 ICU’s in 6 countries </li></ul><ul><li>97 patients included in the study with >24hrs expected stay in ICU </li></ul><ul><li>IAP measured q 24 hrs </li></ul>
  20. 22. Prevalence of intra-abdominal hypertension in critically ill patients Malbrain et al, Intensive Care Med 2004 Conclusion: This study suggests that IAP should be routinely measured Abdominal pressure Total Prevalence MICU prevalence SICU prevalence IAP > 12 58.8% 54.4% 65% IAP > 20 plus organ failure 8.2% 10.5% 5.0%
  21. 23. IAP as a Prognostic Factor IAP is an independent predictor of ICU morbidity and mortality Table: incidence of adverse outcome post major surgery Surgue, Arch Surg 1999 Mortality Abdominal Sepsis Oliguria Renal Impairment IAP 8% 5% 15% 15% Normal 45% 17% 38% 69% > 20
  22. 24. Treatment Threshold <ul><li>In balance, all patients at risk of developing ACS should be monitored by frequent bladder pressure measurements </li></ul><ul><li>Patients who develop organ system dysfunction that, in the judgment of the treating physician, can be causally related to IAH should have therapy initiated </li></ul><ul><li>If the patient has increasing IAP but does not have any organ system dysfunction, then the monitoring should continue with close observation for the development of organ system dysfunction, so that therapy can be initiated at the earliest sign of dysfunction </li></ul><ul><li>Finally, almost all patients with IAP greater than 20 mm Hg and rising, even without evidence of organ system dysfunction, should have therapy for impending ACS </li></ul>
  23. 25. Treatment of Abdominal Compartment Syndrome <ul><li>Therapy for ACS or impending ACS is aimed at reducing IAP </li></ul><ul><li>In the large majority of patients, this entails surgical decompression by performance of a laparotomy and leaving the abdomen open until the visceral swelling and/or the fluid accumulation within the abdomen is diminished to a point that the IAP will not rise to pathological levels on abdominal closure </li></ul><ul><li>As this is fairly radical therapy with significant morbidity, less invasive medical therapy has been attempted </li></ul>
  24. 26. Medical (Minimally Invasive) Management <ul><li>Medical therapy consists of one or more of </li></ul><ul><li>Neuromuscular blockade </li></ul><ul><li>Needle/tube drainage of intraabdominal fluid </li></ul><ul><li>Continuous external negative pressure therapy by special custom-made devices </li></ul><ul><li>Positive end-expiratory pressure (PEEP) may reduce ventilation-perfusion mismatch and improve hypoxemia </li></ul><ul><li>Volume administration temporarily improves cardiac output, renal blood flow, urine output, and visceral perfusion. It also minimizes the potentially negative effects of PEEP on cardiovascular function </li></ul><ul><li>Although the central venous and pulmonary capillary wedge pressures are usually elevated, there is no role for diuretic therapy in the resuscitation of patients with ACS </li></ul>Treatment
  25. 27. Surgical Therapy <ul><li>decompressive laparotomy with the abdomen left open is the most often-used treatment modality for impending or actual ACS </li></ul><ul><li>The available evidence in favor of its use is class II at best and is based on expert opinion and case control studies </li></ul>Treatment
  26. 28. <ul><li>A generous midline laparotomy, then the abdomen is left in the open state </li></ul><ul><li>The method of management of the open abdomen should be </li></ul><ul><ul><li>Performed rapidly </li></ul></ul><ul><ul><li>Prevent heat loss from the internal viscera </li></ul></ul><ul><ul><li>Protect the swollen viscera </li></ul></ul><ul><ul><li>Allow relatively free egress of the large amount of fluid that may accumulate within the cavity with continued resuscitation </li></ul></ul><ul><ul><li>In addition the method should not damage the fascia and skin so that formal closure can be achieved later </li></ul></ul><ul><li>A large plastic sheet is laid over the bowel and tucked deep in the paracolic gutters laterally, over the stomach/spleen and liver superiorly, and deep in the pelvis inferiorly </li></ul><ul><li>This sheet not only protects the internal viscera and prevents heat loss, but it also prevents adhesion formation between the bowel surface and the abdominal wall, allowing for formal fascial closure at a later date </li></ul><ul><li>Small perforations are made in this sheet to allow fluid egress </li></ul>Decompressive laparotomy Treatment
  27. 29. Treatment Decompressive laparotomy
  28. 30. <ul><li>Patient with grossly distended abdomen and abdominal compartment syndrome. </li></ul><ul><li>Patient following trauma with secondary intraperitoneal sepsis, grossly distended abdomen and impending wound dehiscence for a re-laparotomy </li></ul>
  29. 31. <ul><li>Patient with a vacuum-assisted closure dressing in place, controlling abdominal secretions on low suction. </li></ul>
  30. 32. <ul><li>For patients in whom recovery progresses rapidly with brisk diuresis and resolution of bowel edema, it may be possible to achieve fascial closure within 5 to 7 days </li></ul><ul><li>In many instances, however, this does not happen, or the patient develops some septic complication and the bowel becomes swollen again </li></ul>Treatment Decompressive laparotomy
  31. 33. <ul><li>Abdominal compartment syndrome was confirmed by measurement of his intra-abdominal pressure. This was measured via an intra-vesical cathete and a reading of 28cmH20 was obtained. Following discussion with the surgical team the decision was made to undertake decompressive laparotomy. On opening the abdomen peak inspiratory pressures fell immediately. No active bleeding was found but large intra-abdominal and retro-peritoneal haematomas were evacuated </li></ul><ul><li>Primary abdominal closure was not possible. Temporary closure was achieved using part of a sterile opened intravenous fluid bag, stitched to the abdominal wall. The patient was then returned to the ICU, still ventilated but requiring much reduced ventilatory support.  Subsequent progress was complicated by sepsis, secondary to ventilator associated pneumonia, but on day 7 he underwent closure of his abdominal wound. Two days later he underwent internal fixation of his pelvic fractures and was discharged home one week later </li></ul>CASE SUMMARY
  32. 34. Conclusion <ul><li>Raised IAP leads to IAH that can cause organ system dysfunction, and this combination of IAH and organ system dysfunction is termed ACS </li></ul><ul><li>30-50% of all ICU patients have some IAH and are at risk for ACS </li></ul><ul><li>There remain many areas of confusion in terms of terminology, diagnosis, appropriate treatment threshold, and the best treatment </li></ul><ul><li>Any patient with organ system dysfunction or impending dysfunction in association with IAH should have prompt therapy </li></ul><ul><li>Although there are some medical therapies that show some promise, the best therapy to rapidly decrease IAP and reverse the organ system dysfunction remains surgical decompressive laparotomy and leaving the abdomen open </li></ul><ul><li>The open abdomen can be associated with significant morbidity, hence, extreme care is necessary in the management of such patients </li></ul>