1) The splanchnic circulation supplies blood to the gastrointestinal tract and accounts for 30% of total cardiac output. It is regulated by intrinsic, humoral, and extrinsic factors. Disorders include ischemic reperfusion injury and sepsis. 2) Abdominal compartment syndrome occurs when intra-abdominal pressure exceeds 20 mmHg and leads to organ dysfunction. It can be caused by diminished abdominal wall compliance, increased abdominal contents, or fluid resuscitation. 3) Abdominal compartment syndrome causes cardiovascular, respiratory, renal, and central nervous system effects by increasing intra-abdominal and intrathoracic pressures. Management includes lowering intra-abdominal pressure non-surgically or with

1. Dr. Dinesh Mannapperu
Registrar Anaesthesia
TH- Kandy
Splanchnic Circulation
24th June 2016

2. • Briefly describe the splanchnic circulation.
• What is abdominal compartment syndrome
• What are the pathophysiological effects of abdominal compartment
syndrome
• Out line the management of abdominal compartment syndrome.
• Splanchnic circulation in Anaesthesia and critical care.
Objectives

5. Briefly describe the splanchnic circulation. 30%

6. • Coeliac artery T12
1. Common Hepatic
2. Left gastric
3. Splenic

7. • Superior mesenteric artery L2
1. Inferior pancreatico duodenal
2. Intestinal arteries
3. Ileocolic
4. Right colic
5. Middle colic

8. • Inferior mesenteric L3
1. Left colic
2. Sigmoid branches
3. Superior rectal
SBF about 25-30% of COP
30ml/min/100g ( <10ml/min/100g-250ml/min/100g)
Highly adaptive and act as a reservoir of blood

9. Physiological regulation of SBF
Intrinsic
control
Humoral control
Extrinsic
control
Metabolic
H+, K+ , adenosine , CO2
, hypoxia
Myogenic
Mechano sensitive Na+
Channels,
Depolarization,
Ca2+ channels
Sympathetic NS
Noradrenaline mediated
- adrenergic
vasoconstriction
Parasympathetic NS
Vagal and pelvic nerves
M1 mediated NO release
Vasodialators
Bradykinin, gastrin,
secretin, cholecystokinin,
substance P, dopamine,
Vasoconstrictors
Vasopressin, Angiotensin
ii,
Neuropeptide Y,

10. Disorders of Splanchnic Blood flow
1. Ischemic reperfusion injury
2. Sepsis /gut origin hypothesis
3. Portal hypertention
What is abdominal compartment syndrome 5%

11. • Intra Abdominal Hypertention.
Normal IA pressure is 5-7mmHg, if it increases more than 12mmHg
• Intra Abdominal Compartment syndrome
When IA pressure exceeds 20mmHg .
• Grade 1 - 12–15 mm Hg;
• Grade 2 - 16–20 mm Hg;
• Grade 3 - 21–25 mm Hg;
• Grade 4 - >25mm Hg.
Definitions
What is abdominal compartment syndrome 5%

12. 1. Diminished abdominal wall compliance
Acute respiratory failure, especially with elevated Intra thoracic
pressure
Abdominal surgery with subjectively tight primary closure
Major trauma/burns
Prone positioning, head of bed elevated >30°
High BMI, central obesity
Causes for IA compartment syndrome

13. 2. Increased intra-luminal contents
Gastroparesis
Ileus
Colonic pseudo-obstruction
3. Increased abdominal contents
Haemoperitoneum/ pneumoperitoneum
Ascites/liver dysfunction

14. 4. Capillary leak/fluid resuscitation
 Acidosis (pH <7.2)
 Hypotension
 Hypothermia (core temperature <33°C)
 Polytransfusion (>10 units of blood/24 h)
 Coagulopathy (platelets ,55 000 mm-3, prothrombin time >15 s,
partial thromboplastin time 2 times normal, or international
standardized ratio >1.5)

15.  Massive fluid resuscitation (>5 litre/24 h)
 Pancreatitis
 Oliguria
 Sepsis
 Major trauma/burns
 Damage control laparotomy

16. Abdominal Perfusion Pressure = MAP - IAP
Measurement of IA pressure

17. 1. Direct methods
2. Indirect methods
• Intra-gastric
• Intra-uterine
• Rectal
• Intra-vesicular

19. What are the pathophysiological effects of
Abdominal Compartment Syndrome 15%

20. Cardiovascular System
• Increase IAP Direct pressure over abdominal vasculature
Compression of IVC Compression of Aorta
Reduce preload Increase afterload
Increase intra
thoracic
pressure
Reduce compliance and
contractility Reduce COP
Catastrophic intra abdominal ischaemia

21. • basal collapse/atelectasis,
• increasing V/Q mismatch
• decreased pulmonary and chest wall compliance
• increasing hypoxia and hypercarbia
• increased inspiratory pressures and PEEP in ventilated pts can
further compromise VR and COP
Respiratory system

22. •Treatment of intra-abdominal hypertension
has been associated with reduced ventilatory
days

23. Renal system
Reduced GFR
Reduced RBF
Reduced COPIncresed IAP
renal outflow
tract

24. FG = ( MAP – IAP ) -PTP
Normal PTP=15-18mmHg

25. FG = ( MAP - IAP ) - IAP
= MAP - 2IAP
If PTP = IAP, then

26. Hormonal effects from activation of the renin/angiotensin
system and increased ADH have a further adverse effect.

27. Central nervous system
Increased IAP Increased intra thoracic pressure
Reduced venous return
Increased ICP
hypercarbia
Cerebral
vasodilatation

28. • The decrease in gut perfusion
• increased venous obstruction leading to bowel wall oedema.
leading to bowel ischaemia
• loss of cellular integrity, and translocation of bacteria into the systemic
circulation
Gastrointestinal system

29. Hepatic blood flow within the hepatic artery, vein, and
portal system is also adversely affected, leading to
mitochondrial dysfunction and eventually liver
dysfunction and failure.

30. Out line the management of abdominal
compartment syndrome.
Non-surgical
management
surgical
management
Lowering intra abdominal pressure
Organ support
open abdomen

31. • supine positioning ?? Aspiration
• passing a nasogastric tube
• Enemas, flatus tubes, aperients, and pro-kinetic agents
• endoscopic or percutaneous decompression of the
gastrointestinal tract
• Avoid Coughing, straining, and ventilator dyssynchrony
Lowering intra abdominal pressure

32.  optimize cardiac output
 target’ abdominal perfusion pressure of 60 mm Hg
 Initial fluid resuscitation should be aimed at restoring normovolaemia.
 inotrope or vasopressor
 Renal replacement therapy may be necessary
 Lung protective strategies
Organ support

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