Definitions and Consensus Statement - B Periera, President of the World Society of Abdominal Compartment Syndrome

1. INTRA-
ABDOMINAL
HYPERTENSION
ABDOMINAL
COMPARTMENT
SYNDROME

2. BRUNO MT
PEREIRA
MD, MSc, PhD, FACS,
FCCM
● Trauma Surgery &
Surgical Critical Care
● Associate Professor of Surgery
and Surgical Critical Care
University of Campinas/ BR
● PRESIDENT WSACS 2017-2018

3. WSACS
CONSENSUS
● A variety of previous definitions led to confusion
and difficulty in comparing one study with another
● IAH and ACS are recognized as factors that affect
considerably the morbidity / mortality of
critically ill patients
● Consensus Creation
(Intensive Care Medicine 2006; 32:1722-1732)
www.wsacs.org

4. THE STUDY
● 36 Questions
● Sept 2013 – Nov 2013
● 15 Participating Countries
184 Specialists
Portuguese: 64
English: 102
Spanish: 18
5
EXCLUDED
SPAIN (3)/ Finland (1)/ UK
(1)
179

5. IN GENERAL
IAH/ ACS
● 100% are doctors(3% residents or fellows)
● 100% work on ICU
● 43.8% have more than 15 years of experience
● 94.1% answered that are familiar with IAH//ACS
● 89.4% answered that are familiar with APP
● 57.9% affirm that manage less than 5 ACS cases a year
All Americas

6. ● 48.2% consider 6 – 10 mmHg IAP normal value
● Only 22.4% answered correctly
● Only 39.7% recognized the correct definition for ACS
● 33% believe ACS is a pressure above 25 mmHg
94.1% AFFIRM THAT ARE AWARE
ABOUT IAH CONCEPTS
ALTHOUGH

7. WHAT IS
IT?
● IAH = ACS?
● What is IAH? What’s normal?
● What is ACS? Should I intervene? When?
● What are the risk factors?
● What if my patient has an open abdomen...

8. ?

9. OBJECTIVES
1. Recognize IAH / ACS
2 . Manage and Treat

10. ● IAP is the resting pressure contained
in the abdominal cavity
● Increases and decreases according
to the respiratory movements
● Elevated IAP is a common finding in ICU
● It is directly changed by:
PRESSURE?
INTRA-ABDOMINAL
● Volume of internal organs
● Presence of intra-abdominal volume
● Conditions limiting the expansion
of the abdominal wall
DEFINITION 1

11. ● APP = MAP – IAP
● IAP that induces MOF is variant for each patient
● APP demonstrates severity of IAP as well
as abdominal adequacy of blood flow
● APP > IAP> arterial pH> BD> lactate
in predicting prognosis and MOF
● Failure in maintaining APP > 60 mmHg
within 3 days decreases prognosis
PRESSURE?
INTRA-ABDOMINAL
DEFINITION 2

12. ● FG = Glomerular Filtration Pressure –
Proximal Tubular Pressure
● PTP = MAP - (2 x IAH)
● Changes in IAP has a major impact
on renal function and urine production,
increasing finally MAP
● GFP APP
● What is the first sign of elevated IAP?
GRADIENT
FILTRATION
DEFINITION 3
OLIGURIA!

13. ● Normal IAP ranges from 5-7 mmHg
in critically ill patients in the ICU
● IAP will vary with the severity of disease
● IAP above 15 mmHg is associated with
dysfunction and failure of major
intra-abdominal organs leading to
patient’s death
REGULAR IAP
WHAT IS THE
DEFINITION 6
Regular Adult
0-5 mmHg
ICU Patient
5-7 mmHg
After Abdominal Surgery Patient
10-15 mmHg
Septic Shock Patient
15-25 mmHg
Acute Abdomen Patient
25-40 mmHg

14. ● Defined as sustained or repeated pathologic
elevation of IAP > 12 mmHg
● Would IAP 20-25 mmHg safe?
IAH
DEFINITION 7
FAILURE TO INTERVENE
WHEN IAP > 25 MMHG
IS ASSOCIATED WITH
POOR PROGNOSIS

15. CLASSIFICATION
IAH
DEFINITION 8
Grade I
IAH 12 - 15 mmHg
Grade II
IAH 16 - 20 mmHg
Grade III
IAH 21 - 25 mmHg
Grade IV
IAH > 25 mmHg

16. ● Defined as IAP > 20 mmHg (with or without
APP < 60 mmHg) associated with MOF
or isolated organ dysfunction
● ACS = IAH + organ dysfunction
ACS
DEFINITION 9
MOST COMMON CAUSES OF
DYSFUNCTION / ORGAN FAILURE:
● Metabolic acidosis (due to resuscitation), Oliguria
(because of volume repletion), High Airway
Pressure, Refractory Hypercapnia, Hypoxemia
refractory to oxygen support and PEEP,
Intracranial hypertension

17. ● It is a condition associated
with trauma or abdominopelvic
disease that frequently requires
early surgical intervention or
interventional radiology
(interventional radiology)
ACS
PRIMARY
DEFINITION 10 Trauma
Ascites
Tumor

18. ● Refers to conditions which do
not originate from the
abdominopelvic topography
ACS
SECUNDARY
DEFINITION 11
Sepsis
Burns
Massive Volume
Resuscitation

19. ● Refers to the condition where
ACS resurge after medical /
surgical treatment of primary
or secondary ACS
ACS
RECURRENT
DEFINITION 12

20. ● IAP measurement is essential for the
diagnosis and management of IAH / ACS
● Physical examination:
● Sensibility 40 - 61 %
● Positive Predictive Value 45 - 76 %
● The IAP should be measured with the
patient in the supine position and in
expiration with the "zeroed" transducer
at the mid-axillary line
IAP
HOW TO MEASURE
DEFINITION 4
IT IS
NOT
ACCURATE!

21. RISK FACTORS
IAH/ ACS
● Lethal triad
● Multi transfusion /
High volume infusion (>3.5 L /24)
● Pulmonary, renal and / or hepatic dysfunction
● Ileum
● Abdominal Surgery
Risk factors should be assessed at admission
or in the presence of organ dysfunction

22. ● Via bladder instillation of a
maximum of 25 ml saline
● Bladder measurement of IAP
is a safe, fast and
cost-effective method
WHAT IS THE
DEFINITION 5
STANDARD METHOD
FOR MEASURING
THE IAP?

23. One-step
intra-abdominal
pressure monitoring

25. BRUNO M PEREIRA
dr.bruno@gruposurgical.com.br
www.gruposurgical.com.br
PRESIDENTE ELEITO
WSACS 2017 - 2019