Management Strategies and Case Discussion - B Periera, President of the World Society of Abdominal Compartment Syndrome

1. INTRA-
ABDOMINAL
HYPERTENSION
ABDOMINAL
COMPARTMENT
SYNDROME

2. BRUNO M
PEREIRA
MD, MHSc, PhD, FACS,
FCCM
● Trauma Surgery &
Surgical Critical Care
● Associate Professor of Surgery
and Surgical Critical Care
University of Campinas/ BR
● WSACS PRESIDENT (2017-2019)
Speaker ConvaTec/ Acelity/ Harttmann

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)
● NEW ONE IN 2019
www.wsacs.org

4. 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

5. IAH / ACS
MANAGEMENT OF
● Basic Principles
● Continuous monitoring of IAP
● Optimization of systemic
perfusion and organ function
● Institution of specific medical
interventions to reduce IAP
● Immediate surgical
decompression for IAP refractory
to previous interventions

6. TICU
RYDER TRAUMA CENTER PROTOCOL

7. Sepsis / SIRS / Ischemia Reperfusion
IAP MONITORING
INDICATIONS FOR
● Sepsis and resuscitation with > 6 liters crystalloid / colloid or > 4 units blood in 8 hours¹ ³ (1-3)
● Pancreatitis (4,5)
● Peritonitis (2, 3, 6)
● Ileus / Bowel obstruction (2, 3, 7, 8)
● Mesenteric ischemia / necrosis (9)
Visceral compression / Reduction
● Large ascites / peritoneal dialysis (3, 6, 10, 11)
● Retroperitoneal / abdominal wall bleeding (12, 13)
● Large Abdominal tumor (6, 10)
● Laparotomy closed under tension (14, 15)
● Gastroschisis / Omphalocele (16-18)
Surgical
● Intra-operative fluid balance > 6 liters (19)
● Abdominal aortic aneurysm repair (20-23)
Trauma
● Shock requiring resuscitation (ischemia-reperfusion) (3, 24, 25)
● Damage Control Laparotomy
● Multiple trauma resuscitation with > 6 liters crystalloid / colloid or > 4 units blood in 8 hours
(24,25,27,29,30)
● Major bruns (> 25%) (11, 31-34)
IF TWO
RISK FACTOR
IS PRESENT, AN IAP
MUST BE
OBTAINED
IF IAH
IS PRESENT, A
SERIAL MEASUREMENT
OF IAP MUST BE
PERFORMED
THROUGHOUT
THE PATIENT'S
CRITICAL PHASE
APP SHOULD
BE MAINTAINED
BETWEEN 50-60 mmHg
IN PATIENTS WITH
IAH / ACS

8. ACS MANAGEMENT
6 STEPS FOR
Evacuate intraluminal
intestinal contents1
Empty abdomial extra-luminal
contents and / or retroperitoneal2
Improve abdominal
compliance3
Optimize fluid administration
(balanced resuscitation / vasopressor?)4
Optimize tissue
perfusion5
Indicate early surgical
intervention6

9. ABDOMINAL COMPARTMENT
WORLD SOCIETY OF
SYNDROME

10. CONGRESS
6˚ WSACS

11. ABDOMINAL COMPARTMENT
WORLD SOCIETY OF
SYNDROME

13. USPOC in IAH/ ACS

15. • CDS, Fem., 49 y/o
• Heavy Smoker
• Submitted to Dermolipectomy + Liposuction
+ Breast augmentation
• Surgical procedure reported as with no
problems
• Discharged on 1st PO day
Case Report
IMMEDIATE POD

16. • Back to ER complaining of abdominal Pain
• Can’t contact the Surgeon
• Opted to prescribe some pain killers
• Good response to pain
• Discharged home
Case Report
2˚ PO day

17. • Back to ER complaining of abdominal pain, leg
swelling, difficulty to walk
• ER physician thought on perfurated bowel
(Liposuction) – normal abdominal and Chest
X-ray
• Surgeon is outside of the country –
unreachable
• Discharged after normal labs and analgesia
with Morphine
Case Report
4˚ PO day

18. • Low LOC (RASS -2), hypotensive, diaphoretic
• Brought by her family
• Shock diagnosis performed - 4 L of crystalloids,
VAD (norepinephrine)
• LAB’s, new Chest XR, Abdominal CT Scan
• ICU
Case Report
7˚ PO day

22. • Refractory shock management installed
• OTT + MV
• FIO2 80%, PCAV, PEEP 10, hypoxemic on
ABG’s
• Anuria
• Emergency Surgery team called in
Case Report
ICU

27. NEW SEPSIS
AFTER 36 HOURS

30. BRUNO MT
PEREIRA
MD, MSc, PhD, FACS,
FCCM, FSACS
● Trauma Surgery &
Surgical Critical Care
● Associate Professor of Surgery
and Surgical Critical Care
University of Campinas/ BRAZIL
WORLD SOCIETY OF THE
ABDOMINAL COMPARTMENT (WSACS)
PRESIDENT (2017-2019)
Dr.bruno@gruposurgical.com.br