ABDOMINAL COMPARTMENT SYNDROME

1. Hypoperfusion, Shock States, and
Abdominal Compartment
Syndrome (ACS)
Koen Ameloot ,MD, Carl Gillebert, MD, Nele Desie, MD, Manu L.N.G. Malbrain, MD, PhD
Surgical Clinics of North America
Volume 92, Issue 2 , Pages 207-220,
April 2012
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2. DEFINITIONS
• INTRA ABDOMINAL PRESSURE (IAP) varies
from individual to individual and is influenced
by body mass index , body position, and the
severity of a patient’s critical illness.
• NORMAL ADULT IAP IS CONSIDERED 5-7 mm
Hg.
• INTRA ABDOMINAL HYPERTENSION(IAH) is
defined as sustained increased IAP greater
than or equal to 12 mm Hg.
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3. Cont…
• ABDOMINAL COMPARTMENT SYNDROME
(ACS) is defined as IAP greater than or equal
to 20mm Hg with organ dysfunction or
failure.
• ACS is seen when IAP leading to organ
dysfunction hence need urgent abdominal
decompression.
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4. EPIDEMIOLOGY
• A Multicentric study reported, IAH present in
32% of critically ill medical and surgical ICU
patients.
• ACS present in 4% of patients.
• The author has concluded that elevated IAP is
responsible for developing organ failure hence
suggested that IAH may be a key factor in the
development of multiple system organ failure ,
a major cause of ICU mortality.
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5. MEASUREMENT OF IAP
• IAP is difficult to detect by clinical examination
alone.
• Assessment of IAP is done by measuring
intravesicular or bladder pressure.
• Alternately , IAP can be measured continously
via a ballon tipped nasogastric tube in
stomach.
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6. PHYSIOLOGY
IAP ↑
VASCULAR
COMPRESSION
↓ INFERIOR VENACAVA
FLOW
↓ CARDIAC PRELOAD
↓ CARDIAC OUTPUT
↓ ABD PERFUSION
PRESSURE
↑IAP
ORGAN
COMPRESSION
↑RENIN & ALDOSTERONE
↑SYSTEMIC AFTERLOAD
↓CARDIAC OUTPUT
↓ABD PERFUSION
PRESSURE
↑IAP
DIAPHRAGM
ELEVATION
CARDIAC COMPRESSION
↓CARDIAC
CONTRACTILITY
↓ CARDIAC OUTPUT
↓ABD PERFUSION
PRESSURE
↑IAP
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7. CHANGES IN CVS
• Decreased cardiac output
• Decrease preload
• Decrease cardiac contractility
• Increase afterload
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8. EFFECTS ON LUNG
• Increased IAP is transmitted to thorax and it
leads to increase ITP.
• Result being hypoxemia and hypercapnia.
• Other causes of lung oedema in post
operative cases are
• capillary leaks ,
• positive fluid balance.
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9. EFFECTS ON END ORGAN PERFUSION
• CNS lead to decrease cerebral perfusion
pressure.
• KIDNEY-decreases renal venous and arterial
flow , leading to renal dysfunction and failure.
• GASTROINTESTINAL-all intra abdominal and
retroperitoneal organ demonstrate
hypoperfusion , Which may lead to multi organ
dysfunction and failure if not treated.
• HEPATIC-No specific effect seen.
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10. TREATMENT OF ACS
• Patient to be resuscitated to maintain APP
(Abdominal perfusion Pressure) of 50 mm to
60mm Hg through judicious fluid resuscitation
and application of VASOPRESSOR /INOTROPIC
AGENTS.
• If APP cannot be maintained then immediate
abdominal decompression should be done.
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11. • In surgical patient ,decompression laparotomy
or temporary abdominal closure if abdomen
has been already opened.
• This operation dramatically improves cardiac
function and other organ perfusion.
• In medical patient , whose IAP is secondary to
accumulation of ascites , paracentesis should
be considered.
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12. • In medical patient , IAH without ACS , ileus
should be corrected , and diuretics or renal
replacement therapy in combination with
albumin should be used.
• Patient whose IAH secondary to
retroperitoneal hemorrhage or visceral
odema or ileus are best achieved by open
abdominal decompression.
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13. SUMMARY
• Any factor which results in intra abdominal
pressure more than 25 mm of Hg will
adversely affect all tissue leading to multi
organ dysfunction /failure.
• Hence be on watch to control it by various
means as described above to prevent multi
organ failure and dysfunction in critically ill
patient.
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14. THANKING YOU
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