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Abdominal Compartment Syndrome

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James Urry

on 16 September 2014

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Transcript of Abdominal Compartment Syndrome

Abdominal Compartment

An often discussed but under-recognised problem in ICU
Dr R J Urry
Critical Care Medical Officer
Edendale Hospital 2RICU
A Brief History of Abdominal Compartment Syndrome
Identified for the first time in the late 80's.
Four patients who received more than 25L each of resuscitation fluid after abdominal aneurysm repair.
Noted to have increased ventilatory pressures, central venous pressures and decreased urine output.
World Society on Abdominal Compartment Syndrome founded in 2004.
Important Definitions
Intra-abdominal pressure (IAP) is the steady-state pressure concealed in the abdominal cavity.
Intra-abdominal hypertension (IAH) is sustained or repeated pathologic elevation in IAP >= 12mmHg.
Abdominal compartment syndrome (ACS) is sustained IAP > 20mmHg associated with new organ dysfunction or failure.
Significance of ACS
Nearly 50% of all ICU patients are at risk for IAH.
Nearly 8% of all ICU patients are at risk for full blown ACS.
ACS is more prevalent in medical than surgical ICU patients.

IAH during an ICU stay is an independent predictor of outcome.

(Malbrain ML et al. Intensive Care Med 2004; 30:822-9)
(Malbrain ML et al. Crit Care Med 2005; 33:315-22)
Is IAP being measured and are IAH and ACS being and identified?
Numerous reports on critical care physicians knowledge on IAH and ACS.
Despite increasing literature, there is a lack of clinical awareness.
No consensus on timing of IAP measurement.
Many ICUs never measure IAP.
When measured, often only if thought to be clinically relevant, seldom routine.
(Malbrain ML, De Laet. Clin Chest Med 2009; 30: 45-70)
Risk Factors for IAH and ACS
Conditions that decrease abdominal wall compliance.
Conditions that increase intraluminal contents.
Conditions that cause abdominal collections of fluid, air or blood.
Conditions related to capillary leak and fluid resuscitation.
(World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2006; 32: 951-962)
Measuremend of IAP
Pressure measured at one point in the abdomen represents the pressure in the entire compartment (Pascal's Law).
Measurement of intravesical pressure is the gold-standard for intermittent IAP measurement.
Measured in cmH2O but interpreted in mmHg.
1mmHg = 1.36 cmH2O (divide by 1.36).
Grading of IAH and ACS
Normal IAP 0-5mmHg.
Grade I - IAP 12-15 mmHg.
Grade II - IAP 16-20 mmHg.
Grade III - IAP 21-25 mmHg.
Grade IV - IAP > 25 mmHg.
ACS - > 20mmHg and new organ dysfunction.
(World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2006; 32: 951-962)
Abdominal Perfusion Pressure
Abdominal Perfusion Pressure (APP) is analogous to cerebral perfusion pressure in the brain.
APP < 60mmHg insufficient to perfuse the abdominal organs.
In which patients should IAP be measured?
Routine IAP measurement in all ICU patients is not practiced or indicated.
Indicated when two or more risk factors for IAH present - WSACS risk factors.
Measured every 4-6 hours in patients with evolving organ dysfunction, but can be increased to hourly.
Stop measuring when risk factors resolved, there are no signs of organ dysfunction or IAP < 12 for 48 hrs.
Medical Measures to Reduce Intra-abdominal Pressure
Improve abdominal wall compliance
Sedation, analgesia, muscle relaxation.
Evacuate intra-luminal contents
Nasogastric, rectal decompression.
Evacuate abdominal fluid collections
Drain ascites, collections.
Correct positive fluid balance
Avoid excessive fluid resuscitation, diuretics, hemodialysis / ultrafiltration.
(World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2006; 32: 951-962)
Surgical Decompression in ACS
Surgical decompression (decompression laparotomy) remains the only definite management for ACS.
Indicated when measures to lower IAH fail to prevent ACS.
During surgical decompression complex anesthetic challenges need to be solved.
After decompression the patient is at risk for ischemia reperfusion injury, venous stasis, and pulmonary embolism.
(World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2006; 32: 951-962)
Andrade et al. Clinics 2007, 62(6)
Fluid resuscitation and ACS
Fluid overload is cause of IAH.
Fluid resuscitation is the foremost step in hypovolaemic shock, burns and septic shock.
Early administration of isotonic crystalloids is the current gold-standard.
In the presence of capillary leak, crystalloid administration can lead to tissue oedema and the development of a polycompartment syndrome, ultimately leading to multiple organ failure and death.
Acute Intestinal Distress Syndrome (AIDS).
A severe enough stimulus (such as infection, trauma, burns, and sepsis) can lead to activation of the immune system, neutrophil activation and release of cytokines resulting in systemic inflammatory response syndrome (SIRS) and capillary leak.
This mechanism of injury is recognised in the lung, where it is called ALI or ARDS.
The same pathologic process occurs in the gut, and can be called Acute Intestinal Distress Syndrome.
(Malbrain ML, De Laet. Clin Chest Med 2009; 30: 45-70)
PEEP-Albumin-Lasix (PAL) Treatment
In the polycompartment syndrome, achievement of negative fluid balance achieves improved survival.
PAL-treatment combines high levels of positive end-expiratory pressure (PEEP), small volume resuscitation with hyperoncotic albumin, and fluid removal with furosemide or ultrafiltration during continuous renal replacement therapy (CRRT).
Cordemans et al. Annals of Intensive Care 2012, 2(Suppl 1): S15
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