Transcript Abdominal Compartment Syndrome

Abdominal Compartment
Syndrome
John Hartley
Academic Surgical Unit
The University of Hull
Abdominal Compartment
Syndrome (ACS)
Definition
“The adverse physiological consequences of
an acute elevation in intra-abdominal pressure”
- Oliguria
- Increased airway pressures
- Reduced cardiac output
Abdominal Compartment
Syndrome
Historical background
The perils of elevated intra-abdominal pressure…
• 1890’s elevation of IAP caused death in animal
models
• 1911 cardiovascular effects of raised IAP
identified
• 1913 effects of raised IAP on renal function
• 1980’s abdominal decompression for  IAP
Abdominal Compartment Syndrome
Acute elevation IAP >30mmHg
Post-op
Oliguria in 11 pts
7 pts
Re-exploration
Decompression
4 pts
Not re-explored
Immediate diuresis
Renal failure
and died
Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30
Abdominal Compartment Syndrome
Pathophysiology
 abdominal pressure
ICP
Compression of kidneys
 Venous return
 Intrathoracic pressures
 Renal blood flow
 Urine output
 CO
 VEDV
 SV
 SVR
 Oxygen delivery
Hypoxaemia
 Airway pressures
 Compliance
 PA pressures
 CVP readings
Abdominal Compartment Syndrome
Causes of raised intra-abdominal pressure (IAP)
Retroperitoneal
Intraperitoneal
Oedema in necrotising pancreatitis
Haemorrhage
Pelvic haematoma
Visceral oedema
Retroperitoneal haematoma
Abdominal packing
Bleeding after aortic surgery
Bowel dilatation
Oedema related to resuscitation
Mesenteric venous obstruction
Pneumoperitoneum
Acute ascites
Abdominal Compartment Syndrome
At risk patients
• Major trauma
• Damage control surgery
• Laparotomy for bleeding, ischaemia etc
• Re-laparotomy for postoperative
complications
• Massive volume resuscitation
Abdominal Compartment Syndrome
Clinical features
• Abdominal distension
• ELEVATED IAP
• Consequent organ dysfunction
Importance
• Decompression can reverse abnormal physiology
• Probable fatal progression if left untreated
Abdominal Compartment
Syndrome
Measurement of IAP
• Indirect assessment of IAP by bladder
pressure
• 50-100ml saline into bladder
• Manometer readings from symphysis pubis
Abdominal Compartment Syndrome
Problems
• What value of IAP should cause concern?
• Level beyond which ACS is irreversible?
• ABSOLUTE IAP UNHELPFUL
– >20mmHg significant in all pts
– >15mmHg significant in many
– >12mmHg significant in some
Malbrain ML. Intensive Care Med 1999;25:1453-58
Abdominal Compartment Syndrome
Survey of British practice
• 137 of 207 hospitals (66.2% response)
• 1.5% (n=2) no knowledge of ACS
• Some measurement IAP 76% (n=104)
• Upon suspicion of ACS 93% (n=97)
• No consensus on frequency of measurement or indication
for decompression
Ravishankar N, Hunter J.
Br J Anaesth 2005;94:763-6
Abdominal Compartment Syndrome
Incidence
• Prospective measurement of IAP in 9 months
admissions to trauma ICU
• 15 of 706 pts IAH (2%)
• 6 of 15 pts with IAH developed ACS (1%)
• 50% mortality in ACS and 2 of 9 with IAH
Hong JJ, Cohn SM, Perez JM et al Br J Surg
2002;89:591-6
Abdominal Compartment Syndrome
Abdominal decompression
• Reversal of abnormal parameters in approx 80%
• Mean survival approx. 50%
• Intervention too late?
• Inevitable SIRS and MOF?
• PREVENTION BETTER THAN CURE
Sugrue MD’Amour S. J Trauma 2001;51:419
Abdominal Compartment Syndrome
Proposed grading for ACS based on IAP
Grade
IAP
(mmHg)
(cmH2O)
Signs
Treatment
I
10-15
13-20
No signs ACS
Maintain
normovolaemia
II
16-25
21-34
 PAWP + oliguria
? Volume
resuscitation
III
26-35
35-48
Anuria,  CO  PAWP
Consider
decompression
IV
>35
>48
Anuria,  CO  PAWP
Mandatory
decompression
Burch JM, Moore EE, Moore FA et al. Surg Clin North Am 1996;76:833-842
Abdominal Compartment
Syndrome
Abdominal Compartment Syndrome
Conclusions
• Concept of ACS important
• True incidence and significance unclear
• Increasing awareness and measurement of
IAP may lead to:
- Better understanding of pathophysiology
- Evidence based management
Abdominal Compartment
Syndrome
• World Society on
Abdominal
Compartment Syndrome
• www.wsacs.org
• Antwerp 24th-27th March
2007
Abdominal Compartment
Syndrome
Renal effects
• IAP 15-20mmHg  RBF and GFR with anuria when
>30mmHg
• No effect of stenting
• Parenchymal compression and  renal vascular resistance
• Reversible by decompression
Harman PK, Kron IL, McLachlan HD et al Ann Surg
1982;196:594-7
Abdominal Compartment
Syndrome
Gut and hepatic effects
 splanchnic and hepatic blood flow
 flow in animal models with IAP>10mmHg
Ischaemia at >40mmHg
Gastric mucosal acidosis with  IAP improves
with decompression
Ivatury RR, Porter JM, Simon RJ et al J Trauma
1998,44:1016-21
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Abdominal Compartment Syndrome
Other means of detection
• CT changes
- Narrowing of IVC
- Direct renal compression
- Bowel wall thickening
- “Rounded abdomen”
• Splanchnic hypoperfusion and acidosis
• Abdominal perfusion pressure
Abdominal Compartment Syndrome
Management of ACS – the issues
• Indication for decompression
• Timing of decompression
• “point of no return”
• Subsequent laparostomy management
Abdominal compartment syndrome
• Definition
• The adverse physiological consequences
that occur as a result of an acute increase in
IAP
Abdominal compartment syndrome
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Management of ACS
Indication for decompression
Timing of decompression
“point of no return”
Subsequent laparostomy management
Abdominal Compartment
Syndrome
Effects of intra-abdominal hypertension (IAH)
• Gut and hepatic effects
• Renal effects
• Cardiovascular effects
• Respiratory effects
• CNS
• Abdo wall
Abdominal Compartment
Syndrome
Cardiovascular effects
•  venous return by compression of IVC and
portal vein
•  intra-thoracic pressure,  LV compliance,
cardiac contractility and CO
•  peripheral oxygen delivery
Abdominal Compartment
Syndrome
Respiratory effects
• Elevation of diaphragm,  thoracic volume
and compliance,  intra-pleural pressure
•  airway pressures to maintain ventilation
• Compressive atelectasis and V/Q mismatch,
hypoxia, hypercarbia, acidosis
Abdominal Compartment
Syndrome
• Acute elevation of IAP above 30mmHg caused oliguria in
11 postoperative pts
• Re-exploration and decompression in 7 pts resulted in
immediate diuresis.
• 4 pts not re-explored developed renal failure and died.
• If IAP > 25mmHg in the early post period is assoc. with
oliguria and normal blood pressure and cardiac index, the
patient should undergo re-exploration and
decompression of the abdomen
Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30
Abdominal Compartment
Syndrome
CNS effects
• Impaired venous return and cerebral pooling
•  intra-cranial pressure
Ertel W, Oberholzer A, Platz A et al Crit Care
Med 2000; 28:1747-53
Abdominal Compartment Syndrome
Early detection
• Survey trauma surgeons USA
• 6% measured IAP routinely
• 59% selectively
Mayberry JC, Goldman RK, Mullins RJ.
J Trauma 1999;47:509-513