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8/9/2019 6.Abdominal Compartment Syndrome
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ABDOMINAL COMPARTMENTSYNDROME
Symptomatic organ dysfunction that results from increased intraabdominalpressure (IAP)
Increased IAP is an under-recognized source of morbidity and mortality.
1-day point-prevalence observational trial conducted in 13 medical ICUs of sixcountries with 97 patients, 8% had IAP > 20mmHg. 1
The incidence of ACS in trauma patients is estimated to be between 2 and 9percent. 2
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8/9/2019 6.Abdominal Compartment Syndrome
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ABDOMINAL COMPARTMENT SYNDROME
Massive volume resuscitation in the leading cause of ACS.
Inflammatory states with capillary leak, fluid sequestration, inadequate tissueperfusion, and lactic acidosis can develop ACS.
Gastric overdistention following endoscopy has resulted in ACS.
ETIOLOGY
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ABDOMINAL COMPARTMENT SYNDROME
The IAP is usually 0 mmHg during spontaneous respiration, and is slightlypositive in the patient on mechanical ventilation.
IAP increases in direct relation to body mass index, and in one report, supinehospitalized patients had a mean baseline value of 6.5 mmHg.
The compliance of the abdominal wall generally limits the rise in IAP butincreases rapidly after a critical IAP.
Critical IAP varies from patient to patient, based on abdominal wall compliance
on perfusion gradient.
IAH often defined as IAP > 12mmHg.
Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wallcompliance and can be protective .
PATHOPHYSIOLOGY
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ABDOMINAL COMPARTMENT SYNDROME
CLINICAL MANIFESTATIONSCENTRAL NERVOUS SYSTEM
Intracranial pressureCerebral perfusion pressure
CARDIAC
HypovolemiaCardiac outputVenous returnPCWP and CVPSVR
PULMONARY
Intrathoracic pressureAirway pressuresCompliancePaO2 PaCO2Shunt fractionVd/Vt
GASTROINTESTINAL
Celiac blood flowSMA blood flowMucosal blood flowpHi
RENAL
Urinary outputRenal blood flowGFR
HEPATIC
Portal blood flowMitochondrial functionLactate clearance
ABDOMINAL WALL
ComplianceRectus sheath blood flow
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ABDOMINAL COMPARTMENT SYNDROME
50 mL of sterile saline is instilled into the bladder via the aspiration port of the
Foley catheter with the drainage tube clamped. An 18-gauge needle attached to apressure transducer is then inserted in the aspiration port, and the pressure ismeasured. The transducer should be zeroed at the level of the pubic symphysis.
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ABDOMINAL COMPARTMENT SYNDROME
MANAGEMENT
PROPOSED GRADING OF ABDOMINAL COMPARTMENT SYNDROME
Grade Pressure (mmHg) Management
I 10-15 Maintenance of normovolemia
II 16-25 Volume administrationIII 26-35 Decompression
IV >35 Re-exploration
Abdominal perfusion pressure (APP):
APP = MAP - IAPIn one retrospective study, the inability to maintain an APP above 50mmHg predicted mortality with greater sensitivity and specificity thaneither IAP or MAP alone .
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ABDOMINAL COMPARTMENT SYNDROME
OPERATIVE DECOMPRESSION
Vacuum-assistedtemporary abdominalclosure device:
thin plastic sheet, asterile towel, closedsuction drains, and alarge adherentoperative drape. Thisdressing systempermits increases inintra-abdominalvolume, without adramatic elevation inIAP.
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ABDOMINAL COMPARTMENT SYNDROME
ACS is a clinical entity caused by an acute, progressive increase in IAP.
Multiple organ systems are affected, usually in a graded fashion.
The gut is the organ most sensitive to IAH.
Treatment involves expedient decompression of the abdomen.
Since this syndrome affects patients who are already physiologicallycompromised, a high degree of suspicion and a low threshold for checkingbladder pressures are required to prevent the mortality associated with thiscomplex problem.
SUMMARY
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