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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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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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