Abdominal Compartment Syndrome: A Practical Algorithm Homer Tien, MD FRCSC Director, Trauma Services Sunnybrook Health Sciences Centre

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Severe burn with ACS in the ICU. What would you do?

A 45 y/o male presents in the ICU with increased abdominal distension and firmness. He had a 50% BSA burn two weeks ago, and has received vigorous fluid resuscitation, and multiple burn surgeries. He is hemodynamically stable. His airway pressure is borderline high, and his urine output is borderline low. Bladder pressure is 26 mm Hg. Abdominal CT scan shows diffuse small bowel edema, a large amount of low density fluid compatible with resuscitation fluid and no other definite intra-abdominal pathology. You would:

A.  Perform a decompressive laparotomy and definitively close the abdomen. B.  Perform a decompressive laparotomy and perform a temp abdo wall closure. C.  Vigorously fluid resuscitate his hypotension and tachycardia. D.  Monitor him in the ICU with serial bladder pressure measurements. E.  Place him in reverse trendelenberg position, place an NG tube, and consider

paracentesis and fluid restriction.

Hemorrhagic shock from pelvic fracture with ACS in the ICU. What would you do?

A 25 y/o male was involved in an MVC. On arrival, he was unstable. CXR and FAST exam were negative. Xray showed a vertical shear pelvic fracture. He was resuscitated vigorously. Angiography was immediately available, and so he underwent embolization of a transected left internal iliac artery. Following angiography, he stabilized and abdominal CT showed diffuse bowel edema, low-density resuscitation fluid and an extremely large retroperitoneal hematoma associated with his pelvic fracture. On arrival to the ICU, he is now hypotensive and tachycardic. His abdomen is distended and firm to palpate. His airway pressure is high, and his urine output is low. Bladder pressure is 26 mm Hg.

A.  Perform a decompressive laparotomy and definitively close the abdomen. B.  Perform a decompressive laparotomy and perform a temp abdo wall closure. C.  Vigorously fluid resuscitate his hypotension and tachycardia. D.  Monitor him in the ICU with serial bladder pressure measurements. E.  Place him in reverse trendelenberg position, place an NG tube, and consider

paracentesis and fluid restriction.

Intra-abdominal Hypertension and Abdominal Compartment Syndrome

•  IAH and ACS: increasing cause of morbidity/mortality in critically ill patients •  Development of IAH independent predictor of outcome in the ICU •  Lack of clarity in definitions/understanding of the two concepts

IAH and ACS

End-Organ Failure

World Society of the Abdominal Compartment Syndrome:

Intensive Care Med. 2006; 32(11): 1722-1732. .

1.  Intra-abdominal pressure (IAP) is the pressure within the peritoneal cavity. 2.  Normal IAP is 5-7 mm Hg in critically ill adults. 3.  Intra-abdominal hypertension (IAH) is defined as sustained elevation of

IAP >= 12 mm Hg 4.  Intra-abdominal hypertension is graded as follows:

5.  Abdominal compartment syndrome (ACS) is defined as a sustained IAP > 20 mmHg

that is associated with new organ dysfunction / failure. 6.  Abdominal Perfusion Pressure (APP) = MAP - IAP

Important Definitions

How do you measure IAP?

Measuring Intra-abdominal Pressure

•  Direct Method – Peritoneal catheter to manometry

•  Indirect Method –  Intra-gastric: NG to manometry – Bladder pressure

•  1 cm H20 = 0.75 mm Hg! •  1 mm Hg = 1.36 cm H20

Measuring Bladder Pressures

Intra-abdominal Pressure Measurements Should be:

Measured in mm Hg

Measured at end expiration

Performed in the supine position

Zeroed at the level of the mid-axillary line

Performed with less than 25 cc of saline into the bladder

Measured 30-60 seconds after instillation to allow bladder detrusor muscle relaxation

Who gets monitored? •  Patients should get screened for risk

factors upon entering ICU, or if new organ failure;

•  If two more risk factors present, IAP should be measured;

•  If IAH present, serial measurements should be made

•  PHYSICAL EXAM/CLINICAL JUDGEMENT ARE NOT RELIABLE!

•  Decreased abdo wall compliance •  Increased intraluminal contents •  Increased abdominal contents •  Fluid resuscitation/Capillary leak

Risk Factors for IAH

How to Treat IAH and ACS

World Society of the Abdominal Compartment Syndrome:

Intensive Care Med. 2007; 33(6): 951-962. .

Managing Intra-abdominal Hypertension Without Organ Dysfunction

Gr 1 IAH 12-15 mmHg Gr 2 IAH 16-20 mmHg Gr 3 IAH 21-25 mmHg Gr 4 IAH > 25 mmHg

WHAT IS PRIMARY ACS?

“Primary ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention.”

Traumatic Injury Abdominal Tumor

Primary ACS: Decompressive Laparotomy

WHAT IS SECONDARY ACS?

“Secondary ACS refers to conditions that do not originate from the abdominopelvic region.”

Sepsis Burns Massive Resuscitation

WHAT IS RECURRENT ACS? “Recurrent ACS refers to the condition in which ACS

redevelops following previous surgical or medical treatment of primary or secondary ACS.”

You can get ACS despite have an open abdomen!

Keep APP between 50-60 mm Hg

Summary •  Measure bladder pressures in patients with at risk for IAH •  In Grade 1-3 IAH with no end-organ failure, try medical

management first •  Medical Mangement:

–  Judicous fluid management –  Reduce intra-luminal contents –  Reduce intra-abdominal contents –  Improve abdo wall compliance

•  In Primary ACS, strong consideration for decompressive laparotomy

•  Secondary ACS, decompressive laparotomy after medical treatment fails

Thank you!