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Intra-abdominal Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma Program Coordinator/Clinical Nurse Specialist Hospital of the University of Pennsylvania

ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

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Page 1: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Intra-abdominal Hypertension and

Compartment Syndrome

in the Trauma Patient:

Is Your Patient at Risk?

John J. Gallagher MSN, RN, CCNS, CCRN, RRT

Trauma Program Coordinator/Clinical Nurse Specialist

Hospital of the University of Pennsylvania

Page 2: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Objective

Brief review of pathophysiology

Definitions of IAH/ACS

Define the risk in trauma patients

IAP measurement

Prevention and treatment strategies

Page 3: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

World Society of Abdominal Compartment Syndrome

Guidelines 2013

www. WSACS.org

Page 4: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

The Continuum

IAH ACS

Page 5: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Keys to Success

Early Identification of Patients at Risk

Early/Ongoing Assessment – IAP (Bladder Pressure Measurement)

Early Therapeutic Intervention – Non-surgical

– Surgical

Page 6: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma
Page 7: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Shock Inability of the cells to meet their metabolic demands

• Reductions in Oxygen Delivery

• Increases in Oxygen Utilization

• Combination of Both

• O2 deprivation (oxygen debt)

• Cellular acidosis

• Cellular dysfunction

• Cellular death

• Organ dysfunction

• Organ failure

Page 8: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Trauma/Injury Trigger

Hemorrhage

Shock - I.V. Fluid

- Packing

Visceral ischemia - Manipulation

Reperfusion edema Visceral edema

IAH/ ACS

Page 9: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Inflammatory Response

“Two Hit Theory”

Primary Insult (trauma)

Secondary Insult (shock)

Inflammatory Response

Page 10: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

CAPILLARY LEAK

INTRA-ABDOMINAL

TISSUE EDEMA

Page 11: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 12: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

4 Risk Factor Categories

Reduced

Abdominal Wall

Compliance

Increased Abdominal

Contents

Increased

Intraluminal

Contents

Capillary Leak/

Fluid Resuscitation

World Society of Abdominal Compartment Syndrome

Page 13: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Risk Factors

Page 14: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Clinical Scenarios

Abdomen closed post-op

Temporary abdominal closure

Volume Resuscitation/Massive Transfusion

Lethal Triad (acidosis, coagulopathy, hypothermia)

Damage control stage 4 (closure)

Page 15: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Damage Control Laparotomy Stage 1

•Control of hemorrhage

•Control of contamination

•Packing

•Temp closure

Stage 2

•Rewarming

•Correct coagulopathy

•Ventilation

•Hemodynamics

Stage 3

•Re inspection

•Definitive injury repair

•Abdominal Closure

���

Stage 4

•Abdominal Reconstruction

���

Page 16: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Reduced Abdominal Wall Compliance

Closure of the abdomen post-laparotomy

Burns to the thoraco-abdominal wall

Temporary abdominal closure

Page 17: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 18: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 19: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 20: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 21: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 22: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 23: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 24: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 25: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Abdominal Bedside Tote

Photo by John Gallagher

Page 26: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Bogota/Silo Bag Closure

trauma.org Image Bank

Page 27: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Burn Injury

•Hershberger et al. (2007) Journal of Burn Care Research

•Ennis et al. (2008) Journal of Trauma

•Ball et al. (2006) Journal of Trauma

Page 28: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Capillary Leak/Fluid Resuscitation

• Crystalloid Resuscitation

• Massive Transfusion

• Inflammatory Response

• Capillary Leak

SHOCK

Coagulopathy

Lethal

Triad

Page 29: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma
Page 30: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Increased Abdominal Contents

• Hemoperitoneum

• Burns (ascites)

Page 31: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Increase Intraluminal Contents

Ileus

Gastroparesis

Obstructions

Page 32: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Intra-abdominal Pressure

Variations

Normal: 5 – 7mmHg

– Normal in Obesity: 9 – 14 mmHg

HOB elevation: 2 - 5 mmHg above baseline

PEEP > 15 mmHg

– Most profound when IAP is > 12mmHg baseline

Page 33: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Intra abdominal Hypertension

A pathologic elevation of intra-abdominal pressure

– Sustained or reproducible IAP > 12 mmHg

Page 34: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Intra abdominal Hypertension

IAP > 12mmHg

Grade I: 12 - 15 mmHg

Grade II: 16 – 20 mmHg

Grade III: 21 -25 mmHg

Grade IV: > 25 mmHg

World Society of the Abdominal Compartment Syndrome

Page 35: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Abdominal Perfusion Pressure (APP)

APP= MAP- IAP

Target APP > 60 mmHg

APP < 50 mmHg is associated with

increased mortality

Page 36: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Pediatric Considerations

Lower MAP and lower threshold for

hypoperfusion

IAH and ACS occur at lower IAP

– ACS is IAP of > 10 mmHg with new onset

organ dysfunction

Ejike et al (2008) Critical Care Medicine

Page 37: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Abdominal Compartment Syndrome

An increase in intra-abdominal

pressure that exceeds the capacity of the

compartment, resulting in the impaired

perfusion and function of multiple organ systems

Page 38: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Abdominal Compartment Syndrome

Presence of both….

IAP > 20 mm Hg Regardless of APP

New onset single/multiple organ system failure

Page 39: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Abdominal Compartment Syndrome

Primary

Secondary

Recurrent

Page 40: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Primary

Abdominal Compartment Syndrome

Associated with injury or disease in

the abdominopelvic region

Photo by John Gallagher

Page 41: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Secondary

Abdominal Compartment Syndrome

Develops from

conditions outside the abdomen

–Massive fluid resuscitation

–Burns

–Sepsis

Page 42: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

SACS Post Injury

Lower SBP

Penetrating chest

Vascular Injuries

Multiple extremity fractures

Page 43: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Secondary

Abdominal Compartment Syndrome

Inflammatory process that may be more subtle

– Trauma:

» SACS represents 58% of post injury ACS

» 38 – 68 % mortality

Resuscitation outside the OR

– IR and ICU

– More crystalloid

– Longer times to control of bleeding

Page 44: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

22 y.o. unrestrained driver, ejected in a MVC:

– Unresponsive

– Heart rate: 130

– Blood pressure: 80/50 mmHg

L. hemothorax- 750 ml from the chest tube

Abdominal ultrasound positive for fluid LUQ

Taken to OR for splenectomy

Admitted to the SICU

Page 45: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

22 y.o. male post MVC transferred into the SICU

after progressive hemodynamic deterioration

BP 90/50 HR 122 T 102°F Sat 88%

Pale, diaphoretic

Page 46: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Breathing becomes labored, mental status

decreases

– Intubated

– Central line placed

»CVP is 3 mm Hg

– Urinary catheter placed

» 200 ml dark urine

Page 47: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

4 liters additional LR is infused

– MAP: 60, HR: 110, CVP: 10,

– Urine output: 15 ml/hr

• Norepinephrine started

– MAP: 65, HR 116, CVP 11

– Urine output 20 ml for last 2 hours

Would you give this patient volume?

Bladder pressure monitoring device attached:

• IAP 30 mmHg

Page 48: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Recurrent

Abdominal Compartment Syndrome

Abdominal Compartment Syndrome

that re-develops after previous medical

or surgical treatment

Page 49: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Recurrent

Abdominal Compartment Syndrome

Can develop even with an “expanded” (open)

abdomen with temporary closure

Increased morbidity and mortality

Gracias, V.H. et al. 2002. Archives of Surgery

Page 50: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Open Abdomen

Expanded Abdomen

Page 51: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Dynamic Tension

Page 52: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma
Page 53: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Organ Systems Compromised

Gastrointestinal

Pulmonary

Cardiovascular

Renal

Neurological

Page 54: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Gastrointestinal Effects

Increased IAP

Compression of mesenteric vessels

Gastric mucosal acidosis (pHi)

Mesenteric ischemia

Page 55: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Pulmonary Effects

Increased Intra-abdominal

pressure Pressure on

Diaphragm

Lung expansion

Page 56: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Cardiovascular Effects

Increased IAP

Pre-load Afterload

May occur with IAPs of as low as 10 mmHg

Page 57: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Cardiovascular Assessment Findings

Normotensive

CVP, PA, PCOP, SVR, PVR

C.O.

CVP corrected = CVP measured - IAP/2

PCOP corrected = PCOP measured - IAP/2

Page 58: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Renal Impact of Elevated IAP

Page 59: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Neurologic Effect

Increased IAP

Reduced venous return from the brain

Cerebral hyperemia

Increase in ICP

Page 60: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Neurological Manifestations

Refractory Intracranial Hypertension

Elevated ICPs

CPPs

Brain tissue oxygen

Page 61: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma
Page 62: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Early/Ongoing Assessment

Early Initiation of IAP monitoring in patients

with 2 or more risk factors

Serial measurement until IAH risk is past

Page 63: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Bladder Pressure Monitoring

– The current standard for monitoring IAP

– Comparable to direct intraperitoneal pressure

measurements, but is non-invasive (Bailey, Crit Care 2000)

– More reliable and reproducible than clinical judgment (Kirkpatrick, CJS 2000; Sugrue World J Surg 2002)

Page 64: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Intra-Abdominal Pressure Measurement

Performed in the supine position

Zero at the level of the mid-axillary line (pelvis)

Expressed in mmHg (1 mmHg= 1.36 cmH2O)

Measured at End-expiration

Measure 30 – 60 sec after instillation of saline

Page 65: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Transducer

location

The correct transducer position at the iliac crest in the mid-axillary line in

the supine position and with head of bed elevation.

Photo by John Gallagher

Page 66: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Instilled Fluid Volume

Adults

– No greater than 25 ml of saline

Children

– 3ml minimum volume

– 1 ml/kg for children up to 25

Page 67: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Considerations

Neurogenic or contracted bladder

Injuries to the bladder

HOB elevations

Page 68: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

AbViser® Intra-Abdominal Pressure Monitoring Kit

Page 69: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Manometry Measurement

Foley Manometer Holtech Medical

Page 70: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Modified Pressure Monitor System

Page 71: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Bladder Pressure Waveform

Page 72: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Keys to Accuracy

Standardized measurement device

Standardized clinical protocol

Kimball et al. (2007) Intensive Care Medicine

Page 73: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Monitoring Protocols

Trigger Conditions

Monitoring System

• Frequency of Monitoring

• Reporting Thresholds

Criteria for Termination

of Monitoring

Ongoing staff

proficiency

Page 74: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Pitfalls

Failing to identify patients at risk

– Temporary abdominal closure

– Volume resuscitation

– Post-op abdominal closure

Requiring an order to monitor IAP

Staff unfamiliar with the monitoring procedure

Terminating monitoring too soon

Page 75: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Management Strategies

Optimize systemic perfusion/organ function

Non-surgical interventions to reduce IAP

Surgical decompression

Page 76: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Ventilation Strategies

Decreased thoracic compliance

Normal lung tissue compliance

Lung Protective Strategies

– Limit ventilation pressures

– Optimize PEEP

Page 77: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Non-surgical Measures

Optimize Abdominal Perfusion Pressure (APP)

Volume

optimize preload improve cardiac index

worsen edema

Vasopressors » Achieve APP > 60 mmHg after euvolemia

» Risk of intestinal ischemia

Page 78: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Cardiac Output Stroke Volume X HR

Preload Afterload Contractility

Volume •SV SVV •PPV •EDV

•Doppler •Echo

Pressure •CVP

•PCOP

Resistance •SVR •PVR

Stroke Work (I) •RVSW •LVSW

Images provided by J Gallagher

Page 79: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Photo by John Gallagher

Page 80: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Improve Abdominal Wall Compliance

– Analgesia/Sedation

– Remove/Expand Abdominal Closure

– Escharotomy (Burn Patients)

– Positioning » HOB not greater than 30 degrees

» Reverse trendelenberg

» Abdomen unsupported while prone

– Neuromuscular Blocking Agents

Page 81: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Correct Positive Fluid Balance

Avoid excessive fluid resuscitation

Aim for zero/negative fluid balance

Diuretics (hemodynamically stable)

Colloids/Hypertonic fluids

Fluid restriction

CRRT

Page 82: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Evacuation of Abdominal Collections

U/S and CT guided percutaneous drainage

Surgical removal of space occupying lesions

•Ascites evacuation

•Abscess removal

•Hematoma removal

Page 83: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Evacuation of Intraluminal Contents

Gastric/Rectal decompression

Colonoscopic decompression

Gastroprokinetics /Coloprokinetic

Correct electrolyte abnormalities

– Potassium

– Magnesium

– Calcium/Phos

Maintain enteral nutrition unless progression to ACS

Page 84: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Surgical Treatment Measures

Surgical Decompression

– IAP > 20 mmHg & organ dysfunction

Removal of packing

Drainage of intra-abdominal collections

Page 85: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Conclusions Majority of Critically Ill Patients are AT RISK

IAH and ACS increase morbidity, mortality and ICU length of stay

Early detection and intervention can reduce these complications in many patients – Monitoring Bladder Pressure key to early detection

Early treatment of IAH with non-surgical strategies can prevent progression to ACS

Page 86: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Resources

World Society of Abdominal

Compartment Syndrome

www.wsacs.org

Page 87: ABDOMINAL COMPARTMENT SYNDROME - Oregon … Hypertension and Compartment Syndrome in the Trauma Patient: Is Your Patient at Risk? John J. Gallagher MSN, RN, CCNS, CCRN, RRT Trauma

Thank You

[email protected]


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