ABDOMINAL COMPARTMENT SYNDROMEDR. F MOSAIREGISTRAR: GEN SURGERYMEDUNSA
ACSOUTLINE
1. DEFINATIONS: IAH, ACS2. RISK FACTORS3. AETIOLGY4. PATHOPHYSIOLOGY5. DIAGNOSIS6. TECHNIQUES OF MASURING IAP7. PREVENTION OF ACS8. MANAGEMENT9. COMPLICATIONS OF ASSOCIATED WITH Mx
1. DEFINATIONS
IAH: sustained or repeated pathological increase in IAP= 12mmHg or more
[PAEDS:] IAH: sustained or repeated pathological increase in IAP=10mmHg or more
ACS: sustained IAP=20mmHg or more(with or without an APP<60mmHg) that is associated with new organ dysfunction/failure
[PEADS] ACS: sustained increased IAP >10mmHg ass with new or worsening organ dysfx that can be attributed to increase in IAP
2. RISK FACTORS
Diminished abdominal wall compliance Major burns, abd surgery, major trauma, prone position
Increased intraluminal contents Volvulus, gastric distension, gastroparesis, Ileus, colonic
pseudo-obstruction Increased Intra-abdominal contents
Haemoperitonium/pneumoperitonium or intra-peritoneal fluid collection,tumours
2. RISK FACTORS
Capillary leak/fluid resuscitation Massive fluid resuscitation or positive fluid balance, damage
control laparotomy, hypothermia Others/miscellaneous
Mechanical ventilation, increase BMI, sepsis, shock,coagulopathy
3. AETIOLOGY
Acute: Retroperitoneal: pancreatitis, bleed, visceral oedema, aortic
aneurism Intraperitoneal: bleed, bowel obstruction, ileus, oedema,
gastric dilatation Abdominal wall: burn eschar, repair of gastroschisis or
omphalocele, reduction of large hernias, laparotomy closure under tension
Chronic: Obesity,ascitis, intra-abd tumors, preganancy, peritoneal
dialysis
4. PATHOPHYSIOLOGY
CNS: ↓ venous outflow ↑ ICP ->cerebral oedema-> ↓ CPP
CVS: ↑ systemic vascular resistance due to compression at the level of the capillary bed
:↓ venous return:diaphram displacement→↑ intrathoracic pressure→↓ventricular compliance→↓ CO + SV
4. PATHOPHYSIOLOGY
Resp: ↑diaphram →↓ pulmonary compliance
:↓TLC , ↓FRC, ↓RV : V/Q abnormal and hypoventilation→ hypoxia and hypercarbia
ABD:↓ flow in mesenteric, intestinal, hepatic and portal venous flow→ ischaemia and ↑risk of translocation
4. PATHOPHYSIOLOGY
Renal:↑IAP→ obstruct renal outflow +renal arteries :↑ ADH, renin and aldosterone→ ↑vascular resistance, Na + H2O
5. DAIGNOSIS
Hx: ↓urine output with ↑CVP ↑ Peak airway pressure Massive volume resuscitation Damage control laparotomy shock
5. DAIGNOSISCRITERIA FOR Dx1. IAP >25mmHg (30cmH₂O)AND2. One or more of the following
Oligouria (0.5ml/kg/h) ↑pulmonary pressure (>45cmH₂O) Hypoxia ↓CO Hypotension Acidosis
AND(to comfirm Dx)
5. DAIGNOSIS
3. Abdominal decompression lead to clinical improvement
6. TECHNIQUE TO MEASURE IAP
Sterile procedure Supine position, Θ abd muscle contraction Transducer, zero at the level of midaxillary line Place a special catheter and empty bladder Clamp catheter and instill ≤25ml sterile saline into
bladder and wait 30sec for detrusor muscle relaxation before measuring pressure
Measure at end expiration at the phlebostatic axis [Peads: instill 1ml/kg, min:3ml-max:25ml)
7. PREVENTION OF ACS
Prophylactic use of open abdomen after trauma damage control laparotomy
Damage control resuscitation Limitation of crystalloid fluids ↑ratio of plasma/packed red blood cell for resuscitation of
massive haemorrhage Keep fluid balance neutral or even negative Body positioning(trendelenberg)
8. MANAGEMENT
1. Non-operative(MEDICAL) Indications:
IAH Secondary or recurrent ACS with no progressive organ
failure2. Operative Indications:
Primary ACS/ overt ACS Secondary or recurrent ACS with progressive organ failure IAH( failed non-operative Rx)
8. MANAGEMENT
1. Non-operative Mx Improve abdominal wall compliance
Sedation and analgesia Paralysis(neuromascular blockade) Trendelenberg position( avoid head of bed >30°)
Evacuate intraluminal contents NG-decompresion Rectal/colonic decompression Gastro/colo-prokinetics(e.g. Neostigmine)
8. MANAGEMENT
Evacuate abdominal fluid collection PCD(abscess, haematoma) Paracentesis(not recommended)
Correct positive fluid balance Avoid excessive fluid resuscitation Diuretics(NOT RECOMMENDED) Colloid or hypertonic fluids Albumin (NOT RECOMMENDED) Hemodialysis/ultrafiltration(NOT RECOMMENDED)
8. MANAGEMENT
Damage control resuscitation Limit crystalloid iv fluid ↑plasma/packed red blood cell ratio for massive
hemorrhage
8. MANAGEMENT
2. Operative Acute decompresive laparotomy Wound cover after laparotomy
Silo Bag closure 3l Bogota bag (with closed suction to control fluid exudate)
Sandwish and vacuum pack technique NPWT(negative pressure wound therapy) Bioprosthetic mesh closure(NOT RECOMMENDED FOR
ROUTINE USE)
9. COMPLICATIONS
Intraoperative Surgical related
Sudden release of IAP lead to reperfusion injury, SIRS, Acidosis, hyperkalemia and ↑myglobin
Rx: consider: 1l 0.45% saline with 50g Mannitol and 50mmol sodiun bicarbonate
Anaesthetic related Aspiration (↑IAP)
9. COMPLICATIONS
Post-operative Short term(due to prolong open abdomen)
Visceral adhessions Loss of soft tissue coverage Lateralization of the abdominal musculature and its fascia Malnutrion Enteric fistulae
Long term Incisional hernia Adhessive bowel obstruction