Abdominal Compartment Abdominal Compartment SyndromeSyndrome

Increased Intra-abdominal Pressure Increased Intra-abdominal Pressure IAP & Abd. Compartment Synd ACSIAP & Abd. Compartment Synd ACS

• CaseCase

• Definition & prevalenceDefinition & prevalence

• Measurement techniques Measurement techniques

• EtiologyEtiology

• ConsequencesConsequences

• TreatmentTreatment

DefinitionDefinition

• Compartment syndrome exists when increased Compartment syndrome exists when increased pressure in a closed anatomic space threaten pressure in a closed anatomic space threaten the viability of enclosed & surrounding tissuesthe viability of enclosed & surrounding tissues

• ACS ACS organ dysfunction as a result of organ dysfunction as a result of

increased IAPincreased IAP

DefinitionDefinition• 77 patients prospectively studied 77 patients prospectively studied

• IAP by measuring bladder pressure IAP by measuring bladder pressure

• Mean IAP 6.5 mm Hg ( 0.2-16.2 mm Hg). Mean IAP 6.5 mm Hg ( 0.2-16.2 mm Hg).

• BMI & previous abd Sx were the only factors BMI & previous abd Sx were the only factors associated with high IAPassociated with high IAP

Am Surg 2001 MarAm Surg 2001 Mar

DefinitionDefinition

• A lot of literature but no consistent criteria for A lot of literature but no consistent criteria for has been used for diagnosishas been used for diagnosis

• What measurement should be used What measurement should be used maximum Vs mean Vs median?maximum Vs mean Vs median?

• What is the gold standard method of What is the gold standard method of diagnosis? diagnosis?

EtiologyEtiology

• Surgical { primary }Surgical { primary }

Large volume resuscitation in abdominal Large volume resuscitation in abdominal trauma or emergency operationstrauma or emergency operations

Tight surgical suture or burn scarsTight surgical suture or burn scars

• Non surgical { secondary }Non surgical { secondary }

peritonitis , pancreatitis , massive ascitesperitonitis , pancreatitis , massive ascites

bowel obstruction , EGD & NPPVbowel obstruction , EGD & NPPV

EtiologyEtiology• One day prevalence in 13 ICU over 6 countriesOne day prevalence in 13 ICU over 6 countries

• 97 patients with admission > 24h97 patients with admission > 24h

• IAP measured with bladder pressureIAP measured with bladder pressure q 6 h for 24 hoursq 6 h for 24 hours

• Intraabdominal hypertension IAHIntraabdominal hypertension IAH when IAP = or > 12 mm Hg when IAP = or > 12 mm Hg

• ACS when IAP = or > 20 mm HgACS when IAP = or > 20 mm Hg Intensive Care Med. 2004 May Intensive Care Med. 2004 May

EtiologyEtiology

• IAH incidence 50.8 % ACS 8.5%IAH incidence 50.8 % ACS 8.5%

• Only BMI >27 was strongly associated with Only BMI >27 was strongly associated with ACS in multivariate analysisACS in multivariate analysis

• Amount of fluid given Amount of fluid given renal & coagulation dysfunction have a trend renal & coagulation dysfunction have a trend

of important only on univariate analysisof important only on univariate analysis Intensive Care Med. 2004 May Intensive Care Med. 2004 May

Measurement of IVPMeasurement of IVP

• Bladder pressure is the most commonly used method Bladder pressure is the most commonly used method

{gastric, rectal & uterine has been described}{gastric, rectal & uterine has been described}

• Patient supine, measurement during expiration & Patient supine, measurement during expiration & bladder is empty &Foley catheter is clamped bladder is empty &Foley catheter is clamped

• 18 gauge needle attached to transducer is inserted into 18 gauge needle attached to transducer is inserted into the aspiration port & 50 ml NS is injectedthe aspiration port & 50 ml NS is injected

Bladder PressureBladder Pressure

• 37 patient undergoing laparoscopy 37 patient undergoing laparoscopy

• Bladder pressure at different volume 0-200 ml Bladder pressure at different volume 0-200 ml

• Moderate correlation R 0.62Moderate correlation R 0.62

• Bias 3.2 mm HgBias 3.2 mm Hg

• Lowest bias in patient with N IAP Lowest bias in patient with N IAP 50 ml50 ml

in patients with high IAP in patients with high IAP 0 ml 0 ml

J Trauma 2001 FebJ Trauma 2001 Feb

Bladder PressureBladder Pressure• Possible source of errors in measurementPossible source of errors in measurement

Body position , zeroing Body position , zeroing

over or under dampingover or under damping

Baseline IAP Baseline IAP

? Empty bladder ? Empty bladder

Fluctuation in IAP Fluctuation in IAP

Measurement Of IAPMeasurement Of IAP• Continuous fully automated systemContinuous fully automated system

• NGT like tube with air pouch at the tipNGT like tube with air pouch at the tip

• The pressure transducer is integrated in the The pressure transducer is integrated in the monitor monitor

• Excellent correlation with insufflatory pressure Excellent correlation with insufflatory pressure R .99 with bias .5-2.5 mm HgR .99 with bias .5-2.5 mm Hg

Intensive Care Med. 2004 Mar Intensive Care Med. 2004 Mar

ConsequencesConsequences

• Critical IAP Critical IAP IAP at which ACS will developIAP at which ACS will develop

• Variable from patient to patientVariable from patient to patient

• Likely critical IAP is lower in :morbid Likely critical IAP is lower in :morbid obesity , pregnancy & CLD with obesity , pregnancy & CLD with ascites ,previous abdominal surgeriesascites ,previous abdominal surgeries

ConsequencesConsequences

• CNS:CNS:Increase in IAP will increase ICPIncrease in IAP will increase ICP

15 patients with moderate to severe head injury 15 patients with moderate to severe head injury after resolution of initial elevated ICP.after resolution of initial elevated ICP.

IAP was increased by 15 liter water bag over the IAP was increased by 15 liter water bag over the abdomenabdomen

IAP 4.7IAP 4.715.5 & ICP 12 15.5 & ICP 12 15 mm Hg15 mm Hg

This effect was mediated through increase in the This effect was mediated through increase in the intrathoracic pressureintrathoracic pressure

Crit Care Med 2001 Crit Care Med 2001

ConsequencesConsequences

• CVS :CVS : studies in animals mainlystudies in animals mainlyRt ward & flattening of Frank-Starling curveRt ward & flattening of Frank-Starling curveDecrease in compliance & contractility Decrease in compliance & contractility Decrease in VR Decrease in VR Elevated CVP & PCWP Elevated CVP & PCWP not reflector of true intravascular volume not reflector of true intravascular volume use of volumetric parameters in resuscitationuse of volumetric parameters in resuscitation

ConsequencesConsequences

• Respiratory:Respiratory:Animal studiesAnimal studies

Decrease in chest wall complianceDecrease in chest wall compliance

Increase in VQ mismatch & dead spaceIncrease in VQ mismatch & dead space

Hypoxia & hypercapnia Hypoxia & hypercapnia

Best PEEP = IAPBest PEEP = IAP

Pplt = Pplt – IAP Pplt = Pplt – IAP

ConsequencesConsequences• GI:GI:In animal studiesIn animal studies

decrease in blood flow decrease in blood flow

increase risk of bacterial translocation increase risk of bacterial translocation

& decrease hepatic lactate clearance& decrease hepatic lactate clearance

In human studyIn human study

Increase IAP induced in 14 cirrhosis with varices Increase IAP induced in 14 cirrhosis with varices elevation in varices pressure size & wall tensionelevation in varices pressure size & wall tension

Hepatology 2002Hepatology 2002

ConsequencesConsequences

• Renal:Renal:Decrease in venous drainage because of Decrease in venous drainage because of

increased venous pressureincreased venous pressure

Decrease renal perfusion 2ry to arterial Decrease renal perfusion 2ry to arterial vasoconstriction Renin mediated by the fall in vasoconstriction Renin mediated by the fall in cardiac outputcardiac output

Decrease in GFR & UOP with pre renal picture Decrease in GFR & UOP with pre renal picture

ConsequencesConsequences

• Renal:Renal:

Increase IAP was one risk factor in developing Increase IAP was one risk factor in developing hernias & leak in 142 peritoneal dialysis hernias & leak in 142 peritoneal dialysis patients patients

Other factors BMI & ageOther factors BMI & age Peritoneal Dialysis International 2004Peritoneal Dialysis International 2004

DiagnosisDiagnosis• 21/42 trauma patient who had developed IAH 21/42 trauma patient who had developed IAH

diagnosed by bladder pressure were examined diagnosed by bladder pressure were examined clinicallyclinically

Clinical exam sensitivity 56% PPV 35%Clinical exam sensitivity 56% PPV 35%

specificity 87% NPV 64%specificity 87% NPV 64%

accuracy 84%accuracy 84%

Can J Surg 2000 Jun Can J Surg 2000 Jun

ManagementManagement

• Surgical :Surgical :

Decompression with maintenance of open Decompression with maintenance of open abdomen (vacuum pack dressing)abdomen (vacuum pack dressing)

? When to operate? When to operate

Abdominal perfusion pressure APP was shown Abdominal perfusion pressure APP was shown in retrospective study of 144 pt with IAH to be in retrospective study of 144 pt with IAH to be the best predictor of survival the best predictor of survival

J Trauma 2000 OctJ Trauma 2000 Oct

ManagementManagement

• Volume resuscitation Volume resuscitation

Higher filling pressureHigher filling pressure

• Mechanical ventilationMechanical ventilation

Lung protective ventilationLung protective ventilationaim Pplt – IAPaim Pplt – IAP

Best PEEP = IAPBest PEEP = IAP

SummarySummary

• IAH & ACS is infrequent but serious IAH & ACS is infrequent but serious complication of multiple surgical & medical complication of multiple surgical & medical diseasesdiseases

• Clinical examination had low sensitivityClinical examination had low sensitivity

• Till now bladder pressure is the most Till now bladder pressure is the most commonly used method to screen for ACS commonly used method to screen for ACS

SummarySummary

• The effect of IAH is on all other systemsThe effect of IAH is on all other systems

• With the development of continuous With the development of continuous intraabdominal pressure monitors IAP may intraabdominal pressure monitors IAP may become part of the vitalsbecome part of the vitals

• Surgical decompression is the main stay of RxSurgical decompression is the main stay of Rx

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