dig abdominal compartement syndrome

7/24/2019 Dig Abdominal Compartement Syndrome

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INTRAABDOMINALHYPERTENTION &

ABDOMINALCOMPARTMENTSYNDROME Aditya Bhayusakti, M.


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important values

Normal intra-abdominal pressure is 0 - 5mmHg. Pressures > 13mmHg may be sufficient to restrict perfusion

to the organs of the gut. If the abdominal compartment pressures is beteen 1!-"5

mmHg# hyper$olemic $olume e%pansion therapy can be usedto maintain the perfusion pressure gradient for the abdominalorgans.

&hen compartment pressures e%ceed "5mmHg#decompression surgery should be considered to pre$ent

organ damage. Pressure may rise rapidly ith acti$ebleeding. 'dema (hich occurs ith any ischemic insult) illgenerally result in a later rise in the pressure ("* hours ormore post insult).


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Classiy IAH i!t" # $%"us'

Hyperacute(sec,min):laughing,strain,coug-

hing,sneez,physical activities)

Acute(couple H):trauma,hge

Subacute (couple days): most medicalcases.

Chronic: morbid obesity,intraabdominal

tumor,pregnancy.


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Pati(!ts at %isk "% ACSi!)lud(' trauma (blunt or open),as a result of the

accumulation of blood# fluid or edema.

gastrointestinal hemorrhage can also lead to

increased pressure in the abdominal compartment as

ischemic cells sell or fluids collect.

pancreatitis

pneumoperitoneum

neoplasm


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syndrome may ollo! a rupturedabdominal aortic aneurysm

intra-abdominal inection Coagulopathies !ith abdominal

bleeding

cirrhosis, or proound hypothermia


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massive intra-abdominalretroperitoneal hemorrhage,

severe gut edema

intestinal obstruction

ascites under pressure.


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"atients !ho have undergone long surgical

procedures !ith intraoperative hypotension andlarge luid re#uirements are at signiicant ris$,particularly i the abdomen has been closedunder pressure in the %&.

'ternal pressure rom circumerential burnsabout the abdomen, application o military anti-shoc$ trousers (AS*), or even tight abdominalrestraint devices can cause tension !ithin theabdomen due to eternal orces and result inACS.+


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&ecently, a!arenesso the ACS has increased or +

primary reasons.

irst, the increased use o laparoscopy among general

surgeons has brought !ith it an appreciation o A" as a

readily #uantiiable entity.

Second, the more re#uent use o planned repeat

laparotomy or trauma has allo!ed both surgeon andintensivist to appreciate the beneicial eects o

abdominal decompression upon removal o pac$ing or

evacuation o hematoma.


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Th( Path"hysi"l"$y " IAH

I+PASC/0A&

C%"&'SS%1

2&'C* %&3A1

C%"&'SS%1

2A"H&A3A*C

'0'A*%1

&" Clo!Cardiac

compression ntrathoracicpressure

Cardiac preloadCardiac contractility Systemic aterload

,+I+, /P&enal ascular

&esistanceSplanchnic

ascular &esistance

&'1A0 A0/&' A42%1A0 5A00SCHA'A6%'2'A &'S"&A*%&7A0/&'

C" S"0A1CH1CSCHA'A

" pressure


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Compartment syndrome occurs !hen

the pressure !ithin a closedanatomic spaceincreases to the

point !here vascular tissue is

compromised !ith subse#uent losso tissue viability and unction. *his

can occur !ithin any closedbody

cavity.


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ncreased A" leads to decreased

4 and to 4acterial translocation

(4*),!hich may contribute to laterseptic complications and organ

ailure.


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AH provo$es the release o pro-inlammatory cyto$ines !hich may

serve as a second insult or the

induction o %. production o interleu$in-8b (0-

8beta), interleu$in-9 (0-9), tumor

necrosis actor (*1-alpha)


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Anaesthetic Implications ofACS:

Renal implications

PulmonaryImplications

CardiovascularImplications

Porto-systemicvisceral

Implications

Centralnervoussystem

Implications


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E*()ts "! C+S

As intraabdominal pressure increases above 8mmHg, cardiac output declines, despite normalarterial pressures.

Additionally, !hole body oygen consumption, pH,and "%+ decrease.

ntraabdominal hypertension aects cardiac

unction by pushing the hemidiaphragms up!ard,thus transmitting the abdominal pressure to theheart and its vessels.

*his decreases preload and increases aterload onthe let ventricle and at the same time creates ahemodynamic picture o lo! cardiac output andhigh illing pressures.8,;


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O! th( ul"!a%y syst(

he most commonly noted effects of I+H on the

pulmonary system are ele$ated pea2 inspiratory

pressures# decreases in Pao" and increases in

Paco" reuiring the use of complete $entilatory

support to maintain adeuate o%ygenation and$entilation.

Hypercarbia# hypo%emia# and acidosis are e$ident

hen arterial blood gases are measured.!

Positi$e end-e%piratory pressure has been shonto e%acerbate the cardiac and respiratory

conseuences of I+H.


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Pul"!a%y (*()ts " i!)%(as(di!t%a-ad"i!al %(ssu%( /0 mechanical ventilation

oten necessary

high pea$ air!ay

pressures


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Pul"!a%y (*()ts " i!)%(as(di!t%a-ad"i!al %(ssu%( /2

"ressure on the C

predisposes to venous

stasis and increased

ris$ o

thromboembolism


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R(!al (*()ts

include decreased renal plasma flo# glomerular filtrationrate# and glucose reabsorption. /liguriaalso occurs# ithanuria noted in animal models hen I+P reaches 30mmHg.1 hese effects occur ithout significantdecreases in blood pressure(mechanical#4#compression of $ein6outflo obstuction64

intraparenchymal pressure6shunting of blood from corte%) . Impro$ement of cardiac output does not impro$e renal

function# nor do renal blood flo and glomerular filtrationrate impro$e.

the placement of ureteral stents failed to impro$e renal

function. Impro$ement in renal function occurred only after

abdominal decompression.*


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*hese indings suggest that the eects o AHon renal unction are related to compression o

the renal parenchyma itsel and tocompression o renal vasculature and are notrelated to decreased cardiac output. %thermechanisms proposed include shunting oblood a!ay rom the renal corte into the

medulla, decreased renal arterial lo! !ith aconcomitant increase in renal vascularresistance, and the presence o high levels orenin, aldosterone, and antidiuretic hormones.8


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=

8

8=

+

= 8 8= + += luids

A

ldosterone

level

(ng6dl)

A" (mmHg above baseline)

'perimental

Control

'ect o increased intra-abdominal pressure on plasma

aldosterone. *he increased levels are reduced by volume

epansion (J Trauma8>>?@;+:>>?-8)


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=

8

8=

+

+=

= 8 8= + += luids

"las

mareninac

tivity

(ng6ml6hr)

A" (mmHg above baseline)

'perimental

Control

'ect o increased intra-abdominal pressure on plasma

renin activity. *he increased levels are reduced by volume

epansion (J Trauma8>>?@;+:>>?-8)


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ncreases in A" have adverse

eect on splanchnic lo!

B8=mmHgSA blood lo!

mar$ed reduction in hepaticartery and portal venous blood

lo!

leads to mucosal acidosis and

oedema

IAH a!d Sla!)h!i) 3l"4


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Cy)l( " (5(!ts )%(at(d yIAH "! sla!)h!i) )i%)ulati"!

AH

Unrelieved

ACS

Splanchnic

hypoperusion

3ut mucosal acidosis

4o!el oedema


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hey measured mucosal and intestinal blood flo

and intramucosal pH (pHi) and found that

mesenteric and mucosal blood flo decreased henI+P reached "0mmHg# ith intestinal mucosal flo

declining to !17of baseline.

+t an I+P of 80mmHg# intestinal flo decreased to

"97of baseline. he intestinal mucosa shoed signs of a se$ere

degree of acidosis# measured by tonometer. hese

changes in splanchnic blood flo occurred despite

maintenance of baseline cardiac output ith $olumeloading.


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pp

+ ; 9 8

8

=4o!el*"%+

Aillary

*"%+

A" +=mmHg or

9 min

A" 8=mmHg or

9 min

4aseline

'ects o increasing A" on bo!el mucosal oygen (tissue

partial pressure, *"%+) compared !ith systemic tissue

oygenation in the ailla (J Trauma 8>>=@>:=8>-=++)


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blood lo! to virtually every abdominal organ

decreased signiicantly. *he only eception

!as the adrenal gland@ the reason this

organ is not aected is un$no!n >>@;? :=>-=88

Current opinion does

not support liberal use

of an open abdomen

technique to preventACS


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An alternative techni#ue is the vacuum-pac$techni#ue. Here the litre bag is opened and placed

into the abdomen to protect the gut contents, underthe sheath. *his has been reerred to as the 4ogotabag, ater the city in Colombia, South America, o itsinception.>

*!o large calibre suction drains are placed overthis, and a large adherent steridrape placed over the!hole abdomen. *he suction catheters areconnected to high-displacement suction to providecontrol o luid losses and create the vacuum-pac$

eect


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*he easiest method to control the open abdomen is

to use a silo-bag closure. A litre plastic irrigationbag is emptied and cut open so it lies lat. *he

edges are trimmed and sutured to the s$in, a!ay

rom the s$in edges, using a continuous 8 sil$

suture. t is useul to place a sterile absorbent drapeinside the abdomen to soa$ up some o the luid and

ease control o the laparostomy.


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Adverse Efects o Surgical


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Adverse Efects o Surgical

Decompression Sudden release o the abdominal compartment

syndrome may lead to an ischaemia-reperusion inEury

*he mechanism !as postulated to be related to !ashout

o anaerobic metabolic products by reperusion o the

previously underperused splanchnic bed causing

acidosis, vasodilatation, cardiac dysunction and arrest.

"rior to release the patient should be pre-loaded !ith

crystalloid solution. annitol and vasodilators such as

dobutamine or the phosphodiesterase inhibitors may

have a place here.

MEDICAL


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MEDICALDECOMPRESSION

*he adverse cardiovascular and

pulmonary eects o intra-

abdominal hypertension IAHJ!ere reversed !ith

pharmacological neuromuscular

bloc$ade (14(


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Management

Prevention

Identicationof patients at ris!

Monitoring

Ade"uate resuscitationAde"uate ventilation

#on-surgicalinterventions

Paracentesis#euromuscular $loc!adeC#AP

%ut emptying

&ctreotide

Prognosis


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Prognosis

he death rate in patients ith +,? is e%tremely high.

?e$eral small series ha$e reported death rates ranging from

8"7 to *17.hese high rates must be considered in the

conte%t of the patientsA underlying disease.

he maority of these patients are critically ill and are

admitted to the intensi$e care unit ith se$ere intra-abdominal sepsis# intra-abdominal inuries or after repair of

a ruptured abdominal aortic aneurysm.

'$en ith prompt recognition and abdominal

decompression# the freuency of multiple organ dysfunction

and death is high because of the se$erity of the initial

physiologic insult.


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Ho!ever, in the ace o elevated A"

and a clinical picture consistent !ith

ACS, the chance o survival isetremely lo! !ithout urgent

abdominal decompression.8


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THAN9 YO:

dig abdominal compartement syndrome

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