1. Abdominal Compartment Syndrome By Maged Abulmagd,MD,EDIC 2. ? What it is ? A disease process that dramatically increases organ failure and death for medical and surgical ICU patients 3. What is a normal intra-abdominal pressure or IAP This is the pressure within the abdominal cavity 5 7 mmHg is normal in a critically ill adult 4. Intra abdominal Hypertension IAH Defined as sustained or repeatedly elevated abdominal pressure >12 and is graded 5. Grades of IAH Grade I 12 15 mmHg Grade II 16 20 mmHg Grade III 21 25 mmHg Grade IV >25 (ACS) 6. IAH Sustained pressure, >12 that has significant effects on abdominal organs and cardiac output with subsequent dysfunction of both abdominal and extra-abdominal organs 7. Understanding Abdominal Compartment Syndrome APP Abdominal perfusion pressure MAP Mean arterial pressure IAP Intra-abdominal pressure APP = MAP IAP A critical IAP that leads to organ failure is variable by patient & a single threshold cannot be applied globally to all patients APP is superior to IAP, arterial pH, base deficit & lactate in predicting organ failure & patient outcomes 8. Definition of ACS A sustained IAP > 20 mmHg (with or without an APP of 30 leads to anuria Increase of antidiuretic hormone and activation of renin-angiotensin- aldosterone system Increased water retention 19. Pathophysiology Abdominal Visceral Reduced blood flow which leads to intestinal ischemia Decreased blood flow to all abdominal organs 20. Pathophysiology Central Nervous System Increased thoracic and central venous pressure leads to Decreased cerebral outflow of blood Increased intracranial pressure which leads to decreased cerebral perfusion pressure 21. Measuring Intra-Abdominal Pressure 22. Importance of accurate measurement Physical examination yields low levels of detection of IAH/ACS Early detection and intervention reduces morbidity and mortality. Diagnosis is dependent on frequent and accurate measurement of IAP (watching trends) Cost effective, safe and accurate 23. Assessment Guidelines New ICU admission Evidence of clinical deterioration Pt has two risk factors for IAH/ACS Decreased abdominal wall compliance Increased intra-luminal contents ileus, gastroparesis, obstruction Increased abdominal contents Pneumoperitoneum, hemoperitoneum, ascities, liver dysfunction Capillary Leak/fluid resuscitation 24. IAH/ACS Assessment algorithm from World Society of Abdominal Compartment Syndrome (WSACS) www.wsacs.org Excellent references 25. Types of Measurements Direct Pressure via intraperitoneal catheters Indirect Pressure Gastric Measure IVC Rectal Urinary bladder pressure Gold Standard 26. Urinary Bladder Pressure Most technically reliable Correlate closely with pressures measured directly in the abdominal cavity Reliably reproducible Transduced through a Foley catheter 27. Intermittent Monitoring Open Systems Closed Systems 28. Equipment needed for open measurement Disposable transducer 12 pressure monitoring tubing 4-way stopcock Red dead-ender 60 cc, lure-lock syringe, sterile Sterile normal saline Clamp, non-sterile Level 29. Procedure for open, intermittent monitoring Collect and gather all supplies Attach stopcock to end of sterile transducer Important to maintain sterile technique to avoid contamination and potential infectious process 30. Procedure for open, intermittent monitoring Attach pressure tubing to the remaining end of the transducer 31. Procedure for open, intermittent monitoring Fill 60 cc syringe with 40 cc of sterile normal saline Attach syringe to side port of the stopcock Flush stopcock, pressure tubing and transducer with the normal saline ensuring all air is removed 32. Procedure for open, intermittent monitoring Clamp the urinary drain tubing distal to the sampling port Cleanse the sampling port with alcohol Using sterile technique attach the pressure tubing to the LuerLok connecting sampling port of the urinary catheter 33. Procedure for open, intermittent monitoring Instill 25 cc of sterile normal saline into urinary catheter via the sampling port (Larger vol. of NS can result in falsely elevated IAP measurements) Briefly release the clamp to allow fluid from the bladder to fill tubing and reclaim Read the IAP as a mean pressure at end expiration 30 60 seconds after instillation. Perform with patient supine Notify MD for sustained IAP greater than 12 mmHg unless otherwise ordered. 34. Disadvantages with open, intermittent monitoring Collecting a number of items Correct assembly Risk of infection every time system is accessed 35. Closed Monitoring AbViser, Wolfe Tory Medical, SLC, UT Pre-assembled kit Adapts to Foley catheter and any transducer Reduces risk of infection Readily available, easily assessable data 36. Measuring Bladder Pressure Position patient flat & supine Read Mean pressure End Expiration 37. Management Considerations Early detection via frequent monitoring of at risk patients Screen for IAH/ACS in new ICU admissions with new or progressive organ failure Look for trends of increasing abdominal pressures Preserve organ perfusion and treat clinical conditions with grades I & II 38. Management Considerations Early surgical consultations for at risk patients Early intervention for ACS or Grade III Anticipate emergent surgical interventions to prevent tissue damage/death 39. Management Considerations Anticipate patient to return with an alternative surgical closure or open abdomen. The abdominal contents will not be sutured into the abdominal cavity Alternative closures vary from surgeon to surgeon Examples: The Bogata Bag A 3 L IV bag, open and sterilized and applied to the abdominal opening 40. Management Considerations KCI Vac Pac Sponge overlies abd. Dressing/contents Attached to continuous suction canister Covered over with occlusive dressing 41. Management Considerations Ioban Dressing An occlusive dressing with iodine impregnation Surgical towels will overlie abdominal contents with JP drains Ioban overlies abdomen 42. Another Excellent Reference, IAH/ACS Management Algorithm from WSACS www.wsacs.org 43. Conclusion Know the difference between IAH and ACS IAH = Abdominal pressure >12 and graded via severity ACS = Abdominal pressures > 20 25 Identify At risk patient populations abdominal trauma/major burns Pancreatitis Ruptured AAA abdominal obstructions/ischemia ect. 44. Conclusion Understand the pathophysiology Ischemia/inflammation inflammatory response capillary leak + fluid resuscitation = tissue edema in an uncompromising cavity = ACS = tissue/cell death = bad Perform an accurate assessment of abdominal pressure using Abdominal bladder pressure monitoring via Foley catheter or AbViser Wolfe Torey Medical Anticipate patient interventions/outcomes Support/educate family 45. Case Study - 63 Y.O. male pt with pancreatitis is admitted to the ICU. Pt has history of gallbladder disease, COPD and ETOH abuse. He has been without ETOH reportedly for approximately 24 hrs. VS upon admission are T 38.0, HR 130, BP 90/62, MAP 61, RR 30 34 & O2 sat of 91% on 100% NRB, wt approximately 125 kg. His breathing is labored and he has c/o SOB. He is also mildly agitated & resistive to O2 therapy with Bi-Pap. His lung sounds are diminished bilaterally. Denies recent increase in cough. His abdomen is firm and distended. States unknown last BM but + for N/V. 46. He has a Foley catheter in place with approximately 100 cc of dark, amber urine in the collection chamber. Lab values show H&H of 10.2/31.0, wbc 20, K 5.0, Na 142, Foley was placed approximately 4 hours ago in the ED. His peripheral arterial pulses are weak and thready and his BLE show signs of PVD. He is currently receiving bolus # 3 of NS. 47. Does this patient need IAP monitoring? Is he at risk? What could you use as a reference if you were unsure? 48. After consulting with your attending MD, it is decided that a baseline ABP reading would be appropriate for this patient. Your initial ABP is 15mmHg. 49. Does this value represent intra-abdominal hypertension or abdominal compartment syndrome? What is his APP based on his MAP and IAP? 50. What grade would you give this value? Why is this patient at risk? How would you proceed? 51. After reporting the findings to the resident, serial ABP readings are ordered Q6 HR. His SBP continues to remain low with a map consistently < 65 & his respiratory status continues to deteriorate. The resident also orders another fluid bolus. With what you have learned about IAH /ACS management, what clinical suggestions could you collaborate on to advocate for your patient? 52. After collaboration with the medical team the decision is made to intubate as his O2 sats continue to drop and RR rate cont. to increase. After intubation and appropriate sedation, the patient continues to have an increasingly firm abdomen, increased HR and decreased SBP and map