abdominal compartment syndrome[1]
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Abdominal Compartment Syndrome : An Unrecognised Cause of AKI
SAID KHAMIS (MD, KUL Belgium)Professor Of MedicineNephrology ConsultantMenofia University Hospitals
Agenda - IAH and ACS
Definition – what is it? Causes Recent increase in recognition Physiologic Manifestations Prevalence Outcome Treatment Detection:
Bladder pressure monitoring
Abdominal Compartment Syndrome
“…….. multiple organ dysfunction caused by elevated intra-abdominal pressure.”
Tim Wolfe, MD
Definition
What intra-abdominal pressures are concerning?
Pressure (mm Hg) Interpretation 0-5 Normal
5-10 Common in most ICU patients
> 12 Intra-abdominal hypertension
15-20 Dangerous IAH - consider non-invasive interventions
>20-25 Impending abdominal compartment syndrome - strongly consider decompressive laparotomy
Causes of Intra-abdominal Pressure (IAP) Elevation
Retroperitoneal: pancreatitis, retroperitoneal or pelvic bleeding, contained AAA rupture, aortic surgery, abscess, visceral edema
Intraperitoneal: intraperitoneal bleeding, AAA rupture, acute gastric dilatation, bowel obstruction, ileus, mesenteric venous obstruction, pneumoperitoneum, abdominal packing, abscess, visceral edema secondary to resuscitation (SIRS)
Causes of Intra-abdominal Pressure (IAP) Elevation
Abdominal Wall: burn eschar, repair of gastroschisis or omphalocele, reduction of large hernias, pneumatic anti-shock garments, lap closure under tension, abdominal binders
Chronic: central obesity, ascites, large abdominal tumors, PD, pregnancy
Are we seeing more ACS?
Increased Incidence? Syndromes created by medical
“progress” ICU’s full of sicker patientsFluid resuscitation due to early goal
directed therapy for sepsis?
Increased Recognition?
ACS Literature: Publication explosion
0
20
40
60
80
100
120
140
83-84
87-88
91-92
95-96
99-00
003-04
Research Publications
Physiologic Insult
Ischemia Inflammatory response
Capillary leak
Tissue Edema (Including bowel wall and mesentery)
Intra-abdominal hypertension
Fluid resuscitation
Physiologic Sequelae
Cardiac: Increased intra-abdominal pressures
causes: Compression of the vena cava with reduction in
venous return to the heart Elevated ITP with multiple negative cardiac
effects The result:
Decreased cardiac output increased SVR Increased cardiac workload Decreased tissue perfusion, SVO2 Misleading elevations of PAWP and CVP Cardiac insufficiency Cardiac arrest
Physiologic Sequelae
Pulmonary: Increased intra-abdominal pressures causes:
Elevation of the diaphragms with reduction in lung volumes
Cytokines release, immune hyper-responsiveness
The result: Elevated intrathoracic pressure (which further
reduces venous return to heart, exacerbating cardiac problems)
Increased peak pressures, Reduced tidal volumes Barotrauma, atelectasis, hypoxia, hypercarbia ARDS (indirect - extrapulmonary)
Physiologic SequelaeGastrointestinal: Increased intra-abdominal pressures
causes: Compression / Congestion of mesenteric
veins and capillaries Reduced cardiac output to the gut
The result: Decreased gut perfusion, increased gut
edema and leak Ischemia, necrosis, cytokine release,
neutrophil priming Bacterial translocation Development and perpetuation of SIRS Further increases in intra-abdominal
pressure
Physiologic Sequelae
Renal: Elevated intra-abdominal pressure causes:
Compression of renal veins and arteries Reduced cardiac output to kidneys
The Result: Decreased renal artery and vein flow Renal congestion and edema Decreased glomerular filtration rate (GFR) Acute tubular necrosis (ATN) Renal failure, oliguria/anuria
Physiologic Sequelae
Neuro: Elevated intra-abdominal pressure causes:
Increases in intrathoracic pressure Increases in superior vena cava (SVC) pressure with
reduction in drainage of SVC into the thoraxThe Result: Increased CVP and IJ pressure Increased intracranial pressure Decreased cerebral perfusion pressure Cerebral edema, brain anoxia, brain injury
Physiologic Sequelae
Direct impact of IAP on common pressure measurements:
IAP elevation causes immediate increases in ICP, IJP and CVP (also in PAOP)
15 liter bag placed on abdomen (Citerio 2001)
Physiologic SequelaeMiscellaneous
Elevated intra-abdominal pressure causes: Reduces perfusion of surgical and traumatic wounds Reduced blood flow to liver, bone marrow, etc. Blood pooling in pelvis and legs “Second hit” in the two event model of MOF?
The Result: Poor wound healing and dehiscence Coagulopathy Immunosuppression DVT and PE risks
Circling the Drain
Intra-abdominal Pressure
MucosalBreakdown
(Multi-System Organ Failure)
Bacterial translocation
Acidosis
Decreased O2 delivery
Anaerobic metabolism
Capillary leak
Free radical formation
How common is this syndrome?
Malbrain, Intensive Care Medicine (2004):
Abdominal pressure:
Total Prevalence
MICU prevalence
SICU prevalence
IAP > 12 58.8% 54.4% 65%
IAP > 15 28.9% 29.8% 27.5%
IAP > 20 plus organ
failure
8.2% 10.5% 5.0%
Does IAH / ACS affect patient outcome?
Ivatury, J Trauma, 1998: Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome.
70 patients with monitored for IAP > 25 mm Hg 25 had facial closure at time of surgery:
52% developed IAP > 25 39% Died
45 cases had abdomen left “open”: 22% developed IAP > 25 10.6% Died
Does IAH / ACS affect patient outcome?
Points: Clinical signs of IAH are unreliable and only
show up late in clinical course (once ACS occurs).
IAH and ACS increase morbidity, mortality and ICU length of stay.
Preventive therapy plus early detection and intervention can reduce these complications in many patients.
Monitoring early (not waiting for clinical signs) in all high risk patients allows early detection and early intervention.
IAH/ACS Management Fluids – two edged sword
Fluids will absolutely improve cardiac indices if the patient has inadequate RV filling- so early in the course they are necessary
However, over resuscitation will lead to worsened edema
Abdominal perfusion pressure - optimize fluids first then add vasopressors. Shoot for a perfusion pressure > 60 mm Hg
Sedation, Paralytics Cathartics / enema to clear bowel? Colloids Hemofiltration Paracentesis
Need significant free fluid on US Decompressive laparotomy
IAH/ACS Management : Abdominal Perfusion Pressure
APP = MAP - IAP Abdominal perfusion pressure reflects actual
gut perfusion better than IAP alone. Optimizing APP to > 60 mm Hg should
probably be primary endpoint Cheatham 2000
Optimizing APP reduced incidence of ACS - 64% versus 48% Death - 44% versus 28%
IAH/ACS Management: Decompressive Laparotomy
Rigid Abdomen in ACS Post decompressive laparotomy
Surgical Management of Compartment Syndromes
Compartment
Cranium
Chest
Pericardium
Limb
Pathophysiology
ICP elevation
Tension pneumothorax
Cardiac tamponadeExtremity compartment
syndrome
Surgical Management
Mannitol, Craniectomy, etc..
Chest tube
Pericardiocentesis
Fasciotomy
Decompressive Laparotomy
Delay in abdominal decompression may lead to intestinal ischemia
Decompress Early!
Decompressive Laparotomy
Post-operative dressing Several days post-op
Intra-Abdominal Pressure Monitoring
Bladder pressure monitoring through the Foley catheter is: The current standard for monitoring
abdominal pressures (Consensus, World Congress ACS Dec 2004)
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)
“Home Made” Pressure Transducer Technique
Home-made assembly: Transducer 2 stopcocks 1 60 ml syringe, 1 tubing with saline
bag spike / luer connector
1 tubing with luer both ends
1 needle / angiocath Clamp for FoleyAssembled sterilely in
proper fashion
University of Utah: IAP monitoring algorithm
Entry criteria defined in table
Nurse is empowered to enter any patient fulfilling these criteria
Final ThoughtDo NOT wait for signs of ACS to be
present before you decide to check IAP By then the patient has one foot in the
grave! You have lost your opportunity for medical
therapy
Monitor ALL high risk patients early and often: TREND IAP like a vital sign Intervene early, before critical pressure
develops
QUESTIONS?
IAH and ACS Educational Web sites:
www.Abdominalcompartmentsyndrome.org
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