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2006.01.09 ICU Journal Reading

Chi-Mei Medical Center

Department of Intensive Care Medicine

Abdominal compartment syndrome

Michael Sugrue

Curr Opin Crit Care 2005, 11:333-338

Presented by: Dr.

Supervisor: Dr.

,

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Introduction

World Congress on the Abdominal

Compartment Syndrome

December 2004

Australia

170 leaders from around the world

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Definition

Intra-abdominal pressure(IAP)

Pressure concealed within the abdominal cavity

Normal IAP: 5 mm Hg,in obese

Measured

end-expiration

Supine postion Absent of muscle contraction

Zeroed at midaxillary line

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Gold standard measurement

Direct IAP

direct needle puncture and transduction of the pressure

within the abdominal cavity E.q: peritoneal dialysis or laparoscopy

Intermittent indirect IAP

Transduction of the pressure within the bladder

Continuous indirect IAP

Balloon tipped catheter in the stomach or a continuous

bladder irrigation method

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Abdominal perfusion pressure

Abdominal perfusion pressure(APP)

APP = mean arterial pressure IAP

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Intra abdominal hypertension

Intra-abdominal hypertension (IAH)

IAP12mmHg, by a minimum of 3

standardized conducted 4~6 hours apart

APP60mmHg, by at least 2 measurement

conducted 1~6 hours

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Intra abdominal hypertension


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IAP20 mmHg

APP50 mmHg

3 standardized measurement conducted 1~6 hrs

Single or multiple organ system failure

All or nothing phenomenon

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Primary

Injury or disease in the abdominopelvic region

After abdominal surgery

Massive retroperitoneal hematoma

Liver transplantation

Bleeding pelvic fracture

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Secondary

Not originate from abdomen

Sepsis and capillary leak

Major burn

Condition requiring massive fluid resuscitation

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Tertiary or recurrent ACS

ACS develops after prophylactic or therapeutic

surgical or medical treatment of primary ofsecondary ACS

Persistence of ACS after decompressive op

Development of a new ACS after definitive closure

of abdominal wall after previous temporal

abdominal wall closure

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Prevalence

Varied by definition of threshold

MalbrainML, CCM 2005; 33:315-322

265 patients 14 ICU, mixed

Mean APCHE II: 17.4

Admitted for more than 24 hrs, until death, discharge or

28 days

Medical: 46.8%;

Elective, emergent, trauma Sx: 27.9%, 16.6%, 8.7%

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Prevalence

Result

On admission: 32.1% IAH; 4.2% ACS

IAH during ICU stay was an independentpredictor of mortality

Independent predictors of IAH at day 1

Liver dysfunction Abdominal surgery fluid resuscitation 3500 ml

Ileus

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New trend in monitor IAP

Continuous IAP monitor

Balogh

Advantage

Not require change in present practice

Monitor is continuous and not interfere with urinary

flow

Less labor

Better time consuming

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New trend in monitor IAP

Signal Interpretation and Monitor(SIMON)

Grogan EL, J Trauma2005; 58:7-14

Continuous physiologic data in the ICU

HR, BP, CPP, ICP, CI, EDVI, SVO2, SPO2,

SVRI, PAP, and CVP

Hypothesized: heart rate (HR) volatilitypredicts outcome better than measures of

central tendency (mean and median).

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Signal Interpretation and Monitor(SIMON)

Volatility predicts death better than measures of

central tendency

Volatility is a new vital sign that we will apply toother physiologic parameters, and that can only be

fully explored using techniques of dense data

capture like SIMON

Densely sampled aggregated physiologic data may

identify sub-groups of patients requiring new

treatment strategies

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Pathophysiology

Determined by the volume of the viscera

and the intra-compartment fluid load

In general, abdominal cavity has a great

tolerance to fluctuating volume with little

rise in IAP

Laparoscopy: generate 20 mmHg need 8.84.3

L gas

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Pathophyiology

Adaptation occur over time

Ascites

Large ovarian tumor

Pregnancy

Chronic ACS occurs in some morbidly obesepatient

Chronic venous stasis Urinary incontinence

Incisional hernia

Intracranial hypertension

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Pathophysiology

Causes of acutely increased IAP

Trauma or intra abdominal hemorrhage

Abdominal surgery

Retro-peritoneal hemorrhage

Peritonitis

Laparoscopy and pneumoperitoneum

Repair of large incisional hernia

Abdominal banding with postoperative Velcro belt toprevent incisional hernia

Massive fluid resuscitation: 5 L in 24 hrs

Ileus

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Effect of raised IAP

Renal

Bradley; 1945:renal plasma flow and GFR

Harman et al; 1982; dogs IAP increased from 020 mmHg: GFR25% IAP at 40 mmHg: CO normal after resuscitation, but

GFR didnt improvelocal effect on renal flow

Exact cause: not clear Surge, 1996: 20 patient with IAH and renal

impairment13 pt had impairment previously

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Most likely direct effect:renal vascularresistance, coupled withcardiac output

Pressure on ureter: ruled out Stent in ureter: no improvement

Humeral factor?

Intra-parenchymal renal pressure?

Absolute value to influence: not established Cutoff point: 10~15 mmHg ?

Maintain adequate cardiovascular filling pressure

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Cardiovascular

Cardiac output

Stroke volume preload,afterload

Central venous pressure, systemic vascularresistance, pulmonary artery pressure, pulmonary artery

wedge pressure, intrapleural pressure

CVP didnt reflect volume status because ofIntrapleuralpressure

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Cardiovasculer

Left atrial/ Right atrail pressure gradient may

be reversed Venous statsis: IAP12 mmHg

Renin / aldosterone: 4X in laparoscopy

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Respiratory

Restrictive effect

compliance airway pressure

tidal volume

Effect on efficiency of gas exchange:

hypercapniarespiratory acidosis

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Visceral perfusion

Sugrue M, Int Care Med 1994:

Association between IAP and visceral perfusion are measured

by gastric intramucosal pH Abnormal pHi patients were 11.3 times more likely to have an

increased IAP.

Schilling MK, J Am Coll Durg 1997

Reduction of 11~54% in duodenum and stomach blood flow at

IAP of 15 mmHg

Sugrue M, West J Surg, 1996

Early decreased in visceral perfusion are related to level of IAPas low as 15 mmHg

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Schilling MK, J Am Coll Surg, 1997

BACKGROUND:

Splanchnic macrocirculatory changes during

high-pressure CO2 pneumoperitoneum includea decrease in mesenteric arterial blood flow,

and decreased gastric perfusion with a drop in

gastric pH in experimental studies

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STUDY DESIGN:

18 patients undergoing laparoscopy with a CO2

pneumoperitoneum (7 symptomaticcholecystolithiasis, 3 acute cholecystitis, and 8

acute appendicitis)

Gastric, duodenal, jejunal, colonic, hepatic, and

peritoneal blood flow was measured with a

custom-made laser Doppler flow probe at an

intra-abdominal pressure of 0, 10, and 15 mm

Hg

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RESULTS:

IAP elevation from 1015 mm Hgsignificantly decreased the blood flow in thestomach by 40 percent to 54 percent, the

jejunum by 32 percent, the colon by 44 percent,the liver by 39 percent, the parietal peritoneum

by 60 percent, and the duodenum by 11 percent.

Splanchnic blood flow decreased with operativetime at a constant intra-arterial pressure (r =0.88, p < 0.0001).

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CONCLUSIONS:

From our study, we concluded that laparoscopic

procedures with a CO2 pneumoperitoneumshould be performed at apressure of 10 mmHg

or lower to avoid splanchnic microcirculatory

disturbances.

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Visceral perfusion

Increase IAP

Visceral hypoperfusion

Bacterial translocation Affect wound healing

BothIAP and pHi Increased risk of hypotension

Intra-abdominal sepsis Renal impairement

Need for repeat laparotomy

Death

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Indication of IAP monitor

Postoperative (abdominal surgery)

Open or blunt abdominal trauma

Mechanical ventilated ICU pt with organdysfunction

Pt with distended abdomenand s/s consistent

with ACS

Oliguria, hypoxia, hypotension, unexplained acidosis,

mesenteric ischemia, elevated intracranial pressure

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General support NG decompression

Paracentesis Gastric suctioning

Rectal enemas and suctioning

Gastroprokinetics (cisapride, metoclopramide,domperidone, erythromycin)

Colonoprokinetics (prostigmine) Lasix alone or in combination with albumin

CVVH

Continuous negative abdominal pressure

Sedation Curarization

Body positioning

Botulinum toxin into internal anal spnincter

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Surgical management

No exactly guideline for when surgical

decompression is required

Abdominal decompression is the onlytreatment?not supported by level 1 study(Andrews K, ANZ J Surg 2005)

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Surgical management

Indication for Sx are related to correcting

pathyphysiologic abnormalities as much as

achieving a precise and optimum IAP

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Surgical management

Temporary abdominal closure (TAC)

Popular method to reverse IIAP

Some authors advocated prophylactic TAC?

Hard to identify subgroup of high risk pt

Bruch J, Surg Clin North Am 1996

Abdominal decompression reverse the sequlae ofACS

IAP are guide to close the abdominal wall

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Surgical management

Indication of perform TAC

Abdominal decompression both prophylactic

and therapeutic Facilitate re-exploration in abdominal sepsis

Inability to close the abdomen

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Surgical management


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Conclusion

The challenge lies not in identifying

predictors of ACS but in optimizing

treatment, including identifying patientswho need decompression

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Thanks for your attention

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