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Abdominal Compartment Syndrome

Abdominal Compartment Syndrome. John Hartley Academic Surgical Unit The University of Hull. Abdominal Compartment Syndrome (ACS). Definition “The adverse physiological consequences of an acute elevation in intra-abdominal pressure” Oliguria Increased airway pressures

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Abdominal Compartment Syndrome

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  1. Abdominal Compartment Syndrome John Hartley Academic Surgical Unit The University of Hull

  2. Abdominal Compartment Syndrome (ACS) Definition “The adverse physiological consequences of an acute elevation in intra-abdominal pressure” • Oliguria • Increased airway pressures • Reduced cardiac output

  3. Abdominal Compartment Syndrome Historical background The perils of elevated intra-abdominal pressure… • 1890’s elevation of IAP caused death in animal models • 1911 cardiovascular effects of raised IAP identified • 1913 effects of raised IAP on renal function • 1980’s abdominal decompression for  IAP

  4. Abdominal Compartment Syndrome Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30

  5. Abdominal Compartment Syndrome Pathophysiology ICP

  6. Abdominal Compartment Syndrome

  7. Abdominal Compartment Syndrome At risk patients • Major trauma • Damage control surgery • Laparotomy for bleeding, ischaemia etc • Re-laparotomy for postoperative complications • Massive volume resuscitation

  8. Abdominal Compartment Syndrome Clinical features • Abdominal distension • ELEVATED IAP • Consequent organ dysfunction Importance • Decompression can reverse abnormal physiology • Probable fatal progression if left untreated

  9. Abdominal Compartment Syndrome Measurement of IAP • Indirect assessment of IAP by bladder pressure • 50-100ml saline into bladder • Manometer readings from symphysis pubis

  10. Abdominal Compartment Syndrome Problems • What value of IAP should cause concern? • Level beyond which ACS is irreversible? • ABSOLUTE IAP UNHELPFUL • >20mmHg significant in all pts • >15mmHg significant in many • >12mmHg significant in some Malbrain ML. Intensive Care Med 1999;25:1453-58

  11. Abdominal Compartment Syndrome Survey of British practice • 137 of 207 hospitals (66.2% response) • 1.5% (n=2) no knowledge of ACS • Some measurement IAP 76% (n=104) • Upon suspicion of ACS 93% (n=97) • No consensus on frequency of measurement or indication for decompression Ravishankar N, Hunter J. Br J Anaesth 2005;94:763-6

  12. Abdominal Compartment Syndrome Incidence • Prospective measurement of IAP in 9 months admissions to trauma ICU • 15 of 706 pts IAH (2%) • 6 of 15 pts with IAH developed ACS (1%) • 50% mortality in ACS and 2 of 9 with IAH Hong JJ, Cohn SM, Perez JM et al Br J Surg 2002;89:591-6

  13. Abdominal Compartment Syndrome Abdominal decompression • Reversal of abnormal parameters in approx 80% • Mean survival approx. 50% • Intervention too late? • Inevitable SIRS and MOF? • PREVENTION BETTER THAN CURE Sugrue MD’Amour S. J Trauma 2001;51:419

  14. Abdominal Compartment Syndrome Proposed grading for ACS based on IAP Burch JM, Moore EE, Moore FA et al. Surg Clin North Am 1996;76:833-842

  15. Abdominal Compartment Syndrome

  16. Abdominal Compartment Syndrome Conclusions • Concept of ACS important • True incidence and significance unclear • Increasing awareness and measurement of IAP may lead to: - Better understanding of pathophysiology - Evidence based management

  17. Abdominal Compartment Syndrome • World Society on Abdominal Compartment Syndrome • www.wsacs.org • Antwerp 24th-27th March 2007

  18. Abdominal Compartment Syndrome Renal effects • IAP 15-20mmHg  RBF and GFR with anuria when >30mmHg • No effect of stenting • Parenchymal compression and  renal vascular resistance • Reversible by decompression Harman PK, Kron IL, McLachlan HD et al Ann Surg 1982;196:594-7

  19. Abdominal Compartment Syndrome Gut and hepatic effects •  splanchnic and hepatic blood flow • flow in animal models with IAP>10mmHg • Ischaemia at >40mmHg • Gastric mucosal acidosis with  IAP improves with decompression Ivatury RR, Porter JM, Simon RJ et al J Trauma 1998,44:1016-21

  20. Abdominal Compartment Syndrome Other means of detection • CT changes - Narrowing of IVC - Direct renal compression - Bowel wall thickening - “Rounded abdomen” • Splanchnic hypoperfusion and acidosis • Abdominal perfusion pressure

  21. Abdominal Compartment Syndrome Management of ACS – the issues • Indication for decompression • Timing of decompression • “point of no return” • Subsequent laparostomy management

  22. Abdominal compartment syndrome • Definition • The adverse physiological consequences that occur as a result of an acute increase in IAP

  23. Abdominal compartment syndrome • Management of ACS • Indication for decompression • Timing of decompression • “point of no return” • Subsequent laparostomy management

  24. Abdominal Compartment Syndrome Effects of intra-abdominal hypertension (IAH) • Gut and hepatic effects • Renal effects • Cardiovascular effects • Respiratory effects • CNS • Abdo wall

  25. Abdominal Compartment Syndrome Cardiovascular effects •  venous return by compression of IVC and portal vein •  intra-thoracic pressure,  LV compliance, cardiac contractility and CO •  peripheral oxygen delivery

  26. Abdominal Compartment Syndrome Respiratory effects • Elevation of diaphragm,  thoracic volume and compliance,  intra-pleural pressure •  airway pressures to maintain ventilation • Compressive atelectasis and V/Q mismatch, hypoxia, hypercarbia, acidosis

  27. Abdominal Compartment Syndrome • Acute elevation of IAP above 30mmHg caused oliguria in 11 postoperative pts • Re-exploration and decompression in 7 pts resulted in immediate diuresis. • 4 pts not re-explored developed renal failure and died. • If IAP > 25mmHg in the early post period is assoc. with oliguria and normal blood pressure and cardiac index, the patient should undergo re-exploration and decompression of the abdomen Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30

  28. Abdominal Compartment Syndrome CNS effects • Impaired venous return and cerebral pooling •  intra-cranial pressure Ertel W, Oberholzer A, Platz A et al Crit Care Med 2000; 28:1747-53

  29. Abdominal Compartment Syndrome Early detection • Survey trauma surgeons USA • 6% measured IAP routinely • 59% selectively Mayberry JC, Goldman RK, Mullins RJ. J Trauma 1999;47:509-513

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