Abdominal Compartment Syndrome

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Abdominal Compartment Syndrome

• John Hartley
• Academic Surgical Unit
• The University of Hull

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Abdominal Compartment Syndrome (ACS)

• Definition
• The adverse physiological consequences of
• an acute elevation in intra-abdominal pressure
• Oliguria
• Increased airway pressures
• Reduced cardiac output

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Abdominal Compartment Syndrome

• Historical background
• The perils of elevated intra-abdominal pressure
• 1890s elevation of IAP caused death in animal
  models
• 1911 cardiovascular effects of raised IAP
  identified
• 1913 effects of raised IAP on renal function
• 1980s abdominal decompression for ? IAP

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Abdominal Compartment Syndrome
Kron Il, Harman PK, Nolan SP. Ann Surg
198419928-30
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Abdominal Compartment Syndrome
Pathophysiology
?ICP
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Abdominal Compartment Syndrome
Causes of raised intra-abdominal pressure (IAP) Causes of raised intra-abdominal pressure (IAP)
Retroperitoneal Intraperitoneal
Oedema in necrotising pancreatitis Haemorrhage
Pelvic haematoma Visceral oedema
Retroperitoneal haematoma Abdominal packing
Bleeding after aortic surgery Bowel dilatation
Oedema related to resuscitation Mesenteric venous obstruction
Pneumoperitoneum
Acute ascites
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Abdominal Compartment Syndrome

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

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Abdominal Compartment Syndrome

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

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Abdominal Compartment Syndrome

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

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Abdominal Compartment Syndrome

• Problems
• What value of IAP should cause concern?
• Level beyond which ACS is irreversible?
• ABSOLUTE IAP UNHELPFUL
• gt20mmHg significant in all pts
• gt15mmHg significant in many
• gt12mmHg significant in some
• Malbrain ML. Intensive Care Med 1999251453-58

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Abdominal Compartment Syndrome

• Survey of British practice
• 137 of 207 hospitals (66.2 response)
• 1.5 (n2) no knowledge of ACS
• Some measurement IAP 76 (n104)
• Upon suspicion of ACS 93 (n97)
• No consensus on frequency of measurement or
  indication for decompression
• Ravishankar N, Hunter J.
• Br J Anaesth 200594763-6

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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
• 200289591-6

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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 MDAmour S. J Trauma 200151419

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Abdominal Compartment Syndrome
Proposed grading for ACS based on IAP
Grade IAP (mmHg) (cmH2O) Signs Treatment
I 10-15 13-20 No signs ACS Maintain normovolaemia
II 16-25 21-34 ? PAWP oliguria ? Volume resuscitation
III 26-35 35-48 Anuria, ? CO ? PAWP Consider decompression
IV gt35 gt48 Anuria, ? CO ? PAWP Mandatory decompression
Burch JM, Moore EE, Moore FA et al. Surg Clin
North Am 199676833-842
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Abdominal Compartment Syndrome
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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

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Abdominal Compartment Syndrome

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

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Abdominal Compartment Syndrome

• Renal effects
• IAP 15-20mmHg ? RBF and GFR with anuria when
  gt30mmHg
• No effect of stenting
• Parenchymal compression and ? renal vascular
  resistance
• Reversible by decompression
• Harman PK, Kron IL, McLachlan HD et al Ann Surg
• 1982196594-7

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Abdominal Compartment Syndrome

• Gut and hepatic effects
• ? splanchnic and hepatic blood flow
• ? flow in animal models with IAPgt10mmHg
• Ischaemia at gt40mmHg
• Gastric mucosal acidosis with ? IAP improves with
  decompression
• Ivatury RR, Porter JM, Simon RJ et al J Trauma
• 1998,441016-21

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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

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Abdominal Compartment Syndrome

• Management of ACS the issues
• Indication for decompression
• Timing of decompression
• point of no return
• Subsequent laparostomy management

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Abdominal compartment syndrome

• Definition
• The adverse physiological consequences that occur
  as a result of an acute increase in IAP

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Abdominal compartment syndrome

• Management of ACS
• Indication for decompression
• Timing of decompression
• point of no return
• Subsequent laparostomy management

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Abdominal Compartment Syndrome

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

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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

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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

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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 gt 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
  198419928-30

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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 281747-53

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Abdominal Compartment Syndrome

• Early detection
• Survey trauma surgeons USA
• 6 measured IAP routinely
• 59 selectively
• Mayberry JC, Goldman RK, Mullins RJ.
• J Trauma 199947509-513