ABDOMINAL COMPARTMENT SYNDROME

Symptomatic organ dysfunction that results from increased intraabdominal pressure (IAP)
Increased IAP is an under-recognized source of morbidity and mortality. 1-day point-prevalence observational trial conducted in 13 medical ICUs of six countries with 97 patients, 8% had IAP > 20mmHg. 1 The incidence of ACS in trauma patients is estimated to be between 2 and 9 percent.2

1Crit 2Am

Care Med 2005; 33:315. J Surg 2002; 184:538.

ABDOMINAL COMPARTMENT SYNDROME

ETIOLOGY

Massive volume resuscitation in the leading cause of ACS.

Inflammatory states with capillary leak, fluid sequestration, inadequate tissue perfusion, and lactic acidosis can develop ACS. Gastric overdistention following endoscopy has resulted in ACS.

ABDOMINAL COMPARTMENT SYNDROME

PATHOPHYSIOLOGY

The IAP is usually 0 mmHg during spontaneous respiration, and is slightly positive in the patient on mechanical ventilation.
IAP increases in direct relation to body mass index, and in one report, supine hospitalized patients had a mean baseline value of 6.5 mmHg.

The compliance of the abdominal wall generally limits the rise in IAP but increases rapidly after a critical IAP.
Critical IAP varies from patient to patient, based on abdominal wall compliance on perfusion gradient. IAH often defined as IAP > 12mmHg. Previous pregnancy, cirrhosis, morbid obesity, may increase abdominal wall compliance and can be protective .

ABDOMINAL COMPARTMENT SYNDROME

CLINICAL MANIFESTATIONS
CENTRAL NERVOUS SYSTEM Intracranial pressure Cerebral perfusion pressure CARDIAC Hypovolemia Cardiac output Venous return PCWP and CVP SVR PULMONARY Intrathoracic pressure Airway pressures Compliance PaO2 PaCO2 Shunt fraction Vd/Vt GASTROINTESTINAL Celiac blood flow SMA blood flow Mucosal blood flow pHi RENAL Urinary output Renal blood flow GFR HEPATIC Portal blood flow Mitochondrial function Lactate clearance ABDOMINAL WALL Compliance Rectus sheath blood flow
Curr Opin Crit Care 2005; 11:333

ABDOMINAL COMPARTMENT SYNDROME

50 mL of sterile saline is instilled into the bladder via the aspiration port of the Foley catheter with the drainage tube clamped. An 18-gauge needle attached to a pressure transducer is then inserted in the aspiration port, and the pressure is measured. The transducer should be zeroed at the level of the pubic symphysis.

Curr Opin Crit Care 2005; 11:333

ABDOMINAL COMPARTMENT SYNDROME

MANAGEMENT
PROPOSED GRADING OF ABDOMINAL COMPARTMENT SYNDROME

Grade Pressure (mmHg) Management I II III IV 10-15 16-25 26-35 >35 Maintenance of normovolemia Volume administration Decompression Re-exploration

Abdominal perfusion pressure (APP): APP = MAP - IAP In one retrospective study, the inability to maintain an APP above 50 mmHg predicted mortality with greater sensitivity and specificity than either IAP or MAP alone .
Surg Clin North Am 1996; 76:833.

ABDOMINAL COMPARTMENT SYNDROME

OPERATIVE DECOMPRESSION
Vacuum-assisted temporary abdominal closure device: thin plastic sheet, a sterile towel, closed suction drains, and a large adherent operative drape. This dressing system permits increases in intra-abdominal volume, without a dramatic elevation in IAP.

ABDOMINAL COMPARTMENT SYNDROME

SUMMARY

ACS is a clinical entity caused by an acute, progressive increase in IAP.

Multiple organ systems are affected, usually in a graded fashion. The gut is the organ most sensitive to IAH. Treatment involves expedient decompression of the abdomen. Since this syndrome affects patients who are already physiologically compromised, a high degree of suspicion and a low threshold for checking bladder pressures are required to prevent the mortality associated with this complex problem.

ABDOMINAL COMPARTMENT SYNDROME

REFERENCES AND READINGS

Sugrue, M. Abdominal compartment syndrome. Curr Opin Crit Care 2005; 11:333.
Bailey, J, Shapiro, MJ. Abdominal compartment syndrome. Crit Care 2000; 4:23. Malbrain, ML, Chiumello, D, Pelosi, P, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005; 33:315. Kron, IL, Harman, PK, Nolan, SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 1984; 199:28. Hong, JJ, Cohn, SM, Perez, JM, et al. Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg 2002; 89:591. Balogh, Z, McKinley, BA, Cocanour, CS, et al. Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation. Am J Surg 2002; 184:538. Cheatham, ML, White, MW, Sagraves, SG, Johnson, JL. Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. J Trauma 2000; 49:621.