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Abdominal Compartment Syndrome

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Title: Abdominal Compartment Syndrome Author: Wael Last modified by: WBatobara Created Date: 10/13/2004 12:52:40 AM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Abdominal Compartment Syndrome


1
Abdominal Compartment Syndrome
2
Increased Intra-abdominal Pressure IAP Abd.
Compartment Synd ACS
  • Case
  • Definition prevalence
  • Measurement techniques
  • Etiology
  • Consequences
  • Treatment

3
Definition
  • Compartment syndrome exists when increased
    pressure in a closed anatomic space threaten the
    viability of enclosed surrounding tissues
  • ACS ?organ dysfunction as a result of
  • increased IAP

4
Definition
  • 77 patients prospectively studied
  • IAP by measuring bladder pressure
  • Mean IAP 6.5 mm Hg ( 0.2-16.2 mm Hg).
  • BMI previous abd Sx were the only factors
    associated with high IAP

  • Am Surg 2001 Mar

5
Definition
  • A lot of literature but no consistent criteria
    for has been used for diagnosis
  • What measurement should be used ?maximum Vs mean
    Vs median?
  • What is the gold standard method of diagnosis?

6
Etiology
  • Surgical primary
  • Large volume resuscitation in abdominal trauma
    or emergency operations
  • Tight surgical suture or burn scars
  • Non surgical secondary
  • peritonitis , pancreatitis , massive ascites
  • bowel obstruction , EGD NPPV

7
Etiology
  • One day prevalence in 13 ICU over 6 countries
  • 97 patients with admission gt 24h
  • IAP measured with bladder pressure
  • q 6 h for 24 hours
  • Intraabdominal hypertension IAH
  • when IAP or gt 12 mm Hg
  • ACS when IAP or gt 20 mm Hg
  • Intensive
    Care Med. 2004 May

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Etiology
  • IAH incidence 50.8 ACS 8.5
  • Only BMI gt27 was strongly associated with ACS in
    multivariate analysis
  • Amount of fluid given
  • renal coagulation dysfunction have a trend
    of important only on univariate analysis
  • Intensive Care
    Med. 2004 May

10
Measurement of IVP
  • Bladder pressure is the most commonly used method
  • gastric, rectal uterine has been
    described
  • Patient supine, measurement during expiration
    bladder is empty Foley catheter is clamped
  • 18 gauge needle attached to transducer is
    inserted into the aspiration port 50 ml NS is
    injected

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Bladder Pressure
  • 37 patient undergoing laparoscopy
  • Bladder pressure at different volume 0-200 ml
  • Moderate correlation R 0.62
  • Bias 3.2 mm Hg
  • Lowest bias in patient with N IAP ?50 ml
  • in patients with high IAP ?0 ml
  • J
    Trauma 2001 Feb

14
Bladder Pressure
  • Possible source of errors in measurement
  • Body position , zeroing
  • over or under damping
  • Baseline IAP
  • ? Empty bladder
  • Fluctuation in IAP

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Measurement Of IAP
  • Continuous fully automated system
  • NGT like tube with air pouch at the tip
  • The pressure transducer is integrated in the
    monitor
  • Excellent correlation with insufflatory pressure
    R .99 with bias .5-2.5 mm Hg
  • Intensive
    Care Med. 2004 Mar

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Consequences
  • Critical IAP ?IAP at which ACS will develop
  • Variable from patient to patient
  • Likely critical IAP is lower in morbid obesity ,
    pregnancy CLD with ascites ,previous abdominal
    surgeries

21
Consequences
  • CNS
  • Increase in IAP will increase ICP
  • 15 patients with moderate to severe head injury
    after resolution of initial elevated ICP.
  • IAP was increased by 15 liter water bag over the
    abdomen
  • IAP 4.7?15.5 ICP 12 ?15 mm Hg
  • This effect was mediated through increase in the
    intrathoracic pressure

  • Crit Care Med 2001

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Consequences
  • CVS
  • studies in animals mainly
  • Rt ward flattening of Frank-Starling curve
  • Decrease in compliance contractility
  • Decrease in VR
  • Elevated CVP PCWP
  • not reflector of true intravascular volume
  • ?use of volumetric parameters in resuscitation

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Consequences
  • Respiratory
  • Animal studies
  • Decrease in chest wall compliance
  • Increase in VQ mismatch dead space
  • Hypoxia hypercapnia
  • Best PEEP IAP
  • Pplt Pplt IAP

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Consequences
  • GI
  • In animal studies
  • ?decrease in blood flow
  • increase risk of bacterial translocation
  • decrease hepatic lactate clearance
  • In human study
  • Increase IAP induced in 14 cirrhosis with varices
    ?elevation in varices pressure size wall
    tension

  • Hepatology 2002

29
Consequences
  • Renal
  • Decrease in venous drainage because of increased
    venous pressure
  • Decrease renal perfusion 2ry to arterial
    vasoconstriction Renin mediated by the fall in
    cardiac output
  • Decrease in GFR UOP with pre renal picture

30
Consequences
  • Renal
  • Increase IAP was one risk factor in developing
    hernias leak in 142 peritoneal dialysis
    patients
  • Other factors BMI age
  • Peritoneal Dialysis
    International 2004

31
Diagnosis
  • 21/42 trauma patient who had developed IAH
    diagnosed by bladder pressure were examined
    clinically
  • Clinical exam sensitivity 56 PPV 35
  • specificity 87 NPV
    64
  • accuracy 84

  • Can J Surg 2000 Jun

32
Management
  • Surgical
  • Decompression with maintenance of open abdomen
    (vacuum pack dressing)
  • ? When to operate
  • Abdominal perfusion pressure APP was shown in
    retrospective study of 144 pt with IAH to be the
    best predictor of survival

  • J Trauma 2000 Oct

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Management
  • Volume resuscitation
  • Higher filling pressure
  • Mechanical ventilation
  • Lung protective ventilation?aim Pplt IAP
  • Best PEEP IAP

35
Summary
  • IAH ACS is infrequent but serious complication
    of multiple surgical medical diseases
  • Clinical examination had low sensitivity
  • Till now bladder pressure is the most commonly
    used method to screen for ACS

36
Summary
  • The effect of IAH is on all other systems
  • With the development of continuous intraabdominal
    pressure monitors IAP may become part of the
    vitals
  • Surgical decompression is the main stay of Rx

37
Thanks
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