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ABDOMINAL

COMPARTMENT SYNDROME The other ACS



Background
First described in postop AAA patients, back in 1980s
Underecognised in the past, more awareness now www.WSACS.org
ACS Alters organ perfusion and end organ function
Associated with increased morbidity and mortality


Definitions

IAP: Intra-abdominal pressure is defined as the pressure created within the


abdominal cavity the normal IAP for critically ill adults is 57 mmHg
IAH: Intra-abdominal hypertension is a sustained or repeated IAP > than 12
mmHg. There are four grades of IAH, Grade 1 IAP 12 15 mmHg, Grade 2 IAP
1620 mmHg, Grade 3 IAP 21 25 mmHg and grade 4 an IAP > 25 mmHg
ACS: It is defined as a sustained IAP > 20 mmHg (with or without an APP < 60
mmHg) that is associated with new organ dysfunction/failure. (APP=MAP-IAP)
Primary IAH/ACS is a condition associated with injury or disease in the
abdominopelvic region that frequently requires early surgical or interventional
radiological intervention
Secondary IAH/ACS refers to conditions that do not originate from the
abdominopelvic region

Risk Factors
Related to
diminished
abdominal wall
compliance

Related to increased intra abdominal


contents

Related to capillary leak


and fluid resuscitation

High BMI,
Pregnancy
Mechanical
Ventilation
Abdominal Surgery
Abdominal wall
eschar
Major trauma
Prone positioning
Burns
Pnemoperitonem

Gastroparesis
Gastric Distension, Ileus
Colonic pseudoobstruction
Hemo/pneumoperitoneum
Intra-abdominal
infection/abscess
Intra-abdominal tumors
Laparoscopy with excessive
insufflation pressures
Cirrhosis with ascites
Peritoneal dialysis
Acute Pancreatitis

Acidosis (pH below


7.2)
Hypothermia (core
temp < 33 )
Coagulopathy
Multiple
transfusions
Septic shock
Massive fluid
resuscitation
Major burns

Systemic Effects
Cerebral

An Increase in IAP forces the diaphragm up decreasing increasing the


intra-thoracic pressure.
Jugular venous pressure elevates.
Venous return decreases.
Intra cerebral pressure will increase.
Cerebral blood flow decreases.


Cardiac

An increase in IAP causes increased pressure on the IVC.


Venous return is impaired and peripheral edema occurs.
Increase in central venous pressure.
Increased pulmonary artery wedge pressures as the myocardium is
placed under an increasing workload.

An increased in IAP forces the diaphragm up decreasing intra-


thoracic space and restricts respiration.
Result in an increase in intra thoracic pressure particularly
with mechanically ventilated patients.
Decrease in lung compliance, functional residual capacity a
VQ mismatch and hypoxia.


Respiration

Renal

GI


Increase in abdominal pressure decreases renal blood flow/
GFR AKI.
The rennin angiotensin system is activated further adding to
intra- abdominal pressure and cardiac workload.


Increased intra- abdominal pressure results in an increase in
vascular resistance and decreased cardiac output.
Results in a decrease in tissue perfusion/ischemia.
Mucosal sloughing, Bacterial translocation, Sepsis.

Peripheral
Perfusion

Increased intra- abdominal pressure is said to increase


femoral venous pressure increase peripheral vascular
resistance and reduce femoral artery blood flow.



Diagnosis

Checking Intravesical or bladder pressure is the gold standard (with a commercial


device)
Can also be done with Foleys and a transducer,

1. The drainage tube of the patient's Foley (bladder) catheter is clamped.


2. 25ml NS is instilled into the bladder via the aspiration port of the Foley catheter
3. An 18-gauge needle attached to a pressure transducer is inserted into the aspiration
port.
4. Measure at end-expiration in the supine position and zero the transducer at the level
of the midaxillary line.


Treatment

Definitive treatment: Laparotomy (IAP>20mm Hg)


Medical stabilization can improve symptoms, or buy sometime until a surgeon
is available
Medical Mx: Insert nasogastric and rectal tube, Prokinetics, NPO/NBM, drain
ascites/abscess, provide analgosedation +/- NMBAs/ Keep fluid balance zero to
negative


Key Points:
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome
(ACS) occur frequently in critical care and can alter organ perfusion and end
organ function.
Measurement of Intra-abdominal pressure (IAP) is done via the bladder.
ACS is classified as an IAP greater than 20 mmHg with a new organ dysfunction.
Think of ACS in patients with worsening renal function, high peak/plateau
pressures, worsening ICP, decreased UO consider ACS and check bladder
pressure.


For Further Reading:
1.
2.
3.
4.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680657/pdf/134_2013_Article_2906.
pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3925290/pdf/1752-2897-8-2.pdf
http://www.aacn.org/wd/cetests/media/c1212.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3132369/


Thanks!


Questions/Comments/Feedback

Lakshay Chanana
drlakshay_em@yahoo.com
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