ABDOMINAL COMPARTEMENT

SYNDROME

Neil Berry ; Simon Fletcher

Norfolk and Norwich Hospital, UK

Continuing Education in Anaesthesia, Critical Care & Pain 2012

Published : March 8, 2012
By Oxford University Press on behalf of British Journal of Anaesthesia
KEY POINTS
 Mortality for untreated intra abdominal hypertension
and abdominal compartement syndrome is high
 Presentation is commonly a multi system
phenomenon of abdominal distension, renal,
respiratory, and circulatory compromise.
DEFINITIONS & INCIDENCE

Compartement syndrome occurs when a fixed

compartement defined by myofascial layers,
bone, or both becomes subjected to increasing
pressures, leading to vascular compromise and
ischaemia.
DEFINITIONS & INCIDENCE

 Normal intra abdominal pressure in the typical

critical ill, intensive care patient is 5-7 mmHg
 The intra abdominal pressure is dependent on
the volume of intra abdominal contents, for
example visceral volume, tumours, the
pathological presence of fluid (blood, ascites,
pus) and general visceral oedema.
DEFINITIONS & INCIDENCE

 Pathological conditions may also effect the

compliance of the abdominal wall, for example,
burns, oedema, or prolonged prone positioning.
 Positive inspiratory and expiratory pressures
used in mechanical ventilation will indirectly
increase intra abdominal pressure
DEFINITIONS & INCIDENCE
 Intra abdominal hypertension is defined as a
sustained intra abdominal pressure of > 12
mmHg, and abdominal compartement syndrome
occurs at a pressure > 20 mmHg in association
with new organ dyfunction.
 Intra abdominal hypertension is graded as follows:
Grade I = 12-15 mmHg
Grade II = 16-20 mmHg
Grade III = 21-25 mmHg
Grade IV = > 25 mmHg
DEFINITIONS & INCIDENCE

 Acute abdominal compartement syndrome can

be categorized into primary, where the
pathology lies within the abdominal pelvic
cavity or secondary, where the cause lies
outside of this region, for example, extra
abdominal sepsis or fluid overload.
INCIDENCE

 Associated with septic shock : 30-85%

 In acute pancreatitis :

Intra abdominal hypertension : 40-70%

Abdominal compartement syndrome : 10-50%
 In post laparotomy :

Elective : Low
Emergency : Considerable
CLINICAL PRESENTATION

 Commonly abdominal pain and distension are

present associated with hypoxia, hypercarbia,
and oliguria due to respiratory and renal
physiologic changes.
DIAGNOSIS

 The World Society of Abdominal Compartement

Syndrome suggest that any patient with two or
more risk factors is at high enough risk to
warrant intra abdominal pressure monitoring
 The mainstay of diagnosis relies on early
clinical suspicion of raised intra abdominal
pressure in any patient with associated risk
factors
RISK FACTORS
 Diminished abdominal wall compliance
- Acute respiratory failure
- Abdominal surgery with tight primary closure
- Major trauma/burns
- Prone positioning
- High BMI
 Increased intra luminal contents
- Gastroparesis
- Ileus
- Colonic pseudo obstruction
 Increased abdominal content
- Haemoperitoneum/pneumoperitoneum
- Ascites/liver dysfunction
RISK FACTORS
 Capillary leak/fluid resuscitation
- Acidosis (pH < 7.2)
- Hypotension
- Hypothermia (<33oC)
- Polytransfusion
- Coagulopathy
- Massive fluid resuscitation
- Pancreatitis
- Oliguria
- Sepsis
- Major trauma/burns
- Damage control laparotomy
PATHOPHYSIOLOGY

 Cardiovascular system
Increased : Systemic Vascular Resistance
Pulmonar Vascular Resistance
Decreased : Venous return
Cardiac compliance
Cardiac Output
PATHOPHYSIOLOGY

 Respiratory system
Increased : V/Q mismatch
Ventilatory pressure
Basal atelectasis
PaCO2
Decreased : Pulmonary compliance
PaO2
PATHOPHYSIOLOGY

 Central Nervous System

Increased : Intra cranial Pressure
 Renal

Increased : Renal Tubular Pressure

Urinary Obstruction
Decreased : Renal Blood Flow
Urine Output
PATHOPHYSIOLOGY

 Gastro Intestinal and Hepatic

Increased : Oedema
Bacterial translocation
Liver Dysfunction
Decreased : Coeliac, hepatic blood flow
MANAGEMENT
 Non-surgical
1. Lowering intra abdominal pressure
- Supine positioning
- Nasogastric tube
- Enemas
- Pro kinetic agents
- Endoscopy
2. Organ support
Aim : Optimize cardiac output
 Initial fluid resuscitation
MANAGEMENT
 Surgical
- Laparotomy (open abdomen)  improve mortality
in abdominal compartement syndrome
- The timing of surgical decompression is important.
In others who have developed abdominal
compartement syndrome, and where non surgical
methods have failed, decompression should be
performed as an emergency procedure
- The abdomen should only be closed when the risk
of continuing intra abdominal hypertension has
passed, on average 5 days after decompression
ANAESTHESIA CONSIDERATION
There are 4 key concerns spesifically related to
patients with abdominal compartement
syndrome:
1. Pharmacokinetics/dynamics
Patients with abdominal compartement
syndrome may be more sensitive to the cardiac
depressant effects of induction agents due to
liver dysfunction, altered drug handling, altered
volume of distribution and hypovolemia
ANAESTHESIA CONSIDERATION

2. Sudden decrease in intra thoracic pressure

As the abdomen is opened, there is a
consequent decrease in the intra thoracic
pressure. An increase in respiratory compliance
may occur, with the potential of over ventilation
and damage to lung parenchyma due to
barotrauma and volutrauma.
ANAESTHESIA CONSIDERATION

3. Sudden decrease in systemic Vascular

Resistance
 On opening the abdomen, afterload will fall
as may cardiac output and arterial pressure.
Further fluid loading and/or vasopressor may be
required, and resuscitation drugs and equipment
should be close at hand
ANAESTHESIA CONSIDERATION

4. Reperfusion injury
 On opening the abdomen, previously
ischaemic areas of bowel and viscera may once
again be perfused, leading to a systemic
reperfusion insult with potential of myocardial
depression, arrhythmias, and on occasion,
cardiac arrest.
Thank You