Abdominal Compartment Syndrome
First Things First (assess & treat for the following)
First Things First (assess & treat for the following)
First Things First (assess & treat for the following)
- Recognize who is at risk
- Patients after trauma with massive resuscitation or contamination, AAA repair, liver transplant, hepatic failure with ascites, retroperitoneal bleed, massive resuscitation after sepsis or burns, pancreatitis, bowel obstruction, intra-abdominal sepsis (diverticulitis, perforated ulcer, appendicitis), or ARDS.
- Correct what can be corrected
- Ongoing bleeding
- Surgery or interventional radiology
- Coagulopathy
- Intra-abdominal sepsis
- Drainage (open versus percutaneous)
- Bowel resection
- Decompress bowel if obstructed
- NGT
- Enemas
- Prokinetic agents
History and Physical (assess for the following)
History and Physical (assess for the following)
History and Physical (assess for the following)
- Assume in anyone with systemic signs of hypoperfusion and abdominal distention.
- Affects all organ systems
- Neuro
- Cardiovascular
- Increased heart rate
- Decreased BP
- Decreased cardiac output (CO)
- These are from decreased venous return
- Pulmonary
- Decreased FRC
- Increased hypoxia
- Worsening compliance
- Increased pCO2
- Increased plateau/peak airway pressures
- Hepatic/Intestines
- Decreased visceral perfusion and portal venous flow
- Lactic acidosis
- Bacterial translocation
- Worsening coagulopathy due to decreased synthesis
- Renal
- Decreased GFR due to lack of blood flow
- Decreased urine output
- Skin and soft tissue
- Decreased fascial blood flow
- Decreased capillary refill
- Can contribute to wound infections or dehiscence
Diagnosis
Diagnosis
Diagnosis
- Have low index of suspicion in patients developing signs of hypoperfusion.
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- Once suspected, measure bladder pressure.
- Clamp Foley distally (towards collection bag).
- Instill 25 mL saline into Foley catheter.
- Measure with manometer or place pressure transducer to sampling port.
- Pubic symphysis is reference point.
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- Intra-abdominal hypertension (IAH) = sustained intra-abdominal pressure >12 mmHg
- 12-15 mmHg = Grade I IAH
- 16-20 mmHg = Grade II IAH
- 21-25 mmHg = Grade III IAH
- >25 mmHg = Grade IV IAH
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- Abdominal compartment syndrome is IAH >20 mmHg plus end-organ dysfunction. It is not graded but is an all-or-nothing diagnosis.
- Primary - occurs due to abdominal/pelvic process - bleed from trauma or ruptured vessel, liver transplant, retroperitoneal hemorrhage, or intra-abdominal sepsis
- Secondary - occurs from resuscitation for an extra-abdominal process such as burns, sepsis, or ARDS
- Recurrent - occurs after treatment of primary or secondary ACS following closure of decompressive laparotomy
- Also monitor other measures of end-organ hypoperfusion
- Creatinine
- Base deficit
- Lactate
- Liver enzymes
- CPK
- ABGs
- PT/PTT/INR
- Urine output
General Management Principles
General Management Principles
General Management Principles
- As with most ICU emergencies, IAH/ACS management centers around early diagnosis, correction of treatable conditions, and frequent re-assessment.
Specific Treatment
Specific Treatment
Specific Treatment
- Intra-abdominal hypertension (bladder pressure >12 mmHg)
- Improve abdominal wall compliance
- Sedation and analgesia
- Reverse Trendelenburg
- Neuromuscular blockade
- Minimize intra-abdominal volume
- Bowel decompression with NGT and/or enemas
- Paracentesis
- GI prokinetics (metoclopramide, erythromycin, neostigmine)
- Correct positive fluid balance
- Avoid over-resuscitation
- Diuretics (if blood pressure allows)
- Hypertonic saline
- Hemofiltration if oliguric
- Abdominal compartment syndrome (IAH >20 mmHg + end-organ dysfunction)
- Decompressive laparotomy
- Consider early to improve outcome and rates of closure
Ongoing Assessment
Ongoing Assessment
Ongoing Assessment
- Monitor bladder pressure until < 12 mmHg
- Monitor end-organ function
- Creatinine
- Base deficit
- Lactate
- Liver enzymes
- CPK
- ABGs
Complications
Complications
Complications
- If untreated or delay in diagnosis
- Renal failure
- Hypoxia
- Hypercapnea
- Visceral ischemia
- Rhabdomyolysis
- Related to therapy
- Hernia
- Enterocutaneous fistula
Author
Author
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