Abdominal Compartment
Syndrome
Moderator:
Dr. Rakesh Kumar Gupta
Professor
Department of
General Surgery
Presenter:
Dr. Pravakar Shrestha (JR3)
Department of
General Surgery
IAP
• Steady state pressure concealed within abdominal cavity
• Normal IAP :0-5 mm of Hg
• approximately 5-7 mm Hg in critically ill adults
Malbrain MLNG, De Laet I, Cheatham M. Consensus Conference Definitions and
Recommendations on intra-abdominal hypertension (IAH) and the Abdominal
Compartment Syndrome (ACS
Intraabdominal hypertension
• Sustained or repeated pathological elevation in IAP ≥ 12 mm of Hg without
obvious organ failure
• Grading as per WSACS
• Grade I- IAP 12-15 mm of Hg
• Grade II- IAP 16-20 mm of Hg
• Grade III- IAP 21-25 mm of Hg
• Grade IV- IAP 25 mm of Hg
Abdominal Perfusion pressure
• Calculated as the mean arterial pressure minus IAP
• APP=MAP –IAP
• A target APP of at least 60 mm of Hg – improved survival from IAH and ACS
Abdominal compartment syndrome
• Sustained IAP >20 mmHg (with or without an abdominal perfusion pressure < 60
mm of Hg ) associated with new organ dysfunction /failure.
Zhou JC, Zhao HC, Pan KH, Xu QP. Current recognition and management of intra-
abdominal hypertension and abdominal compartment syndrome among tertiary
Chinese intensive care physicians. J Zhejiang Univ Sci B. 2011;12(2):156–162
TYPES
• Primary ACS
• Associated with injury or disease in the abdominopelvic region that
frequently require early surgical or interventional radiological intervention
• secondary ACS
• develops in the absence of abdominal injury
• Recurrent ACS
• Condition in which ACS redevelops following previous surgical or medical
treatment of primary/secondary ACS
Risk factors
1.Diminished abdominal wall compliance
• Abdominal surgery
• Major trauma
• Major burns
• Prone positioning
• Increased intraluminal contents
• Gastroparesis
• gastric distention
• ileus
• volvulus
• Increased extraluminal abdominal volume
• Hemoperitoneum
• pneumoperitoneum
• severe pancreatitis
• liver failure with ascites,
• retroperitoneal or intra-abdominal tumors
• intra-abdominal abscesse
• laparoscopy with excessive insufflation pressures
• peritoneal dialysis.
• Capillary leak /fluid resuscitation
• Acidosis
• Damage control laparotomy
• Hypothermia
• Massive fluid resuscitation or positive fluid balance
• Miscellaneous
• Bacteremia
• Coagulopathy
• Increased head of bed angle
• Massive incisional hernia repair
• Mechanical ventilation
• obesity
Pathophysiology
• Cardiovascular system:
• Increased IAP-cause compression of aorta and IVC
Decreased venous return to heart
Decreased cardiac output
Decreased tissue perfusion
• Additionally ,increased IAP causes diaphragm to move upward
Which raises intra-thoracic pressure
Direct pressure on heart
Decreases ventricular compliance
• Pulmonary
• Increased IAP will cause diaphragmatic compression causing
• Increased Intrathoracic pressure
• Increased Peak inspiratory pressure
• Increased Airway pressure
• Decreased Compliance
• Atelectasis
• Decreased Po2 (hypoxia) , hypercarbia and ARDS
• Increased Intrathoracic pressure also leads to decrease venous return
exacerbating cardiac problem
• Renal:
• Increased IAP causes compression of the renal arteries and veins causing
• Decreased renal blood flow
• Decreased GFR
• Decreased urine output
• Oliguria , anuria and renal failure
• Gastrointestinal tract
• Increased IAP causes compression and congestion of the mesenteric veins
and capillaries resulting in
• Decreased splanchnic blood flow causing tissue hypoxia , increased
capillary permeability and oedema
• Decreased gut perfusion leading to ischaemia , necrosis , cytokine
release , bacterial translocation and infection
• Abdominal wall
• Increased IAP causes
• Decreased compliance
• Decreased rectus sheath blood flow
• Nervous system:
• Elevated IAP decreases venous drainage from the brain resulting in increased
ICP and decreased cerebral blood flow
Presentation
• Observed in critically ill and more frequently diagnosed in ICU
• High clinical suspicion for ACS
• Penetrating abdominal trauma
• Patient who has received large amount of fluid resuscitation
• Undergone extensive abdominal surge
• Tense abdominal distension and elevated IAP
• Difficulty ventilating due to elevated airway pressures
• Low blood pressure (due to decreased venous return and low cardiac output),
• decreased urine output, visceral hypoperfusion
• Progressive acidosis
• Inappropriate response to resuscitation – sign of ACS
Diagnosis
• Imaging modalities - not standard practice for the diagnosis of ACS
• can show early indicators of IAH that may ultimately lead to ACS
• peritoneal-to-abdominal height ratio >0.52,
• a maximal anteroposterior to transverse abdominal diameter ratio of >0.8
• bowel wall thickening
• elevation of the diaphragm
• narrowing of the vena cava <3 mm
• large amount of intra-abdominal fluid
• Displacement of solid abdominal viscera
• Measurement of IAP
• Direct method:
• Using pressure transducer (eg, Veress needle during laparoscopic surgery)
• intraperitoneal catheters (eg, peritoneal dialysis catheter
• Indirect method
• Intravesicular catheter pressure
Treatment :
• Medical treatment:
• Improve abdominal wall compliance
• Sedation and analgesia
• Neuromuscular blockade
• Eschar release
• Avoid head of bed > 30 degrees
• Evacuate intraluminal content
• Nasogastric decompression
• Rectal decompression
• prokinetic agent
• Evacuate abdominal fluid collections
• Paracentesis
• Percutaneous drainage
• Correct positive fluid balance
• Avoid excessive fluid resuscitation
• Diuretics
• Colloids/hypertonic fluids
• Hemodialysis /ultrafiltration
Surgical approach
• Emergency abdominal decompression with temporary abdominal closure
including NPWT /prosthesis (e.g., Bogota bag, Whit- man patch)
• Pitfalls of open abdomen
• Fluid and protein loss
• Loss of abdominal domain
• Enteroatmospheric fistula
• Prevention of complication
• Abdominal re-exploration should be performed and the abdomen should be
closed as soon as the patient’s physiology and visceral edema allow.
• Restrictive fluid resuscitation
• Use of negative pressure therapy dressings
• Use of biological mesh as appropriate for definitive fascial closure
• Abdominal wall reconstruction may be necessary to facilitate abdominal closure-
component separation technique
• VAC decompression had
• Faster abdominal closure rate (4.4 vs 6.6 days)
• Decreased ICU length of stay (13.3 vs 19.2 days)
• Decreased hospital LOS (28.5 vs 34.9 days)
