Trauma Scenario. Abdominal Compartment Syndrome. Disclosure Statement of Financial Interest 8/17/2015

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1 Abdominal Compartment Syndrome Diane Cobble M.D., FACS Professor, ETSU Dept. of Surgery 7 th Annual Rural Trauma Symposium August 27, 2015 Disclosure Statement of Financial Interest I DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. Trauma Scenario A 32yof was stabbed in the liver. She arrived in the ER hypotensive & unresponsive to pain. After she had a massive transfusion & emergent ex lap, she was admitted to the ICU. During the next 6, mechanical ventilation became progressively more difficult. Although cvp remained slightly, her CO d markedly 1

2 General Surgery Scenario An 87yo NH resident had severe abd pain. His care providers reported that he had recently experienced several episodes of protracted vomiting progressing to bp, hr & LOC. Transfer for tests to determine if he had sepsis was arranged & he was admitted to ICU. Despite administration of multiple fluid boluses, he remained hypotensive & anuric. Continuous ngt suctioning produced large amt of green-brown fluid & abd CT revealed complete sbo History Recognized clinically 19 th century when Marey & Burt observed its assoc w/declines in respiratory fxn Forgotten after WWI & rediscovered near end 20 th century More recently, Kron (1984) developed simple method of accurately measuring IAP which led to better understanding of relationship btwn IAP & ACS 2004 group of international physicians & surgeons developed World Society of ACS (WSACS) definitions Nl IAP: 0-5 mmhg IAH: sustained IAP 12mmHg ACS: sustained IAP > 20mmHg w/new organ dysfxn Morbidly obese & pregnant pts can have chronically IAP mmhg w/o adverse sequelae 2

3 categories Primary (surgical): intra-abd pathology is directly & proximally responsible for the ACS Secondary (medical): no visible intra-abd injury is present but injuries outside the abd cause fluid accumulation Recurrent: ACS redevelops after surgical/medical tx of 1 or 2 causes Risk factors Primary Major trauma Liver transplantation Ruptured AAA Mechanical bowel obst Retroperitoneal hemorrhage Postop bleeding/abd closure under tension Bleeding pelvic fxs Secondary Obesity or BMI Pregnancy Major burns/sepsis Ileus/pancreatitis/ascites Large vol fluid replacement Severe intra-abd infexn CAPD Typical scenarios Abdominal injury w/ongoing intra-abd bleeding After DCL 2 packing therefore vac closure 3

4 pathophysiology organ level w/direct compression Hollow systems (GI tract & portal-caval system) collapse Immediate effects (thrombosis or bowel wall edema) translocation of bacterial products additional fluid accumulation IAP Cellular level: O2 impaired ischemia & anaerobic metabolism Vasoactive substances (histamine & serotonin) endothelial permeability Further capillary leak impairs rbc transport & ischemia worsens Cellular hypoxia sequelae Release of cytokines Formation of O2 free radicals Cellular production of ATP Cardiovascular Pulmonary Renal Systems Most Affected 4

5 CV Effects Intrathoracic pressure compresses heart/great vessels CO due to venous return SVR CVP/PCWP falsely IAH causes pressure on femoral veins stasis DVT. When resolved, risk of PE May be one of the earliest signs Pulmonary excursion of diaphragm pulmonary compliance airway pressure w/ tidal volume & respiratory acidosis 2 to pco2 Hypoxemia Other System Dysfunction Renal Oliguria anuria 2 direct parenchymal compression & shunting of renal plasma flow Cr may not be seen for 2-3d Visceral blood flow w/subsequent intestinal necrosis Hepatic dysfunction w/ glucose metabolism & lactate clearance Gut anastomotic breakdown 5

6 brain Obstruction of cerebral venous outflow ICP CPP Organ Dysfunction Grading ACs Grade I: mmhg Grade II: mmhg Grade III: mmhg Grade IV: >35 mmhg 6

7 Abdominal perfusion pressure Measure of visceral organ perfusion Suggested as a guide by some authors APP = MAP-IAP More accurate predictor of abd organ perfusion & more effective guide for resuscitation measures Ideal level is anything > 60 mmhg app Cheatham et al J Trauma 2000 Concluded that APP 60 mmhg in pts w/acs 98% sensitive in predicting survival compared to APP 40 mmhg being 70% sensitive in population largely comprised of trauma pts (n=144) Also concluded APP more accurate predictor of resuscitation than lactate, MAP, arterial ph, base deficit, IAP Retrospective study 5/97-6/99 Bladder pressure Can be measured intermittently or continuously if foley connected to pressure transducer w/recording device Instill ~25cc NS in bladder & clamp foley 18 gauge needle inserted into aspiration port & attached to pressure transducer Pressure end-expiration & midaxillary line 7

8 Measuring Bladder Pressure May not be accurate w/morbid obesity, massive ascites, pelvic hematoma, adhesions or neurogenic bladder Can use intragastric, intracolonic or IVC catheters Frequency of monitoring risk should have IAP measured q4-6 Pts HD unstable or w/rapidly deteriorating organ dysfxn should be measured q1 D/C after condition resolved & IAP remains for epidemiology 5-15% freq in trauma ICU adm according to recent lit 1% gen trauma admissions 8

9 prevalence Malbrain et al Intensive Care Medicine 2004: Prevalence study in 13 ICU s involving 97 pts Overall rate IAH 58.8% 65% surgical, 54.4% medical pts Medical pts prevalence IAP > % vs 27.5% Medical pts prevalence ACS 10.5% vs 5% prevalence Reintam et al Intensive Care Medicine 2008: 257 ventilated pts IAH developed in 95 pts 60 primary, 35 secondary During 1 st 3 days, IAP w/primary & w/secondary Mortality rates w/iah ICU mortality 37.9% 28d mortality 48.4% 90d mortality 53.7% w/o IAH ICU mortality 19.1% 28d mortality 27.8% 90d mortality35.8% Independent risk fx for death Secondary common, different dev course & worse outcome 9

10 incidence Vidal et al Critical Care Medicine 2008: Studied incidence of IAP in 83 critically ill pts in single ICU 31% pts had ICU adm & 33% developed it after adm Pts w/iah were sicker w/ mortality rate 53% vs 27% IAH independent predictor of mortality ACS developed in 10 pts w/80% mortality Treatment (physician) Burn pts may respond to escharotomy alone Grade I: doubtful abd decompression warranted Grade II: need for tx based on pts clinical condition Absence of oliguria, hypoxia or sig airway pressure difficult to justify abd decompression Grade III: most req decompression Grade IV: all req immed decompression b/c may cardiac any time Treatment (nursing) Maintain patency of NGT & rectal tube if used Monitor & record daily BM s Check qd for fecal impaction if pt unconscious, sedated or paralyzed Assess tolerance to enteral TF s & adjust accordingly if residuals too high For pts able to eat, minimize/eliminate gas-producing foods Avoid prone position & place pt in reverse Trendelenberg Must be supine to measure bladder pressure 10

11 mortality Early decompression improves survival Mortality rates range from 25-75% High rate even w/tx reflects fact that condition affects multiple organ systems Furthermore often a sequelae to severe injuries that independently carry high morbidity/mortality Assoc w/ LOS, costs & further dev of comorbidities World society acs Updated consensus definitions & clinical practice guidelines published in 2013 Intensive Care Medicine (prev 2006) Patient (P) Interventions (I) Comparison (C) Outcome (O) Wsacs definitions IAP ~5-7 mmhg in critically ill pts Max of 25ml NS instilled to determine bladder pressure IAH Grade I: mmhg Grade II: mmhg Grade III: mmhg Grade IV: >25 mmhg 11

12 recommendations Measuring IAP when any known risk fx for IAH/ACS is present in a critically ill/injured pt Studies should adopt the trans-bladder technique as std IAP measurement technique Use of protocolized monitoring & mgmt of IAP vs not Efforts &/or protocols to avoid sustained IAH as compared to inattention to IAP among critically ill or injured pts Cont,d Decompressive lap in cases of overt ACS compared to strategies that do not use DL in critically ill adults w/acs Among ICU pts w/open abdominal wounds, conscious &/or protocolized efforts be made to obtain an early least same-hospital-stay abd fascial closure Among critically ill/injured pts w/open abdominal wounds, strategies utilizing NPW therapy should be used vs not suggestions Enhanced ratio plasma/prbc s for massive hemorrhage Perc catheter drainage to remove fluid when technically possible (may alleviate need for DL) Prophylactic use of open abd when undergoing lap for physiologic exhaustion Not routinely using open abd for pts w/severe abd contamination Bioprosthetic meshes not routinely used in early closure open abd vs alt. strategies 12

13 No recommendations Use of APP Use of diuretics or RRT Albumin administration Prophylactic use of open abd in non-trauma acute care surg pts Acute component separation technique to facilitate fascial closure questions 13