Case Presentation. Joseph M Brandel, MD Kings County Hospital Center Department of Surgery Friday, November 12, 2004

Transcription

1 Case Presentation Joseph M Brandel, MD Kings County Hospital Center Department of Surgery Friday, November 12, 2004

2 The Abdominal Compartment Syndrome

3 Definition A syndrome of intra-abdominal hypertension resulting in organ dysfunction which may be reversed by abdominal decompression

4 History 1863: Etienne-Jules Marey wrote that the effects that respiration produces on the thorax are the inverse of those present in the abdomen 1873: EC Wendt of Germany measured IAP through the rectum, noting that elevated pressures corresponded with diminished excretion of urine 1890: Heinricius of Germany found that IAPs between 27 and 46 cmh 2 O were fatal to animals owing to prevention of respiration

5 History 1911: Haven Emerson publishes his treatise, 'intra-abdominal pressures' contraction of the diaphragm identified as chief factor in the rise of IAP during inspiration excessive IAP can cause death from cardiac failure even before terminal asphyxia develops Observed that cardiovascular collapse associated with 'distention of the abdomen with gas or fluid, as in typhoid fever, ascites, or peritonitis' are caused by 'overloading the resistance in the splanchnic area' and that 'relief of the laboring heart is constantly seen after removal of ascitic fluid.' Emerson H. Intra-abdominal pressures. Arch Intern Med 1911;7:

6 History 1940: Sir William Heneage Ogilvie 1 In a letter to Lancet described a dodge that has twice helped me out, a technique for avoiding closing a burst abdomen Sutured vaseline impregnated canvas to wound edges to cover abdominal contents 1984: Kron et al 2 Published landmark case series on IAH 11 patients with elevated IAP after aortic repair (>30 mmhg) 7 patients decompressed with immediate diuresis The other 4 patients died 1 Ogilvie WH. The late complications of abdominal war wounds. Lancet 1940;2: Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressures a criterion for abdominal re-exploration. Ann Surg 1984;199:28-30

7 Pathophysiology Causes of intra-abdominal hypertension Primary: due to intra-abdominal process Trauma: Intra-abdominal bleeding, MAST, damage control surgery Retroperitoneal: Pancreatitis, ruptured AAA, abscess Intraperitoneal: Gastric dilatation, bowel obstruction, visceral edema, tension pneumoperitoneum Abdominal wall: Burn eschar, reduction of large hernias Secondary: due to massive fluid administration for extra-abdominal process Capillary leak Ischemia-reperfusion: release of inflammatory mediators, free radicals Ivatury RR, Diebel L, Porter JM, Simon RJ. Intraabdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am 1997;77:

8 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Hemodynamics Pulmonary Renal Intestinal/mucosal Neurologic Clinical Effects Decreased cardiac output Decreased preload Increased afterload Increased CVP and PCWP Increased peak inspiratory pressures Increased airway pressures Decreased PaO 2 Increased PaCO 2 Decreased dynamic compliance Decreased renal plasma flow Decreased GFR Decreased glucose reabsorption Oliguria or anuria Decreased blood flow to all abdominal organs expect adrenals Decreased mesenteric and mucosal blood flow Decreased phi Increased ICP Decreased CPP Cullen DJ, Coyle JP, Teplick R, Long MC. Cardiovascular, pulmonary, and renal effects of massively increased intraabdominal pressure in critically ill patients. Crit Care Med 1989; 17:

9 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Hemodynamics Clinical Effects Decreased cardiac output Decreased preload Increased afterload Increased CVP and PCWP Cardiac output Elevation of diaphragm transmits pressure to heart and great vessels CVP and PCWP are spuriously elevated not a reflection of volume status Intra-abdominal pressure (mmhg) Ridings PC, Bloomfield GL, Blocher CR, Sugerman HJ. Cardiopulmonary effects of raised intraabdominal pressure before and after intravascular volume expansion. J. Trauma 1995;39:

10 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Pulmonary Clinical Effects Increased peak inspiratory pressures Increased airway pressures Decreased PaO 2 Increased PaCO 2 Decreased dynamic compliance Peak airway pressure Increases in pleural pressures evident at IAP of 15 mmhg or greater Exacerbated by PEEP Normalizes after surgical decompression Intra-abdominal pressure (mmhg) Ridings PC, Bloomfield GL, Blocher CR, Sugerman HJ. Cardiopulmonary effects of raised intraabdominal pressure before and after intravascular volume expansion. J. Trauma 1995;39:

11 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Renal Clinical Effects Decreased renal plasma flow Decreased GFR Decreased glucose reabsorption Oliguria or anuria IAP of mmhg coincides with oliguria; over 30 mmhg causes anuria Compression of renal vasculature, parenchyma Stimulation of juxtaglomerular apparatus Cullen DJ, Coyle JP, Teplick R, Long MC. Cardiovascular, pulmonary, and renal effects of massively increased intraabdominal pressure in critically ill patients. Crit Care Med 1989; 17:

12 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Intestinal/mucosal Clinical Effects Decreased blood flow to all abdominal organs except adrenals Decreased mesenteric and mucosal blood flow Decreased phi Intestinal mucosal perfusion IAH found to decrease perfusion of every intraabdominal viscus (except adrenals) Effect persists even when cardiac output is corrected Intra-abdominal pressure (mmhg) Diebel LN, Dulchavsky SA, Wilson RF. Effect of increased intraabdominal pressure on mesenteric and intestinal mucosal blood flow. J Trauma 1992;33:45 49.

13 Pathophysiology Clinical Effects of Increased Abdominal Pressure System Neurologic Clinical Effects Increased ICP Decreased CPP Increase in IAP Increase in ITP Increase in CVP Decrease in CPP Bloomfield GL, Dalton JM, Sugerman HJ, Ridings PC, DeMaria EJ, Bullock R. Treatment of increasing intracranial pressure secondary to the acute abdominal compartment syndrome in a patient with combined abdominal and head trauma. J Trauma 1995;39:

14 Statistics Review of 13,817 consecutive trauma admissions revealed incidence of 15% among patients undergoing staged laparotomy with packing 1 Of 145 acutely injured patients with ISS 15, twenty-one (14%) developed ACS 2 Review of 70 patients with life-threatening penetrating injuries revealed an incidence of 33% 3 In a prospective study of 706 consecutive patients admitted to a trauma ICU incidence of ICH was 2% and ACS 1% 4 1 Morris JA Jr, Eddy VA, Blinman TA, Rutherford EJ, Sharp KW. The staged celiotomy for trauma. Issues in unpacking and reconstruction. Ann Surg May;217(5): Meldrum DR, Moore FA, Moore EE, Francoise RJ, Sauaia A, Burch JM. Prospective characterization and selective management of the abdominal compartment syndrome. Am JSurg 1997; 174: Ivatury RR, Porter JM, Simon RJ, Islam S, John R, Stahl WM. Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal ph and abdominal compartment syndrome. J Trauma 1998; 44: Hong JJ, Cohn SM, Perez JM, Dolich MO, Brown M, McKenney MG. Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg May;89(5):591-6

15 Diagnosis High index of suspicion Clinical signs: Abdominal distention, tension Decreased urine output Elevated filling pressures Elevated ICP Worsening acidosis Elevated peak airway pressures Confirmation Balogh Z, McKinley BA, Holcomb JB, Miller CC, Cocanour CS, Kozar RA, Valdivia A, Ware DN, Moore FA. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma 2003 May;54(5):848-59

16 Diagnosis Direct monitoring of IAP Intraperitoneal catheter connected to water manometer or pressure transducer Most accurate Preferred in experimental studies Clinical use limited by risk of peritoneal contamination, bowel perforation

17 Diagnosis Indirect monitoring of IAP Measuring pressure within abdominal organs Less invasive Less reliable Transfemoral caval catheter Gastric tube Rectal tube Intravesical pressure monitoring

18 Diagnosis Intravesical monitoring Most closely reflects direct monitoring 1,2 Foley clamped distal to aspiration port 50 to 100 cc saline injected into bladder 16-guage needle connected to pressure transducer, inserted into aspiration port 1 Obeid F, Saba A, Fath J, et al. Increases in intraabdominal pressure affect pulmonary compliance. Arch Surg 1995; 130: Iberti TJ, Kelly KM, Gentili DR, Hirsch S, Benjamin E. A simple technique to accurately determine intraabdominal pressure. Crit Care Med 1987;

19 Treatment: An Ounce of Prevention Identify patients at risk Major trauma, damage control surgery Laparotomy for major bleeding Edematous and/or ischemic bowel Abdominal vascular procedures Mechanically difficult closure High-volume resuscitation Avoid primary fascial closure Offner PJ, de Souza AL, Moore EE, Biffl WL, Franciose RJ, Johnson JL, Burch JM. Avoidance of abdominal compartment syndrome in damage-control laparotomy after trauma. Arch Surg 2001;136:

20 Treatment: An Ounce of Prevention

21 Treatment: Surgical decompression Timing of intervention IAH ACS Recommendations differ Modest IAH + organ dysfunction 1 Marked IAH 2 No absolute evidence-based guidelines 1 Meldrum DR, Moore FA, Moore EE, Franciose RJ, Sauaia A, Burch JM. Prospective characterization and selective management of the abdominal compartment syndrome. Am J Surg 1997; 174: Ivatury RR, Sugerman HJ. Abdominal compartment syndrome: a century later, isn t it time to pay attention? Crit Care Med 2000; 28:

22 Treatment: Surgical Decompression Proposed ACS grading system: Grade IAP (mmhg) Associated signs Treatment I No signs of ACS Maintain normovolemia II May have increased PAWP and oliguria Hypervolemic resuscitation may be employed but could have drawbacks III Anuria, decreased cardiac output, raised PAWP Consider abdominal decompression IV >35 Anuria, decreased cardiac output, raised PAWP Abdominal decompression and re-exploration Meldrum DR, Moore FA, Moore EE, Franciose RJ, Sauaia A, Burch JM. Prospective characterization and selective management of the abdominal compartment syndrome. Am J Surg 1997; 174:

23 Treatment: Hazards of Laparostomy Reperfusion injury Morris et al 1 reported fatal cardiac arrest in 4 of 16 patients undergoing decompressive laparostomy Prevention Abrupt shift in vent requirements Sudden fluid shifts Loss of tamponade Complications of open abdomen Large surface for fluid loss Exposes viscera to trauma, desiccation Route for infection Morris JA Jr, Eddy VA, Blinman TA, et al. Staged celiotomy for trauma: issues in unpacking and reconstruction. Ann Surg 1993;217:

24 Treatment: Nonoperative management Progression of IAH to ACS may be arrested by nonoperative maneuvers Paralysis Diuresis or fluid resuscitation Attempts at management of ACS with percutaneous decompression have been almost universally catastrophic Patients with ACS secondary to abdominal burns may represent an exception Alain and Sherman (2001): Case series in which ACS in burn patients was managed successfully by percutaneous intraperitoneal drainage catheter Alain CC, Sherman HF. Percutaneous treatment of secondary abdominal compartment syndrome. J Trauma, 2001;51:

25 Outcome Intervention successful vis-à-vis early endpoints Airway pressures Cardiac output Urine output High mortality rate ( %) Most commonly succumb to MOF, sepsis Paucity of data on short-term and long-term morbidity Bailey J, Shapiro MJ. Abdominal compartment syndrome. Crit Care 2000;4(1):23-9

26 ACS and the General Surgeon Preponderance of data on ACS based on trauma patients Retrospective review by McNelis et al of nontrauma SICU admissions developing ACS: Study population: Eighteen patients M:F ratio 1:2 8 AAA repairs 6 laparotomies 3 cases of pancreatitis 1 cerebral aneurysm Appropriate response to decompression ( UO, PIP, CO) Mortality 61.1% Mcnelis J, Soffer S, Marini CP, Jurkiewicz A, Ritter G, Simms HH, Nathan I. Abdominal compartment syndrome in the surgical intensive care unit. Am Surg Jan;68(1):18-23

27 ACS and Acute Pancreatitis Current paradigm for acute pancreatitis: Delayed operation 1 Operation for infected necrosis 2 Retrospective review of 23 patients with pancreatitis and ACS: Severe Acute Pancreatitis complicated with ACS 3 Total Laparostomy performed No laparostomy performed SIRS stage Infected stage n Mortality (%) 7(30.4) 3(16.7) 4(80%) 1 Mier J, Leon EL, et al. Early versus late necrosectomy in severe necrotizing pancreatitis. Am J Surg 1997;173: Bradley III EL, Allen KA. Prospective longitudinal study of observation vs surgical intervention in the management of necrotizing pancreatitis. Am J Surg 1991;161: Tao J, Wang C, Chen L, Yang Z, Xu Y, Xiong J, Zhou F. Diagnosis and management of severe acute pancreatitis complicated with abdominal compartment syndrome. J Huazhong Univ Sci Technolog Med Sci. 2003;23(4):

28 Conclusions Abdominal compartment syndrome is a potentially fatal constellation of symptoms with many disparate etiologies A high index of suspicion and astute decisionmaking are required for successful management Further data would help guide treatment of this syndrome in both the injured and the general surgical population

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