Abdominal Compartment Syndrome. Jeff Johnson, MD
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1 Abdominal Compartment Syndrome Jeff Johnson, MD Acute Care Surgeon, Denver Health Associate Professor of Surgery, University of Colorado Denver
2 The Abdomen A Forgotten Closed Compartment
3 Early Animal Models of Intraabdominal Hypertension (IAH) Emerson (1911) Pressures > 27 46cm H 2 O Fatal to small animals Respiratory failure Thorington (1923) Oliguria in dogs with IAP 15-30mm Hg Anuria with pressure > 30
4 Early Observations: Human IAH Gross (1948) Forced closures of large omphaloceles could cause cardiovascular collapse in infants Richards (1982) 4 AAA patients with post-op hemorrhage developed anuria which reversed with reoperation Kron (1984) Described bladder pressure measurement
5 ACS: Cardiovascular Pathophysiology Venous return Cardiac filling Cardiac output PVR Transiently Reversible with volume
6 Pulmonary Pathophysiology Airway pressures (ventilated pts) O 2, CO 2 Compliance P/F Restrictive pulmonary disease Reversible with decompression
7 Renal Pathophysiology Vascular Resistance blood flow GFR Urine flow Renin
8 ACS First Classification System Grade I (10-15): Fluid Responsive Grade II (15-25): Transient response to fluid Grade III (25-35): Urgent Decompression Grade IV (>35): Emergent Decompression Burch, 1996
9 Current IAH Grading Scale IAH is graded as follows: Grade I IAP mmhg Grade II IAP mmhg Grade III IAP mmhg Grade IV IAP > 25mmHg. The IAH grades have been revised downward as the detrimental impact of elevated IAP on endorgan function has been recognized
10 ACS Definition: IAP >20 (Grade III or IV IAH) + Adverse physiological consequences ACS is defined as a sustained IAP > 20mmHg (with or without an APP < 60mmHg) that is associated with new organ dysfunction/ failure.
11 ACS: Primary vs Secondary Primary: Due to Abdominal injury or condition Major hepatic injury Perforated viscus Primary insult likely determines outcome Secondary : Develops during resuscitation Capillary leak Massive transfusion Vigorous crystalloid resuscitation Early recognition and treatment
12 ACS: Who gets it? Trauma Damage Control (packing) Post-op hemorrhage Septic Shock Severe Burns Severe Pancreatitis Portal Hypertension Ligation / thrombosis PV Intrinsic liver disease
13 Pathophysiology -- Summary Increased IAP affects many compartments Extremities: Venous return Thorax Pleural Pericardial Abdominal: kidney, liver and gut Intracranial Multiple Compartment Syndrome
14 ACS: How is it recognized? Appropriate suspicion: At risk patient Oliguria, increased airway pressures, abdominal distension Measurement of IAP Direct measurements: impractical Gastric/Rectal measurements suboptimal Bladder pressures: surrogate for IAP Instill 25 cc into empty bladder/clamp/use manometer May be unreliable in pts with abnormal bladder compliance Elderly Postoperative Pelvic Packing
15 Modern Natural History Data 83 ICU Patients prospectively followed Mixed med/surg population 46% developed IAH (IAP>12) No specific therapies directed at IAH Mortality associated with IAH = 53% Mortality without IAH = 27% Mortality of ACS = 80% Vidal, Crit Care Med, 2008
16 Factors Affecting Intraabdominal Pressure Inciting Event Abdominal Wall Compliance Obesity Air, fluid, blood, bowel edema Level of sedation and analgesia Patient Positioning Geisel, Hop on Pop 1963
17 ICU Management Patient positioning IAP raised by Reverse Trendelenberg Semirecumbant Supine (or <20 deg HOB) appears best Patient comfort No high quality data Deep sedation Good Analgesia Trials of NM blockers appropriate
18 Abdominal Contents ICU Management Good gastric decompression Colonic decompression Enteral feeding acceptable Fluid Management Again, No high quality data Hypertonic crystalloids, colloids have been recommended Diuresis when tolerated (?day 3) Consider CRRT
19 Catheter Drainage Described in small case series Reed (2005) DPL catheter placed in 8 consecutive pts with IAP > 20 Results: IAP fell by mean 6 mm Hg Abdominal perfusion pressure increased by 15 mm Hg Four patients (50%) still required laparotomy DH practice: use bedside ultrasound. Two groups: Ascites: pigtail catheter Bowel edema laparotomy
20
21 Decompressive Laparotomy When other measures fail to alleviate ACS, prompt surgical decompression is mandatory Bedside ICU decompression a good option Bring the OR to the patient Prompt improvement can be expected Subsequent surgical interventions in OR Minimally invasive approaches Endoscopic subcutaneous division of linea alba 50% success described Proceed with caution
22 Now What?
23 Why is closure so important? Chronic open abdomen Spontaneous rupture of organs beginning at 2 weeks
24 The Goal: Fascial Closure How do we go from: To:
25 Temporary Options Bogotá bag closure temporary silo 3L sterile GU irrigation bag sewn to skin contains the edematous bowel no issues with angiography suturing - time consuming
26 Temporary Options 10 x 10 drape & ioban closure temporary covering no issues with angiography less time consuming
27 Early Primary Closure Able to close primarily at repeat exploration
28 Sequential Fascial Closure: DHMC Technique white sponge under the fascia PDS sutures to pull fascia toward midline black sponge covering fascia and subq
29 Sequential Fascial Closure: DHMC Technique interrupted closure of fascia at superior and inferior edges replace white sponge black sponge covering fascia and subq
30 Sequential Fascial Closure: DHMC Technique entire fascial defect closed place JP drains CLOSED!!
31 Skin Grafting Temporary coverage granulation tissue over bowel STSG covers bowel 9 months later loose covering
32 Component Separation removing STSG lateral release midline closure fully healed
33 Modern Outcomes with Protocol-Driven IAH Rx Cheathem Crit Care Med, 2010
34 Current DH Results Primary fascial closure approaches 100% Complications: Occur in 40% patients GI: anastamotic leaks, bilomas, fistulas Low mortality, however, long Length of mechanical ventilation ICU stay
35 ACS: Summary Persistent IAP >12 is abnormal Conservative measures warranted Must be monitored IAP >20 with organ dysfunction = ACS Life threatening condition Demands prompt resolution ACS treatment Continues to improve Has likely decreased mortality
36 ??
37 THANK YOU
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