Abdominal Compartment Syndrome


Epidemiology

Risk Factors

Capillary Leak/Fluid Resuscitation

Other


Etiology

Decreased Abdominal Wall Compliance

Increased Intra-Luminal Contents

Increased Retroperitoneal Volume

  • Acute Pancreatitis (see Acute Pancreatitis)
    • Physiology
      • Edema from inflammation and large volume IVF resuscitation
  • Retroperitoneal Hemorrhage (see Retroperitoneal Hemorrhage)
    • Epidemiology
      • Due to Penetrating/Blunt Trauma, Aortic Surgery, Ruptured Abdominal Aortic Aneurysm
  • Retroperitoneal Neoplasm
    • Etiology
      • XXXXXXX

Increased Intraperitoneal Volume


Physiology

Acute Increase in Intra-Abdominal Pressure

  • Transmission of Intra-Abdominal Pressure to the Thorax
    • Studies Indicate that Approximately Half of the Intra-Abdominal Pressure is Transmitted to the Plateau Pressure on the Ventilator (J Trauma Acute Care Surg, 2013) [MEDLINE]
      • Therefore, the plateau pressure on the ventilator should be corrected down for this effect in the setting of abdominal compartment syndrome, to give a “true” plateau pressure
      • Note: pressure measurements require conversion of abdominal pressure (in mm Hg) to plateau pressure (in cm H20): 1 cm H20 = 0.736 mm Hg
        • Example: intra-abdominal pressure of 25 mm Hg = 33.97 cm H20
    • Measuring Esophageal Pressure May Be Used as a Surrogate for Pleural Pressure (NEJM, 2008) [MEDLINE]: this may facilitate higher levels of PEEP, if required for oxygenation
      • Trans-Pulmonary Distending Pressure = Plateau Pressure – Esophageal Pressure


Diagnosis

Bladder Pressure (via Foley Catheter) (see Foley Catheter)

  • Normal Intra-Abdominal Pressure
    • Intra-Abdominal Pressure is Approximately 5-7 mm Hg in Critically Ill Adults (Intensive Care Med, 2013) [MEDLINE]
  • Bladder Pressure in Abdominal Compartment Syndrome: usually >20-25 mm Hg
  • Bladder Pressure Correlates with Intra-Abdominal Pressure (Endoscopy, 1998) [MEDLINE]
  • Recommendations (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]
    • Intra-Abdominal Pressure Should Be Measured When Any Known Risk factor for Intra-Abdominal Hypertension or Abdominal Compartment Syndrome Exists (Grade 1C Recommendation)


Clinical Definitions (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]


Clinical Manifestations

Cardiovascular Manifestations

Hypotension/Cardiogenic Shock (see Hypotension and Cardiogenic Shock)

  • Physiology
    • Increased Intra-Abdominal Pressure, Which is Consequently Transmitted to the Thorax
    • Decreased Venous Return/Decreased Preload, Resulting in Decreased Cardiac Filling
    • Increased Afterload
  • Diagnosis
    • Central Venous Pressure (CVP): increased (without increased right end-diastolic volume) -> may lead to spurious interpretation of CVP measurements
    • Pulmonary Capillary Wedge Pressure (PCWP): increased (without increased left end-diastolic volume) -> may lead to spurious interpretation of PCWP measurements
    • Cardiac Output (CO): decreased
    • Systemic Vascular Resistance (SVR): increased
  • Treatment
    • Intravenous Fluid Administration Administration May Worsen Bowel Wall Edema, Exacerbating the Abdominal Compartment Syndrome

Pulsus Paradoxus (see Pulsus Paradoxus)

  • Physiology
    • Due to transmission of high intra-abdominal pressures to thorax -> impaired right-sided venous return

Gastrointestinal Manifestations

  • Physiology
    • Increased Intra-Abdominal Pressure Resulting in Decreased Mesenteric Perfusion
  • Clinical

Pulmonary Manifestations

Hypoxemia (see Hypoxemia)

  • Physiology
    • Increased Intra-Abdominal Pressure Resulting in the Following
      • Decreased Functional Residual Capacity (FRC)
      • Ventilation/Perfusion (V/Q) Mismatch

Acute Respiratory Failure (see Respiratory Failure)

  • Physiology
    • Increased Intra-Abdominal Pressure Resulting in the Following
      • Atelectasis (see Atelectasis)
      • Decreased Chest Wall Compliance, Resulting in Excessive Work of Breathing
      • Ventilation/Perfusion (V/Q) Mismatch
  • Diagnosis
    • Increased Peak Inspiratory Pressure (PIP) and Increased Plateau Pressure (Pplat) on Ventilator

Renal Manifestations

Acute Kidney Injury (AKI) (see Acute Kidney Injury)

  • Physiology
    • Renal Artery Vasoconstriction and Vein Compression
      • Resulting in Decreased Renal Blood Flow
    • Kidneys are Early Sensors for the Presence of Abdominal Compartment Syndrome
    • Increases in Abdominal Pressure as Low as 12 mm Hg May be Associated with Acute Kidney Injury (Acta Clin Belg, 2007) [MEDLINE]
    • Sustained Intra-Abdominal Pressure >20 mm Hg in Association with New Organ Dysfunction are Associated with AKI in >30% of Cases (Arch Surg, 1999) [MEDLINE] (Intensive Care Med, 2007) [MEDLINE]
  • Clinical
    • Oliguria

Lactic Acidosis (see Lactic Acidosis)

  • Physiology
    • The Liver’s Ability to Remove Lactic Acid is Impaired by Increased Intra-Abdominal Pressure as Small by as Little as 10 mm Hg (Gastroenterology, 1993)[MEDLINE] (J Trauma, 1998) [MEDLINE]
      • This Occurs Even in the Presence of a Normal Cardiac Output and Mean Arterial Blood Pressure
  • Clinical
    • Lactic Acidosis May Clear More Slowly than Expected, Despite Adequate Resuscitation

Multiple Compartment Syndrome

  • Epidemiology
    • Occurs in the Setting of Polytrauma
  • Physiology
    • Intravenous Fluid Administration and Acute Lung Injury Increase Intra-Abdominal and Intrathoracic Pressures
      • These lead to increased intracranial pressure after traumatic brain injury
    • Additional Intravenous Fluids Administered to Maintain Cerebral Perfusion or Increased Ventilatory Support to Treat Acute Lung Injury Further Raise the Intracranial Pressure
    • These Mechanisms Can Result in a Cycle that Culminates in Multiple Compartment Syndrome
  • Treatment


Treatment

Supine Position

  • Rationale
    • Avoid elevation of head of bed and proning, as both increase intra-abdominal pressure

Ventilator Management

  • Decrease Tidal Volume (VT)
    • Instituting a decrease in tidal volume has traditionally been recommended to decrease extrinsic pressure on the abdominal compartment
    • However, Studies Indicate that Approximately Half of the Intra-Abdominal Pressure is Transmitted to the Plateau Pressure on the Ventilator (J Trauma Acute Care Surg, 2013) [MEDLINE]: therefore, the plateau pressure should be corrected down for this effect in the setting of abdominal compartment syndrome, to give a “true” plateau pressure
      • Note: pressure measurements require conversion of abdominal pressure (in mm Hg) to plateau pressure (in cm H20): 1 cm H20 = 0.736 mm Hg
      • Example: intra-abdominal pressure of 25 mm Hg = 33.97 cm H20
    • Consequently, if the Corrected Plateau Pressure is Acceptable, a Decrease in Tidal Volume May Not Be Warranted
      • This is especially true in a patient with severe metabolic acidosis and inability to compensate with current mechanical ventilation settings, where decreasing the tidal volume may worsen the compensation for acidosis

Sedation with Neuromuscular Blockade

  • Rationale
    • Both may reduce intra-abdominal pressure in patients who are dyssynchronous with the ventilator

Prokinetic Agents

  • Rationale
    • May be useful in patients with severe ileus

Surgical Decompression

  • Decompressive Laparotomy (see Laparotomy)
  • Other Aspects
    • Bogota Bag: plastic bag over opened abdominal wall
    • Definitive Closure: can usually be performed within 48 hrs

Management Recommendations (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]

Recommendations

  • Decompressive Laparotomy is Recommended in Critically Ill Adults with Overt Abdominal Compartment Syndrome Over Strategies that Do Not Use Decompressive Laparotomy (Grade 1D Recommendation)
  • In ICU patients with Open Abdominal Wounds, Conscious and/or Protocolized Efforts are Recommended to Obtain an Early or at Least Same-Hospital-Stay Abdominal Fascial Closure (Grade 1D Recommendation)
  • In Critically Ill/Injured Patients with Open Abdominal Wounds, Strategies Utilizing Negative Pressure Wound Therapy are Recommended (Grade 1C Recommendation)

Suggestions

  • Potential Contribution of Body Position to Elevated Intra-Abdominal Pressure Should Be Considered in Patients with (or at risk of) Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 2D Recommendation)
    • Use Reverse Trendelenburg Position, as Required
  • Enteral Decompression with Nasogastric or Rectal Tubes Should Be Used When Stomach or Colon are Dilated in the Presence of Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 1D Recommendation)
  • Neostigmine Should Be Used for the Treatment of Established Colonic Pseudo-Obstruction Not Responding to Other Simple Measures and Associated with Intra-Abdominal Hypertension (Grade 2D Recommendation)
  • Sedation/Analgesia/Paralysis
    • Critically Ill or Injured Patients Should Receive Optimal Pain and Anxiety Relief (Grade 2D Recommendation)
    • Brief Neuromuscular Blockade as a Temporizing Measure Should Be Considered in the Treatment of Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 2D Recommendation)
  • Resuscitation Strategy
    • Avoid Positive Cumulative Fluid Balance in the Critically Ill or Injured Patient with (or at risk of) Intra-Abdominal Hypertension/Abdominal Compartment Syndrome After the Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed (Grade 2C Recommendation)
    • Enhanced Ratio of Plasma/Packed Red Blood Cells Should Be Used for Resuscitation of Massive Hemorrhage (Grade 2D Recommendation)
  • Percutaneous Catheter Drainage
    • Percutaneous Catheter Drainage Should Be Used to Remove Fluid (with Obvious Intraperitoneal Fluid) in those with Intra-Abdominal Hypertension/Abdominal Compartment Syndrome When this is Technically Feasible (Grade 2C Recommendation)
    • Percutaneous Catheter Drainage Should Be Used to Remove Fluid (with Obvious Intraperitoneal Fluid) in those with Intra-Abdominal Hypertension/Abdominal Compartment Syndrome When this is Technically Feasible, as Compared to Immediate Decompressive Laparotomy as this May Alleviate the Need for Decompressive Laparotomy (Grade 2D Recommendation)
  • In Patients Undergoing Laparotomy for Trauma Suffering from Physiologic Exhaustion Should Be Treated with Prophylactic Use of Open Abdomen, as Compared to Intraoperative Abdominal Fascial Closure and Expectant Intra-Abdominal Pressure Management (Grade 2D Recommendation)
  • Open Abdomen Should Not Be Routinely Used for Patients with Severe Intraperitoneal Contamination Undergoing Emergency Laparotomy for Intra-Abdominal Sepsis Unless Intra-Abdominal Hypertension is a Specific Concern (Grade 2B Recommendation)
  • Bioprosthetic Mesh Should Not Be Routinely Used in the Early Closure of the Open Abdomen, as Compared to Alternative Strategies (Grade 2D Recommendation)

No Recommendations

  • No Recommendation Regarding Use of Abdominal Perfusion Pressure in the Resuscitation or Management of the Critically Ill or Injured Patient
  • Techniques to Mobilize Fluid
    • No Recommendation Regarding Use of Diuretics to Mobilize Fluids in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After the Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
    • No Recommendation Regarding the Use of Renal Replacement Therapy to Mobilize Fluid in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After the Acute resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
    • No Recommendation Regarding the Administration of Albumin to Mobilize Fluid in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
  • No Recommendation Regarding the Prophylactic Use of the Open Abdomen in Non-Trauma Acute Care Surgery Patient with Physiologic Exhaustion vs Intraoperative Abdominal Fascial Closure and Expectant IAP Management
  • No Recommendation Regarding use of an Acute Component Separation Technique to Facilitate Earlier Abdominal Fascial Closure


Prognosis


References

General

Etiology

Diagnosis

Clinical

Treatment