Abdominal Compartment Syndrome

Epidemiology

  • xxx

Etiology

Increased Retroperitoneal Volume

  • Acute Pancreatitis (see Acute Pancreatitis, [[Acute Pancreatitis]]): edema from inflammation and large volume IVF resuscitation
  • Retroperitoneal Hemorrhage (see Retroperitoneal Hemorrhage, [[Retroperitoneal Hemorrhage]]): due to penetrating/blunt trauma, aortic surgery, ruptured AAA

Increased Intraperitoneal Volume

  • Abdominal Neoplasm
    • Ovarian Cancer with Bulky Masses (see Ovarian Cancer, [[Ovarian Cancer]])
  • Bowel Distention
  • Hemoperitoneum (see Hemoperitoneum, [[Hemoperitoneum]]): associated with penetrating/blunt trauma
  • Massive Splenomegaly (see Splenomegaly, [[Splenomegaly]])
    • Epidemiology: massive splenomegaly with abdominal compartment syndrome has been reported in association with myelofibrosis (Am J Hematol, 2005) [MEDLINE]
  • Mesenteric Venous Obstruction (see Mesenteric Vein Thrombosis, [[Mesenteric Vein Thrombosis]])
    • Epidemiology: xxx
  • Pneumoperitoneum (see Pneumoperitoneum, [[Pneumoperitoneum]])
  • Post-Liver Transplant (see Liver Transplant, [[Liver Transplant]])
  • Pregnancy (see Pregnancy, [[Pregnancy]])
  • Tense Ascites (see Ascites, [[Ascites]])

Extrinsic Compression of the Abdomen

  • Abdominal Wall Burn Eschar (see Burns, [[Burns]])
  • Tight Abdominal Closure After Surgery

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 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, [[Foley Catheter]])

  • Bladder Pressure in Abdominal Compartment Syndrome: usually >20-25 mm Hg
  • Bladder Pressure Correlates with Intra-Abdominal Pressure (Endoscopy, 1998) [MEDLINE]

Clinical Manifestations

Cardiovascular Manifestations

Hypotension/Cardiogenic Shock (see Hypotension, [[Hypotension]] and Cardiogenic Shock, [[Cardiogenic Shock]])

  • Physiology: increased intra-abdominal pressure, which is transmitted to the thorax -> decreased cardiac filling (decreased preload) and 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 abdominal compartment syndrome

Pulsus Paradoxus (see Pulsus Paradoxus, [[Pulsus Paradoxus]])

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

Pulmonary Manifestations

Hypoxemia (see Hypoxemia, [[Hypoxemia]])

  • Physiology decreased FRC and V/Q mismatch

Acute Respiratory Failure (see Respiratory Failure, [[Respiratory Failure]])

  • Physiology: increased intra-abdominal pressure -> decreased chest wall compliance and excessive work of breathing
  • Diagnosis
    • Increased PIP and Plateau Pressure on Ventilator

Renal Manifestations

Acute Kidney Injury (see Acute Kidney Injury, [[Acute Kidney Injury]])

  • Physiology
    • 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 AKI (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]

Multiple Compartment Syndrome

  • Epidemiology: occurs in setting of multiple trauma
  • 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 IVF 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
    • Decompressive Craniectomy (see Decompressive Craniectomy, [[Decompressive Craniectomy]]): lowers intracranial pressure [MEDLINE]
    • Decompressive Laparotomy: lowers intra-abdominal pressure and intracranial pressure [MEDLINE]

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

  • Bogota Bag: plastic bag over opened abdominal wall
  • Definitive Closure: can usually be performed within 48 hrs

Prognosis

  • Untreated: universally fatal
  • Treated
    • Organ System Dysfunction Resolves in 93% of Cases
    • Survival Rate: 59%

References

  • Oliguria from high intra-abdominal pressure secondary to ovarian mass. Crit Care Med. 1987;15:78-79
  • Cardiovascular, pulmonary and renal effects of massively increased intra-abdominal pressure in critically-ill patients. Crit Care Med. 1989;17:118-121
  • Is urinary bladder pressure a sensitive indicator of intra-abdominal pressure? Endoscopy. 1998 Nov;30(9):778-80 [MEDLINE]
  • Abdominal compartment syndrome. Crit Care. 1999;3:R103-104
  • Intra-abdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg 1999; 134:1082–1085 [MEDLINE]
  • Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134-138
  • Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg. 2002;89:591-596
  • Myelofibrosis-associated massive splenomegaly: a cause of increased intra-abdominal pressure, pulmonary hypertension, and positional dyspnea. Am J Hematol. 2005 Oct;80(2):128-32 [MEDLINE]
  • Results from the International Conference of Experts on Intra-abdominal Hypertension and the Abdominal Compartment Syndrome II. Intensive Care Med 2007;33:951-962 [MEDLINE]
  • Abd Compt Syndrome: World Society of Abd Compt Syndrome (WSACS), Intensive Care Med 2006: 32(11): 1722-1732, 2007: 33(6): 951-962
  • Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome. J Trauma 2007 Mar; 62(3):647-656 [MEDLINE]
  • Renal implications of increased intraabdominal pressure: are the kidneys the canary for abdominal hypertension? Acta Clin Belg Suppl 2007:119 –130 [MEDLINE]
  • Mechanical ventilation guided by esophageal pressure in acute lung injury.  N Engl J Med.  2008;359:2095–2104 [MEDLINE]
  • Experimental intra-abdominal hypertension influences airway pressure limits for lung protective mechanical ventilation.  J Trauma Acute Care Surg. 2013 Jun;74(6):1468-73. doi: 10.1097/TA.0b013e31829243a7 [MEDLINE]
  • Driving pressure and survival in the acute respiratory distress syndrome.  N Engl J Med.  2015;372:747–757 [MEDLINE]