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Update on Abdominal Compartment Syndrome

Update on Abdominal Compartment Syndrome

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Update on Abdominal Compartment Syndrome

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  1. Update on Abdominal Compartment Syndrome Joint Hospital Surgical Grand Round Dr. Leung Tak Lun Canice Prince of Wales Hospital

  2. Definition • Abdominal compartment syndrome (ACS) • adverse physiological consequences that occur as a result of an acute increase in IAP Burch et al. Surg Clin North Am 1996;76:834-422 • increased abdominal pressure with increased airway pressure, hypoxia, and oliguria Ivatury et al. Surg Clin North Am 1997;77:783-99

  3. Definition • Primary ACS • abdominal injury is present • Secondary ACS • In patients with severe shock requiring massive resuscitation • Without abdominal injury

  4. Risk Factors • Severe penetrating and blunt abdominal trauma • Ruptured abdominal aortic aneurysm • Retroperitoneal haemorrhage • Pneumoperitoneum • Neoplasm • Pancreatitis • Massive ascites • Liver transplantation • Abdominal wall burn eschar Crit Care 2000, 4:23-29

  5. Pathophysiology • Pulmonary function • Mechanical • Decreased lung compliance • Increased pulmonary vascular resistance • Manifest as hypoxia, hypercapnia, increasing ventilatory pressure

  6. Renal • Reduction in renal plasma flow • Direct pressure effect on the parenchyma • Activation of renin-angiotension system • In a prospective study • u/o < 0.5mL/kg/min in 65% patient with IAP between 16-25mmHg • Oliguric in 100% of patient with IAP > 35mmHg Meldrum et al Am J Surg 1997:174:667-72

  7. Cardiovascular • Reduction in CO • Decreased venous return • Reduction in end-diastolic volume • Splanchnic blood flow decreased • Decreased cardiac output • Abnormal mucosal barrier, bacterial translocation, septic complication

  8. CNS dysfunction • Elevation in ICP • Impaired venous outflow

  9. Measurement?

  10. Techniques • Direct • Catheter in the peritoneum • Indirect • Bladder • Stomach • Rectal pressure • Uterine pressure • Inferior vena cava pressure

  11. Intravesical pressure measurement • First described by Kron in 1984 • Foley catheter • Instillation of 50ml normal saline • Clamped distal to the culture aspiration port • A 16G needle inserted into the aspiration port and connected to a 3-way connector or pressure tranducer • Pubic symphysis is used as the zero point

  12. Management • Definitive treatment is decompressive laparotomy

  13. Meldrum et al. Am J Surg.1997;174:667-672

  14. Management • Decompress when • IAP persistently > 20mmHg Ivatury et al Sury Clinic North Am 1997;77:783-800 • IAP > 20mmHg with • U/O < 0.5ml/kg/min • PIP > 45mmHg • Oxygen delivery < 600 • IAP > 26mmHg Meldrum et al. Surg Clinic North Am 1997;77/801-11

  15. Complications • Reperfusion Syndrome • Occurs when IAH is suddenly relieved • Sudden increase in tidal volume, causing respiratory alkalosis • Sudden increase of products of anaerobic metabolism • Arrhythmia and asystole

  16. How to management the open abdomen?

  17. Towel Clip closure

  18. Bogota bag

  19. Vacuum-assisted wound closure G.B. Garner et al. Am J Surg 2001;182:630-638

  20. After the acute phase…………..

  21. Primary closure could be carried out in 50-60% patient after 7-10days • Absorbable mesh and skin graft • Large ventral hernia • Require repair later

  22. Bring Home Messages • ACS is a life-threatening condition • Mortality 10.6 -68% Crit care 2000, 4:23-29 • Early recognition and treatment is essential for improving outcome • Decompress when IAP > 20mmHg with deranged physiological parameter