Abdominal compartment syndrome in trauma

Acs

1. Abdominal Compartment Syndrome Dr Pramitha Gishan Tilakaratne Registrar in Anaesthesiology

2. Outline Definition Pathophysiology Risk factors Diagnosis of ACS Management ACS Complications of ACS Poly Compartment Syndrome/ Pelvic Compartment Syndrome

3. Definitions Intra abdominal pressure (IAP) Steady state pressure concealed within the abdominal cavity 5-7mmHg Intra abdominal Hypertension Sustained or repeated pathologic elevation of IAP more than 12 mmHg with out organ dysfunction Grade I 12 – 15 mmHg Grade II 16 – 20 mmHg Grade III 21 – 25 mmHg Grade IV > 25mmHg

4. Abdominal Compartment Syndrome (ACS) sustained IAP > 20 mmHg (with or without an APP < 60 mmHg) that is associated with new organ dysfunction / failure Abdominal perfusion pressure APP = MAP - IAP

5. Acute IAH Increase IAP over hours :- trauma / ruptured AAA Sub acute IAH Increase IAP over days :- pancreatitis / peritonitis Chronic IAH Increase IAP over days months :- pregnancy Recurrent ACS condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS

6. Primary ACS associated with injury or disease in the abdomino -pelvic region that frequently requires early surgical or interventional radiological intervention Secondary ACS conditions that do not originate from the abdomino -pelvic region

7. Pathophysiology Speed of increase of abdominal volume

8. Pregnancy lead to slight increase of IAP

9. Pathophysiology of complications

10. Risk factors Reduced abdominal wall compliance Increased intra-luminal contents Abdominal cavity collections Capillary leak and fluid resuscitation

11. Risk factors

12. Diagnosis History, physical examination and Evaluation History penetrating abdominal trauma extensive abdominal surgery Sepsis Large volume fluid resuscitation Major burns Look for risk factors

13. Examination increased abdominal girth tense abdomen New onset organ dysfunction difficulty in ventilation new onset oliguria /AKI new onset cardiovascular instability

14. Evaluation Measurement of intra abdominal pressure

15. Urinary bladder pressure End expiration Supine position Abdominal muscle contraction absent Zero at mid axillary line at iliac crest

16. Management Medical Surgical

17. Management goals Identify cause Identify complications Evacuate intra luminal content Evacuate intra abdominal space occupying lesions Improve abdominal wall compliance Optimize fluid management Optimize systemic / regional perfusion

18. Surgical decompression If nonsurgical techniques fail to reduce the IAP Decompressive laparotomy + negative pressure peritoneal therapy to reduces the IAP improves visceral perfusion reduces the transmission of inflammatory mediators

19. open abdomen the abdominal wall incision is temporarily left unrepaired at the end of the surgery Temporary closure using vacuum-assisted closure patch technique silo technique ( Bagota bag) skin-only technique using towel clips

20. IAP and LUNG

21. POLYCOMPARTMENT SYNDROME IN ICU 2 or more anatomical compartments have elevated pressures poly-compartment syndrome, abdomen plays a central role

22. PELVIC COMPARTMENT SYNDROME increased pressure within the true pelvis typically follows an expanding hematoma secondary to trauma reduced pelvic venous return and ureteral dilatation results in pelvic compartment syndrome diagnosed by elevated bladder pressure and should be differentiated from IAH/ACS

23. Summary

24. Summary

25. Reference World society of abdominal compartment syndrome Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units. World J Gastroenterol 2020 January 21; 26(3): 266-278 A Clinician’s Guide to Management of Intra abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients. De Laet et al. Critical Care (2020) 24:97 Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know. Regli et al. Ann. Intensive Care (2019) 9:52

26. Thank you