abdominal compartment syndrome in trauma

ACS

1. Case presentation Rasangi Suraweera Senior Registrar Critical care

2. A 35 year old transferred from Vavuniya M= multiple stab injuries into I=injuries –anterior and posterior neck lacerations r/s 8-10 th rib fractures Multiple l/s transverse process fractures L1,L2,L3 l/s iliac fracture Base of skull fracture and large liver laceration S= GCS 15/15 BP= 97/64mmHg HR=138 reduced air entry on the right side RR=28 FAST right side pleural effusion Large liver laceration moderate to gross haemoperitoneum T= Transfused with 6 PRBC,3FFP and 20 units of cryo and 1g of tranexamic acid.

3. CECT showed a large liver laceration 9.5cm extending to the porta hepatis.Large intraparenchymal hematoma of the liver.Moderate to gross free fluid . CT brain =base of skull fracture , subtentorial SAH CT cervical spine= multiple left side transverse process fractures L1,L2,L4

4. What should the management be at this time?

5. ROTEM guided transfusion/Damage control rescuitation ratio based concept 1:1:1 of PRBC:FFP:PLT/Lab based concept based on INR,aPTT,platelet count Exploratory laparotomy and packing of the liver laceration Intubation of patient in the expectation of lowering GCS during transfer with MILS Suturing of the neck and scalp lacerations

6. What are the advantages of ROTEM guided transfusion? Advantages of ROTEM guided transfusion. reduced transfusion requirements, • reduced incidence of transfusion- associated adverse events, and • improved patients’ outcomes

7. What are the components of damage control resuscitation?

8. is known as haemostatic resuscitation or controlled/permissive hypotension. The principles of Damage Control Surgery (DCS) should be to control haemorrhage , limit contamination, and temporize rather than seek definitive therapy of all trauma injuries. severe hypothermia impairs thrombin generation and contributes to platelet dysfunction. Management techniques can be divided into passive rewarming, active external rewarming, and active internal rewarming During the active phase of bleeding, several animal models and a few prospective human studies have demonstrated reduced bleeding and improved survival when managed with lower transfusion volumes and lower mean arterial blood pressure.

9. The goal of limited crystalloid resuscitation. a “resuscitation injury” occurs from excessive crystalloid fluids, including disruption of clot formation, dilutional coagulopathy, glycocalyx disruption, and immunomodulation. CRASH-2 revealed a mortality advantage to early use of tranexamic acid (TXA), presumably by mitigating the hyperfibrinolytic response in severely injured patients. Ratio-based blood component therapy should be instituted in the initial management of the severely injured patient, until laboratory evidence can be obtained to guide transfusion. RBC transfusion should target haemoglobin between 7-9 g dL 1 . 76 This recommendation is not patient specific and must be increased in patients with a greater demand for oxygen carrying capacity (elderly and cardiovascular disease)

10. benefit to early transfusion of platelets to > 50 109 l 1 or > 100 109 l 1 in TBI. One unit of apheresis platelets (or 6 pooled units) should be given with each six units of RBC and six units of FFP. Early use of viscoelastic testing in trauma is an essential component of resuscitation and often reveals decreased clot strength and hyperfibrinolysis in ATC. When using cryoprecipitate, the component should be filtered and delivered “cold” using 15-20 single donor units (approximately two units per 10 kg/body weight). For fibrinogen concentrate, 3-4 g are administered early

11. The use of fresh whole blood (FWB) for resuscitation has seen a renewal of interest with the use of 1:1:1 protocols sometimes referred to as reconstituted whole blood (RWB) it is recommended that all patients presumed to be at risk for significant bleeding, receive TXA 1 gram loading dose followed by a 1 gram 8-h infusion.

12. Left loin region laceration ,anterior neck laceration,scalp and posterior neck laceration were sutured Patient was referred for embolization to the interventional radiologist the following morning .Hepatic angiogram was done .A delayed blush of contrast noted and small bleeding point noted and advised to observe for 24 hours. ROTEM guided resuscitation of blood products

13. On the 14 /07/2020 patient desaturated SPO2 94% with 60 % intubated and ventilated .TV 180 ml -240 ml .ET CO2 >55mmHg. She was tachycardiac HR=120 BP=121/65mmHg GCS 6/15 sedated and ventilated . Bladder pressure was 29 cmH20 Lapratomy and laparostomy were done Large laceration of the right lobe of the liver extending into porta hepatis through segments V to VIII.only mesenteric hematoma noticed after bowel walk was done

14. What complication was she developing?

15. Abdominal compartment syndrome compromising ventilation

16. What is the definition of abdominal compartment syndrome? ACS is defined as “sustained intra-abdominal pressure (IAP) exceeding 20 mmHg associated with new organ dysfunction or failure

17. What are the effects of increased intraabdominal pressure on ventilation?

18. What are the effects of intrabominal pressure on end organ function? Gastrointestinal direct compression thrombosis -> bowel wall ischaemia + oedema -> translocation of bacterial products leading to additional accumulation Renal direct compression of renal parenchyma and ischaemia -> AKI Neurological increased ICP Cardiovascular elevated CVP and PCWP however, decreased VR -> decreased cardiac output

19. What are the effects of intrabominal pressure on end organ function?

20. Hb=13.7 PCV=38.1 WBC=27.2 PLT=107 PT=26.4 INR=2.48 Cr=1.89 AST=4213 ALT=4817

21. Based on the investigations what were her problems? Acute kidney Liver laceration causing transaminitis Trauma induced coagulopathy

22. What is trauma induced coagulopathy? Acute Traumatic Coagulopathy occurs immediately after massive trauma when shock, hypoperfusion, and vascular damage are present. Mechanisms for this acute coagulopathy include activation of protein C, endothelial glycocalyx disruption, depletion of fibrinogen, and platelet dysfunction. Hypothermia and acidaemia amplify the endogenous coagulopathy and often accompany trauma. These multifactorial processes lead to decreased clot strength, autoheparinization , and hyperfibrinolysis.

23. Post op patient was intubated and ventilated TV=180ml -240 ml ETCO2>60 mmHG pH7.0 lac 3.8 FIO2 =100% PEEP=10 PS=18 Decreased air entry on the lower bases

24. Post op CXR= right upper lobe collapse noted and ETT tube adjusted to a lip level of 19 Bronchoscopy was done. Ventilator settings improved. FIO2 =0.65 % PEEP=7 PS=18 TV=317

25. Following morning urine out put was low overnight. By mid afternoon TV=200ml ,PEEP 18 PS=25 on SIMV PC PCO2 =rose from 50 to 70.She was ambu ventilated for a while before connecting to the ventilator. Due to the rise in intra abdominal pressure to 31 cm H20 it was decided to reopen the patient and remove the packs.

26. What is the management of intraabdominal hypertension? what can be done?

27. Reducing intraluminal volume Reducing intraluminal volume: evacuation of excess volume from the GIT can be established by prokinetics and enema Decompression by gastric or rectal tubes Small bowel difficult to treat non invasively Decompressive lapratomy

28. Reducing extraluminal volume Percutaneous catheter drainage can be used as a definitive treatment in some cases (e.g., ascites in liver cirrhosis , burn patients with ACS  Some cases it is used as a temporary measure while treating the underlying organ dysfunction

29. Improving abdominal wall compliance Burn eschars – escharotomy Tight bandages can be released Body position can be changed Sedation,analgesia and neuromuscular blockers Bedside ultrasound and removal of moderate amounts of ascites

30. Correct Positive Fluid Balance avoid excessive fluid aim for zero to negative balance diuretics colloids/hypertonic fluids haemodialysis /filtration

31. Decompressive laparotomy Decompressive laparotomy will decrease intra-abdominal volume in relation to the abdominal cavity and abdominal wall compliance and is as such the ultimate treatment for ACS.  can be a severe ischemia-reperfusion event, especially when IAP has been elevated for some time, and patients may require supportive measures to tolerate the intervention.

32. Date 12/07 13/07 13/07 14/07 14/07 15/07 15/07 Fio2 60% 60% 50% 60% 65% 45% 45% Ph 7.25 7.25 7.21 7.11 7.315 7.32 7.205 Pco2 35 36 40 40.4 35.4 41.5 40.6 PO2 94 79 53.4 40.8 190.9 139 72.6 P/F 158 135 293 310 161.4 HCO3 15.7 14.9 21.7 13.3 18.2 18.6 18.6 BE -11.8 -12.5 -5.2 -13.8 -6.6 -8.1 -8.1 lacatate 2.7 3.6 2.7 0.8 3.5 2.6 2.9

33. Tidal volumes The perioperative use of lower tidal volumes (6-8ml/kg of predicted body weight ) plus the application of PEEP as opposed to higher tidal volumes and no PEEP is associated with reduced respiratory complications in patients undergoing major abdominal surgery .

34. Airway pressures Lung protective ventilation implies opening the lungs with a recruitment manouever and keeping them open.The altered lung mechanics in the context of IAH may require higher than usual pressures to open the airways and keeping the airways open.

35. To avoid alveolar overdistension one would measure oesophageal pressure in critically ill patients and aim for inspiratory transpulmonary pressures <25 cmH2O. Plateau pressure target . Corrected target plateau pressure = target plateau pressure − 7 + IAP (mmHg) * 0.7

36. Driving pressure a large international study of 29,144 ventilated patients found that a driving pressure of less than 14 cm H2o is associated with improved hospital survival inpatients with ARDS.In obese ARDS patients an increased driving pressure was not associated with an increased mortality.

37. PEEP in the setting of IAH the lung will collapse at higher closing pressures during expiration.there remains the fear that in the context of IAH increased atelectrauma due to into increased atelectasis formation and insufficient PEEP may contribute lung injury found in the presence of IAH.Gattinoni et al applied different levels of PEEP in patients with ARDS.the patients with extrapulmonary had IAH and PEEP improved respiratory compliance due to a reduction in chest wall compliance

38. Mode of ventilation . Results from animal studies suggests that assisted ventilation might be associated with improved oxygentation and less lung injury and inflammation in mild to moderate (extrapulmonary ARDS ) in the presence of IAH .This was likely due to reduced atelectasis and more homogenous distribution of ventilation

39. Prone and other positioning: In the setting of IAH there seems to be some merit by suspending and offloading the abdomen during prone ventilation.Prone position improves pulmonary gas exchange to a greater degree in the presence of IAH as shown by increases in PaO2 and decreases in ventilation perfusion heterogenity