1. Abdominal Compartment Syndrome By Maged
Abulmagd,MD,EDIC
2. ? What it is ? A disease process that dramatically increases
organ failure and death for medical and surgical ICU patients
3. What is a normal intra-abdominal pressure or IAP This is the
pressure within the abdominal cavity 5 7 mmHg is normal in a
critically ill adult
4. Intra abdominal Hypertension IAH Defined as sustained or
repeatedly elevated abdominal pressure >12 and is graded
5. Grades of IAH Grade I 12 15 mmHg Grade II 16 20 mmHg Grade
III 21 25 mmHg Grade IV >25 (ACS)
6. IAH Sustained pressure, >12 that has significant effects
on abdominal organs and cardiac output with subsequent dysfunction
of both abdominal and extra-abdominal organs
7. Understanding Abdominal Compartment Syndrome APP Abdominal
perfusion pressure MAP Mean arterial pressure IAP Intra-abdominal
pressure APP = MAP IAP A critical IAP that leads to organ failure
is variable by patient & a single threshold cannot be applied
globally to all patients APP is superior to IAP, arterial pH, base
deficit & lactate in predicting organ failure & patient
outcomes
8. Definition of ACS A sustained IAP > 20 mmHg (with or
without an APP of 30 leads to anuria Increase of antidiuretic
hormone and activation of renin-angiotensin- aldosterone system
Increased water retention
19. Pathophysiology Abdominal Visceral Reduced blood flow which
leads to intestinal ischemia Decreased blood flow to all abdominal
organs
20. Pathophysiology Central Nervous System Increased thoracic
and central venous pressure leads to Decreased cerebral outflow of
blood Increased intracranial pressure which leads to decreased
cerebral perfusion pressure
21. Measuring Intra-Abdominal Pressure
22. Importance of accurate measurement Physical examination
yields low levels of detection of IAH/ACS Early detection and
intervention reduces morbidity and mortality. Diagnosis is
dependent on frequent and accurate measurement of IAP (watching
trends) Cost effective, safe and accurate
23. Assessment Guidelines New ICU admission Evidence of
clinical deterioration Pt has two risk factors for IAH/ACS
Decreased abdominal wall compliance Increased intra-luminal
contents ileus, gastroparesis, obstruction Increased abdominal
contents Pneumoperitoneum, hemoperitoneum, ascities, liver
dysfunction Capillary Leak/fluid resuscitation
24. IAH/ACS Assessment algorithm from World Society of
Abdominal Compartment Syndrome (WSACS) www.wsacs.org Excellent
references
25. Types of Measurements Direct Pressure via intraperitoneal
catheters Indirect Pressure Gastric Measure IVC Rectal Urinary
bladder pressure Gold Standard
26. Urinary Bladder Pressure Most technically reliable
Correlate closely with pressures measured directly in the abdominal
cavity Reliably reproducible Transduced through a Foley
catheter
27. Intermittent Monitoring Open Systems Closed Systems
28. Equipment needed for open measurement Disposable transducer
12 pressure monitoring tubing 4-way stopcock Red dead-ender 60 cc,
lure-lock syringe, sterile Sterile normal saline Clamp, non-sterile
Level
29. Procedure for open, intermittent monitoring Collect and
gather all supplies Attach stopcock to end of sterile transducer
Important to maintain sterile technique to avoid contamination and
potential infectious process
30. Procedure for open, intermittent monitoring Attach pressure
tubing to the remaining end of the transducer
31. Procedure for open, intermittent monitoring Fill 60 cc
syringe with 40 cc of sterile normal saline Attach syringe to side
port of the stopcock Flush stopcock, pressure tubing and transducer
with the normal saline ensuring all air is removed
32. Procedure for open, intermittent monitoring Clamp the
urinary drain tubing distal to the sampling port Cleanse the
sampling port with alcohol Using sterile technique attach the
pressure tubing to the LuerLok connecting sampling port of the
urinary catheter
33. Procedure for open, intermittent monitoring Instill 25 cc
of sterile normal saline into urinary catheter via the sampling
port (Larger vol. of NS can result in falsely elevated IAP
measurements) Briefly release the clamp to allow fluid from the
bladder to fill tubing and reclaim Read the IAP as a mean pressure
at end expiration 30 60 seconds after instillation. Perform with
patient supine Notify MD for sustained IAP greater than 12 mmHg
unless otherwise ordered.
34. Disadvantages with open, intermittent monitoring Collecting
a number of items Correct assembly Risk of infection every time
system is accessed
35. Closed Monitoring AbViser, Wolfe Tory Medical, SLC, UT
Pre-assembled kit Adapts to Foley catheter and any transducer
Reduces risk of infection Readily available, easily assessable
data
36. Measuring Bladder Pressure Position patient flat &
supine Read Mean pressure End Expiration
37. Management Considerations Early detection via frequent
monitoring of at risk patients Screen for IAH/ACS in new ICU
admissions with new or progressive organ failure Look for trends of
increasing abdominal pressures Preserve organ perfusion and treat
clinical conditions with grades I & II
38. Management Considerations Early surgical consultations for
at risk patients Early intervention for ACS or Grade III Anticipate
emergent surgical interventions to prevent tissue damage/death
39. Management Considerations Anticipate patient to return with
an alternative surgical closure or open abdomen. The abdominal
contents will not be sutured into the abdominal cavity Alternative
closures vary from surgeon to surgeon Examples: The Bogata Bag A 3
L IV bag, open and sterilized and applied to the abdominal
opening
40. Management Considerations KCI Vac Pac Sponge overlies abd.
Dressing/contents Attached to continuous suction canister Covered
over with occlusive dressing
41. Management Considerations Ioban Dressing An occlusive
dressing with iodine impregnation Surgical towels will overlie
abdominal contents with JP drains Ioban overlies abdomen
42. Another Excellent Reference, IAH/ACS Management Algorithm
from WSACS www.wsacs.org
43. Conclusion Know the difference between IAH and ACS IAH =
Abdominal pressure >12 and graded via severity ACS = Abdominal
pressures > 20 25 Identify At risk patient populations abdominal
trauma/major burns Pancreatitis Ruptured AAA abdominal
obstructions/ischemia ect.
44. Conclusion Understand the pathophysiology
Ischemia/inflammation inflammatory response capillary leak + fluid
resuscitation = tissue edema in an uncompromising cavity = ACS =
tissue/cell death = bad Perform an accurate assessment of abdominal
pressure using Abdominal bladder pressure monitoring via Foley
catheter or AbViser Wolfe Torey Medical Anticipate patient
interventions/outcomes Support/educate family
45. Case Study - 63 Y.O. male pt with pancreatitis is admitted
to the ICU. Pt has history of gallbladder disease, COPD and ETOH
abuse. He has been without ETOH reportedly for approximately 24
hrs. VS upon admission are T 38.0, HR 130, BP 90/62, MAP 61, RR 30
34 & O2 sat of 91% on 100% NRB, wt approximately 125 kg. His
breathing is labored and he has c/o SOB. He is also mildly agitated
& resistive to O2 therapy with Bi-Pap. His lung sounds are
diminished bilaterally. Denies recent increase in cough. His
abdomen is firm and distended. States unknown last BM but + for
N/V.
46. He has a Foley catheter in place with approximately 100 cc
of dark, amber urine in the collection chamber. Lab values show
H&H of 10.2/31.0, wbc 20, K 5.0, Na 142, Foley was placed
approximately 4 hours ago in the ED. His peripheral arterial pulses
are weak and thready and his BLE show signs of PVD. He is currently
receiving bolus # 3 of NS.
47. Does this patient need IAP monitoring? Is he at risk? What
could you use as a reference if you were unsure?
48. After consulting with your attending MD, it is decided that
a baseline ABP reading would be appropriate for this patient. Your
initial ABP is 15mmHg.
49. Does this value represent intra-abdominal hypertension or
abdominal compartment syndrome? What is his APP based on his MAP
and IAP?
50. What grade would you give this value? Why is this patient
at risk? How would you proceed?
51. After reporting the findings to the resident, serial ABP
readings are ordered Q6 HR. His SBP continues to remain low with a
map consistently < 65 & his respiratory status continues to
deteriorate. The resident also orders another fluid bolus. With
what you have learned about IAH /ACS management, what clinical
suggestions could you collaborate on to advocate for your
patient?
52. After collaboration with the medical team the decision is
made to intubate as his O2 sats continue to drop and RR rate cont.
to increase. After intubation and appropriate sedation, the patient
continues to have an increasingly firm abdomen, increased HR and
decreased SBP and map