Abdominal Compartment Syndrome Anna M. Alvarez UCF CNS II 11/10/11

Abdominal Compartment Syndrome

Abdominal Compartment Syndrome (ACS) Objectives Define Abdominal Compartment Syndrome Identify populations at risk Discuss key physiological changes Discuss treatment modalities Identify CNS implications

Abdominal Compartment Syndrome Definition Sustained intra abdominal pressure (IAP) greater than 20 mm Hg ( with or without abdominal perfusion pressure < 60 mm Hg) Associated with new organ dysfunction and/or failure. Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934.

Abdominal Compartment Syndrome Morbidity & Mortality Rate Vidal, M.G. et al ( 2008) Prospective cohort study of IAH/ACS 64% IAH; 43% mortality rate 12% ACS, n= 10 2 patients with primary ACS survived Total mortality rate of 20% Vidal, M.G. …..& Estenssoro,E., (2008). Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Critical Care Medicine, 36. Doi: 10.1097/ccm.0b013e31817c7a4d.

Etiology Primary ACS – increased intra abdominal volume Secondary ACS – decreased abdominal wall compliance Combination of both decreased wall compliance and increased intra abdominal volume De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

Primary ACS GI tract dilation Gastroparesis Ileus Intra abdominal masses or retroperitoneal masses (tumors) Obstruction , volvulus Ascites Hemiperitoneum De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra- abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

http://www. bing. com/i mages/search http://www.bing.com/i mages/search?q=open+ abdominal+wound+pict ures&view=detail&id=11 4E30671179C1F40F8A9 E7DBEE3B1EADDC9 Dilated loops of bowel

Secondary ACS Abdominal surgery with tight suturing Abdominal wall bleeding, rectus sheath hematomas Large abdominal hernias De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra- abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

Tight Suturing

Abdominal Hernia http://www.bing.com/i mages/search?q=open+ abdominal+wound+pic tures&view=detail&id= 114E30671179C1F40F8 A9E7DBEE3B1EADDC 9

Combined Primary and Secondary ACS Obesity Sepsis Severe pancreatitis Massive fluid resuscitation Burns Intra abdominal infection De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

Pathophysiology (Cheatham, 2009)

Pathophysiology Cardiovascular: Increased intrathoracic pressure – reduced cardiac output. Decreased venous return and cardiac pre-load. Increased femoral vein pressures with increased venous hydrostatic pressure promotes peripheral edema and increase risk of DVT. Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

Pathophysiology Pulmonary Compression of lungs Alveolar atelectasis Decreased oxygen transport across the pulmonary capillary membrane Pulmonary infection Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

Pathophysiology Renal Decreased renal perfusion Increased renal vein pressure Increased renal vasculature Shunting blood from renal cortex and glomeruli. Compression of the renal vein Elevated BUN, creatnine, NA, CL, antiduretic and anti aldosterone hormones. Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

Pathophysiology (Cheatham,2009) Gastrointestinal Reduction of arterial perfusion to the mesentery Bowel ischemia Feeding intolerance Decreased intramucosal pH Metabolic acidosis Visceral edema Impaired hepatic circulation and reduction of lactic acid clearance

Pathophysiology Central Nervous System Decreased cerebral perfusion Increased intracranial pressure Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10

Clinical Presentation Pt has had abdominal surgery with a tight closure of the suture line or abdominal injury( ICC, surgical floor) decreasing urinary output, abdominal distention Pt s/p MVC with pelvic fractures, hemodynamically unstable (ED, ICU) aggressive fluid resuscitation Pt is septic and with decreasing BP, decreasing urinary output, respiratory distress. (ICC, med-tele unit)

Clinical Presentation Breath sounds diminished Abdomen distended Lower extremity edema Lab work: BUN, creatinine, lactic acid, Na, Cl, elevated.

Treatment Algorithms Sedation and analgesia – reduce muscle tone Neuromuscular blockade – Evacuating intralumen contents- N/G, rectal drainage, enemas, medication : neostigmine Fluid Resuscitation CRRT Percutaneous decompression Surgical decompression- T.A.C. Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934.

World Society of the Abdominal Compartment Syndrome Consensus Recommendations Risk Factors for IAH/ACS – Screening upon ICU and with new or progressive organ failure (Grade 1B) IAP Measurement- 2 or > risk factors for IAH ; baseline. (Grade 1C) APP- sustained >60 for pts with IAH/ACS. (Grade 1 C) Sedation and analgesia- Insufficient data NMB- Brief trial may be considered (Grade 2C) Body positioning- May contribute to >IAH in severe IAH/ACS (Grade C) Gastric/Colonic decompression- insufficient data. Fluid resuscitation- Carefully monitored (Grade 1B), Hypertonic crystalloid/ colloid –based to decrease progression to ACS (Grade 2C)

World Society of the Abdominal Compartment Syndrome Consensus Recommendations cont. Diuretic/hemofiltration - insufficient data Percutaneous decompression – Should be considered with presence of abscess, fluid, blood (Grade 2C) Abdominal decompression – (Grade 1B) Definitive abdominal closure –( insufficient data) World Society of the Abdominal Compartment Syndrome (WSACS)downloaded from http://www.wsacs.org

Review of the Evidence Credibility: Guidelines developed by members of the WACS; predominantly surgeons Funded by WACS Researchers funded of the reviewed studies- unknown

Review of the Evidence- cont. Valid development strategy – none reported Impartial process of selecting literature- unknown Outcomes and options: Yes Recommendations tagged – yes Recommendations reflecting outcomes: yes Guidelines subjected to peer review and testing- yes

Review of the Evidence - cont. Applicability International use Clinically relevant? Yes Help me care for my patients? Yes. Recommendations practical/feasible? Yes Major variation from current practice – No Measureable outcomes through standard care - Yes Melnyk B.M., & Fineout-Overholt, E . (2nd ED) . (2011). Evidence-based Practice in Nursing and Healthcare: A guide to best practice. Philadelphia, Pa.: Lippincott Williams and Wilkins.

Case Study Mr. S. is a 54 y/o Caucasian male admitted through the ED with c.c. of worsening abdominal pain. PMH: + chronic pancreatitis, ETOH abuse, polypharmacy abuse, COPD, asthma, bronchitis, 35 pack year h/o tobacco abuse. Medications: Oxycontin, Nebulizer treatments. VS: BP 130/60, HR 100, R 28, T 97. Surgical History: exploratory laparatomy, bowel resection removed ischemic bowel and re anastomosis.

Case study cont: Elevated temp – no UTI, No line infection, chest xray negative for infection. Abdominal CT shows multiple abscess . Back to surgery: per the chart, found abscess formation, washout with warm saline. Temporary closure with the Negative pressure

Abthera by KCI

Currently Draining abdominal cavity Decreasing abdominal defect by suturing around the fistulae

Role of the CNS 1. Identify the at risk patient 2. Initiate intravesicular pressure readings to monitor IAP. ?

Role of the CNS Identify patients at risk Initiate treatment algorithm per unit based hospital policy Collaborate with multidisciplinary team Educate and advocate for family Educate staff Review current EB guidelines

Reference Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10 Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934. De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169. Melnyk B.M., & Fineout-Overholt, E . (2nd ED) . (2011). Evidence-based Practice in Nursing and Healthcare: A guide to best practice. Philadelphia, Pa.: Lippincott Williams and Wilkins.

Reference cont. Vidal, M.G. …..& Estenssoro, E., (2008). Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Critical Care Medicine, 36. Doi: 10.1097/ccm.0b013e31817c7a4d. World Society of the Abdominal Compartment Syndrome (WSACS)downloaded from http://www.wsacs.org