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

2. Abdominal Compartment Syndrome

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

4. 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: /MCC.0b013e

5. 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: /ccm.0b013e31817c7a4d.

6. 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.

7. 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.

8. http://www. bing. com/i mages/search
mages/search?q=open+ abdominal+wound+pict ures&view=detail&id=11 4E C1F40F8A9 E7DBEE3B1EADDC9
Dilated loops of bowel

9. 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.

10. Tight Suturing

11. Abdominal Hernia
mages/search?q=open+ abdominal+wound+pic tures&view=detail&id= 114E C1F40F8 A9E7DBEE3B1EADDC 9

12. 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.

13. Pathophysiology (Cheatham, 2009)

14. 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: /

15. 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: /

16. 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: /

17. 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

18. 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: /

19. 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)

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

21. 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: /MCC.0b013e

22. 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)

23. 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

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

25. 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

26. 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.

27. 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.

28. 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

29. Abthera by KCI

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

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

32. 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

33. Reference
Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: /
Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: /MCC.0b013e
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.

34. 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: /ccm.0b013e31817c7a4d.
World Society of the Abdominal Compartment Syndrome (WSACS)downloaded from