1. Abdominal Compartment Syndrome
John Hartley
Academic Surgical Unit
The University of Hull

2. Abdominal Compartment Syndrome (ACS)
Definition
“The adverse physiological consequences of
an acute elevation in intra-abdominal pressure”
Oliguria
Increased airway pressures
Reduced cardiac output

3. Abdominal Compartment Syndrome
Historical background
The perils of elevated intra-abdominal pressure…
1890’s elevation of IAP caused death in animal models
1911 cardiovascular effects of raised IAP identified
1913 effects of raised IAP on renal function
1980’s abdominal decompression for  IAP

4. Abdominal Compartment Syndrome
Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30

5. Abdominal Compartment Syndrome
Pathophysiology
ICP

6. Abdominal Compartment Syndrome
Causes of raised intra-abdominal pressure (IAP)
Retroperitoneal
Intraperitoneal
Oedema in necrotising pancreatitis
Haemorrhage
Pelvic haematoma
Visceral oedema
Retroperitoneal haematoma
Abdominal packing
Bleeding after aortic surgery
Bowel dilatation
Oedema related to resuscitation
Mesenteric venous obstruction
Pneumoperitoneum
Acute ascites

7. Abdominal Compartment Syndrome
At risk patients
Major trauma
Damage control surgery
Laparotomy for bleeding, ischaemia etc
Re-laparotomy for postoperative complications
Massive volume resuscitation

8. Abdominal Compartment Syndrome
Clinical features
Abdominal distension
ELEVATED IAP
Consequent organ dysfunction
Importance
Decompression can reverse abnormal physiology
Probable fatal progression if left untreated

9. Abdominal Compartment Syndrome
Measurement of IAP
Indirect assessment of IAP by bladder pressure
50-100ml saline into bladder
Manometer readings from symphysis pubis

10. Abdominal Compartment Syndrome
Problems
What value of IAP should cause concern?
Level beyond which ACS is irreversible?
ABSOLUTE IAP UNHELPFUL
>20mmHg significant in all pts
>15mmHg significant in many
>12mmHg significant in some
Malbrain ML. Intensive Care Med 1999;25:

11. Abdominal Compartment Syndrome
Survey of British practice
137 of 207 hospitals (66.2% response)
1.5% (n=2) no knowledge of ACS
Some measurement IAP 76% (n=104)
Upon suspicion of ACS 93% (n=97)
No consensus on frequency of measurement or indication for decompression
Ravishankar N, Hunter J.
Br J Anaesth 2005;94:763-6

12. Abdominal Compartment Syndrome
Incidence
Prospective measurement of IAP in 9 months admissions to trauma ICU
15 of 706 pts IAH (2%)
6 of 15 pts with IAH developed ACS (1%)
50% mortality in ACS and 2 of 9 with IAH
Hong JJ, Cohn SM, Perez JM et al Br J Surg
2002;89:591-6

13. Abdominal Compartment Syndrome
Abdominal decompression
Reversal of abnormal parameters in approx 80%
Mean survival approx. 50%
Intervention too late?
Inevitable SIRS and MOF?
PREVENTION BETTER THAN CURE
Sugrue MD’Amour S. J Trauma 2001;51:419

14. Abdominal Compartment Syndrome
Proposed grading for ACS based on IAP
Grade
IAP
(mmHg) (cmH2O)
Signs
Treatment I
No signs ACS
Maintain normovolaemia II
 PAWP + oliguria
? Volume resuscitation
III
Anuria,  CO  PAWP
Consider decompression IV
> >48
Mandatory decompression
Burch JM, Moore EE, Moore FA et al. Surg Clin North Am 1996;76:

15. Abdominal Compartment Syndrome

16. Abdominal Compartment Syndrome
Conclusions
Concept of ACS important
True incidence and significance unclear
Increasing awareness and measurement of IAP may lead to:
- Better understanding of pathophysiology
- Evidence based management

17. Abdominal Compartment Syndrome
World Society on Abdominal
Compartment Syndrome
Antwerp 24th-27th March 2007

19. Abdominal Compartment Syndrome
Renal effects
IAP 15-20mmHg  RBF and GFR with anuria when >30mmHg
No effect of stenting
Parenchymal compression and  renal vascular resistance
Reversible by decompression
Harman PK, Kron IL, McLachlan HD et al Ann Surg
1982;196:594-7

20. Abdominal Compartment Syndrome
Gut and hepatic effects
 splanchnic and hepatic blood flow
 flow in animal models with IAP>10mmHg
Ischaemia at >40mmHg
Gastric mucosal acidosis with  IAP improves with decompression
Ivatury RR, Porter JM, Simon RJ et al J Trauma
1998,44:

21. Abdominal Compartment Syndrome
Other means of detection
CT changes
- Narrowing of IVC
- Direct renal compression
- Bowel wall thickening
- “Rounded abdomen”
Splanchnic hypoperfusion and acidosis
Abdominal perfusion pressure

22. Abdominal Compartment Syndrome
Management of ACS – the issues
Indication for decompression
Timing of decompression
“point of no return”
Subsequent laparostomy management

23. Abdominal compartment syndrome
Definition
The adverse physiological consequences that occur as a result of an acute increase in IAP

24. Abdominal compartment syndrome
Management of ACS
Indication for decompression
Timing of decompression
“point of no return”
Subsequent laparostomy management

25. Abdominal Compartment Syndrome
Effects of intra-abdominal hypertension (IAH)
Gut and hepatic effects
Renal effects
Cardiovascular effects
Respiratory effects
CNS
Abdo wall

26. Abdominal Compartment Syndrome
Cardiovascular effects
 venous return by compression of IVC and portal vein
 intra-thoracic pressure,  LV compliance, cardiac contractility and CO
 peripheral oxygen delivery

27. Abdominal Compartment Syndrome
Respiratory effects
Elevation of diaphragm,  thoracic volume and compliance,  intra-pleural pressure
 airway pressures to maintain ventilation
Compressive atelectasis and V/Q mismatch, hypoxia, hypercarbia, acidosis

28. Abdominal Compartment Syndrome
Acute elevation of IAP above 30mmHg caused oliguria in 11 postoperative pts
Re-exploration and decompression in 7 pts resulted in immediate diuresis.
4 pts not re-explored developed renal failure and died.
If IAP > 25mmHg in the early post period is assoc. with oliguria and normal blood pressure and cardiac index, the patient should undergo re-exploration and decompression of the abdomen
Kron Il, Harman PK, Nolan SP. Ann Surg 1984:199:28-30

29. Abdominal Compartment Syndrome
CNS effects
Impaired venous return and cerebral pooling
 intra-cranial pressure
Ertel W, Oberholzer A, Platz A et al Crit Care
Med 2000; 28:

30. Abdominal Compartment Syndrome
Early detection
Survey trauma surgeons USA
6% measured IAP routinely
59% selectively
Mayberry JC, Goldman RK, Mullins RJ.
J Trauma 1999;47: