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ABDOMINAL COMPARTMENT SYNDROME DR. F MOSAI REGISTRAR: GEN SURGERY MEDUNSA
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ACS OUTLINE 1.DEFINATIONS: IAH, ACS 2.RISK FACTORS 3.AETIOLGY 4.PATHOPHYSIOLOGY 5.DIAGNOSIS 6.TECHNIQUES OF MASURING IAP 7.PREVENTION OF ACS 8.MANAGEMENT 9.COMPLICATIONS OF ASSOCIATED WITH Mx
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1. DEFINATIONS IAH: sustained or repeated pathological increase in IAP= 12mmHg or more [PAEDS:] IAH: sustained or repeated pathological increase in IAP=10mmHg or more ACS: sustained IAP=20mmHg or more(with or without an APP<60mmHg) that is associated with new organ dysfunction/failure [PEADS] ACS: sustained increased IAP >10mmHg ass with new or worsening organ dysfx that can be attributed to increase in IAP
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2. RISK FACTORS Diminished abdominal wall compliance Major burns, abd surgery, major trauma, prone position Increased intraluminal contents Volvulus, gastric distension, gastroparesis, Ileus, colonic pseudo-obstruction Increased Intra-abdominal contents Haemoperitonium/pneumoperitonium or intra-peritoneal fluid collection,tumours
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2. RISK FACTORS Capillary leak/fluid resuscitation Massive fluid resuscitation or positive fluid balance, damage control laparotomy, hypothermia Others/miscellaneous Mechanical ventilation, increase BMI, sepsis, shock,coagulopathy
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3. AETIOLOGY Acute: Retroperitoneal: pancreatitis, bleed, visceral oedema, aortic aneurism Intraperitoneal: bleed, bowel obstruction, ileus, oedema, gastric dilatation Abdominal wall: burn eschar, repair of gastroschisis or omphalocele, reduction of large hernias, laparotomy closure under tension Chronic: Obesity,ascitis, intra-abd tumors, preganancy, peritoneal dialysis
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4. PATHOPHYSIOLOGY CNS: ↓ venous outflow ↑ ICP ->cerebral oedema-> ↓ CPP CVS: ↑ systemic vascular resistance due to compression at the level of the capillary bed : ↓ venous return :diaphram displacement →↑ intrathoracic pressure →↓ ventricular compliance →↓ CO + SV
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4. PATHOPHYSIOLOGY Resp: ↑ diaphram →↓ pulmonary compliance : ↓ TLC, ↓ FRC, ↓ RV : V/Q abnormal and hypoventilation → hypoxia and hypercarbia ABD: ↓ flow in mesenteric, intestinal, hepatic and portal venous flow → ischaemia and ↑ risk of translocation
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4. PATHOPHYSIOLOGY Renal: ↑ IAP → obstruct renal outflow +renal arteries : ↑ ADH, renin and aldosterone → ↑ vascular resistance, Na + H2O
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5. DAIGNOSIS Hx: ↓ urine output with ↑ CVP ↑ Peak airway pressure Massive volume resuscitation Damage control laparotomy shock
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5. DAIGNOSIS CRITERIA FOR Dx 1.IAP >25mmHg (30cmH ₂ O) AND 2. One or more of the following Oligouria (0.5ml/kg/h) ↑ pulmonary pressure (>45cmH ₂ O) Hypoxia ↓ CO Hypotension Acidosis AND(to comfirm Dx)
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5. DAIGNOSIS 3. Abdominal decompression lead to clinical improvement
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6. TECHNIQUE TO MEASURE IAP Sterile procedure Supine position, Θ abd muscle contraction Transducer, zero at the level of midaxillary line Place a special catheter and empty bladder Clamp catheter and instill ≤25ml sterile saline into bladder and wait 30sec for detrusor muscle relaxation before measuring pressure Measure at end expiration at the phlebostatic axis [Peads: instill 1ml/kg, min:3ml-max:25ml)
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7. PREVENTION OF ACS Prophylactic use of open abdomen after trauma damage control laparotomy Damage control resuscitation Limitation of crystalloid fluids ↑ ratio of plasma/packed red blood cell for resuscitation of massive haemorrhage Keep fluid balance neutral or even negative Body positioning(trendelenberg)
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8. MANAGEMENT 1.Non-operative(MEDICAL) Indications: IAH Secondary or recurrent ACS with no progressive organ failure 2. Operative Indications: Primary ACS/ overt ACS Secondary or recurrent ACS with progressive organ failure IAH( failed non-operative Rx)
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8. MANAGEMENT 1.Non-operative Mx Improve abdominal wall compliance Sedation and analgesia Paralysis(neuromascular blockade) Trendelenberg position( avoid head of bed >30°) Evacuate intraluminal contents NG-decompresion Rectal/colonic decompression Gastro/colo-prokinetics(e.g. Neostigmine)
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8. MANAGEMENT Evacuate abdominal fluid collection PCD(abscess, haematoma) Paracentesis(not recommended) Correct positive fluid balance Avoid excessive fluid resuscitation Diuretics(NOT RECOMMENDED) Colloid or hypertonic fluids Albumin (NOT RECOMMENDED) Hemodialysis/ultrafiltration(NOT RECOMMENDED)
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8. MANAGEMENT Damage control resuscitation Limit crystalloid iv fluid ↑ plasma/packed red blood cell ratio for massive hemorrhage
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8. MANAGEMENT 2. Operative Acute decompresive laparotomy Wound cover after laparotomy Silo Bag closure 3l Bogota bag (with closed suction to control fluid exudate) Sandwish and vacuum pack technique NPWT(negative pressure wound therapy) Bioprosthetic mesh closure(NOT RECOMMENDED FOR ROUTINE USE)
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9. COMPLICATIONS Intraoperative Surgical related Sudden release of IAP lead to reperfusion injury, SIRS, Acidosis, hyperkalemia and ↑ myglobin Rx: consider: 1l 0.45% saline with 50g Mannitol and 50mmol sodiun bicarbonate Anaesthetic related Aspiration ( ↑ IAP)
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9. COMPLICATIONS Post-operative Short term(due to prolong open abdomen) Visceral adhessions Loss of soft tissue coverage Lateralization of the abdominal musculature and its fascia Malnutrion Enteric fistulae Long term Incisional hernia Adhessive bowel obstruction
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