By: Yonatan Yohannes, MD
Abdominal Compartment Syndrome
Who: The critically ill. Most commonly in shock, burn patients, polytrauma patients.
What:
Primary -> abdominopelvic disease/injury: trauma, pancreatitis, surgery, etc.
Secondary -> conditions originating elsewhere: sepsis, burns
When:
Normal IAP (intra-abdominal pressure) 5-7mmHg
IAH (intra-abdominal hypertension) IAP ≥ 12mmHg
ACS (abdominal compartment syndrome) IAP ≥ 20mmHg w/ new organ dysfunction
*A gradient exists for everyone; Mesenteric perfusion has been shown to decrease at IAP 10mmHg, while obese and pregnant patients may have IAP 10-15mmHg and remain asymptomatic.
Where: Most commonly seen in ICU settings. Stay vigilant as it may be coming to an ED near you…
Why: Results in local ischemia (similar to any other compartment syndrome, i.e. extremity, heart, eye, brain) in addition to decrease in cardiac output that in turn leads to diminished end-organ perfusion
Abdominal perfusion pressure (APP)
- APP = MAP – IAP
- APP is better resuscitation endpoint than arterial lactate, pH, base deficit, urinary output
- APP > 60mmHg correlates with improved survival
How:
~ Pulmonary: diaphragm obstruction, decreased lung compliance
~ Cardiovascular: decreased venous return, increased afterload, decreased cardiac output
~ Renal: oliguria, renal failure
~ GI: malperfusion of gut, loss of mucosal barrier, bacterial translocation, sepsis
~ CNS: increased intracranial pressure
* Overall result: decreased end-organ perfusion -> multi-organ failure
Diagnosis: High index of suspicion as most patients can’t speak!
Findings such as:
Abdominal distention             Refractory oliguria        Hypercarbia      Â
Refractory hypoxemia             Elevated IAP             Elevated PIP    Â
Refractory metabolic acidosis          Â
In mechanically ventilated patients: peak airway pressure > 45cmH20 (normal is <35cmH20)
CT findings: collapse of IVC, bowel wall thickening, bilateral inguinal herniation
Bedside sono: likely collapsed IVC and bowel wall thickening
*Intravesicular pressure (most specific) -> strong correlation with intra-abdominal pressure
How to measure Intravesicular (bladder) pressure:
~ Lie the patient supine. Insert a 3-way foley. Clamp the foley port (used for bladder drainage) and insert 25mL sterile water into the irrigation port. Now clamp your irrigation port. Connect to a pressure transducer and an arterial line (and monitor). Zero you pressure to the level of the bladder and unclamp your irrigation port.
Image taken from Cheatham, ML and Safcsak K. Intraabdominal pressure: a revised method for measurement. J Am Coll Surg. 1998.
~ Alternatively, you can insert a 3-way foley catheter and drain the bladder. Clamp your foley tubing. Insert 25mL sterile water into the irrigation port, followed by clamping. Raise the foley tubing in the air, directly perpendicular to the supine patient. Unclamp the irrigation port. Measure how high the vertical column of fluid rises from the pubic symphysis to the fluid meniscus in centimeters. Now plug this measured number into your favorite unit converter (website, phone app, etc.) to convert from centimeters of water to millimeters of mercury.
Image take from Cresswell AB, Jassem W, Srinivasan P, et al. The effect of body position on compartmental intra-abdominal pressure following liver transplantation. Ann Intensive Care 2012.
**This should only be used for single measurements, not continuous monitoring as this would mean leaving the foley port clamped for long periods of time.
Management:
- Surgical decompression -> usually ex-lap, may include newer surgical techniques
- ED decompression -> NG tube, foley catheter, rectal tube (sigh)
- Percutaneous decompression -> temporizing measure, can be done at bedside
- Maximize abdominal wall compliance -> sedate agitated patients, paralyze intubated patients
- Intubated patients -> lower tidal volumes, pressure control mode, be cautious with PEEP as it increases intra-abdominal pressure
- Vasopressors as needed
References:
Roepke C, Benjamin E, Jhun P, et al. Air in the Belly: A Discussion of Abdominal Compartment Syndrome. Ann Emerg Med. 2016. 67;1:17-19.
Cheatham ML. Abdominal Compartment Syndrome: Pathophysiology and definitions. Scand J Trauma Resusc Emerg Med. 2009; 17:10.
Gestring M, Sanfey H, Bulger EM. Abdominal Compartment Syndrome. UptoDate. http://www.uptodate.com/contents/abdominal-compartment-syndrome?source=see_link#H2. Last updated Feb 2015.
Paula R, Talavera F, Lang ES. Abdominal Compartment Syndrome. Medscape. http://emedicine.medscape.com/article/829008-overview. Last updated Sept 2015.
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