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Lee Abdominal Hypertension and Abdominal abdominal distention

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					Abdominal Hypertension and
 Abdominal Compartment
       Syndrome
         Lane Lee DO FACOS
   Trauma Director Trinity Health Minot
         Objectives
Understand Definition of ACS IAH
Understand Rubric of Compartment
pressure
Know common measurement options
Understand Common Etiologies
Understand Reasons for Mortality Risk
Be aware of treatment Options
             Comparison
Ophthalmic

Cranial

Chest

Fascial
             Intraorbital
Glaucoma
Pressures in Eye exceeding 20mmHg
pressure compromises the retina and
unabated will eventually lead to blindness
            Intracranial
High Pressure Hydrocephalus
Pressures generally exceed 20mmHg
untreated leads to intracranial injury
           Intrathoracic
Tension Pneumothorax
Pressures in excess of 20mmHg can
compromise reinflation of a collapsed lung
     Fascial Compartment
Muscle Compartments that develop acute
elevation of pressures beyond 20mmHg
Leads to Nerve Compromise untreated will
result in permanent nerve Injury
Apache II score predictors of
          Mortality
ICU Monitors
Organ Failure Mortality Increase
 Acute Renal Failure
 Bowel Ischemia
 Acute Drop in Cardiac Output
 Acute Elevation of Intra cerebral pressure
        Abdominal Hypertension
Intra abdominal pressure greater than 15-
20 mmHg
Sugrue M, Jones F, Lee A, Buist MD, Deane S, Bauman A, Hillman
K. Intra-abdominal pressure and gastric intramucosal pH: is there an
association? World J Surg 1996;20:988-91
 Abdominal Hypertension
IAH
– 12 mmHg or greater
– minimum of three standardized
  measurements
– four to six hours apart

– Sugrue M. Abdominal compartment syndrome. Curr Opinion in
  Critical Care 2005;11:333-8
    Abdominal Compartment
         Syndrome
Consequence of IAH effect over time
Classically 5 Components
                5 Components
– Abdominal Distention
– Increased Peak Inspiratory pressure
– Increased Central Venous Pressure
– Oliguria
– Hypercarbia
– Schein M, Wittmann DH, Aprahamian CC, Condon RE. The
  abdominal compartment syndrome: the physiological and clinical
  consequences of elevated intra-abdominal pressure. J Am Coll
  Surg. 1995; 180: 745-53
                ACS
Intraabdominal pressure resulting in
compromised intraabdominal blood flow
Subsequent MSOF
                       ACS
Decrease Cardiac Output




Richardson JD, Trinkle JK. Hemodynamic and
respiratory alterations with increased intraabdominal
pressure. J Surg Res.1976; 20: 401-04.
                             ACS
Oliguria
Anuria- above 30mmHg




Harman PK, Kron IL, McLaachlan HD, Freedlender AE, Nolan SP. Elevated
intraabdominal pressure and renal function. Ann Surg .1982; 196: 594-97   .
                      ACS
Decrease in Blood flow bowel

Diebel LN, Dulchavsky SA, Wilson RF. Effect of
increased intra-abdominal pressure on mesenteric
arterial and intestinal mucosal blood flow. J Trauma.
1992; 33: 45-9.Diagnosis
Bowel Edema
Bowel Edema
                      ACS

Decrease in Cerebral Perfusion Pressure

Bloomfield GL, Ridings PC, Blocher CR, Marmarou A,
Sugerman HJ. Effects of increased intra-abdominal
pressure upon intracranial and cerebral perfusion
pressure before and after volume expansion. J Trauma.
1996; 40: 936-43
                 Etiology
Decreased permeability
– Infection
– Hypotension (hemorrhage)
– Inflammation (pancreatitis)
Increased volume
Classic High Volume Resuscitation Patient
Measurement of IA pressure
Measurement of IA pressure
             Measurement
Direct
– intraperitoneal catheter
Indirect
– percutaneous inferior vena cava catheter
– nasogastric catheter
– urinary bladder catheter
       Basis of Treatment
Prevention
– Permissive Hypotension
– Damage control surgery
– Colloids
– 1-1-1 Rule
          Basis of Treatment
Intervention
– Decrease Pressure
– Restablish Perfusion
– Decrease Permeability
– ie Laparotomy

– Schachtrupp A, Fackeldey V, Klinge U, Hoer J, Tittel
  A, Toens C, Schumpelick V. Temporary closure of the
  abdominal wall (laparostomy). Hernia 2002;6:155-62
Laparotomy decreases IAH and
          Mortality
Burch JM, Moore EE, Moore FA, Franciose R. The abdominal
compartment syndrome. Surg Clin North Am 1996;76:833-42
Cullen DJ, Coyle JP, Teplick R, Long MC. Cardiovascular,
pulmonary and renal effects of massively increased intra-abdominal
pressure in critically ill patients. Crit Care Med 1989;17:118-21
Chang MC, Miller PR, D’Agostino R Jr, Meredith JW. Effects of
abdominal decompression on cardiopulmonary function and visceral
perfusion in patients with intra-abdominal hypertension. J Trauma
1998;44(3):440-5
           Early Decompression
Mortality without Laparotomy Averages
>60%




Beck, R., et al., Abdominal compartment syndrome in children.
Pediatr Crit Care Med, 2001. 2(1): p. 51-6.
            Laparotomy
        even without Pressure
           Measurement
Morris JA, Eddy VA, Blinman TA, Rutherford EJ, Sharp
KW. The staged celiotomy for trauma Issues in
unpacking and reconstruction. Ann Surg. 1993; 217:
576-86
Laparotomy Versus Percutaneous
Surgery Vs Percutaneous Puncture in
Patients With Abdominal Compartment
Syndrome During Acute Pancreatitis
(DECOMRESS)
           Management
Closure with moisture barrier
          Management
With Vacuum Assisted Closure
            Management


When to close
            Silo lessons

Incremental
When stable
Liberal use of Mesh
Questions

				
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Description: Lee Abdominal Hypertension and Abdominal abdominal distention