Abdominal compartment syndrome
•Abdominal compartment syndrome
Abdominal compartment syndrome (ACS) is defined by the presence of organ dysfunction as a result of increased abdominal pressure or intraabdominal hypertension. The increased abdominal pressure reduces blood flow to internal organs, which can lead to multiple system failure and death if not promptly recognized and treated.
•Causes :
Ascites
Reduction of large long-standing hernia
Hemoperitoneum
Direct closure of large, long-standing abdominal wall defect
Abdominal packs
Peritonitis
Retroperitoneal edema (pancreatitis)
Large pelvic, retroperitoneal hematoma
Large pelvic, retroperitoneal hematoma
Intestinal obstruction
Ileus
Gastric distention (esophageal ventilation)
Abdominal aortic aneurysm
Severe constipation
Large abdominal tumor
Morbid obesity
Pregnancy
•PHYSICAL FINDINGS & CLINICAL PRESENTATION
• The most striking physical exam finding is often massive abdominal distention.
• Difficulty maintaining respiratory support and decreased urine output are also typical hallmarks.
• Other common findings include those associated with poor perfusion states and hypotension such as skin mottling, cool extremities, and obtundation. Patients will often have abdominal tenderness, signs of volume overload such as edema and elevated jugular venous pressures and may present with acute respiratory decompensation.
•WORKUP
Measurement of intraabdominal pressure is required to make a definitive diagnosis. Bladder pressure is the most common surrogate used to estimate intraabdominal pressures and is measured using a bladder catheter.
The most accurate measurements can be obtained with the patient in supine position at end expiration in the absence of abdominal contractions. The threshold abdominal pressure often set for research purposes to define
ACS is >20 mm Hg, but patients may have ACS with pressures of >10 mm Hg and above. Oliguria tends to develop at a pressure of 15 mm Hg, and anuria occurs around 30 mm Hg.
•Treatment
Supportive care and, when appropriate, surgical abdominal decompression are the mainstays of ACS treatment
Supportive care, often with hemodynamic and ventilatory support, as well as techniques to improve abdominal wall compliance, are the foundations of ACS management.
• Severe burns to the abdomen leading to ACS will require surgical escharotomy to improve abdominal wall compliance.
• Patients with tense ascites leading to ACS will require large volume paracentesis to decrease intraabdominal pressures.
• Patients should be positioned supine if possible as any elevation of the head will increase abdominal pressures.
• Rectal and nasogastric decompression is required if ACS is due to massive bowel distention.
• Proper sedation and pain control can decrease intraabdominal pressures, and some patients may require ventilatory support and chemical paralysis to maximize abdominal wall relaxation.
• Mechanical ventilation is often difficult due to the high pressures that need to be generated to overcome the increased intraabdominal pressures. Often a combination of low tidal volumes, permissive hypercapnia, chemical paralysis, and high PEEP are required to ensure adequate ventilatory support.
ACUTE GENERAL treatment
There are no direct pharmacologic agents that treat ACS other than pressors, sedatives, pain medications, and paralytics required for supportive care as described above. Despite underlying volume overload, diuretics have no role in therapy. Definitive management is surgical decompression.