Abdominal Compartment Syndrome

1. Abdominal Compartment Syndrome Anna M. Alvarez UCF CNS II 11/10/11

2. Abdominal Compartment Syndrome

3. Abdominal Compartment Syndrome (ACS) Objectives • Define Abdominal Compartment Syndrome • Identify populations at risk • Discuss key physiological changes • Discuss treatment modalities • Identify CNS implications

4. Abdominal CompartmentSyndrome Definition • Sustained intra abdominal pressure (IAP) greater than 20 mm Hg ( with or without abdominal perfusion pressure < 60 mm Hg) • Associated with new organ dysfunction and/or failure. Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934.

5. Abdominal Compartment Syndrome Morbidity & Mortality Rate • Vidal, M.G. et al ( 2008) • Prospective cohort study of IAH/ACS • 64% IAH; 43% mortality rate • 12% ACS, n= 10 • 2 patients with primary ACS survived • Total mortality rate of 20% Vidal, M.G. …..& Estenssoro,E., (2008). Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Critical Care Medicine, 36. Doi: 10.1097/ccm.0b013e31817c7a4d.

6. Etiology • Primary ACS – increased intra abdominal volume • Secondary ACS – decreased abdominal wall compliance • Combination of both decreased wall compliance and increased intra abdominal volume De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

7. Primary ACS • GI tract dilation • Gastroparesis • Ileus • Intra abdominal masses or retroperitoneal masses (tumors) • Obstruction , volvulus • Ascites • Hemiperitoneum De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra- abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

8. http://www.bing.com/images/search?q=open+abdominal+wound+pictures&view=detail&id=114E30671179C1F40F8A9E7DBEE3B1EADDC9http://www.bing.com/images/search?q=open+abdominal+wound+pictures&view=detail&id=114E30671179C1F40F8A9E7DBEE3B1EADDC9 Dilated loops of bowel

9. Secondary ACS • Abdominal surgery with tight suturing • Abdominal wall bleeding, rectus sheath hematomas • Large abdominal hernias De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra- abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

10. Tight Suturing

11. Abdominal Hernia http://www.bing.com/images/search?q=open+abdominal+wound+pictures&view=detail&id=114E30671179C1F40F8A9E7DBEE3B1EADDC9

12. Combined Primary and Secondary ACS • Obesity • Sepsis • Severe pancreatitis • Massive fluid resuscitation • Burns • Intra abdominal infection De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169.

13. Pathophysiology (Cheatham, 2009)

14. Pathophysiology Cardiovascular: • Increased intrathoracic pressure – reduced cardiac output. • Decreased venous return and cardiac pre-load. • Increased femoral vein pressures with increased venous hydrostatic pressure promotes peripheral edema and increase risk of DVT. Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

15. Pathophysiology Pulmonary • Compression of lungs • Alveolar atelectasis • Decreased oxygen transport across the pulmonary capillary membrane • Pulmonary infection Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

16. Pathophysiology Renal • Decreased renal perfusion • Increased renal vein pressure • Increased renal vasculature • Shunting blood from renal cortex and glomeruli. • Compression of the renal vein • Elevated BUN, creatnine, NA, CL, antiduretic and anti aldosterone hormones. Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10.

17. Pathophysiology (Cheatham,2009) Gastrointestinal • Reduction of arterial perfusion to the mesentery • Bowel ischemia • Feeding intolerance • Decreased intramucosal pH • Metabolic acidosis • Visceral edema • Impaired hepatic circulation and reduction of lactic acid clearance

18. Pathophysiology Central Nervous System • Decreased cerebral perfusion • Increased intracranial pressure Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10

19. Clinical Presentation • Pt has had abdominal surgery with a tight closure of the suture line or abdominal injury( ICC, surgical floor) decreasing urinary output, abdominal distention • Pt s/p MVC with pelvic fractures, hemodynamically unstable (ED, ICU) aggressive fluid resuscitation • Pt is septic and with decreasing BP, decreasing urinary output, respiratory distress. (ICC, med-tele unit)

20. Clinical Presentation • Breath sounds diminished • Abdomen distended • Lower extremity edema • Lab work: BUN, creatinine, lactic acid, Na, Cl, elevated.

21. Treatment Algorithms • Sedation and analgesia – reduce muscle tone • Neuromuscular blockade – • Evacuating intralumen contents- N/G, rectal drainage, enemas, medication : neostigmine • Fluid Resuscitation • CRRT • Percutaneous decompression • Surgical decompression- T.A.C. Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934.

22. World Society of the Abdominal Compartment Syndrome Consensus Recommendations • Risk Factors for IAH/ACS – Screening upon ICU and with new or progressive organ failure (Grade 1B) • IAP Measurement- 2 or > risk factors for IAH ; baseline. (Grade 1C) • APP- sustained >60 for pts with IAH/ACS. (Grade 1 C) • Sedation and analgesia- Insufficient data • NMB- Brief trial may be considered (Grade 2C) • Body positioning- May contribute to >IAH in severe IAH/ACS (Grade C) • Gastric/Colonic decompression- insufficient data. • Fluid resuscitation- Carefully monitored (Grade 1B), Hypertonic crystalloid/ colloid –based to decrease progression to ACS (Grade 2C)

23. World Society of the Abdominal Compartment Syndrome Consensus Recommendations cont. • Diuretic/hemofiltration - insufficient data • Percutaneous decompression – Should be considered with presence of abscess, fluid, blood (Grade 2C) • Abdominal decompression – (Grade 1B) • Definitive abdominal closure –( insufficient data) World Society of the Abdominal Compartment Syndrome (WSACS)downloaded from http://www.wsacs.org

24. Review of the Evidence Credibility: • Guidelines developed by members of the WACS; predominantly surgeons • Funded by WACS • Researchers funded of the reviewed studies- unknown

25. Review of the Evidence- cont. • Valid development strategy – none reported • Impartial process of selecting literature- unknown • Outcomes and options: Yes • Recommendations tagged – yes • Recommendations reflecting outcomes: yes • Guidelines subjected to peer review and testing- yes

26. Review of the Evidence - cont. Applicability • International use • Clinically relevant? Yes • Help me care for my patients? Yes. • Recommendations practical/feasible? Yes • Major variation from current practice – No • Measureable outcomes through standard care - Yes Melnyk B.M., & Fineout-Overholt, E . (2nd ED) . (2011). Evidence-based Practice in Nursing and Healthcare: A guide to best practice. Philadelphia, Pa.: Lippincott Williams and Wilkins.

27. Case Study Mr. S. is a 54 y/o Caucasian male admitted through the ED with c.c. of worsening abdominal pain. PMH: + chronic pancreatitis, ETOH abuse, polypharmacy abuse, COPD, asthma, bronchitis, 35 pack year h/o tobacco abuse. Medications: Oxycontin, Nebulizer treatments. VS: BP 130/60, HR 100, R 28, T 97. Surgical History: exploratory laparatomy, bowel resection removed ischemic bowel and re anastomosis.

28. Case study cont: • Elevated temp – no UTI, No line infection, chest xray negative for infection. Abdominal CT shows multiple abscess . • Back to surgery: per the chart, found abscess formation, washout with warm saline. • Temporary closure with the Negative pressure

29. Abthera by KCI

30. Currently Draining abdominal cavity Decreasing abdominal defect by suturing around the fistulae

31. Role of the CNS • 1. Identify the at risk patient • 2. Initiate intravesicular pressure readings to monitor IAP. ?

32. Role of the CNS • Identify patients at risk • Initiate treatment algorithm per unit based hospital policy • Collaborate with multidisciplinary team • Educate and advocate for family • Educate staff • Review current EB guidelines

33. Reference Cheatham , M. L., (2009) . Abdominal compartment syndrome: pathophysiology and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 17:10 doi: 10.1186/1757-7241-17-10 Cheatham, M. L. ( 2009) . Abdominal compartment syndrome . Current Opinion in Critical Care , 15, 154 – 162. DOI: 10.1097/MCC.0b013e3283297934. De Waele, J. J., De Laet, I., Kirkpatrick, A.W., & Hoste, E. ( 2011). Intra-abdominal hypertension and abdominal compartment syndrome. American Journal of Kidney Disease , 57 (1): 159 – 169. Melnyk B.M., & Fineout-Overholt, E . (2nd ED) . (2011). Evidence-based Practice in Nursing and Healthcare: A guide to best practice. Philadelphia, Pa.: Lippincott Williams and Wilkins.

34. Reference cont. Vidal, M.G. …..& Estenssoro, E., (2008). Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Critical Care Medicine, 36. Doi: 10.1097/ccm.0b013e31817c7a4d. World Society of the Abdominal Compartment Syndrome (WSACS)downloaded from http://www.wsacs.org