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Abdominal Compartment Syndrome & Renal Failure. Peggy Beeley, MD October 12 th , 2011. Case. 49 yo female admitted with cirrhosis and worsening ascites, Cr 2.8 on admission Had diagnostic paracentesis on admission negative for infection

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abdominal compartment syndrome renal failure

Abdominal Compartment Syndrome & Renal Failure

Peggy Beeley, MD

October 12th, 2011

slide2
Case

49 yo female admitted with cirrhosis and worsening ascites, Cr 2.8 on admission

Had diagnostic paracentesis on admission negative for infection

Nephrology consulted. Urine sediment c/w ATN with prerenal component suspected

Large volume paracentesis of 3.5 L, next diagnostic tap 4 days later was bloody

Cr began to climb, bladder pressure was 32-34 mmHg

Large volume paracentesis removed 5 L of bloody fluid, bladder pressure 24 mmHg

Cr continued to climb, comfort care measures instituted

Patient died

objectives
Objectives

Understand pathophysiology of increased intraabdominal pressure (IAP) and organ failure

Learn current methods used in determining IAP

Learn limitations of such measurements

Evaluate literature for use in cirrhotic patients with ascites

acs importance in hospitalist medicine
ACS: Importance in Hospitalist Medicine
  • Occurs in
    • Patients with rapid volume resuscitation (especially in early goal directed therapy for sepsis)
    • Acute formation of ascites
    • In visceral edema
  • May see this more commonly as we see more acutely ill patients
  • High mortality rate associated with ACS
  • Early recognition leads to improved outcomes
history of abdominal compartment syndrome acs
History of Abdominal Compartment Syndrome (ACS)

Wendt in 1876 the association of intra-abdominal hypertension (IAH) and renal dysfunction

Recognized as a complication in trauma surgery in 1970s

Most early descriptions in trauma literature

Now recognized as occurring in critically ill patients and in medical conditions

Not universally appreciated across different specialties

Not much in nephrology literature by my search

abdominal compartment syndrome acs
Abdominal Compartment Syndrome (ACS)

Rotondo, et al 1983 recognized that IAH as cause of multi-organ failure

↓preload, ↑afterload and extrinsic compression leads to decreased oxygen delivery in abdominal organs

Resultant pressure-volume dysregulation syndrome is known as ACS

world society of the acs
World Society of the ACS

The mission of the WSACS is to promote research, foster education, and improve the survival of patients with intra-abdominal hypertension (IAH) and/or abdominal compartment syndrome (ACS) All who have an interest in the diagnosis, management, and/or treatment of IAH / ACS are invited to join the Society.

definitions
Definitions
  • Normal intraabdominal pressure (IAP) is <5-7 mmHg
  • Upper limit of normal IAP is 12 mmHg
  • > 12 mmHg is Intraabdominal Hypertension (IAH), must be sustained to meet criteria
    • Grade I is 12-15 mm Hg
    • Grade II is 16-20 mm Hg
    • Grade III 21-24 mm Hg
    • Grade IV > 25 mm Hg
  • ACS : sustained IAP >20 mmHg that is associated with new organ dysfunction
  • Morbidly obese and pregnant women may have pressure as high as 10-15 mmHg without adverse sequela
primary vs secondary acs
Primary vs. Secondary ACS
  • Primary ACS injury or dz within abd or pelvis
    • Surgical interventions often needed
  • Secondary ACS
    • Often from conditions outside the abd or pelvis., e.g. burns, sepsis
  • Recurrent ACS
    • Condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS
mechanism of organ injury in acs
Mechanism of Organ injury in ACS

Ischemia, either venous or arterial

Release of vasodilatory substances

As ischemia progresses capillary integrity fails and leads to extravasation of fluid, lytes, proteins

Increased distance between tissue and capillaries

Viscous cycle compromises organ viability

renal injury due to acs
Renal Injury due to ACS

First oliguria

Then rise in serum creatinine

Rise of < 0.3 mg in creatinine = AKI

Rise of more that 0.3 mg = ARF

As oliguria worsens no amount of fluid resuscitation will help

ATN occurs upon reperfusion, usually by abdominal decompression

cirrhosis and ascites in acs
Cirrhosis and Ascites in ACS

Mentioned in several articles as potential cause of ACS

Removal of ascites in IAPs > 18.4 mmHg does improve renal function

Intravasc volume may improve renal function in chronic ascites where ACS it does not

Most cirrhotics tolerate > 15 liters of ascites w/o renal failure or organ ischemia

Abdominal wall compliance remains if fluid accumulation is slow

renal failure in cirrhotics with ascites
Renal Failure in Cirrhotics with Ascites

IAH/ACP

Hepato-renal

Oliguria

Often looks like ATN

Acute ischemia to kidney

Vasodilators: Lactate and adenosine

Elevated ADH, usually increased more than twice baseline

Oliguria

Bland urine sediment

Slowly progressive ischemia

Vasodilator: Nitric Oxide, ?prostaglandins

Salt conserving state, elevated ADH

incidence of iah and acs in critically ill
Incidence of IAH and ACS in Critically ill
  • Multicenter prospective study of 265 patients admitted to ICU
    • 32% IAH
    • 4% ACS
    • 53% normal IAP
  • IAH was strongly associated with multi-organ dysfunction and nearly all had ARF
  • Another prospective study of 706 pts at U of Miami showed an incidence of 2% IAH and 1% ACS in trauma population

Malbrain et al, Crit Care Med 2005 ; 33

Hong et al Br J Surg 2002: 89

associated signs and organ failure in acs
Associated signs and organ failure in ACS
  • Hypovolemic shock
    • ↓ SBP,↓ pulse pressure, lactic acidosis, tachy
    • Increased core to peripheral temp grad, weak pulses, abnormal mentation
  • Acute kidney injury/acute renal failure
  • Acute respiratory failure
    • Hypoxia & hypercarbia
    • Increased peak airway pressures
    • ↓tidal volume
  • Acute hepatic failure
    • ↑LFTs, coagulopathy
estimating measuring iap
Estimating & Measuring IAP

Bladder pressure

NGT pressure

Condom Cath measurement

Gastric tonometry

Direct measurements by laparoscopy

Direct measurement in femoral vein or inferior vena cava

validity of bladder pressure as an estimation of iap
Validity of Bladder Pressure as an estimation of IAP
  • 37 patients undergoing laparoscopy
  • Measured direct IAP with laparoscopic insufflation
  • Simultaneously measured bladder pressure
    • At O ml bladder volume
    • 50 ml, 100 ml, 150 ml, & 200 ml
  • 1110 data points of bladder pressure at various IAPs were collected
  • Findings showed high correlation of bladder pressure to IAP (R2 = 0.68)
  • Least bias with the 50 ml instillation

Fusco et al, J of Trauma,: 2001: 50

measuring bladder pressure
Measuring Bladder Pressure

Cheatham et al J Am Coll Surg 1998

other causes of elevated iap estimates in bladder pressure
Other Causes of Elevated IAP Estimates in Bladder Pressure
  • Central Obesity
  • Pregnancy
  • Not reliable in the following
    • Low intrinsic bladder compliance
    • bladder trauma
    • Pelvic hemorrhage
    • Overestimated in these conditions
therapeutic interventions
Therapeutic Interventions
  • Laparotomy with temporary closure to enlarge peritoneal space
  • Non-surgical
    • Catheter drainage
    • Therapeutic paracentesis
    • Dialysis
    • Neuromuscular blockage
    • Prokinetic agents if intestinal distension is present.
    • Control underlying etiology (hemorrhage, ascites)
  • No prospective RCT have been done to compare efficacy of Non-surgical decompression vs. surgical
nonoperative management of iah acs
Nonoperative Management of IAH & ACS

Evacuate intraluminal contents

Evacuate intraabdominal space-occupying lesions

Improve abdominal wall compliance

Optimize fluid administration

Optimize systemic and regional tissue perfusion

Cheatham, World J Surg 2009 33

slide23
Case

49 yo female admitted with cirrhosis and worsening ascites, Cr 2.8 on admission

Although patient did have a slowly worsening ascites, she develop hemorrhage after paracentesis

High risk patient

Acute on chronic elevation in IAP could have led to ACP

Therapeutic tap seemed reasonable, did we not take off enough?

May have been Hepatorenal but bladder pressure of 32 made ACP a compelling diagnosis

recommendations
Recommendations

Consider ACS in your differential diagnosis, especially after rapid fluid resuscitation

Acute ACS is generally a surgical disease with abdominal decompression

If recommended by consultant, ask to review rational

Remember to do albumin replacement in large volume paracentesis

Group did not come to clear consensus about how to use bladder pressures in cirrhotic patients with ascites.