Outline the causes, consequences and the management of abdominal compartment syndrome.
Massive retroperitoneal hematomas
Major burns following fluid resuscitation
Massive intra-abdominal hemorhage
a) Decrease in Qt because of a decrease in venous return
b) Decreased renal perfusion
c) Impaired thoracic compliance
d) Bowel ischemia
a) Monitoring intra-abdominal pressure
b) Abdominal decompression
c) Adequate decompression of GI tract
d) Avoiding excess fluid resuscitation
A slightly more formal-looking exploration of abdominal compartment syndrome can be found in Question 8 from the first paper of 2013. Brief notes on the pathophysiology of abdominal compartment pressure and its measurement are available, with references for the time-rich exam candidate.
Causes of abdominal compartment syndrome:
Primary ACS: increased compartment pressure due to abdominal pathology
- Massive ascites, eg. portal vein thrombosis
- Retroperitoneal hematoma
- Abdominal trauma with crush injury
Secondary ACS: increased compartment pressure due to fluid resuscitation
- Abdominal infection eg peritonitis
- Major trunk burns with massive fluid resusicitation (thus, restriction of abdominal expansion)
Consequences of abdominal compartment syndrome:
- Hypotension due to decreased preload
- Renal failure due to decreased renal blood flow (venous and arterial)
- Lactic acidosis due to impared hepatic blood flow
- Gastric erosions and ulceration due to impaired gastric blood flow
- Intestinal ischaemia due to impaired intestinal blood flow
- Poor gut transit, ileus, and decreased tolerance of NG feeds
- Decreased FRC and therfore increased atelectasis, worsening gas exchange, decreased compliance of the respiratory system, leading to hypoxia and hypercapnea
- Raised intracranial pressure
Management of abdominal compartment syndrome:
- Avoid overvigorous fluid resusictation
- Patients at risk of ACS should perhaps remain open-abdomen after largescale abdominal surgery
- monitor the compartment pressure
- Staged closure of abdominal defect
- Vasopressors to maintain MAP within a certain range (some aim for an abdominal perfsion pressure of >60mmHg)
- Titrate PEEP to optimise V-Q matching, to maintain normoxia and normocapnea
- If compartment pressure remains elevated, neuromuscular blockade can be considered
- If pressure remains high in spire of NMJ blockade, may consider opening the abdomen (if it is closed)
Cheatham, Michael Lee. "Abdominal compartment syndrome." Current opinion in critical care 15.2 (2009): 154-162.
Maerz, Linda, and Lewis J. Kaplan. "Abdominal compartment syndrome."Critical care medicine 36.4 (2008): S212-S215.
Saggi, Bob H., et al. "Abdominal compartment syndrome." Journal of Trauma-Injury, Infection, and Critical Care 45.3 (1998): 597-609.
Cheatham, Michael L., et al. "Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension." Journal of Trauma-Injury, Infection, and Critical Care 49.4 (2000): 621-627.