Abdominal compartment syndrome

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Abdominal compartment syndrome
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Abdominal compartment syndrome (ACS) occurs when the abdomen becomes subject to increased pressure reaching past the point of intra-abdominal hypertension (IAH). ACS is present when intra-abdominal pressure rises and is sustained at > 20 mmHg and there is new organ dysfunction or failure. [1] ACS is classified into three groups: Primary, secondary and recurrent ACS. [2] It is not a disease and as such it occurs in conjunction with many disease processes, either due to the primary illness or in association with treatment interventions. [3] Specific cause of abdominal compartment syndrome is not known, although some causes can be sepsis and severe abdominal trauma. Increasing pressure reduces blood flow to abdominal organs and impairs pulmonary, cardiovascular, renal, and gastro-intestinal (GI) function, causing obstructive shock, multiple organ dysfunction syndrome and death. [4] [5] [6]

Contents

Causes

Pathophysiology

Abdominal compartment syndrome occurs when tissue fluid within the peritoneal and retroperitoneal space (either edema, retroperitoneal blood or free fluid in the abdomen) accumulates in such large volumes that the abdominal wall compliance threshold is crossed and the abdomen can no longer stretch. Once the abdominal wall can no longer expand, any further fluid leaking into the tissue results in fairly rapid rises in the pressure within the closed space. Initially this increase in pressure does not cause organ failure but does prevent organs from working properly – this is called intra-abdominal hypertension and is defined as a pressure over 12 mmHg in adults. ACS is defined by a sustained IAP(intra-abdominal pressure) above 20 mmHg with new-onset or progressive organ failure. [10] Severe organ dysfunctionent syndrome. These pressure measurements are relative. Small children get into trouble and develop compartment syndromes at much lower pressures while young previously healthy athletic individuals may tolerate an abdominal pressure of 20 mmHg very well. The underlying cause of the disease process is capillary permeability caused by the systemic inflammatory response syndrome (SIRS) that occurs in every critically ill patient. SIRS leads to leakage of fluid out of the capillary beds into the interstitial space in the entire body with a profound amount of this fluid leaking into the gut wall, mesentery and retroperitoneal tissue.

Abdominal compartment syndrome follows a destructive pathway similar to compartment syndrome of the extremities. When increased compression occurs in such a hollow space, organs will begin to collapse under the pressure. As the pressure increases and reaches a point where the abdomen can no longer be distended it starts to affect the cardiovascular and pulmonary systems. When abdominal compartment syndrome reaches this point without surgery and help of a silo the patient will most likely die. There is a high mortality rate associated with abdominal compartment syndrome. [4] [11]

Diagnosis

Abdominal compartment syndrome is defined as an intra-abdominal pressure above 20 mmHg with evidence of organ failure. Abdominal compartment syndrome develops when the intra-abdominal pressure rapidly reaches certain pathological values, within several hours (intra-abdominal hypertension is observed), and lasts for 6 or more hours. The key to recognizing abdominal compartment syndrome is the demonstration of elevated intra-abdominal pressure which is performed most often via the urinary bladder, and it is considered to be the "gold standard". The increased intra-abdominal pressure leads to compression of the renal veins, which, in turn, to an oliguria that is unresponsive to fluid resuscitation. Diagnosis should be based on clinical findings in conjunction with a measurement of a bladder pressure. The trend of the bladder pressure may be more helpful than the absolute number. [12]

Multiorgan failure includes damage to the cardiac, pulmonary, renal, neurological, gastrointestinal, abdominal wall, and ophthalmic systems. The gut is the most sensitive to intra-abdominal hypertension, and it develops evidence of end-organ damage before alterations are observed in other systems. [13] In a recent systematic review, Holodinsky et al. described 25 risk factors associated with IAH (intra-abdominal hypertension) and 16 with ACS (abdominal compartment syndrome). These can be roughly categorized in three categories, which may be more helpful at the bedside to identify patients at risk (Table 1). Especially noteworthy is the potential role of fluid resuscitation in the development of IAH and ACS. Recognizing the pivotal role of fluid resuscitation in the pathogenesis of IAH and ACS supplies the clinician with a target for preventive measures. Large volume resuscitation with crystalloids should be avoided in patients with or at risk of ACS. [14]

Table 1 When to suspect intra-abdominal hypertension and abdominal compartment syndrome
Abdominal catastrophesSevere organ dysfunctionFluid balance
Trauma, peritonitis, acute pancreatitis, ruptured abdominal aortic aneurysm

Often post-surgery

Metabolic respiratory renal hemodynamic>3000–4000 mL in 24 h window

Treatment

Treatment algorithm for IAH/ ACS IAP monitoring algorithm.jpg
Treatment algorithm for IAH/ ACS

Operative decompression

The mortality rate associated with abdominal compartment syndrome is significant, ranging between 60% and 70%. The poor outcome relates not only to abdominal compartment syndrome itself but also to concomitant injury and hemorrhagic shock. [15] The surgical decompression of the abdomen remains the treatment of choice of abdominal compartment syndrome; this usually improves the organ changes and is followed by one of the temporary abdominal closure techniques in order to prevent secondary intra-abdominal hypertension. [13] Surgical decompression can be achieved by opening the abdominal wall and abdominal fascia anterior in order to physically create more space for the abdominal viscera. Once opened, the fascia can be bridged for support and to prevent loss of domain by a variety of medical devices (Bogota bag, artificial bur, and vacuum devices using negative pressure wound therapy [16] ).

Related Research Articles

<span class="mw-page-title-main">Peritoneum</span> Serous membrane that forms lining of abdominal cavity or coelom

The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue. This peritoneal lining of the cavity supports many of the abdominal organs and serves as a conduit for their blood vessels, lymphatic vessels, and nerves.

<span class="mw-page-title-main">Pancreatitis</span> Inflammation of the pancreas

Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancreatitis.

<span class="mw-page-title-main">Peritonitis</span> Medical condition

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Shock (circulatory)</span> Medical condition of insufficient blood flow

Shock is the state of insufficient blood flow to the tissues of the body as a result of problems with the circulatory system. Initial symptoms of shock may include weakness, fast heart rate, fast breathing, sweating, anxiety, and increased thirst. This may be followed by confusion, unconsciousness, or cardiac arrest, as complications worsen.

<span class="mw-page-title-main">Sepsis</span> Life-threatening response to infection

Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs.

<span class="mw-page-title-main">Compartment syndrome</span> Condition in which increased pressure results in insufficient blood supply

Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the leg or arm are most commonly involved.

<span class="mw-page-title-main">Acute respiratory distress syndrome</span> Human disease

Acute respiratory distress syndrome (ARDS) is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. Symptoms include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin coloration (cyanosis). For those who survive, a decreased quality of life is common.

<span class="mw-page-title-main">Internal bleeding</span> Medical condition

Internal bleeding is a loss of blood from a blood vessel that collects inside the body, and is not usually visible from the outside. It can be a serious medical emergency but the extent of severity depends on bleeding rate and location of the bleeding. Severe internal bleeding into the chest, abdomen, pelvis, or thighs can cause hemorrhagic shock or death if proper medical treatment is not received quickly. Internal bleeding is a medical emergency and should be treated immediately by medical professionals.

<span class="mw-page-title-main">Hypovolemic shock</span> Medical condition

Hypovolemic shock is a form of shock caused by severe hypovolemia. It can be caused by severe dehydration or blood loss. Hypovolemic shock is a medical emergency; if left untreated, the insufficient blood flow can cause damage to organs, leading to multiple organ failure.

<span class="mw-page-title-main">Acute pancreatitis</span> Medical condition

Acute pancreatitis (AP) is a sudden inflammation of the pancreas. Causes, in order of frequency, include: a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; heavy alcohol use; systemic disease; trauma; and, in children, mumps. Acute pancreatitis may be a single event; it may be recurrent; or it may progress to chronic pancreatitis and/or pancreatic failure.

Oliguria or hypouresis is the low output of urine specifically more than 80 ml/day but less than 400ml/day. The decreased output of urine may be a sign of dehydration, kidney failure, hypovolemic shock, hyperosmolar hyperglycemic nonketotic syndrome (HHNS), multiple organ dysfunction syndrome, urinary obstruction/urinary retention, diabetic ketoacidosis (DKA), pre-eclampsia, and urinary tract infections, among other conditions.

<span class="mw-page-title-main">Grey Turner's sign</span> Medical condition

Grey Turner's sign refers to bruising of the flanks, the part of the body between the last rib and the top of the hip. The bruising appears as a blue discoloration, and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum, which is a lining of the abdominal cavity. Grey Turner's sign takes 24–48 hours to develop, and can predict a severe attack of acute pancreatitis.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

Retroperitoneal fibrosis or Ormond's disease is a disease featuring the proliferation of fibrous tissue in the retroperitoneum, the compartment of the body containing the kidneys, aorta, renal tract, and various other structures. It may present with lower back pain, kidney failure, hypertension, deep vein thrombosis, and other obstructive symptoms. It is named after John Kelso Ormond, who rediscovered the condition in 1948.

Early goal-directed therapy was introduced by Emanuel P. Rivers in The New England Journal of Medicine in 2001 and is a technique used in critical care medicine involving intensive monitoring and aggressive management of perioperative hemodynamics in patients with a high risk of morbidity and mortality. In cardiac surgery, goal-directed therapy has proved effective when commenced after surgery. The combination of GDT and Point-of-Care Testing has demonstrated a marked decrease in mortality for patients undergoing congenital heart surgery. Furthermore, a reduction in morbidity and mortality has been associated with GDT techniques when used in conjunction with an electronic medical record.

<span class="mw-page-title-main">Retroperitoneal bleeding</span> Medical condition

Retroperitoneal bleeding is an accumulation of blood in the retroperitoneal space. Signs and symptoms may include abdominal or upper leg pain, hematuria, and shock. It can be caused by major trauma or by non-traumatic mechanisms.

The Wittmann Patch is a temporary abdominal fascia prosthesis for the planned open abdomen to ease the management of cases where the abdomen cannot be closed due to abdominal compartment syndrome or because multiple further operations are planned. It consists of a sterile hook and a sterile loop sheet made from propylene and nylon.

Abdominal decompression is an obstetric procedure during which a negative pressure is applied intermittently to a pregnant woman's abdomen.

Damage control surgery is surgical intervention to keep the patient alive rather than correct the anatomy. It addresses the "lethal triad" for critically ill patients with severe hemorrhage affecting homeostasis leading to metabolic acidosis, hypothermia, and increased coagulopathy.

Ken Hillman AO FRCP FRCA FCICM is an Australian doctor and researcher. He is an intensive care specialist with research interests including health system reforms and end of life care. He has been Professor of Intensive Care at the University of New South Wales since 1990.

References

  1. ↑ Cheatham, Michael Lee (April 2009). "Abdominal compartment syndrome". Current Opinion in Critical Care. 15 (2): 154–162. doi:10.1097/MCC.0b013e3283297934. ISSN   1070-5295. PMID   19276799. S2CID   42407737.
  2. ↑ Hunt, Leanne; Frost, Steve A.; Hillman, Ken; Newton, Phillip J.; Davidson, Patricia M. (2014-02-05). "Management of intra-abdominal hypertension and abdominal compartment syndrome: a review". Journal of Trauma Management & Outcomes. 8 (1): 2. doi: 10.1186/1752-2897-8-2 . ISSN   1752-2897. PMC   3925290 . PMID   24499574.
  3. ↑ De Waele, J. J.; De laet, I.; Malbrain, M. L. N. G. (12 October 2015). "Understanding abdominal compartment syndrome". Intensive Care Medicine. 42 (6): 1068–1070. doi:10.1007/s00134-015-4089-2. PMID   26459879. S2CID   9692082.
  4. 1 2 Kirkpatrick, Andrew W.; Roberts, Derek J.; De Waele, Jan; Jaeschke, Roman; Malbrain, Manu L. N. G.; De Keulenaer, Bart; Duchesne, Juan; Bjorck, Martin; Leppaniemi, Ari; Ejike, Janeth C.; Sugrue, Michael; Cheatham, Michael; Ivatury, Rao; Ball, Chad G.; Reintam Blaser, Annika; Regli, Adrian; Balogh, Zsolt J.; d'Amours, Scott; Debergh, Dieter; Kaplan, Mark; Kimball, Edward; Olvera, Claudia; Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome (2013). "Intra-abdominal hypertension and the abdominal compartment syndrome: Updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome". Intensive Care Medicine. 39 (7): 1190–1206. doi:10.1007/s00134-013-2906-z. PMC   3680657 . PMID   23673399.
  5. ↑ Malbrain, Manu L. N. G.; Cheatham, Michael L.; Kirkpatrick, Andrew; Sugrue, Michael; Parr, Michael; De Waele, Jan; Balogh, Zsolt; Leppäniemi, Ari; Olvera, Claudia (2006-11-01). "Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions". Intensive Care Medicine. 32 (11): 1722–1732. doi:10.1007/s00134-006-0349-5. ISSN   0342-4642. PMID   16967294. S2CID   6673937.
  6. ↑ Cheatham, Michael L.; Malbrain, Manu L. N. G.; Kirkpatrick, Andrew; Sugrue, Michael; Parr, Michael; De Waele, Jan; Balogh, Zsolt; Leppäniemi, Ari; Olvera, Claudia (2007-06-01). "Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations". Intensive Care Medicine. 33 (6): 951–962. doi: 10.1007/s00134-007-0592-4 . ISSN   0342-4642. PMID   17377769. S2CID   10770608.
  7. ↑ Garner, Jeff (June 2005). "Blunt and penetrating trauma to the abdomen". Surgery (Oxford). 23 (6): 223–228. doi:10.1383/surg.23.6.223.66552.
  8. ↑ van Brunschot, Sandra; Schut, Anne Julia; Bouwense, Stefan A.; Besselink, Marc G.; Bakker, Olaf J.; van Goor, Harry; Hofker, Sijbrand; Gooszen, Hein G.; Boermeester, Marja A.; van Santvoort, Hjalmar C. (2014). "Abdominal compartment syndrome in acute pancreatitis: a systematic review". Pancreas. 43 (5): 665–674. doi:10.1097/MPA.0000000000000108. ISSN   1536-4828. PMID   24921201. S2CID   24784362.
  9. ↑ Wittmann, Dietmar H; Iskander, Gaby A (2000). "The Compartment Syndrome of the Abdominal Cavity: A State of the Art Review". Journal of Intensive Care Medicine. 15 (4): 201–20. doi:10.1046/j.1525-1489.2000.00201.x.
  10. ↑ Malbrain, Manu L.N.G.; De laet, Inneke E. (March 2009). "Intra-Abdominal Hypertension: Evolving Concepts". Clinics in Chest Medicine. 30 (1): 45–70. doi:10.1016/j.ccm.2008.09.003. PMID   19186280.
  11. ↑ Abdominal Compartment Syndrome at eMedicine
  12. ↑ Feliciano, David V. (2020). Trauma (9th ed.). McGraw Hill, Medical. p. 642. ISBN   978-1260143348.
  13. 1 2 Deenichin, Georgi Petrov (24 December 2007). "Abdominal Compartment Syndrome". Surgery Today. 38 (1): 5–19. doi:10.1007/s00595-007-3573-x. PMID   18085356. S2CID   10613413.
  14. ↑ De Waele, J. J.; De laet, I.; Malbrain, M. L. N. G. (12 October 2015). "Understanding abdominal compartment syndrome". Intensive Care Medicine. 42 (6): 1068–1070. doi:10.1007/s00134-015-4089-2. PMID   26459879. S2CID   9692082.
  15. ↑ Patel, Aashish; Lall, Chandana G.; Jennings, S. Gregory; Sandrasegaran, Kumaresan (November 2007). "Abdominal Compartment Syndrome". American Journal of Roentgenology. 189 (5): 1037–1043. doi:10.2214/AJR.07.2092. PMID   17954637.
  16. ↑ Fitzgerald, James EF; Gupta, Shradha; Masterson, Sarah; Sigurdsson, Helgi H (2013). "Laparostomy management using the ABThera open abdomen negative pressure therapy system in a grade IV open abdomen secondary to acute pancreatitis". International Wound Journal. 10 (2): 138–44. doi:10.1111/j.1742-481X.2012.00953.x. PMC   7950789 . PMID   22487377. S2CID   2459785.
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