Post on 06-Feb-2018
PACT module���Abdominal Problems
Intensive Care Training Program Radboud University Medical Centre Nijmegen
Definition • Normal abdominal pressure 5 - 7 mm Hg
• Intra-abdominal hypertension
• Sustained IA pressure ≥ 12 mm Hg
• Grade 1: 12-15, Grade 2: 16-20, Grade 3: 21-25, Grade 4: > 25
• Abdominal compartment syndrome
• IA pressure > 20 mm Hg associated with new organ failure
Definition • Primary: associated with disease/injury in
the abdominopelvic region and frequently requires surgery/radiological intervention
• Secondary: without disease in abdomino- pelvic region
• Recurrent: redevelops after previous medical or surgical therapy for primary or secondary ACS
Point prevalence
IAH = 58.8% ACS = 8.2% N = 97
Maximal IAP (mm Hg) Organ failure
Abdominal compliance
Pressure
Volume
Normal
Abdominal wall compliance decrease
due to hematoma muscle activity, edema
“Supranormal” fluid resuscitation and IAH
DO2 > 600
(N = 85) DO
2 > 500
(N = 71)
Intra-abdominal hypertension 42 20
Abdominal compartment syndrome 16 8
Multiple organ failure 22 9
Death 27 11
Abdominal compartment syndrome without IA injury
• Excessive fluid resuscitation
• PEEP
Kf increase intestines
Starling’s law of ultrafiltration: FM = K[Pc + πi) - (Pi + πc)]
where FM = fluid movement, K = filtration coefficient of the capillary wall, Pc = hydrostatic pressure in the capillary, Pi =
hydrostatic pressure in the interstitial fluid, πc = oncotic pressure in the plasma (capillary), and πi = oncotic pressure
in the interstitial fluid.
Physical examination and IAH
Sensitivity 56%
Specificity 87%
PPV 35%
NPV 94%
Accuracy 84%
IAP > 15 mm Hg
Measurement
• Transvesical - end expiration - supine
• Continuous - zero at midaxillary line
• Installation volume 25 ml
• Not with intrapelvic mass
• Measure abdominal perfusion pressure (MAP - IAP) which should be > 60 mm Hg
Abdominal compartment syndrome
mm
Hg
and
cm H
2O
350 200 400 Tidal volume
Decompression
Abdominal compartment syndrome
mm
Hg
Decompression
7.2 3.8 8.4 Cardiac output Lactate 2.1 12 4.6
Diuresis 220 20 200
Abdominal compartment syndrome (IAP 30 mmHG)
Abdominal compartment syndrome
CO
(m
l/min
/kg)
R = 0.86
Abdominal compartment syndrome
Ischemia Reperfusion
Decompressie
Second hit
Volume therapy and threatening ACS
ACS Non-ACS
Packed cells 11 ± 2 2 ± 0.2
Cristalloids (l) 13 ± 2 4.2 ± 0.3
PCWP (mm Hg) 20 ± 1.5 15 ± 0.5
Cardiac Index (l/min/m2) 3.2 ± 0.2 4.2 ± 0.1
PgCO2 (mm Hg) 70 ± 7 48 ± 1
Intra-abdominal hypertension and ICP
mm
Hg
Decompression
Intra-abdominal hypertension and neurotrauma
** ** ** **
mm
Hg
Treatment
• Non-surgical
‣ Evacuate intraluminal contents
‣ Evacuate extraluminal contents
‣ Sedation and neuromuscular blockers
‣ Correction of positive fluid balance
Treatment
1. Improvement of abdominal wall compliance: Sedation, Neuromuscular blockade
2. Evacuation of intra-luminal contents: Gastric tube and suctioning Gastroprokinetics (erythromycin, metoclopramide) Rectal tube and enemas
Colonoprokinetics (neostigmine, prostygmine) Endoscopic decompression of large bowel
3. Evacuation of peri-intestinal and abdominal fluids: Ascites evacuation Percutaneous drainage of collections
5. Correction of capillary leak and positive fluid balance: Albumin in combination with diuretics Dialysis or ultrafiltration ���You must first obtain source control then you can try to get rid of the excess fluids by albumin (see SAFE study results, reference below, showing a more positive fluid balance in the saline group and showing a trend towards better outcomes in septic patients 30% vs 35%, p=0.09)
5. Specific therapeutic interventions: Continuous negative abdominal pressure (CNAP)
Negative external abdominal pressure (NEXAP) Targeted abdominal perfusion pressure (APP)
Open abdomen
• Extensive fluid loss
• Infection
• Enterocutaneous fistulae
• Ventral hernia
• Cosmetic dysfunction
Open abdomen
• With pressure > 20 and progressive organ failure despite conservative measures
• Temporary abdominal closure
‣ Bogota bag
‣ Zipper-Wittman patch
‣ Vacuum-assisted closure
Therapy
• Based on IAP + clinical signs
• No rigid scheme
Grade Pressure (mm Hg) Therapy
Grade 1 10 - 15 Normovolemia
Grade 2 16 - 25 Hypervolemia
Grade 3 26 - 35 Decompression
Grade 4 > 35 Decompression + exploration