ABHISHEK CHANDNA

Normal intra-abdominal pressure is 5-7mmHg

in critically ill patients. In healthy patient
individuals, subatmospheric to 5mmHg.
Intra-abdominal hypertension- sustained or
repeated pathologic elevation in intra-
abdominal pressure > or equal to 12 mmHg
Grading of IAH :
I 12-15mmHg
II 16-20mmHg
III 21-25 mmHg
IV >25mmHg
Abdominal Compartment syndrome is defined
as sustained intra-abdominal pressure
>20mmHg (with or without abdominal
perfusion pressure <60mmHg) associated with
new organ dysfunction or failure.

Primary : in the presence of an intra-abdominal
pathology

Secondary : in the absence of an intra-
abdominal pathology, injury or intervention.
It is mostly iatrogenic.

Recurrent : ACS redevelops following previous
surgical or medical treatment of primary or
secondary ACS

Polytrauma patients, especially after damage
control surgery
Ascites
Retroperitoneal haemmorhage
Pancreatitis
Pneumoperitonium
After complex abdominal procedures
Liver transplantation
Reduction of chronic hernias that have lost their
domain
Ruptured abdominal aortic aneurysm

Aggressive fluid resuscitation with
crystalloids(significant increase in risk with
infusions more than 3L)
Thermal injuries (Hobson et al demonstrated abdominal
compartment syndrome within 24 hours in burn patients who had
received an average of 237 mL/kg over a 12-hour period)
Shock trauma victims
Critically ill hypothermic and septic patients
Pts who have sustained cardiac arrest
Peritoneal dialysis
Morbid obesity
Cirrhosis
Meigs syndrome
Intra-abdominal mass

Signs and symptoms can include the following:
Abdominal pain
Increase in abdominal girth
Difficulty breathing
Decreased urine output
Syncope
Melena
Abdominal compartment syndrome may occur in
critically ill patients who may not be able to
communicate or in whom the symptoms of ACS may
be obscured due to other critical injuries.

IAH should be considered and documented in the
following patients
Intubated patients who have high peak and plateau pressures and
are difficult to ventilate
Patients who have GI bleeding or pancreatitis and are not
responding to intravenous (IV) fluids, blood products, and
pressors
Patients who have severe burns or sepsis with decreasing urine
output and are not responding to IV fluids and pressors.


Abdominal compartment syndrome itself can
involve almost any organ system, as described in
the following:
Renal failure
Respiratory distress and failure : increased
airway pressures and decreased tidal volumes
Bowel ischemia
Increased intracranial pressure (ICP)
Failing cardiac output and refractory shock :
falsely elevated CVP and PCWP

Use of the urinary bladder has been the gold
standard and is the indirect method used to
measure IAP.
Using a regular foley catheter, disconnect from
drainage tubing, directly inject 50ml saline, clamp
,insert needle and measure.
A three way foley catheter
A regular foley connected to a three way stopcock and
a transducer

Gastric mucosal pH
Near infrared spectroscopy to measure gastric
and muscle tissue oxygenation
Abdominal perfusion pressure (MAP-IAP)
Renal filtration gradient (MAP-2x IAP)
CT Scan
Round-belly sign: Abdominal distention with an
increased ratio of anteroposterior-to-transverse
abdominal diameter (ratio >0.80)
Collapse of the vena cava
Bowel wall thickening with enhancement


Leaving the peritoneal cavity open in patients for at risk for
IAH and after high risk surgical procedures.

Patients at risk for secondary ACS receiving crystalloids
must be monitored closely,and IAP must be measured in
those given more than 6 litres of fluid in 6 hrs.

APP measurement-helpful indicator of resuscitation end
point

Monitoring of gastric pH can detect secondary ACS after
admission in the ICU

Measures to prevent progression to ACS
Conservative fluid management

Administration of analgesia

Sedatives

Neuromuscular blockers

Patient positioning, don't place anything on the
patients abdomen like excessive blankets


Escharotomy
Renal replacement therapy
Diuretics
Drainage of abdominal fluid (paracentesis)
Found effective in burns patients and pts with chronic
abdominal compartment syndrome resulting from large
volume ascites

Measures to avoid primary closure of wound :
Vacuum pack
Artificial burr (whittmann patch)
Dynamic retention sutures
Plastic silo (Bagota bag)
Mesh nonabsorbable/absorbable(biological)
Skin approximation
Fascial release
Decision not based on IAH alone, but on the
presence of organ dysfunction associated with
IAH.
With grade III IAH,when abdomen is tense and
signs and symptoms of extreme ventilatory
dysfunction and oliguria develop.
Grade IV IAH,with signs of renal and
ventilatory failure,decompression is indicated.

Sudden decrease in IAH, severe hypotension as
a result of sudden decrease in SVR.
Abrupt increase in true tidal volume, leading to
washout of byproducts of anaerobic
metabolism leading to respiratory alkalosis.


Hence, decompression performed after
adequate preload with volume has been
established.