Search our site 
 
Advanced Search
 
Home | News | Exam dates | Contact us | About us | Testimonials |
 
 

map
You are in Home >> Intensive Care >> Gastroenterology >> Gastro - articles and literature

Abdominal Compartment Syndrome and the role of laparostomy

Created: 22/5/2007

 

Abdominal Compartment Syndrome and the role of laparostomy in the ICU

Dr John Griffiths DICM MRCP FRCA MA
CriticalCareUK Editor

Focus on Abdominal compartment syndrome

The term abdominal compartment syndrome (ACS) was first introduced by Kron et al in 1984 after studying patients with ruptured abdominal aortic aneurysms. ACS is diagnosed when there is high intra abdominal pressure (IAP) associated with multiple organ dysfunction syndrome that is improved by decompression of the abdomen. Increasing IAP causes hypoperfusion and ischaemia of intra-abdominal organs. This has been hypothesised to cause release of cytokines, formation of oxygen free radicals and decreased production of cellular ATP, leading to dysfunction of the renal, cardiovascular, respiratory, splanchnic and neurological organ systems. ACS is associated with high mortality if left untreated.

Focus on Intra-Abdominal Pressure

Normal IAP is between zero and subatmospheric. IAP in critically ill patients has been measured at about 16 mmHg. Numerous studies have tried to evaluate the level at which IAP becomes critical. In animal studies it has been shown that IAP of about 20 mmHg decreases glomerular filtration rate (GFR) and renal plasma flow to about 25% of normal with resulting oliguria. At an IAP of 40 mmHg, GFR dropped to 7% with ensuing anuria. In healthy human volunteers an IAP of 20 mmHg resulted in a drop in GFR and renal blood flow. Acute renal failure appears to be related both to the level of raised IAP and its duration. Oliguria related to a raised IAP can be reversed when the pressure is relieved. No study has defined the level of IAP (critical pressure and duration), when acute renal failure (ARF) becomes inevitable. In critically ill ICU patients ARF is associated with mortality above 60%. Sugrue et al analysed a series of 88 patients admitted to ICU following laparotomy, and found the odds ratio for ARF and death in patients with IAP above 20 mmHg was 12.4 and 11.2 respectively.

A critical pressure of 25 cm H20 for IAP has been suggested. Burch and Meldrum devised a grading system for IAP with recommended management steps (Table 1). IAP graded as Class 3 (bladder pressure 26—35 mmHg) and Class 4 (bladder pressure >35 mmHg) was associated with the worst outcome and recommendations were for decompression in these groups. However, there is a group of critically ill patients where abdominal girth is expanding with no equivalent rise in IAP. Given this scenario, repeated measures of IAP need to be taken and the trend measured. If there is an upward trend in pressure with a concomitant deterioration in the clinical state, in terms of decreased cardiac output, pulmonary atelectasis and oliguria, then perhaps an argument for decompression can be made.


Table 1.
Recommended management with different grades of intra-abdominal pressure

Grade

Bladder pressure (mmHg)

Clinical Signs

Recommended management steps

1

10-15

None

Maintain normovolaemia

2

16—25

Oliguria

Volume infusion

3

26—35

Anuria

Decreased cardiac output

Elevated peak airway pressure

Decompression

4

>35

Anuria

Decreased cardiac output

Elevated peak airway pressure

Decompression and reexploration



There are a number of different causes for ACS and commonly include peritonitis, massive fluid resuscitation, coagulopathy, abdominal aortic aneurysm, postoperative laparotomy and pancreatitis (Table 2). Mortality rates can be as high as 61%. Ertel et al looked at over 300 trauma patients after ‘damage-control’ surgery. Seventeen patients (5.5%) developed ACS: 12 (70.6%) due to on-going bleeding, and 5 (29.4%) due to visceral oedema. These patients were managed with decompressive laparotomy that resulted in physiological improvements. However, the decision to proceed to decompression of ACS needs to be taken carefully as this intervention can be associated with major complications such as cardiac arrest, bleeding and death. With the rise in IAP, there is a resultant rise in vasoactive metabolites. Release of this pressure can result in reperfusion injury and also loss of the tamponade effect.

Table 2. Common causes of abdominal compartment syndrome

Abdominal packing

Intra-abdominal bleeding secondary to surgery or trauma

Bowel swelling secondary to infarction or oedema

Massive fluid resuscitation

 

Focus on Laparostomy

Laparostomy is the process by which the abdomen is left open. The concept of leaving abdominal wounds open is not new but the term ‘laparostomy’ was first used in the 1970’s. There have been many series reviewing laparostomies and their outcome. Mortality ranges from 7% to 60%. Clinical outcome is dependent on many factors. Bailey et al analysed sepsis scores in their patients who required laparostomy for postoperative colorectal patients with peritonitis. Mortality was 28.6%. They concluded that laparostomy was an effective method of managing patients with severe intra-abdominal sepsis. Is there an argument for performing laparostomies in all patients presenting with post-operative or complicated abdominal sepsis? There is certainly a strong case for this. However randomised, control trials are obviously difficult to organise in clarifying this dilemma. The creation of laparostomy has obvious impact on hospital resources secondary to prolonged intensive therapy. Most patients having laparostomy are initially managed on the ICU. Kriwanek et al evaluated hospital costs and long-term outcome of 147 patients undergoing laparostomy for abdominal infection or pancreatic necrosis. The effective cost of treatment per surviving patient was £97,000 in the pancreatic necrosis group and £129,000 in the intra-abdominal sepsis group. However, they also looked at quality of life and found that nearly three quarters of the patients described their quality of life as good in terms of functional and employment status after recovery.

The management of the open abdomen on ICU requires a multi-disciplinary approach involving intensive care doctors and nurses as well their surgical colleagues. Experience varies greatly between units. Problems specific to the open abdomen include significant fluid losses that can be difficult to measure accurately. After trauma or severe sepsis, the abdominal cavity needs to be regularly inspected to ensure there is no further contamination. This can be done on the ICU and avoids the risk of moving the patient to the operating theatre. Patients with open abdomens can be weaned in the same way as those with closed abdomens. There is certainly no reason to keep patients sedated for prolonged periods. In some centres, laparostomy can be managed on a general surgical ward. Another important aspect is the psychological response of the patient. In all but a few cases, the patient is not warned about the formation of the open abdomen as it is often performed as a life saving procedure.

Table 3. Indications for laparostomy

Intra-abdominal sepsis

Visceral oedema

Abdominal compartment syndrome

Abdominal packing

Abdominal wall defects


There have been several techniques for abdominal closure in laparostomy. Table 4 lists some of the techniques currently used. Closure can broadly be divided into either definitive or temporary. In some cases, it has to be accepted that the abdomen cannot be closed at the early stage and a temporising measure is required before definitive closure. The different methods outlined use materials such as the ‘Bogota’ bag or meshes with or without vacuum application. The abdomen can be assessed every few days in order to assess whether fascial closure is possible.

Table 4. Management of the open abdomen.


Definitive

Early primary closure

Usually within ten days before granulation formation makes any such procedure more difficult

Late primary closure

The abdomen is left up to a period of six months to allow a neoperitoneum to form


Temporary

Open saline bags (‘Bogota Bag’)

Prosthetic mesh (vicryl, polyprolene)

Vacuum Pack

Modified Vacuum Pack
Vacuum Assisted Closure therapy



Key Learning points

  • Emergency decompressive laparostomy may have a role in the treatment of severe abdominal compartment syndrome
  • Emergency decompressive laparostomy should be considered early in the management of a catastrophic abdomen
  • Laparostomy is becoming an increasingly common intervention on a modern day ICU, but exactly when to perform it and what affect it has on patient outcome remain uncertain
  • Patients that survive an emergency laparostomy have considerable mortality and morbidity associated with an open abdomen initially on the ICU and then on the general ward

 

Key references

Sugrue M.
Abdominal compartment syndrome.
Curr Opin Crit Care. 2005 11(4):333-8.

Hunter JD, Damani Z.
Intra-abdominal hypertension and the abdominal compartment syndrome.
Anaesthesia. 2004 59(9):899-907.

McNelis J, Marini CP, et al.
Predictive factors associated with the development of abdominal compartment syndrome in the surgical intensive care unit.
Arch Surg 2002; 137(2): 133-6.

Bailey CMH, Thompson-Fawcett MW, Kettlewell MGW et al.
Laparostomy for severe intra-abdominal infection complicating colorectal disease.
Dis Colon Rectum 2000; 43, (1): 25-30.

Ivatury RR, Sugerman HJ.
Abdominal compartment syndrome: a century later, isn’t it time to pay attention?
Crit Care Med 2000 28:2137-8.

Ertel W,
Oberholzer A, Platz A, Stocker R, Trentz C.
Incidence and clinical pattern of the abdominal compartment syndrome after “damage-control” laparotomy in 311 patients with severe abdominal and/or pelvic trauma.
Crit Care Med 2000 28(6): 1747- 53.

Kriwanek S, Armbruster C, Dittrich K et al.
Long-term outcome after open treatment of severe intra abdominal infection and pancreatic necrosis.
Arch Surg 1998; 133: 140-4.

Meldrum DR,
Moore FA, Moore EE, et al.
Prospective characterization and selective management of abdominal compartment syndrome.
Am J Surg 1997 174: 667-73.

Burch JM, Moore EE, Moore FA, et al.
The abdominal compartment syndrome.
Surg Gun North Am 1996; 76: 833-42.


ArticleDate:20070522
SiteSection: Article
 
   
    
                                            
  Posting rules

     To view or add comments you must be a registered user and login  




Login Status  

You are not currently logged in.
UK/Ireland Registration
Overseas Registration

  Forgot your password?








 
All rights reserved © 2016. Designed by AnaesthesiaUK.

{Site map} {Site disclaimer} {Privacy Policy} {Terms and conditions}

 Like us on Facebook 

vp