Overview of Abdominal Compartment Syndromes PowerPoint Presentation

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QUICK ASSESSMENT OF INTRA-ABDOMINAL PRESSURE FOR BETTER DECISION MAKING IN CASES OF ACUTE ABDOMEN IN RURAL SETUP Dr Sankalp Dwivedi Professor surgical discipline and Dean Academic Affairs MMIMSR, Maharishi Markandeshwar University Mullana, Ambala, India

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INTRODUCTION Intra-abdominal hypertension (IAH) is the steady-state pressure concealed within the abdominal cavity Early recognition of IAH is of extreme importance to prevent devastating complications

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In cases of critically ill adults, the IAP is around 5-7mmHg In IAH cases, the IAP becomes greater than 12 mm Hg In cases of Abdominal compartment syndrome (ACS) the IAP is usually ≥20 mm Hg With dysfunction of at least one thoraco-abdominal organ

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GRADING World Society of Abdominal Compartment Syndrome (WSACS, 2006) classified IAH as Grade IAP (mm of Hg) Grade I 12-15 Grade II 16-20 Grade III 21-25 Grade IV >25 Grades III and IV (IAP >20 mm) classified ACS when associated with new organ dysfunction or failure

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Options available for IAP measurement

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DIRECT MEASUREMENT Intraperitoneal catheter inserted for ascites drainage peritoneal dialysis Intraperitoneal pressure transducer During laparoscopic surgery

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INDIRECT MEASUREMENT Intra-vesical pressure Intra-gastric pressure Inferior vena cava Airway pressure measurements Rectal pressure Intra-uterine pressure

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WHAT WE PREFERRED ??? Intra-vesical pressure (IVP) monitoring through Foley's manometer

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Why IVP??? Validated and widely accepted for clinical use Feasible at ICU and normal ward for quick assessment Compliant Bladder wall functions as passive reservoir and transducer of IAP IVP measurements may not accurately reflect intra-abdominal pressure in neurogenic bladder, abdominal packing or adhesions

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OBJECTIVES OF STUDY To measure intra abdominal pressure via IVP monitoring in acute surgical abdomen for early pick up of IAH/ACS

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METHODOLOGY A Prospective Study planned after ethical clearance 30 patients of acute surgical abdomen who were suspected IAH/ACS selected randomly

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INCLUSION CRITERIA All admitted patients of acute abdomen with suspected IAH/ACS due to Perforation peritonitis Acute intestinal obstruction Acute Pancreatitis Abdominal sepsis/ Septic Shock Blunt trauma abdomen

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EXCLUSION CRITERIA Patients in whom Foley’s Catheter cannot be introduced Diagnosed patients of non surgical Acute abdomen Acute renal failure Chronic renal failure Abdominal packing or adhesions

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KEY PARAMETERS Intra-Vesical Pressure (IVP) Abdominal perfusion pressure (APP) CT Scan criteria

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IVP Foley Manometer method The measuring tube inserted between the catheter and the collecting bag The tube elevated with the base at the symphysis pubis Maximum bladder instillation- 20-25 mL of sterile saline The IAP/IVP Expressed in millimeters of mercury (mm Hg) Measured at end-expiration in the complete supine position After ensuring that abdominal muscle contractions are absent And that the transducer zeroed at the level of the mid-axillary line

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APP APP = MAP – IAP More accurate predictor of visceral perfusion A potential endpoint for resuscitation

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CT SCAN CRITERIA Elevated Diaphragm Compression IVC and Renal Vein Hemo-peritoneum/ Ascites Small-Bowel Dilatation Round Belly Sign1 Bilateral Inguinal Herniation Shock Bowel 2 Gastric Distention Mosaic liver perfusion with trauma

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OBSERVATION

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AGE AND SEX

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CAUSE & RISK FACTORS

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PRESENTATION- ACUTE PAIN

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OTHER SYMPTOMS

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VITAL STATUS

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STATUS OF ABDOMEN

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BLOOD ANALYSIS Early renal compromise

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IAP ( mm/Hg)

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IAP ACCORDING TO WSACS

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PATTERN OF IAP (mm/Hg)

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MAP ( mm/Hg)

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APP ( mm/Hg)

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PATTERN Of APP (mm/Hg)

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USG ABDOMEN

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CT SCAN FINDINGS IN IAH / ACS

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ASSOCIATED ORGAN DYSFUCTIONS

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MEDICAL THERAPY

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SURGICAL SUPPORT

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OUTCOME

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COMPLICATIONS

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CONCLUSION Raised IAP is a hidden threat to acute surgical abdomen Majority of IAH/ACS cases are abdominal sepsis due to gut perforation or obstruction Measurement of IAP may be the quick help in such chases to pick up IAH/ACS and treat them appropriately

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REFERENCES Manu Malbrain; Abdominal compartment syndrome; F1000 Medicine Reports 2009, 1:86 Dariusz Onichimowski1,2, Iwona Podlińska1, Sebastian Sobiech1, Robert Ropiak3 Measurement of intra-abdominal pressure in clinical practice; Anaesthesiology Intensive Therapy, 2010,XLII,2; 96-101 D. Turnbull1*, S. Webber2, C. H. Hamnegard3 and G. H. Mills2 Intra-abdominal pressure measurement: validation of intragastric pressure as a measure of intra-abdominal pressure British Journal of Anaesthesia 98 (5): 628–34 (2007) Jens Otto*1, Daniel Kaemmer1, Marcel Binnebösel1, Marc Jansen1, Rolf Dembinski2, Volker Schumpelick1 and Alexander Schachtrupp1; Direct intra-abdominal pressure monitoring via piezoresistive pressure measurement: a technical note; BMC Surgery 2009, 9:5 Malbrain ML, Deeren DH. Effect of bladder volume on measured intravesical pressure: a prospective cohort study. Crit Care 2006; 10(4): 98. Zhao-Xi Sun, Hai-Rong Huang, Hong Zhou; Indwelling catheter and conservative measures in the treatment of abdominal compartment syndrome in fulminant acute pancreatitis; World J Gastroenterol 2006 August 21; 12(31) Jens Otto, Daniel Kaemmer, Marcel Binnebösel, Marc Jansen, Rolf Dembinski, Volker Schumpelick and Alexander Schachtrupp Direct intra-abdominal pressure monitoring via piezoresistive pressure measurement: a technical note; BMC Surgery 2009, 9:5 Jian-cang Hong-chen Kong-han Qiu-ping Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians J Zhejiang Univ-Sci B (Biomed & Biotechnol) 2011 12(2):156-162 Mentula P, Hienonen P, Kemppainen E, Lippaniemi A. Surgical Decompression for Abdominal Compartment Syndrome in severe acute pancreatitis. Arch Surg 2010;145(8):764-769. Lee RK. Intraabdominal hypertension and abdominal compartment syndrome: a comprehensive review. Crit Care Nurse 2012;32(1):19-32. Kim IB, Prowle J, Baldwin I, Bellomo R. Incidence, risk factors and outcome associations of intra-abdominal hypertension in critically ill patients. Anaesth Int Care 2012;40:79-89. Zhou JC, Zhau HC, Pan KH, Zu QP. Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians. J Zhejiang Univ 2011;12(2):156-162. Hill L, Hill B, Miller M, Michell WL. The effect of intra-abdominal hypertension on gastrointestinal function. South Afr J Crit Care 2011; 27(1):12-19.

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Additional therapy Additional therapy Brachytherapy or Photodynamic therapy Described for malignant pleural mesothelioma Could be applied for SFTP Reports of this are rare and Effectiveness is uncertain. THANK YOU