• Abdominal compartment syndrome
    Link:www.wsacs.org
    • Normal IAP is zero or sub-atmospheric, but can be 5-7mmHg in critically ill patients
    • It causes an artificially high PAOP and CVP
    • Fluid requirements of patients with an open abdomen can be up to 10L per day
    • Aim to maintain an abdominal perfusion pressure of >60mmHg
    • Severity of Intra-abdominal hypertension
      • Measure IAP if 2 or more risk factors are present
      • Grade I
        • 12-15mmHg
          • Maintain normovolaemia
      • Grade II
        • 16-20mmHg
          • Hypervolaemic resuscitation
      • Grade III
        • 21-25mmHg
          • Decompression
      • Grade IV
        • > 25mmHg
          • Decompression
    • Systemic effects
      • Cardiovascular
        • Reduced c.o.
          Reduced venous return
          Increased SVR
      • Pulmonary
        • Reduced PaO₂:FiO₂ ratio
          Hypercarbia
          Increased inspiratory pressure
      • Renal
        • Reduced GFR
          Oliguria
      • Neuro
        • Increased ICP
      • GI
        • Gut mucosal ischaemia
    • Measurement of IAH
      • Direct
        • Needle with transducer directly into peritoneum
        • High risk of iatrogenic injury
      • Indirect
        • Intravesical
          • Foley catheter connected to 3-way tap and pressure transducer
          • Positioned supine, zeroed at MAL
          • 25ml of saline infiltrated into the bladder and wait 60s
          • Measure at end expiration
        • Intragastric
        • Intra-uterine
        • Rectal
    • Management
      • Lower IAP
        • Pass ngt
        • Flatus tubes
        • Positioning
        • Sedation and paralysis
      • Organ support
        • Careful fluid management
        • CVC readings may be falsely elevated
        • Lung protective strategy
        • Renal support
        • Aim to maintain enteral feed
      • Surgical
        • Abdominal decompression syndrome
          • Sudden drop in SVR
            • Use fluid preload
          • Fall in intra thoracic pressure
            • Beware administrating high Vt post decompression
          • Washout of toxic products
            • Can cause asystolic arrest, some give a reperfusion cocktail of 2L of 0.45% saline with 50g mannitol and 50 milliequivalents of bicarbonate.
      • Consider closure of the abdomen after about 4-5 days
    • Predisposing factors
      • Increased peritoneal fluid
        • Traumatic haemorrhage
          Ruptured AAA
          Ascites
          Pancreatitis
      • Visceral oedema
        • Blunt trauma
          Pancreatitis
          Post-haemorrhagic
          Sepsis
      • Pneumoperitoneum
        • Laparoscopy
          Visceral rupture
      • Bowel gas
        • Gastric dilatation
          Bowel obstruction
          Ileus
      • Solid objects
        • Neoplasms
          Surgical packs
      • Abdominal wall factors
        • Loss of domain post hernia repair
          Pelvic #
          retroperitoneal haemorrhage
          Burn eschars
          Morbid obesity
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/early/2012/03/08/bjaceaccp.mks006.full.pdf