Hypoperfusion, Shock States, and Abdominal Compartment

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Hypoperfusion, Shock States, and Abdominal Compartment Syndrome (ACS) Koen Ameloot ,MD,  Carl Gillebert, MD, Nele Desie, MD, Manu L.N.G. Malbrain, MD, PhD :

Hypoperfusion, Shock States, and Abdominal Compartment Syndrome (ACS) Koen   Ameloot ,MD,   Carl Gillebert , MD,   Nele Desie , MD,   Manu L.N.G.  Malbrain , MD, PhD Surgical Clinics of North America Volume 92, Issue 2  , Pages 207-220, April 2012 1 Surgical Clinics of North America, vol92,issue 2

DEFINITIONS:

DEFINITIONS INTRA ABDOMINAL PRESSURE (IAP) varies from individual to individual and is influenced by body mass index , body position, and the severity of a patient’s critical illness. NORMAL ADULT IAP IS CONSIDERED 5-7 mm Hg. INTRA ABDOMINAL HYPERTENSION(IAH) is defined as sustained increased IAP greater than or equal to 12 mm Hg. 2 Surgical Clinics of North America, vol92,issue 2

Cont…:

Cont… ABDOMINAL COMPARTMENT SYNDROME (ACS) is defined as IAP greater than or equal to 20mm Hg with organ dysfunction or failure. ACS is seen when IAP leading to organ dysfunction hence need urgent abdominal decompression. 3 Surgical Clinics of North America, vol92,issue 2

EPIDEMIOLOGY :

EPIDEMIOLOGY A Multicentric study reported, IAH present in 32% of critically ill medical and surgical ICU patients. ACS present in 4% of patients. The author has concluded that elevated IAP is responsible for developing organ failure hence suggested that IAH may be a key factor in the development of multiple system organ failure , a major cause of ICU mortality. 4 Surgical Clinics of North America, vol92,issue 2

MEASUREMENT OF IAP:

MEASUREMENT OF IAP IAP is difficult to detect by clinical examination alone. Assessment of IAP is done by measuring intravesicular or bladder pressure. Alternately , IAP can be measured continously via a ballon tipped nasogastric tube in stomach. 5 Surgical Clinics of North America, vol92,issue 2

PHYSIOLOGY:

PHYSIOLOGY 6 Surgical Clinics of North America, vol92,issue 2

CHANGES IN CVS:

CHANGES IN CVS Decreased cardiac output Decrease preload Decrease cardiac contractility Increase afterload 7 Surgical Clinics of North America, vol92,issue 2

EFFECTS ON LUNG:

EFFECTS ON LUNG Increased IAP is transmitted to thorax and it leads to increase ITP. Result being hypoxemia and hypercapnia. Other causes of lung oedema in post operative cases are capillary leaks , positive fluid balance. 8 Surgical Clinics of North America, vol92,issue 2

EFFECTS ON END ORGAN PERFUSION:

EFFECTS ON END ORGAN PERFUSION CNS lead to decrease cerebral perfusion pressure. KIDNEY -decreases renal venous and arterial flow , leading to renal dysfunction and failure. GASTROINTESTINAL -all intra abdominal and retroperitoneal organ demonstrate hypoperfusion , Which may lead to multi organ dysfunction and failure if not treated. HEPATIC -No specific effect seen. 9 Surgical Clinics of North America, vol92,issue 2

TREATMENT OF ACS:

TREATMENT OF ACS Patient to be resuscitated to maintain APP ( Abdominal perfusion Pressure ) of 50 mm to 60mm Hg through judicious fluid resuscitation and application of VASOPRESSOR /INOTROPIC AGENTS. If APP cannot be maintained then immediate abdominal decompression should be done. 10 Surgical Clinics of North America, vol92,issue 2

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In surgical patient ,decompression laparotomy or temporary abdominal closure if abdomen has been already opened. This operation dramatically improves cardiac function and other organ perfusion. In medical patient , whose IAP is secondary to accumulation of ascites , paracentesis should be considered. 11 Surgical Clinics of North America, vol92,issue 2

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In medical patient , IAH without ACS , ileus should be corrected , and diuretics or renal replacement therapy in combination with albumin should be used. Patient whose IAH secondary to retroperitoneal hemorrhage or visceral odema or ileus are best achieved by open abdominal decompression. 12 Surgical Clinics of North America, vol92,issue 2

SUMMARY:

SUMMARY Any factor which results in intra abdominal pressure more than 25 mm of Hg will adversely affect all tissue leading to multi organ dysfunction /failure. Hence be on watch to control it by various means as described above to prevent multi organ failure and dysfunction in critically ill patient. Surgical Clinics of North America, vol92,issue 2 13

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THANKING YOU 14 Surgical Clinics of North America, vol92,issue 2

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