Question 21

Created on Fri, 05/29/2015 - 02:24
Last updated on Sun, 04/30/2017 - 17:44
Pass rate: 100%
Highest mark: ?

Other SAQs in this paper

Other SAQs on this topic

Outline the causes, consequences and the management of abdominal  compartment syndrome.

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College Answer

Causes:

Abdominal trauma
Massive retroperitoneal hematomas

Major burns following fluid resuscitation

Massive intra-abdominal hemorhage

Major Consequences:
a)  Decrease in Qt because of a decrease in venous return

b)  Decreased renal perfusion

c)  Impaired thoracic compliance

d)  Bowel ischemia

Management
a)  Monitoring intra-abdominal pressure

b)  Abdominal decompression

c)  Adequate decompression of GI tract

d)  Avoiding excess fluid resuscitation

Discussion

A slightly more formal-looking exploration of abdominal compartment syndrome can be found in Question 8 from the first paper of 2013. Brief notes on the pathophysiology of abdominal compartment pressure and its measurement are available, with references for the time-rich exam candidate.

Causes of abdominal compartment syndrome:

Primary ACS: increased compartment pressure due to abdominal pathology

  • Massive ascites, eg. portal vein thrombosis
  • Retroperitoneal hematoma
  • Abdominal trauma with crush injury

Secondary ACS: increased compartment pressure due to fluid resuscitation

  • Abdominal infection eg peritonitis
  • Pancreatitis
  • Major trunk burns with massive fluid resusicitation (thus, restriction of abdominal expansion)

Consequences of abdominal compartment syndrome:

  • Hypotension due to decreased preload
  • Renal failure due to decreased renal blood flow (venous and arterial)
  • Lactic acidosis due to impared hepatic blood flow
  • Gastric erosions and ulceration due to impaired gastric blood flow
  • Intestinal ischaemia due to impaired intestinal blood flow
  • Poor gut transit, ileus, and decreased tolerance of NG feeds
  • Decreased FRC and therfore increased atelectasis, worsening gas exchange, decreased compliance of the respiratory system, leading to hypoxia and hypercapnea
  • Raised intracranial pressure

Management of abdominal compartment syndrome:

  • Prevention:
    • Avoid overvigorous fluid resusictation
    • Patients at risk of ACS should perhaps remain open-abdomen after largescale abdominal surgery
    • monitor the compartment pressure
  • Management
    • Staged closure of abdominal defect
    • Vasopressors to maintain MAP within a certain range (some aim for an abdominal perfsion pressure of >60mmHg)
    • Titrate PEEP to optimise V-Q matching, to maintain normoxia and normocapnea
    • If compartment pressure remains elevated, neuromuscular blockade can be considered
    • If pressure remains high in spire of NMJ blockade, may consider opening the abdomen (if it is closed)

References

Cheatham, Michael Lee. "Abdominal compartment syndrome." Current opinion in critical care 15.2 (2009): 154-162.

Maerz, Linda, and Lewis J. Kaplan. "Abdominal compartment syndrome."Critical care medicine 36.4 (2008): S212-S215.

Saggi, Bob H., et al. "Abdominal compartment syndrome." Journal of Trauma-Injury, Infection, and Critical Care 45.3 (1998): 597-609.

Cheatham, Michael L., et al. "Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension." Journal of Trauma-Injury, Infection, and Critical Care 49.4 (2000): 621-627.