Trauma and Critical Care—Abdominal Compartment Syndrome (ACS)

Trauma and Critical Care—Abdominal Compartment Syndrome (ACS)

Concept

Increased pressure in a confined space will lead to decreased perfusion of all organs in the abdomen

Way Question May be Asked?

Commonly a disguised question like—“You are called to see a 68 y/o male in the recovery room 5 h after a LAR, per- formed by your partner who just left on vacation, begins to have a decreasing urine output. What do you want to do?” It very well could be a patient you are called to see because of high ventilatory pressures where you have to rule out ARDS, pneumothorax, mucus plug, too little sedation, . . .)

How to Answer?

Have to understand that ACS will affect all intraab- dominal organs. Elevated intraabdominal pressure will effect the cardiopulmonary system and increase ventila- tor peak pressures and decrease cardiac output. It will also precipitate renal failure because of direct pressure effects on the kidney, as well as decreased kidney perfu- sion

Have to be systematic and work through algorithm for renal failure including:

Prerenal

Shock-Hemorrhagic Septic

Third-space losses related to burn or long operation

Pump failure Acute MI/CHF

Compartment syndrome Vascular

Emboli after suprarenal aorta clamp

Intrarenal

ATN from any hypotension (sepsis, intra-op) Toxic Medication (aminoglycosides)

Systemic diseases (SLE,TTP) Postrenal

Bilateral ureteral occlusion/injury (rare) Foley problems (kink, clogged)

Answer should include a discussion of:

Pt’s volume status (place CVP or SGC after thorough H&P although examiner is likely to tell you that pt is intubated)

Pt’s baseline renal function

Intra-op events—transfusion, hypotension, placement of CVP with tension pneumotho- rax, or meds administered

Review meds—any excreted only by kidney (digoxin)

Is Foley patent?

All this done quickly so examiner can focus on ACS with discussion of how you diagnose (bladder pressures or gastric O

measure- ments) and how you treat (open abdomen and close with mesh or Bogata bag)

Common Curveballs

Pt had several liters of NSS intra-op to lead you away from thinking further boluses (insensible loses alone up to 6 cc/kg per hour OR time)

Pt has normal SGC parameters

Pt had history of renal insufficiency, MI, or only has one kidney

Nothing you do will work (just testing your thinking—

make sure you follow labs for electrolyte abnormali- ties, especially K

, change any meds that need renal dosing, and consider early hemodialysis)

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Strikeouts

Not considering compartment syndrome (check bladder pressures!)

Not ruling out other causes of renal failure (it will be whatever you leave out!)

Not being invasive to determine volume status (CVP or SGC)

Not checking CXR to r/o pneumothorax from intra-op line or CHF

Not placing Foley catheter or checking its patency Giving diuretic before ensuring adequate volume status Not frequently reassessing pt if all else fails (labs/PE) Not being complete:

not performing physical exam (JVD, rales, skin tugor, abdominal distension, ventilator pressures) or checking labs (lytes, BUN, Cr, U/A, urine lytes)

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