The Secondary, & Tertiary Abdominal Compartment Syndrome: An Overview

1. The Secondary, & Tertiary Abdominal Compartment Syndrome: An Overview Andy Kirkpatrick Calgary, Alberta, Canada

2. Previously healthy 42 year old male • 29th January • 52% deep partial & full thickness burns

3. Admission • Inhalational injury • Parkland formula • 80 kg x 50% x 4 cc/kg = 16000 cc N/S • Received 18.4 Liters over the first 24 hours • 8 U PRBC • 4 U FFP

4. 2° ACS 29 - 31 Jan 2004 Bedside Decompressive Laparotomy 34 mmHg 36 mmHg Last documented bladder pressures

5. Urgent midline laparotomy performed • Burn grafting & excision day 4 • Fluids • 23 additional liters • 42.9 liters • 536 ml/kg since admission

6. Tertiary (Recurrent) Abdominal Compartment Diagnosed • Physiologic Deterioration • Pip - 52 cm H20 • Paw - 26 mmHg • Bladder pressure - 29 mmHg • Repeat laparotomy (removal of previous temporizing closure) • Necrotic • stomach • small bowel • Extension of incision & larger bag improved physiology

7. Awaiting my return

8. Questions • Should the 2° ACS have been anticipated (expected) ? • Should the 3° (recurrent) ACS have been anticipated (expected) ? • Are these iatrogenic diseases? • Can we do something different? • Can we do something better?

9. Philosophy • Tremendous advances have been made in resuscitation during the last century • Often precipitated by human conflict • Often due to recognition of previously unknown complications unmasked by prior advances Kabul, July 2004

10. The last century • 1 st quarter • shock results from intra-vascular volume deficits requiring colloid and blood • 2 nd half • Aggressive (frequently massive) crystalloid resuscitation all but eliminates early renal failure • 3 rd quarter • ARDS arises (“Da Nang” Lung) • 4 th quarter • MSOF emerges as leading cause of in-hospital trauma death • Close of the century • 2° ACS is now emerging as a post-injury complication that we understand very poorly Cannon 1923; Pope 1999; Pruitt 1999, 2004; Moore 2004; Sauaia 1995

11. Secondary Abdominal Compartment Syndrome • Secondary ACS definitions • Post-injury ACS is referred to secondary when there are no intra-peritoneal injuries1 • Conditions that do not originate from the abdomen (such as sepsis and capillary leak, major burns, and other conditions requiring massive fluid resuscitation), yet result in the signs and symptoms commonly associated with Primary ACS2 1Balogh J Trauma 2003, 2web site www.wsacs.org, Nov 7 2004

12. “Spill your guts” survey • 90% respondents had “left an abdomen open” • 84% have re-opened an abdomen due to ACS concerns • Kirkpatrick, Laupland, Karmali et al, & the Canadian Trauma Trials Collaborative • http://www.calgaryhealthregion.ca/clin/rts/CTTC_10_form_newer.htm

13. Will 1° ACS go the way of the DoDo bird? • If 1° ACS is a post-operative condition shouldn’t we be able to prevent it by not closing the abdomens in sick patients?? Dodo Bird

14. 2 ACS first reported in burn patients (1994) • 30 pediatric burn patients requiring “resuscitation” (prospective) • IAP > 30 mmHg (11) • Mean TBSA – 67%, 55% mortality • IAP < 30 mmHg (19) • Mean TBSA – 50%, 16% mortality • 2 periods of IAH • Initial resuscitation • Septic episodes Greenlaugh, J Trauma 1994;36:685-690

15. A wolf in wolf’s clothing • Burrows – secondary ACS from massive resuscitation from a crushed extremity requiring amputation • Burrows R, et al. SAMJ 1995;85:46-48 • Accepted for publication in 1992

16. Recognition & quantification

17. 2° ACS and burn resuscitation in adults • 3 adults with burns > 70% • All required > 20 L fluid • 2 patients no complete abdominal burn – therefore circumferential eschar not required!! • 2 inhalation injuries • 1 developed 2° ACS after the resuscitation when septic!! • All died!! Yale University Ivy, J Burn Care Rehabil 1999;20:351-353

18. Prospective study of IAP in burned adults • TBSA > 20% in 1999 • 7/10 had IAP > 25 mmHg • 2/10 developed 2° ACS • Linear regression analysis • 250 ml/kg fluid predicts an IAP of 25 mmHg • Caution extrapolating • “most patients who have undergone abdominal surgery will develop an IAP > 25 mmHg with significantly … < 250 ml/kg” Ivy, J Trauma 2000;49:387-391

19. Abdominal decompression in 2° ACS from burns • 10 of 1014 developed IAP > 30 mmHg with physiologic compromise • Mean TBSA = 70% • 2 incidences of ACS • Resuscitation • Sepsis • Marker of ACS during resuscitation • 237 ml/kg first 12 hours • Recommended • Routine IAP monitoring • Attempt catheter decompression • Immediate laparotomy if not improved UC Davis Hobson, J Trauma 2002; 53:1129-1134

20. Secondary ACS • Terminology attributed to Maxwell from the Presley Regional Trauma Center Maxwell, J Trauma 1999;47:995-999

21. Memphis, Tennessee • 46 open abdomen secondary to edema • 6 had no significant abdominal trauma but required massive resuscitation • Survivors decompressed 20 hours sooner than deaths • Recommended • Monitor bladder pressure in everyone receiving • 10 or more L crystalloid fluid • 10 or more U PRBC Maxwell, J Trauma 1999;47:995-999

22. Pelvic fractures considered secondary (ie extra-peritoneal)1-4 Balogh, J Trauma 2003 World’s largest series Pelvic fractures constituted 73% of 15 patients Pelvic fractures considered primary (ie intra-abdominal)5,6 World Congress on the Abdominal Compartment Syndrome Preliminary Consensus Definition “bleeding pelvic fractures or other causes of massive retroperitoneal hematomas” are considered 1° Evolving Literature: 2° ACS Definition 1Maxwell J Trauma 1999, 2Kopelman J Trauma 2000, 3Balogh Am J Surg 2002, 4Balogh J Trauma 2003 5Biffl Am J Surg 2001, 6wsacs.org 2004

23. Epidemiology of the 2° ACS • Prospective shock trauma database • 0.09% of trauma admissions • 0.7% of trauma ICU admissions • 8% of all trauma patients requiring an aggressive resuscitation • Initial base deficit > 6 mEq/l • 6 U PRBC/first 6 hrs • 58% of all post-injury ACS • ** pelvic fractures included ** Balogh Am J Surg 2002;184:538-544

24. Comparative epidemiology of 1° & 2° ACS • 26 trauma patients developed ACS • 11 primary versus 15 secondary • Similar • Demographics • Shock • ISS • Longer pre-ICU course • (3.7 vs 6.2 hrs) • Operative intervention • (82% vs 40%) • Often long delay to angiography for pelvic angiography • Crystalloid infusions • (20 vs 32 L/first 24 hours) • Crystalloid/PRBC ratio • 0.55 vs 1.92 Balogh J Trauma 2003;54:848-861

25. Time to manifestation • “Historical” 2 ACS studies reported long delays in recognition1,2 • “Recent” reports note ACS developing within 12 – 14 hours in those with “massive resuscitation”3,4 1Maxwell 1999, 2Kopelman 2000, 3Balogh Am J Surg 2002, 4Biffl 2001

26. The Secondary ACS: An iatrogenic disease • Goal (DO2I) directed resuscitation • 500 vs. 600 ml/min/m2 • Similar demographics • 13 vs 7 liters crystalloid/first 24 hours • IAH • 42% vs 20% • ACS • 16% vs 8% • MOF • 22% vs 9% • Mortality • 27% vs 11% Balogh, Arch Surg 2003;138:637-643

27. Treatments offered • Abdominal escharotomy • Pharmacologic paralysis • Percutaneous catheter insertion • Sometimes works well • Decompressive laparotomy • If doesn’t work the diagnosis was wrong • Radical cure fraught with complications Greenlaugh, J Trauma 1994, Corocos J Trauma 2001, Latenser J Burn Care Rehab 2002

28. Outcomes • 55% of 2° ACS develop MSOF • Conclusions of previous authors4 that earlier decompression would improve outcome based on speculation1,2 • Recent studies have found no difference between survivors and non-survivors in the time to decompression3,4 1Maxwell 1999, 2Kopelman 2000, 3Biffl 2001, 4Balogh 2002

29. Tertiary (Recurrent) Abdominal Compartment Syndrome • Previously the “open abdomen compartment syndrome” • Reports of the ACS occurring in an already open abdomen1,2 • Termed tertiary by the WCACS working group • Believe the index case is the first reported 3° case after 2° ACS or thermal injury3 1Gracias Arch Surg 2002, 2Raeburn Am J Surg 2001, 3Ball (submitted)

30. An open abdomen does not preclude the ACS! • Continuous monitoring • Vigilant if previous and especially ongoing massive resuscitation • Beware septic episode • Treatment • Re-opening • Full extension of incision • Applying a larger dressing

31. Newer Suction Dressings • Continuous negative abdominal pressure • Anesthetized swine model • IAP raised to 25 mmHg • Negative applied for 2 hours • Significant decreases in • ↓ IAP • ↓ CVP • ↓ IVC pressure • ↓ ICP VAC Dressing ? Bloomfield, J Trauma 1999;46:1009-1014

32. Quaternary ACS? • Signs and end-organ effects of increased intra-abdominal pressure • Occurring after the reconstruction of the abdominal wall of a patient who was purposely left with a fascial dehiscence due to concerns of intra-abdominal hypertension • Reinforces another dimension of our infancy in knowledge regarding the treatment of the ACS

33. Prevention of the 2° & 3° ACS • Minimize the period of the initial insult!! • Correction rather than resuscitation!!

34. Prevention ? • Unproven but suggested • Non-crystalloid resuscitation fluids that may modulate ischemia/reperfusion-induced inflammation in the gut • Hypertonic saline • Albumin • Ethyl Ringer’s pyruvate • 2° & 3° HBOC’s Balogh 2003;186:602-608, Textbook on the ACS (in press)

35. Pentaspan versus crystalloid • Pentaspan had overall less fluid requirements • 7550mL±4313.4 vs 17200mL±1838.5 • less animal weight change • 4.78kg±14.1 versus 18.78kg • decreased maximum bladder pressure • 16.5cmH2O±2.1 vs 29.0cmH2O±7.1. Konkin et al., Vancouver General Hospital Not statistically significant

36. Abdominal Compartment Syndrome Conclusions • 2° ACS is common! • Maybe more common than 1° • Not limited to trauma laparotomies! • Even an open abdomen does not mean we can ignore it! • Reaffirms the principles of early hemorrhage control • Tremendous opportunities for research!