ACS and CRITICAL CARE: Recurrent ACS

1. ACS and CRITICAL CARE:Recurrent ACS Zsolt Balogh, MD Szeged, Hungary

2. DEFINITIONScenario 1. • ACS once decompressed and temporary abdominal • closure applied • ACS recurs on the ICU in a previously decompressed • patient with open abdomen.

3. DEFINITIONScenario 2. • ACS once decompressed and temporary abdominal • closure applied • ACS recurs after the temporary closure removed and • the fascia closed

4. DEFINITIONScenario 3. • The abdomen left open preventively • ACS develops on the ICU in a patient with open • abdomen This is not recurrent ACS! Important for monitoring purposes.

5. DEFINITIONScenario 1. Postdecompression

6. DEFINITIONScenario 1. Postdecompression mmHg #p<0.05 between survived and died # Balogh et al. Am J Surg 2002

7. DEFINITIONScenario 1. Postdecompression From 11 secondary ACS: 6 (55%) had recurrent IAH/ACS All died Balogh et al. Am J Surg 2002

8. DEFINITIONScenario 2. After Closure

9. DEFINITIONScenario 3. ACS in open abdomen This is not recurrent ACS! Important for monitoring purposes.

10. DEFINITIONScenario 3. ACS in open abdomen Especially in trauma this is the group where we continue to see primary ACS: From 12 primary ACS 10 developed in open abdomen Balogh et al. J Trauma 2003

11. VACUUM ASSISTED CLOSURE • Probably no as a first closure after decompression • Increase vacuum if the patient tolerates • Not a problem after the 1st day

12. Pathophysiology • ACS is rather a process than a state • Intestinal swelling, ascites production still • continued after decompression.

13. * * * *

14. Prevention - Recognition • Keep in mind the three discussed scenarios • ACS could develop or recur in open abdomen • Monitoring • Intraoperative • Postoperative • Adequate decompression, spacious TAC

15. Monitoring • Continuous IAP measurement • Gastric tonometry

16. Continuous IAP

17. FUTURE DIRECTIONS • Intra-operative use • Decision making: close or leave it open

18. BACKGROUND Postinjury ACS is a preventable link (second hit) between traumatic shock and MOF Balogh et al. SHOCK 2003 Trauma surgeons are reluctant to decompress abdomens merely on IAP measurements Mayberry et al. J Trauma 1999

19. BACKGROUND Clinical observations described intestinal mucosal acidosis (pHi) in ACS Sugrue et al. World J Surg 1996 Ivatury et al. J Trauma 1998

20. PURPOSE To evaluate the role of gastric tonometry (GT) as a monitoring tool of intestinal perfusion in the prediction of ACS.

21. Met inclusion criteria On ICU admission: art, PA, NG tonometer catheters baseline ABG, Hb, lactate I DO goal Yes No 2 Monitor: > 1) Hb (PRBC; Hb 10 g/dL) lactate, BD, PrCO > 2) volume (LR; PAWP 15 mmHg) 2 bladder pressure Q 4h (reassess sooner if Q 4h (reassess sooner if abnormal) abnormal) 3) Optimize CI - PAWP (Starling curve) 4) low dose inotrope No 24 hours? 24 hours? 5) vasopressor Yes stop resuscitation stop resuscitation Echocardiography standard ICU care standard ICU care

22. Results • 188 patients, 26 (14%) ACS

23. RESULTS P<0.05 Hours

24. RESULTS *

25. RESULTS * *

26. RESULTS: multivariate analysis GAPCO2 = PrCO2 – EtCO2

27. RESULTS: multivariate analysis Area under the ROC curves GAPCO2 alone: 0.629 Combined predictors: 0.993

28. PrCO2 measured by tonometry differentiates impending ACS earlier than IAP measurement • If PrCO2 is normal ACS can be excluded • PrCO2 indicates the response to decompression • Combining tonometry data with other independent predictors available at the time of ICU admission results in a powerful prediction model

29. SUMMARY • Recurrent ACS could have many faces • Open abdomen does not entirely prevent ACS • Monitoring is essential : CIAP, tonometry • Re-exploration, changing the TAC size and/or method