World’s Status of the Abdominal Compartment Syndrome: A North American Perspective

1. World’s Status of the Abdominal Compartment Syndrome: A North American Perspective AW Kirkpatrick CD MD MHSc FRCSC FACS Calgary, Alberta, Canada

2. Canadians sometimes have different health-care concerns than our Southern neighbors

3. Canadians are not typical Americans work Summer Winter

4. Trauma Activations

5. We take the bus to work when not on call We take the bus to work when not on call

6. And drinking with our buddies

7. But look forward to weekends at the cottage

8. The textbooks

9. The last decade • Schwartz – Surgery (6th ed 1994) • No mention • Harrison’s – Internal Medicine (14 ed 1998) • No mention • Civetta’s – Critical Care (3rd ed 1997) • Minor • Cameron – Surgery (8th ed 2004) • 2 chapters • ACS • Open Abdomen

10. Are we paying attention? • 2000 • “A century later isn’t it time to pay attention?”1 • 1863-1873 • IAP recognized2, measured3, diaphragmatic influence described4 • “the higher the IAP the less the secretion of urine”5 Ivatury Crit Care Med 2000;28:2137-21381., Marey2, Braune3, Bert4, Wendt5, quoted by Schein in: The Abdominal Compartment Syndrome (in press).5Ivartury.,

11. “Mr & Mrs Open Abdomen”

12. Do we know what it is? • American association for the Surgery of Trauma • (Mayberry 1999) • 86% respondents had diagnosed the ACS in the previous year • Trauma Association of Canada • (Kirkpatrick 2004) • 90% had left an abdomen open after a trauma lap • 84% have re-opened an abdomen due to ACS concerns • 46% had diagnosed a secondary ACS case • 28% had seen a tertiary (recurrent) ACS case • (http://www.calgaryhealthregion.ca/clin/rts/CTTC_10_form_newer.htm) Mayberry., J Trauma 1999;47:509-514

13. Routine Monitoring

14. Are we paying attention to intra-abdominal pressure? Mayberry 1999 – 292 respondents (62% of the AAST) • 6% routinely • 59% selectively • 34% rarely or never • Kirkpatrick 2004 – 86 respondents (84% of the TAC) • 52% routinely screen for IAP • Bladder pressure measurements in 95% • No institution had a mandatory policy or protocol • Half the time we are not!! Sugrue 2002, Kirkpatrick 2000, Ertel 2000

15. What about increased pressure without an obvious syndrome? • Mayberry 1999 • Only 14% would decompress a patient with increased IAP and no obvious syndrome (actual pressure not stated) • Kirkpatrick 2004 • Only 8% would decompress an abdomen with a bladder pressure of 25 mmHg and no obvious syndrome Mayberry et al. J Trauma 1999;47:509-514

16. What pressure should we be concerned about? • What is the threshold for pathologic IAP? • Mayberry 1999 • Undecided – 18% • > 20 cm H20 – 11% • > 25 cm H20 – 22% • > 30 cm H20 – 32% • > 35 cm H20 – 12% • Kirkpatrick 2004 • 5/86 were brave enough to answer • Average response 34.3 mmHg Mayberry et al. J Trauma 1999;47:509-514

17. The Abdominal Compartment Syndrome in 2004 - Where are we? • We know it exists • We know it can be bad • We sometimes look for it • We don’t know to prevent it before it occurs • We don’t know exactly when to intervene • We need an International Group dedicated to understanding it!!