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OSCE 007: Abdominal Compartment Syndrome

Introduction

A 54-year-old man is admitted from the ward with severe acute pancreatitis…

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Question No. 2

Q: How is pancreatitis defined? (2 marks)

Answer No. 2

Pancreatitis is typically established by the presence of two of the following criteria: 1. Abdominal pain consistent with the disease 1 2. Serum amylase and/or lipase greater than three times the upper limit of normal 1 3. Characteristic findings from abdominal imaging 1

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Case Information

He is noted to have increasing abdominal distension 6 hours later on the intensive care unit and the nurses tell you his abdomen is very tense…

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Question No. 4

Q: How would you assess this? (3 marks)

Answer No. 4

  • Detailed clinical assessment 1
  • CT of the abdomen 1 if the patient is stable enough
  • A bedside ultrasound 1
  • Intra-abdominal pressure measurement 1

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Question No. 5

Q: How can intrabdominal hypertension be graded? (2 marks)

Answer No. 5

IAH is defined by the World Society of Abdominal Compartment Syndrome as:

A sustained or repeated pathological elevation in IAP >12 mmHg

It is graded according according to pressure:

Grade I
12-15 mmHg 0.5
Grade II
16-20 mmHg 0.5
Grade III
21-25 mmHg 0.5
Grade IV
>25 mmHg 0.5

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Question No. 6

Q: How is abdominal compartment syndrome (ACS) defined? (2 marks)

Answer No. 6

ACS is defined by the World Society of Abdominal Compartment Syndrome as:

A sustained IAP >20 mmHg 1that is associated with new organ dysfunction/failure 1

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Question No. 7

Q: What is primary and secondary ACS? (2 marks)

Answer No. 7

Primary ACS or IAH
  • Due to a condition associated with injury or disease in the abdominopelvic region 1
  • Frequently requires early surgical or interventional radiological intervention
Secondary ACS or IAH
  • Due to a conditions that do not originate from the abdominopelvic region 1

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Question No. 8

Q: Describe a method for measuring the pressure via the bladder using a pressure transducer? (3 marks)

Answer No. 8

  • It is recommended that intravesicular pressure is measured via foley catheter
  • The 'Modified Kron' method is the most popular method due to its simplicity and low cost:
  • Patient should in the supine position 1 for measurement:
  • If not clinically feasible:
    • Recognize head elevation will result in a higher pressure
    • Ensure all subsequent readings are taken in the same position.
  • Adjust the height of the transducers and ensure it is zeroed level with the mid-axillary line
  • Clamp the drainage tube to the urine bag 1
  • Connect the needle to the rigid tubing of the pressure transducer 1
  • Insert the needle into the sampling port of the catheter 1
  • Fill the bladder with 1ml/kg (maximum 25mls) of 0.9% sodium chloride using the syringe 1
  • Close the stopcock of the syringe and allow 30 seconds for equilibrium to occur 1
  • Obtain the mean pressure reading upon end-expiration to minimize the effects of pulmonary pressures
  • Fluctuations in the pressure waveform should be seen with pulsations in abdominal blood flow.

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Question No. 9

Q: What are the 5 main principles of management for ACS? (5 marks)

Answer No. 9

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Question No. 10

Q: What is the mortality associated with ACS? (1 marks)

Answer No. 10

  • Severity of organ failure related to the duration of intra-abdominal hypertension
  • Abdominal compartment syndrome carries a poor prognosis:
    • Without treatment the mortality is 100%
    • Studies have shown mortality of 35-50% despite treatment 1

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