Trauma and IAH
The abdominal compartment syndrome was originally recognized as a new entity in patients suffering from major trauma who underwent massive fluid resuscitation. Early literature in the late 1980’s and through the 1990’s focused almost exclusively on this population and ACS soon became synonymous with major trauma. Today we know IAH/ACS is a syndrome ubiquitous to critical care, not just major trauma. However, trauma patients are still one of the primary groups of concern. Furthermore, major trauma patients often have dual reasons for getting into trouble with IAH/ACS. They not only suffer from the ischemic reperfusion injuries leading to SIRS and capillary permeability that are seen in medical patients with IAH/ACS but trauma patients also commonly have direct injury to organs and tissue with the abdominal cavity which dramatically increases their risk of an inflammatory response and fluid sequestration in that tissue.
Initially the only issue really concerning to trauma surgeons was fully advanced abdominal compartment syndrome manifesting as abdominal distention, elevated peak airway pressures, CO2 retention, acidosis and oliguria.[1, 2] The primary treatment (only known treatment) was decompressive laparotomy. Despite this very aggressive surgical approach, many if not most of these patients died. Recognition of the fact that delaying care until a patient had multiple organ dysfunction/failure was perhaps too little too late, surgeons began investigating preventive measures including prophylactic open abdomens in high risk patients and supra-normal resuscitation to drive oxygen to the tissue and prevent ACS induced ischemia. The former concept worked – Ivatury and colleagues showed dramatic improvements in outcomes (ACS dropping from 52% to 22% and mortality decreasing from 39% to 11% in high risk damage control surgery) and the open abdomen for major trauma and ACS is now considered an important contributor to the improvement in trauma care of the last decade.[3, 4] The later concept – supranormal fluid resuscitation to drive oxygen delivery to tissue however, failed. In fact, in this situation, patients outcomes were worse and the incidence of abdominal compartment syndrome was markedly increased.[5, 6] These same authors found that IAH and ACS could be predicted very early in trauma patients with the major risk being 3 liters or more of crystalloid given in the emergency room, or seven liters or more by the time the patient reached the ICU.[7] Similarly, the concept of fluid “creep” and excessive crystalloid administration became recognized as a cause of IAH/ACS in the burn trauma population.[8, 9]
This recognition that fluid resuscitation carried risks – primarily risks of tissue edema, IAH, ACS and eventually organ failure and death was somewhat surprising but led these authors and others to begin more carefully monitoring the number of fluid “boluses” provided to patients in an effort to reduce the known complication of ACS. Using the latest advances in trauma care has now resulted in little or NO abdominal comparment syndrome and markedly better outcomes in advanced trauma units that employ these strategies: hemostatic resuscitation (blood rather than salt water); limitations of fluid administration (fluid caps) to prevent IAH; careful IAP monitoring allowing early detection of IAH and prevention of ACS; bedside medical therapy for rising IAH to prevent ACS; prophylactic open abdomens in patients at significant risk for ACS; earlier open abdominal care if the patients IAP advances; advanced open abdominal wound management to mobilize fluids and close the abdomen faster.[10, 11]
In summary, IAH and ACS are common problems in severely injured patients. However, huge advances in both understanding the cause and improving the care of trauma patients at risk for IAH/ACS have occurred during the first decade of the 21st century. A multifaceted approach is critical but to obtain optimal results needs to include comprehensive screening for the presence of IAH, focused goal-directed fluid management (with fluid caps) rather than empiric fluid boluses, aggressive implementation of bedside medical treatment as IAP begins to rise and early or prophylactic decompressive surgery (with aggressive bowel management and early closure) if warranted BEFORE full blown abdominal compartment syndrome and its accompanying ischemic injury and multiple organ failure occur.[12, 13]
References:
1.
Meldrum, D.R., et al.,
Jack A. Barney Resident Research Award. Cardiopulmonary hazards of
perihepatic packing for major liver injuries. Am J Surg, 1995.
170(6): p. 537-40;
discussion 540-2.
2.
Burch, J.M., et al.,
The abdominal compartment syndrome. Surg Clin North Am, 1996.
76(4): p. 833-42.
3.
Ivatury, R.R., et al.,
Intra-abdominal hypertension after life-threatening penetrating
abdominal trauma: prophylaxis, incidence, and clinical relevance to
gastric mucosal pH and abdominal compartment syndrome. J Trauma,
1998. 44(6): p. 1016-21.
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Diaz, J.J., Jr., et al.,
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abdomen in trauma and emergency general surgery: part 1-damage
control. J Trauma, 2010.
68(6): p. 1425-38.
5.
Balogh, Z., et al.,
Patients with impending abdominal compartment syndrome do not
respond to early volume loading. Am J Surg, 2003.
186(6): p. 602-7;
discussion 607-8.
6.
Balogh, Z., et al.,
Supranormal trauma resuscitation causes more cases of abdominal
compartment syndrome. Arch Surg, 2003.
138(6): p. 637-43.
7.
Balogh, Z., et al.,
Both primary and secondary abdominal compartment syndrome can be
predicted early and are harbingers of multiple organ failure. J
Trauma, 2003. 54(5): p.
848-59.
8.
Lawrence, A., et al.,
Colloid administration normalizes resuscitation ratio and
ameliorates "fluid creep". J Burn Care Res, 2010.
31(1): p. 40-7.
9.
Saffle, J.I., The
phenomenon of "fluid creep" in acute burn resuscitation. J Burn
Care Res, 2007. 28(3): p. 382-95.
10.
Balogh, Z.J., et al.,
Mission to Eliminate Postinjury Abdominal Compartment Syndrome.
Arch Surg, 2011.
11.
Cheatham, M.L. and K. Safcsak,
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intra-abdominal hypertension and abdominal compartment syndrome
improving survival? Crit Care Med, 2010.
38(2): p. 402-7.
12.
Balogh, Z. and M. Malbrain,
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intra-abdominal hypertension and abdominal compartment syndrome.
Am Surg, 2011. 77(7): p.
S31-S33.
13.
Anand, K.J. and R. Ivatury,
Surgical Management of
intra-abdominal hypertension and abdominal compartment syndrome.
Am Surg, 2011. 77(7): p.
S42-S45.