Page 51 - Cote clinical veterinary advisor dogs and cats 4th

2.e2 Abdominal Compartment Syndrome

○ More accurate predictor of abdominal • Grade IV ACS (IAP > 25 mm Hg, > 34 cm • Blood pressure
organ perfusion than IAP alone H 2 O): severe disease • Serial serum biochemistry panel, lactate,
VetBooks.ir All measurements should be obtained with the laparotomy) is required to prevent further • Urine output
urine specific gravity
○ Surgical decompression (exploratory
○ Goal to maintain APP of 50-60 mm Hg
in patients with ACS
• Patient’s comfort level and presence of
organ damage and potentially reverse
patient in lateral recumbency and at the end
existing organ dysfunction.
of expiration. ○ If the cause of severe IAP elevation is rapid abdominal pain
• Patient position should be the same each accumulation of fluid or gas within the PROGNOSIS & OUTCOME
time IAP is measured, as body position can abdomen, abdominocentesis or gastrocen-
affect IAP. tesis may be considered over surgical Definitive predictors of prognosis and outcome
• Measurement of IAP in patients at risk for intervention. in veterinary patients are unknown.
or with IAH can be done every 4-8 hours. • Medical management • In humans, development of ACS is associated
• Trends of serial IAP measurements are more ○ Not recommended for severe (grade IV) with high morbidity and mortality rates.
useful clinically than single measurements. ACS • Recognition of patients at risk for IAH and
• Abdominal wall muscle contraction, pain, ○ Remove constrictive abdominal bandages. prompt intervention to prevent complica-
or constrictive wraps around the abdomen ○ Sedation and analgesia to reduce patient tions of ACS are likely to improve outcomes.
can increase IAP. anxiety and pain
○ Nasogastric emptying of gastric contents PEARLS & CONSIDERATIONS
Advanced or Confirmatory Testing ○ Administer enemas to promote removal
• Serial laboratory testing is recommended to of colonic contents. Comments
evaluate organ function and changes in tissue ○ Discontinue enteral nutrition. • Critically ill patients with known risk factors
perfusion. ○ Prokinetics to improve gastrointestinal are at highest risk for development of ACS.
○ Lactate, alkaline phosphatase (ALP), (GI) motility and reduce intraluminal GI • Iatrogenic IAH can occur secondary to
alanine aminotransferase (ALT), total content diagnostic peritoneal lavage and peritoneal
bilirubin, blood urea nitrogen (BUN), ○ Abdominocentesis to remove fluid and dialysis.
creatinine, urine specific gravity gas from abdominal cavity • Progressive increases in IAP and decreasing
• Assess patient volume status: serial body ○ Aim for euvolemic patient status. urine output may indicate the need for
weight measurement, record “ins and outs” ■ If the patient is volume overloaded, surgery or aggressive medical management
(fluid volume administered compared to consider management with fluid restric- of intra-abdominal disease.
urine and drain output), edema formation tion, diuretics, or hemodialysis in severe
• Evaluation of hemodynamic stability: heart cases. Prevention
rate, pulse quality, and blood pressure ■ If patient is hypovolemic, administer • Avoid high-volume fluid resuscitation and
monitoring, mentation checks q 2-4h, crystalloids or colloids as needed to fluid overload in critically ill patients.
mucous membrane color, and capillary refill restore vascular volume, tissue perfu- • Intensive supportive care and monitoring is
time sion, and APP necessary to identify development of ACS.
• Indirect IAP has also been measured using • Surgical management
nasogastric or esophageal catheters, gastros- ○ Indicated for severe ACS (grade IV) or if Technician Tips
tomy tubes, abdominal drains, rectal cath- patient is refractory to medical management • IAP should be measured in lateral recum-
eters, and caudal vena cava catheters. ○ Direct removal of fluid or tissue contribut- bency using a consistent technique.
• Direct peritoneal pressure measurement with ing to severe IAP elevation • If the hospital does not have a rigid water
an intra-abdominal catheter is the gold ○ Postoperative open abdominal manage- manometer, a manometer can be constructed
standard for IAP measurement. ment, negative-pressure wound therapy, by using extension fluid tubing affixed to a
○ Rarely used in clinical patients due to cost, or temporary abdominal closure tech- ruler or measuring stick; use cm markers to
invasiveness, and potential complications niques may be necessary. estimate cm H 2 O. This tubing is attached
Associated with improved survival in to the upright 3-way stopcock port as
■
TREATMENT humans described previously.
■ Rarely necessary in dogs and cats • If the patient has an indwelling urinary catheter,
Treatment Overview an e-collar should be worn at all times.
Medical management of patients at risk for or Chronic Treatment
with IAH is necessary to prevent progressive, Continue treatment of the underlying disease SUGGESTED READING
clinically relevant elevations in IAP. Surgical to reduce risk of developing ACS. Nielsen LK, et al: Compartment syndrome: patho-
management of IAH is necessary if the patient physiology, clinical presentations, treatment, and
has severe IAP elevation and evidence of organ Nutrition/Diet prevention in human and veterinary medicine. J
dysfunction. Enteral nutrition may be suspended during Vet Emerg Crit Care 22:291-302, 2012.
medical management.
Acute General Treatment ADDITIONAL SUGGESTED
• Grade I ACS (IAP of 12-15 mm Hg, Drug Interactions READINGS
16-20 cm H 2O): mild disease Dose adjustment of commonly used medica-
○ Ensure the patient is normovolemic, and tions or parenteral fluids may be necessary if Kirkpatrick AW, et al: Intra-abdominal hypertension
treat underlying disease. Monitor organ the patient has liver dysfunction, renal failure, and the abdominal compartment syndrome:
updated consensus definitions and clinical practice
function. ascites, or decreased urine production. guidelines from the World Society of the Abdominal
• Grade II and III ACS (IAP 16-25 mm Hg, Compartment Syndrome. Intensive Care Med
21-34 cm H 2 O): moderate to severe disease Possible Complications 39:1190-1206, 2013.
○ Volume resuscitation is used if indicated. Shock, sepsis, SIRS, multiple organ dysfunction Smith SW, et al: Measurement of intra-abdominal
Pursue diagnostics to identify cause of syndrome (MODS) or failure (MOF), death pressure in dogs and cats. J Vet Emerg Crit Care
IAH. (San Antonio) 22:530-544, 2012.
○ Consider surgical decompression or Recommended Monitoring AUTHOR: Selena L. Lane, DVM, DACVECC
abdominocentesis if IAP elevation • For IAP measurement in critically ill patients, EDITOR: Benjamin M. Brainard, VMD, DACVAA,
progresses. serial evaluation is preferred. DACVECC
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