Page 1648 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 120: Torso Trauma 1167

include an increase in intra-abdominal pressure above 20 cm H O, peak
2
airway pressure of greater than 40 cm H O, oxygen saturation of less than
2
90% on 100% oxygen, and oxygen delivery index of less than 600 mL/m
2
per minute, as well as oliguria of less than 0.5 mL/kg per minute. The
condition is diagnosed usually at the end of a surgical procedure when
attempts are made to close the abdomen or early in the postopera-
tive period of the massively injured patient, although it may occur in
patients with major intra-abdominal hemorrhage or retroperitoneal
hemorrhage prior to surgical intervention. The source of the increased
intra-abdominal pressure is usually edema, blood accumulation, or
distention of the hollow viscera. Prevention of this syndrome therefore
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is achieved by minimizing intra-abdominal edema through decreasing
the period of hypotension, minimizing crystalloid infusion, minimizing
manipulation of the bowel, limiting the duration of surgical procedures,
adequate control of hemorrhage, and appropriate decompression of the
gastrointestinal tract.
In the setting of hemodynamically compromised patients requiring
massive blood transfusions leading to hypocoagulability states, acido-
sis, and hypothermia, major definitive surgical procedures should be
postponed in order to eliminate factors that predispose to increases in
intra-abdominal pressure. The concept of damage-control laparotomy is
therefore an important consideration in this setting. 9
The increase in intra-abdominal pressure affects virtually all systems
in the body including a decrease in cardiac output from the decrease
in venous return arising from compression of the vena cava, decreased
renal perfusion, decreased myocardial perfusion, and increased airway
pressure resulting in inability to mechanically ventilate and maintain
oxygenation of the patient—all of which are associated with a poor
outcome unless the increase in intra-abdominal pressure is treated
promptly by abdominal decompression. In the OR, apart from the
practice of damage-control laparotomy, if on attempting formal closure
FIGURE 120-7. Spontaneous resolution of renal injury. A. Intravenous pyelogram of the abdomen there is major increase in intra-abdominal pressure, as
showing extravasation of contrast material immediately after blunt trauma with hematuria. reflected by an extraordinary increase in airway pressures with difficulty
B. Repeat intravenous pyelogram after 5 days of observation shows no extravasation.
in ventilating the patient, the formal closure should be aborted. In these
circumstances, the abdominal viscera are contained by using temporary
as a reflection of the hemodynamic status, there are certain contraindi- devices such as plastic bags sutured to the edges of the skin. In some
cations to catheterization per urethra. Blood at the urethral meatus or instances, skin closure without fascia closure may be possible without
the presence of scrotal or perineal hematomas with a large, high-riding, a major increase in intra-abdominal pressure. The patient is returned
boggy prostate may signal injury to the urethra; these findings necessi- to the ICU for stabilization, monitoring, and correction of associated
tate a urethrogram to exclude urethral laceration prior to transurethral abnormalities. With improvement in these parameters and signs of
placement of a Foley catheter. Urethral rupture necessitates urologic reduction in the intra-abdominal pressure, the patient is returned to the
consultation and treatment. OR for further surgical intervention, which may allow either primary
Postoperative care of these patients requires maintenance of renal closure of the fascia with skin closure or the use of mesh for closing the
perfusion; thus careful attention to maintenance of normovolemia is fascia followed by skin closure or skin grafts later on. Other more elabo-
important. In addition, maintenance of good urinary output and close rate techniques of abdominal wall closure are required in the long term
monitoring of the degree of hematuria, as well as the volume of urine, for some of these patients. 10
are required in the ICU setting. An occult injury to the genitourinary Apart from recognition of this entity in the OR, it may develop slowly
tract with extravasation of urine that is left undiagnosed is another or abruptly without previous surgery (eg, the patient with major retro-
means by which a multiple-trauma patient may develop septic complica- peritoneal hemorrhage from a pelvic fracture) or in the postoperative
tions in the ICU. This type of complication is diagnosed by ultrasonog- period during the patient’s ICU stay. In a patient in whom this syndrome
raphy or CT and is treated by drainage of the urinoma with or without is likely to develop, close monitoring of airway pressures, hemodynam-
direct repair of the source of the urinoma. ics, renal perfusion, gas exchange, and intra-abdominal pressure is
■ TRAUMATIC ABDOMINAL COMPARTMENT SYNDROME required. A simple means of monitoring intra-abdominal pressure is
by attaching a three-way stopcock to the side tubing of a Foley catheter
Although the deleterious effects of increased intra-abdominal pressure after instilling 50 to 100 mL of sterile saline into the bladder through the
have been identified prior to the twentieth century, improvements in catheter. On clamping the Foley catheter tubing distal to the three-way
prehospital care and the rapidity with which multiply injured patients stopcock, the stopcock is opened to a manometer that is zeroed at the
are taken to the OR have led to an increased recognition of the syn- level of the symphysis pubis.
drome caused by acute increases in intra-abdominal pressure because The mainstay of treatment of patients with this traumatic abdominal
this syndrome is more likely to occur in the presence of multiple major compartment syndrome is immediate abdominal decompression, which
intra-abdominal injuries resulting in severe blood loss, massive fluid can sometimes be performed in the ICU. Without decompression, mor-
requirements, and prolonged surgery. Previously, most of these patients tality is prohibitive and arises from the development of cardiopulmo-
would not survive to reach the operating room. The traumatic abdomi- nary failure, renal failure, hepatic failure, and bowel ischemia.
nal compartment syndrome may be defined as the adverse clinical con- Patients at particularly high risk of developing this entity include
sequences of an acute increase in intra-abdominal pressure following those with massive retroperitoneal hematomas from conditions such
trauma. The generally accepted parameters for defining this syndrome as pelvic fractures and those with major intra-abdominal hemorrhage

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