Abdominal kompartment-syndrome – a complex of pathological changes which arise against the background of permanent increase in the intra belly pressure (VBD) and cause development of polyorgan insufficiency. It is observed after operations, at heavy injuries and diseases of abdominal organs, zabryushinny space, is more rare – at ekstraabdominalny pathology. It is shown by heart, renal, respiratory failure, violations of work of a liver and GIT. The basis of early diagnostics is made by repeated measurements of VBD, data of tool and laboratory researches are in addition used. Treatment – an urgent operational decompression, infusional therapy, IVL.
The Abdominal Kompartment-syndrome (AKS) – the terrible complication which is found at a serious illness, traumatic damages and surgical interventions. According to different data, it is diagnosed for 2-30% of the patients operated concerning stomach injuries. Among the patients who are at the time of receipt in critical condition and needing holding resuscitation actions, significant increase in intra belly pressure is found more than in 50% of cases, clinical signs of AKS come to light approximately in 4% of cases. The first messages on negative influence of the increased intraabdominalny pressure upon a condition of patients appeared at the end of the 19th century, but the pathogenesis of AKS and value of a syndrome as the reasons of mortality were established only in the eighties the last century. Without treatment the lethality makes 100%.
The abdominal cavity represents the closed space limited to bone and myagkotkanny structures. Normal pressure in it is close to zero. At obesity and during pregnancy this indicator raises, however because of slow development of changes the patient's organism gradually adapts to this state. At bystry increase in VBD the organism of the patient does not manage to adapt to changes that involves violations of activity of various bodies. The probability of formation of AKS increases in the presence of the following factors:
- Reduction of tensile properties of a belly wall. It is found at extensive rough hems, intensive abdominal pains, a muscular spasm, after plasticity of large hernias, at a pleuropneumonia, during IVL, especially – against the background of incorrect settings of parameters of an artificial respiration.
- Increase in volume of contents of an abdominal cavity. It is noted at large new growths, intestinal impassability, big hematomas in the field of zabryushinny cellulose, aneurisms of a belly aorta.
- Congestion of liquid or gas. Peritonitis, at injuries, ascites at tumors, cirrhosis and other diseases can become the reason of a congestion of liquid. Significant usually arises at torakoabdominalny damages with violation of integrity of a lung and a diaphragm. Forcing of air in an abdominal cavity at endoscopic interventions can play a part.
- Syndrome of capillary leak. It is characterized by increase in permeability of capillaries and an exit of liquid in fabric from the vascular course. It is observed at sepsis, extensive burns, acidosis, a koagulopatiya, overcooling, massive blood transfusion and blood substitutes, solutions for intravenous infusions.
Heterogeneity of provocative factors is the cause of a kompartment-syndrome at a wide range of diseases and states, including, not connected with abdominal pathology. Severe injuries of a stomach, intra belly bleedings of various genesis, liver transplantation, peritonitis, sharp destructive pancreatitis, multiple fractures of pelvic bones, extensive burns, infusional therapy of shock states become the most frequent reasons of AKS. Less often the syndrome is observed at intestinal impassability, after plasticity of hernia, when carrying out peritonealny dialysis.
At increase in intraabdominalny pressure the blood-groove in an abdominal cavity is broken, it provokes damage mucous a stomach and intestines up to formation of sites of a necrosis, a perforation of hollow body and development of peritonitis. Disorders of blood circulation in vessels of a liver become the reason of necrosis of more than 10% of hepatocytes and corresponding changes of hepatic tests. Barrier function of intestines suffers that is shown by contact, limfogenny and hematogenic distribution of bacterial agents. The probability of emergence of infectious complications increases. Sdavleniye of the operated bodies exponentiates insolvency of anastomoz.
The diaphragm is displaced up, it causes increase in pressure in a pleural cavity and disorders of air exchange. Arises respiratory, and in the subsequent – metabolic acidosis. The respiratory distress syndrome is formed. Supply of a myocardium with oxygen is broken. Because of a sdavleniye of large venous trunks the central venous pressure increases, venous return to heart decreases, the intra cranial hypertensia caused by difficulty of outflow of blood from a brain develops. Owing to a sdavleniye of kidneys blood circulation in a kidney parenchyma worsens, the glomerular filtration is broken, the necrosis centers are formed. Defeat of renal fabric provokes increase in content of the hormones participating in regulation of function of kidneys. At a part of patients the sharp renal failure with an oliguriya or an anury is observed.
Steady increase in VBD carries the name of intrabryushny hypertensia. For definition of tactics of treatment use Bertsch's classification with coauthors in which four degrees of this state are allocated: 12-15, 16-20, 21-25 and more than 25 mm of mercury. AKS is associated with the intraabdominalny pressure making 20 mm of mercury. or more, exact indicators at which there occur zhizneugrozhayushchy changes are not established yet. Taking into account an etiologichesky factor distinguish three options of an abdominal kompartment-syndrome:
- Primary. It is provoked by pathological processes in a cavity of a stomach and zabryushinny space. It is found at injuries, peritonitis, pancreatitis, a rupture of aneurism of a belly aorta, extensive abdominal operations, large hematomas of zabryushinny cellulose.
- Secondary. It is formed at ekstraabdominalny pathological processes. It is diagnosed at heavy burns, sepsis, massive infusions.
- Tertiary. It is characterized by repeated emergence of symptomatology at the patients who transferred primary or secondary options of a syndrome. Change of the factors influencing VBD, for example, ushivany laparostoma becomes the reason usually. Indicators of mortality are higher, than at other forms.
Clinical displays of pathology are not specific, include the violations from different bodies and systems demonstrating development and progressing of polyorgan insufficiency. Data on the first symptoms differ. One researchers specify that the syndrome demonstrates tension of belly muscles, increase in volume of a stomach which are combined with respiratory frustration, reduction of a diuresis. Other experts believe that respiratory violations and an oliguriya advance abdominal symptomatology.
Breath is frequent, superficial. Oliguriya is replaced by an anury. Heartbeat increase, a lowering of arterial pressure at not changed or raised TsVD is noted. The phenomena of a respiratory, heart and renal failure quickly accrue, at independent breath there is a need of the transfer of the patient to IVL, stimulation of a diuresis is required, but use of diuretics quite often does not provide desirable result. In the absence of a decompression there comes death from the progressing violation of activity of vitals.
Characteristic complications of the kompartment-syndrome which arose after surgical interventions are insolvency of seams and anastomoz, suppuration of wounds. The probability of formation of intra belly abscesses, peritonitis, sepsis increases. After carrying out a decompressive laparotomy at 90% of patients hernias and intestinal fistulas are formed, at 22% multiple ligaturny fistulas are formed. Because of dysfunction of lungs the risk of pneumonia increases. At some patients with OPN phenomena in the remote period the chronic renal failure develops. Duration of treatment of the main diseases increases, the worst functional outcomes at injuries are noted.
Because of not specificity of manifestations and other possible reasons of polyorgan insufficiency diagnostics of this state on the basis of clinical symptoms causes essential difficulties. Taking into account weight of pathology and its threat for life of the patient with an optimal variant periodic preventive measurement of VBD at persons with risk of development of a kompartment-syndrome is considered. In case of existence of a laporostoma, drainage of an abdominal cavity, performance of peritonealny dialysis or a laparoscopy direct measurements of an indicator are possible, but because of complexity and invasiveness these methods are applied seldom.
The most widespread research is measurement of pressure in a bladder by a kateterization after removal of urine and introduction of 20-25 ml of warm solution. Besides, for measurement the stomach (via the nazogastralny probe) and the lower hollow vein can be used. Indicators of measurements can disperse a little from real VBD, however correctly carried out repeated procedures allow to receive rather exact picture of change of intra belly pressure. For early identification of dysfunction of kidneys exercise control of a diuresis.
Also include a X-ray analysis of a thorax and a number of laboratory researches in the program of inspection. On roentgenograms raising of domes of a diaphragm is noted. In the analysis of gases of arterial blood is defined sharp respiratory . At laboratory blood test increase in level of a lactate, urea, creatinine, alanineaminotransferase, alkaline phosphatase, decrease in pH of blood is found. In analyses of urine the proteinuria, an eritrotsituriya, a tsilindruriya comes to light.
Treatment of AKS
The surgical decompression is considered the main method of treatment of AKS, but indications to intervention are definitely not defined so far. In clinical practice the algorithm according to which at 1 and 2 degrees of intraabdominalny hypertensia observation and correction of infusional therapy is recommended is often used, at 3 – a decompressive laparotomy against the background of intensive therapy, at 4 – an urgent operational decompression and resuscitation actions. In the presence of ascites at the initial stage carrying out a puncture of an abdominal cavity, a laparotsentez or laparoscopy with the subsequent drainage is possible.
The surgical decompression is carried out in the conditions of the operating room or intensive care unit. Apply a cross or median section. Further carry out maintaining by method of "an open stomach". At normalization of VBD, absence of hypostasis of internals and surrounding fabrics the wound is taken in for 1-8 days. In other cases make the delayed closing of a laparostoma. For decrease in risk of development of hernias establish mesh transplants. Operational actions carry out against the background of control of vital indicators, IVL, stimulation of a diuresis, correction of exchange frustration, the prevention of a cardiovascular collapse owing to decrease in peripheral vascular resistance, prevention of the warm violations caused by receipt of a lactate and potassium in a blood-groove after elimination of ischemia.
Forecast and prevention
The forecast at an abdominal kompartment-syndrome is defined by timeliness of holding medical actions. At an operational decompression within the first 6 hours after emergence of signs of AKS (before formation of the developed picture of polyorgan insufficiency) survival makes 80%. At late interventions 43-65% of patients perish. In the absence of actions for a decompression the lethality reaches 100%. Prevention includes medical vigilance at arrival of patients with risk of formation of AKS, regular measurement of VGD, adequate respiratory support, correct infusional therapy. Some authors suggest not to impose seams on an aponeurosis at the severe injuries of a stomach and other pathologies provoking AKS, however this measure not always is effective.