Definisi
Abdominal compartement syndrome (ACS): peningkatan intra
abdominal pressure (IAP) >20 mmHg + gagal organ. IAP Normal: 5-7 mmHg, batas atas 12 mmHg (kronik 10-15 mmHg) Intra abdominal hypertension (IAH): IAP 12 mmHg (1876) Abdominal perfusion pressure (APP): MAP-IAP (normal = 60 mmHg) evaluasi efek relatif IAH terhadap perfusi organ
(World Society of the Abdominal Compartment Syndrome, 2009)
Epidemiologi
Mengikuti trauma abdomen, perdarahan hebat, syok,
resusitasi cairan masif, operasi lama & koagulopati Meldrum et al: 21 (14%) dari 145 pasien trauma abdomen berat (Injury Severity Score >15), 60% trauma tumpul, 100% damage control laparotomy, 67% abdominal packing, liver injuries (57%), multiple injuries (splenic, renal, hollow viscus) WSACS: ~ 4,2% dari pasien ICU. Insiden ACS pada usia, jenis kelamin dan ras tertentu?
Etiologi
1. Akut: intraperitoneal (peritonitis, ruptur aorta, AGD, obstruksi & distensi usus, obstruksi vena mesenterium, pneumo/hematoperitoneum, abdominal packing, abscess, edema visceral) retroperitoneal (pankreatitis, perdarahan, operasi aorta, abscess, edema visceral) dinding abdomen (burn eschar, repair gastroschisis/ omphalocele, reduksi hernia yang besar, military anti-shock garments, laparotomy closure under extreme tension) 2. Kronik: obesitas sentral, ascites, tumor, CAPD, kehamilan.
Faktor Resiko
1. Penurunan komplians dinding abdomen: operasi abdomen, ventilasi mekanik, ARDS, prone position, luka bakar luas/trauma, obesitas (BMI>30) 2. Intra-abdominal content: disfungsi liver (ascites), acute colonic pseudo-obstruction; colonic dilatation (Olgivies syndrome), tumour, hemo/pneumoperitoneum, Ileus/gastroparesis, increasing intraluminal fluid content (e.g., contrast enema) 3. Kebocoran kapiler/resusitasi: resusitasi masif, hipotensi, politransfusi (>10 unit/24 jam), koagulopati, asidosis (pH<7.2), luka bakar luas/trauma, sepsis, laparotomi emergensi, hipothermia (<33oC)
Klasifikasi ACS
Primer: cedera atau penyakit regio abdominopelvik
Patofisiologi
mengejan, bersin, defekasi, atau aktivitas fisik). Akut: IAP terjadi beberapa jam (trauma atau perdarahan intraabdomen ). Subakut: IAP terjadi beberapa hari (pasien medik). Kronik: IAP terjadi beberapa bulan (kehamilan) atau tahun (obesitas morbid).
Anamnesis
Sakit berat & sulit berkomunikasi Kembung Nyeri perut Malaise Sesak Sinkop Melena NSAID Alcohol abuse Nausea dan vomiting Riwayat pankreatitis
Pemeriksaan Fisik
Distensi abdomen (lingkar perut ) Nyeri tekan abdomen Hipoperfusi: akral dingin, sianosis Frekuensi nafas , Wheezing, ronkhi Lain-lain: hipotensi, takikardia, JVP meningkat, edema
perifer Oliguria refrakter Peningkatan PIP Hiperkarbia Hipoksemia refrakter Asidosis metabolik refrakter Peningkatan ICP
Pemeriksaan Penunjang
Lab: CBC, PT, aPTT, LFT, RFT, SE, BGA, Albumin, amilase, lipase Radiologis: Foto polos: penurunan volume paru, atelektasis, elevasi
hemidiafragma. USG: FAST CT Scan: Tense infiltration retroperitoneum Kompresi ekstrinsik IVC Distensi abdomen masif (round belly sign) Kompresi renal Penebalan dinding usus Herniasi inguinal bilateral
Foto polos
Elevasi hemidiafragma
USG
CT Scan
IVC kolaps
Diagnosis
Definitif: pengukuran IAP Direk (kateter intraperitoneal), indirek (intragastric, intracolonic, intravesical, kateter vena cava inferior) Intravesical pressure: metode standar untuk screening, sederhana, minimal invasif, akurat & resiko rendah Indikasi: Postop abdomen dengan distensi abdomen Trauma abdomen (tajam atau tumpul) Pasien terpasang ventilator dengan gagal organ Distensi abdomen dengan tanda-tanda ACS High cumulative fluid balance Abdominal packing (Deenichin GP, 2008)
Pressure Transducer
Monitor
Klem
Penatalaksanaan
1. Supportif menurunkan IAP NGT Drainase rektal Dekompresi kateter perkutan Posisi supine/ elevasi 30o Komplians dinding abdomen: kontrol nyeri & sedasi Ventilator Hemodinamik: batasi jumlah cairan, koloid > kristaloid
2. Surgical Decompression Indikasi: intervensi medik gagal, IAP > 25 mmHg Waktu: dekompresi dini lebih efektif Tehnik: midline laparostomy, transverse bilateral extended incision Tempat: OK atau bedside ICU. Komplikasi: jarang, berhubungan dengan manajemen & komplikasi open abdomen
Algoritme Tatalaksana
atmospheric fistulae) Temporary abdominal closure (TAC): plastic silo (Bogota bag), vacuum pack (polyurethane sheet), kombinasi vacuum-dressing dan temporary mesh, zipper komplikasi: kehilangan cairan dan protein, fistula, kontaminasi, eviscerasi, obstruksi, hernia, hipotermia
Zipper. 1938
Leppaniemi A, 2009
Vacuum asisted
Primary Fascial Closure: Sumber infeksi terkontrol Selama periode awal rawat inap Gradual Mesh prosthesis Planned Hernia: Skin coverage with subsequent delayed abdominal wall reconstruction Autologous STSG
Pencegahan
1. Primary ACS IAP monitoring Predictors: low temperature, low hemoglobin concentration, high base deficit 2. Secondary ACS Routine IAP monitoring Predictors: high crystalloid infusion volume, impaired renal function Systemic oxygenation, normovolemia, & correction of coagulopathy. Open drainage (laparostomy) 3. Serum d-lactate level: serum marker, product of bacterial metabolism
Prognosis
Mortalitas karena ACS>non ACS (38-71%), perawatan
adekuat (40%), setelah dekompresi (47%), setelah laparotomi (49,2%), ACS sekunder 67% Insiden disfungsi multiorgan tetap tinggi mesti ACS dikenali dan diterapi secara dini
Kesimpulan
Peningkatan IAP mempengaruhi perfusi regional dan
sistemik Meskipun dapat dikenali dan diterapi secara dini insiden MOF tetap tinggi Penyebab klasik: trauma berat, resusitasi cairan masif, dan operasi lama Curiga ACS: distensi abdomen, nyeri tekan, peristaltik menurun, oligoanuria, pasien dengan ventilator, progresifitas MOF Diagnosis: pengukuran IAP Tatalaksana: laparotomi dekompresi dengan TAC
Daftar Pustaka
Cheatham ML. 2009. Abdominal Compartment Syndrome: pathophysiology
and definitions. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Leppaniemi A. 2009. Surgical management of abdominal compartement syndrome; indication and techniques. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Luckianow GM, Ellis M, Governale D, and Kaplan LJ. 2009. Abdominal Compartment Syndrome: Risk Factors, Diagnosis, and Current Therapy. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Walker J and Criddle LM. 2003. Pathophysiology and Management of Abdominal Compartment Syndrome. American Journal of Critical Care Deenichin GP. 2008. Abdominal Compartment Syndrome. Surgery Today. 38:519 Deslauriers N, Dery R, Denault A. 2009. Abdominal Compartement Syndrome. Canadian Journal of Anesthesiology. Stassen NA, Lukan JK, Dixon MS, Carillo EH. 2002. Abdominal Compartement Syndrome. Scandinavian Journal of Surgery. Laffargue G, Taourel P, Saguintaah M, Lesnik A. 2002. CT Diagnosis of Abdominal Compartment Syndrome. American Journal of Roentgenology.