Intraabdominelle Hypertonie und abdominelles Kompartmentsyndrom – Basiswissen und anästhesiologische Aspekte

Zusammenfassung

Ein pathologischer Anstieg des intraabdominellen Drucks kann Funktionsstörungen der Niere, des Darms, der Lunge, des Herzens, aber auch einen erhöhten intrakraniellen Druck nach sich ziehen. Risikofaktoren und pathophysiologische Konsequenzen der intraabdominellen Hypertonie und des abdominellen Kompartmentsyndroms werden diskutiert. Es wird auf anästhesiologische Aspekte bei der Betreuung dieser meist schwer kranken Patienten eingegangen, wie Aspirationsgefahr, Kreislaufinsuffizienz und differenzierte maschinelle Beatmung.

Abstract

The increase in intra–abdominal pressure may be followed by a renal, gut, respiratory and cardial dysfunction and an increase in intra–cranial pressure. The review focuses risk factors and pathophysiological consequences of intra–abdominal hypertension and of abdominal compartment syndrome. Patients with intra–abdominal hypertension and abdominal compartment syndrome are critical ill and need special anesthesiological care due to risk of pulmonary aspiration, hemodynamic disturbances and difficult mechaninal ventilation.

Schlüsselwörter:

intraabdomineller Druck - IAH - ACS - intraabdominelle Druckmessung

Key words:

intraabdominal pressure - IAH - ACS - intra–abdominal pressure monitoring

Kernaussagen

• Eine prolongierte IAH kann zu einer Beeinflussung aller Vitalfunktionen führen.

• Folgende Konstellation sollte immer an ein ACS denken lassen: prall gespanntes Abdomen, rückläufige Diurese, Anstieg des Beatmungsdruckes und zunehmende hämodynamische Instabilität.

• Mittels meist indirekter Messverfahren zur Abschätzung des IAP können Risikopatienten identifiziert werden; die Palpation des Abdomens allein gilt als unzuverlässig.

• Ergebnisse wiederholter Messungen sind als Trend zu betrachten und sollten im Kontext mit beeinträchtigten kardiorespiratorischen Parametern interpretiert werden, da der Krankheitswert eines erhöhten IAP interindividuell unterschiedlich ist.

• Die Entscheidung über ein therapeutisches Vorgehen kann nicht allein an pathologischen Einzelmesswerten fixiert werden.

• Eine Dekompressionslaparotomie ist die lebensrettende Intervention bei therapierefraktärem ACS und kann in total intravenöser oder balancierter Anästhesie (ohne N₂O) erfolgen.

• Die Dekompressionslaparotomie hat ein abdominelles Reperfusionssyndrom zur Folge, kann von einer Kreislaufdekompensation begleitet sein, erfordert die Anpassung der Beatmungsparameter bei akut veränderter Atemmechanik und sollte eine postoperative Fortführung des IAP–Monitorings nach sich ziehen.

Literaturverzeichnis

• 1 Malbrain M, Cheatham M, Kirkpatrick A. et al. . Results from the international conference of experts on intra–abdominal hypertension and abdominal compartment syndrome. I. Definitions.  Intensive Care Med. 2006;  32 1722-32
• 2 Malbrain M.. Different techniques to measure intra–abdominal pressure (IAP): time for a critical re–appraisal.  Intensive Care Med. 2004;  30 357-71
• 3 Suominen PK, Pakarinen MP, Rautiainen P. et al. . Comparison of direct and intravesical measurement of intraabdominal pressure in children.  J Pediatr Surg. 2006;  41 1381-5
• 4 Ejike JC, Bahjri K, Mathur M.. What is the normal intra–abdominal pressure in critically ill children and how should we measure it?.  Crit Care Med. 2008;  36 2157-62
• 5 Sugrue M.. Abdominal compartment syndrome.  Curr Opin Crit Care. 2005;  11 333-38
• 6 Cheatham M, Malbrain M, Kirkpatrick A. et al. . Results from the international conference of experts on intra–abdominal hypertension and abdominal compartment syndrome II. Recommendations.  Intensive Care Med. 2007;  33 951-62
• 7 Balogh Z, Mc BA Kinley, Holcomb JB. et al. . Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure.  J Trauma. 2003;  54 848-59
• 8 Harman P, Kron I, McLachlan H. et al. . Elevated intra–abdominal pressure and renal function.  Ann Surg. 1982;  196 594-97
• 9 Toens C, Schachtrupp A, Hoer J. et al. . A porcine model of the abdominal compartment syndrome.  Shock. 2002;  18 316-21
• 10 Knichwitz G, Kruse C, Aken H. Intestinale Perfusionsstörungen beim Intensivpatienten.  Anaesthesist. 2005;  54 41-8
• 11 Doty JM, Oda J, Ivatury RR. et al. . The effects of hemodynamic shock and increased intra–abdominal pressure on bacterial translocation.  J Trauma. 2002;  52 13-7
• 12 Alexakis N, Gakiopoulou H, Dimitriou C. et al. . Liver histology alterations during carbon dioxide pneumoperitoneum in a porcine model.  Surg Endosc. 2008;  22 415-20
• 13 Sugrue M, D'Amours S. The problems with positive end expiratory pressure (PEEP) in association with abdominal compartment syndrome (ACS).  J Trauma. 2001;  51 419-20
• 14 Zavorsky GS, Hoffman SL. Pulmonary gas exchange in the morbidly obese.  Obes Rev. 2008;  9 326-39
• 15 Ridings PC, Blocher CR, Sugerman HJ.. Cardiopulmonary effects of raised intra–abdominal pressure before and after intravascular volume expansion.  J Trauma. 1995;  39 1071-75
• 16 Cheatham M, Safcsak K, Block E. et al. . Preload assessment in patients with an open abdomen.  J Trauma. 1999;  46 16-22
• 17 Cheatham M, Malbrain M.. Intra–abdominal hypertension and the cardiovascular system. In: Ivatury R, Cheatham M, Malbrain M, Sugrue M. Abdominal compartment syndrome. Georgetown, TX: Landes Bioscience 2006: 89-104
• 18 Deeren D, Dits H, Malbrain M.. Correlation between intra–abdominal and intracranial pressure in nontraumatic brain injury.  Intensive Care Med. 2005;  31 1577-81
• 19 Bloomfield GL, Ridings PC, Blocher CR. et al. . A proposed relationship between increased intra–abdominal, intrathoracic, and intracranial pressure.  Crit Care Med. 1997;  25 496-503
• 20 Gennarelli TA, Champion HR, Copes WS. et al. . Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries.  J Trauma. 1994;  37 962-68
• 21 Balogh Z, Moore FA, Goettler CE. et al. .Surgical management of abdominal compartment syndrome. In: Ivatury R, Cheatham M, Malbrain M, Sugrue M: Abdominal compartment syndrome. Georgetown, TX: Landes Bioscience 2006: 266-93
• 22 Lavery GG, McCloskey BV.. The difficult airway in adult critical care.  Crit Care Med. 2008;  36 2163-73
• 23 Berthoud MC, Peacock JE, Reilly CS.. Effectiveness of preoxygenation in morbidly obese patients.  Br J Anaesth. 1991;  67 464-66
• 24 Duggan M, Kavanagh BP.. Pulmonary atelectasis. A pathogenic perioperative entity.  Anesthesiology. 2005;  102 838-54
• 25 Coussa M, Proietti S, Schnyder P. et al. . Prevention of atelectasis formation during the induction of general anesthesia in morbidly obese patients.  Anesth Analg. 2004;  98 1491-5
• 26 Dixon BJ, Dixon JB, Carden JR. et al. . Preoxygenation is more effective in the 25° head–up position than in the supine position in severely obese patients.  Anesthesiology. 2005;  102 1110-5
• 27 Neumann P, Rothen HU, Berglung JE. et al. . Positive end–expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration.  Acta Anaesthesiol Scand. 1999;  43 295-301
• 28 Pelosi P, Ravagnan I, Giurati G. et al. . Positive end–expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis.  Anesthesiology. 1999;  91 1221-31
• 29 Whalen FX, Ognjen O Gajic, Thompson GB. et al. . The effects of the alveolar recruitment maneuver and positive end–expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery.  Anesth Analg. 2006;  102 298-305
• 30 Ezri T, Hazin V, Warters D. et al. . The endotracheal tube moves more often in obese patients undergoing laparoscopy compared with open abdominal surgery.  Anesth Analg. 2003;  96 278-82
• 31 Mertens zur Borg IR, Verbrugge SJ, Kolkman KA.. Anesthetic considerations in abdominal compartment syndrome. In: Ivatury RR, Cheatham ML, Malbrain MLNG, Sugrue M, eds. Abdominal compartment syndrome. Georgetown, TX: Landes Bioscience 2006: 254-265
• 32 Hogan QH, Prost R, Kulier A. et al. . Magnetic resonance imaging of cerebrospinal fluid volume and the influence of body habitus and abdominal pressure.  Anesthesiology. 1996;  84 1341-9
• 33 Anderton JM.. The prone position for the surgical patient: A historical review of the principles and hazards.  Br J Anaesth. 1991;  67 452-63
• 34 Huang GJ, Bajaj AK, Gupta S. et al. . Increased intraabdominal pressure in abdominoplasty: delineation of risk factors.  Plast Reconstr Surg. 2007;  119 1319-25
• 35 Park CK.. The effect of patient positioning on intraabdominal pressure and blood loss in spinal surgery.  Anesth Analg. 2000;  91 552-7
• 36 Perilli V, Sollazzi L, Bozza P. et al. . The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery.  Anesth Analg. 2000;  91 1520-5
• 37 Valenza F, Vagginelli F, Tiby A. et al. . Effects of the beach chair position, positive end–expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis.  Anesthesiology. 2007;  107 725-32
• 38 Burns SM, Egloff MB, Ryan B. et al. . Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites.  Am J Crit Care. 1994;  3 102-6
• 39 Malhotra SK, Nakra D.. Detection of impending abdominal compartment syndrome.  Anaesthesia. 2004;  59 1146-47
• 40 Biancofiore G, Bindi ML, Romanelli AM. et al. . Intra–abdominal pressure monitoring in liver transplant recipients: A prospective study.  Intensive Care Med. 2003;  29 30-6
• 41 Yaster M, Scherer TL, Stone MM. et al. . Prediction of successful primary closure of congenital abdominal wall defects using intraoperative measurements.  J Pediatr Surg. 1989;  24 1217-20
• 42 Ertel W, Oberholzer A, Platz A. et al. . Incidence and clinical pattern of the abdominal compartment syndrome after ”damage control” laparotomy in 311 patients with severe abdominal trauma.  Crit Care Med. 2000;  28 1747-53
• 43 Cheatham M, White M, Sagraves S. et al. . Abdominal perfusion pressure: a superior parameter in the assessment of intra–abdominal hypertension.  J Trauma. 2000;  49 621-26
• 44 Balogh Z, McKinley B, Cocanour C. et al. . Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome.  Arch Surg. 2003;  138 637-42
• 45 Dos Santos CC, Slutsky AS.. Invited review: mechanisms of ventilator–induced lung injury: a perspective.  J Appl Physiol. 2000;  89 1645-55