The secondary abdominal compartment syndrome (ACS) is defined as the presence of organ dysfunction with concurrent intra-abdominal hypertension (IAH) in a scenario lacking primary intraperitoneal injury or intervention. This state appears to be related to visceral, abdominal wall and retroperitoneal edema and ascites induced by resuscitation. Despite a diverse range of associated causes such as pancreatitis, intra-abdominal sepsis, cardiac arrest, thermal injury and extraperitoneal trauma, this class of ACS is characterized by the presence of shock requiring aggressive fluid resuscitation. Secondary ACS is an extreme condition along a continuum of raised intra-abdominal pressure (IAP) that is pathoneumonic when associated with new overt organ failure. When IAP is above normal but is not associated with organ failure, IAH is diagnosed. Because these conditions are common among critically ill patients, the measurement of IAP is crucial. It is unclear whether preventing IAH reduces progression to ACS or influences outcomes. When overt ACS is confirmed, immediate surgical decompression of the patient's abdomen via a standard laparotomy is usually required. Because many disease processes resulting in critical illness require aggressive fluid resuscitation as a primary therapy, it is likely that secondary ACS is much more common than previously believed. Further study is needed.
AIM: To study retrospectively the influence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in patients with early acute pancreatitis (AP) (during the first week after admission) on physiological functions, and the association of the presence of IAH/ACS and outcome.
METHODS: Patients (n = 74) with AP recruited in this study were divided into two groups according to intra-abdominal pressure (IAP) determined by indirect measurement using the transvesical route via Foley bladder catheter during the first week after admission. Patients (n = 44) with IAP ≥ 12 mmHg were assigned in IAH group, and the remaining patients (n = 30) with IAP < 12 mmHg in normal IAP group. For analysis of the influence of IAH/ACS on organ function and outcome, the physiological parameters and the occurrence of organ dysfunction during intensive care unit (ICU) stay were recorded, as were the incidences of pancreatic infection and in-hospital mortality.
RESULTS: IAH within the first week after admission was found in 44 patients (59.46%). Although the APACHE II scores on admission and the Ranson scores within 48 h after hospitalization were elevated in IAH patients in early stage, they did not show the statistically significant differences from patients with normal IAP within a week after admission (16.18 ± 3.90 vs 15.70 ± 4.25, P = 0.616; 3.70 ± 0.93 vs 3.47 ± 0.94, P = 0.285, respectively). ACS in early AP was recorded in 20 patients (27.03%). During any 24-h period of the first week after admission, the recorded mean IAP correlated significantly with the Marshall score calculated at the same time interval in IAH group (r = 0.635, P < 0.001). Although ACS patients had obvious amelioration in physiological variables within 24 h after decompression, the incidences of pancreatitic infection, septic shock, multiple organ dysfunction syndrome (MODS) and death in the patients with ACS were significantly higher than that in other patients without ACS (pancreatitic infection: 60.0% vs 7.4%, P < 0.001; septic shock: 70.0% vs 11.1%, P < 0.001; MODS: 90.0% vs 31.5%, P < 0.001; mortality: 75.0% vs 3.7%, P < 0.001).
CONCLUSION: IAH/ACS is a frequent finding in patients admitted to the ICU because of AP. Patients with IAP at approximately 10-12 mmHg and early signs of changes in physiologic variables should be seriously considered for urgent decompression to improve survival.
Acute pancreatitis; Abdominal compartment syndrome; Intra-abdominal pressure; Intra-abdominal hypertension; Organ dysfunction
Abdominal compartment syndrome has been described in patients with severe acute pancreatitis, but its clinical impact remains unclear. We therefore studied patient factors associated with the development of intra-abdominal hypertension (IAH), the incidence of organ failure associated with IAH, and the effect on outcome in patients with severe acute pancreatitis (SAP).
We studied all patients admitted to the intensive care unit (ICU) because of SAP in a 4 year period. The incidence of IAH (defined as intra-abdominal pressure ≥ 15 mmHg) was recorded. The occurrence of organ dysfunction during ICU stay was recorded, as was the length of stay in the ICU and outcome.
The analysis included 44 patients, and IAP measurements were obtained from 27 patients. IAH was found in 21 patients (78%). The maximum IAP in these patients averaged 27 mmHg. APACHE II and Ranson scores on admission were higher in patients who developed IAH. The incidence of organ dysfunction was high in patients with IAH: respiratory failure 95%, cardiovascular failure 91%, and renal failure 86%. Mortality in the patients with IAH was not significantly higher compared to patients without IAH (38% versus 16%, p = 0.63), but patients with IAH stayed significantly longer in the ICU and in the hospital. Four patients underwent abdominal decompression because of abdominal compartment syndrome, three of whom died in the early postoperative course.
IAH is a frequent finding in patients admitted to the ICU because of SAP, and is associated with a high occurrence rate of organ dysfunction. Mortality is high in patients with IAH, and because the direct causal relationship between IAH and organ dysfunction is not proven in patients with SAP, surgical decompression should not routinely be performed.
To investigate the effects of positive end-expiratory pressure (PEEP) on respiratory function and hemodynamics in patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) with normal intra-abdominal pressure (IAP < 12 mmHg) and with intra-abdominal hypertension (IAH, defined as IAP ≥ 12 mmHg) during lung protective ventilation and a decremental PEEP, a prospective, observational clinical pilot study was performed.
Twenty patients with ALI/ARDS with normal IAP or IAH treated in the surgical intensive care unit in a university hospital were studied. The mean IAP in patients with IAH and normal IAP was 16 ± 3 mmHg and 8 ± 3 mmHg, respectively (P < 0.001). At different PEEP levels (5, 10, 15, 20 cmH2O) we measured respiratory mechanics, partitioned into its lung and chest wall components, alveolar recruitment, gas-exchange, hemodynamics, extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI).
We found that ALI/ARDS patients with IAH, as compared to those with normal IAP, were characterized by: a) no differences in gas-exchange, respiratory mechanics, partitioned into its lung and chest wall components, as well as hemodynamics and EVLWI/ITBVI; b) decreased elastance of the respiratory system and the lung, but no differences in alveolar recruitment and oxygenation or hemodynamics, when PEEP was increased at 10 and 15cmH2O; c) at higher levels of PEEP, EVLWI was lower in ALI/ARDS patients with IAH as compared with those with normal IAP.
IAH, within the limits of IAP measured in the present study, does not affect interpretation of respiratory mechanics, alveolar recruitment and hemodynamics.
Postoperative intra-abdominal hypertension (IAH) is a frequent occurrence in critically ill patients operated on for severe abdominal trauma, secondary peritonitis or ruptured abdominal aortic aneurysm. IAH may progress to abdominal compartment syndrome (ACS) with new-onset organ dysfunction. Early recognition of IAH and interventions that prevent the development of ACS may preserve vital organ functions and increase the probability of survival. The best method to prevent postoperative ACS is to leave the abdomen open during the operation. The decision to leave the abdomen open is usually based on the surgeon's judgment without intra-abdominal pressure (IAP) measurements during the operation. Because significant morbidity and mortality are associated with the open abdomen, the measurement of IAP immediately after the fascial closure, when feasible, could offer an objective method for determining the optimal IAP threshold for leaving the abdomen open. The management of the open abdomen requires a temporary abdominal closure (TAC) system that would ideally prevent the development of ACS and facilitate later primary fascia closure. Among several TAC systems, the most promising are those that provide negative pressure to the wound or continuous fascial traction or both.
Abdominal compartment syndrome (ACS) and intra abdominal hypertension(IAH) are common clinical findings in patients with severe acute pancreatitis(SAP). It is thought that an increased intra abdominal pressure(IAP) is associated with poor prognosis in SAP patients. But the detailed effect of IAH/ACS on different organ system is not clear. The aim of this study was to assess the effect of SAP combined with IAH on hemodynamics, systemic oxygenation, and organ damage in a 12 h lasting porcine model.
Measurements and Methods
Following baseline registrations, a total of 30 animals were divided into 5 groups (6 animals in each group): SAP+IAP30 group, SAP+IAP20 group, SAP group, IAP30 group(sham-operated but without SAP) and sham-operated group. We used a N2 pneumoperitoneum to induce different levels of IAH and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. The investigation period was 12 h. Hemodynamic parameters (CO, HR, MAP, CVP), urine output, oxygenation parameters(e.g., SvO2, PO2, PaCO2), peak inspiratory pressure, as well as serum parameters (e.g., ALT, amylase, lactate, creatinine) were recorded. Histological examination of liver, intestine, pancreas, and lung was performed.
Cardiac output significantly decreased in the SAP+IAH animals compared with other groups. Furthermore, AST, creatinine, SUN and lactate showed similar increasing tendency paralleled with profoundly decrease in SvO2. The histopathological analyses also revealed higher grade injury of liver, intestine, pancreas and lung in the SAP+IAH groups. However, few differences were found between the two SAP+IAH groups with different levels of IAP.
Our newly developed porcine SAP+IAH model demonstrated that there were remarkable effects on global hemodynamics, oxygenation and organ function in response to sustained IAH of 12 h combined with SAP. Moreover, our model should be helpful to study the mechanisms of IAH/ACS-induced exacerbation and to optimize the treatment strategies for counteracting the development of organ dysfunction.
The abdominal compartment syndrome (ACS) was first described in surgical patients with abdominal aortic aneurysm repair, trauma, bleeding, or infection, but in recent years it has also been described in patients with other pathologies such as burn injury and sepsis and in medical patients. This F1000 Medicine Report is intended to provide critical care physicians a clear insight into the current state of knowledge regarding intra-abdominal hypertension (IAH) and ACS, and will focus primarily on the recent literature as well as on the definitions and recommendations published by the World Society of the Abdominal Compartment Syndrome. The definitions regarding increased intra-abdominal pressure (IAP) will be listed, followed by a brief but comprehensive overview of the different mechanisms of organ dysfunction associated with IAH. The gold standard measurement technique for IAP as well as recommendations for organ function support in patients with IAH and options for medical and surgical treatment of IAH and ACS will be discussed.
The last several decades have seen many advances in the recognition and prevention of the abdominal compartment syndrome (ACS) and its precursor, intra-abdominal hypertension (IAH). There has also been a relative explosion of knowledge in the critical care, trauma, and surgical populations, and the inception of a society dedicated to its understanding, the World Society of the Abdominal Compartment Syndrome (WSACS). However, there has been almost no recognition or appreciation of the potential presence, influence, and management of intra-abdominal pressure (IAP), IAH, and ACS in pregnancy. This review highlights the importance and relevance of IAP in the critically ill parturient, the current lack of normative IAP values in pregnancy today, along with a review of the potential relationship between IAH and maternal diseases such as preeclampsia-eclampsia and its potential impact on fetal development. Finally, current IAP measurement guidelines are questioned, as they do not take into account the gravid uterus and its mechanical impact on intra-vesicular pressure.
intra-abdominal pressure; intra-abdominal hypertension; pregnancy; preeclampsia-eclampsia.
Studies have documented the impact of intra-abdominal hypertension (IAH) on virtually every organ. However, it still remains strangely underdiagnosed. The aims of the study were to assess, in patients undergoing emergency laparotomy, whether intra-abdominal pressure (IAP) is an independent predictor of morbidity and mortality, to evaluate the effects of IAH, and to identify hidden cases of abdominal compartment syndrome (ACS).
Materials and Methods:
The study comprised
197 patients undergoing emergency laparotomy. IAP was measured preoperatively and then postoperatively at 0, 6, and 24 hours. Duration of hospital stay, occurrence of burst abdomen, and mortality were noted as outcomes.
At admission, incidence of IAH was 80%. No significant association was found between IAP and occurrence of burst abdomen (P > 0.1). IAP was found to be a significant predictor of mortality in patients undergoing laparotomy (P < 0.001). Elevated IAP was found to affect all the organ systems adversely. The incidence of post-op ACS was 3.05% in the general population and 13.16% in trauma patients. The mortality rate for this subgroup was 100%.
IAP is a significant predictor of mortality in patients undergoing laparotomy. IAH has detrimental effects on various organ systems. A more frequent monitoring with prompt decompression may be helpful in decreasing the mortality rate. Further studies are required to establish a screening protocol in patients undergoing laparotomy to detect and manage cases of IAH and ACS.
Abdominal compartment syndrome; intra-abdominal hypertension; intra-abdominal pressure
Data on intra-abdominal hypertension [IAH] and secondary abdominal compartment syndrome [ACS] due to neurological insults are limited.
This was a prospective observational study conducted between January 2010 and January 2011 in the neurological ICU [NICU]. Forty-one consecutive patients with sellar region tumors [SRT] were enrolled into the study. If conservative therapy was ineffective in patients with ACS, thoracic epidural anesthesia [EA] was performed. Primary endpoint was defined as the efficacy of conservative treatment and EA in patients with IAH and ACS; secondary endpoint, the influence of IAH and ACS on outcomes.
Of the 41 patients, 13 (31.7%) had normal intra-abdominal pressure and 28 (68.3%) developed IAH, of whom 9 (22%) had ACS (group II). On average, IAH developed on the second postoperative day, while ACS, between the third and the fifth day. Multiple organ dysfunction developed in 3 (23.1%) patients of group I and in 23 (82%) patients of group II (p = 0.0003). Ileus due to gastrointestinal dysmotility was present in 6 (46.2%) patients of group I and in all patients of group II (p = 0.0001). Significant risk factors for ileus were diencephalon dysfunction (whole group - in 33 patients (80.5%); group I - in 6 patients (46.2%); group II - in 27 patients (96.4%), p = 0.0002) and sepsis (whole group - in 8 patients (19.5%); group I - no cases; group II - in 8 patients (28.6%), p = 0.03). Conservative treatment was effective in the majority of patients (78.9%) with IAH and only in 3 (33%) patients with ACS. Thoracic EA was performed in four patients with ACS with success. Length of stay in the NICU was 6.5 ± 4.6 days in group I and 24.1 ± 25.7 (p = 0.02) days in group II. Five out of nine (55.6%) patients with ACS died. None of these patients received EA. All patients with EA had favorable outcomes.
The development of IAH is common after SRT surgery. If conservative treatment is ineffective, EA can be considered in patients with secondary ACS. Further studies are warranted.
intra-abdominal pressure; intra-abdominal hypertension; abdominal compartment syndrome; epidural anesthesia; neurocritical care; sellar region tumor; ileus; postoperative complication.
The importance of intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) in cirrhotic patients with septic shock is not well studied. We evaluated the relationship between IAP and APP and outcomes of cirrhotic septic patients, and assessed the ability of these measures compared to other common resuscitative endpoints to differentiate survivors from nonsurvivors.
This study was a post hoc analysis of a randomized double-blind placebo-controlled trial in which mean arterial pressure (MAP), central venous oxygen saturation (ScvO2) and IAP were measured every 6 h in 61 cirrhotic septic patients admitted to the intensive care unit. APP was calculated as MAP - IAP. Intra-abdominal hypertension (IAH) was defined as mean IAP ≥ 12 mmHg, and abdominal hypoperfusion as mean APP < 60 mmHg. Measured outcomes included ICU and hospital mortality, need for renal replacement therapy (RRT) and ventilator- and vasopressor-free days.
IAH prevalence on the first ICU day was 82%, and incidence in the first 7 days was 97%. Compared to patients with normal IAP, IAH patients had significantly higher ICU mortality (74.0% vs. 27.3%, p = 0.005), required more RRT (78.0% vs. 45.5%, p = 0.06) and had lower ventilator- and vasopressor-free days. On a multivariate logistic regression analysis, IAH was an independent predictor of both ICU mortality (odds ratio (OR), 12.20; 95% confidence interval (CI), 1.92 to 77.31, p = 0.008) and need for RRT (OR, 6.78; 95% CI, 1.29 to 35.70, p = 0.02). Using receiver operating characteristic curves, IAP (area under the curve (AUC) = 0.74, p = 0.004), APP (AUC = 0.71, p = 0.01), Acute Physiology and Chronic Health Evaluation II score (AUC = 0.71, p = 0.02), but not MAP, differentiated survivors from nonsurvivors.
IAH is highly prevalent in cirrhotic patients with septic shock and is associated with increased ICU morbidity and mortality.
liver cirrhosis; sepsis; compartment syndrome; septic shock; ascites; mortality.
Background. We aimed to describe the incidence of intra-abdominal hypertension (IAH) and gastrointestinal (GI) symptoms and related outcome in mechanically ventilated (MV) patients. Methods. Intra-abdominal pressure (IAP) and gastric residual volumes were measured at least twice daily. IAH was defined as a mean daily value of IAP ≥ 12 mmHg. Results. 398 patients were monitored for all together 2987 days. GI symptom(s) occurred in 80.2% patients. 152 (38.2%) patients developed IAH. Majority (93.4%) of patients with IAH had GI symptoms. The more severe IAH was associated with the higher number of concomitant GI symptoms (P < .001). 142 (35.7%) patients developed both IAH and at least one GI symptom at any time in ICU, and in 77 patients they occurred simultaneously on the same day. This subgroup had the highest ICU mortality (21.8%). In contrast, the small group of patients presenting only IAH, but not GI symptoms (10 patients), had no lethal outcome. Three patients (4.4%) died without showing either IAH or GI symptoms. Conclusions. GI symptoms and IAH often, but not always, occur together. The patients having IAH solely without developing GI symptoms have rather good outcome.
The aim of this study was to determine the incidence of intra-abdominal hypertension (IAH) in patients with two or more categorized risk factors (CRF) for IAH, and their morbidity and mortality during their intensive care unit (ICU) stay.
Prospective cohort study carried out at a medical ICU. A total of 151 medical patients were enrolled during a period of 3 months. After ICU whole staff training, we conducted daily screening of the four CRF for IAH based on the World Society of Abdominal Compartment Syndrome (WSACS) guidelines (namely, diminished abdominal wall compliance, increased intraluminal content, increased abdominal content, and capillary leak syndrome or fluid resuscitation). In those patients with risk factors of at least two different categories (≥2 CRF), intra-abdominal pressure (IAP) was measured every 8 h during ICU stay. Data included demographics, main diagnosis on admission, severity scores, cumulative fluid balance, daily mean IAP, resolution of IAH, days of ICU and hospital stay, and mortality.
Eighty-seven patients (57.6%) had ≥2 CRF for IAH, 59 (67.8%) out of whom developed IAH. Patients with ≥2 CRF had a significantly higher mortality rate (41.4 vs. 14.3%, p < 0.001). Patients with IAH had higher body mass index, severity scores, organ dysfunctions/failures, number of CRF for IAH, days of ICU/hospital stay and hospital mortality rate (45.8 vs. 32.1%, p = 0.22). Non-resolution of IAH was associated with a higher mortality rate (64.7 vs. 35.3%, p = 0.001). None of the cohort patients developed abdominal compartment syndrome. The multivariate analysis showed that IAH development (odds ratio (OR) 4.09; 95% confidence interval (CI) 0.83-20.12) was a non-independent risk factor for mortality, and its non-resolution (OR 13.15; 95% CI 22.13-81.92) was an independent risk factor for mortality.
Critically ill medical patients admitted to ICU with ≥2 CRF have high morbidity, mortality rate, and incidence of IAH, so IAP should be measured and monitored as recommended by the WSACS. Our study highlights the importance of implementing screening and assessment protocols for an early diagnosis of IAH.
intra-abdominal hypertension; abdominal compartment syndrome; intra-abdominal pressure; multiple organ failure; critically ill patients; intensive care.
Critically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control.
This prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring.
The Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups.
Patients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and earlier discharge from the ICU as compared to similar patients treated with the Bogota bag.
Several decades ago, the beneficial effects of goal-directed therapy, which include decompressive laparotomy (DL) and open abdomen procedures in cases of intra-abdominal hypertension (IAH) in children, were proven in the context of closures of abdominal wall defects and large-for-size organ transplantations. Different neonatologic and pediatric disease patterns are also known to be capable of increasing intra-abdominal pressure (IAP). Nevertheless, a considerable knowledge transfer regarding such risk factors has hardly taken place. When left undetected and untreated, IAH threatens to evolve into abdominal compartment syndrome (ACS), which is accompanied by a mortality rate of up to 60% in children. Therefore, the present study looks at the recognition and knowledge of IAH/ACS among German pediatric intensivists.
In June 2010, a questionnaire was mailed to the heads of pediatric intensive care units of 205 German pediatric hospitals.
The response rate was 62%. At least one case of IAH was reported by 36% of respondents; at least one case of ACS, by 25%. Compared with adolescents, younger critically ill children appeared to develop IAH/ACS more often. Routine measurements of IAP were said to be performed by 20% of respondents. Bladder pressure was used most frequently (96%) to assess IAP. Some respondents (17%) only measured IAP in cases of organ dysfunction and failure. In 2009, the year preceding this study, 21% of respondents claimed to have performed a DL. Surgical decompression was indicated if signs of organ dysfunction were present. This was also done in cases of at least grade III IAH (IAP > 15 mmHg) without organ impairment.
Although awareness among pediatricians appears to have been increasing over the last decade, definitions and guidelines regarding the diagnosis and management of IAH/ACS are not applied uniformly. This variability could express an ever present lack of awareness and solid prospective data.
intra-abdominal pressure; intra-abdominal hypertension; abdominal compartment syndrome; children; intensive care unit; questionnaire; decompressive laparotomy.
Intra-abdominal pressure (IAP) is seldom measured by default in intensive care patients. This review summarises the current evidence on the prevalence and risk factors of intra-abdominal hypertension (IAH) to assist the decision-making for IAP monitoring.
IAH occurs in 20% to 40% of intensive care patients. High body mass index (BMI), abdominal surgery, liver dysfunction/ascites, hypotension/vasoactive therapy, respiratory failure and excessive fluid balance are risk factors of IAH in the general ICU population. IAP monitoring is strongly supported in mechanically ventilated patients with severe burns, severe trauma, severe acute pancreatitis, liver failure or ruptured aortic aneurysms. The risk of developing IAH is minimal in mechanically ventilated patients with positive end-expiratory pressure < 10 cmH2O, PaO2/FiO2 > 300, and BMI < 30 and without pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding or laparotomy and the use of vasopressors/inotropes on admission. In these patients, omitting IAP measurements might be considered.
In conclusions, clear guidelines to select the patients in whom IAP measurements should be performed cannot be given at present. In addition to IAP measurements in at-risk patients, a clinical assessment of the signs of IAH should be a part of every ICU patient's bedside evaluation, leading to prompt IAP monitoring in case of the slightest suspicion of IAH development.
intra-abdominal pressure; intra-abdominal hypertension; abdominal compartment syndrome; patient monitoring; intensive care; epidemiology.
Intra-abdominal hypertension [IAH] occurs frequently among critically ill patients and is associated with increased mortality and organ failure. Two porcine models of IAH that cause abdominal compartment syndrome [ACS] with organ dysfunction were created. We investigated whether the two methods used to create IAH - CO2 pneumoperitoneum or adding volume to the intra-abdominal space - exerted different impacts on the temporal development of organ dysfunction.
Twenty-four 40-kg female pigs were allocated to four groups: 25 mmHg IAH with CO2 pneumoperitoneum (n = 8), >20 mmHg IAH caused by addition of volume (n = 8), and two corresponding sham groups (each n = 4). The two sham groups were later pooled into one control group (n = 8). The animals were monitored for 12 h. Repeated serial measurements were taken of group differences over time and analyzed using analysis of variance.
Thirty-eight percent of the animals (n = 3) in each intervention group died near the end of the 12-h experiment. Both intervention groups experienced kidney impairment: increased creatinine concentration (P <0.0001), anuria (P = 0.0005), hyperkalemia (P <0.0001), decreased abdominal perfusion pressure, and decreased dynamic lung compliance. CO2 pneumoperitoneum animals developed hypercapnia (P <0.0001) and acidosis (P <0.0001).
Both methods caused ACS and organ dysfunction within 12 h. Hypercapnia and acidosis developed in the CO2 pneumoperitoneum group.
multiple organ failure; multiple organ dysfunction syndrome; swine; acute kidney injury; acidosis; abdomen.
The aims of our study were to evaluate the impact of increased intra-abdominal pressure (IAP) on central nervous system (CNS) cytokines (Interleukin 6 and tumor necrosis factor), lactate and perfusion pressures, testing the hypothesis that intra-abdominal hypertension (IAH) may possibly lead to CNS ischemia.
Fifteen pigs were studied. Helium pneumoperitoneum was established and IAP was increased initially at 20 mmHg and subsequently at 45 mmHg, which was finally followed by abdominal desufflation. Interleukin 6 (IL-6), tumor necrosis factor alpha (TNFa) and lactate were measured in the cerebrospinal fluid (CSF) and intracranial (ICP), intraspinal (ISP), cerebral perfusion (CPP) and spinal perfusion (SPP) pressures recorded.
Increased IAP (20 mmHg) was followed by a statistically significant increase in IL-6 (p = 0.028), lactate (p = 0.017), ICP (p < 0.001) and ISP (p = 0.001) and a significant decrease in CPP (p = 0.013) and SPP (p = 0.002). However, further increase of IAP (45 mmHg) was accompanied by an increase in mean arterial pressure due to compensatory tachycardia, followed by an increase in CPP and SPP and a decrease of cytokines and lactate.
IAH resulted in a decrease of CPP and SPP lower than 60 mmHg and an increase of all ischemic mediators, indicating CNS ischemia; on the other hand, restoration of perfusion pressures above this threshold decreased all ischemic indicators, irrespective of the level of IAH.
Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.
Abdominal compartment syndrome (ACS) is a syndrome associated with multi-system effects of elevated intra-abdominal pressure (IAP) in critically ill children. It has a 90-100% mortality rate if not recognized and treated promptly. Measuring IAP helps identify patients developing intra-abdominal hypertension (IAH) which allows for timely intervention before progression to ACS. IAP helps identify ACS and guides its medical and surgical management. IAP is often measured by the bedside nurse in the intensive care unit. Pediatric critical care nurses (PCCN) play a key role in managing critically ill patients and recognizing potential causes for clinical deterioration such as ACS therefore should be knowledgeable about this entity.
The aim of this study was to assess the awareness and current knowledge of ACS among PCCN.
A ten-item written questionnaire was distributed at a National Critical Care Conference in 2006 and again in 2010. Participants of the conference voluntarily completed and immediately returned the survey. Results from the two questionnaires were compared.
Sixty-two percent of 691 questionnaires were completed. The awareness of ACS improved from 69.3% in 2006 to 87.8% in 2010 (p < 0.001) among PCCN. "Years in practice" influenced awareness of ACS. Nurses working for 5-10 and > 10 years were, respectively, 2.34 and 1.89 times more likely to be aware of ACS than those working for < 5 years. Hands-on experience managing a child with ACS by PCCN also improved from 49.1% to 67.9% (p < 0.001) but remains low. The number of participants who never measured IAP fell from 27.3% to 19.1% (p = 0.101). The most common method being used to measure IAP is the bladder method. Knowledge of the definition of ACS remains poor with only 13.2% associating the definition of ACS with organ dysfunction in 2010 which was even lower than in 2006.
There is increasing awareness of ACS and experience in its management among PCCN. However, few PCCN correctly understand the definition of ACS. Since recognition of IAH and early intervention can reduce morbidity and mortality in critically ill patients, further educational efforts should be directed toward improving the knowledge and recognition of ACS by PCCN.
critical care; nurses; abdominal compartment syndrome; intra-abdominal; pressure.
Prone ventilation (PV) is a ventilatory strategy that frequently improves oxygenation and lung mechanics in critical illness, yet does not consistently improve survival. While the exact physiologic mechanisms related to these benefits remain unproven, one major theoretical mechanism relates to reducing the abdominal encroachment upon the lungs. Concurrent to this experience is increasing recognition of the ubiquitous role of intra-abdominal hypertension (IAH) in critical illness, of the relationship between IAH and intra-abdominal volume or thus the compliance of the abdominal wall, and of the potential difference in the abdominal influences between the extrapulmonary and pulmonary forms of acute respiratory distress syndrome. The present paper reviews reported data concerning intra-abdominal pressure (IAP) in association with the use of PV to explore the potential influence of IAH. While early authors stressed the importance of gravitationally unloading the abdominal cavity to unencumber the lung bases, this admonition has not been consistently acknowledged when PV has been utilized. Basic data required to understand the role of IAP/IAH in the physiology of PV have generally not been collected and/or reported. No randomized controlled trials or meta-analyses considered IAH in design or outcome. While the act of proning itself has a variable reported effect on IAP, abundant clinical and laboratory data confirm that the thoracoabdominal cavities are intimately linked and that IAH is consistently transmitted across the diaphragm - although the transmission ratio is variable and is possibly related to the compliance of the abdominal wall. Any proning-related intervention that secondarily influences IAP/IAH is likely to greatly influence respiratory mechanics and outcomes. Further study of the role of IAP/IAH in the physiology and outcomes of PV in hypoxemic respiratory failure is thus required. Theories relating inter-relations between prone positioning and the abdominal condition are presented to aid in designing these studies.
Intra-abdominal hypertension (IAH) associated with organ dysfunction defines the abdominal compartment syndrome (ACS). Elevated intra-abdominal pressure (IAP) adversely impacts pulmonary, cardiovascular, renal, splanchnic, musculoskeletal/integumentary, and central nervous system physiology. The combination of IAH and disordered physiology results in a clinical syndrome with significant morbidity and mortality. The onset of the ACS requires prompt recognition and appropriately timed and staged intervention in order to optimize outcome. The history, pathophysiology, clinical presentation, and management of this disorder is outlined.
compartment; abdomen; syndrome; hypertension
The purpose of the present study was to quantify bacterial translocation to mesenteric lymph nodes due to different levels of intra-abdominal hypertension (IAH; 15 vs. 30 mmHg) lasting for 24 h in a porcine model.
We examined 18 anesthetized and intubated pigs (52.3 ± 4.7 kg) which were randomly allocated to three experimental groups (each n = 6) and studied over a period of 24 h. After preparation and establishing a steady state, the intra-abdominal pressure (IAP) was increased stepwise to 30 mmHg in six animals using a carbon dioxide (CO2) insufflator (IAP-30 group). In the second group, IAP was increased to 15 mmHg (IAP-15 group), while IAP remained unchanged in another six pigs (control group). Using a pulse contour cardiac output (PiCCO®) monitoring system, hemodynamic parameters as well as blood gases were recorded periodically. Moreover, peripheral and portal vein blood samples were taken for microbiological examinations. Lymph nodes from the ileocecal junction were sampled during an intra-vital laparotomy at the end of the observational period. After sacrificing the animals, bowel tissue samples and corresponding mesenteric lymph nodes (MLN) were extracted for histopathological and microbiological analyses.
Cardiac output decreased in all groups. In IAP-30 animals, volumetric preload indices significantly decreased, while those of IAP-15 pigs did not differ from those of controls. Under IAH, the mean arterial pressure (MAP) in the IAP-30 group declined, while MAP in the IAP-15 group was significantly elevated (controls unchanged). PO2 and PCO2 remained unchanged. The grade of ischemic damage of the intestines (histopathologically quantified using the Park score) increased significantly with different IAH levels. Accordingly, the amount of translocated bacteria in intestinal wall specimens as well as in MLN significantly increased with the level of IAH. Lymph node cultures confirmed the relation between bacterial translocation (BT) and IAP. The most often cultivated species were Escherichia coli, Staphylococcus, Clostridium, Pasteurella, and Streptococcus. Bacteremia was detected only occasionally in all three groups (not significantly different) showing gut-derived bacteria such as Proteus, Klebsiella, and E. coli spp.
In this porcine model, a higher level of ischemic damage and more BT were observed in animals subjected to an IAP of 30 mmHg when compared to animals subjected to an IAP of 15 mmHg or controls.
abdominal compartment syndrome; intra-abdominal hypertension; pneumoperitoneum; bacterial translocation; bowel; ischemia; histologic; mesenteric lymph node; pig; animal.
AIM: To assess the value of widely used clinical scores in the early identification of acute pancreatitis (AP) patients who are likely to suffer from intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).
METHODS: Patients (n = 44) with AP recruited in this study were divided into two groups (ACS and non-ACS) according to intra-abdominal pressure (IAP) determined by indirect measurement using the transvesical route via Foley bladder catheter. On admission and at regular intervals, the severity of the AP and presence of organ dysfunction were assessed utilizing different multifactorial prognostic systems: Glasgow-Imrie score, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, and Multiorgan Dysfunction Score (MODS). The diagnostic performance of scores predicting ACS development, cut-off values and specificity and sensitivity were established using receiver operating characteristic (ROC) curve analysis.
RESULTS: The incidence of ACS in our study population was 19.35%. IAP at admission in the ACS group was 22.0 (18.5-25.0) mmHg and 9.25 (3.0-12.4) mmHg in the non-ACS group (P < 0.01). Univariate statistical analysis revealed that patients in the ACS group had significantly higher multifactorial clinical scores (APACHE II, Glasgow-Imrie and MODS) on admission and higher maximal scores during hospitalization (P < 0.01). ROC curve analysis revealed that APACHE II, Glasgow-Imrie, and MODS are valuable tools for early prediction of ACS with high sensitivity and specificity, and that cut-off values are similar to those used for stratification of patients with severe acute pancreatitis (SAP).
CONCLUSION: IAH and ACS are rare findings in patients with mild AP. Based on the results of our study we recommend measuring the IAP in cases when patients present with SAP (APACHE II > 7; MODS > 2 or Glasgow-Imrie score > 3).
Acute pancreatitis; Abdominal compartment syndrome; Intra-abdominal pressure; Intra-abdominal hypertension; Organ dysfunction
Primary non-Hodgkin’s lymphoma of the ovary is a rare occurrence. An ovarian involvement by non-Hodgkin lymphoma (NHL) may include one of the four subtypes of lymphoma: diffuse large B-cell lymphoma, Burkitt’s lymphoma (BL), lymphoblastic lymphoma or anaplastic large cell lymphoma. Burkitt’s lymphoma is a rare entity with a specific poorly differentiated pattern.
Most women experience an ovarian BL with abdominal pelvic pain, abnormal vaginal bleeding, bowel obstruction, urinary frequency, incontinence and abdominal mass. Sometimes these warning signs may be absent, causing a late and more difficult diagnosis.
Here we report a case of a primary ovarian Burkitt’s lymphoma with bilateral involvement in a 57 year old patient. She firstly presented neurological symptoms in the upper limbs and she was treated with surgery and combined chemotherapy. The diagnosis of malignant lymphoma was established after bilateral adnexectomy and histological study of the excised tissue.
Burkitt; Ovarian lymphoma; Hypoaesthesia; Oophorectomy; Chemotherapy