Prevalence of intra-abdominal hypertension and abdominal compartment syndrome in the ICU:
The data confirming a high prevalence/incidence of IAH and ACS in critically ill populations is extensive. Though originally described in the trauma literature it is now clear this syndrome is ubiquitous throughout ICU populations with the higher reported incidence in the septic shock situation. This is not surprising – since this syndrome is a result of tissue ischemia and immune inflammatory responses causing a massive inflammatory cytokine response and capillary permeability syndrome – one should expect the presence of IAH across all groups of patients who are suffering from substantial inflammation. The following table provides the most common patient groups in whom IAH is found, the percentage of cases detected and the supporting references.
Table: How common is IAH?
|
Disease process |
IAH incidence |
References |
|
Severe sepsis |
41% - 87% |
[1-6,46] |
|
Major Burns |
22% - 100% (Using IAP > 20 mm Hg) |
[7-17] |
|
Major trauma |
2% - 50% (Using IAP > 25 mm Hg) |
[18-26] |
|
Major abdominal surgery |
32% - 45% |
[27] [28-30] |
|
Pancreatitis |
31% - 40% |
[31-35] |
|
Decompensated CHF, Post CABG |
40% - 60% |
[36-40] |
|
Mixed MICU population |
33% - 64% |
[2, 4, 41-43, 49] |
|
PICU |
1% - 18% (ACS) |
[44, 45] |
Conclusions from Malbrain as far back as 2004:[43]
“Our study suggests that there is no specific type of patient or disease or treatment that reliably indicates when IAP needs to be measured, or when measurement is not necessary in a mixed ICU population. Indeed, it seems that ..IAP should be routinely measured.”
Recommendations of the World Society of Abdominal Compartment Syndrome on which patients should be monitored for elevated intraabdominal pressure:
Several investigators have looked at these risk factors to determine how accurate they are at predicting the presence of IAH in critically ill patients. Pat Posa from Ann Arbor Michigan retrospectively assessed how often a patient with 2 or more risk factors had IAH when their bladder pressure was measured.[47] They found that 86-90% of patients with 2 risk factors had IAH. The most common cases were severe sepsis. She concluded that if a patient has risk factors they likely have IAH and they required medical bedside interventions. Furthermore, she found the implementing this screening as a nursing empowered task resulted in better compliance with routine monitoring and more frequent detection of patients with IAH. Pearson an colleagues conducted a similar 1 year study looking at all 115 patients that they monitored using entry criteria as the above risk factors or clinician suspicion.[48] They noted 74% of cases had IAH. Both these studies confirm that these risk criteria are very accurate (perhaps they actually need to be more liberal given positive predictive values of 74-90%).
Summary:
IAH is very
common and it is present in every single ICU population so you must
be suspicious even if you do not work in a surgical or trauma unit.
To simplify the entire issue – patients are at risk if they enter
the ICU (i.e. they are selected out as fairly sick) and they either
have a major problem in their abdomen or retroperitoneal space, or
they are getting or have receive a lot of fluid resuscitation due to
organ dysfunction or shock. Using these major criteria will detect
most cases of IAH. Later in the course of illness be suspicious of
patients who have inadequate urine output, new organ failure or who
you cannot seem to wean from the ventilator.
References:
1. Efstathiou, E., et al., Intra-abdominal pressure monitoring in septic patients. Intensive Care Medicine, 2005. 31, Supplement 1(131): p. S183, Abstract 703.
2. Malbrain, M.L.N.G., et al., Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med, 2005. 33(2): p. 315-22.
3. Reintam, A., et al., Intra-abdominal hypertension as a risk factor of death in patients with severe sepsis or septic shock. Critical Care, 2007. 11 (Suppl 2): p. Abstract P319.
4. Daugherty, E.L., et al., Abdominal compartment syndrome is common in medical intensive care unit patients receiving large-volume resuscitation. J Intensive Care Med, 2007. 22(5): p. 294-9.
5. Regueira, T., et al., Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock. J Crit Care, 2008. 23(4): p. 461-7.
6. Regueira, T., et al., Intraabdominal hypertension in patients with septic shock. Am Surg, 2007. 73(9): p. 865-70.
7. Greenhalgh, D.G. and G.D. Warden, The importance of intra-abdominal pressure measurements in burned children. J Trauma, 1994. 36(5): p. 685-90.
8. Ivy, M.E., et al., Intra-abdominal hypertension and abdominal compartment syndrome in burn patients. J Trauma, 2000. 49(3): p. 387-91.
9. Ivy, M.E., et al., Abdominal compartment syndrome in patients with burns. J Burn Care Rehabil, 1999. 20(5): p. 351-3.
10. Corcos, A.C. and H.F. Sherman, Percutaneous treatment of secondary abdominal compartment syndrome. J Trauma, 2001. 51(6): p. 1062-4.
11. Latenser, B.A., Critical care of the burn patient: the first 48 hours. Crit Care Med, 2009. 37(10): p. 2819-26.
12. Latenser, B.A., et al., A pilot study comparing percutaneous decompression with decompressive laparotomy for acute abdominal compartment syndrome in thermal injury. J Burn Care Rehabil, 2002. 23(3): p. 190-5.
13. O'Mara, M.S., et al., A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients. J Trauma, 2005. 58(5): p. 1011-8.
14. Oda, J., et al., Effects of escharotomy as abdominal decompression on cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients. J Trauma, 2005. 59(2): p. 369-74.
15. Oda, J., et al., Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients. J Trauma, 2006. 60(1): p. 64-71.
16. Oda, J., et al., Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns. Burns, 2006. 32(2): p. 151-4.
17. Kowal-Vern, A., et al., Elevated cytokine levels in peritoneal fluid from burned patients with intra-abdominal hypertension and abdominal compartment syndrome. Burns, 2006.
18. Balogh, Z., et al., Patients with impending abdominal compartment syndrome do not respond to early volume loading. Am J Surg, 2003. 186(6): p. 602-7; discussion 607-8.
19. Balogh, Z., et al., Supranormal trauma resuscitation causes more cases of abdominal compartment syndrome. Arch Surg, 2003. 138(6): p. 637-43.
20. Balogh, Z., et al., Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma, 2003. 54(5): p. 848-59.
21. McNelis, J., et al., Predictive factors associated with the development of abdominal compartment syndrome in the surgical intensive care unit. Arch Surg, 2002. 137(2): p. 133-6.
22. McNelis, J., C.P. Marini, and H.H. Simms, Abdominal compartment syndrome: clinical manifestations and predictive factors. Curr Opin Crit Care, 2003. 9(2): p. 133-6.
23. McNelis, J., et al., Abdominal compartment syndrome in the surgical intensive care unit. Am Surg, 2002. 68(1): p. 18-23.
24. Ivatury, R.R., et al., Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome. J Trauma, 1998. 44(6): p. 1016-21.
25. Hong, J.J., et al., Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg, 2002. 89(5): p. 591-6.
26. Cheatham, M.L., Intraabdominal pressure monitoring during fluid resuscitation. Curr Opin Crit Care, 2008. 14(3): p. 327-33.
27. Sugrue, M. and Y. Buhkari, Intra-abdominal pressure and abdominal compartment syndrome in acute general surgery. World J Surg, 2009. 33(6): p. 1123-7.
28. Serpytis, M. and J. Ivaskevicius, The influence of fluid balance on intra-abdominal pressure after major abdominal surgery. Medicina (Kaunas), 2008. 44(6): p. 421-7.
29. Sugrue, M., et al., Intra-abdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg, 1999. 134(10): p. 1082-5.
30. Biancofiore, G., et al., Postoperative intra-abdominal pressure and renal function after liver transplantation. Arch Surg, 2003. 138(7): p. 703-6.
31. Dambrauskas, Z., et al., Early recognition of abdominal compartment syndrome in patients with acute pancreatitis. World J Gastroenterol, 2009. 15(6): p. 717-21.
32. Leppaniemi, A., K. Johansson, and J.J. De Waele, Abdominal compartment syndrome and acute pancreatitis. Acta Clin Belg Suppl, 2007(1): p. 131-5.
33. Tao, H.Q., J.X. Zhang, and S.C. Zou, Clinical characteristics and management of patients with early acute severe pancreatitis: experience from a medical center in China. World J Gastroenterol, 2004. 10(6): p. 919-21.
34. De Waele, J.J., et al., Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit Care, 2005. 9(4): p. R452-7.
35. Pupelis, G., et al., Conservative approach in the management of severe acute pancreatitis: eight-year experience in a single institution. HPB (Oxford), 2008. 10(5): p. 347-55.
36. Mullens, W., et al., Prompt reduction in intra-abdominal pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated heart failure. J Card Fail, 2008. 14(6): p. 508-14.
37. Mullens, W., et al., Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol, 2008. 51(3): p. 300-6.
38. Tang, W.H. and W. Mullens, Cardio-Renal Syndrome in Decompensated Heart Failure. Heart, 2009.
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41. Reintam, A., et al., Primary and secondary intra-abdominal hypertension-different impact on ICU outcome. Intensive Care Med, 2008. 34(9): p. 1624-31.
42. Vidal, M.G., et al., Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Crit Care Med, 2008. 36(6): p. 1823-31.
43. Malbrain, M.L.N.G., et al., Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med, 2004. 30(5): p. 822-9.
44. Beck, R., et al., Abdominal compartment syndrome in children. Pediatr Crit Care Med, 2001. 2(1): p. 51-6.
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