Balogh, Z. and F. A. Moore (2004). "Recent advance in the characterisation of post-injury abdominal compartment syndrome." International J Intensive Care 11(1): 30-42.

BACKGROUND: The incidence and clinical relevance of increased intraabdominal pressure after orthotopic liver transplantation (OLT) has not yet been evaluated despite the finding that occurrence of this condition in postsurgical critically ill patients may impair various organ functions. The aim of this study was to assess whether the occurrence of abdominal hypertension among a population of OLT recipients was an important cofactor producing early postoperative complications. METHOD: This prospective clinical study measured abdominal pressure every 6 hours during the intensive care unit (ICU) stay using the urinary bladder method. A value of >/=25 mm Hg was considered high. Hemodynamic status was simultaneously evaluated and renal function assessed based on the hourly urinary output, and by calculating serum creatinine on postoperative days 2 and 4. Renal failure was defined as a serum creatinine level of >1.5 mg/dL, or an increase in peak of >1 mg/L within 72 hours of surgery. The filtration gradient and patient outcomes were also considered. RESULTS: Intraabdominal hypertension was observed in 32% of cases. The subjects displaying high IAP showed significantly lower artery pressure values (P <.01), but did not differ in terms of central venous pressure or cardiac output. High intraabdominal pressure was more frequently associated with renal failure (P <.01), a lower filtration gradient (P <.001), delayed postsurgical weaning from the ventilation (P <.001), and increased ICU mortality (P <.05). A receiver operator characteristic curve analysis showed that the critical IAP values, namely those with the best sensitivity/specificity, were 23 mm Hg for postoperative ventilatory delayed weaning (P <.05), 24 mm Hg for renal dysfunction (P <.05), and 25 mm Hg for death (P <.01). CONCLUSIONS: Abdominal hypertension occurs frequently after OLT and may be associated with a complicated postoperative course.

BACKGROUND. Carbon dioxide (CO(2)) pneumoperitoneum (PP) increases mean arterial blood pressure (MAP) and systemic vascular resistance (SVR) but decreases stroke volume (SV) and cardiac output (CO). This study evaluated the hemodynamic effects of elevated intraabdominal pressure (IAP) occurring during laparoscopic donor nephrectomy (LDN).METHODS. Twenty-two patients undergoing LDN were investigated and hemodynamic parameters, P(v)CO(2 )(carbon dioxide partial pressure), and VCO(2) (carbon dioxide production) were monitored during the procedure. Before and after PP, IAP was raised from 12 to 20 mmHg and the hemodynamic effects were measured every 30 s.RESULTS. During IAP of 12 mmHg and stable serum CO(2), there was no change in SV compared to preinsufflation levels. When IAP was elevated from 12 to 20 mmHg, SV initially decreased ( p < 05), followed by an increase in MAP and SVR ( p < 0.05).CONCLUSION. This study shows that with the fluid and ventilation protocol used, PP has no significant effect on SV at an IAP of 12 mmHg, whereas increasing IAP to 20 mmHg does. In this study, the hemodynamic effects induced by CO(2) PP of 12 mmHg are not due to changes in serum CO(2). Compression of the venous system during a PP of 20 mmHg reduces preload, with an subsequent increase in SVR.

BACKGROUND: Abdominal compartment syndrome secondary to a very large benign ovarian tumor has been rarely reported in gynecology. With the increase of intraabdominal pressure in abdominal compartment syndrome, all major organ systems are adversely affected, causing a potentially fatal condition. CASE: A 43-year-old woman presenting with a tensely distended abdomen developed hypotension, difficulty in ventilation, and anuria. An ovarian tumor complicated by abdominal compartment syndrome was diagnosed, along with hemodynamic decompensation. Prompt resuscitation with immediate surgical removal of the tumor reversed the life-threatening situation. CONCLUSION: Timely aggressive resuscitation, prompt surgical decompression, and intensive perioperative hemodynamic management are required for patients with ovarian mucinous cystadenoma complicated by abdominal compartment syndrome.

BACKGROUND: The long-term physical, mental, and functional consequences of abdominal decompression for intra-abdominal hypertension are unknown. METHODS: Thirty patients in various stages of abdominal decompression and delayed fascial closure for massive incisional hernia completed the SF-36 Health Survey and answered questions regarding their employment and pregnancy status. RESULTS: Patients awaiting abdominal wall reconstruction demonstrated significantly decreased perceptions of physical, social, and emotional health (p < 0.05), whereas patients who had completed definitive fascial closure demonstrated physical and mental health scores equivalent to the U.S. general population. Ultimately, 78% of patients employed before decompression returned to work. CONCLUSION: Abdominal decompression with skin grafting and delayed fascial closure initially decreases patient perception of physical, social, and emotional health, but subsequent abdominal wall reconstruction restores physical and mental health to that of the U.S. general population. Abdominal decompression does not prevent return to gainful employment and should not be considered a permanently disabling condition.

Abdominal compartment syndrome resulting from intra-abdominal hypertension can be prevented or treated with the formation of a laparostomy. In the majority of cases this is followed by delayed abdominal wall reconstruction involving the use of prosthetic materials and split-skin grafts. The authors present a case study involving a patient who underwent repair of a ruptured abdominal aortic aneurysm and required a laparostomy to prevent abdominal compartment syndrome. He also had significant perioperative morbidity and poor nutritional status. Despite this, satisfactory wound healing was achieved without the need for split-skin grafting, thus avoiding further surgery and its associated complications.

BACKGROUND: Critically ill trauma patients are often too unstable for safe transfer to the operating room. Damage control laparotomy patients frequently require early reoperation and have a reported mortality of 50-60%. As a result, many of these patients must undergo laparotomy in the intensive care unit. We hypothesized that patients undergoing bedside laparotomy (BSL) and managed with the abdomen left open would have an unacceptably high mortality or intra-abdominal complications. METHODS: We performed a retrospective chart review of our Trauma Registry. Of the 11,096 consecutive trauma admissions from March 1, 1996 to May 20, 2000, 75 patients underwent 95 BSL. Patients were stratified according to injury severity score (ISS), base deficit (BD), lactic acid (LA), total transfusion (TRBC) requirements, indication for BSL, mechanism of injury, infectious complications (intra-abdominal abscess (IAA), fistula), and length of hospital stay. RESULTS: Seventy-five patients underwent 95 BSL. Mean ISS was 50.6 +/- 18.9, mean BD was -11.9 (+/- 5), and the mean LA was 5 +/- 5 for the study group. The TRBC for the group was 43.7 +/- 42.6 units. Indications for the 95 BSL were (1) abdominal compartment syndrome (n = 47, 49.5%); (2) suspected intra-abdominal infection (n = 18, 19.0%); (3) washout/pack removal (n = 14, 14.7%); (4) washout with fascial closure (n = 12, 12.6%); and (5) other (n = 4, 4.2%). Twenty-nine of 75 patients (39.2%; ISS 52.3 +/- 18.8) died within 72 h of operation. Of the 46 remaining patients, an additional eight died 72 h or more after operation, for a late mortality rate of 17.4% and a total mortality rate of 49%. None of these deaths were attributable to either the operation or to post-operative IAA or fistula formation; all late deaths were secondary to multiple organ failure. Intra-abdominal abscesses developed in three of 46 patients (6.5%), each of whom had a TRBC of >100 units (mean, 160 units). Five of 46 patients (10.9%) developed enterocutaneous fistulae. None of these eight patients died. Thirty-eight of 75 patients (50.7%) survived to discharge, with a mean ISS of 40 (+/- 11.9). CONCLUSIONS: Despite the high acuity of the population undergoing BSL, 50.7% of patients survived. Moreover, during BSL, IAA and fistula formation occurred at low rates.

OBJECTIVES: Abdominal compartment syndrome is an infrequent clinical entity, the course of which has a rapid progression with multiorgan compromise leading to a fatal outcome if appropriate and urgent action is not undertaken. METHODS AND RESULTS: We report the clinical case of a patient who developed the clinical picture after renal trauma. Diagnosis was obtained by CT scan and arteriography, afterwards the patient required ICU admission with intra-abdominal pressure monitoring, and several decompression laparotomies before definitive closure with a reabsorbable mesh. CONCLUSIONS: Urologists should know the existence of this syndrome its appropriate treatment, because we manage patients who are candidates to suffer it. Due to the high mortality rate associated, it is essential to know how to recognize it in order to act fast.

BACKGROUND/AIMS: The use of drainage after liver resection remains controversial. Data of the usefulness of drains in cirrhotic patients undergoing surgical resection are scarce. The objective of our study is to assess the usefulness of intra-abdominal drainage after liver resection for hepatocellular carcinoma in cirrhotic patients. METHODOLOGY: We performed a randomized controlled trial to assess the benefits of abdominal drainage after resection of hepatocellular carcinoma in cirrhotic patients. The main end point was to compare postoperative complications and hospital stay in both groups. RESULTS: Abdominal drainage decreased ascites leakage and significantly reduced hospital stay in comparison to the non-drainage group. In addition, local complications were less frequent in the drainage group. Postoperative ascites leakage significantly complicated patients with clinically relevant portal hypertension. CONCLUSIONS: Intra-abdominal closed drainage is advisable in cirrhotic patients undergoing liver resection for hepatocellular carcinoma, mainly if presenting preoperative portal hypertension.

Abdominal compartment syndrome(ACS) is a clinical entity characterised by increased intraabdominal pressure leading to multiple organ failure, fatal if left untreated. The treatment of abdominal compartment syndrome is surgical decompression with a temporary abdominal wall substitute. To avoid the development of abdominal compartment syndrome, temporary abdominal closure (TAC) should be considered after celiotomy for trauma. A new method for TAC was introduced at Ullevaal University Hospital in 2002, the "vac pac". METHOD:The "vac pac" technique is described and the patients treated with "vac pac" during the first year after introduction are presented. RESULTS: Five patients were treated using the "vac pac". One patient had acute pancreatitis and developed abdominal compartment syndrome. The other patients were severely injured and the indication for TAC was abdominal compartment syndrome in one patient, intestinal oedema in another, and damage control surgery with packing in two patients. Delayed primary closure was achieved within five days in all our patients. There were no fatalities and no complications related to the use of "vac pac" were registered. : CONCLUSION:The "vac pac" technique seems to be a good method for TAC.

The importance of chest wall elastance in characterizing acute lung injury/acute respiratory distress syndrome patients and in setting mechanical ventilation is increasingly recognized. Nearly 30% of patients admitted to a general intensive care unit have an abnormal high intra-abdominal pressure (due to ascites, bowel edema, ileus), which leads to an increase in the chest wall elastance. At a given applied airway pressure, the pleural pressure increases according to (in the static condition) the equation: pleural pressure = airway pressure x (chest wall elastance/total respiratory system elastance). Consequently, for a given applied pressure, the increase in pleural pressure implies a decrease in transpulmonary pressure (airway pressure - pleural pressure), which is the distending force of the lung, implies a decrease of the strain and of ventilator-induced lung injury, implies the need to use a higher airway pressure during the recruitment maneuvers to reach a sufficient transpulmonary opening pressure, implies hemodynamic risk due to the reductions in venous return and heart size, and implies a possible increase of lung edema, partially due to the reduced edema clearance. It is always important in the most critically ill patients to assess the intra-abdominal pressure and the chest wall elastance.

BACKGROUND: Increased intra-abdominal pressure (IAP) elevates thoracic pressure and airway pressures and reduces lung compliance in humans and laboratory animals. We studied respiratory alterations and arterial blood gas changes in pigs with IAP maintained at 20 mmHg or 30 mmHg for 3 h. METHODS: Domestic pigs of both sexes weighing 30.0 +/- 5.1 kg (mean +/- SD) (n = 21) were divided into three groups. The animals were anesthetized and kept at 20 mmHg IAP (n = 7) or 30 mmHg IAP (n = 7) for 3 h. The third group (n = 7) served as control without an elevated IAP. We recorded respiratory alterations and changes in acid-based parameters at baseline and after 90 min and 180 min of increased IAP. RESULTS: No significant hypoxia or hypercarbia was found in animals with an IAP of 20 mmHg IAP. At an IAP of 30 mmHg, pO2 decreased to an average 19.6 kPa and pCO2 increased to about 6 kPa, and the animals were slightly acidotic. Airway pressure increased significantly and lung compliance decreased in both groups of elevated IAP. CONCLUSION: In our porcine model, an IAP of 20 mmHg or higher for 3 h is harmful for the respiratory function of the animals due to deterioration of respiratory parameters, increased airway pressure and decreased lung compliance.

We report a rare case in which abdominal compartment syndrome resulting from venous hemorrhaging developed in a patient with stable pelvic fractures, resulting in a fatal outcome. An 84-year-old man with mild pelvic fractures developed hypovolemic shock and underwent transcatheter arterial embolization. He became hemodynamically stable after the procedure, but became hypotensive for the second time 11 h after admission. Urinary bladder pressure rose to 32 mmHg from 4-7 mmHg. Rebleeding from the pelvis with the development of abdominal compartment syndrome was suspected. Repeated transcatheter arterial embolization and laparotomy were performed; however, 1 min into the procedure, both pupils symmetrically dilated and the light reflex disappeared. This case suggests that brain death can sometimes occur due to abdominal compartment syndrome.

BACKGROUND: Inability to close the abdominal wall after laparotomy for trauma may occur as a result of visceral edema, retroperitoneal hematoma, use of packing, and traumatic loss of tissue. Often life-saving, decompressive laparotomy and temporary abdominal closure require later restoration of anatomic continuity of the abdominal wall. METHODS: The trauma registry, open abdomen database, and patient medical records at a level 1 university-based trauma center were reviewed from January 1988 to December 2001. RESULTS: During the study period, more than 15,000 trauma patients were admitted, with 88 patients (0.6%) requiring temporary abdominal closure (TAC). Patients ages ranged from 12 to 75 years with a mean injury severity score (ISS) of 28 (range 5 to 54). Forty-five patients (51%) suffered penetrating injuries, and 43 (49%) were victims of blunt trauma. Indications for TAC included visceral edema in 61 patients (70%), abdominal compartment syndrome in 10 patients (11%), traumatic tissue loss in 9 patients (10%), and wound sepsis and fascial necrosis in 8 patients (9%). Fifty-six patients (64%) underwent TAC at admission laparotomy, whereas 32 patients (36%) required TAC at reexploration. Seventy-one patients (81%) survived and 17 (19%) died. Of the survivors, 24 patients (34%) underwent same-admission direct fascial closure, and 47 patients (66%) required visceral skin grafting and readmission closure. Reconstructive procedures in the patients requiring skin graft excision included direct fascial repair (20 patients, 44%), components separation closure with or without subfascial tissue expansion (18 patients, 40%), pedicled or free-tissue flaps (4 patients, 8%), and mesh repair (4 patients, 8%). One patient refused closure. The mean follow-up was 48 months (range 6 to 144), with an overall recurrence rate of 15% (range 10% to 50%), highest in the mesh repair group. CONCLUSIONS: Silicone sheeting TAC provides a safe and reliable temporary abdominal closure allowing for later definitive reconstruction. Direct fascial repair or components separation closure with or without tissue expansion can be utilized in the majority of patients for definitive reconstruction with low recurrence rate.

The pressure within the abdominal cavity is normally little more than atmospheric pressure. However, even small increases in intra-abdominal pressure can have adverse effects on renal function, cardiac output, hepatic blood flow, respiratory mechanics, splanchnic perfusion and intracranial pressure. Although intra-abdominal pressure can be measured directly, this is invasive and bedside measurement of intra-abdominal pressure is usually achieved via the urinary bladder. This cheap, easy approach has been shown to produce results that correlate closely with directly measured abdominal pressures. Significant increases in intra-abdominal pressure are seen in a wide variety of conditions commonly encountered in the intensive care unit, such as ruptured aortic aneurysm, abdominal trauma and acute pancreatitis. Abdominal compartment syndrome describes the combination of increased intra-abdominal pressure and end-organ dysfunction. This syndrome has a high mortality, most deaths resulting from sepsis and multi-organ failure. Detection of abdominal compartment syndrome requires close surveillance of intra-abdominal pressure in patients thought to be at risk of developing intra-abdominal hypertension. The only available treatment for established abdominal compartment syndrome is decompressive laparotomy. Prevention of abdominal compartment syndrome after laparotomy by adoption of an open abdomen approach may be preferable in the patient at significant risk of developing intra-abdominal hypertension, but this has not been demonstrated in any large trials. Most surgeons prefer to adopt a 'wait and see' policy, only intervening when clinical deterioration is associated with a significant increase in intra-abdominal pressure.

INTRODUCTION:: Increases in intra-abdominal pressure (IAP) can cause increases in intracranial pressure (ICP). Recently, we noticed that abdominal fascial release could be useful in treating intracranial hypertension (ICH) after traumatic brain injury (TBI). We added this as an option in our treatment of TBI. METHODS:: In our institution, ICH is treated with an algorithm using osmolar therapy, CSF drainage and barbiturates. Patients with refractory ICH have routine measurement of IAP. If elevated, consideration is given to decompressive laparotomy. We retrospectively reviewed all patients admitted from January 2000 through July 2003 who had abdominal decompression to treat refractory ICH. RESULTS:: From 1/00 to 7/03, 17 patients underwent decompressive laparotomy for intractable ICH. Thirteen male and 4 females all sustained blunt injury. All had failed maximal therapy including 14 who had had decompressive craniectomy. Mean ICP was 30 +/- 8.1 mm Hg (range 20-40 mm Hg) before decompression. No patients had evidence of abdominal compartment syndrome (ACS). Before decompression mean IAP was 27.5 (+/- 5.2) mmHg (range 21-35 mm Hg). After abdominal decompression ICP dropped precipitously by at least 10 mm Hg to a mean of 17.5 (+/- 3.2) mmHg (range 10-25 mm Hg). In 6 patients the decrease in ICP was transient. All died. The remaining 11 had sustained decreases in ICP. All survived, made neurologic recovery and were discharged to a rehabilitation facility. CONCLUSION:: Decompressive laparotomy can be a useful adjunct in the treatment of ICH failing maximal therapy following TBI. More work will need to be done to precise the exact indications for this therapy.

Ischemia/reperfusion injury plays an important role in the pathogenesis of abdominal compartment syndrome, which is characterized by increased intra-abdominal pressure. The aim of this study was to investigate whether octreotide, a synthetic somatostatin analogue, improves the reperfusion injury after decompression of acute abdominal hypertension. This study was carried out in Wistar albino rats. With the rats under anesthesia, an arterial catheter was inserted intraperioneally and with the use of an aneroid manometer connected to the catheter, intra-abdominal pressure was kept at 20 mm Hg (ischemia group) for 1 hour. In the ischemia/reperfusion group, pressure applied for 1 hour was decompressed and a 1-hour reperfusion period was allowed. In another ischemia/reperfusion group, octreotide was administered (50 microg/kg intraperitoneally) immediately before the decompression of intra-abdominal pressure. At the end of the experiment, liver and intestinal tissues were taken and malondialdehyde (an index of lipid peroxidation) and glutathione (a key to antioxidant) levels and myeloperoxidase (an index of tissue neutrophil infiltration) activity were estimated. The results demonstrated that tissue levels of malondialdehyde and myeloperoxidase activity were elevated, whereas glutathione levels were reduced in both the ischemia and ischemia/reperfusion groups. Octreotide treatment reversed these oxidant responses. In conclusion, increased intra-abdominal pressure causes oxidative organ damage and octreotide, by controlling the reperfusion of abdominal organs and inhibiting neutrophil infiltration, could improve the reperfusion-induced oxidative damage. Therefore its therapeutic role as a "reperfusion injury-limiting" agent must be further elucidated in intra-aortic pressure-induced abdominal organ injury.

PURPOSE: Patients with penetrating trauma often have multiorgan involvement that may complicate the management of any single organ system. Here we review the incidence of associated injuries in patients with penetrating renal trauma and our extended experience treating these patients at a busy inner city trauma center. MATERIALS AND METHODS: All trauma cases presenting to Temple University Trauma Center during a 6-year period were identified through our institutional databases and were reviewed (5,276). Penetrating trauma represented 41% of all cases (2,163). Of these we identified 123 patients with penetrating renal trauma (5.7%). A total of 93 cases were available for review. Multiorgan injury was staged in the operating room if patients were hemodynamically unstable or radiographically if they were stable. Renal injuries were staged by high dose, single shot excretory urogram in patients taken immediately to surgery or by computerized tomography if stable. Renal injuries were classified using the American Association for Surgery of Trauma (AAST) grading system. AAST classifications were subcategorized for purposes of streamlining. Grade 1 and 2 injuries were grouped as low grade, grades 3 and 4 nonvascular injuries were grouped as intermediate grade, and AAST grade 4 vascular and grade 5 injuries were grouped as high grade. Demographic, clinical and intraoperative variables, as well as number and severity of associated injuries, were then assessed to determine the relationship with various renal surgical outcomes including the requirement of surgical intervention, type of surgical intervention, need for nephrectomy and associated adverse outcomes. RESULTS: The median age of injured patients was 28 years (range 14 to 80). The majority of victims were male (93%). The mechanism of injury was predominantly gunshot wound (GSW, 86%) while 14% were due to stab wounds. Renal injuries were low grade (19%), intermediate grade (44%) and high grade (37%). Nearly all patients with penetrating renal injury had associated multiorgan injury (94.6%). Associated injuries for penetrating renal trauma on the right side predominately involved the liver, small bowel and vertebra while injury to the left kidney was most often associated with trauma to the stomach, colon and spleen. Patients suffered extensive renal injury as evidenced by the high rate of intraoperative urinomas (30.1%) and hematomas (97.5%) identified. In the absence of an expanding hematoma and/or hemodynamic instability, associated injuries by themselves did not increase the risk of nephrectomy. Despite multiorgan penetrating injury 54% of kidneys were salvageable. CONCLUSIONS: Isolated penetrating trauma to the kidney is rare. The majority of patients with penetrating renal trauma have associated adjacent organ injuries that may complicate treatment. In the absence of an expanding hematoma with hemodynamic instability, associated multiorgan injuries did not increase the risk of nephrectomy. With appropriate radiographic and/or surgical staging, it is possible to repair and salvage many of these kidneys despite extensive associated intraabdominal trauma.

Control of intra-abdominal fluid secretion, facilitation of abdominal exploration, and preservation of the fascia for abdominal wall closure is a major challenge in the management of patients with an open abdomen. Studies comparing different protocols of care have not been conducted and frequency of exploration, surgical procedures, and indications for definitive closure are generally based on clinical judgment. Morbidity and mortality rates are high. Vacuum-assisted therapy has been reported to help meet the challenges of managing the open abdomen and is particularly useful in patients with abdominal compartment syndromes, traumatic injuries, and severe intra-abdominal sepsis. Over the years, clinicians have developed various approaches to achieve vacuum-assisted closure using wall suction. Some disadvantages of the wall-suction methods are eliminated when using more recently developed vacuum therapy devices. These devices apply subatmospheric pressure, reducing bowel edema, bacterial counts, and inflammatory substances found in open abdominal wounds while eliminating the need for frequent dressing changes, maintaining intact skin, and improving fluid management. The results of six case studies presented are encouraging, suggesting that this treatment approach is safe and effective. Controlled clinical studies to establish the safety and effectiveness of this treatment approach and to facilitate the development of treatment guidelines are needed to help manage an increasingly common group of patients who might benefit from this treatment approach.

The issues of pathophysiology, diagnosis and surgical treatment of postoperative intraabdominal purulent-septic complications were suggested. Noncontrolled abortion of mediators with subsequent development of inflammation and damage in the organs, localized far from primary focus, constitutes the main factor of the postoperative intraabdominal purulent-septic complications occurrence. In such a situation the intraabdominal hypertension and abdominal compartment syndrome also promote the deepening of multiple dysfunctions of organs due to mechanical failure of functions in respiratory, hemodynamical, excretional systems of the organism, what promotes the development of vicious circles and the cascade reactions, leading to exitus lethalis. The modern strategy and tactics of complex treatment of such patients is enlighted.

The diagnosis of intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) is heavily dependent on the reproducibility of the intra-abdominal pressure (IAP) measurement technique. Recent studies have shown that a clinical estimation of IAP by abdominal girth or by examiner's feel of the tenseness of the abdomen is far from accurate, with a sensitivity of around 40%. Consequently, the IAP needs to be measured with a more accurate, reproducible and reliable tool. The role of the intra-vesical pressure (IVP) as the gold standard for IAP has become a matter of debate. This review will focus on the previously described indirect IAP measurement techniques and will suggest new revised methods of IVP measurement less prone to error. Cost-effective manometry screening techniques will be discussed, as well as some options for the future with microchip transducers.

PURPOSE OF REVIEW: This review focuses on the available literature published in the past 2 years. MEDLINE and PubMed searches were performed using intraabdominal pressure, intraabdominal hypertension, and abdominal compartment as search items. The aim was to find an answer to the question: "Is it wise not to measure or even not to think about intraabdominal hypertension in ICU?" RECENT FINDINGS: It is difficult to find a good gold standard for intraabdominal pressure measurement. Bladder pressure can be used as an intraabdominal pressure estimate provided it is measured in a reproducible way. Automated continuous intraabdominal pressure monitoring has recently become available. Key messages are (1). body mass index and fluid resuscitation are independent predictors of intraabdominal hypertension; (2). intraabdominal hypertension increases intrathoracic, intracranial, and intracardiac filling pressures; (3). transmural or transabdominal filling pressures combined with volumetric parameters better reflect preload; (4). volumetric target values need to be corrected for baseline ejection fractions; (5). intraabdominal hypertension decreases left ventricular, chest wall and total respiratory system compliance; (6). best positive end-expiratory pressure can be set to counteract intraabdominal pressure; (7). acute respiratory distress syndrome definitions should take into account best positive end-expiratory pressure and intraabdominal pressure but not wedge pressure; (8). lung protective strategies should aim at deltaPplat (plateau pressure - intraabdominal pressure); (9). intraabdominal hypertension causes atelectasis and increases extravascular lung water; (10). intraabdominal hypertension is an independent predictor of acute renal failure; (11). monitoring of abdominal perfusion pressure can be useful; and (12). intraabdominal hypertension triggers bacterial translocation and multiple organ system failure. SUMMARY: The answer is that it is unwise not to measure intraabdominal pressure in the ICU or even not to think about it.

OBJECTIVE. Although intra-abdominal hypertension (IAH) can cause dysfunction of several organs and raise mortality, little information is available on the incidence and risk factors for IAH in critically ill patients. This study assessed the prevalence of IAH and its risk factors in a mixed population of intensive care patients. DESIGN. A multicentre, prospective 1-day point-prevalence epidemiological study conducted in 13 ICUs of six countries. INTERVENTIONS. None. PATIENTS. Ninety-seven patients admitted for more than 24 h to one of the ICUs during the 1-day study period. METHODS. Intra-abdominal pressure (IAP) was measured four times (every 6 h) by the bladder pressure method. Data included the demographics, medical or surgical type of admission, SOFA score, etiological factors such as abdominal surgery, haemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia and bacteraemia. RESULTS. We enrolled 97 patients, mean age 64+/-15 years, 57 (59%) medical and 40 (41%) surgical admission, SOFA score of 6.5+/-4.0. Mean IAP was 9.8+/-4.7 mmHg. The prevalence of IAH (defined as IAP 12 mmHg or more) was 50.5 and 8.2% had abdominal compartment syndrome (defined as IAP 20 mmHg or more). The only risk factor significantly associated with IAH was the body mass index, while massive fluid resuscitation, renal and coagulation impairment were at limit of significance. CONCLUSION. Although we found a quite high prevalence of IAH, no risk factors were reliably associated with IAH; consequently, to get valid information about IAH, IAP needs to be measured.

OBJECTIVE:: The goal of this report is to examine the success of vacuum-assisted fascial closure (VAFC) under a carefully applied protocol in abdominal closure after open abdomen. SUMMARY BACKGROUND DATA:: With the development of damage control techniques and the understanding of abdominal compartment syndrome, the open abdomen has become commonplace in trauma patients. If the abdomen is not closed in the early postoperative period, the combination of adhesions and fascial retraction frequently make primary fascial closure impossible and creation of a planned ventral hernia is required. We have previously reported our experience with the development of a technique for VAFC that allowed for closure of the fascia in many such patients long after initial operation. During this previous study, during which the technique was being developed, VAFC was successful in 69% of patients in whom it was applied, and 22 patients were successfully closed at >/= 9 days after initial surgery (range, 9 to 49 days). A protocol for the use of VAFC in patients with open abdomen was developed on the basis of these data and has been employed since October 2001. The outcome of this protocol's use is examined. METHODS:: This is a prospective evaluation of all trauma patients admitted to Wake Forest University Baptist Medical Center over a 19-month period who required management with an open abdomen. VAFC employs suction applied to a large polyurethane sponge under an occlusive dressing in the wound and allows for constant medial traction of the abdominal fascia. It is attempted in all patients in whom the rectus muscles and fascia are intact. Studied variables include fascial closure rate, time to closure, incidence of wound dehiscence, and hernia development after closure. RESULTS:: From November 1, 2001, through May 31, 2003, 212 laparotomies were performed in injured patients; 53 (25%) of these patients required open abdomen management. Mean injury severity score for the group was 34, with an average abdominal abbreviated injury score of 2.9. Forty-five (78%) survived until abdominal closure. Vacuum dressings were used in all 45 but VAFC was not attempted in 2 patients (1 due to development of enterocutaneous fistula, 1 because a rectus flap was used for another wound). Closure rate in those undergoing VAFC was 88% (38), with mean time to closure being 9.5 days. This is significantly higher than the 69% rate of fascial closure during the time in which the technique was developed (P = 0.03). Twenty-one patients (48%) were closed at >/= 9 days (range, 9 to 21 days). Two patients (4.6%) developed wound dehiscence and underwent successful reclosure. One patient (2.3%) developed a ventral hernia on follow-up, which has since been repaired CONCLUSIONS:: The use of VAFC under a carefully defined protocol has resulted in significantly higher fascial closure rates, obviating the need for subsequent hernia repair in most patients. The utility of this technique is not limited to the early postoperative period, but it can be successful as much as 3 to 4 weeks after initial operation.

BACKGROUND: Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure is abnormally high in association with organ dysfunction. It tends to have a poor outcome, even when treated promptly by abdominal decompression. METHODS: A search of the Medline database was performed to identify articles related to intra-abdominal hypertension and ACS. RESULTS: Currently there is no agreed definition or management of ACS. However, it is suggested that intra-abdominal pressure should be measured in patients at risk, with values above 20 mmHg being considered abnormal in most. Abdominal decompression should be considered in patients with rising pressure and organ dysfunction, indicated by increased airway pressure, reduced cardiac output and oliguria. Organ dysfunction often occurs at an intra-abdominal pressure greater than 35 mmHg and may start to develop between 26 and 35 mmHg. The mean survival rate of patients affected by compartment syndrome is 53 per cent. CONCLUSION: The optimal time for intervention is not known, but outcome is often poor, even after decompression. Most of the available information relates to victims of trauma rather than general surgical patients.

CONCLUSION: Elevated intraabdominal pressure (IAP) was associated with significant organ dysfunction after repair of ruptured abdominal aortic aneurysm (AAA). Elevated IAP was not found to be a significant complicating factor after elective or endovascular AAA repair. SUMMARY: In a prospective observational study the authors measured IAP after AAA surgery and correlated outcomes with levels of IAP. The study included 75 patients undergoing infrarenal AAA repair, 40 with conventional elective repair of a nonruptured infrarenal AAA, 13 with endovascular repair of a nonruptured AAA, and 22 with conventional repair of a ruptured infrarenal AAA. IAP was determined with bladder manometry at the end of the operative procedure and every 24 hours after surgery in patients in whom ventilation tubes remained. The patients were then observed for indications of organ dysfunction.After abdominal closure for ruptured AAA, IAP was higher (15.4 mm Hg) than after elective open repair (10.5 mm Hg) or endovascular elective repair (6.4 mm Hg). Patients with IAP measurements greater than 15 mm Hg had significant impairment of organ dysfunction compared with patients with IAP less than 15 mm Hg with regard to pH (P =.027), base excess (P =.005), peak inspiratory pressure (P =.0015), and central venous pressure and urine output (P =.0029). A receiver operator characteristic curve analysis indicated that a cutoff of 15 mm Hg of IAP indicated patients at risk for death with sensitivity of 66% and specificity of 79%. COMMENT: The adverse effects of elevated IAP after abdominal surgery have become more widely recognized. The data presented here suggest that initial mesh closure of the abdomen, followed by removal of the mesh and primary closure when immediate postoperative swelling has resolved, may lead to improved outcomes in patients with initial IAP exceeding 15 mm Hg after AAA repair.

Authors inform about the group of 8 patients with abdominal compartment syndrome (ACS) occurred as a complication in large blunt injury of abdominal cavity. To the ACS diagnose, the measurement of intracystic pressure is used routinely, whose values correlate fully with values of intraabdominal pressure (IAP). In case of increasing values of IAP over 25 mm Hg with positive clinical signs of ACS, authors indicate decompression laparotomy with temporary closing of abdominal cavity by sterile plastic foil or Ethizip. This preventive temporary laparostomy is recommended also in serious injuries of abdominal cavity in patients with fatal haemorrhage, treated by the method of staged laparotomy with tamponade of abdominal cavity and with massive blood and volume resuscitation.

Increased abdominal pressure is common in intensive care unit patients. To investigate its impact on respiration and hemodynamics we applied intraabdominal pressure (aIAP) of 0 and 20 cm H(2)O (pneumoperitoneum) in seven pigs. The whole-lung computed tomography scan and a complete set of respiratory and hemodynamics variables were recorded both in healthy lung and after oleic acid (OA) injury. In healthy lung, aIAP 20 cm H(2)O significantly lowered the gas content, leaving the tissue content unchanged. In OA-injured lung at aIAP 0 cm H(2)O, the gas content significantly decreased compared with healthy lung. The excess tissue mass (edema) amounted to 30 +/- 24% of the original tissue weight (455 +/- 80 g). The edema was primarily distributed in the base regions and was not gravity dependent. Heart volume, central venous, pulmonary artery, wedge, and systemic arterial pressures significantly increased. At aIAP 20 cm H(2)O in OA-injured lung, the central venous and pulmonary artery pressures further increased. The gas content further decreased, and the excess tissue mass rose up to 103 +/- 37% (tissue weight 905 +/- 134 g), with homogeneous distribution along the cephalocaudal and sternovertebral axis. We conclude that in OA-injured lung, the increase of IAP increases the amount of edema.

In case of abdomen compartment syndrome, measurement of bladder pressure is an accurate means to assess peritoneal pressure. Authors describe measurement technique and pitfalls to avoid.

Abdominal compartment syndrome is a systemic syndrome involving derangement in cardiovascular hemodynamics, respiratory and renal function as a result of sustained increase in intra-abdominal pressure. This results in multi-organ failure requiring prompt action and treatment. Presentation can be acute, chronic and acute on chronic. Initial diagnosis is clinical, confirmed by measurement of urinary bladder pressure. Treatment is abdominal decompression by laparostomy and delayed abdominal closure. Awareness among the surgeons has increased because laparoscopy has resulted in determination of intra-abdominal pressure as a readily measurable quantity. They have been able to appreciate the benefit of abdominal decompression by performing repeated planned laparotomies for trauma.

BACKGROUND: Perioperative disturbances of microvascular blood flow and oxygenation in the intestinal tract have been hypothesized to play an important role in development of the multiple organ dysfunction syndrome. Herein, increased intra-abdominal pressure (IAP) has been identified as a key factor in the initiation of the pathophysiologic cascade. The authors hypothesized that increasing the IAP by intraperitoneal insufflation of carbon dioxide attenuates microvascular oxygen saturation in gastric mucosa. They tested this hypothesis in a prospective, observational study in 16 patients scheduled to undergo elective diagnostic laparoscopy. METHODS: The authors continuously assessed microvascular oxygen saturation in gastric mucosa by reflectance spectrophotometry. Simultaneously systemic oxygen saturation, heart rate, arterial blood pressure, and ventilation-derived variables were measured noninvasively. During general anesthesia and controlled mechanical ventilation, baseline values were obtained. Thereafter, the IAP was increased to 8 and 12 mmHg, respectively, followed by a control period after desufflation. RESULTS: The increase in IAP from baseline to 8 mmHg decreased microvascular oxygen saturation in gastric mucosa from 69+/-7% (mean +/- SD) to 63+/-8% at 8 mmHg IAP (P <0.05), with a further significant reduction to 54+/-13% at 12 mmHg IAP (P <0.01). Microvascular oxygen saturation in gastric mucosa recovered rapidly to baseline level (66 +/- 10%) after release of increased IAP. In striking contrast to regional mucosal oxygen saturation, systemic oxygenation did not change with either of the interventions. CONCLUSIONS: The results suggest that increasing intraabdominal pressure to moderate levels, commonly applied to induce a surgical pneumoperitoneum, decreases gastric mucosal oxygen saturation.

Hemorrhage is the most common cause of shock in patients with polytrauma, leading to cellular hypoxia and death. A large body of experimental and clinical research has greatly expanded our knowledge of cellular mechanisms and clinical outcomes in resuscitation of patients with hypovolemic shock. However, the fundamental principles of fluid resuscitation have not changed during the past few decades. Aggressive resuscitation to correct tissue hypoperfusion within 24 hours of injury is associated with improved clinical outcomes. Initial volume expanders of choice are crystalloid solutions, with blood and blood products used for patients who are hemodynamically unstable, patients with Class III and Class IV hemorrhage, and patients with ongoing uncontrolled sources of bleeding. The incidence of immunologic and infectious complications associated with blood transfusions in resuscitation of patients with polytrauma has not been shown to be any higher than in other clinical settings. Massive resuscitations, however, are associated with specific complications such as hypothermia, coagulopathy, and abdominal compartment syndrome. Novel blood substitutes, hypertonic saline, and minimally invasive hemodynamic monitoring techniques have the potential of optimizing fluid resuscitation in patients with polytrauma. Additional research using standardized animal models and randomized clinical trials is needed.

We report a case in which a non-trauma patient suffering hematemesis and undergoing massive volume resuscitation developed abdominal compartment syndrome (ACS). The abdominal distension severely compromised his pulmonary functioning: a chest radiograph showed low lung volumes and dense bilateral parenchymal opacities. His blood oxygen saturation reached as low as 32%. Because he was hemodynamically unstable and coagulopathic, decompressive surgery was not possible. We gradually raised the ventilator settings to reinflate the lungs (positive end-expiratory pressure [PEEP] was raised to 50 cm H(2)O, peak inspiratory pressure to 100 cm H(2)O, and plateau inspiratory pressure to 80 cm H(2)O) and continued fluid resuscitation, and within an hour his blood oxygen saturation increased to 100%. In this case high PEEP was beneficial in a situation in which decompressive surgery was not feasible, but we do not suggest that high PEEP necessarily improves survival or that high PEEP is better than surgical decompression. On the contrary, high-pressure ventilation can be harmful in the setting of acute lung injury and acute respiratory distress syndrome, so we do not advocate high PEEP for all patients with hypoxemia and ACS, especially considering that many of the conditions associated with ACS can also precipitate acute lung injury and acute respiratory distress syndrome. As well, high-pressure ventilation can increase the risk of hypotension by impairing venous return. However, our case suggests that high PEEP may temporize in certain situations in which ACS causes life-threatening hypoxia but surgical decompression is not possible.

AIM: To study clinical characteristics and management of patients with early severe acute pancreatitis (ESAP). METHODS: Data of 297 patients with severe acute pancreatitis (SAP) admitted to our hospital within 72 h after onset of symptoms from January 1991 to June 2003 were reviewed for the occurrence and development of early severe acute pancreatitis (ESAP). ESAP was defined as presence of organ dysfunction within 72 h after onset of symptoms. Sixty-nine patients had ESAP, 228 patients without organ dysfunction within 72 h after onset of symptoms had SAP. The clinical characteristics, incidence of organ dysfunction during hospitalization and prognosis between ESAP and SAP were compared. RESULTS: Impairment degree of pancreas (Balthazar CT class) in ESAP was more serious than that in SAP (5.31+/-0.68 vs 3.68+/-0.29, P<0.01). ESAP had a higher mortality than SAP (43.4% vs 2.6%, P<0.01), and a higher incidence of hypoxemia (85.5% vs 25%, P<0.01), pancreas infection (15.9% vs 7.5%, P<0.05), abdominal compartment syndrome (ACS) (78.3% vs 23.2%, P<0.01) and multiple organ dysfunction syndrome (MODS)(78.3% vs 10.1%, P<0.01). In multiple logistic regression analysis, the main predisposing factors to ESAP were higher APACHE II score, Balthazar CT class, MODS and hypoxemia. CONCLUSION: ESAP is characterised by MODS, severe pathological changes of pancreas, early hypoxemia and abdominal compartment syndrome. Given the poor prognosis of ESAP, these patients should be treated in specialized intensive care units with special measures such as close supervision, fluid resuscitation, improvement of hypoxemia, reduction of pancreatic secretion, elimination of inflammatory mediators, prevention and treatment of pancreatic infections.

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Physiologic changes in renal transplant patients, such as transiently low central venous pressure, may be related to increased intra-abdominal pressure, from the volume of the transplanted kidney itself. Using intraoperative and postoperative Doppler ultrasound of the transplant renal vessels, we identified changes in flow dynamics following closure of the abdomen and reversal of the changes when the abdomen was reopened. This was attributed to abdominal compartment syndrome and a fasciotomy was created in the abdominal wall to accommodate the transplanted kidney. The findings in this case, in keeping with abdominal compartment syndrome, are not often considered in transplant recipients, but may explain some of the postsurgical physiology in some patients, particularly in the pediatric population.