Al-Bahrani, A. Z., G. H. Abid, et al. (2007). "A prospective evaluation of CT features predictive of intra-abdominal hypertension and abdominal compartment syndrome in critically ill surgical patients." Clin Radiol 62(7): 676-82.

AIM: The aim of this study was to validate the computed tomography (CT) features of intra-abdominal hypertension (IAH) by relating them to the clinical measurement of intra-abdominal pressure (IAP) in critically ill surgical patients. MATERIALS AND METHODS: The intra-vesical pressure was measured to reflect IAP in 24 critically ill patients. CT examinations obtained within 24h of IAP measurement were reviewed and scored independently by two consultant radiologists. Each CT examination was scored for the seven proposed features of IAH. Images obtained during the presence of IAH were compared with those obtained in the absence of IAH. RESULTS: Forty-eight abdominal CT examinations were evaluated, of which 18 (38%) were obtained in the presence of IAH, whereas eight (17%) were obtained in the presence of abdominal compartment syndrome (ACS). At CT, the round belly sign (RBS) and bowel wall thickening with enhancement (BWTE) were significantly more frequently detected during the presence of IAH than when the IAP was less than 12mmHg (78 versus 20% of examinations, p<0.001 and 39 versus 3% of examinations, p=0.003, respectively), but only BWTE was significantly associated with the presence of ACS (40 versus 11% of examinations, p=0.047). CONCLUSION: The presence of RBS and BWTE on CT images of critically ill surgical patients should alert clinicians to the possibility of presence of IAH and ACS, and prompt measurement of the IAP and consideration of suitable interventions.

Balogh, Z., J. J. De Waele, et al. (2007). "Intra-abdominal pressure measurement and abdominal compartment syndrome: the opinion of the World Society of the Abdominal Compartment Syndrome." Crit Care Med 35(2): 677-8; author reply 678-9.

Balogh, Z., J. J. De Waele, et al. (2007). "Continuous intra-abdominal pressure monitoring." Acta Clin Belg Suppl(1): 26-32. BACKGROUND: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) can develop within 12 hours of ICU admission in high-risk patients. Until recently the intermittent intra-abdominal pressure (IAP) measurement via the urinary catheter was the clinical standard. This is a relatively labour intensive technique and its intermittent nature could prevent timely recognition of significant changes in IAP. The historical continuous IAP (CIAP) measurements were poorly reproducible (gastric route) or invasive/impractical (direct measurement). The aim of this paper is to review the current evidence on CIAP monitoring. METHODS: A broad Medline search of the English literature was performed using the terms of "intra abdominal pressure" and "continuous". This result was analysed based on the title and abstract. Only original clinical studies with continuous IAP measurement were considered in this review. New techniques of CIAP monitoring evaluated in large animal models are discussed as potential future directions. RESULTS: There is a growing evidence of measuring (monitoring) CIAP using several techniques (gastric, direct abdominal, inferior vena cava, and urinary bladder.The strongest evidence supports the direct abdominal, the gastric and the bladder route. From these three techniques the CIAP monitoring via the bladder has excellent agreement with the current standard of intermittent bladder pressure measurement. While the direct measurement could be very accurate it is an invasive method and feasible in patient who underwent laparotomy or laparoscopy. CONCLUSIONS: Until a better technique is available the CIAP monitoring via the bladder or stomach should be considered as the standard for continuous monitoring of the IAP. It is a less labour intensive, safe, less invasive and reliable method.

Balogh, Z., F. A. Moore, et al. (2007). "Secondary abdominal compartment syndrome: A potential threat for all trauma clinicians." Injury 38(3): 272-9.

Post-injury abdominal compartment syndrome (ACS) is an increasingly recognised phenomenon in critical care. During the last decade, ACS had also been characterised in patients without abdominal injuries, referred to as secondary ACS. Recent investigation has described this elusive syndrome better, with up to 70% mortality. Regardless of the cause of the syndrome and the nature of any extra-abdominal injuries, secondary ACS is invariably associated with massive fluid resuscitation. With a reliable, predictive model and new monitoring techniques, trauma clinicians should be able to identify the high-risk patient and attenuate the impact of this syndrome.

Barker, D. E., J. M. Green, et al. (2007). "Experience with vacuum-pack temporary abdominal wound closure in 258 trauma and general and vascular surgical patients." J Am Coll Surg 204(5): 784-92; discussion 792-3.

BACKGROUND: Temporary closure of an open abdominal wound by vacuum-pack is the method of choice for patients requiring open abdomen management in our institution. We have previously reported our experience with a vacuum-pack in trauma patients and have expanded its use to general and vascular surgery patients. STUDY DESIGN: This is a descriptive study performed through review of medical records of all patients undergoing vacuum-pack closure after celiotomy from January 1999 to May 2006. Clinical and demographic data were collected. RESULTS: Seven hundred seventeen vacuum-pack closures were performed in 258 surgical patients (116 trauma versus 142 general and vascular surgery). The most common indication for open abdomen management was damage control in trauma patients and planned reexploration in general and vascular surgery patients. Total abdominal complication rate was 15.5% (14.7% trauma versus 16.2% general and vascular surgery). Fistulas occurred in 13 (5%), intraabdominal abscesses in 9 (3.5%), bowel obstruction in 3 (1.2%), abdominal compartment syndrome in 3 (1.2%), and evisceration in 1 (0.4%). Two hundred twenty-six patients survived to permanent abdominal wound closure. Of these, 154 (68.1%) patients underwent primary fascial closure of their abdominal wounds. Seventy-two patients (31.9%) required delayed closure. In-hospital mortality rate was 26.0% (25.9% trauma versus 26.1% general and vascular surgery). The cost of vacuum-pack materials is less than $50. CONCLUSIONS: Indication for open abdomen management varied between general and vascular surgery and trauma patients. Complication rates were similar. Primary closure of open abdominal wounds was achieved in 68.4% of patients. Vacuum-pack temporary abdominal wound closure, initially used in trauma patients, continues to demonstrate ease of mastery, effectiveness in patient care and comfort, consistently low associated complication rate, and low cost in both general and vascular surgery and trauma patients.

Basu, A. (2007). "A low-cost technique for measuring the intraabdominal pressure in non-industrialised countries." Ann R Coll Surg Engl 89(4): 434-5.

Brush, K. A. (2007). "Abdominal compartment syndrome: The pressure is on." Nursing 37(7): 36-41.

Find out how this sometimes deadly condition develops and what you can do to take the pressure off vulnerable organs.

Brush, K. A. (2007). "Measuring intra-abdominal pressure." Nursing 37(7): 42-4.

Learn how to monitor IAP through your patient's indwelling urinary catheter to detect signs of abdominal compartment syndrome.

Calzia, E., S. Klaus, et al. (2007). "Decompression in abdominal compartment syndrome: How early is early?" Intensive Care Med.

Castellanos, G., A. Pinero, et al. (2007). "[Intra-abdominal hypertension and abdominal compartment syndrome. What should surgeons know and how should they manage these entities?]." Cir Esp 81(1): 4-11.

Correct monitoring of medicosurgical critically-ill patients aids the early diagnosis and appropriate treatment of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The abdominal cavity and the retroperitoneum act sealed compartments and any change in the volume of their contents can increase intraabdominal pressure (IAP). IAH is only one measure of elevated IAP, and ACS represents the end result of sustained IAH with the appearance of organ dysfunction. To diagnose IAH and ACS, measurement of IAP, abdominal perfusion pressure and intramucous gastric pH must be performed and the results correlated with signs of clinical deterioration in the patient. Medical therapeutic measures in ACS are limited and abdominal decompression is the established symptomatic treatment of this entity.

Cheatham, M. and K. Safcsak (2007). "Is the evolving management of IAH/ACS improving survival?" Acta Clinica Belgica 62-supplement 1: 268 - Abstract O61.

Cheatham, M. L. (2007). "Is the canary still singing?" Crit Care Med 35(1): 320-1.

Cheatham, M. L. and M. L. Malbrain (2007). "Cardiovascular implications of abdominal compartment syndrome." Acta Clin Belg 62 (Suppl 1)(1): 98-112.

Cardiovascular dysfunction and failure are commonly encountered in the patient with intraabdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload, in conjunction with appropriate goal-directed resuscitation and abdominal decompression when indicated, are essential to restoring end-organ perfusion and maximizing patient survival. The validity of traditional hemodynamic resuscitation endpoints, such as pulmonary artery occlusion pressure and central venous pressure, must be reconsidered in the patient with intra-abdominal hypertension as these pressure-based estimates of intravascular volume have significant limitations in patients with elevated intra-abdominal pressure. If such limitations are not recognized, misinterpretation of the patient's cardiac status is likely, resulting in inappropriate and potentially detrimental therapy. Appropriate fluid administration is mandatory as under-resuscitation leads to organ failure and over-resuscitation the development of secondary abdominal compartment syndrome, both of which are associated with increased morbidity and mortality. Volumetric monitoring techniques have been proven to be superior to traditional intra-cardiac filling pressures in directing the appropriate resuscitation of this patient population. Calculation of the "abdominal perfusion pressure", defined as mean arterial pressure minus intra-abdominal pressure, has been shown to be a beneficial resuscitation endpoint as it assesses not only the severity of the patient's intra-abdominal hypertension, but also the adequacy of abdominal blood flow. Application of a goal-directed resuscitation strategy, including abdominal decompression when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.

Cheatham, M. L. and M. L. Malbrain (2007). "Cardiovascular implications of abdominal compartment syndrome." Acta Clin Belg Suppl(1): 98-112.

Cardiovascular dysfunction and failure are commonly encountered in the patient with intraabdominal hypertension or abdominal compartment syndrome. Accurate assessment and optimization of preload, contractility, and afterload, in conjunction with appropriate goal-directed resuscitation and abdominal decompression when indicated, are essential to restoring end-organ perfusion and maximizing patient survival. The validity of traditional hemodynamic resuscitation endpoints, such as pulmonary artery occlusion pressure and central venous pressure, must be reconsidered in the patient with intra-abdominal hypertension as these pressure-based estimates of intravascular volume have significant limitations in patients with elevated intra-abdominal pressure. If such limitations are not recognized, misinterpretation of the patient's cardiac status is likely, resulting in inappropriate and potentially detrimental therapy. Appropriate fluid administration is mandatory as under-resuscitation leads to organ failure and over-resuscitation the development of secondary abdominal compartment syndrome, both of which are associated with increased morbidity and mortality. Volumetric monitoring techniques have been proven to be superior to traditional intra-cardiac filling pressures in directing the appropriate resuscitation of this patient population. Calculation of the "abdominal perfusion pressure", defined as mean arterial pressure minus intra-abdominal pressure, has been shown to be a beneficial resuscitation endpoint as it assesses not only the severity of the patient's intra-abdominal hypertension, but also the adequacy of abdominal blood flow. Application of a goal-directed resuscitation strategy, including abdominal decompression when indicated, improves cardiac function, reverses end-organ failure, and minimizes intra-abdominal hypertension-related patient morbidity and mortality.

Cheatham, M. L., M. L. Malbrain, et al. (2007). "Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations." Intensive Care Med 33(6): 951-62.

OBJECTIVE: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. DESIGN: An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. METHODS: Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. RESULTS: The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. CONCLUSIONS: These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.

Cheatham, M. L., K. Safcsak, et al. (2007). "Nitrogen balance, protein loss, and the open abdomen." Crit Care Med 35(1): 127-131.

OBJECTIVE:: Goal-directed nutritional support is essential to improving morbidity and mortality. Open abdominal decompression is similarly crucial to the successful treatment of intra-abdominal hypertension and abdominal compartment syndrome. The open abdomen, however, places the patient at risk for potentially significant fluid, electrolyte, and presumably protein losses from the exposed viscera. Although nutritional protein assessments are frequently utilized to measure urinary nitrogen, these calculations do not consider the loss of protein from the open abdomen. We hypothesize that accurate assessment of nitrogen balance in the patient requiring an open abdomen must include either a measurement or estimation of abdominal fluid nitrogen loss. DESIGN:: Prospective, observational cohort study. SETTING:: Adult surgical/trauma intensive care unit of a level I trauma center. PATIENTS:: Surgical/trauma patients requiring laparotomy. INTERVENTIONS:: Serial 24-hr collections of urine and abdominal fluid protein were performed to characterize abdominal fluid protein loss and evaluate the clinical effect of accounting for abdominal fluid nitrogen as part of nitrogen balance calculations. MEASUREMENTS AND MAIN RESULTS:: Nitrogen intake correlates with urinary nitrogen loss but not with abdominal fluid nitrogen loss. Abdominal fluid nitrogen loss is significant and remains relatively stable in the early postoperative period. Nutritional calculations that fail to account for abdominal fluid nitrogen loss significantly overestimate actual nitrogen balance by an average of 3.5 g/24 hrs. CONCLUSIONS:: The open abdomen represents a significant source of protein/nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a direct effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.

Collier, B., J. Diaz, et al. (2007). "Feeding the open abdomen is associated with earlier abdominal closure and less fistulae." Acta Clin Belg Suppl 62-supplement 1: O65 Abstract.

Collier, B., O. Guillamondegui, et al. (2007). "Feeding the open abdomen." JPEN J Parenter Enteral Nutr 31(5): 410-5.

BACKGROUND: The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA). METHODS: Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation. RESULTS: Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than $50,000. CONCLUSIONS: EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Cresswell, A. B. and J. A. Wendon (2007). "Hepatic function and non-invasive hepatosplanchnic monitoring in patients with abdominal hypertension." Acta Clin Belg Suppl(1): 113-8.

A better understanding of intra-abdominal hypertension with relation to the liver is vital to the management of all forms of liver pathophysiology. Supporting good hepatic function within the critically ill patient is important not only in maintaining synthetic function, but also in avoiding the multi-organ complications of liver dysfunction. The resulting reduction in hepato-splanchnic blood flow (HSBF) observed with increasing intra-abdominal pressure has been clearly documented and seen to be exaggerated in animals with established liver disease. Unfortunately the tools required to measure this, remain difficult to apply routinely in the clinical setting and as such goal directed therapy to specifically improve the hepatosplanchnic circulation remains elusive. Given the documented effects of lAP on HSBF and the relatively high incidence of intra-abdominal hypertension and the abdominal compartment syndrome within "liver patients" as a whole, close attention to IAP and timely correction by appropriate medical or surgical means would appear to be essential.

De Dooy, J. and J. Ramet (2007). "ACS in paediatrics." Acta Clin Belg Suppl(1): 149-51.

Abdominal Compartment Syndrome (ACS) occurs relatively infrequent in a paediatric population when compared with adults. Overall mortality is still high. Also, the pathophysiologic mechanism that leads to ACS is different in children. In this review, we will present an overview on ACS in children admitted to a paediatric intensive care unit.

De laet, I., G. Citerio, et al. (2007). "The influence of intraabdominal hypertension on the central nervous system: current insights and clinical recommendations, is it all in the head?" Acta Clin Belg Suppl(1): 89-97.

INTRODUCTION: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are a common occurrence in ICU patients. The deleterious effects of IAH on organ function are well known and increasingly appreciated in recent years, especially where renal and respiratory function are concerned. METHODS: This review will focus on the available literature from the last years.A Medline and PubMed search was performed in order to find an answer to the question "What is the impact of increased IAP on neurologic function in the critically ill?" RESULTS: The amount of data on the influence of IAH on the central nervous system is more scarce, but several animal and human studies have demonstrated a clear correlation between intra-abdominal pressure (IAP) and intracranial pressure (ICP). This correlation is probably due to transmission of the increased IAP to the thorax leading to increased intrathoracic, pleural pressure and central venous pressure, decreased venous return from the brain and increased ICP.This hypothesis is supported by the observation that the increase in ICP is abolished when a sternotomy and pleuropericardotomy are performed, and by the fact that abdominal decompression has produced good results in treating refractory intracranial hypertension (ICH) in patients with both IAH and ICH. CONCLUSIONS: A close relationship between IAP and ICP has been observed in several animal and human studies. The clinical impact of this association is dependent on the baseline ICP and the compensatory reserve of the patient. Some studies have reported good results in treating refractory ICH by abdominal decompression in patients with concomitant IAH. Monitoring of IAP and ICP in risk patients is essential.

De laet, I. and M. L. Malbrain (2007). "ICU management of the patient with intra-abdominal hypertension: what to do, when and to whom?" Acta Clin Belg Suppl(1): 190-9.

INTRODUCTION: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognised to be a contributing cause of organ dysfunction and mortality in critically ill patients. The number of publications describing and researching this phenomenon is increasing exponentially but there are still very limited data about treatment and outcome. METHODS: This review will focus on the available literature from the last years. A Medline and PubMed search was performed using the search terms "abdominal compartment syndrome" and "treatment". RESULTS: This search yielded 437 references, most of which were not relevant to the subject of this paper. The remaining abstracts were screened and selected on the basis of relevance, methodology and number of cases. Full text articles of the selected abstracts were used to supplement the authors' expert opinion and experience. The abdomino-thoracic transmission of pressure has direct clinical consequences on the cardiovascular, respiratory and central nervous systems in terms of monitoring and management.These interactions are discussed and treatment recommendations are made. IAH-induced renal dysfunction is addressed as a separate issue. Finally, an overview of non-invasive measures to decrease IAP is given. CONCLUSION: This paper describes current insights on management of IAP induced organ dysfunction and lists the most widely used and published non-invasive techniques to decrease IAP with their limitations and pitfalls.

de Laet, I. E. and M. Malbrain (2007). "Current insights in intra-abdominal hypertension and abdominal compartment syndrome." Med Intensiva 31(2): 88-99.

A compartment syndrome exists when increased pressure in a closed anatomic space threatens the viability of the tissue within the compartment. When this occurs in the abdominal cavity it threatens not only the function of the intra-abdominal organs, but it can have a devastating effect on distant organs as well. Recent animal and human data suggest that the adverse effects of elevated intra-abdominal pressure (IAP) can occur at lower levels than previously thought and even before the development of clinically overt abdominal compartment syndrome (ACS). The ACS is not a disease but truly a syndrome, a spectrum of symptoms and signs that can and mostly does have multiple causes. It is only recently that this condition received a heightened awareness. This article reflects the current state of knowledge on intra-abdominal pressure regarding etiology, epidemiology, diagnosis, IAP measurement, organ dysfunction, prevention and treatment.

De Waele, J. J., F. Berrevoet, et al. (2007). "Semicontinuous intra-abdominal pressure measurement using an intragastric Compliance catheter." Intensive Care Med 33(7): 1297-300.

OBJECTIVE: To compare intra-abdominal pressure (IAP) measurements obtained from an intragastric Compliance catheter with the pressure measured directly in the abdominal cavity. DESIGN AND SETTING: Prospective cohort study in an operating room of the Ghent University Hospital PATIENTS: Seven patients undergoing elective laparoscopic cholecystectomy. INTERVENTIONS: IAP was obtained from both an intragastric catheter and directly from the peritoneal cavity at 1-minute intervals in patients undergoing elective cholecystectomy and compared using Bland-Altman analysis. MEASUREMENTS AND RESULTS: In 156 paired measurements obtained from 7 patients the mean difference between IAP(gastric) and IAP(ref) was 0.12[Symbol: see text]+/-[Symbol: see text] 0.70[Symbol: see text]mmHg (95% CI 0.01-0.23). CONCLUSIONS: IAP measured using an intragastric Compliance catheter reliably reflects the reference IAP in patients undergoing laparoscopic cholecystectomy.

De Waele, J. J., I. De laet, et al. (2007). "Intraabdominal hypertension and abdominal compartment syndrome: we have paid attention, now it is time to understand!" Acta Clin Belg Suppl(1): 6-8.

De Waele, J. J., I. De laet, et al. (2007). "Rational intraabdominal pressure monitoring: how to do it?" Acta Clin Belg Suppl(1): 16-25.

INTRODUCTION: Intraabdominal hypertension (IAH) is increasingly appreciated by intensivists as an important cause of organ dysfunction, even at pressure levels which were previously thought to be harmless. Therefore, the goal of this review is to describe the different methods commonly used in clinical practice for intraabdominal pressure (IAP) measurement, the advised methodology for each measurement method, and finally to give a rational approach for IAP monitoring in daily clinical practice. METHODS: A Medline search of the English literature was performed using the term "intra abdominal pressure" and "measurement". This resulted in 194 studies, which were then analysed based on the title and abstract. Only clinical studies in human subjects with IAP measurement or related issues as the subject of the study, were considered for inclusion in the study. Reviews, animal experiments and case reports were excluded, while one specific review on IAP measurement and 3 large animal studies (domestic swine > 40 kg) were included in the analysis. This left us with 19 studies, published between 1984 and 2006: 1 specific review, 2 studies in children, 13 in adults and 3 in domestic swine. The references from these studies were searched for relevant articles that may have been missed in the primary search. These articles served as the basis for the recommendations below. RESULTS: Clinical data regarding the validation of new IAP measurement methods or the reliability of established measurement techniques are scarce. The transvesical route, which has been studied most extensively, can be used as reliable route for intermittent IAP measurement, as long as instillation volumes below 25mL are used. Continuous IAP and APP monitoring can be done via a balloon-tipped catheter placed in the stomach or directly intraperitoneal. CONCLUSIONS: Rational IAP monitoring should be based on a site specific protocol, based on known risk factors, the monitoring equipment available and nursing staff experience, and should be linked directly to a local treatment protocol.

Duperret, S., F. Lhuillier, et al. (2007). "Increased intra-abdominal pressure affects respiratory variations in arterial pressure in normovolaemic and hypovolaemic mechanically ventilated healthy pigs." Intensive Care Med 33(1): 163-71.

OBJECTIVE: To evaluate the effect of increased intra-abdominal pressure (IAP) on the systolic and pulse pressure variations induced by positive pressure ventilation in a porcine model. DESIGN AND SETTING: Experimental study in a research laboratory. SUBJECTS: Seven mechanically ventilated and instrumented pigs prone to normovolaemia and hypovolaemia by blood withdrawal. INTERVENTION: Abdominal banding gradually increased IAP in 5-mmHg steps up to 30[Symbol: see text]mmHg. MEASUREMENTS AND MAIN RESULTS: Variations in systolic pressure, pulse pressure, inferior vena cava flow, and pleural and transmural (LVEDPtm) left-ventricular end-diastolic pressure were recorded at each step. Systolic pressure variations were 6.1[Symbol: see text]+/-[Symbol: see text]3.1%, 8.5[Symbol: see text]+/-[Symbol: see text]3.6% and 16.0[Symbol: see text]+/-[Symbol: see text]5.0% at 0, 10, and 30[Symbol: see text]mmHg IAP in normovolaemic animals (mean[Symbol: see text]+/-[Symbol: see text]SD; p<[Symbol: see text]0.01 for IAP effect). They were 12.7[Symbol: see text]+/-[Symbol: see text]4.6%, 13.4[Symbol: see text]+/-[Symbol: see text]6.7%, and 23.4[Symbol: see text]+/-[Symbol: see text]6.3% in hypovolaemic animals (p<[Symbol: see text]0.01 vs normovolaemic group) for the same IAP. Fluctuations of the inferior vena cava flow disappeared as the IAP increased. Breath cycle did not induce any variations of LVEDPtm for 0 and 30[Symbol: see text]mmHg IAP. CONCLUSIONS: In this model, the systolic pressure and pulse pressure variations, and inferior vena cava flow fluctuations were dependent on IAP values which caused changes in pleural pressure swing, and this dependency was more marked during hypovolaemia. The present study suggests that dynamic indices are not exclusively related to volaemia in the presence of increased IAP. However, their fluid responsiveness predictive value could not be ascertained as no fluid challenge was performed.

Ejike, J. C., S. Humbert, et al. (2007). "Outcomes of children with abdominal compartment syndrome." Acta Clin Belg 62 (Suppl 1)(1): 141-8.

INTRODUCTION: Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations. OBJECTIVE: To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS. SETTING: 25 bed tertiary pediatric intensive care unit. PATIENTS: Patients less than 50 kg on mechanical ventilation and a urethral catheter. MEASUREMENTS: Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored. MAIN RESULTS: 14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondaryACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17- 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of >17 were predictive of developing ACS. CONCLUSIONS: ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Fenton, S. J., C. M. Dodgion, et al. (2007). "Temporary abdominal vacuum-packing closure in the neonatal intensive care unit." J Pediatr Surg 42(6): 957-60; discussion 960-1.

BACKGROUND: Temporary abdominal vacuum-packing (vac-pac) closure is well known in adult literature, yet has not been reported in infants. METHODS: A review of children in the neonatal intensive care unit who underwent vac-pac closure from 2000 to 2006 was performed. RESULTS: During this time, 7 infants underwent vac-pac closure after abdominal surgery. Median age was 39 days, with a median weight of 3.2 kg. Reasons for vac-pac included abdominal compartment syndrome (3), ongoing intraabdominal sepsis (1), anticipated second-look procedures (2), and abdominal observation after repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation (1). PaCO2 revealed a drop from a median preoperative level of 50.3 to 44.0 mm Hg postoperatively. Median preoperative urine output was 3.9 and 3.1 mL/(kg h) postoperatively. One patient died with an open abdomen from overwhelming Escherichia coli sepsis, and all surviving patients (85.7%) proceeded to definitive abdominal closure with the median time of vac-pac use being 4 days. CONCLUSION: Vac-pac closure in infants is a safe and effective method of temporary abdominal closure. The detrimental effects of intraabdominal hypertension as well as risk of hemorrhage after repair of congenital diaphragmatic hernia while on extracorporeal membrane oxygenation also make this an important technique for abdominal observation.

Frezza, E. E., K. O. Shebani, et al. (2007). "Morbid obesity causes chronic increase of intraabdominal pressure." Dig Dis Sci 52(4): 1038-41.

Intraabdominal hypertension and the abdominal compartment syndrome are known to deleteriously affect a wide array of organ systems. We retrospectively reviewed 62 women who underwent either laparoscopic gastric bypass surgery or adjustable gastric banding. Their age, body mass index (BMI), and race were known. Their opening abdominal pressure was recorded by connecting a Verress needle to a pressure monitor. Linear regression was used to assess the contribution of age, race, and BMI to the observed variation in opening abdominal pressure. Neither variation in age or race explained the variation in opening pressure (P > .05). By contrast, variation in BMI explained 8% of the observed variation in opening pressure (P < .05). For every 1 kg/mm(2) increase in BMI, there was on average a 0.07 mm Hg increase in opening pressure. Increases in BMI are associated with increases in intraabdominal pressure.

Germanos, S., S. Gourgiotis, et al. (2007). "Damage control surgery in the abdomen: An approach for the management of severe injured patients." Int J Surg.

Damage control is well established as a potentially life-saving procedure in a few selected critically injured patients. In these patients the 'lethal triad' of hypothermia, acidosis, and coagulopathy is presented as a vicious cycle that often can not be interrupted and which marks the limit of the patient's ability to cope with the physiological consequences of injury. The principles of damage control have led to improved survival and to stopped bleeding until the physiologic derangement has been restored and the patient could undergo a prolong operation for definitive repair. Although morbidity is remaining high, it is acceptable if it comes in exchange for improved survival. There are five critical decision-making stages of damage control: I, patient selection and decision to perform damage control; II, operation and intraoperative reassessment of laparotomy; III, resuscitation in the intensive care unit; IV, definitive procedures after returning to the operating room; and V, abdominal wall reconstruction. The purpose of this article is to review the physiology of the components of the 'lethal triad', the indication and principles of abdominal damage control of trauma patients, the reoperation time, and the pathophysiology of abdominal compartment syndrome.

Hadeed, J. G., G. W. Staman, et al. (2007). "Delayed primary closure in damage control laparotomy: the value of the Wittmann patch." Am Surg 73(1): 10-2.

Damage control laparotomy has become an accepted practice in trauma surgery. A number of methods leading to delayed primary closure of the abdomen have been advocated; complications are recognized with all these methods. The approach to staged repair using the Wittmann patch (Star Surgical Inc., Burlington, WI) combines the advantages of planned relaparotomy and open management, while minimizing the rate of complications. The authors hypothesized that use of the Wittmann patch would lead to a high rate of delayed primary closure of the abdomen. The patch consists of two sheets sutured to the abdominal fascia, providing for temporary closure. Advancement of the patch and abdominal exploration can be done at bedside. When the fascial edges can be reapproximated without tension, abdominal closure is performed. Twenty-six patients underwent staged abdominal closure during the study period. All were initially managed with intravenous bag closure. Eighty-three per cent (20 of 24) went on to delayed primary closure of the abdomen, with a mean time of 13.1 days from patch placement to delayed primary closure. The rate of closure using the Wittmann patch is equivalent to other commonly used methods and should be considered when managing patients with abdominal compartment syndrome or severe abdominal trauma.

Huang, G. J., A. K. Bajaj, et al. (2007). "Increased intraabdominal pressure in abdominoplasty: delineation of risk factors." Plast Reconstr Surg 119(4): 1319-25.

BACKGROUND: Abdominoplasty is associated with a 1.1 percent risk of deep venous thrombosis. This has been attributed to rectus plication causing intraabdominal hypertension, known to effect decreased venous return, venous stasis, and thus thrombosis. The authors conducted a pilot study to determine which components of the abdominoplasty procedure (i.e., general anesthesia, flexion of the bed, plication, and/or binder placement) may elevate intraabdominal pressures and whether this was clinically relevant. METHODS: Twelve abdominoplasty and 10 breast reduction (control) patients were enrolled prospectively. Intraabdominal pressure was transduced through the bladder before plication in the supine and flexed positions, after plication in both positions, after skin closure in the flexed position, and on postoperative day 1 with and without a binder in the flexed position. RESULTS: All intraabdominal pressures measured were clinically insignificant (<20 mm Hg). A statistically significant increase was found from flexion of the bed (mean difference, 3.80 +/- 2.0, p < 0.001, in the control group; and 4.39 +/- 1.68, p < 0.001, in the study group); rectus plication (mean difference, 2.78 +/- 2.11, p = 0.001, in the supine position; and 2.03 +/- 2.48, p = 0.016, in the flexed position); and binder placement (2.63 mm Hg for no binder versus 4.5 mm Hg with binder, p = 0.004). Both groups also showed an increase from preoperative to skin closure (mean difference, 2.03 +/- 6.7, p = 0.035, for the control group; and 2.83 +/- 3.97, p = 0.031, for the study group), suggesting general anesthesia as a risk factor. CONCLUSIONS: This study confirms the effect of rectus plication on increasing intraabdominal pressures but also implicates bed position, binder placement, and general anesthetic as risk factors. A larger study is needed to clarify the role of these variables in elevating intraabdominal pressure during abdominoplasty.

Ivatury, R. R., K. A. Kolkman, et al. (2007). "Management of open abdomen." Acta Clin Belg Suppl(1): 206-9.

Non-closure of abdominal fascia and the resultant open abdomen after laparotomy has become a major advance in the management of critically ill or injured patients.The benefits of open abdomen are many and include the prevention of intra-abdominal hypertension and the consequent abdominal compartment syndrome. Appropriately and exquisitely managed, it can provide all the benefits and prevent highly morbid complications of leaving the abdomen open.This review will provide some insights into such management.

Keskinen, P., A. Leppaniemi, et al. (2007). "Intra-abdominal pressure in severe acute pancreatitis." World J Emerg Surg 2: 2.

ABSTRACT: BACKGROUND: Hospital mortality in patients with severe acute pancreatitis (SAP) remains high. Some of these patients develop increased intra-abdominal pressure (IAP) which may contribute to organ dysfunction. The aims of this study were to evaluate the frequency of increased IAP in patients with SAP and to assess the development of organ dysfunction and factors associated with high IAP. METHODS: During 2001-2003 a total of 59 patients with severe acute pancreatitis were treated in the intensive care unit (ICU) of Helsinki University Hospital. IAP was measured by the intravesical route in 37 patients with SAP. Data from these patients were retrospectively reviewed. RESULTS: Maximal IAP, APACHE II score, maximal SOFA score, maximal creatinine, age and maximal lactate were significantly higher in nonsurvivors. There was a significant correlation of the maximal IAP with the maximal SOFA, APACHE II, maximal creatinine, maximal lactate, base deficit and ICU length of stay. Patients were divided into quartiles according to the maximal IAP. Maximal IAP was 7-14, 15-18, 19-24 and 25-33 mmHg and the hospital mortality rate 10%, 12.5%, 22.2% and 50% in groups 1-4, respectively. A statistically significant difference was seen in the maximal SOFA, ICU length of stay, maximal creatinine and lactate values. The mean ICU-free days in groups 1-4 were 45.7, 38.8, 32.0 and 27.5 days, respectively. The difference between groups 1 and 4 was statistically significant. CONCLUSION: In patients with SAP, increased IAP is associated with development of early organ failure reflected in increased mortality and fewer ICU-free days. Frequent measurement of IAP during intensive care is important in optimizing abdominal perfusion pressure and recognizing patients potentially benefitting from decompressive laparotomy.

Khan, M., S. J. Grimsley, et al. (2007). "Do changes in intra-abdominal pressure during air travel increase risk of spontaneous rupture of the renal pelvis?" Med Hypotheses.

Kimball, E. J., W. Kim, et al. (2007). "Clinical awareness of intra-abdominal hypertension and abdominal compartment syndrome in 2007." Acta Clin Belg Suppl(1): 66-73.

INTRODUCTION: There has been an exponentially increasing interest in intra-abdominal hypertension (IAH).The aim of this review is to evaluate the evolution in clinical awareness of this syndrome. METHODS: A PubMed (U.S. National Library of Medicine) search and a ScienceDirect (Elsevier B.V.) search of recent literature were performed in order to assess clinical awareness of IAH and abdominal compartment syndrome (ACS). RESULTS: In total, 489 articles and 8 clinical surveys have been identified. The results of the landmark papers and the surveys will be briefly discussed in this review. CONCLUSION: Clinical awareness of ACS is steadily increasing. It is time to pay attention to ACS, but further, it is time to move forward with therapeutic bundles in a multi-centered, outcome trial on IAH/ACS therapy in order to elevate IAH/ACS management to an international standard of care.

Kimball, E. J., M. C. Mone, et al. (2007). "Reproducibility of bladder pressure measurements in critically ill patients." Intensive Care Med 33(7): 1195-8.

OBJECTIVE: Intra-abdominal hypertension is an independent cause of multiorgan failure and directly effects other physiological measurements, making it an important factor in the management of critically ill patients, but no clinical studies have investigated the reproducibility of intra-abdominal pressure (IAP) measurement to ensure diagnostic accuracy. This study evaluated the intraobserver and interobserver variability of bladder pressure measurements. DESIGN AND SETTING: Prospective, observational study in a university-based adult surgical intensive care unit. PATIENTS: Critically ill patients undergoing intra-abdominal pressure readings, measured by nursing staff. MEASUREMENTS AND RESULTS: The study compared patient IAP measurements obtained by the same nurse (intraobserver variation) and between two different nurses (interobserver variation) in critical care patients with clinical indications for IAP monitoring. Data related to the nursing technique and performance were observed and collected for each IAP measurement obtained. Good correlation of bladder pressure measurements between the same and different individuals was found. Intraobserver and interobserver Pearson's correlations for measured IAP were 0.934 and 0.950, respectively. A unit protocol for IAP measurement standardization was modified based on observational data collected. CONCLUSIONS: Intra-abdominal pressure can be accurately and reliably measured in critically ill patients by utilizing a standardized measurement device combined with a standardized clinical protocol.

Kimball, E. J., M. C. Mone, et al. (2007). "Reproducibility of bladder pressure measurements in critically ill patients." Intensive Care Med 33.

OBJECTIVE: Intra-abdominal hypertension is an independent cause of multiorgan failure and directly effects other physiological measurements, making it an important factor in the management of critically ill patients, but no clinical studies have investigated the reproducibility of intra-abdominal pressure (IAP) measurement to ensure diagnostic accuracy. This study evaluated the intraobserver and interobserver variability of bladder pressure measurements. DESIGN AND SETTING: Prospective, observational study in a university-based adult surgical intensive care unit. PATIENTS: Critically ill patients undergoing intra-abdominal pressure readings, measured by nursing staff. MEASUREMENTS AND RESULTS: The study compared patient IAP measurements obtained by the same nurse (intraobserver variation) and between two different nurses (interobserver variation) in critical care patients with clinical indications for IAP monitoring. Data related to the nursing technique and performance were observed and collected for each IAP measurement obtained. Good correlation of bladder pressure measurements between the same and different individuals was found. Intraobserver and interobserver Pearson's correlations for measured IAP were 0.934 and 0.950, respectively. A unit protocol for IAP measurement standardization was modified based on observational data collected. CONCLUSIONS: Intra-abdominal pressure can be accurately and reliably measured in critically ill patients by utilizing a standardized measurement device combined with a standardized clinical protocol.

Kirkpatrick, A. W., R. Colistro, et al. (2007). "Renal arterial resistive index response to intraabdominal hypertension in a porcine model." Crit Care Med 35(1): 207-213.

OBJECTIVE:: The abdominal compartment syndrome is a potentially life-threatening condition with frequent renal involvement. There are few if any means of inferring subclinical effects before organ dysfunction. Because intrarenal pressure correlates with renal sonographic indices in other renal diseases, the purpose of this study was to determine the relationship between increasing intraabdominal hypertension and renal vascular flow velocities in a porcine model using renal Doppler ultrasound. DESIGN:: Animal study. SETTING:: University research laboratory. SUBJECTS:: Eight anesthetized, mechanically ventilated, well-hydrated, 30-kg female Yorkshire pigs. INTERVENTIONS:: Intraabdominal hypertension was induced by instillation of warmed intraperitoneal saline through a midline laparoscopic port. Intraabdominal pressure (IAP) was continuously monitored directly from the peritoneum and indirectly from the bladder. IAP was varied from 0 to 50 mm Hg in increments of 5 mm Hg. At each IAP level, gray-scale, color, and spectral Doppler renal arcuate artery ultrasound was obtained and resistive index (RI) and peak airway pressure calculated. MEASUREMENTS AND MAIN RESULTS:: Excellent agreement between direct and indirect IAP was found (bias, 0.032 mm Hg; 95% limits, -5.5 to 5.6 mm Hg). A linear relationship between RI and indirect IAP was observed and was defined by the regression equation: RI = 0.553 + 0.0104 x bladder pressure. There was a trend toward different RIs between left and right kidneys (p = .052) at the same IAP. RI varied in a linear fashion at low peak airway pressure and demonstrated an inflection point with steeper subsequent slope after peak airway pressure of 30 cm H2O. RI values rapidly returned to near baseline after abdominal decompression. CONCLUSIONS:: In this model, the renal artery RI correlated strongly and linearly with the severity of intraabdominal hypertension, making renal Doppler ultrasound a potential noninvasive screening tool for the renal effects of intraabdominal hypertension. Further studies are warranted.

Kirkpatrick, A. W., J. J. De Waele, et al. (2007). "The secondary and recurrent abdominal compartment syndrome." Acta Clin Belg Suppl(1): 60-5.

INTRODUCTION: The Secondary Abdominal Compartment Syndrome (SACS) refers to cases of the ACS that do not originate from the abdomino-pelvic region. With greater awareness of the physiologic consequences of raised intra-abdominal hypertension (IAH), cases of the SACS are being increasingly described. The prior treatment or the presence of a partially open abdomen does not preclude the ACS if the abdomen and viscera continue to swell or the clinician is not vigilant in monitoring intra-abdominal pressure (lAP). Such recurrent cases (RACS) have been defined as those which redevelop following the previous medical or surgical treatment of primary or SACS. Although there has been a diverse range of etiologies implicated, these cases seem to be linked by the common occurrence of severe shock requiring aggressive fluid resuscitation. The aim of this paper is to thus to review the historical background, awareness, definitions, pathophysiological implications and treatment options for SACS and RACS. METHODS: This review will focus on the available literature regarding SACS and RACS. A Medline and Pubmed search was performed using the keywords; secondary abdominal compartment syndrome AND secondary AND tertiary AND recurrent AND abdominal compartment syndrome AND intra-abdominal pressureAND intra-abdominal hypertension. Bibliographies of recovered papers were hand-searched for other appropriate references. The resulting references were included in the current review on the basis of relevance and scientific merit RESULTS: There has been remarkably little specific study of these entities outside of specific groups such as those injured by thermal or traumatic injury. The epidemiology, risk factors for, treatment of and most importantly, strategies for prevention all remain scientifically unknown and therefore based on opinion. Notable, although small, studies suggest that specific resuscitation practices may avert these conditions. CONCLUSIONS: ACS can occur in any patient who is critically ill and subject to visceral and somatic swelling, regardless of whether the inciting pathology is extra-abdominal. The ACS may also reoccur with recurrent shock and swelling even if previous therapies had partially addressed IAH. Therefore IAP measurements should be considered a routine monitoring for the critically ill, especially those subjected to shock and requiring a subsequent resuscitation. Much further study is required to understand the differences in etiology, diagnosis, pathophysiology, and treatment for all cases of the ACS.

Larsson, A. (2007). "Clinical significance of elevated intraabdominal pressure during common conditions and procedures." Acta Clin Belg Suppl(1): 74-7.

INTRODUCTION: Pregnancy, obesity, peritoneal dialysis, pneumoperitoneum, prone position and application of positive end-expiratory pressure are associated with elevated intraabdominal pressure (lAP). OBJECTIVE:To review the relation between these conditions and procedures, and intraabdominal hypertension (IAH) or abdominal compartment syndrome (ACS). METHODS: Search of PubMed and Google Scholar and review of article bibliographies. RESULTS AND CONCLUSION: Only obesity, peritoneal dialysis, and pneumoperitoneum are associated with symptoms related to IAH and these symptoms are reversible.

Leppaniemi, A., K. Johansson, et al. (2007). "Abdominal compartment syndrome and acute pancreatitis." Acta Clin Belg Suppl(1): 131-5.

Significant visceral edema associated with massive fluid resuscitation, paralytic ileus and formation of pancreatic ascites in patients with severe acute pancreatitis (SAP) can lead to abdominal compartment syndrome (ACS) that can contribute to the early development of multiple organ dysfunction syndrome (MODS), especially in the early stages of the disease. The prevalence of intra-abdominal hypertension (IAH) in SAP is about 40% and a manifest ACS occurs in about 10% of the patients warranting close monitoring of intra-abdominal pressure (lAP) in all patients with the severe form of the disease. Although nonsurgical management utilizing percutaneous drainage of ascites or continuous hemodiafiltration may decrease IAP, most patients require decompressive laparostomy and temporary abdominal closure. The primary aim in managing the ensuing open abdomen is delayed fascial closure during initial hospitalization. On many occasions a planned hernia approach, either with early skin grafting over the exposed bowel or managing the ASC primarily with a subcutaneous linea alba fasciotomy, is the only available option. The development of ACS in patients with SAP seems to be associated with increased mortality.

Libberecht, K., S. D. Colpaert, et al. (2007). "New developments in abdominal wall reconstruction after abdominal compartment syndrome decompression." Acta Clin Belg Suppl(1): 220-4.

The acute abdominal compartment syndrome (ACS) is most often treated with surgical abdominal decompression. After the acute phase, primary closure of the abdominal wall may not be possible, due to tissue loss and retraction of the abdominal wall and its musculofascial components. This article gives an update of the reconstructive ladder for abdominal wall defects. Because of improved intensive care treatment and wound dressing, reconstruction can usually be delayed until infection and oedema have settled. Recent developments in bioprosthetics and new surgical techniques like component separation make better results with less donor site morbidity possible. However, there is still a place for local and distant flaps.

Madi-Jebara, S., G. Hayek, et al. (2007). "[Abdominal compartment syndrome after cardiac surgery]." Ann Fr Anesth Reanim 26(9): 799-801.

We report the case of a 60-year-old woman who underwent mitral valve replacement and tricuspid valve repair. Following surgery she developed rapid onset of ascitis and secondary abdominal compartmental syndrome with low cardiac output and oliguria. Following drainage of the ascitis, the abdominal pressure dropped with a spectacular improvement of both the cardiac ant the urine output.

Mahjoub, Y. and G. Plantefeve (2007). "Cardiac ultrasound and abdominal compartment syndrome." Acta Clin Belg Suppl(1): 183-9.

This review focuses on the available literature published about the evaluation of haemodynamic consequences of the abdominal compartment syndrome (ACS). Animal and clinical studies described decreased venous return, systemic vasoconstriction, systolic and diastolic dysfunction of left and right ventricles. Doppler echocardiography is a non-invasive bedside procedure which provides a complete haemodynamic evaluation of patients with ACS. Despite numerous evaluations in anesthesia during laparoscopic surgery, the use of echocardiography remains scarce in critically ill patients with ACS.

Malbrain, M. L. (2007). "Abdominal compartment syndrome: it is time." Acta Clin Belg Suppl(1): 1-5.

Malbrain, M. L., I. De laet, et al. (2007). "Consensus conference definitions and recommendations on intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS)--the long road to the final publications, how did we get there?" Acta Clin Belg Suppl(1): 44-59.

OBJECTIVE: There has been an exponentially increasing interest in intraabdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) over the last decade, and different definitions have been suggested. Nevertheless, there has been an impetus from experts in the field to modify these definitions to reflect our current understanding of the pathophysiology of these syndromes. An international multidisciplinary group of interested doctors met with the goal of agreeing on a set of definitions that could be applied to patients with IAH and ACS. The goal of this consensus group was to provide a conceptual and practical framework to further define ACS, a progressive injurious process that falls under the generalized term 'IAH' and that includes IAH-associated organ dysfunction. DESIGN: In total, 21 North American, Australasian and European surgical, trauma and critical care specialists agreed to standardize the current definitions for IAH, ACS and related conditions in preparation for the second World Congress on Abdominal Compartment Syndrome (WCACS).The WCACS-meeting was endorsed by the European Society of Intensive Care Medicine (ESICM) and the World Society on Abdominal Compartment Syndrome (WSACS). METHODS: The consensus conference (Noosa, Australia; December 7, 2004) was attended by 21 specialists from Europe, Australasia and North America and approximately 70 other congress participants. In advance of the conference, a blueprint for the various definitions was suggested. After the conference the participants corresponded electronically with feedback. A writing committee was formed at the conference and developed the final manuscript based on executive summary documents generated by each participant.The final report of the 2004 International ACS Consensus Definitions Conference has recently been published. This article will describe the long road towards this final publication with the evolution of the different definitions and recommendations from the initial suggestions in 2004 to the further refinement and final publications in 2006 and 2007. It will try to explain how we got there and will also give the percentage of agreement with each proposed definition by the participants. RESULTS: New definitions were offered for some terms, while others were discarded and not kept in the final manuscript. Different cut-offs for defining IAH and ACS were given, as well as broad definitions of primary, secondary and recurrent IAH/ACS. A classification system was introduced taking into account the duration, origin, and etiology of IAH. The use of an organ severity scoring method, by means of the Sequential Organ Failure Assessment (SOFA) score when dealing with ACS patients was not recommended as an adjunctive tool to assess morbidity in the final publication. CONCLUSION: This document reflects a process whereby a group of experts and opinion leaders suggested definitions for IAH and ACS. This document should be used as a reference for the next consensus definitions conference in March 2007.

Malbrain, M. L., P. Pelosi, et al. (2007). "Lymphatic drainage between thorax and abdomen: please take good care of this well-performing machinery." Acta Clin Belg Suppl(1): 152-61.

INTRODUCTION: Patients with sepsis often receive large amounts of fluids and the presence of capillary leak, trauma or bleeding results in ongoing fluid resuscitation. This increases interstitial and intestinal edema and finally leads to intra-abdominal hypertension (IAH), which in turn impedes lymphatic drainage. Patients with IAH often develop secondary respiratory failure needing mechanical ventilation with high intrathoracic pressure or PEEP that might further alter lymphatic drainage. This review will try to convince the reader of the importance of the lymphatics in septic patients with IAH. METHODS: A Medline and PubMed literature search was performed using the terms "abdominal pressure", "lymphatic drainage" and "ascites formation".The references from these studies were searched for relevant articles that may have been missed in the primary search. These articles served as the basis for the recommendations below. RESULTS: Induction of sepsis with lesion of the capillary alveolar barrier results in an increased water gradient between the capillaries and the interstitium in the lungs. The drainage flow to the thoracic duct is initially increased in order to protect the Lung and maintain the pulmonary interstitium as dry as possible, however this results in increased intrathoracic pressure. Sepsis also increases the permeability of the capillaries in the splanchnic beds. In analogy to the lungs the lymphatic flow in the splanchnic areas increases together with the pressure inside as a physiological response in order to limit the increase in IAP. At a critical IAP level (around 20 cmH2O) the lymph flow starts to decrease and the splanchnic water content progressively increases.The lymph flow from the abdomen to the thorax is progressively decreased resulting in increased splanchnic water content and ascites formation. The presence of mechanical ventilation with high PEEP reduces the lymph drainage further which together with the increase in IAP decreases the lymphatic pressure gradient in the splanchnic regions, with a further increase in water content and IAP triggering a vicious cycle. CONCLUSION: Although often overlooked the role of lymphatic flow is complex but very important to determine not only the fluid balance in the lung but also in the peripheral organs. Different pathologies and treatments can markedly influence the pathophysiology of the lymphatics with dramatic effects on endorgan function.

McBeth, P. B., D. A. Zygun, et al. (2007). "Effect of patient positioning on intra-abdominal pressure monitoring." Am J Surg 193(5): 644-7; discussion 647.

BACKGROUND: Intra-abdominal hypertension affects multiple organ systems. Current measurement standard requires supine positioning, which jeopardizes patient safety by increasing the risk for ventilator-associated pneumonia. This study evaluated the relationship between intra-abdominal pressure (IAP) and head-of-bed (HOB) positioning in critically ill intubated patients. METHODS: IAP measurements were performed using intravesical catheters with manometry. IAP was measured in a range of patient HOB increases from 0 degrees to 45 degrees. Multivariable generalized estimating equation modeling was performed to describe the relationship between IAP and HOB positioning. RESULTS: Three hundred (300) observations were performed on 37 patients. In multivariable modeling, HOB increase was significantly associated with IAP. Body mass index, positive end-expiratory pressure, temperature, and diagnostic category were significant in this model, whereas age and Riker sedation score were not. CONCLUSIONS: There is a significant, positive association between IAP and HOB positioning in critically ill patients. Clinically relevant changes in IAP occur at HOB increases >20 degrees.

McGee, M. F., M. J. Rosen, et al. (2007). "A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery." Surg Endosc.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) provides surgical access to the peritoneal cavity without skin incisions. The NOTES procedure requires pneumoperitoneum for visualization and manipulation of abdominal organs, similar to laparoscopy. Accurate measurement of the pneumoperitoneum pressure is essential to avoid potentially deleterious effects of intraabdominal compartment syndrome. A reliable method for monitoring pneumoperitoneum pressures during NOTES has not been identified. This study evaluated several methods of monitoring intraabdominal pressures with a standard gastroscope during NOTES. METHODS: Four female pigs (25 kg) were sedated, and a single-channel gastroscope was passed transgastrically into the peritoneal cavity. Pneumoperitoneum was achieved via a pressure insufflator through a percutaneous, intraperitoneal 14-gauge catheter. Three other pressures were recorded via separate catheters. First, a 14-gauge percutaneous catheter passed intraperitoneally measured true intraabdominal pressure. Second, a 14-gauge tube attached to the endoscope was used to measure endoscope tip pressure. The third pressure transducer was connected directly to the accessory channel of the endoscope. The abdomen was insufflated to a range of pressures (10-30 mmHg), and simultaneous pressures were recorded from all three pressure sensors. RESULTS: Pressure correlation curves were developed for all animals across all intraperitoneal pressures (mean error, -4.25 to -1 mmHg). Endoscope tip pressures correlated with biopsy channel pressures (R (2 )= 0.99). Biopsy channel and endoscope tip pressures fit a least-squares linear model to predict actual intraabdominal pressure (R = 0.99 for both). Both scope tip and biopsy channel port pressures were strongly correlative with true intraabdominal pressures (R (2) = 0.98 and R (2 )= 0.99, respectively). CONCLUSION: This study demonstrates that monitoring pressure through an endoscope is reliable and predictive of true intraabdominal pressure. Gastroscope pressure monitoring is a useful adjunct to NOTES. Future NOTES procedures should incorporate continuous intraabdominal pressure monitoring to avoid the potentially deleterious effects of pneumoperitoneum during NOTES. This can be achieved by the integration of pressure-monitoring capabilities into gastroscopes.

Meier, C., C. Contaldo, et al. (2007). "A New Model for the Study of the Abdominal Compartment Syndrome in Rats." J Surg Res.

BACKGROUND: The purpose of the present study was to develop of a rodent model of abdominal compartment syndrome (ACS), which allows detailed analysis of intra-abdominal hypertension (IAH)- and decompression-associated reperfusion injury. METHODS: In 20 anesthetized and ventilated Sprague-Dawley rats an IAH of 20 mmHg was induced for 3 h by intraperitoneal infusion of gelatin polysuccinate. After decompression, an additional 3-h period of reperfusion was studied. Sham-operated animals, undergoing identical procedures without IAH induction, served as controls. Controlled hyperventilation and intravenous fluid substitution were adapted to keep PCO(2) <60 mmHg and mean arterial pressure (MAP) >100 mmHg. RESULTS: IAH of 20 mmHg could successfully be maintained for the entire 3-h period. MAP was not affected during IAH, however, decreased upon decompression despite forced fluid resuscitation. CVP was markedly elevated during IAH, but returned to baseline after decompression. Of interest, the IAH-induced reduction of PaO(2) did not recover to baseline after decompression, indicating a persistent deterioration of gas exchange. In contrast, IAH-associated elevation of PaCO(2) normalized during reperfusion. IAH was further accompanied by metabolic acidosis, which persisted after decompression, indicating reperfusion injury. IAH was further associated with a significant increase of serum potassium, lactate, AST, LDH, bilirubin, urea, and creatinine as well as creatine kinase (CK) and CK-MB. Histomorphological analysis revealed parenchymal injury in liver, lung, intestine, and myocardium. CONCLUSION: We established an easily reproducible ACS model in the rat, demonstrating hemodynamic deteriorations and organ dysfunctions similar as known from patients with IAH. Decompression did not restore functional deteriorations, indicating persistent post-ACS reperfusion injury. The model may be suitable to study mechanisms and novel treatment strategies in ACS.

Meier, C., C. Contaldo, et al. (2007). "Microdialysis of the rectus abdominis muscle for early detection of impending abdominal compartment syndrome." Intensive Care Med.

OBJECTIVE: To investigate whether microdialysis is capable of assessing metabolic derangements during intra-abdominal hypertension (IAH), and whether monitoring of the rectus abdominis muscle (RAM) by microdialysis represents a reliable approach in the early detection of organ dysfunctions in abdominal compartment syndrome (ACS). DESIGN: Prospective, randomized, controlled animal study. SETTING: University animal research facility. SUBJECTS: Fifteen isoflurane-anesthetized and mechanically ventilated Sprague-Dawley rats. INTERVENTIONS: IAH of 20[Symbol: see text]mmHg was induced for 3[Symbol: see text]h and followed by decompression and reperfusion for another 3-h period (n[Symbol: see text]=[Symbol: see text]10). Five sham-operated animals served as controls. Microdialysis was performed in the anterior gastric wall, liver, kidney, and RAM. The anterior cervical muscles served as distant reference. Glucose, lactate, pyruvate, and glycerol was analyzed throughout the 6-h experiment. MEASUREMENTS AND MAIN RESULTS: Prolonged IAH induced significant cardiopulmonary dysfunction and persistent abdominal organ injury. Microdialysis revealed a significant increase of lactate/pyruvate and glycerol in kidney, intestine and liver, indicating ischemia, energy failure, and cell membrane damage. In addition, at 3[Symbol: see text]h IAH glucose was significantly decreased in all organs studied. The distant reference did not show any alteration of lactate/pyruvate, glycerol, and glucose over the entire 6-h observation period. In contrast to the other organs, microdialysis of the RAM showed an early and more pronounced increase of lactate, lactate/pyruvate and glycerol already at 1[Symbol: see text]h IAH. It is noteworthy that lactate, glycerol, and glucose did not completely recover upon decompression of IAH. CONCLUSIONS: Our data suggest that continuous microdialysis in the RAM may represent a promising tool for early detecting IAH-induced metabolic derangements.

Meireles, O., S. V. Kantsevoy, et al. (2007). "Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery." Surg Endosc.

BACKGROUND: The peroral transgastric endoscopic approach for intraabdominal procedures appears to be feasible, although multiple aspects of this approach remain unclear. This study aimed to measure intraperitoneal pressure in a porcine model during the peroral transgastric endoscopic approach, comparing an endoscopic on-demand insufflator/light source with a standard autoregulated laparoscopic insufflator. METHODS: All experiments were performed with 50-kg female pigs under general anesthesia. A standard upper endoscope was advanced perorally through a gastric wall incision into the peritoneal cavity. The peritoneal cavity was insufflated with operating room air from an endoscopic light source/insufflator. Intraperitoneal pressure was measured by three routes: (1) through the endoscope biopsy channel, (2) through a 5-mm transabdominal laparoscopic port, and (3) through a 16-gauge Veress needle inserted into the peritoneal cavity through the anterior abdominal wall. The source of insufflation alternated between on-demand manual insufflation through the endoscopic light source/insufflator using room air and a standard autoregulated laparoscopic insufflator using carbon dioxide (CO(2)). RESULTS: Six acute experiments were performed. Intraperitoneal pressure measurements showed good correlation regardless of measurement route and were independent of the type of insufflation gas, whether room air or CO(2). On-demand insufflation with the endoscopic light source/insufflator resulted in a wide variation in pressures (range, 4-32 mmHg; mean, 16.0 +/- 11.7). Intraabdominal pressures using a standard autoregulated laparoscopic insufflator demonstrated minimal fluctuation (range, 8-15 mmHg; mean, 11.0 +/- 2.2 mmHg) around a predetermined value. CONCLUSION: Use of an on-demand unregulated endoscopic light source/insufflator for translumenal surgery can cause large variation in intraperitoneal pressures and intraabdominal hypertension, leading to the risk of hemodynamic and respiratory compromise. Safety may favor well-controlled intraabdominal pressures achieved with a standard autoregulated laparoscopic insufflator.

Milanchi, S., D. Magner, et al. (2007). "Abdominal compartment syndrome secondary to retroperitoneal hematoma as a complication of ERCP after liver transplantation." Transplant Proc 39(1): 169-71.

Endoscopic retrograde cholangiopancreatography (ERCP) is frequently employed in the management of postoperative biliary complications in the liver transplant patient. Bleeding after ERCP most commonly presents as gastrointestinal bleeding and often can be managed with repeat endoscopy. ERCP can also be complicated by retroperitoneal hematoma, which in rare cases can lead to hemodynamic compromise due to relentless hemorrhage or from secondary abdominal compartment syndrome. We describe the first reported case of post-ERCP retroperitoneal hematoma in a liver transplant recipient that led to abdominal compartment syndrome and shock liver. We will present the case, discuss management, and review the complications of ERCP in the liver transplant recipient. Close post-procedure monitoring, rapid detection, and low threshold for decompressive laparotomy are keys to the successful management of the liver transplant recipient experiencing expanding retroperitoneal hematoma after ERCP.

Morrell, B. J., C. Vinden, et al. (2007). "Secondary abdominal compartment syndrome in a case of pediatric trauma shock resuscitation." Pediatr Crit Care Med 8(1): 67-70.

OBJECTIVE: To report a rare case of secondary abdominal compartment syndrome during shock resuscitation in a pediatric trauma patient. DESIGN: Case report and literature review. SETTING: A community hospital and a designated children's trauma hospital. PATIENT: A 17-yr-old trauma patient. INTERVENTIONS: Advanced trauma life support, trauma laparotomy, and superficial temporal artery ligation. MEASUREMENTS AND MAIN RESULTS: A 17-yr-old trauma patient with ongoing blood loss from a lacerated superficial temporal artery received aggressive crystalloid resuscitation before arrival at a designated trauma hospital. His injury severity score was 16. The first hemoglobin drawn was 55 g/L with a hematocrit of 0.16 L/L. Within 3 hrs of the trauma, an abdominal computed tomography scan demonstrated a moderate amount of free peritoneal fluid, edematous bowel with marked enhancement, and a compressed inferior vena cava. Shortly after completion of imaging studies, the patient's abdomen became increasingly tense with poor perfusion to the lower extremities. Urgent laparotomy for abdominal compartment syndrome identified excessive ascites and extensive bowel edema with no blood or traumatic injuries. Abdominal decompression resulted in immediate improvement of hemodynamics and restored lower limb perfusion. Primary abdominal closure was obtained and the patient recovered fully with gentle diuresis. CONCLUSIONS: Secondary abdominal compartment syndrome developed in this pediatric trauma patient with hemorrhagic shock, possibly from aggressive crystalloid resuscitation. This trauma case highlights the importance of early hemorrhagic control with balanced crystalloid/transfusion therapy. Secondary abdominal compartment syndrome in pediatric trauma is rare and may reflect physiologic differences during development, less aggressive resuscitation practices, and/or underrecognition.

Nickkholgh, A., M. Barro-Bejarano, et al. (2007). "Signs of reperfusion injury following CO(2) pneumoperitoneum: an in vivo microscopy study." Surg Endosc.

BACKGROUND: During laparoscopic surgery, pneumoperitoneum is generally established by means of carbon dioxide (CO(2)) insufflation which may disturb hepatic microperfusion. It has been suggested that the desufflation at the end of the procedure creates a model of reperfusion in a previously ischemic liver, thus predisposing it to reperfusion injury. METHODS: To study the effects of pneumoperitoneum on hepatic microcirculation, Sprague-Dawley rats underwent pneumoperitoneum with an intraabdominal pressure of 8 or 12 mmHg for 90 min. Subsequently, in vivo microscopy was performed to assess intrahepatic microcirculation and transaminases were measured to index liver injury. RESULTS: A CO(2) pneumoperitoneum of 8 mmHg did not change serum transaminases; however, further increase of intraperitoneal pressure to 12 mmHg significantly increased AST, ALT, and LDH measured after desufflation to almost 1.5 times as much as control values of 49 +/- 5 U/L, 31 +/- 3 U/L, and 114 +/- 12 U/L. In parallel, in all subacinar zones the permanent adherence of both leukocytes and platelets to the endothelium increased by about sixfold and threefold, respectively. Furthermore, Kupffer cells labeled with latex beads as an index for their activation were significantly increased compared to controls. CONCLUSION: This in vivo observation demonstrated traces of reperfusion injury in liver induced by the insufflation and desufflation of CO(2 )pneumoperitoneum. The clinical relevance of this finding and the issue of using hepatoprotective substances to prevent this injury should be further investigated.

Oda, J., K. Yamashita, et al. (2007). "Acute lung injury and multiple organ dysfunction syndrome secondary to intra-abdominal hypertension and abdominal decompression in extensively burned patients." J Trauma 62(6): 1365-9.

BACKGROUND: Secondary abdominal compartment syndrome (ACS) is a lethal complication after resuscitation from burn shock, even after abdominal decompression (AD) is performed. This study investigated increased susceptibility to multiple organ dysfunction syndrome (MODS) in extensively burned patients with ACS. METHODS: Patients admitted to our burn unit between 2002 and 2005 with burns affecting 40% or more of the total body surface area without severe inhalation injury were analyzed. Hemodynamic parameters, blood gas analysis, and intrabladder pressure as intra-abdominal pressure were recorded. Serum interleukin (IL)-8 and IL-6 concentrations were measured in 20 of these patients. Lung injury score and Sequential Organ Failure Assessment scores were serially determined. RESULTS: Fourteen of 38 patients developed intra-abdominal hypertension in 22.9 +/- 8.9 hours postburn. Hemodynamic parameters in these 14 patients, including peak intra-abdominal pressure (46.6 +/- 11.2 to 19.8 +/- 9.9 cm H2O), peak inspiratory pressure (51.4 +/- 10.5 to 31.8 +/- 7.0 cm H2O), and abdominal perfusion pressure (51.3 +/- 18.3 to 73.9 +/- 13.6 mm Hg), were improved immediately after AD. Despite AD, lung injury score and Sequential Organ Failure Assessment scores increased significantly 2 and 3 days postburn in patients who required AD. Plasma concentration of IL-8 was elevated in intra-abdominal hypertension patients 3 days postburn. CONCLUSION: Intra-abdominal hypertension induced acute lung injury and MODS with IL-8 elevation, even though AD improved hemodynamic parameters in extensively burned patients.

Okhuysen-Cawley, R., P. Prodhan, et al. (2007). "Management of abdominal compartment syndrome during extracorporeal life support." Pediatr Crit Care Med.

OBJECTIVE:: To describe the successful use of a peritoneal dialysis catheter for emergent decompression of abdominal compartment syndrome during extracorporeal life support for septic shock. DESIGN:: Case report. SETTING:: Pediatric intensive care unit at a freestanding tertiary children's hospital. PATIENT:: Two-year-old toddler with influenza A complicated by methicillin-resistant Staphylococcus aureus pneumonia and septic shock. INTERVENTIONS:: . MEASUREMENTS AND MAIN RESULTS:: . CONCLUSIONS:: Although the standard therapy for abdominal compartment syndrome is decompressive laparotomy, a minimally invasive percutaneous approach may be effective and should be considered in selected patients.

Ortega-Carnicer, J., M. Delgado Portela, et al. (2007). "[Diffuse cerebral edema and pseudo-subarachnoid hemorrhaging in a patient with abdominal compartment syndrome due to acute peritonitis.]." Med Intensiva 31(1): 51-3.

Pelosi, P., E. Calzia, et al. (2007). "It's time to measure intra-abdominal pressure to optimize hemodynamics!" Intensive Care Med 33(1): 6-8.

Pelosi, P., M. Quintel, et al. (2007). "Effect of intra-abdominal pressure on respiratory mechanics." Acta Clin Belg 62 (Suppl 1)(1): 78-88.

INTRODUCTION: There has been an exponentially increasing interest in intra-abdominal hypertension (IAH).The intra-abdominal pressure (IAP) markedly affects the function of the respiratory system. METHODS: This review will focus on the available literature from the past few years. A Medline and Pubmed search was performed in order to find an answer to the question "What is the impact of increased IAP on respiratory function in the critically ill?". RESULTS: In particular, increased IAP increases chest wall elastance (or decreases compliance) and promotes cranial shift of the diaphragm, with consequent reduction in lung volume and atelectasis formation. Compression of the lung parenchyma also triggers pulmonary infection. During general anaesthesia, in normal subjects, IAP does not affect the chest wall mechanics, but plays a relevant role in the caudal-cranial displacement of the abdominal content, the diaphragm and consequent changes in lung mechanics and function. In obese patients, the increased IAP is the major determinant of the reduction in lung volume, atelectasis formation and alterations in chest wall mechanics. In ARDS patients the measurement of IAP and chest wall mechanics is important for a better interpretation of respiratory mechanics, hemodynamics and appropriate setting of the ventilator. Furthermore, increased IAP promotes lung oedema, ventilator induced lung injury and reduced lymphatic flow in normal and diseased lungs. CONCLUSION: Increased IAP markedly affects respiratory function in such a way that it has an impact on daily clinical practise.

Plantefeve, G., R. Hellmann, et al. (2007). "Abdominal compartment syndrome and intraabdominal sepsis: two of the same kind?" Acta Clin Belg Suppl(1): 162-7.

BACKGROUND: Abdominal compartment syndrome and intra-abdominal hypertension are frequently associated with peritonitis. The aim of this study is to establish the relationship between intra-abdominal hypertension and intra-abdominal sepsis especially in critically ill patients. METHODS: Relevant information was identified through a Medline search (1966-October 2006). The terms used were "intra-abdominal sepsis", "peritonitis", "abdominal compartment syndrome", "intra-abdominal hypertension" and "relaparotomy for sepsis". The search was limited to English- and French-language publications. RESULTS: Only a few clinical trials exist on this specific topic. Further investigations are required to define the incidence of intra-abdominal hypertension in intra-abdominal sepsis, and the prognostic impact of this setting and finally the potential specific treatment. Abdominal compartment syndrome is more likely linked to the abdominal surgery than to peritonitis itself. CONCLUSION: Intra-abdominal pressure monitoring can be valuable in critically ill patients with suspicion of persisting intra-abdominal sepsis after surgical peritonitis treatment.

Rosas, J. M., S. N. Soto, et al. (2007). "Intra-abdominal pressure as a marker of severity in acute pancreatitis." Surgery 141(2): 173-8.

BACKGROUND: Acute pancreatitis is one of the main causes of intra-abdominal hypertension, which may lead to multiple physiologic alterations. The aim of this study was to determine the relationship between acute pancreatitis and intra-abdominal hypertension, and to evaluate the utility of intra-abdominal pressure (IAP) as a marker of severity in acute pancreatitis. METHODS: From July 2002 to July 2004, 45 patients admitted for acute pancreatitis were included in this prospective, observational study. The diagnostic criteria for acute pancreatitis were compatible clinical manifestations and a 3-fold increase in serum amylase levels. Severe pancreatitis was defined as Apache II score >or=8. IAP was determined every 12 hours, and the maximum and the mean values were used for analysis and correlated with prognostic factors of acute pancreatitis. RESULTS: A statistical relationship was observed between maximum IAP and the typical prognostic factors of acute pancreatitis. Maximum IAP had a significant relationship with the computed tomography severity index and the number of complementary tests required. The maximum IAP was significantly greater in patients who died and in patients requiring vasoactive drugs, total parenteral nutrition, or operative treatment related to complications. The maximum IAP was also greater in patients who developed systemic inflammatory response syndrome, multiorgan failure, increase in number and/or volume of intra-abdominal collections, those who required aspiration of the necrosis for suspected infection, those who demonstrated the presence of microorganisms, and those with positive blood cultures. CONCLUSION: The maximum IAP is a useful, inexpensive, and easy method to measure prognostic marker of the evolution and complications of acute pancreatitis.

Saffle, J. R. (2007). "The Phenomenon of "Fluid Creep" in Acute Burn Resuscitation." J Burn Care Res.

Several reports have documented that modern burn patients receive far more resuscitation fluid than predicted by the Parkland formula-a phenomenon termed "fluid creep." This article reviews the incidence, consequences, and possible etiologies of fluid creep in modern practice and uses this information to propose some therapeutic strategies to reduce or eliminate excessive fluid resuscitation in burn care. A literature review was performed of historical references that form the foundation of modern fluid resuscitation, as well as reports of fluid creep and its consequences. The original Parkland formula required a 24-hour volume of 4 ml/kg/%TBSA lactated Ringer's solution followed by an infusion of 0.3-0.5 ml/kg/%TBSA plasma. Modern iterations of this formula have omitted the colloid bolus. Numerous exceptions to the formula have been noted, most consistently patients with inhalation injuries. In contrast, recent reports document greatly increased fluid requirements in unselected patients, which seems to consist largely of progressive edema formation in unburned areas, increasing after the first 8 hours post-burn. This has been linked to occurrence of the abdominal compartment syndrome and other serious complications. Strategies to reduce fluid creep include the avoidance of early overresuscitation, use of colloid as a routine component of resuscitation or for "rescue," and adherence to protocols for fluid resuscitation. Fluid creep is a significant problem in modern burn care. Review of original investigations of burn shock, coupled with modern reports of fluid creep, suggests several mechanisms by which this problem can be controlled. Prospective trials of these therapies are needed to confirm their effectiveness.

Sanda, R. B. (2007). "Abdominal compartment syndrome." Ann Saudi Med 27(3): 183-90.

The term abdominal compartment syndrome (ACS) describes the clinical manifestations of the pathologic elevation of the intra-abdominal pressure (IAP). When the IAP exceeds 12 mm Hg it is referred to as intra-abdominal hypertension (IAH) while ACS generally sets in at an IAP in excess of 20 mm Hg. This syndrome is most commonly observed in the setting of severe abdominal trauma and in the aftermath of major abdominal operations. ACS affects mainly the respiratory, cardiovascular, renal, gastrointestinal and the central nervous systems. Fundamental to the development of ACS are the obstruction of venous return to the heart via the inferior vena cava and the splinting of the diaphragm due to elevated IAP. Preventing ACS by the identification of patients at risk and early diagnosis is paramount to its successful management. To this end a high index of suspicion is sine qua non. The management of established ACS requires clinical astuteness and decisiveness with a readily available and generous team support. The purpose of this review is to enhance awareness among clinicians about a subtle condition with a devastating impact on morbidity and mortality if undiagnosed.

Scalea, T. M., G. V. Bochicchio, et al. (2007). "Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome." J Trauma 62(3): 647-56; discussion 656.

OBJECTIVES: Fluid therapy and/or acute lung injury may increase intra-abdominal pressure (IAP) and intrathoracic pressure, thereby increasing intracranial pressure (ICP) after traumatic brain injury (TBI). Further fluid administration to support cerebral perfusion or increasing ventilatory support to treat acute lung injury further increases ICP. This can create a cycle that ultimately produces multiple compartment syndrome (MCS). Both decompressive craniectomy (DC) and decompressive laparotomy (DL) decrease ICP. DL can also decrease IAP and ICP. We evaluated the serial application of DC and DL to treat MCS. METHODS: Data were analyzed for 102 consecutive patients with severe TBI who underwent DC alone to decrease ICP or in combination with DL to treat MCS. RESULTS: All 102 patients sustained blunt injury. Seventy percent were men with a mean age of 29.5 years, an Injury Severity Score of 34.4, and admission Glasgow Coma Scale score of 7.1. Fifty-one patients had diffuse brain injury and 51 had mass lesions. Seventy-eight patients (76%) underwent DC alone. Twenty-four (22%) had both therapies for MCS. Fifteen patients had DC before DL and nine had DL before DC. Mean time between DC and DL was 3.4 +/- 6 days. The mean IAP before DL was 28 +/- 5 mm Hg. Twenty-four-hour cumulative mean intrathoracic pressure decreased significantly after DL in the MCS group (p = 0.01). Mean ICP decreased significantly after both DC and DL (p < 0.05). CONCLUSION: Increased ICP may be from primary TBI or MCS. Patients with MCS have a higher Injury Severity Score, ICP, and fluid requirements, but no increase in mortality. Both DC and DL reduce ICP and can be used in sequence. MCS should be considered in multiply injured patients with increased ICP that does not respond to therapy.

Schachtrupp, A., J. Wauters, et al. (2007). "What is the best animal model for ACS?" Acta Clin Belg Suppl(1): 225-32.

INTRODUCTION: Current treatment of the abdominal compartment syndrome (ACS) is based on consensus definitions but several questions regarding fluid regime or critical level of intra-abdominal hypertension (IAH)) remain unsolved. It is questionable whether these issues can be addressed in prospective randomized trials in the near future.This review aimed to summarize current animal models and to outline requirements for the best model. METHODS: PubMed data base was searched for articles describing animal models of ACS. RESULTS: 25 articles were found. ACS in animals has not been defined yet. Investigations varied considerably regarding the experimental design. Animals were rats, rabbits, dogs and pigs with a bodyweight from 200g to 70 kg. IAP increase varied from 20 to 50 mmHg.The time period of IAH ranged between 30 min and 24h. The time between the IAH insult and organ dysfunction varied between 15 min and 18h. Investigations demonstrated that IAH is able to induce loss of intravascular volume, organ hypoperfusion, ischemic organ damage and multiple organ failure within 4 to 6h. CONCLUSION: In contrast to IAH or pneumoperitoneum for surgical exposure, ACS in an animal may be stated if an artificially increased IAP leads to circulatory, respiratory and renal insufficiency. A next step in animal research would be the development of a "pathological" model in which haemorrhage or systemic inflammation together with resuscitation lead to abdominal fluid accumulation and increased intra-abdominal pressure.

Sonne, M. E., J. G. Hillingso, et al. (2007). "[Measurement of intraabdominal pressure and abdominal compartment syndrome in surgical and intensive care units.]." Ugeskr Laeger 169(8): 705-710.

INTRODUCTION: Over the past number of years, there has been an increasing interest in the pathophysiological phenomena intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Foreign studies have shown considerably national differences in the interpretation of the two phenomena. The purpose of this questionnaire study was to survey which group of patients is examined for IAH and ACS, how the examination is carried out and how the two conditions are treated in surgical and intensive care units in Denmark. MATERIALS AND METHODS: A questionnaire was sent to all relevant surgical and intensive care units in Denmark. RESULTS: The response rate was 81%. 74% intensive care units and 31% surgical wards measured IAP. 100% used the intravesical method. International guidelines were followed in 11% of surgical wards and 18% of the intensive care units regarding how often IAP should be measured and 44%/ 32% regarding at what IAP level surgical intervention should be considered. 78% of the wards and 79% of the intensive care units that measured IAP had celiotomy as a treatment modality. There were major differences between both surgical wards and intensive care units regarding which group of patients should have IAP measured. CONCLUSION: Considering the differences in clinical practice and the discrepancy to international guidelines interdisciplinary national guideline might contribute to a more uniform evaluation and treatment of patients with IAH or ACS.

Sugimoto, T., A. Omura, et al. (2007). "An abdominal aortic rupture due to seatbelt blunt injury: report of a case." Surg Today 37(1): 86-8.

A 66-year-old man, who was a passenger in a car involved in a low-speed head-on motor vehicle accident, was rushed to our hospital. His abdomen was tender and distended. An enhanced computed tomography scan showed a massive retroperitoneal hematoma, and its three-dimensional imaging revealed an active leak of the contrast medium from the aortic bifurcation. He went into shock, and was immediately transferred to the operating theater. Through a median laparotomy, a ruptured site measuring 5 mm in diameter was found at the aortic bifurcation and it was closed with sutures under a proximal aortic control. The other organs showed no evidence of injury. Because of the remarkable edema of the bowel, mesentery, and retroperitoneum, the abdomen was temporarily closed with a mesh sheet to prevent the occurrence of abdominal compartment syndrome. A delayed closure was then successfully performed 4 days later, and he was discharged with no residual sequelae 17 days after the initial operation.

Sugrue, M., S. K. D'Amours, et al. (2007). "Temporary abdominal closure." Acta Clin Belg Suppl(1): 210-4.

The increasing recognition of abdominal compartment syndrome's adverse effect on patient outcome has been coupled with our expanding knowledge of techniques of temporary abdominal closure. Temporary abdominal closure can be used prophylactically to prevent abdominal compartment syndrome developing and more commonly in the treatment of patients with progressing or advanced abdominal compartment syndrome. The preferred technique involves a negative suction dressing protecting the fascial and skin edges, collecting intraperitoneal fluid and reducing contamination. Attempts of early closure will facilitate recovery.

Teplick, R. (2007). "Intra-abdominal pressure measurement and abdominal compartment syndrome: The opinion of the World Society of the Abdominal Compartment Syndrome." Crit Care Med 35(2): 678-9.

Tuggle, D., S. Skinner, et al. (2007). "The abdominal compartment syndrome in patients with burn injury." Acta Clin Belg Suppl(1): 136-40.

INTRODUCTION: Intra-abdominal hypertension (IAH) and subsequent abdominal compartment syndrome (ACS) in burned patients is common.This sequence of events typically occurs in patients with larger burns receiving high volume fluid resuscitation. METHODS: A review of the literature was performed. The National Library of Medicine (PUBMED) was queried for "Burn" and "Abdominal Compartment Syndrome". Twenty-nine articles were retained for study. RESULTS: Abdominal pressure monitoring is appropriate in all patients with burns that require significant volume resuscitation (>30% total burned surface area-TBSA). Prevention of ACS in burns includes limiting fluid resuscitation, burn escharotomy, and percutaneous drainage when abdominal pressures are reaching perilous levels. Treatment includes all of the above and in addition, decompressive laparotomy when needed. However, despite decompressive laparotomy, mortality rates among burn victims with ACS remain unacceptably high. CONCLUSION: Increasing amounts of volume delivery are associated with an increased risk of IAH. Therefore, intra-abdominal pressure should be monitored in all burn patients requiring massive fluid resuscitation. Escharotomy, paracentesis, and decompressive laparotomy may all be needed to counter the side effects of appropriate fluid resuscitation in the severely burned patient. Nevertheless, the prognosis in burn patients developing ACS is grim.

Turnbull, D., S. Webber, et al. (2007). "Intra-abdominal pressure measurement: validation of intragastric pressure as a measure of intra-abdominal pressure." Br J Anaesth 98(5): 628-34.

BACKGROUND: The diagnosis of abdominal compartment syndrome depends upon the demonstration of an elevated intra-abdominal pressure (IAP). Direct measures of IAP are impractical in the critical care unit; intravesical pressure (IVP) and intragastric pressure (IGP) should represent acceptable surrogate measures. IVP is the preferred measure of IAP in critical care. We considered that IGP represents a practical alternative. The objective of this preliminary study was to observe the relationship between IGP and IAP. METHODS: After Institutional Ethics Board approval, 29 patients having elective laparoscopic surgery were recruited. IAP was measured directly via the abdominal trochar. This was compared with IGP measured via a commercial balloon catheter placed into the stomach. RESULTS: Measured IGP was always more positive than IAP; both showed linear correlation (r2>0.9). When IGP was calibrated against IAP, an estimated difference between the IGP and IAP of+/-2.5 mm Hg for 95% of the measurements was seen. CONCLUSIONS: The study demonstrates the strength of the relationship between IGP and IAP in normal individuals. Application of IGP measurement in the critical care patient is necessary to demonstrate its suitability for continuous IAP assessment.

van As, A. B., P. Navsaria, et al. (2007). "Modified sandwich vacuum pack technique for temporary closure of abdominal wounds: an African perspective." Acta Clin Belg Suppl(1): 215-9.

INTRODUCTION: South Africa has very high levels of accidental trauma as well as interpersonal violence. There are more admissions for trauma in South Africa than for any other disease; therefore it can be regarded as the Number 1 disease in the country. Complex abdominal injuries are common, requiring specific management techniques.The aim is to document our experience with the Modified Sandwich Vacuum Pack technique for temporary closure of abdominal wounds. METHODS: After providing a short historical overview, we will demonstrate the technique which we carefully adapted over the last decade to the present Modified Sandwich Vacuum Pack technique. RESULTS: In the Last 5 years we utilized our Modified Sandwich Vacuum Pack technique 153 times in 69 patients. Five (5) patients were under the age of 12 years. In the patient group over 12 years the most common indication for using our technique were penetrating injuries (40), abdominal sepsis (28), visceral edema (10), abdominal compartment syndrome (9), abdominal packs (6),Abdominal wall defects (2). In the group under 12-years the 2 children had liver ruptures (posttraumatic) and 3 liver transplantations. The average cost for the materials used with our technique was ZAR 96. (10 Euro and 41 cents). CONCLUSION: In our experience the Modified Sandwich Vacuum Pack technique is an effective, cheap methodology to deal with open abdomens in the African setting.A drawback may be the technical expertise required, particular in centers dealing with low numbers of complex abdominal trauma.

Van Hee, R. (2007). "Historical highlights in concept and treatment of abdominal compartment syndrome." Acta Clin Belg Suppl(1): 9-15.

Three types of historical events are of interest, when dealing with the topic of abdominal compartment syndrome. The first concerns the evolution in the understanding of the pathophysiologic features of a compartment syndrome in general. The symptoms were well described by Richard von Volkmann in the 19th century. The second consists of the experimental studies devoted to measurements of intra-abdominal pressure. Different devices and techniques were used, in particular using detection locations approachable via natural body orifices (bladder/uterus/rectum etc). A third point of interest has come forward after the empirical assessment, in particular by sir Heneage Ogilvie that open laparostomies were beneficial in the healing of great abdominal war wounds, or later, of congenital abdominal wall defects. These three different views on pathology and treatment of life threatening abdominal hypertension have evolved to a concept of abdominal compartment syndrome, that with adequate diagnostic measures and accurate and timely intervention can now be treated with great success.

Vans Wessem, K. J., P. J. Mackay, et al. (2007). "Ts08 prospective validation of the independent predictors for postinjury intra-abdominal hypertension." ANZ J Surg 77 Suppl 1: A94.

Purpose Prospective validation of recently established independent predictors for postinjury abdominal compartment syndrome (ACS) was performed. Methodology All trauma patients who met inclusion criteria (ICU admission, ISS > 15, Base Deficit (BD) > 5, or resuscitation with >5 L crystalloids) were prospectively monitored. Patients with isolated head injuries were excluded. Demographics, ISS, resuscitation fluids, physiological parameters, intra-abdominal pressure (IAP) and the independent predictors in two time windows "ED discharge"[SBP, crystalloids, Time-to OR, transfusions] and "ICU admission"[crystalloids, urine output (UO), Hb, Temperature, BD] were collected. Data are presented as mean +/- SEM, p < 0.05 considered significant. Results Twenty-two blunt trauma patients were monitored (Age 39 +/- 5 years, 77% males, ISS 32 +/- 2, SBP 107 +/- 5 mmHg, BD 7 +/- 1). No patients developed ACS. Seven patients developed IAH (IAP > 20 mmHg). IAH and non-IAH patients had the same age (41 +/- 7 vs 37 +/- 5 yrs) and admission BD (7.5 +/- 1.3 vs 6.3 +/- 1.2). IAH patients had higher ISS than non-IAH patients (39 +/- 3 vs 30 +/- 2). Outcomes (IAH vs non-IAH): ICU LOS (39 +/- 3 vs 30 +/- 2), Mortality (0% vs 7%), MOF (29% vs 0%). "ED-discharge predictors": The IAH and non-IAH patients had similar admission SBP, ED crystalloid volume, transfusions and ED time. "ICU-admission predictors": IAH and non-IAH patients had similar UO, crystalloid infusions, BD, temperature but the IAH group had lower Hb (99 +/- 5 vs 111 +/- 3 g/dl) than the non-IAH patients. Conclusions The incidence of ACS decreased from 14% to 0% in a comparable population. The predictors for ACS did not predict IAH. After the elimination of the lethal ACS, the clinical importance of postinjury IAH has to be defined.

Wauters, J. and A. Wilmer (2007). "Noosa, 2 years later... a critical analysis of recent literature." Acta Clin Belg Suppl(1): 33-43.

INTRODUCTION: Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially.This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS. METHODS: A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items. RESULTS: Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS. CONCLUSIONS: After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.

Wauters, J., A. Wilmer, et al. (2007). "Abdomino-thoracic transmission during ACS: facts and figures." Acta Clin Belg Suppl(1): 200-5.

Elevated intra-abdominal pressure (IAP) exerts effects not only on intra-abdominal organs, but also on organs distant to the abdominal compartment. Abdomino-thoracic interaction during intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) interferes with pulmonary, cardiovascular and cerebral function. In accordance with recent guidelines, IAH is defined as IAP above 12 mmHg and ACS as IAP more than 20 mmHg with one or more new organ failures. In this review we will first discuss the effects of elevated IAP on pulmonary dynamics and the relevance for interpreting airway pressures and adjusting ventilator settings. We will then discuss the interaction between abdomino-thoracic pressure transmission and global haemodynamics, the knowledge of which is necessary for correct assessment of cardiac preload and to optimize fluid therapy in the setting of IAH/ACS. A discussion on the relationship between increased IAP, increased intracranial pressure (ICP) and decreased cerebral perfusion pressure (CPP) will follow. Finally, we will review ventilator-induced thoracic pressure swings and their transmission to the abdominal compartment.

Zubritskii, V. F., I. S. Osipov, et al. (2007). "[Syndrome of intraabdominal hypertension in patients with destructive forms of pancreatitis]." Khirurgiia (Mosk)(1): 29-32.

Results of intraabdominal pressure examination in 129 patients with acute destructive pancreatitis are presented. It is demonstrated that pancreonecrosis was associated with intraabdominal pressure rise in 78% cases, and intraabdominal hypertension syndrome developed in 9.3% patients. Prolonged intraabdominal hypertension in patients with advanced pancreonecrosis requires laparotomy. Correlation between intraabdominal hypertension and diffusion of pancreatogenic intra- and retroabdominal inflammation, and also between intraabdominal hypertension and condition severity according to APACHE II scale is demonstrated.