(2008). "[Abdominal compartment syndrome in urgent surgery]." Khirurgiia (Mosk)(7): 33-5.

               Results of measurement and monitoring of intraabdominal pressure at 288 patients treated for different abdominal diseases and trauma were analyzed. In early postoperative period the increase intraabdominal pressure to 10-15 mm Hg (I degree) was revealed at 161 (56.0%) patients, from 16 to 25 mm Hg (II degree)--at 95 (33.0%), from 25 to 35 mm Hg (III degree)--at 23 (8.0%), more 35 mm Hg (IV degree)--at 8 (2.7%) patients. When intraabdominal pressure decreased on 4-5 mm per day the prognosis was positive at 257 (89.2%) operated patients. Critical type regarded as compartment syndrome (III-IV degree) was diagnosed at 31 (10.8%) patients. Relaparotomy was performed at 23 (8.0%) patients with III degree hypertension, the lethal outcome was at 6 (26.1%) cases. Relaparotomy at 8 (2.7%) patients with IV degree hypertension was late, and all the outcomes at these patients were lethal. General lethality at compartment syndrome was 45.2%. It is concluded that monitoring of intraabdominal hypertension should be mandatory diagnostic method, and critical parameters of abdominal hypertension--absolute indication to repeated laparotomy and decompression of abdominal cavity.

 (2008). "[Impact of hyperbaric oxygen therapy on the clinical course of acute pancreatitis and systemic inflammation response syndrome]." Anesteziol Reanimatol(4): 34-8.

               Feasibility of hyperbaric oxygen therapy (HBO) as an efficient and safe adjunct to the standardized treatment protocol and its possible immunomodulatory impact were assessed in the prospective and controlled study of 44 patients with diagnosed acute pancreatitis (AP). The course of the disease was accompanied by systemic inflammatory response syndrome (AIRS) in all the patients on admission. The impact of AP and HBO on homeostasis, the number of performed operations, mortality rates, the levels of two cytokines, intraabdominal pressure, and side effects caused by HBO were evaluated. A treatment group consisted of 22 patients receiving HBO therapy for 3 days (twice a day) using a monoplace chamber under pressures of 1.7-1.9 ATA. Patients (n = 22) in the control group were managed in accordance with the standardized treatment protocol. The authors found more stable homeostasis, decreased mortality rate, and the number of operations in the HBO group. This type of additional therapy, possibly contributed to the decrease of intraabdominal pressure within the first six days after admission. The findings suggest HBO can affect an inflammatory response, by decreasing the levels pro-inflammatory cytokines and increasing those of anti-inflammatory ones.

Al-Bahrani, A. Z., G. H. Abid, et al. (2008). "Clinical relevance of intra-abdominal hypertension in patients with severe acute pancreatitis." Pancreas 36(1): 39-43.

               OBJECTIVES: Intra-abdominal hypertension (IAH) contributes to organ failure in patients with abdominal trauma and sepsis and leads to the development of abdominal compartment syndrome (ACS). This study aims to investigate the clinical significance of IAH in patients with severe acute pancreatitis (SAP). METHODS: Patients admitted to intensive care with SAP underwent daily measurement of intra-abdominal pressure (IAP), recording of the clinical data, and calculation of 4 organ dysfunction scores. RESULTS: Among 18 patients with SAP, 11 (61%) developed IAH (median, 20 mm Hg), whereas 10 (56%) developed ACS. The IAP correlated significantly with the 4 organ dysfunction scores; the scores were significantly higher when IAH existed than when it did not. The admission IAP correlated significantly with the duration of intensive care stay. Patients who developed IAH/ACS had significantly higher organ failure score and greater mortality compared with those who did not. Laparotomy and drainage reduced the IAP by a median of -11 mm Hg and relieved the IAH/ACS in all patients. CONCLUSIONS: Intra-abdominal hypertension and ACS are frequent findings in patients with SAP and are associated with deterioration in organ function. Intra-abdominal pressure correlates with the severity of organ failure, and a high admission IAP is associated with prolonged intensive care stay.

Alder, A. C., J. L. Hunt, et al. (2008). "Abdominal compartment syndrome associated with tension pneumoperitoneum in an elderly trauma patient." J Trauma 64(1): 211-2.

An, G. and M. A. West (2008). "Abdominal compartment syndrome: a concise clinical review." Crit Care Med 36(4): 1304-10.

               OBJECTIVE: There has been an increased awareness of the presence and clinical importance of abdominal compartment syndrome. It is now appreciated that elevations of abdominal pressure occur in a wide variety of critically ill patients. Full-blown abdominal compartment syndrome is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction resulting from elevated intra-abdominal pressure. This review provides a current, clinically focused approach to the diagnosis and management of abdominal compartment syndrome, with a particular emphasis on intensive care. METHODS: Source data were obtained from a PubMed search of the medical literature, with an emphasis on the time period after 2000. PubMed "related articles" search strategies were likewise employed frequently. Additional information was derived from the Web site of the World Society of the Abdominal Compartment Syndrome (http://www.wsacs.org). SUMMARY AND CONCLUSIONS: The detrimental impact of elevated intra-abdominal pressure, progressing to abdominal compartment syndrome, is recognized in both surgical and medical intensive care units. The recent international abdominal compartment syndrome consensus conference has helped to define, characterize, and raise awareness of abdominal compartment syndrome. Because of the frequency of this condition, routine measurement of intra-abdominal pressure should be performed in high-risk patients in the intensive care unit. Evidence-based interventions can be used to minimize the risk of developing elevated intra-abdominal pressure and to aggressively treat intra-abdominal hypertension when identified. Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of intra-abdominal hypertension and abdominal compartment syndrome.

Arigon, J. P., O. Chapuis, et al. (2008). "[Managing the open abdomen with vacuum-assisted closure therapy: retrospective evaluation of 22 patients]." J Chir (Paris) 145(3): 252-61.

               BACKGROUND: The authors reviewed their experience in the management of "open abdomen" using the vacuum-assisted closure device (VAC), in order to assess its morbidity particularly in terms of fistula, and the outcome of abdominal wall integrity. METHODS: Between January 2003 and October 2006, 22 patients required management with an "open abdomen" technique (18 patients were managed with the VAC abdominal dressing device with application of a specific sheet and 4 other patients simply required a dressing with the polyurethane sponge). The mean age was 55 years, and M/F sex ratio was 2.67. Indications were abdominal compartment syndrome in 7 patients, initial "abdominal closure" after trauma in one patient, severe abdominal sepsis in 7 patients, and abdominal wound dehiscence where closure was impossible in 7 patients. RESULTS: There were no enteric fistulae. Two infections were seen--a chronic suppuration which resolved with antibiotic therapy and a deep abscess which was drained with radiologic guidance. Of the 18 cases of "open abdomen" managed with the VAC, 15 were alive. Six (40%) underwent a delayed primary closure at a mean interval of 9 days; the others underwent secondary healing by granulation, and 10 eventually underwent split thickness skin grafting at a mean interval of 50 days. With VAC closure of the "open abdomen", the development of ventral hernia is an anticipated outcome; in four cases, patients underwent abdominal wall reconstruction at an interval of one year. CONCLUSION: Laparostomy or "open abdomen" using the VAC dressing system should be considered an established and well-defined technique which provides temporary abdominal coverage with limited morbidity.

Ball, C. G., A. W. Kirkpatrick, et al. (2008). "The secondary abdominal compartment syndrome: not just another post-traumatic complication." Can J Surg 51(5): 399-405.

               The secondary abdominal compartment syndrome (ACS) is defined as the presence of organ dysfunction with concurrent intra-abdominal hypertension (IAH) in a scenario lacking primary intraperitoneal injury or intervention. This state appears to be related to visceral, abdominal wall and retroperitoneal edema and ascites induced by resuscitation. Despite a diverse range of associated causes such as pancreatitis, intra-abdominal sepsis, cardiac arrest, thermal injury and extraperitoneal trauma, this class of ACS is characterized by the presence of shock requiring aggressive fluid resuscitation. Secondary ACS is an extreme condition along a continuum of raised intra-abdominal pressure (IAP) that is pathoneumonic when associated with new overt organ failure. When IAP is above normal but is not associated with organ failure, IAH is diagnosed. Because these conditions are common among critically ill patients, the measurement of IAP is crucial. It is unclear whether preventing IAH reduces progression to ACS or influences outcomes. When overt ACS is confirmed, immediate surgical decompression of the patient's abdomen via a standard laparotomy is usually required. Because many disease processes resulting in critical illness require aggressive fluid resuscitation as a primary therapy, it is likely that secondary ACS is much more common than previously believed. Further study is needed.

Basterra Longas, A., S. Arizcun Gonzalez, et al. (2008). "[Abviser Kit intra-abdominal pressure monitoring]." Rev Enferm 31(10): 43-4.

               The authors explain what an Abviser Kit consists of as an appropriate technique to measure intra-abdominal pressure, especially for patients in critical condition who have a depressed immune system since this deals with a closed system which prevents the movements a bladder catheter causes. This method minimizes the risk of infection, shortening hospital stays.

Basu, A. and D. R. Pai (2008). "Early elevation of intra-abdominal pressure after laparotomy for secondary peritonitis: a predictor of relaparotomy?" World J Surg 32(8): 1851-6.

               BACKGROUND: Patients with secondary peritonitis often require relaparotomy; however, there is no consensus about the criteria for selecting patients who would benefit from early relaparotomy. Our goal was to evaluate whether elevated intra-abdominal pressure (IAP) during the early postoperative period could predict the need for relaparotomy. METHODS: A total of 102 consecutive adult patients with acute intra-abdominal conditions were admitted for laparotomy. Seventy-eight patients, who were diagnosed with secondary peritonitis at index surgery, underwent serial measurements of IAP. The primary outcomes measured in the study were incidence of postoperative peritonitis and mortality. RESULTS: Thirty-two of 78 patients with secondary peritonitis (41%) developed elevated IAP postoperatively. Sixteen (20.5%) of 78 patients developed postoperative peritonitis. Twelve of these 16 patients (75%) with postoperative peritonitis had significantly elevated IAP (P = 0.002) during the immediate postoperative period. Regression analysis revealed elevated IAP (P = 0.055) to be third most predictive of postoperative peritonitis in patients who underwent laparotomy for secondary peritonitis, after septic shock at admission (P = 0.012) and POSSUM score (P = 0.018). CONCLUSION: Our study shows that development of elevated IAP during the early postoperative period can increase the risk of postoperative peritonitis. IAP measured during the immediate postoperative period can be used as a predictor of early relaparotomy.

Bee, T. K., M. A. Croce, et al. (2008). "Temporary abdominal closure techniques: a prospective randomized trial comparing polyglactin 910 mesh and vacuum-assisted closure." J Trauma 65(2): 337-42; discussion 342-4.

               OBJECTIVE: The options for abdominal coverage after damage control laparotomy or abdominal compartment syndrome vary by institution, surgeon preference, and type of patient. Some advocate polyglactin mesh (MESH), while others favor vacuum-assisted closure (VAC). We performed a single institution prospective randomized trial comparing morbidity and mortality differences between MESH and VAC. METHODS: Patients expected to survive and requiring open abdomen management were prospectively randomized to either MESH or VAC. After randomization, an enteral feeding tube was inserted and the closure device placed. VAC patients returned to the operating room every 3 days for a total of three changes at which time polyglactin mesh was placed if closure was not possible. The MESH group had twice daily assessments for the possibility of bedside mesh cinching and closure. Both groups underwent split thickness skin grafting when granulation tissue was evident, if delayed primary closure was not possible. RESULTS: Fifty-one patients were randomized. Both cohorts were matched for Injury Severity Scale score, gender, blunt/penetrating/abdominal compartment syndrome and age. Three patients died within 7 days and were excluded from closure rate calculation. There were no differences between delayed primary fascial closure rates in the VAC (31%) or MESH (26%) groups. The fistula rate in the VAC group was 21% but not statistically different from the 5% rate for MESH. Intraabdominal rates were not statistically different. All VAC fistulas were related to feeding tubes and suture line areas; the MESH fistula followed a retroperitoneal colon leak remote from the mesh. CONCLUSIONS: MESH and VAC are both useful methods for abdominal coverage, and are equally likely to produce delayed primary closure. The fistula rate for VAC is most likely due to continued bowel manipulation with VAC changes with a feeding tube in place-enteral feeds should be administered via nasojejunal tube. Neither method precludes secondary abdominal wall reconstruction.

Beltran, M. A., R. A. Villar, et al. (2008). "Abdominal compartment syndrome in patients with strangulated hernia." Hernia.

               BACKGROUND: Intestinal obstruction (IO) leads to increased intra-abdominal pressure and abdominal compartment syndrome. The purpose of this study was to investigate the characteristics of abdominal compartment syndrome in patients with IO secondary to strangulated hernia. METHODS: We studied 81 consecutive unselected patients presenting complicated hernias and IO. We measured intra-abdominal pressure using the intra-vesicular pressure method. RESULTS: Preoperative (15 min) intra-abdominal pressure was higher in patients with strangulated hernias. Postoperative (15 min) intra-abdominal pressure in both groups decreased to similar values. Intra-abdominal pressure was measured during the preoperative period in patients with strangulated hernias and during the postoperative period at 15 min (13.8 +/- 6.4 mmHg), 24 h (9.8 +/- 3.2 mmHg) and 48 h (7.4 +/- 2.4 mmHg). Abdominal compartment syndrome developed in 47% cases with strangulated hernias with a mortality of five patients. CONCLUSIONS: Serial measurements of intra-abdominal pressure evidenced the clinical severity of strangulated hernia. Intra-abdominal pressure measurement may be used as a predictor of intestinal strangulation in patients presenting acute abdominal compartment syndrome secondary to complicated hernia.

Benninger, E., L. Labler, et al. (2008). "In vitro comparison of intra-abdominal hypertension development after different temporary abdominal closure techniques." J Surg Res 144(1): 102-6.

               BACKGROUND: To compare volume reserve capacity (VRC) and development of intra-abdominal hypertension after different in vitro temporary abdominal closure (TAC) techniques. METHODS: A model of the abdomen was designed. The abdominal wall was simulated with polychloroprene, a synthetic rubber compound. A lentil-shaped defect of 150 cm(2) was cut into the anterior aspect of the abdominal wall. TAC of this defect was performed by a zipper system (ZS), a bag silo closure (BSC), or a vacuum assisted closure (VAC) with subatmospheric pressures ranging from 0- to 200 mmHg. The model with intact abdominal wall served as reference. The model was filled with water to baseline level. The intra-abdominal pressure was increased in 2 mmHg steps from baseline level (6 mmHg) to 40 mmHg by adding volume to the system according to a standardized protocol. VRC with corresponding intra-abdominal pressure were analyzed and compared for the different TAC techniques. RESULTS: VRC was the highest after BSC at all pressure levels studied (P < 0.05). VAC and ZS resulted in significantly lower VRC compared with BSC and reference (P < 0.05). The magnitude of negative pressure on the VAC did not significantly influence the VRC. CONCLUSIONS: In the present in vitro model, BSC demonstrated the highest VRC of all evaluated TAC techniques. Different levels of subatmospheric pressures applied to the VAC did not affect VRC. The results for ZS and VAC indicate that these TAC techniques may increase the risk for recurrent intra-abdominal hypertension and should therefore not be used in high-risk patients during the initial phase after abdominal decompression.

Biancofiore, G. and M. L. Bindi (2008). "Measurement and knowledge of intra-abdominal pressure in Italian Intensive Care Units." Minerva Anestesiol 74(1-2): 5-9.

               BACKGROUND: With this survey, we aimed at investigating the knowledge, recognition and management of intra-abdominal pressure (IAP) and abdominal hypertension (IAH) in Italian Intensive Care Units. METHODS: A questionnaire was sent to the ''Intensive Care Unit lead physician'' of 114 italian hospitals. RESULTS: One hundred fourteen questionnaires were sent, and 77 (67.5%) of them were returned completed. IAP was measured in 51 Units (66.3%). The most frequent reasons for not measuring IAP were the lack of a specific IAP monitoring kit (34.6%) and not knowing how to make the measurement (23.0%). Urinary bladder pressure was the only method used to measure IAP, the most frequent timing for IAP measurements was once every 4 h. An IAP value of 15 mmHg was considered to be the threshold for IAH in 33.4% of the cases, whereas in 31.4% of cases it was 20 mmHg. The presence of risk factors for IAH (64.7%) and a previous urgent surgery (21.5 %) were indicators of IAP monitoring. Diagnosis of IAH prompted a surgical consultation and evaluation, also in view of a possible abdominal decompression in 64.7 % of cases. More than half (54.9%, n=28) of the 51 ICUs where IAP was measured reported to be unaware of the World Society of the Abdominal Compartment Syndrome. CONCLUSION: Italian intensive care unit physicians show a certain interest towards IAP monitoring and its implications in the management of critically ill patients. However, IAP, IAH and abdominal compartment syndrome still require greater basic understanding.

Bjorck, M., A. Wanhainen, et al. (2008). "The clinical importance of monitoring intra-abdominal pressure after ruptured abdominal aortic aneurysm repair." Scand J Surg 97(2): 183-90.

               AIM: The aim of this paper was to review the literature on the clinical importance of monitoring intra-abdominal pressure (IAP) after ruptured abdominal aortic aneurysm (rAAA) repair. METHOD: The literature was searched for abdominal compartment syndrome (ACS) or intra-abdominal pressure and aortic aneurysm. Original articles were studied. Personal experiences were reported. RESULTS: The Consensus Documents of the World Society on the Abdominal Compartment Syndrome (wsacs.org), with their definitions and guidelines, constitute an important step forward for the possibilities to study this clinical entity. Few papers were published describing the problem specifically in the patient population operated on for ruptured abdominal aortic aneurysm (rAAA). The incidence was approximately 5% when the patients were not monitored with IAP, and above 10% when IAP was monitored. The incidence seems to be similar irrespective if open or endovascular repair is performed, though comparative prospective studies were not published. Patients with intra-abdominal hypertension (IAH) or ACS have higher mortality and more complications. If IAH is recognized early conservative treatment may be effective to prevent development of ACS. After ACS has developed, surgical decompression is usually required. A proposed algorithm on how to act on different levels of IAH is presented. CONCLUSIONS: IAH/ACS is an important complication after operation on patients with rAAA. Monitoring IAP may be associated with improved outcomes.

Bodnar, Z., S. Sipka, et al. (2008). "The abdominal compartment syndrome (ACS) in general surgery." Hepatogastroenterology 55(88): 2033-8.

               BACKGROUND: The abdominal compartment syndrome is a life threatening clinical entity which can develop within the first 12 hours of intensive care unit admission in high-risk surgical patients. The aim of this paper is to show the definitions, ethiology, pathophysiology, diagnosis and treatment of this serious, not only surgical problem. METHODOLOGY: The mortality due to the abdominal compartment syndrome is extremely high (38-71%). It can be defined as adverse physiologic consequences that occur as a result of an acute increase in the intraabdominal pressure. The most common causes are retroperitoneal haemorrhage, visceral oedema, pancreatitis, bowel obstruction, tense ascites, peritonitis, tumor. The mostly affected systems are cardiovascular, pulmonary, renal, central nervous systems and splanchnic organs. The gold standard diagnostic method is the continuous intra-abdominal pressure monitoring. The treatment consists of adequate fluid resuscitation and surgical decompression. RESULTS: We show three typical short case reports treated by the above mentioned theories. CONCLUSIONS: Intraabdominal hypertension and abdominal compartment syndrome are frequent clinical findings among acute general surgical patients. Patients with comparable demographics and acute severity of illness are more likely to die if intraabdominal hypertension or abdominal compartment syndrome is present. We conclude that the early recognition and surgical decompression is urgent.

Burke, B. A. and B. A. Latenser (2008). "Defining intra-abdominal hypertension and abdominal compartment syndrome in acute thermal injury: a multicenter survey." J Burn Care Res 29(4): 580-4.

               The definitions of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are not uniform despite the increasing awareness of IAH/ACS in burn patients. A short survey including definitions, resuscitation protocols, and monitoring practices was sent to every physician listed in the American Burn Association Directory. Thirty-two of 123 (26%) surveys were returned; 22 (69%) were from verified burn centers. Survey respondents said that bladder pressure indicating IAH is 19.6 mm Hg (range 12-30) and ACS is 25.9 mm Hg (range 15-40). Fifteen percentage of those responding do not include clinical sequellae in their definition of ACS. Bladder pressure is not routinely measured by 22 (69%) burn physicians, and staff at 17 centers (53%) wait until the abdomen is tense to measure abdominal pressure. Tense abdomen, along with elevated peak inspiratory pressures (PIP), is used in most centers (94%) to determine IAH/ACS, followed by oliguria (88%), and difficulty ventilating (78%). Resuscitation formulae used are primarily the Parkland/modified Parkland in 24 (75%) burn centers. Criteria for abdominal decompression is based on bladder pressures alone in 25 centers (78%); 16/32 (50%) use PIP, and 10/32 (31%) staff use other criteria including organ dysfunction or increased lactate. Eleven physicians (34%) advocate percutaneous decompression before decompressive laparotomy. Although most United States burn physicians define ACS as >or=25 mm Hg along with physiologic compromise, bladder pressure is routinely measured by only 31% of burn physicians. Most burn staff do not differentiate between IAH and ACS. Consensus definitions of IAH/ACS are necessary for burn care practitioners to compare research studies and discuss outcomes. Concise definitions will promote understanding of the pathophysiological processes involved and allow us to develop data-driven patient care protocols.

Cardia, G., A. Centonze, et al. (2008). "Abdominal compartment syndrome: a situation thet needs to be better known." Chir Ital 60(3): 381-9.

               Abdominal compartment syndrome was initially described as a cascade of physiopathological events triggered by the increase in intra-abdominal pressure induced by a surgical procedure for aneurysm of the abdominal aorta. In practice, it is a complication that can arise after various procedures; it has a multi-organ impact and can lead to exitus. We retrospectively analyzed a total of 9 patients with abdominal compartment syndrome. In 5 cases onset of the syndrome was due to a secondary complication of a vascular procedure (3 mesenteric, 2 renal). The clinical data characterizing the disease included abdominal distension and reduced diuresis. In all cases the finding of increased necrosis scores (LDH, CPK) was evident, while the appearance of leukocytosis occurred only in 4 (44%). The basic treatment was surgical decompression. In one case we obtained an excellent result with medical treatment alone, consisting in steroids and PGE1; these were useful in all cases in which an inflammatory bowel component played a role. Our experience encourages us to stress the importance of early assessment of abdominal hypertension in patients with a potential risk of abdominal compartment syndrome. In this phase, appropriate medical and supportive treatment could limit the surgical indications or at any rate favour the healing process after surgical decompression, the basic treatment indicated for this syndrome.

Cheatham, M. L. (2008). "Are children really just small adults?" Crit Care Med 36(7): 2215-6.

Cheatham, M. L. (2008). "Intraabdominal pressure monitoring during fluid resuscitation." Curr Opin Crit Care 14(3): 327-33.

               PURPOSE OF REVIEW: Elevated intraabdominal pressure is commonly encountered in the critically ill, has detrimental effects on all organ systems, and is associated with significant morbidity and mortality. Serial intraabdominal pressure measurements are essential to the diagnosis, management, and fluid resuscitation of patients who develop intraabdominal hypertension and/or abdominal compartment syndrome. RECENT FINDINGS: Over the past year, the importance of intraabdominal pressure measurements and their accurate determination has been further defined. Several nonoperative therapies have been demonstrated to reduce the morbidity and mortality of intraabdominal hypertension/abdominal compartment syndrome, all of which are guided by measurements of intraabdominal pressure. The World Society of the Abdominal Compartment Syndrome has published evidence-based medicine consensus guidelines for the measurement of intraabdominal pressure and its utilization in the diagnosis and resuscitation of the critically ill. SUMMARY: Serial intraabdominal pressure measurements are essential for the diagnosis and management of intraabdominal hypertension/abdominal compartment syndrome. Intraabdominal pressure must be measured accurately and utilized in a goal-directed fashion to guide fluid and end-organ resuscitation. As a result of its ability to predict survival among the critically ill, intraabdominal pressure should be routinely monitored in the patient who demonstrates risk factors for intraabdominal hypertension/abdominal compartment syndrome.

Cheatham, M. L. (2008). "Resuscitation end points in severe sepsis: central venous pressure, mean arterial pressure, mixed venous oxygen saturation, and... intra-abdominal pressure." Crit Care Med 36(3): 1012-4.

               Severe sepsis is widely recognized as a significant cause of morbidity and mortality in the critically ill. The appropriate treatment strategy has long been the subject of controversy and has centered on the pros and cons of crystalloid vs. colloid, fluids vs. vasopressors, and steroids vs. no steroids. In recent years, however, an algorithmic evidence-based approach to the treatment of severe sepsis has been advocated by the Surviving Sepsis Campaign and broadly adopted worldwide. This strategy includes the use of goal directed fluid and norepinephrine administration to restore systemic perfusion and oxygenation and ultimately improve patient survival. Resuscitation end points, such as central venous pressure, mean arterial pressure, and mixed venous oxygen saturation, are central to this approach. Intra-abdominal hypertension (IAH), or elevated intra-abdominal pressure (IAP), and abdominal compartment syndrome (ACS), the development of organ dysfunction and failure secondary to IAH, have similarly gained increasing, though less noticeable, recognition as causes of morbidity and mortality in a variety of different patient populations.

Severe sepsis and IAH/ACS share many of the same risk factors and are frequently encountered concurrently within the same patient. The World Society of the Abdominal Compartment Syndrome has recently published consensus definitions and recommendations that include evidence-based–medicine assessment and management algorithms for the resuscitation of patients with IAH/ACS (available at: http://www.wsacs.org). This treatment strategy represents an organ systems– based approach designed to reduce IAP and its injurious effects and to ensure adequate systemic perfusion and organ function. Prominent in this approach are the judicious administration of fluid to avoid resuscitation-induced visceral edema and elevated IAP, the early application of vasopressor therapy to maintain systemic perfusion, and the use of surgical decompression for IAH/ACS refractory to less invasive therapies. This management strategy for patients with early IAH/ACS has been demonstrated to significantly reduce the associated mortality of elevated IAP and the need for emergent surgical decompression of the abdomen. The relatively new resuscitation end points of IAP and abdominal perfusion pressure (APP) (calculated as mean arterial pressure minus IAP) are central to this approach. Maintenance of an APP greater than 50–60 mm Hg has been demonstrated to predict patient survival from IAH/ACS.

Given their mutual risk factors, severe sepsis and IAH/ACS should be carefully sought and, when present, aggressively treated to reduce their similar morbidity and mortality. Patients should be screened for IAH/ACS risk factors at intensive care unit admission and in the presence of new or progressive organ failure. If IAH is present, serial IAP measurements should be performed throughout the patient’s critical illness. APP should be maintained above 50–60 mm Hg. Combination therapy using both crystalloids/colloids and vasopressors should be employed, carefully titrated to central venous pressure, mean arterial pressure, mixed venous oxygen saturation, and IAP to ensure restoration of end-organ perfusion and function while minimizing the detrimental effects of over resuscitation. This approach is consistent both with the current Surviving Sepsis Campaign and World Society of the Abdominal Compartment Syndrome resuscitation algorithms.

Cheatham, M. L. and J. Fowler (2008). "Measuring intra-abdominal pressure outside the ICU: validation of a simple bedside method." Am Surg 74(9): 806-8.

               Intra-abdominal pressure measurement is essential to the diagnosis of patients with intraabdominal hypertension or abdominal compartment syndrome. The most common method for measuring intra-abdominal pressure (IAP) is the intravesicular or "bladder" technique, which requires electronic monitoring technology not available on the typical surgical ward. Herein we describe and validate a simple, rapid screening method for bedside IAP measurement using the patient's indwelling urinary catheter and a readily available intravenous tubing extension. Validation of this technique across the clinically important IAP diagnostic spectrum demonstrated acceptable bias (1.6 mm Hg; 95% confidence interval 1.4-1.8) with limits of agreement of 0.36 to 2.8. This demonstrates good agreement between the two IAP methods and validates the bedside technique as a simple, cost-effective, and reproducible method for screening IAP measurements outside of the critical care setting.

Cheatham, M. L., J. Fowler, et al. (2008). "Subcutaneous linea alba fasciotomy: a less morbid treatment for abdominal compartment syndrome." Am Surg 74(8): 746-9.

               Abdominal compartment syndrome is a cause of significant morbidity and mortality among surgical patients. It has traditionally been treated by abdominal decompression with the associated risks of chronic incisional hernia and enteroatmospheric fistula. Subcutaneous linea alba fasciotomy has recently been described as a new surgical technique for the treatment of abdominal compartment syndrome secondary to acute pancreatitis. This technique reduces intraabdominal pressure and restores organ function while maintaining the skin and peritoneum intact for visceral protection. We describe the application of subcutaneous linea alba fasciotomy as a safe and effective alternative for the surgical management of abdominal compartment syndrome in a traumatically injured patient refractory to comprehensive medical interventions.

Cheatham, M. L. and K. Safcsak (2008). "Longterm impact of abdominal decompression: a prospective comparative analysis." J Am Coll Surg 207(4): 573-9.

               BACKGROUND: Abdominal decompression is widely used to treat end-organ dysfunction associated with intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS). The longterm impact of abdominal decompression on physical and mental health, quality of life, and subsequent employment remains unclear. STUDY DESIGN: A prospective cohort study was performed at a tertiary referral/Level I trauma center. All patients who required abdominal decompression for more than 48 hours were asked to complete the SF-36v2 health survey at regular intervals for 2 years postdecompression. Patients discharged with a chronic incisional hernia (OPEN) were compared with those discharged with primary fascial closure (CLOSED) and with the general population. Quality-adjusted life years (QALYs) and successful return to employment were determined. RESULTS: From June 2002 to May 2005, 245 consecutive patients required abdominal decompression for intraabdominal hypertension and abdominal compartment syndrome. Forty-four patients (30 OPEN, 14 CLOSED) met inclusion criteria and completed their health surveys. At 6 months postdecompression, physical and social functioning were significantly decreased among OPEN, but not CLOSED, patients when compared with the general population. By 18 months, OPEN patients demonstrated normal physical and mental health perception. OPEN and CLOSED patients exhibited decreased, but identical, quality-adjusted life years (1.20+/-0.11 versus 1.23+/-0.25 [mean +/- SD]; p=0.39) and similar ability to resume employment (41% versus 55%; p=0.49). CONCLUSIONS: Abdominal decompression does not have a negative impact on longterm physical or mental health perception. Quality of life and ability to resume employment are not improved by same-admission primary fascial closure. Abdominal decompression is not as debilitating and life altering as might be expected.

Chen, H., F. Li, et al. (2008). "Abdominal compartment syndrome in patients with severe acute pancreatitis in early stage." World J Gastroenterol 14(22): 3541-8.

               AIM: To study retrospectively the influence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in patients with early acute pancreatitis (AP) (during the first week after admission) on physiological functions, and the association of the presence of IAH/ACS and outcome. METHODS: Patients (n = 74) with AP recruited in this study were divided into two groups according to intra-abdominal pressure (IAP) determined by indirect measurement using the transvesical route via Foley bladder catheter during the first week after admission. Patients (n = 44) with IAP >= 12 mmHg were assigned in IAH group, and the remaining patients (n = 30) with IAP < 12 mmHg in normal IAP group. For analysis of the influence of IAH/ACS on organ function and outcome, the physiological parameters and the occurrence of organ dysfunction during intensive care unit (ICU) stay were recorded, as were the incidences of pancreatic infection and in-hospital mortality. RESULTS: IAH within the first week after admission was found in 44 patients (59.46%). Although the APACHE II scores on admission and the Ranson scores within 48 h after hospitalization were elevated in IAH patients in early stage, they did not show the statistically significant differences from patients with normal IAP within a week after admission (16.18 +/- 3.90 vs 15.70 +/- 4.25, P = 0.616; 3.70 +/- 0.93 vs 3.47 +/- 0.94, P = 0.285, respectively). ACS in early AP was recorded in 20 patients (27.03%). During any 24-h period of the first week after admission, the recorded mean IAP correlated significantly with the Marshall score calculated at the same time interval in IAH group (r = 0.635, P < 0.001). Although ACS patients had obvious amelioration in physiological variables within 24 h after decompression, the incidences of pancreatitic infection, septic shock, multiple organ dysfunction syndrome (MODS) and death in the patients with ACS were significantly higher than that in other patients without ACS (pancreatitic infection: 60.0% vs 7.4%, P < 0.001; septic shock: 70.0% vs 11.1%, P < 0.001; MODS: 90.0% vs 31.5%, P < 0.001; mortality: 75.0% vs 3.7%, P < 0.001). CONCLUSION: IAH/ACS is a frequent finding in patients admitted to the ICU because of AP. Patients with IAP at approximately 10-12 mmHg and early signs of changes in physiologic variables should be seriously considered for urgent decompression to improve survival.

Choi, J. Y., P. Burton, et al. (2008). "Abdominal compartment syndrome after ruptured abdominal aortic aneurysm." ANZ J Surg 78(8): 648-53.

               Abdominal Compartment Syndrome (ACS) is an increasingly recognized syndrome of intra-abdominal hypertension and generalized physiological dysfunction in critically ill patients. Patients suffering a ruptured abdominal aortic aneurysm (rAAA) are at risk of developing ACS. The objective of the study was to compare the current views on the importance, prevalence and management of ACS after rAAA among Australian vascular surgeons and intensivists. A questionnaire was mailed to 116 registered vascular fellows from the Royal Australasian College of Surgeons and 314 registered fellows of the Joint Faculty of Intensive Care Medicine. Data were collected on the prevalence and importance of ACS after rAAA and whether prophylactic measures were or should be taken to prevent ACS. Hypothetical clinical scenarios representing a range of ACS after rAAA were also presented. The responses were compared using chi(2)-test and t-test. Sixty-seven per cent (78 of 116) of surgeons and 39% (122 of 314) of intensivists responded. Both groups estimated the prevalence of ACS after rAAA as between 10 and 30% and considered it an important entity. Only 30% of surgeons and 50% of intensivists suggested routine intra-abdominal pressure (IAP) monitoring. In patients with borderline IAP (18 mmHg), both groups believed that surgical intervention was unnecessary. Intensivists were more inclined to suggest surgical intervention for clinically deteriorating patients with an increased IAP (30 mmHg) compared with surgeons. Forty-three per cent of intensivists and 17% of surgeons suggested prophylactic (leaving the abdomen open) measures to prevent ACS in high-risk patients. Surgeons and intensivists have similar views on the prevalence and clinical importance of ACS after rAAA. Intensivists more frequently monitored IAP and suggested both early prophylactic and therapeutic intervention for ACS based on physiological and IAP findings.

Dalfino, L., L. Tullo, et al. (2008). "Intra-abdominal hypertensionand acute renal failurein critically ill patients." Intensive Care Med 34(4): 707-13.

               OBJECTIVE: To investigate the relationship between intra-abdominal hypertension (IAH) and acute renal failure (ARF) in critically ill patients. DESIGN AND SETTING: Prospective, observational study in a general intensive care unit. PATIENTS: Patients consecutively admitted for[Symbol: see text]>[Symbol: see text]24[Symbol: see text]h during a 6-month period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Intra-abdominal pressure (IAP) was measured through the urinary bladder pressure measurement method. The IAH was defined as a IAP >/=12[Symbol: see text]mmHg in at least two consecutive measurements performed at 24-h intervals. The ARF was defined as the failure class of the RIFLE classification. Of 123 patients, 37 (30.1%) developed IAH. Twenty-three patients developed ARF (with an overall incidence of 19%), 16 (43.2%) in IAH and 7 (8.1%) in non-IAH group (p[Symbol: see text]<[Symbol: see text]0.05). Shock (p[Symbol: see text]<[Symbol: see text]0.001), IAH (p[Symbol: see text]=[Symbol: see text]0.002) and low abdominal perfusion pressure (APP; p[Symbol: see text]=[Symbol: see text]0.046) resulted as the best predictive factors for ARF. The optimum cut-off point of IAP for ARF development was 12[Symbol: see text]mmHg, with a sensitivity of 91.3% and a specificity of 67%. The best cut-off values of APP and filtration gradient (FG) for ARF development were 52 and 38[Symbol: see text]mmHg, respectively. Age(p[Symbol: see text]=[Symbol: see text]0.002), cumulative fluid balance (p[Symbol: see text]=[Symbol: see text]0.002) and shock (p[Symbol: see text]=[Symbol: see text]0.006) were independent predictive factors of IAH. Raw hospital mortality rate was significantly higher in patients with IAH; however, risk-adjusted and O/E ratio mortality rates were not different between groups. CONCLUSIONS: In critically ill patients IAH is an independent predictive factor of ARF at IAP levels as low as 12[Symbol: see text]mmHg, although the contribution of impaired systemic haemodynamics should also be considered.

De Laet, I., E. Hoste, et al. (2008). "Transvesical intra-abdominal pressure measurement using minimal instillation volumes: how low can we go?" Intensive Care Med 34(4): 746-50.

               OBJECTIVE: To determine the minimal instillation volume at which an intra-abdominal pressure (IAP) curve can be obtained and to compare this with the IAP measured at 20[Symbol: see text]ml instilled volume. DESIGN AND SETTING: Prospective cohort study in the Intensive Care Unit of Ghent University Hospital. PATIENTS: Twenty-five critically ill sedated and ventilated patients at risk for intra-abdominal hypertension (IAH). INTERVENTIONS: IAP was measured transvesically using a custom-designed IAP monitoring set. Measurement was started without any additional instillation of saline and was continued at 1-ml increments up to 10[Symbol: see text]ml. Finally, IAP was measured with 20[Symbol: see text]ml instillation volume. MEASUREMENTS AND RESULTS: After each instillation an "oscillation test" was performed. The minimal volume at which the oscillation test was positive was recorded. These values were compared to the IAP obtained using 20[Symbol: see text]ml saline (IAP(20[Symbol: see text]ml)). At 2[Symbol: see text]ml installed saline volume an oscillation curve could be obtained in all patients. Mean IAP(2[Symbol: see text]ml) was 11.2[Symbol: see text]+/-[Symbol: see text]3.2[Symbol: see text]mmHg, IAP(10[Symbol: see text]ml) 11.4[Symbol: see text]+/-[Symbol: see text]3.7[Symbol: see text]mmHg, and IAP(20[Symbol: see text]ml) 11.7[Symbol: see text]+/-[Symbol: see text]3.2[Symbol: see text]mmHg. In four patients (16%) there was a clinically significant difference of 2[Symbol: see text]mmHg or more between IAP(2[Symbol: see text]ml) and IAP(20[Symbol: see text]ml). The mean difference between IAP(20[Symbol: see text]ml) and IAP(2[Symbol: see text]ml) was 0.60[Symbol: see text]+/-[Symbol: see text]0.91[Symbol: see text]mmHg (95% CI 0.22-0.98). CONCLUSIONS: In this sample of patients at risk for IAH 2[Symbol: see text]ml saline was sufficient for IAP signal transduction. Higher volumes for transvesical IAP measurement resulted in higher pressure readings in some patients.

De Laet, I. E., M. Ravyts, et al. (2008). "Current insights in intra-abdominal hypertension and abdominal compartment syndrome: open the abdomen and keep it open!" Langenbecks Arch Surg.

               BACKGROUND AND AIMS: The abdominal compartment syndrome (ACS) is associated with organ dysfunction and mortality in critically ill patients. Furthermore, the deleterious effects of increased IAP have been shown to occur at levels of intra-abdominal pressure (IAP) previously deemed to be safe. The aim of this article is to provide an overview of all aspects of this underrecognized pathological syndrome for surgeons. METHODS AND CONTENTS: This review article will focus primarily on the recent literature on ACS as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased IAP will be listed, followed by a brief but comprehensive overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, surgical treatment and management of the open abdomen are briefly discussed, as well as some minimally invasive techniques to decrease IAP. CONCLUSIONS: The ACS was first described in surgical patients with abdominal trauma, bleeding, or infection, but in recent years ACS has also been described in patients with other pathologies such as burn injury and sepsis. Some of these so-called nonsurgical patients will require surgery to treat their ACS. This review article is intended to provide surgeons with a clear insight into the current state of knowledge regarding IAH, ACS, and the impact of IAP on the critically ill patient.

De Waele, J. J., I. De Laet, et al. (2008). "The effect of different reference transducer positions on intra-abdominal pressure measurement: a multicenter analysis." Intensive Care Med 34(7): 1299-303.

               OBJECTIVE: To investigate the effect of different reference transducer positions on intra-abdominal pressure (IAP) measurement. Three reference levels were studied: the symphysis pubis; the phlebostatic axis; and the midaxillary line at the level of the iliac crest. DESIGN: Prospective cohort study. SETTING: The intensive care units of participating hospitals PATIENTS AND PARTICIPANTS: One hundred thirty-two critically ill patients at risk for intra-abdominal hypertension (IAH). INTERVENTIONS: In each patient, three sets of IAP measurements were obtained in the supine position, using the different reference levels. The IAP measurements obtained at the different reference levels were compared using a paired t-test and Bland-Altman statistics were calculated. MEASUREMENTS AND RESULTS: IAP(phlebostatic) (9.9[Symbol: see text]+/-[Symbol: see text]4.67[Symbol: see text]mmHg) and IAP(pubis) (8.4[Symbol: see text]+/-[Symbol: see text]4.60[Symbol: see text]mmHg) were significantly lower that IAP(midax) (12.2[Symbol: see text]+/-[Symbol: see text]4.66[Symbol: see text]mmHg; p[Symbol: see text]<[Symbol: see text]0.0001 for both comparisons). The bias between the IAP(midax) and IAP(pubis) was 3.8[Symbol: see text]mmHg (95%[Symbol: see text]CI 3.5-4.1) and 2.3[Symbol: see text]mmHg (95%[Symbol: see text]CI 1.9-2.6) between the IAP(midax) and the IAP(phlebostatic). The precision was 3.03 and 3.40, respectively. CONCLUSIONS: In the supine position, IAP(midax) is higher than both IAP(phlebostatic) and IAP(pubis), differences found to be clinically significant; therefore, the symphysis pubis or phlebostatic axis reference lines are not interchangeable with the midaxillary level.

De Wolf, A., J. Poelaert, et al. (2008). "Surgical decompression for abdominal compartment syndrome after emergency cardiac surgery." Ann Thorac Surg 85(6): 2133-5.

               Abdominal compartment syndrome typically occurs in patients after abdominal surgical procedures or trauma. Abdominal compartment syndrome is also increasingly described in conditions not related to abdominal operations, such as fluid resuscitation or burns. We report two patients who required surgical abdominal decompression for abdominal compartment syndrome that developed early after emergency coronary artery bypass graft surgery. No intraabdominal abnormalities were found at operation. Both patients had a protracted clinical course, but they survived and were discharged from the hospital.

Deenichin, G. P. (2008). "Abdominal compartment syndrome." Surg Today 38(1): 5-19.

               Compartment syndrome is a pathophysiological term, comprising a variety of tissues and organ alterations, due to a higher than normal pressure in an anatomically detached space (compartment). In the human body, areas denoted as compartments include the orbital globe, the sub and epidural space, the abdomen, pleura, pericardium, and others. Compartment syndrome was described initially in limbs. Abdominal compartment syndrome is defined as an intra-abdominal pressure above 20 mmHg with evidence of organ failure. Abdominal compartment syndrome develops when the intra-abdominal pressure rapidly reaches certain pathological values, within several hours (intra-abdominal hypertension is observed), and lasts for 6 or more hours. The key to recognizing abdominal compartment syndrome is the demonstration of elevated intra-abdominal pressure which is performed most often via the urinary bladder, and it is considered to be the "gold standard." Multiorgan failure includes damage to the cardiac, pulmonary, renal, neurological, gastrointestinal, abdominal wall, and ophthalmic systems. The gut is the most sensitive to intra-abdominal hypertension, and it develops evidence of end-organ damage before alterations are observed in other systems. The surgical decompression of the abdomen remains the treatment of choice of abdominal compartment syndrome; this usually improves the organ changes, and is followed by one of the temporary abdominal closure techniques in order to prevent secondary intra-abdominal hypertension.

Deenichin, G. P., R. S. Dimov, et al. (2008). "Acute perforated diverticulitis of the colon as a rare cause for development of abdominal compartment syndrome." Folia Med (Plovdiv) 50(2): 32-6.

               AIM: The aim of the present retrospective study was to assess the surgical approaches to acute perforated diverticulitis of the colon causing peritonitis and in some cases complicated with abdominal compartment syndrome (ACS). PATIENTS AND METHODS: A total of eight patients (6 males and 2 females) have been operated on for 5 years for perforated diverticulum of the colon. The males had a mean age of 72 +/- 2.6 years and the females--69 +/- 3.1 years. Case history records of the patients were studied retrospectively to evaluate the effectiveness of different surgical approaches used in patients with such disorders. The females had perforation of cecal diverticulum, five of the males had perforated diverticulum of the sigmoid colon and one had perforation of diverticulum of the descending colon. The diagnosis in all patients was made intraoperatively and only in two cases was it assumed prior to operation. In the female patient with cecal pathology right-sided hemicolectomy with primary anastomosis was performed. In the other six patients Hartmann's procedure was applied with a subsequent second-stage intervention to restore the intestinal continuity. RESULTS: Total feculent peritonitis was found in four of the patients with perforated diverticulum of the sigmoid colon, with signs of multiorgan failure, intra-abdominal hypertension (IAH >25 cm H2O level) and developed ACS. Despite the severity of the condition there was no lethal outcome. Two patients developed incisional hernia on the anterior abdominal wall. CONCLUSION: Based on the retrospective clinical analysis the authors conclude that primary hemicolectomy with one-stage anastomosis is the best procedure in patients in good condition and early stage on Hinchey classification. Total feculent peritonitis, associated with stage IV on Hinchey classification and signs of ACS requires Hartmann's procedure, following the principles of damage control surgery with obligatory use of temporary abdominal closure technique to control the syndrome and prevent a secondary one in the postoperative period. The indirect intravesical method of verification of IAH and ACS (the golden standard) is sufficiently precise for the clinical practice.

Drekonja, D. M., M. A. Kuskowski, et al. (2008). "Antimicrobial urinary catheters: a systematic review." Expert Rev Med Devices 5(4): 495-506.

               Catheter-associated urinary tract infection (CAUTI) is a common occurrence, often clinically unapparent and with a benign course. However, in a small fraction of patients catheter-associated bacteriuria/funguria (CABF) produces overt clinical manifestations and adverse consequences, including (at the extreme end of the spectrum) urosepsis and death. Antimicrobial-coated catheters have been proposed as a method to prevent CAUTI and are in use worldwide, although their clinical efficacy is not well known. Randomized and quasi-randomized clinical trials have demonstrated that antimicrobial-coated catheters do decrease the incidence of CABF; however, evidence that such devices provide clinically meaningful benefit is lacking. Moreover, uncertainty exists as to which of the currently marketed catheters is most effective against CABF, since no published trial has directly compared different antimicrobial-coated catheters. We conducted a systematic review to summarize and evaluate existing evidence, and to address areas of uncertainty. We found consistent but variable evidence that antimicrobial-coated catheters prevent CABF during short-term catheterization; however, no study demonstrated a clinical benefit. Future efforts in this field should include randomized trials with clinically relevant end points, as well as research to develop improved mechanisms for bladder drainage, preferably without the risks and discomfort currently associated with urinary catheters.

Ejike, J. C., K. Bahjri, et al. (2008). "What is the normal intra-abdominal pressure in critically ill children and how should we measure it?" Crit Care Med 36(7): 2157-62.

               INTRODUCTION: The intravesical method has been validated and is considered the gold standard for indirect intra-abdominal pressure (IAP) measurements. In adults, a standard volume (25 mL) is instilled into the bladder to measure IAP. However, the optimal volume for accurate IAP measurements in children has not been well studied and using inappropriate volumes could give erroneous IAP readings. OBJECTIVE: To determine the normal IAP in critically ill children and the optimal volume for IAP measurement by the intravesical method in this population. DESIGN: Prospective observational study. SETTING: Tertiary pediatric intensive care unit. PATIENTS: Ninety-six mechanically ventilated children younger than 18 yrs of age with no clinical evidence of intra-abdominal hypertension. MEASUREMENTS AND RESULTS: Graduated volumes of normal saline in increments of 3-50 mL were instilled in the bladder via a urethral catheter. IAP was recorded by using the AbViser device (WolfeTory Medical, Inc., Salt Lake City, UT) with each instillation. A pressure-volume curve was generated for every patient, and the minimum and mean optimal volumes were determined from this curve. Data were analyzed by stratification of patients according to weights 0-10 kg, >10-20 kg, and >20-50 kg. Descriptive statistics was used for statistical analysis. Normal IAP for critically ill children was 7 +/- 3 and was similar in the different weight groups (p = .745). Although the mean optimal volume to measure accurate IAP was variable in the different weight groups, the minimum optimal volume was 3 mL irrespective of weight. CONCLUSIONS: Mean IAP in critically ill children is 7 +/- 3 mm Hg. The minimum optimal volume needed to accurately measure IAP by the intravesical method in children is 3 mL. We recommend that 3 mL be the standard instillation volume for IAP measurement by the intravesical method in children. IAP >10 mm Hg should be considered elevated in children.

Ennis, J. L., K. K. Chung, et al. (2008). "Joint Theater Trauma System implementation of burn resuscitation guidelines improves outcomes in severely burned military casualties." J Trauma 64(2 Suppl): S146-51; discussion S151-2.

               BACKGROUND: Between March 2003 and June 2007, our burn center received 594 casualties from the conflicts in Iraq and Afghanistan. Ongoing acute burn resuscitation as severely burned casualties are evacuated over continents is very challenging. To help standardize care, burn resuscitation guidelines (BRG) were devised along with a burn flow sheet (BFS) and disseminated via the new operational Joint Theater Trauma System to assist deployed providers. METHODS: After the BRG was implemented in January 2006, BRF data were prospectively collected in consecutive military casualties with >30% total body surface area (TBSA) burns (BRG Group). Baseline demographic data and fluid requirements for the first 24 hours of the burn resuscitation were collected from the BFS. Percentage full thickness TBSA burns, presence of inhalation injury, injury severity score, resuscitation-related abdominal compartment syndrome, and mortality were collected from our database. Individual charts were reviewed to determine the presence of extremity fasciotomies and myonecrosis. These results were compared with consecutive military casualties admitted during the 2-year- period before the system-wide implementation of the BRG (control group). RESULTS: One hundred eighteen military casualties with burns >30% TBSA were admitted between January 2003 and June 2007, with n = 56 in the BRG group and n = 62 in the control group. The groups were different in age, but similar in %TBSA, %full thickness, presence of inhalation injury, and injury severity score. There was no difference in the rate of extremity fasciotomies or the incidence of myonecrosis between groups. CONCLUSIONS: The composite endpoint of abdominal compartment syndrome and mortality was significantly lower in the BRG group compared with the control group (p = 0.03). Implementation of the BRG and system-wide standardization of burn resuscitation improved outcomes in severely burned patients. Utilization of the joint theater trauma system to implement system-wide guidelines is effective and can help improve outcomes.

Fontana, I., M. Bertocchi, et al. (2008). "Renal transplant compartment syndrome: a case report." Transplant Proc 40(6): 2065-6.

               An unusual case of early double kidney transplant dysfunction due to abdominal compartment syndrome is herein reported. A 62-year-old woman on peritoneal dialysis underwent dual kidney transplantation. The grafts were positioned extraperitoneally in both iliac possae using standard techniques. Surgical procedures and immediate postoperative period were uneventful. The urine output was immediate and the creatinine decreased, but in a few days she developed severe ascites with reduced urine output, increased creatinine, and progressive changes on Doppler ultrasound. The patient underwent paracentesis: the kidney function recovered as well as the Doppler ultrasound. Kidney biopsy was negative for rejection or renal pathology. Graft dysfunction was related to the presence of ascites. A catheter inserted in the abdomen measured intra-abdominal pressure (IAP) of 14 mm Hg. IAP correlated with renal function showing that IAP probably explained renal flow modifications.

Gelabert Payes, L. and D. Vicente Pastor (2008). "[How to measure intra-abdominal pressure, the bladder pressure method]." Rev Enferm 31(10): 34-8.

               Abdominal pressure, abdominal hypertension and abdominal compartment syndrome are not synonyms but well-differentiated entities which have been studied over the last century in patients who have medical or surgical problems and in those who have undergone laparotomies to control abdominal damage. There are numerous bibliographical references and studies which have been carried out in this field by medical personnel to provide evidence of a tight relationship among abdominal hypertension and secondary physio-pathological alterations related to abdominal hypertension; therefore, it is important to monitor patients which will help to prevent abdominal compartment syndrome. The indirect intra-abdominal pressure measurement technique based on bladder pressure measurement is a useful procedure which nursing personnel administer and can even be practiced in doctors' offices. This technique is easy, well-known in surgical emergency wards and in reanimation wards; it is minimally invasive, has few side effects and its results can benefit patients; at present time, it is the preferred method to determine intra-abdominal pressure. The authors describe this technique, the materials necessary to administer it, and some of the aforementioned concepts to provide knowledge about abdominal compartment syndrome. Prevention, diagnosis and early measurement of bladder pressure and a timely decompression are the keys to decrease the death rate in patients affected by this syndrome.

Germanos, S., S. Gourgiotis, et al. (2008). "Damage control surgery in the abdomen: an approach for the management of severe injured patients." Int J Surg 6(3): 246-52.

               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.

Giuliani, A., L. Basso, et al. (2008). "Bilateral ovarian mucinous cystadenoma in an adolescent presenting as abdominal compartment syndrome." Eur J Obstet Gynecol Reprod Biol 140(2): 278-9.

Grevious, M. A., R. Iqbal, et al. (2008). "Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients." Pediatr Transplant.

               Primary closure of the abdominal wall after combined liver and intestine transplantation from a living donor into a pediatric patient is usually not possible, because of the size of the donor organ, graft edema, and preexisting scars or stomas of the abdominal wall. Closure under tension may lead to abdominal compartment syndrome with vascular compromise and necrosis of the transplanted organ. We describe our experience of abdominal wound closure after liver and intestinal transplant in the pediatric patient using a staged approach. From February 2003 to June 2006, we managed five pediatric liver and intestinal living donor transplant recipients. Because of the large post-transplantation abdominal wall defect, a staged technique of abdominal wound closure was utilized. Initially, an absorbable Polygalactin mesh was sutured around the layer of the defect. As soon as adequate granulation tissue was formed over the mesh a STSG was applied. From the wound stand point all five patients were managed successfully with staged wound closure after transplantation. Granulation tissue filled and covered the mesh within 7.6 wk. A STSG was then used to cover the defect. All infants recovered well and none had a significant wound complication in the immediate post-operative period following STSG. At a mean follow-up of 24 months only one patient developed an entero-cutaneous fistula five months post-transplant. Staged abdominal wall coverage with the use of Polygalactin mesh followed by STSG is a simple and effective technique. A closed wound is achieved in a timely fashion with protection of the viscera. Residual ventral hernia will need to be managed in the future with one of several reconstructive techniques.

Gruenewald, M., J. Renner, et al. (2008). "Reliability of continuous cardiac output measurement during intra-abdominal hypertension relies on repeated calibrations: an experimental animal study." Crit Care 12(5): R132.

               ABSTRACT: INTRODUCTION: Monitoring cardiac output (CO) may allow early detection of haemodynamic instability aiming to reduce morbidity and mortality in critically ill patients. Continuous cardiac output (CCO) monitoring is recommended in septic or postoperative patients with high incidences of intra-abdominal hypertension (IAH). The aim of the present study was to compare the agreement between three CCO methods and bolus thermodilution CO technique during acute IAH and volume loading. METHODS: Ten pigs were anaesthetised and instrumented for haemodynamic measurements. Cardiac output was obtained by (I) PulseCO - pulse wave analysis (LIDCO monitor), (II) PCCO - pulse contour analysis (PiCCO monitor), (III) CCOPAC - continuous pulmonary artery thermodilution and compared to COTCP - bolus trans-cardiopulmonary thermodilution at baseline (BL), after fluid loading (FL), at IAH and after an additional FL at IAH. Whereas PulseCO was only calibrated at BL, PCCO was calibrated at each experimental step. RESULTS: PulseCO and PCCO underestimated CO as overall bias +/- SD was 1.0 +/- 1.5 l/min and 1.0 +/- 1.1 l/min compared to COTCP. A clinical accepted agreement between all CCO methods and COTCP was observed only at BL. Whereas IAH did not influence CO, increased CO following FL at IAH was only reflected by CCOPAC and COTCP, not by uncalibrated PulseCO and PCCO. After recalibration, PCCO was comparable with COTCP. CONCLUSIONS: Cardiac output obtained by uncalibrated PulseCO and PCCO failed to agree with COTCP during intra-abdominal hypertension and fluid loading. In the critically ill patient, recalibration of continuous arterial waveform CO methods should be performed after fluid loading or before a major change in therapy is initiated.

Gutarra, F., J. R. Asensio, et al. (2008). "Closure of a contained open abdomen using a bipedicled myofascial oblique rectus abdominis flap technique." J Plast Reconstr Aesthet Surg.

               A contained open abdomen is commonly used during damage control laparotomy and consists of the temporary coverage of the abdomen for protection of the viscera and reduction of intra-abdominal pressure. Definitive closure of a contained open abdomen is technically difficult due to the inability to obtain primary fascial suture. The insertion of a prosthetic mesh can be complicated with enterocutaneous fistula, and other definitive closure techniques need several surgical procedures. We describe a low cost technique that allows definitive closure of large abdominal wall defects avoiding the risk of intestinal fistula.

Hakobyan, R. V. and G. G. Mkhoyan (2008). "Epidural analgesia decreases intraabdominal pressure in postoperative patients with primary intra-abdominal hypertension." Acta Clin Belg 63(2): 86-92.

               INTRODUCTION: Surgical decompression is a lifesaving procedure in patients with severe intraabdominal hypertension. However, it involves subsequent management of an open abdomen. Therefore, it is not recommended for moderate intra-abdominal hypertension. Our literature search did not show any studies relating the efficacy of epidural analgesia in decreasing elevated intraabdominal pressure (IAP) in critically-ill surgical patients with primary intra-abdominal hypertension. MATERIAL AND METHODS: Through a blinded prospective study, we investigated postoperative critically-ill surgical and trauma patients with primary intra-abdominal hypertension, who received postoperative thoracic epidural analgesia (n = 58) or intravenous opioid analgesia (n = 130). Patients in the epidural group received ropivacaine 0.2% 10 ml, followed by an infusion of 5 ml/h for 96 hours. Patients in the opioid group could receive morphine hydrochloride (0.1 mg/kg IV for every 4-6 hours as needed) with or without ketorolac trometamol (up to 90 mg/day IV). IAP was measured transvesically, for every 6 hours. Additionally, measurements immediately before and 1 hour after the initiation of epidural analgesia were taken. Abdominal Perfusion Pressure (APP) was calculated for each IAP measurement as APP = MAP - IAP where MAP is the mean arterial pressure. RESULTS: In the epidural group we found a consistent decrease in IAP from 16.82 +/- 4.56 to 6.30 +/- 3.11 mmHg and an increase in APP from 60.26 +/- 21.893 to 76.10 +/- 17.54 mmHg between baseline values until the second day of epidural analgesia, which remained stable afterwards. There were no significant differences of IAP and APP in the opioid group. CoNCLUSION: Continuous thoracic epidural analgesia decreases IAP and improves APP without haemodynamic compromise in postoperative critically-ill patients with primary intra-abdominal hypertension.

Harrisson, S. E., J. E. Smith, et al. (2008). "Abdominal compartment syndrome: an emergency department perspective." Emerg Med J 25(3): 128-32.

               Compartment syndromes can occur in many body regions. Abdominal compartment syndrome, initially described many years ago, has become increasingly recognised in critical care patients. The key points regarding its definition, pathophysiology, aetiology and treatment are described and discussed. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of organ dysfunction. At risk patients should be identified in the emergency department and early monitoring of intra-abdominal pressure instituted. Interventions in the emergency department potentially contribute to the development of abdominal compartment syndrome during subsequent phases of care. The need to ensure an early multidisciplinary approach in the management of this complex condition is essential for the best possible patient outcome.

Hedenstierna, G. and M. Lattuada (2008). "Lymphatics and lymph in acute lung injury." Curr Opin Crit Care 14(1): 31-6.

               PURPOSE OF REVIEW: Lymph flow will be discussed as part of the drainage and fluid balance of lung tissue and abdomen as well as a qualitative analysis of inflammatory processes. RECENT FINDINGS: Measurement of lung lymph is still a technical challenge. Mechanical ventilation and positive end-expiratory pressure impede lung lymph flow by increased intrathoracic pressure and increased central venous pressure. Positive end-expiratory pressure may thus enhance edema formation of the lung. Inflammatory spread from abdomen to the lung via the lymphatic system has been shown in a number of experimental studies. Ligation or diversion of the thoracic duct has been proposed to blunt the effects of noxious stimuli mediated by lymphatics to the lungs. Lymphatics have a major role on abdominal fluid balance while draining extravascular fluid accumulation and edema, especially during sepsis. Mechanical ventilation with high airway pressure increases abdominal edema (ascites) and spontaneous breathing protects from edema formation. SUMMARY: Lymph flow measurements are still a difficult task to perform; however, new results show an important function in the fluid balance of the lung and abdomen. Inflammatory spread may occur from the lung to the periphery by the blood stream and from the abdomen to the lung by lymph flow.

Hongyan, L., E. L. Daugherty, et al. (2008). "Recognition and importance of forced exhalation on the measurement of intraabdominal pressure: a subgroup analysis from a prospective cohort study on the incidence of abdominal compartment syndrome in medical patients." J Intensive Care Med 23(4): 268-74.

               Intraabdominal pressure is measured conventionally at end-expiration; however, the significance of forced exhalation on this measurement has not been evaluated previously. Using data from a previous prospective cohort study of the incidence of intraabdominal hypertension and abdominal compartment syndrome in medical intensive care unit patients, the authors evaluated 65 strip-chart recordings obtained from 28 patients who had measurements of intraabdominal pressure and airway pressures taken simultaneously. Forced exhalation was identified by a rise in intraabdominal pressure during exhalation. Forced exhalation was observed in 4 patients; with a mean intraabdominal pressure increase of 14.3 +/- 1.3 mm Hg at end-exhalation, compared with a decrease of -2.5 +/- 1.2 mm Hg in 24 patients without forced exhalation and absolute pressures of 28.0 +/- 6.6 versus 13.8 +/- 3.9 mm Hg (P < .001). However, there was no difference in end-inspiratory values. Forced exhalation is not uncommon in acutely ill, mechanically ventilated medical intensive care unit patients and may increase intraabdominal pressure significantly to values that exceed the diagnostic threshold for abdominal compartment syndrome.

Hunter, J. D. (2008). "Abdominal compartment syndrome: an under-diagnosed contributory factor to morbidity and mortality in the critically ill." Postgrad Med J 84(992): 293-8.

               As the abdomen is a closed cavity, it follows that any increase in abdominal contents will inexorably lead to a rise in the intra-abdominal pressure. Normally this is less than 7 mm Hg, but when it persistently exceeds 12 mm Hg, renal, intestinal, pulmonary, cardiovascular and central nervous system dysfunction arises. A wide range of conditions encountered in both medical and surgical intensive care units are associated with a rise in intra-abdominal pressure. When this pressure is continually above 20 mm Hg, organ system failure can occur, a condition known as abdominal compartment syndrome. Failure to recognise and treat this syndrome is associated with a high morbidity and mortality.

Jonsson, M., S. Linder, et al. (2008). "[Life-saving decompression in abdominal compartment syndrome and severe acute pancreatitis]." Lakartidningen 105(40): 2770-1.

Karakoulas, K., V. Grosomanidis, et al. (2008). "The effect of intra-abdominal hypertension alone or combined intra-abdominal hypertension-endotoxemia in cerebral oxygenation in a porcine model." Hippokratia 12(4): 225-9.

               Background: Abdominal compartment syndrome (ACS) has been recognized as an entity, affecting cardiovascular, pulmonary, and cerebral function, while it is often complicated with sepsis. Goal of the study was the evaluation of brain oxygenation during ACS alone and in combination with endotoxinemia.Materials and Methods: Sixteen pigs, undergone intra-abdominal hypertension, were allocated to receive intravenous administration of either saline or endotoxin. Pigs were evaluated regarding brain tissue oxygenation (PbrO(2)), systemic oxygenation (PaO(2)) and regional cerebral blood flow (rCBF).Results: Statistical analysis revealed significant reduction of PbrO(2) over time for sepsis group, after endotoxin administration. Regarding differences between groups, sepsis group experienced lower PbrO(2) values, compared to saline group, only after endotoxin administration.. Both groups experienced reduction in arterial oxygenation, with greater pertubations seen after sepsis induction. Regarding rCBF, septic pigs showed greater flow values, while ACS alone did not influence rCBF. ACS has no deleterious effects in cerebral oxygenation and flow, provided systemic oxygenation and CPP are maintained above normal value.Conclusions: Combined sepsis-ACS lead to perturbations in cerebral oxygenation, in conjunction with greater rCBF values. The latter could be ascribed to abnormalities in oxygen extraction.

Keramati, M., A. Srivastava, et al. (2008). "The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn." Burns 34(4): 493-7.

               BACKGROUND: Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem. METHODS: From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound. RESULTS: Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up. CONCLUSION: In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.

Khadaroo, R. G. and J. C. Marshall (2008). "Gastrointestinal dysfunction in the critically ill: can we measure it?" Crit Care 12(5): 180.

               ABSTRACT: Gastrointestinal dysfunction is an intuitively important, yet descriptively elusive component of the multiple organ dysfunction syndrome. Reintam and colleagues have attempted to quantify this dimension using a combination of intolerance of enteral feeding, and the development of intra-abdominal hypertension. While they show that both parameters are associated with an increased risk of death (and therefore that, in combination, the risk of death is even greater), they fall short in developing a novel descriptor of gastrointestinal dysfunction. Nonetheless, and even with its shortcomings, their effort is a welcome contribution to the surprisingly complex process of describing the morbidity of critical illness.

Kula, R., P. Szturz, et al. (2008). "Negative fluid balance in patients with abdominal compartment syndrome--case reports." Acta Chir Belg 108(3): 346-9.

               Abdominal compartment syndrome (ACS) is defined as a sustained increase of intra-abdominal pressure (IAP) above 20 mmHg followed by the development of organ dysfunction. Treatment of ACS is still a question to be discussed and surgical decompression is usually preferred. According to recent data, massive crystalloid resuscitation of shock plays a key role in the development of secondary ACS in trauma patients. As mentioned previously, a high volume of infused crystalloids and a positive fluid balance were associated with ACS development in trauma patients as well as in septic patients. Moreover, we observed that a treatment strategy based on the achievement of a negative fluid balance resulted in a dramatic decrease in IAP and an improvement in haemodynamics and ventilation. This approach has been indicated as an interesting option for non-surgical treatment, with a caution that such intervention may exacerbate gut hypoperfusion. In this report we present two patients with secondary ACS development following abdominal surgery in which the achievement of a negative fluid balance showed a similar effect. Moreover, the fluid removal procedure also seemed to be associated with an improvement in splanchnic perfusion, as measured by gastric tonometry.

Lam, M. C., P. T. Yang, et al. (2008). "Abdominal compartment syndrome complicating paediatric extracorporeal life support: diagnostic and therapeutic challenges." Anaesth Intensive Care 36(5): 726-31.

               We report three paediatric cases, and summarise the reported experience in two others, with cardiorespiratory failure requiring extracorporeal life support for which supportive pump flows could not be maintained due to abdominal compartment syndrome. In two of our patients, the mechanism of abdominal compartment syndrome was massive intra-abdominal fluid extravasation secondary to sepsis, while in the third, the mechanism was post-traumatic intra-abdominal haemorrhage. Although all three children eventually died, decompressive laparotomy and arrest of haemorrhage in the trauma patient restored venous return and enabled technically adequate extracorporeal life support. In two previously reported cases of sepsis with massive fluid resuscitation resulting in abdominal compartment syndrome, one patient died without attempted decompression, while the other patient survived after peritoneal catheter placement restored venous return. Once correctable causes of inadequate venous cannula drainage have been excluded, abdominal compartment syndrome should be considered in any patient on extracorporeal life support with a taut abdomen and reduced venous return. If abdominal compartment syndrome can be proven or is strongly suspected, there may be a role for selective decompressive laparotomy.

Lerner, S. M. (2008). "Review article: the abdominal compartment syndrome." Aliment Pharmacol Ther 28(4): 377-84.

               BACKGROUND: The term abdominal compartment syndrome refers to hypoperfusion and ischaemia of intra-abdominal viscera and structures caused by raised intra-abdominal pressure. It occurs most commonly following major trauma and complex surgical procedures, but can also occur in their absence. Definitive treatment is decompression at laparotomy. Prevention and recognition of abdominal compartment syndrome are crucial to avoid additional morbidity and mortality. Postinjury abdominal compartment syndrome continues to complicate current resuscitation methods and new strategies for resuscitating critically ill patients need to be explored in addition to more accurate monitoring of intra-abdominal pressure. AIM: To examine the published literature regarding the pathogenesis, diagnosis and management of the abdominal compartment syndrome. METHODS: A comprehensive review of the literature was undertaken. RESULTS: This syndrome is an important complication of major trauma and surgery as well as being recognized in critically-ill medical patients. It requires prompt recognition with a view to decompression at laparotomy. CONCLUSIONS: The abdominal compartment syndrome is an important complication of trauma, surgery and resuscitation. Key to its management are its prompt recognition and abdominal decompression.

Lingegowda, V., A. A. Ejaz, et al. (2008). "Normotensive ischemic acute kidney injury as a manifestation of intra-abdominal hypertension." Int Urol Nephrol.

               Intra-abdominal hypertension (IAH), leading to abdominal compartment syndrome (ACS), is a frequent cause of acute kidney injury (AKI) in surgical and trauma intensive care units not commonly recognized by nephrologists. Multiple organ systems are often affected and frequently culminate in disastrous outcomes. The diagnosis of AKI as a manifestation of IAH requires a high index of clinical suspicion, especially, because laboratory and imaging studies are unreliable. Early recognition and treatment of the condition is associated with good clinical outcome. We report a typical case of normotensive ischemic AKI as a manifestation of IAH following abdominal surgery.

Liotier, J., M. Barbier, et al. (2008). "A rare cause of abdominal compartment syndrome: acute trichlorethylene overdose." Clin Toxicol (Phila) 46(9): 905-7.

               INTRODUCTION: The clinical signs of acute trichlorethylene overdose are commonly coma, cardiac conduction disturbances, diarrhea, and vomiting. We report a case of intentional massive trichlorethylene ingestion inducing a fatal abdominal compartment syndrome (ACS). CASE REPORT: A 47-year-old woman was admitted to the emergency department after intentionally ingesting 500 mL of trichlorethylene and benzodiazepines. She rapidly developed coma and abdominal distension leading to multiple organ failure. Subsequent surgical evaluation revealed abdominal perforation and necrosis, and life-sustaining treatments were therefore withdrawn. DISCUSSION: This is a primary ACS that can be explained from experimental data on the pathophysiology of pneumatosis cystoides coli. For this case, we discuss multiple etiological factors for intra-abdominal hypertension (IAP), such as paralytic ileus and massive fluid resuscitation due to the direct toxicity of ingested trichlorethylene. CONCLUSION: Patients ingesting trichlorethylene need to be closely evaluated for risk of digestive damage and perforation. Early prompt laparotomy must be performed in cases of ACS.

Liu, Y., D. F. Wang, et al. (2008). "[Monitoring of intra-abdominal pressure in management of abdominal compartment syndrome complicating severe acute pancreatitis.]." Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 20(9): 574.

Lo, E., L. Nicolle, et al. (2008). "Strategies to prevent catheter-associated urinary tract infections in acute care hospitals." Infect Control Hosp Epidemiol 29 Suppl 1: S41-50.

Lynn, J. J., Y. M. Weng, et al. (2008). "Perforated peptic ulcer associated with abdominal compartment syndrome." Am J Emerg Med 26(9): 1071 e3-5.

               Abdominal compartment syndrome (ACS) is defined as an increased intra-abdominal pressure with adverse physiologic consequences. Abdominal compartment syndrome caused by perforated peptic ulcer is rare owing to early diagnosis and management. Delayed recognition of perforated peptic ulcer with pneumoperitoneum, bowel distension, and decreased abdominal wall compliance can make up a vicious circle and lead to ACS. We report a case of perforated peptic ulcer associated with ACS. A 74-year-old man with old stroke and dementia history was found to have distended abdomen, edema of bilateral legs, and cyanosis. Laboratory tests revealed deterioration of liver and kidney function. Abdominal compartment syndrome was suspected, and image study was arranged to find the cause. The study showed pneumoperitoneum, contrast stasis in heart with decreased caliber of vessels below the abdominal aortic level, and diffuse lymphedema at the abdominal walls. Emergent laparotomy was performed. Perforated peptic ulcer was noted and the gastrorrhaphy was done. The symptoms, and liver and kidney function improved right after emergent operation.

Madigan, M. C., C. D. Kemp, et al. (2008). "Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame?" J Trauma 64(2): 280-5.

               INTRODUCTION: Secondary abdominal compartment syndrome (ACS) is the development of ACS in the absence of abdominal injury. The development of secondary ACS has been viewed by some authors as an unavoidable sequela of the aggressive crystalloid resuscitation often employed in the treatment of severe shock. We hypothesized that poor resuscitation techniques, including early and excessive crystalloid administration, places patients with extremity injuries at risk for developing secondary ACS. METHODS: The Trauma Registry of the American College of Surgeons database was queried for all patients with an extremity Abbreviated Injury Scale (AIS) score of 3 or greater and abdominal AIS score of 0 treated at our institution between January 1, 2001 and December 31, 2005. The study group included those patients who developed secondary ACS, whereas the comparison cohort included those who did not develop secondary ACS. RESULTS: Forty-eight patients developed secondary ACS and were compared with 48 randomly selected patients who had an extremity AIS score of 3 or greater and an abdomen AIS score of 0. There were no differences between the groups with respect to age, sex, race, or individual AIS scores. However, the secondary ACS group had a slightly higher Injury Severity Score (25.6 vs. 21.4, p = 0.02), significantly higher operating room crystalloid administration (9.9 L vs. 2.7 L, p < 0.001), and more frequent use of a rapid infuser (12.5% vs. 0.0%, p = 0.01). Multiple logistic regression identified prehospital and emergency department crystalloid as predictors of secondary ACS. CONCLUSIONS: Aggressive resuscitation techniques, often begun in the prehospital setting, appear to increase the likelihood of patients with severe extremity injuries developing secondary ACS. Early, large volume crystalloid administration was the greatest predictor of secondary ACS.

Maerz, L. and L. J. Kaplan (2008). "Abdominal compartment syndrome." Crit Care Med 36(4 Suppl): S212-5.

               Acute renal failure frequently occurs in the intensive care unit as a primary or secondary event in association with trauma, surgery, or comorbid medical disease. An increasingly common thread linking surgical and medical disease management is the abdominal compartment syndrome. In particular, the rise of early goal-directed therapy for the initial resuscitation and management of severe sepsis and septic shock is associated with an increased frequency of secondary abdominal compartment syndrome. This paper will explore the pathophysiology underpinning the abdominal compartment syndrome and its contribution to acute kidney injury and acute renal failure with regard to intra-abdominal pressure dynamics, preload limitation, and afterload augmentation. Diagnostic modalities and therapeutic interventions will be addressed as a means of reducing the frequency of acute kidney injury and acute renal failure in the critically ill.

Mahajna, A., S. Mitkal, et al. (2008). "Postoperative gastric dilatation causing abdominal compartment syndrome." World J Emerg Surg 3: 7.

               ABSTRACT: OBJECTIVE: To study the effect of postoperative gastric dilatation on intra-abdominal pressure (IAP). DESIGN AND SETTING: Single case report from a primary teaching hospital. PATIENTS AND METHODS: A 72-year-old woman demonstrated a sudden respiratory and cardiovascular collapse following resection of a retroperitoneal sarcoma. This collapse was caused by abdominal compartment syndrome due to gastric dilatation. RESULTS: The patient was re-explored, an enormously distended stomach was found with the nasogastric tube situated in a small sliding hernia which prevented drainage of the distended stomach. Re-positioning of the nasogastric tube, allowed the decompression of the stomach and the patient's condition immediately improved. CONCLUSION: Acute abdominal distention following major abdominal surgery may result from acute gastric dilatation, leading to oliguria and increased airway pressures. Untreated gastric dilatation can cause abdominal compartment syndrome.

Malbrain, M. L. and I. De Laet (2008). "Epidemiology on intra-abdominal hypertension: an urgent call for multicenter trials." Crit Care Med 36(6): 1972-4.

Malbrain, M. L. and I. De Laet (2008). "Functional haemodynamics during intra-abdominal hypertension: what to use and what not use." Acta Anaesthesiol Scand 52(4): 576-7.

Malbrain, M. L., I. De Laet, et al. (2008). "Non-invasive treatment of intraabdominal hypertension: the search for the Holy Grail continues." Acta Clin Belg 63(2): 63-6.

Malbrain, M. L., I. De Laet, et al. (2008). "Continuous intra-abdominal pressure monitoring: this is the way to go!" Int J Clin Pract 62(3): 359-62.

Malbrain, M. L., I. De laet, et al. (2008). "In vitro validation of a novel method for continuous intra-abdominal pressure monitoring." Intensive Care Med 34(4): 740-5.

               OBJECTIVE: Intra-abdominal pressure (IAP) measurement is important in daily clinical practice. Most measurement techniques vary in automaticity and reproducibility. This study tested a new fully automated continuous technique for IAP measurement, the CiMON. METHODS: Three IAP measurement catheters (a Foley manometer and two balloon-tipped catheters) contained in a 50-ml infusion bag were placed on the bottom of a half open 3-l container. To simulate IAH the container was filled with water using 5 cmH2O increments (0-30 cmH2O). Pressure was estimated by observers using the Foley manometer (IAP(FM)) and simultaneously recorded using two IAP monitors: IAP(spie) with Spiegelberg and IAP(CiM) with CiMON. Observers were blinded to the reference levels. Fifteen observers (three intensivists, four residents, two medical students, and six nurses) conducted three pressure readings at each of the seven pressure levels with the FM technique, giving 315 readings. These were paired with the automated IAP(spie) and IAP(CiM) readings and the height of the H2O column. RESULTS: The intra- and interobserver coefficients of variation (COVA) were low for all methods. There was no difference in the results between specialists, physicians in training, andnurses. Spearman's correlation coefficient (R2) values for all paired measurements were greater than 0.9, and Bland-Altman analysis comparing the reference H2O column, IAP(FM), and IAP(spie) to IAP(CiM) showed a very good agreement at all pressure levels (bias -0.1+/-0.6 cmH2O, 95%CI -0.2 to 0). There was a consistent, low underestimation of the reference H2O pressure by the Spiegelberg technique and a low overestimation at pressures below 20 cmH2O by both other techniques. CONCLUSIONS: All three measurement techniques, IAP(FM), IAP(spie), and IAP(CiM) have good agreement with the applied hydrostatic pressure in this in vitro model of IAP measurement.

Malbrain, M. L., W. Vidts, et al. (2008). "Acute intestinal distress syndrome: the importance of intra-abdominal pressure." Minerva Anestesiol.

Malhotra, A. and D. Hillman (2008). "Obesity and the lung: 3. Obesity, respiration and intensive care." Thorax 63(10): 925-31.

               Obesity is a major problem from a public health perspective and a difficult practical matter for intensivists. The obesity pandemic has required treating clinicians to develop an appreciation of the substantial pathophysiological effects of obesity on the various organ systems. The important physiological concepts are illustrated by focusing on obstructive sleep apnoea, obesity hypoventilation syndrome, abdominal compartment syndrome and ventilatory management of the obese patient with acute respiratory distress syndrome.

Martinez-Lage, J. F., J. M. Martos-Tello, et al. (2008). "Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update." Childs Nerv Syst 24(4): 431-5.

               BACKGROUND: Increased intra-abdominal pressure has been reported to result in raised intracranial pressure in a variety of conditions such as obesity and pregnancy, and it also constitutes an infrequent cause of ventriculoperitoneal (VP) shunt malfunction. Patients with neurological deficits, as those with myelomeningocele or cerebral palsy, are prone to developing a neurogenic bowel and to suffer chronic constipation. Although previously recognized, VP shunt failure attributed to constipation has only recently been described. We briefly review the etiopathogenesis, diagnosis and management of severe constipation leading to VP shunt malfunction. Our aim is to draw the attention of pediatric neurosurgeons towards severe constipation as a possible cause of VP shunt failure thus avoiding unnecessary surgical valve revisions, to which children with hydrocephalus are often submitted to. ILLUSTRATIVE CASES: We report two children that developed transient VP shunt failure because of intense constipation that caused exacerbation of previously shunted hydrocephalus. One of the patients constitutes the first description of this complication associated with an anteriorly placed anus and the other with intestinal paresis after ileostomy. Conservative treatment aimed at alleviating the increased intra-abdominal pressure resulted in complete resolution of the children's manifestations of VP shunt failure, without having to resort to surgical revision of the VP shunt.

McBeth, P. B., I. Zengerink, et al. (2008). "Comparison of intermittent and continuous intra-abdominal pressure monitoring using an in vitro model." Int J Clin Pract 62(3): 400-5.

               INTRODUCTION: Intra-abdominal pressure (IAP) is increasingly being considered as an important physiologic parameter to be measured in critically ill patients. Traditional methods of monitoring IAP rely on intermittent IAP (IIAP) measurements using indwelling bladder catheters. Recently, a method of continuous IAP (CIAP) monitoring has been developed using a three-way bladder catheter. This study evaluates the reliability of IIAP and CIAP measurement techniques using an in vitro model. METHODS: An in vitro model of the abdomen was constructed using a 50 l container with a 100 ml infusion bag at the base to simulate a bladder. A three-way catheter tip was centered within the infusion bag filled with 50 ml saline. To simulate IAP the container was filled with water at 5 cm H(2)O increments from 10 to 25 cm H(2)O. Pressures were recorded by observers from a bedside monitor interfaced with a three-way Foley catheter using alternating intermittent and continuous techniques. Each subject was blinded to the known pressure values. Descriptive statistics and a generalised estimating equation (GEE) was used to describe the relationship of IIAP and CIAP to known pressures. RESULTS: One hundred and thirty-two (132) observations were made by 20 subjects for both IIAP and CIAP estimates. In 45.5% of IIAP measures, the estimate was correct, and it was never more than 1 cm H(2)O different from the actual. Similarly, in 38.6% of CIAP measures, the estimate was correct, and was never more than 2 cm H(2)O from the actual. The GEE regression coefficients comparing known pressures with IIAP and CIAP were 1.007 and 0.976 respectively. The minimum and maximum pressure deviations never exceeded more than 1.3 cm H(2)O from the actual. CONCLUSION: Intermittent IAP and CIAP are both reliable and reproducible methods to measure IAP in an in vitro model. There exists a direct and significant association between both measurements and the actual value. Neither measure was shown to be superior.

Mogilner, J. G., H. Bitterman, et al. (2008). "Effect of elevated intra-abdominal pressure and hyperoxia on portal vein blood flow, hepatocyte proliferation and apoptosis in a rat model." Eur J Pediatr Surg 18(6): 380-6.

               BACKGROUND/PURPOSE: Indications for a laparoscopic approach for the management of biliary atresia in children are not clearly defined. We have recently shown that persistent intra-abdominal pressure (IAP) significantly decreased portal vein (PV) flow. Ventilation with a high concentration of oxygen after abdomen deflation raises concerns of increased oxidative stress but has also been shown to exert beneficial effects on splanchnic ischemia/reperfusion. The purpose of the present study was to evaluate the effects of IAP and hyperoxia on liver histology, hepatocyte proliferation and apoptosis in a rat model of abdominal compartment syndrome (ACS). METHODS: Male Sprague-Dawley rats were anesthetized with intraperitoneal ketamine and xylasine. After a midline laparotomy, the PV was isolated. Ultrasonic blood flow probes were placed on the vessel for continuous measurement of regional blood flow. Mean arterial blood pressure (MABP) was continuously measured. Two large-caliber percutaneous peripheral intravenous catheters were introduced into the peritoneal cavity for inflation of air and measurement of IAP. Rats were divided into three experimental groups: 1) Sham rats were subjected to IAP of 0 mmHg; 2) ACS rats were subjected to IAP of 6 mmHg for 2 hours and were ventilated with air; and 3) ACS-O (2) rats were subjected to IAP of 6 mmHg for 2 hours and were ventilated with 100 % O (2) during the operation and ventilation was continued for 6 hours after operation. Liver structural changes, hepatocyte proliferation (using BrdU assay) and apoptosis (using Tunel assay) were determined 24 hours following operation. RESULTS: IAP at 6 mmHg caused a twofold decrease in PV flow compared to sham animals. Hyperoxia resulted in a less significant decrease in PV flow compared to air-ventilated animals. Despite a significant decrease in PV blood flow, 24 hours after abdominal deflation only a few animals demonstrated histological signs of liver damage. The small histological changes were accompanied by increased hepatocyte apoptosis and enhanced hepatocyte proliferation in 25 % of animals, suggesting a liver repair response. CONCLUSIONS: Despite a significant decrease in PV blood flow, persistent IAP for 2 hours results in few changes in liver histology, and stimulates hepatocyte proliferation and apoptosis in only a few animals, supporting the presence of a recovering mechanism. Treatment with hyperoxia did not significantly change hepatocyte proliferation and apoptosis.

Mullens, W., Z. Abrahams, et al. (2008). "Prompt reduction in intra-abdominal pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated heart failure." J Card Fail 14(6): 508-14.

               BACKGROUND: Our group recently reported that elevated intra-abdominal pressure (IAP, defined as > or = 8 mm Hg) can be associated with renal dysfunction in patients with advanced decompensated heart failure (ADHF). We hypothesize that in the setting of persistently elevated IAP and progressive renal insufficiency refractory to intensive medical therapy, mechanical fluid removal can be associated with improvements in IAP and renal function. METHODS AND RESULTS: The renal and hemodynamic profiles of 9 consecutive, volume-overloaded subjects with ADHF and elevated IAP, refractory to intensive medical therapy, were prospectively collected. All subjects experienced progressive elevation of serum creatinine and IAP in response to intravenous loop diuretics. Within 12 hours after mechanical fluid removal via paracentesis (n = 5, mean volume removed 3187 +/- 1772 mL) or ultrafiltration (n = 4, mean volume removed 1800 +/- 690 mL), there was a significant reduction in IAP (from 13 +/- 4 mm Hg to 7 +/- 2 mm Hg, P = .001), with corresponding improvement in renal function (serum creatinine from 3.4 +/- 1.4 mg/dL to 2.4 +/- 1.1 mg/dL, P = .01) without significantly altering any hemodynamic measurement. CONCLUSION: In volume-overloaded patients admitted with ADHF refractory to intensive medical therapy, we observed a reduction of otherwise persistently elevated IAP with corresponding improvement in renal function after mechanical fluid removal.

Mullens, W., Z. Abrahams, et al. (2008). "Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function?" J Am Coll Cardiol 51(3): 300-6.

               OBJECTIVES: This study sought to determine whether changes in intra-abdominal pressure (IAP) with aggressive diuretic or vasodilator therapy are associated with improvement in renal function in acute decompensated heart failure (ADHF). BACKGROUND: Elevated IAP (>or=8 mm Hg) is associated with intra-abdominal organ dysfunction. There is potential for ascites and visceral edema causing elevated IAP in patients with ADHF. METHODS: Forty consecutive patients admitted to a specialized heart failure intensive care unit for management of ADHF with intensive medical therapy were studied. The IAP was measured using a simple transvesical technique at time of admission and before removal of the pulmonary artery catheter. RESULTS: In our study cohort (mean age 59 +/- 13 years, mean left ventricular ejection fraction 19 +/- 9%, baseline serum creatinine 2.0 +/- 0.9 mg/dl), the mean baseline IAP was 8 +/- 4 mm Hg, with 24 (60%) patients having elevated IAP. Elevated IAP was associated with worse renal function (p = 0.009). Intensive medical therapy resulted in improvement in both hemodynamic measurements and IAP. A strong correlation (r = 0.77, p < 0.001) was observed between reduction in IAP and improved renal function in patients with baseline elevated IAP. However, changes in IAP or renal function did not correlate with changes in any hemodynamic variable. CONCLUSIONS: Elevated IAP is prevalent in patients with ADHF and is associated with impaired renal function. In the setting of intensive medical therapy for ADHF, changes in IAP were better correlated with changes in renal function than any hemodynamic variable.

Mysliwiec, P. and B. Kedra (2008). "[Abdominal compartment syndrome--current recommendations]." Przegl Lek 65(9): 401-4.

               Abdominal compartment syndrome (ACS) occurs in critically ill patients for surgical, as well as medical reasons. It implies significant mortality. Therefore diagnostic vigilance and agressive treatment are necessary. All patients at elevated risk of ACS should have their intraabdominal pressure monitored, which is best measured in the urinary bladder. The currently adopted borderline of intra-abdominal hypertension is 12 mmHg and of ACS -20 mmHg, if it is accompanied by abdominal or thoracic organ insufficiency. The gold standard of quick and definitive treatment of ACS is surgical decompression by opening the abdomen and leaving it open until intraabdominal pressure decreases. Dressings with aspiration of abdominal fluid seem the most helpful, although prospective studies are necessary. The methods of non-operation decompression are a good alternative, when intraabdominal pressure is lower and in oncological patients.

Otto, J., D. Kaemmer, et al. (2008). "Clinical evaluation of an air-capsule technique for the direct measurement of intra-abdominal pressure after elective abdominal surgery." BMC Surg 8: 18.

               BACKGROUND: The gold standard for assessment of intraabdominal pressure (IAP) is via intravesicular pressure measurement (IVP). This accepted technique has some inherent problems, e.g. indirectness. Aim of this clinical study was to assess direct IAP measurement using an air-capsule method (ACM) regarding complications risks and agreement with IVP in patients undergoing abdominal surgery. METHODS: A prospective cohort study was performed in 30 patients undergoing elective colonic, hepatic, pancreatic and esophageal resection. For ACM a Probe 3 (Spiegelberg, Germany) was placed on the greater omentum. It was passed through the abdominal wall paralleling routine drainages. To compare ACM with IVP t-testing was performed and mean difference as well as limits of agreement were calculated. RESULTS: ACM did not lead to complications particularly with regard to organ lesion or surgical site infection. Mean insertion time of ACM was 4.4 days (min-max: 1-5 days). 168 pairwise measurements were made. Mean ACM value was 7.9 +/- 2.7 mmHg while mean IVP was 8.4 +/- 3.0 mmHg (n.s). Mean difference was 0.4 mmHg +/- 2.2 mmHg. Limits of agreement were -4.1 mmHg to 5.1 mmHg. CONCLUSION: Using ACM, direct IAP measurement is feasible and uncomplicated. Associated with relatively low pressure ranges (<17 mmHg), results are comparable to bladder pressure measurement.

Panagiotis, H., D. Panagiotis, et al. (2008). "Abdominal compartment syndrome post-late Bochdalek hernia repair: A case report." Cases J 1(1): 199.

               ABSTRACT: The aim of this case report is to discuss the rare postoperative complication of abdominal compartment syndrome in a 19-year-old Caucasian Greek male that was electively operated on for a congenital diaphragmatic hernia. The hernia was completely asymptomatic and was found in chest radiography for employment reasons. Abdominal compartment syndrome is related in most reports with trauma and abdominal operations. Timely diagnosis is key to the prevention of further organ damage and multisystem organ dysfunction because the syndrome once instituted is highly fatal.

Parsak, C. K., T. O. Acarturk, et al. (2008). "The Relationship Between Increased Intra-Abdominal Pressure and Morbid Obesity." World J Surg.

Parsak, C. K., G. Seydaoglu, et al. (2008). "Abdominal compartment syndrome: current problems and new strategies." World J Surg 32(1): 13-9.

               BACKGROUND: Abdominal compartment syndrome (ACS) is a difficult entity with two main problems during its course: (1) survival of the patient during the early period and (2) closure of the open wounds during the late period. In this study we evaluated the decision to decompress according to the level of intraabdominal pressure (IAP) and analysis of any recurrent or persistent increase in IAP. METHODS: A prospective study was undertaken on 119 patients with increased IAP. The IAP was measured daily by obtaining the bladder pressure. Patients were monitored via a central venous line; and vital signs, arterial blood gases, the Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score, and abbreviated mental tests were recorded. The suggestions of Meldrum et al. were taken as a guideline during the treatment. The sensitivity and specifity of IAP and APACHE II scores for different cutoff values were calculated using the receiver operating characteristic curve. RESULTS: Hospital mortality was 33.6%, which increased with co-morbidities (p = 0.03). A cutoff value for IAP of 23 mmHg was considered an optimal point predicting mortality. The IAP within the first 3 days for patients who died was higher than the cutoff value. For patients with IAP of 15 to 25 mmHg, nonsurgical therapy increased the rate of mortality (odds ratio 5.2, 95% confidence interval 1.0-27.7; p = 0.03). CONCLUSIONS: In patients with ACS emergency, it is recommended that decompressive laparotomy to be performed even if the IAP falls below 25 mmHg. For patients with IAP levels higher than 25 mmHg, the IAP should be meticulously brought below the cutoff level during the postoperative period.

Peng, Z. Y., L. A. Critchley, et al. (2008). "Effects of norepinephrine during intra-abdominal hypertension on renal blood flow in bacteremic dogs." Crit Care Med 36(3): 834-41.

               OBJECTIVE: Intraabdominal hypertension reduces organ blood flow. Restoring abdominal perfusion pressure (APP) may restore renal blood flow, especially when sepsis is present. The effects of intra-abdominal pressure (IAP), followed by restoration of APP with norepinephrine, on renal blood flow were determined. DESIGN: Longitudinal study with bacteremia after nonbacteremic (control) conditions. SETTING: University animal laboratory. SUBJECTS: Ten anesthetized mongrel dogs. INTERVENTIONS: IAP was raised to 10, 20, and 30 mm Hg, using intra-abdominal bags filled with saline. After each intervention, decompression was achieved by emptying the bag. Bacteremia was induced by injection of Escherichia coli. Cardiac output and renal blood flow were measured using surgically placed flow probes. Norepinephrine infusion was used to restore the mean arterial pressure to baseline at each IAP. A hypervolemic circulation was maintained throughout by infusing saline. MEASUREMENTS AND MAIN RESULTS: Induction of bacteremia resulted in significant decreases in blood pressure, cardiac output, and renal blood flow (p < .01). Serial increases in IAP decreased cardiac output and renal blood flow both in control and bacteremic dogs (p < .001). These decreases were substantially corrected by abdominal decompression. In nonbacteremic control conditions, restoring APP back to baseline with norepinephrine did not fully restore cardiac output and renal blood flow (p < .001). However, in bacteremic conditions, norepinephrine was able to substantially restore cardiac output and renal blood flow to bacteremic baseline at all levels of IAP. In bacteremic conditions, the renal perfusion fraction returned to bacteremic baseline levels after correction of APP with norepinephrine and after decompression. CONCLUSIONS: Restoration of APP using norepinephrine improves renal blood flow in bacteremic animals with IAPs up to 30 mm Hg, and maintaining a therapeutic APP may preserve renal blood flow in patients with intra-abdominal hypertension who are at risk of IAP-induced renal injury but who have yet to meet accepted criteria for surgical decompression.

Peparini, N., F. M. Di Matteo, et al. (2008). "Abdominal hypertension in Meigs' syndrome." Eur J Surg Oncol 34(8): 938-42.

               AIMS: Two cases of chronic abdominal hypertension in pseudo-Meigs' syndrome, one sustained by a large ovarian bilateral carcinoma and the other by a giant genital angiomyolipoma, are reported. METHODS AND RESULTS: Both patients presented to the emergency room for abdominal distention and pain with progressive respiratory dysfunction, hypotension over several days, and early symptoms of renal failure, together suggestive of chronic, intra-abdominal hypertension. DISCUSSION: Intra-abdominal hypertension and abdominal compartment syndrome are serious conditions which may complicate large tumors and tense ascites, apart from their benign or malignant nature. The chronic development of abdominal hypertension and onset of the abdominal compartment syndrome associated with Meigs' syndrome must be recognized in a timely manner and promptly treated by performing as complete a resection of the pelvic mass as possible; alternatively, in acute abdominal hypertension the monitoring of bladder pressure can evaluate the effectiveness of medical therapy and determine the optimal timing of decompressive laparotomy in case of the abdominal compartment syndrome.

Pupelis, G., K. Zeiza, et al. (2008). "Conservative approach in the management of severe acute pancreatitis: eight-year experience in a single institution." HPB (Oxford) 10(5): 347-55.

               Introduction. Recognition of severe acute pancreatitis (SAP), intensive care, shifting away from early surgical treatment, and monitoring of the intra-abdominal pressure (IAP) is important in the management of SAP. The aim of our study was retrospective evaluation and critical assessment of the experience with SAP management protocol involving new strategy in the university hospital. Methods. Protocols of 274 SAP patients treated in our institution during the last eight years were reassessed. APACHE II, CRP and SOFA score, IAP, pulmonary complications, ventilatory support and infection rate were evaluated. The success of the conservative treatment, surgical interventions and mortality was analysed comparing period 1 from 1999 to 2002 and period 2 from 2003 to 2006. Results. More patients with necrotising SAP were treated in period 2. The average CRP and SOFA score was higher in period 2, p=0.018; p=0.011. A total of 139 patients underwent continuous veno-venouse haemofiltration (CVVH) as a component of fluid resuscitation and IAP control. Application of CVVH increased in period 2, p<0.005. Only 5-8% of patients were managed with ventilatory support. The overall infection rate decreased in period 2 comprising 21%, p<0.005. Success rate of the conservative therapy reached 69% in period 2, p<0.01. Surgical treatment was performed in 41% of patients in period 1 vs. 19% in period 2, p<0.001. Overall mortality was 19%, with a reduction to 12% in year 2006. Conclusion. The conservative protocol-based approach is a rational treatment strategy for the management of SAP and can be successfully implemented in the setting of the university hospital.

Qvarfordt, P., M. Bjorck, et al. (2008). "[Acute compartment syndromes in the abdomen and extremities. Big clinical problem which is frequently missed]." Lakartidningen 105(40): 2765-8.

Rasner, J. N., K. Parrott, et al. (2008). "Management of abdominal compartment syndrome in a very low birth weight neonate using penrose drains and subsequent management of abdominal-wall defects." J Laparoendosc Adv Surg Tech A 18(4): 657-60.

               Abstract Percutaneous drainage of the peritoneal cavity has been recently evaluated for the treatment of perforated viscous in the very low birth weight (VLBW) neonate and percutaneous decompression for abdominal compartment syndrome (ACS) has been studied in older patient populations. This is the first reported case of using this technique to treat ACS in a VLBW neonate.

Regueira, T., A. Bruhn, et al. (2008). "Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock." J Crit Care 23(4): 461-7.

               PURPOSE: The objective of this article is to study the cumulative incidence of intra-abdominal hypertension (IAH) in septic shock (SS) patients during the first 72 hours of intensive care unit (ICU) admission and to determine if the presence and severity of IAH are associated with sepsis morbidity and mortality. MATERIALS AND METHODS: Eighty-one consecutive SS patients admitted to a surgical-medical ICU of an academic university hospital (January 2005 to January 2006) were included. Intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) were measured every 6 h (intermittently) for 72 h. Intra-abdominal pressure was registered as minimal, mean, and maximal values per day, during shock and throughout the study period. Intra-abdominal hypertension was diagnosed if IAP remained 12 mm Hg or higher on 2 consecutive measurements and stratified according to the most recent consensus definition (www.wsacs.org). RESULTS: According to maximal and mean IAP values, 67 (82.7%) and 62 (76.5%) of the patients developed IAH during the study period, respectively. Mean IAP values remained stable throughout the study period. Surgical patients had a higher incidence of IAH than medical patients (93% vs 73%, P < .009). Maximal IAPs were normally distributed, with nonsurvivors exhibiting significantly higher IAP levels during shock (survivors, 17.2 +/- 5.3; nonsurvivors, 19.9 +/- 5.6 mm Hg; P < .04). Patients with IAH exhibited significantly lower values of APP and diuresis, higher values of lactate and creatinine, and higher maximal norepinephrine doses, and were more frequently mechanically ventilated (P < .05 for all). Increasing degrees of IAH and the development of the abdominal compartment syndrome were associated with lower APP and higher maximal serum creatinine levels (P < .03 for both). CONCLUSIONS: Septic shock patients have a very high incidence of IAH, which seems to be associated with the severity of shock and could be related to the development of organ dysfunctions, particularly renal dysfunction. Intra-abdominal pressure should be routinely monitored during the course of SS.

Reintam, A., P. Parm, et al. (2008). "Primary and secondary intra-abdominal hypertension--different impact on ICU outcome." Intensive Care Med 34(9): 1624-31.

               OBJECTIVE: To investigate the differences in incidence, time course and outcome of primary versus secondary intra-abdominal hypertension (IAH), and to evaluate IAH as an independent risk factor of mortality in a presumable risk population of critically ill patients. DESIGN: Prospective observational study. SETTING: General intensive care unit of a university hospital. PATIENTS: A total of 257 mechanically ventilated patients at presumable risk for the development of IAH were studied during their ICU stay and followed up for 90-day survival. INTERVENTIONS: Repeated measurements of intra-abdominal pressure (IAP). MEASUREMENTS AND RESULTS: IAP was measured intermittently, via bladder. IAH (sustained or repeated IAP > or = 12 mmHg) developed in 95 patients (37.0%). Primary IAH was observed in 60 and secondary IAH in 35 patients. Patients with secondary IAH demonstrated a significant increase of mean IAP during the first three days (mean DeltaIAP was 2.2 +/- 4.7 mmHg), whilst IAP decreased (mean DeltaIAP -1.1 +/- 3.7 mmHg) in the patients with primary IAH. The patients with IAH had a significantly higher ICU- (37.9 vs. 19.1%; P = 0.001), 28-day (48.4 vs. 27.8%, P = 0.001), and 90-day mortality (53.7 vs. 35.8%, P = 0.004) compared to the patients without the syndrome. Patients with secondary IAH had a significantly higher ICU mortality than patients with primary IAH (P = 0.032). Development of IAH was identified as an independent risk factor for death (OR 2.52; 95% CI 1.23-5.14). CONCLUSIONS: Secondary IAH is less frequent, has a different time course and worse outcome than primary IAH. Development of IAH during ICU period is an independent risk factor for death.

Reintam, A., P. Parm, et al. (2008). "Primary and secondary intra-abdominal hypertension-different impact on ICU outcome." Intensive Care Med 34(9): 1624-31.

               OBJECTIVE: To investigate the differences in incidence, time course and outcome of primary versus secondary intra-abdominal hypertension (IAH), and to evaluate IAH as an independent risk factor of mortality in a presumable risk population of critically ill patients. DESIGN: Prospective observational study. SETTING: General intensive care unit of a university hospital. PATIENTS: A total of 257 mechanically ventilated patients at presumable risk for the development of IAH were studied during their ICU stay and followed up for 90-day survival. INTERVENTIONS: Repeated measurements of intra-abdominal pressure (IAP). MEASUREMENTS AND RESULTS: IAP was measured intermittently, via bladder. IAH (sustained or repeated IAP >/= 12 mmHg) developed in 95 patients (37.0%). Primary IAH was observed in 60 and secondary IAH in 35 patients. Patients with secondary IAH demonstrated a significant increase of mean IAP during the first three days (mean DeltaIAP was 2.2 +/- 4.7 mmHg), whilst IAP decreased (mean DeltaIAP -1.1 +/- 3.7 mmHg) in the patients with primary IAH. The patients with IAH had a significantly higher ICU- (37.9 vs. 19.1%; P = 0.001), 28-day (48.4 vs. 27.8%, P = 0.001), and 90-day mortality (53.7 vs. 35.8%, P = 0.004) compared to the patients without the syndrome. Patients with secondary IAH had a significantly higher ICU mortality than patients with primary IAH (P = 0.032). Development of IAH was identified as an independent risk factor for death (OR 2.52; 95% CI 1.23-5.14). CONCLUSIONS: Secondary IAH is less frequent, has a different time course and worse outcome than primary IAH. Development of IAH during ICU period is an independent risk factor for death.

Reintam, A., P. Parm, et al. (2008). "Gastrointestinal Failure score in critically ill patients: a prospective observational study." Crit Care 12(4): R90.

               ABSTRACT: INTRODUCTION: There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality. The prognostic value of the GIF score alone and in combination with the Sequential Organ Failure Assessment (SOFA) score is evaluated, and the incidence and outcome of gastrointestinal failure is described relative to the GIF score. METHODS: A total of 264 subsequently hospitalized patients, who were mechanically ventilated on admission and stayed in the intensive care unit (ICU) for longer than 24 hours, were prospectively studied. GIF score was documented daily as follows: 0 = normal gastrointestinal function; 1 = enteral feeding with under 50% of calculated needs or no feeding 3 days after abdominal surgery; 2 = FI or IAH; 3 = FI and IAH; and 4 = abdominal compartment syndrome (ACS). Admission parameters and mean GIF and SOFA scores for the first 3 days were used to predict ICU outcome. RESULTS: FI developed in 58.3%, IAH in 27.3%, and both together in 22.7% of patients. The mean GIF score for the first 3 days in the ICU was identified as an independent risk factor for mortality (odds ratio = 3.02, 95% confidence interval = 1.63 to 5.59; P < 0.001). The GIF score integrated into the SOFA score allowed better prediction of ICU mortality than did the SOFA score alone, and was an independent predictor of mortality (odds ratio = 1.49, 95% confidence interval = 1.28 to 1.74; P < 0.001). The development of gastrointestinal failure (FI plus IAH) was associated with significantly higher ICU and 90-day mortality. CONCLUSION: The GIF score is useful for classifying information on the gastrointestinal system. The mean GIF score during the first 3 days in the ICU had high prognostic value for ICU mortality. Development of gastrointestinal failure is associated with significantly impaired outcome.

Saint, S., C. P. Kowalski, et al. (2008). "Preventing hospital-acquired urinary tract infection in the United States: a national study." Clin Infect Dis 46(2): 243-50.

               BACKGROUND: Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS: We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS: The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS: Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Serpytis, M. and J. Ivaskevicius (2008). "The influence of fluid balance on intra-abdominal pressure after major abdominal surgery." Medicina (Kaunas) 44(6): 421-7.

               OBJECTIVE: The objectives of this study were to determine the incidence of intra-abdominal hypertension in patients after major abdominal surgery and to evaluate the correlation of intra-abdominal pressure with fluid balance and systemic inflammatory response syndrome. MATERIAL AND METHODS: This is a prospective observational study. Patients, admitted to intensive care unit after major abdominal surgery, were included into the study. Intra-abdominal pressure was measured via a urinary bladder catheter twice daily. Twenty-four-hour fluid balance and systemic inflammatory response syndrome criteria met by the patients were collected daily. RESULTS: Seventy-seven patients were included into the study. Intra-abdominal hypertension was diagnosed in about 40% of the patients in the early postoperative period. The study showed a significant positive correlation between 24-hour fluid balance and daily changes in intra-abdominal pressure. A significant association was also seen between the number of positive systemic inflammatory response syndrome criteria and intra-abdominal pressure, and intra-abdominal pressure was significantly higher in patients with systemic inflammatory response syndrome. Besides, patients with intra-abdominal hypertension on the first postoperative day had longer length of stay in the intensive care unit. CONCLUSIONS: Intra-abdominal hypertension occurs commonly in patients after major abdominal surgery, and patients with positive 24-hour fluid balance and/or systemic inflammatory response syndrome are at risk of having higher intra-abdominal hypertension.

Shaikh, N., M. A. Kettern, et al. (2008). "A rare and unsuspected complication of Clostridium difficile infection." Intensive Care Med 34(5): 963-6.

               OBJECTIVE: To report the occurrence of abdominal compartment syndrome (ACS) due to infection with Clostridium difficile. DESIGN: Case report. SETTING: Trauma intensive care unit (TICU) of Hamad General Hospital, a teaching hospital in Doha, Qatar. PATIENT: A 36-year-old man involved in a motor vehicle accident had severe traumatic brain injury and received ceftriaxone. On day 7, he developed severe abdominal distension and diarrhoea followed by paralytic ileus with oliguria, hyperkalaemia, and intra-abdominal hypertension. The patient's stool sample was positive for C. difficile toxin A and B MEASUREMENTS AND RESULTS: An ACS was diagnosed. The patient was successfully treated in the TICU by stopping the offending antibiotic and starting metronidazole plus neostigmine as a prokinetic agent. The fluid status was guided by pulse-induced continuous cardiac output, and frusemide was added to the treatment. With this aggressive management the abdominal pressure decreased and the renal function improved, with full recovery of renal function by day 21. Unfortunately the patient's Glasgow coma score (GCS) deteriorated, so percutaneous tracheostomy was performed. He was transferred to the neurosurgical ward on day 35. A week later he was shifted to the rehabilitation unit for further management. CONCLUSIONS: C. difficile colitis can cause intra-abdominal hypertension (IAH) and ACS. Rapid diagnosis, early aggressive supportive care, metronidazole and prokinetics are necessary to lower the morbidity and mortality of C. difficile colitis associated with IAH and ACS.

Siebig, S., I. Iesalnieks, et al. (2008). "Recovery from respiratory failure after decompression laparotomy for severe acute pancreatitis." World J Gastroenterol 14(35): 5467-70.

               We present three cases of patients (at the age of 56 years, 49 years and 74 years respectively) with severe acute pancreatitis (SAP), complicated by intra-abdominal compartment syndrome (ACS) and respiratory insufficiency with limitations of mechanical ventilation. The respiratory situation of the patients was significantly improved after decompression laparotomy (DL) and lung protective ventilation was re-achieved. ACS was discussed followed by a short review of the literature. Our cases show that DL may help patients with SAP to recover from severe respiratory failure.

Singh, M. K., J. P. Rocca, et al. (2008). "Open abdomen management with human acellular dermal matrix in liver transplant recipients." Transplant Proc 40(10): 3541-4.

               BACKGROUND: Abdominal wall closure after liver transplantation is not always feasible and may result in increased intra-abdominal pressure along with associated complications. Various temporary closure techniques as well as open wound management have been used to address this complex problem. The aim of this series was to describe an approach to definitive wound closure of the open abdomen in liver transplant patients. METHODS: We performed a retrospective review of all liver transplant patients at our institution from September 2005 to November 2007. The management of the open abdomen in 10 liver transplant patients was reviewed, and a novel approach described to manage these defects. RESULTS: Ten patients with open wounds were closed during the study period using human acellular dermal matrix (HADM). There were 7 men and 3 women of median age 55 years. Average size of HADM was 235 cm(2). The median follow-up is 10 months with no incidence of evisceration or hernia. In 1 patient, the graft failed along the lateral side due to infection; it dislodged during vacuum-assisted closure dressing change in another patient at 5 months after closure. Fascial closure was not possible due to organ edema (n = 3), a large liver (n = 4) or wound infection with dehiscence (n = 3). CONCLUSIONS: HADM can be used for primary wound closure in both clean and contaminated wounds as an alternative to an open abdomen post-liver transplantation.

Soltsman, S., P. Russo, et al. (2008). "Abdominal compartment syndrome after laparoscopic salpingectomy for ectopic pregnancy." J Minim Invasive Gynecol 15(4): 508-10.

               Abdominal compartment syndrome is a consequence of increased intraabdominal pressure. It can be triggered by inflammation, hemorrhage, chemical peritonitis, or prolonged insufflations during laparoscopy. It is a well-known phenomenon for intensive care specialists, but gynecologists are relatively unfamiliar with its occurrence. A woman with heterotopic pregnancy underwent urgent laparoscopy because of abdominal hemorrhage. The postoperative course was complicated by abdominal pain, ascites, bowel dysfunction, and renal failure, which resolved rapidly after catheterization and paracentesis. In this case, abdominal compartment syndrome developed after unremarkable laparoscopy, and appeared to be triggered by change of progesterone formulation. Decompression by paracentesis was lifesaving, and led to rapid resolution of the symptoms.

Sonne, M. and J. Hillingso (2008). "[Intraabdominal hypertension and abdominal compartment syndrome]." Ugeskr Laeger 170(7): 527-31.

               Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are rare conditions with high mortality. IAH is an intraabdominal pressure (IAP) above 12 mmHg and ACS an IAP above 20 mmHg with evidence of organ dysfunction. IAP is measured indirectly via the bladder or stomach. Various medical and surgical conditions increase the intraabdominal volume. When the content exceeds the compliance of the abdominal wall, the IAP rises. Increased IAP affects the functioning of the brain, lungs, circulation, kidneys, and bowel. The treatment of ACS is a reduction of IAP.

Spencer, P., L. Kinsman, et al. (2008). "A critical care nurse's guide to intra abdominal hypertension and abdominal compartment syndrome." Aust Crit Care 21(1): 18-28.

               Abdominal compartment syndrome (ACS) is a life-threatening syndrome that is increasing in incidence amongst critically ill patients. A 2005 survey of critical care nurses revealed that there were recognised knowledge deficits of ACS amongst surveyed nurses. The purpose of this review is to inform critical care nurses about ACS and its antecedent, intra abdominal hypertension (IAH). Detection techniques, causes, clinical manifestations and pathophysiology of IAH and ACS will be outlined and medical and nursing management will be reviewed. The incidence of ACS is reported to be up to 35% in the intensive care population with reduced survival when compared to other intensive care patients. Physiological changes that occur with ACS include compromise to the cardiovascular, respiratory, renal and neurological systems and development of metabolic acidosis. Management may incorporate percutaneous drainage of ascitic fluid, use of muscle relaxants, prone positioning and surgical intervention to open, decompress and gradually close the abdomen. Throughout this care the critical care nurse should ensure accurate monitoring of organ function, assessment for recurrence of ACS as well as the amount and type of drainage, appropriate wound management and provision of physical and psychosocial support of the patient. These aspects of care have the potential to impact significantly on patient outcome.

Sturini, E., A. Saporito, et al. (2008). "Respiratory variation of intra-abdominal pressure: indirect indicator of abdominal compliance?" Intensive Care Med.

               OBJECTIVE: To assess if the observed respiratory cycle-related variation in intra-abdominal pressure is reliably quantifiable and a possible indirect indicator of abdominal compliance. Secondary issues were to assess the roles played by respiratory parameters in determining this oscillation and by patients' position in increasing their intra-abdominal pressure. DESIGN AND SETTING: Prospective observational study in a 26-bed medical-surgical intensive care unit. PATIENTS: Sixteen consecutive patients admitted to intensive care for at least 24 h, requiring mechanical ventilation and intra-abdominal pressure monitoring. MEASUREMENTS AND RESULTS: Intra-abdominal pressure was measured with a modified Kron technique; its waveform was recorded and inspiratory and expiratory values were measured during five consecutive respiratory cycles for 5 days, both in the supine and the 30 degrees head-up position. Inspiratory values were significantly higher than expiratory values (p = 0.001) and a correlation was found between their difference and intra-abdominal pressure basal values (p = 0.025). A positive linear relationship was shown between intra-abdominal pressure and the amplitude of its oscillation (r = 0.4), particularly in the subgroup of patients with intra-abdominal hypertension (r = 0.9). Intra-abdominal pressure was lower in patients supine than in the 30 degrees head-up position (p = 0.001). CONCLUSIONS: Respiratory cycle-related variations in intra-abdominal pressure were specifically investigated, quantified and shown as linearly increasing with end-expiratory intra-abdominal pressure; this phenomenon could be explained by patients' abdominal compliance status. Supine posture should be an important consideration in specific patients affected by intra-abdominal hypertension.

Sukhotnik, I., J. Mogilner, et al. (2008). "Effect of elevated intra-abdominal pressure and 100% oxygen on superior mesenteric artery blood flow and enterocyte turnover in a rat." Pediatr Surg Int.

               PURPOSE: Elevated intra-abdominal pressure (IAP) has been shown to reduce mesenteric blood flow and cause intestinal damage. The purpose of the present study was to evaluate the effects of IAP and hyperoxia on superior mesenteric artery (SMA) blood flow, enterocyte proliferation and apoptosis in a rat model of abdominal compartment syndrome (ACS). METHODS: Male rats underwent midline laparotomy. SMA was isolated and ultrasonic blood flow probes were placed on the vessel for continuous measurement of regional blood flow. Two catheters were introduced into the peritoneal cavity for inflation of air and for measurement of IAP. Rats were divided into three experimental groups: (1) Sham rats were subjected to IAP of 0 mmHg, (2) ACS-air rats were subjected to IAP of 6 mmHg for 2 h and were ventilated with air, and (3) ACS-O(2) rats were subjected to IAP of 6 mmHg and were ventilated with 100% oxygen (O(2)) during the operation and for 6 h after the operation. Intestinal structural changes, enterocyte proliferation and enterocyte apoptosis were evaluated at 24 h after operation. A paired Student's t test and the non-parametric Kruskal-Wallis ANOVA test were used as indicated. P < 0.05 was considered statistically significant. RESULTS: IAP at 6 mmHg caused a moderate decrease in SMA blood flow. Inhalation of 100% oxygen resulted in a trend toward an increase in SMA flow when compared to air-ventilated animals. ACS rats demonstrated a significantly lower index of proliferation in jejunum and ileum as well as a significantly greater apoptotic index in jejunum compared to sham animals. Exposure to 100% oxygen resulted in a significant increase in cell proliferation in jejunum and ileum as well as in a significant decrease in cell apoptosis in jejunum compared to air-breathing animals. CONCLUSIONS: In a rat model of ACS, elevated IAP decreases SMA blood flow and inhibits enterocyte turnover. Hyperoxia results in a trend toward an increase in SMA blood flow, increases enterocyte proliferation and inhibits cell death via apoptosis. These findings may have significant implications for ventilation strategies during laparoscopy.

Tavares-de la Paz, L. A., P. Andrade-de la Garza, et al. (2008). "[Open abdomen. Evolution in management.]." Cir Cir 76(2): 177-86.

               The open abdomen (OA) strategy is accepted in the treatment of extremely ill surgical patients. Its usage has increased in the last decade as the understanding of its functions, advantages and disadvantages increases. Unfortunately, it continues to be associated with very high morbidity and mortality, and the different techniques used to protect the intra-abdominal contents cannot be standardized for all surgical circumstances. The objective is to review the origins, actual indications and controversies of the staged abdominal repair (STAR) and to report on the latest and most used techniques to ensure an optimal temporary abdominal closure (TAC). A search was done in Medline and Ovid for articles with key words of open abdomen, temporary abdominal closure and staged abdominal repair. We found the use of the technique is justified in patients with trauma, abdominal compartment syndrome and patients with severe intra-abdominal sepsis. The technique used for TAC must always be individualized for each clinical circumstance. The best reported results have been obtained with the vacuum pack technique. In our own experience and as a general rule we discouraged the use of mesh to protect intra-abdominal contents. The strategy of OA is useful in complex surgical situations in extremely ill patients. Its use must be very carefully evaluated, knowing the potentially serious complications that the patient may develop with its use.

Tenke, P., B. Kovacs, et al. (2008). "European and Asian guidelines on management and prevention of catheter-associated urinary tract infections." Int J Antimicrob Agents 31 Suppl 1: S68-78.

               We surveyed the extensive literature regarding the development, therapy and prevention of catheter-associated urinary tract infections (UTIs). We systematically searched for meta-analyses of randomised controlled trials available in Medline giving preference to the Cochrane Central Register of Controlled Trials and also considered other relevant publications, rating them on the basis of their quality. The studies' recommendations, rated according to a modification of the US Department of Health and Human Services (1992), give a close-to-evidence-based guideline for all medical disciplines, with special emphasis on urology where catheter care is an important issue. The survey found that the urinary tract is the commonest source of nosocomial infection, particularly when the bladder is catheterised (IIa). Most catheter-associated UTIs are derived from the patient's own colonic flora (IIb) and the catheter predisposes to UTI in several ways. The most important risk factor for the development of catheter-associated bacteriuria is the duration of catheterisation (IIa). Most episodes of short-term catheter-associated bacteriuria are asymptomatic and are caused by a single organism (IIa). Further organisms tend to be acquired by patients catheterised for more than 30 days. The clinician should be aware of two priorities: the catheter system should remain closed and the duration of catheterisation should be minimal (A). While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended (A), except for some special cases. Routine urine culture in an asymptomatic catheterised patient is also not recommended (C) because treatment is in general not necessary. Antibiotic treatment is recommended only for symptomatic infection (B). Long-term antibiotic suppressive therapy is not effective (A). Antibiotic irrigation of the catheter and bladder is of no advantage (A). Routine urine cultures are not recommended if the catheter is draining properly (C). A minority of patients can be managed with the use of the non-return (flip) valve catheter, avoiding the closed drainage bag. Such patients may exchange the convenience of on-demand drainage with an increased risk of infection. Patients with urethral catheters in place for 10 years or more should be screened annually for bladder cancer (C). Clinicians should always consider alternatives to indwelling urethral catheters that are less prone to causing symptomatic infection. In appropriate patients, suprapubic catheters, condom drainage systems and intermittent catheterisation are each preferable to indwelling urethral catheterisation (B).

Timerbulatov, V. M., R. R. Faiazov, et al. (2008). "[Abdominal compartment syndrome in urgent surgery]." Khirurgiia (Mosk)(7): 33-5.

               Results of measurement and monitoring of intraabdominal pressure at 288 patients treated for different abdominal diseases and trauma were analyzed. In early postoperative period the increase intraabdominal pressure to 10-15 mm Hg (I degree) was revealed at 161 (56.0%) patients, from 16 to 25 mm Hg (II degree)--at 95 (33.0%), from 25 to 35 mm Hg (III degree)--at 23 (8.0%), more 35 mm Hg (IV degree)--at 8 (2.7%) patients. When intraabdominal pressure decreased on 4-5 mm per day the prognosis was positive at 257 (89.2%) operated patients. Critical type regarded as compartment syndrome (III-IV degree) was diagnosed at 31 (10.8%) patients. Relaparotomy was performed at 23 (8.0%) patients with III degree hypertension, the lethal outcome was at 6 (26.1%) cases. Relaparotomy at 8 (2.7%) patients with IV degree hypertension was late, and all the outcomes at these patients were lethal. General lethality at compartment syndrome was 45.2%. It is concluded that monitoring of intraabdominal hypertension should be mandatory diagnostic method, and critical parameters of abdominal hypertension--absolute indication to repeated laparotomy and decompression of abdominal cavity.

Tsuchida, T., K. Makimoto, et al. (2008). "Relationship between catheter care and catheter-associated urinary tract infection at Japanese general hospitals: a prospective observational study." Int J Nurs Stud 45(3): 352-61.

               BACKGROUND: The risk factors for catheter-associated urinary tract infections (CAUTIs) that are associated with catheter care have not been examined in detail by prospective studies or randomised clinical trials. OBJECTIVES: To examine the patterns of catheter care and to identify the CAUTI risk factors associated with catheter care. DESIGN: Prospective observational study. METHODS: Between January and December 2004, 555 adult patients who were catheterised for 3 days in five general hospitals in Japan were surveyed. One researcher collected the following data twice a week: catheter insertion method, catheter management, and signs and symptoms of urinary tract infections. The relative risk exceeding 1 by the Poisson regression were selected for Cox proportional hazard analysis in order to calculate adjusted risks. In addition, expected reductions in the incidence of CAUTIs by elimination of the risk factors were estimated using the population attributable risk percent. RESULTS: The mean duration of catheterisation was 25 days. The overall incidence of CAUTIs was 3.9 cases per 1000-device days; the incidence of CAUTIs ranged from 0.6 to 7.2 cases per 1000-device days among the five hospitals. Only fecal incontinent patients were analysed since they accounted for 94% of the CAUTI cases. In the univariate analysis, the silver-alloy catheter, which contains antimicrobial property, emerged as a potential risk. Since silver-alloy catheters were used in only one hospital, silver-alloy catheter care was compared with that of the other types of catheter, and a significantly higher percentage of inappropriate care was observed. In the final Cox model, two variables remained: 'non-pre-connected closed system (standard system)' (RR 2.35, 95%CI 1.20-4.60, p = 0.013) and 'no daily cleansing of the perineal area' (RR 2.49, 95%CI 1.32-4.69, p = 0.005). The population attributable risk percent suggested that the use of a 'pre-connected closed system' and 'daily cleansing of the perineal area' could reduce the incidence of CAUTIs by nearly 50%. CONCLUSIONS: Our investigation identified fecal incontinence as the major risk factor for CAUTIs in the study population. However, attributable risk percent indicates that the implementation of two basic elements of catheter care could reduce CAUTIs by nearly 50%. The hospital using silver-alloy catheters had the highest CAUTI rates, strongly suggesting the hazards of relying on the antimicrobial property of silver and the resultant laxity in care.

Umgelter, A., W. Reindl, et al. (2008). "Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial." Crit Care 12(1): R4.

               INTRODUCTION: Circulatory dysfunction in cirrhotic patients may cause a specific kind of functional renal failure termed hepato-renal syndrome (HRS). It contributes to the high incidence of renal failure in cirrhotic intensive care unit (ICU) patients. Fluid therapy may aggravate renal failure by increasing ascites and intra-abdominal pressure (IAP). This study investigates the short-term effects of paracentesis on haemodynamics and kidney function in volume resuscitated patients with HRS. METHODS: Nineteen consecutive cirrhotic patients with HRS were studied. Circulatory parameters and renal function were analysed before and after plasma expansion and paracentesis. Haemodynamic monitoring was performed by transpulmonary thermodilution. RESULTS: After infusion of 200 ml of 20% human albumin solution, mean arterial pressure (MAP) and central venous pressure remained unchanged. Global end-diastolic volume index (GEDVI) increased from 791 ml m(-2) (693 to 862) (median and 25th to 75th percentile) to 844 ml m(-2) (751 to 933). Cardiac index (CI) increased from 4.1 l min(-1) m(-2) (3.6 to 5.0) to 4.7 l min(-1) m(-2) (4.0 to 5.8), whereas systemic vascular resistance index (SVRI) decreased from 1,422 dyn s cm(-5) m(-2) (1,081 to 1,772) to 1,171 dyn s cm(-5) m(-2) (893 to 1,705). Creatinine clearance (CC) and fractional excretion of sodium (FeNa) were not affected. During paracentesis, IAP decreased from 22 mmHg (18 to 24) to 9 mmHg (8 to 12). MAP decreased from 81 mmHg (74 to 100) to 80 mmHg (71 to 89), and CI increased from 4.1 l min(-1) m(-2) (3.2 to 4.3) to 4.2 l min(-1) m(-2) (3.6 to 4.7), whereas SVRI decreased from 1,639 dyn s cm(-5) m(-2) (1,168 to 2,037) to 1,301 dyn s cm(-5) m(-2) (1,124 to 1,751). CC during the 12-hour interval after paracentesis was significantly higher than during the 12 hours before (33 ml min(-1) (16 to 50) compared with 23 ml min(-1) (12 to 49)). CC remained elevated for the rest of the observation period. FeNa increased after paracentesis but returned to baseline levels after 24 hours. CONCLUSION: Paracentesis with parameter-guided fluid substitution and maintenance of central blood volume may improve renal function and is safe in the treatment of ICU patients with hepato-renal failure.

van Ramshorst, G. H., J. F. Lange, et al. (2008). "Non-invasive measurement of intra-abdominal pressure: a preliminary study." Physiol Meas 29(8): N41-N47.

               The importance of measuring intra-abdominal pressure (IAP) has increased since the negative effects of sustained increased IAP, also known as intra-abdominal hypertension (IAH), have become known. The relation between IAP and abdominal wall tension has been included in several reports. We have developed a device to measure abdominal wall tension by measuring force and distance. This device enables us to investigate the correlation between the abdominal wall tension and IAP. The abdomens of two corpses (one female, one male) were insufflated with air. IAP was increased and measured at intervals by means of a laparoscopic set-up. Abdominal tension was measured at seven points on the abdominal wall at each interval. Pearson's correlation coefficients were used to determine the relationship between IAP and tension for each point measured. ANOVA was used to assess relations between measured tensions versus applied pressure, locations and subjects. In both corpses, all points showed significant (p < 0.001) correlations between IAP and abdominal wall tension. The points along the mid transverse plane appear to be more similar compared to more cranial and caudal points. We have assessed the feasibility of a device that non-invasively can track changes in IAP. Measurements performed with the device are preliminary results, and further investigation is needed.

Vegar-Brozovic, V., J. Brezak, et al. (2008). "Intra-abdominal hypertension: pulmonary and cerebral complications." Transplant Proc 40(4): 1190-2.

               Intra-abdominal hypertension causes many physiologic changes, primarily by reducing thoracic compliance and secondarily causing organ failure, which is the body's normal response to trauma or acute inflammatory response. Compartment syndrome as a cause of abdominal hypertension has adverse effects on the circulation, threatening the function and viability of tissues. Intra-abdominal hypertension with the clinical picture of compartment syndrome is a reperfusion injury that is a cyclic event. Elevated intra-abdominal pressure due to whatever mechanism affects all intra-abdominal viscera, including the abdominal wall. Due to edema reducing thoracic compliance, producing severe encephalopathy and leading to severe ischemia with generation of significant quantities of reactive oxygen free radicals as well peroxidation products released from the intestine, liver and spleen. Elevated intracranial pressure causes encephalopathy and the risk of neuronal damage due to the sharp decrease in cerebral perfusion pressure. Elevated intracranial pressure is due to restriction of outflow from the lumbar venous plexus. The etiology of the sudden increase in capillary permeability remains unclear. Decompressive laparotomy leads to a rapid improvement in pulmonary parameters and oxygen delivery. The clinical state after decompression is an example of ischemia-reperfusion injury requiring therapy with inotropes and other agents to improve cardiac, respiratory, renal and cerebral hemodynamics with life saving effects.

Vidal, M. G., J. Ruiz Weisser, et al. (2008). "Incidence and clinical effects of intra-abdominal hypertension in critically ill patients." Crit Care Med 36(6): 1823-31.

               OBJECTIVE: The objective of this study was to determine the epidemiology and outcomes of intra-abdominal hypertension in a heterogeneous intensive care unit population. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a medical-surgical intensive care unit in a university hospital. PATIENTS: Study patients included all those consecutively admitted during 9 months, staying > 24 hrs, and requiring bladder catheterization. MEASUREMENTS AND MAIN RESULTS: On admission, epidemiologic data and risk factors for intra-abdominal hypertension were studied; then, daily maximal and mean intra-abdominal pressures (IAP(max) and IAP(mean)), abdominal perfusion pressure, fluid balances, filtration gradient, and sequential organ failure assessment score, were registered. IAPs were recorded through a bladder catheter every 6 hrs until death, discharge, or along 7 days. Intra-abdominal hypertension was defined as IAP > or = 12 mm Hg. Abdominal compartment syndrome was defined as IAP > or = 20 mm Hg plus > or = 1 new organ failure. Main outcome measure was hospital mortality. Of 83 patients, considering IAP(max), 31% had intra-abdominal hypertension on admission and another 33% developed it after (23% and 31% with IAP(mean)). Main risk factors were mechanical ventilation, acute respiratory distress syndrome, and fluid resuscitation (relative risk, 5.26, 3.19, and 2.50, respectively). Patients with intra-abdominal hypertension were sicker, had higher mortality (53% vs. 27%, p = .02), and consistently showed higher total and renal sequential organ failure assessment score, daily and cumulative fluid balances, and lower filtration gradient. Nonsurvivors had higher IAP(max), IAP(mean), and fluid balances and lower abdominal perfusion pressure. Abdominal compartment syndrome developed in 12%; 20% survived. Logistic regression identified IAP(max) as an independent predictor of mortality (odds ratio, 1.17; 95% confidence interval, 1.05-1.30; p = .003) after adjusting with Acute Physiology and Chronic Health Evaluation II and comorbidities (odds ratio, 1.15; 95% confidence interval, 1.06-1.25; p = .001; and odds ratio, 2.68; 95% confidence interval, 1.27-5.67; p = .013, respectively). Models with IAP(mean) and abdominal perfusion pressure also performed well. Areas under receiver operating characteristic curves were .81 and .83. CONCLUSIONS: Intra-abdominal hypertension, diagnosed either with IAP(max) or IAP(mean), was frequent and showed an independent association with mortality. Intra-abdominal hypertension was significantly associated with more severe organ failures, particularly renal and respiratory, and a prolonged intensive care unit stay.

Whitson, B. A. and S. Ikramuddin (2008). "Intra-abdominal Pressure Cutoffs Should not be Absolutes." World J Surg.

Wolfe, T. R., E. J. Kimball, et al. (2008). "The interrelationship of severe sepsis, sepsis resuscitation and the abdominal compartment syndrome." Int J Intensive Care(Spring): 22-29.

               In the last 7 years an explosion in interest regarding interventional therapies for severe sepsis has occurred.  Simultaneously there has been a dramatic increase in the recognition, understanding and management of intra-abdominal hypertension and the abdominal compartment syndrome. What may be less apparent is the profound inter-relationship between these two disease processes. Patients suffering septic shock and receiving early goal directed therapy are almost perfect candidates for developing intra-abdominal hypertension.  However, the pathophysiologic manifestations of sepsis and intraabdominal hypertension are so similar that the later syndrome frequently goes unrecognized and therefor untreated.  Furthermore, elevated intra-abdominal pressure profoundly influences commonly used septic shock resuscitation endpoints such as CVP (falsely elevated) and urine output (markedly decreased). Failure to adjust for the impact of intraabdominal pressure on these endpoints may negatively impact resuscitation decisions, potentially worsening sepsis patients’ outcomes. 

This manuscript will review the inter-relationships between severe sepsis, sepsis resuscitation protocols and intraabdominal hypertension. It will then discuss the clinical reasoning and outcomes data that suggest that patients who undergo sepsis resuscitation should have intraabdominal pressure monitoring started during the resuscitation phase and intraabdominal hypertension interventional therapies implemented, if necessary, during the management-bundle phase.

Xia, G. X. (2008). "[Reiteration on abdominal compartment syndrome]." Zhonghua Shao Shang Za Zhi 24(2): 81-3.

               Since we called for the attention of the occurrence of abdominal compartment syndrome in 2002, forty cases of this complication have been recognized and reported by six burn units in this journal, including three cases accompanied with massive pleural effusion (1601 - 3240 mL). Most cases emerged after "aggressive" fluid resuscitation, especially after massive infusion of crystalloid fluid. The idea "more fluid no harm" should be corrected. The goal of early fluid resuscitation in burn is to correct the hypovolemia and cell hypoxia, and circulating fluid just serves as a carrier in bringing O2 to the cells and carrying out CO2 and other metabolites from tissues. In face of "leaking while infusing", heavy accumulation of fluid in the third spaces may worsen the cell hypoxia. Some of the parameters we get from invasive monitoring systems can be misleading. Now, the trend of overloading should be prevented, and it behaves us to study the regime of lower fluid volume with proper contents in burn shock resuscitation.

Xia, Z. F. and G. Y. Wang (2008). "[Discussion on the fluid resuscitation and monitoring during burn shock period]." Zhonghua Shao Shang Za Zhi 24(4): 241-4.

               The index of monitoring burn shock resuscitation includes clinical signs and symptoms, laboratory examinations, hemodynamic variables. In recent years, there exists a tendency that the amount of transfused fluid for burn shock resuscitation is notably increased and complications of some cases, such as abdominal compartment syndrome have been reported. One of the major reasons for excessive fluid resuscitation is to try to normalize hemodynamic parameters with the help of invasive hemodynamic monitoring. Instead of hemodynamic variables, urinary output combined with other traditional variables still should be considered primary criteria of adequate fluid therapy. Specification of the variables of monitoring burn shock resuscitation is also the basis to revise and optimize the fluid resuscitation formula.

Yokoyama, A., N. Dairaku, et al. (2008). "[Autopsy case of abdominal compartment syndrome in a patient with schizophrenia]." Nippon Shokakibyo Gakkai Zasshi 105(8): 1205-12.

               A 61-year-old man who had taken several kinds of psychotropic agents for schizophrenia from eighteen was admitted due to acute abdomen. In spite of any treatment he died after arrival. The autopsy revealed marked dilation of gastrointestinal tracts without necrosis through stomach to rectum and pathological examination disclosed hypoganglionosis of whole gastrointestinal wall. We thought that he died of abdominal compartment syndrome as a result of acute on chronic secondary pseudo-obstruction of gastrointestinal tracts due to acquired hypoganglionosis, megacolon, and aerophagia.

Zengerink, I., P. B. McBeth, et al. (2008). "Validation and experience with a simple continuous intra-abdominal pressure measurement technique in a multidisciplinary medical/surgical critical care unit." J Trauma 64(5): 1159-64.

               BACKGROUND: Raised intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) may induce many adverse effects including the abdominal compartment syndrome. We evaluated a new technique for continuous monitoring of intra-abdominal pressure (CIAP) using a standard three-way bladder catheter in a diverse group of intensive care unit patients. METHODS: CIAP measured using a standard three-way bladder catheter was compared with five standard intermittent IAP (IIAP) measurements in 79 patients. RESULTS: Mean (standard deviation) CIAP was identical (15.4 mm Hg [5.8]) for CIAP and IIAP one minute after saline injection. Mean differences between methods were less than 1 mm Hg, and similar whether IIAP was measured at 1 minute, 2 minutes, 3 minutes, 4 minutes, or 5 minutes. Bland-Altman analysis comparing CIAP and IIAP (1 minute) revealed a mean difference (95% confidence interval) of -0.06 mm Hg (-0.51, 0.39). Limits of agreement were -4.12 mm Hg to 4.00 mm Hg. Considering gradations of IAH defined by the World Society of the Abdominal Compartment Syndrome, CIAP was sensitive for detecting slightly elevated IAP (>11 mm Hg) but is less sensitive for distinguishing between higher grades of IAH (e.g., pressures >20 mm Hg or 25 mm Hg). Limits of agreement were best for patients with IAP less than 20 mm Hg, surgical or traumatic diagnoses and for patients with BMI less than 26. CONCLUSIONS: Overall, CIAP is an accurate and simple means of measuring IAP when compared with the current standardized method. Elevated CIAP measurements should be confirmed with IIAP measurements if accurate grading is required until further validation and experience is obtained.

Zhang, M. J., G. L. Zhang, et al. (2008). "Treatment of abdominal compartment syndrome in severe acute pancreatitis patients with traditional Chinese medicine." World J Gastroenterol 14(22): 3574-8.

               AIM: To investigate the therapeutic effect of traditional Chinese traditional medicines Da Cheng Qi Decoction (Timely-Purging and Yin-Preserving Decoction) and Glauber's salt combined with conservative measures on abdominal compartment syndrome (ACS) in severe acute pancreatitis (SAP) patients. METHODS: Eighty consecutive SAP patients, admitted for routine non-operative conservative treatment, were randomly divided into study group and control group (40 patients in each group). Patients in the study group received Da Cheng Qi Decoction enema for 2 h and external use of Glauber's salt, once a day for 7 d. Patients in the control group received normal saline (NS) enema. Routine non-operative conservative treatments included non-per os nutrition (NPON), gastrointestinal decompression, life support, total parenteral nutrition (TPN), continuous peripancreatic vascular pharmaceutical infusion and drug therapy. Intra-cystic pressure (ICP) of the two groups was measured during treatment. The effectiveness and outcomes of treatment were observed and APACHE II scores were applied in analysis. RESULTS: On days 4 and 5 of treatment, the ICP was lower in the study group than in the control group (P < 0.05). On days 3-5 of treatment, acute physiology and chronic health evaluation II (APACHE II) scores for the study and control groups were significantly different (P < 0.05). Both the effectiveness and outcome of the treatment with Da Cheng Qi Decoction on abdominalgia, burbulence relief time, ascites quantity, cyst formation rate and hospitalization time were quite different between the two groups (P < 0.05). The mortality rate for the two groups had no significant difference. CONCLUSION: Da Cheng Qi Decoction enema and external use of Glauber's salt combined with routine non-operative conservative treatment can decrease the intra-abdominal pressure (IAP) of SAP patients and have preventive and therapeutic effects on abdominal compartment syndrome of SAP.