Risk factors and outcome of intra-abdominal hypertension in patients with severe acute pancreatitis. World J Surg. 2012;36:171-178. [PMID: 21964817 DOI: 10.1007/s00268-011-1295-0]

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to 60% and ACS in 15% to 30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiology of IAH/ACS development in patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and the management of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

The Role of Short-Chain Fatty Acids in Acute Pancreatitis

Acute pancreatitis (AP) is a digestive emergency and can develop into a systematic illness. The role of the gut in the progression and deterioration of AP has drawn much attention from researchers, and areas of interest include dysbiosis of the intestinal flora, weakened intestinal barrier function, and bacterial and endotoxin translocation. Short-chain fatty acids (SCFAs), as one of the metabolites of gut microbiota, have been proven to be depleted in AP patients. SCFAs help restore gut homeostasis by rebuilding gut flora, stabilizing the intestinal epithelial barrier, and regulating inflammation. SCFAs can also suppress systematic inflammatory responses, improve the injured pancreas, and prevent and protect other organ dysfunctions. Based on multiple beneficial effects, increasing SCFAs is an essential idea of gut protective treatment in AP. Specific strategies include the direct use of butyrate or indirect supplementation through fiber, pre/pro/synbiotics, or fecal microbiota transplantation as a promising adjective therapy to enteral nutrition.

Evaluation of Intra-Abdominal Hypertension Parameters in Patients with Acute Pancreatitis

BACKGROUND

Patients with acute pancreatitis develop numerous complications and organ damage due to increased intra-abdominal pressure (IAP). These extrapancreatic complications determine the clinical outcome of the disease.

MATERIALS AND METHODS

A total of 100 patients with acute pancreatitis were included in the prospective cohort study. Observed patients were divided into two groups according to their mean values of IAP (normal IAP values and elevated IAP values), which were compared with examined variables. Patients with intra-abdominal hypertension (IAH) were divided into four groups by IAP values, and those groups of patients were also compared with the examined variables.

RESULTS

Differences between body mass index (BMI) (p = 0.001), lactates (p = 0.006), and the Sequential Organ Failure Assessment (SOFA) score (p = 0.001) were statistically significant within all examined IAH groups. Differences between the mean arterial pressure (MAP) (p = 0.012) and filtration gradient (FG) (p < 0.001) were statistically significant between the first and second IAH groups in relation to the fourth. Differences in diuresis per hour (p = 0.022) showed statistical significance in relation to the first and third groups of IAH patients.

CONCLUSIONS

Changes in IAP values lead to changes in basic vital parameters MAP, APP, FG, diuresis per hour, and lactate levels in patients with acute pancreatitis. Early recognition of changes in the SOFA score accompanying an increase in the IAP value is essential.

Abdominal paracentesis drainage improves outcome of acute pancreatitis complicated with intra-abdominal hypertension in early phase

BACKGROUND

Intra-abdominal hypertension (IAH) is an important risk factor for organ dysfunction, and it occurs in the early phase of severe acute pancreatitis (SAP). We have reported a novel step-up approach and shown the benefit of performing abdominal paracentesis drainage (APD) ahead of percutaneous catheter drainage (PCD) when treating Patients with SAP with fluid collections. This study aimed to evaluate the efficacy of APD in Patients with SAP complicated with IAH in the early phase.

METHODS

In the present study, 206 AP patients complicated with IAH in the early phase were enrolled in hospital between June 2017 and December 2020. The patients were divided into two groups: 109 underwent APD (APD group) and 97 were managed without APD (non-APD group). We retrospectively compared the outcomes of the APD and non-APD groups for IAH treatment. The parameters including mortality, infection, organ failure, inflammatory factors, indications for further interventions, and drainage-related complications were observed.

RESULTS

The demographic data and severity scores of the two groups were comparable. The mortality rate was lower in the APD group (3.7%) than in the non-APD group (8.2%). Compared with the non-APD group, the intra-abdominal pressure and laboratory parameters of the APD group decreased more rapidly, and the mean number of failed organs was lower. However, there was no significant difference in incidence of infections between the two groups.

CONCLUSIONS

Application of APD is beneficial to AP patients. It significantly attenuated inflammation injury, avoided further interventions, and reduced multiple organ failure.

Fluid Management, Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome: A Narrative Review

BACKGROUND

General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear.

OBJECTIVES

This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS).

METHODS

We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH.

RESULTS

We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality.

CONCLUSIONS

Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

Impact of intra-abdominal pressure on early kidney transplant outcomes

Increased intra-abdominal pressure (IAP) is common among post-surgical patients and may cause organ dysfunction. However, its impact after kidney transplantation on early postoperative complications and graft recovery remains unclear. We designed a prospective, observational cohort study to describe the prevalence and determinants of IAP, as well as its effect on delayed graft function, postoperative complications, and graft recovery. IAP was measured in 205 kidney transplant recipients every 8 h during the first 72 h after surgery using the urinary bladder technique. Intra-abdominal hypertension was defined as IAP ≥ 12 mmHg. Patients were followed for 6 months or until graft failure/death. Mean IAP was 12 ± 3.3 mmHg within the first 24 h. 78% of subjects presented with intra-abdominal hypertension during the first 72 h. Increased IAP was associated with higher renal resistive index [r = 0.213; P = 0.003] and lower urine output [r =  - 0.237; P < 0.001]. 72 h mean IAP was an independent risk factor for delayed graft function [OR: 1.31; 95% CI: 1.13-1.51], postoperative complications [OR: 1.17; 95% CI: 1.03-1.33], and absence of graft function recovery [HR for graft function recovery: 0.94; 95% CI: 0.88-0.99]. Increased IAP was highly prevalent after transplantation and was independently associated with delayed graft function, postoperative complications, and absence of graft function recovery. Routine IAP monitoring should be considered post-transplantation to facilitate early recognition of relevant complications.

Who would benefit from open abdomen in severe acute pancreatitis?-a matched case-control study

BACKGROUND

Selection of patients for open abdomen (OA) treatment in severe acute pancreatitis (SAP) is challenging. Treatment related morbidity and risk of adverse events are high; however, refractory abdominal compartment syndrome (ACS) is potentially lethal. Factors influencing the decision to initiate OA treatment are clinically important. We aimed to study these factors to help understand what influences the selection of patients for OA treatment in SAP.

METHODS

A single center study of patients with SAP that underwent OA treatment compared with conservatively treated matched controls.

RESULTS

Within study period, 47 patients treated with OA were matched in a 1:1 fashion with conservatively treated control patients. Urinary output under 20 ml/h (OR 5.0 95% CI 1.8-13.7) and ACS (OR 4.6 95% CI 1.4-15.2) independently associated with OA treatment. Patients with OA treatment had significantly more often visceral ischemia (34%) than controls (6%), P = 0.002. Mortality among patients with visceral ischemia was 63%. Clinically meaningful parameters predicting developing ischemia were not found. OA treatment associated with higher overall 90-day mortality rate (43% vs 17%, P = 0.012) and increased need for necrosectomy (55% vs 21%, P = 0.001). Delayed primary fascial closure was achieved in 33 (97%) patients that survived past OA treatment.

CONCLUSION

Decreased urine output and ACS were independently associated with the choice of OA treatment in patients with SAP. Underlying visceral ischemia was strikingly common in patients undergoing OA treatment, but predicting ischemia in these patients seems difficult.

Computed tomography features predictive of intra-abdominal hypertension in acute necrotizing pancreatitis: A prospective study

BACKGROUND

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in acute pancreatitis (AP) are associated with development and worsening of organ failures and poor prognosis. Limited studies suggest that contrast-enhanced computed tomography (CECT) can predict the presence of IAH/ACS. We aimed to study clinical profile of patients with AP and IAH and identify predictive factors of IAH on CECT abdomen.

METHODS

Consecutive patients admitted with moderately severe and severe acute pancreatitis (SAP) were recruited. Clinical and radiological data were recorded prospectively. Intra-abdominal pressure was measured via a urinary catheter to document the presence of IAH/ACS. CECT abdomen was done within the first week of admission and various features that may predict the presence of IAH were studied.

RESULTS

Thirty-seven patients (24 SAP) (mean age: 39.78 ± 13.43 years and 67.6% males) with  AP were studied. The most common etiology was alcohol (37.7%). IAH developed in 54.05% of patients; patients with IAH had significantly higher bedside index of severity in AP (BISAP), Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) score, persistent acute lung injury (ALI), persistent acute kidney injury (AKI), persistent cardiovascular failure (CVSF), intensive care unit (ICU) stay, and mortality. Among the CT predictors, patients with IAH more commonly had moderate-gross ascites (60% vs. 23.5%, p-value - 0.026), a pancreatic necrosis of > 50% (50% vs. 17.6%, p-value - 0.04), and a round belly sign (RBS) (50% vs. 5.9%, p-value 0.03). On multivariate analysis, only RBS was predictive of  IAH (odds ratio 12.6, 95% confidence interval 1.3-124.2, p-value 0.03). The sensitivity, specificity, positive predictive value, and negative predictive value for RBS were 50%, 94.12%, 90.9%, and 61.54%, respectively.

CONCLUSION

Presence of RBS, moderate-gross ascites, and pancreatic necrosis of > 50% on CECT can predict the presence of IAH in these groups of patients.

Computed Tomography Findings in Intraabdominal Hypertension in Patients with Acute Pancreatitis

Purpose  Intraabdominal hypertension (IAH) in acute pancreatitis (AP) may reduce tissue perfusion and impair organ function and has been shown to portend poor prognosis. We investigated the computed tomography (CT) findings in patients with AP with IAH. Methods  This retrospective study comprised of consecutive patients with AP from June 2016 to June 2018 in whom intraabdominal pressure (IAP) was measured. The patients who underwent a contrast-enhanced CT within 7 days of IAP measurement were included. Using a cutoff of 12 mm Hg for IAP, the patients were divided into IAH and non-IAH groups. Measures of severity and clinical outcome were evaluated. CT parameters were compared between the groups. Results  The IAH group comprised of 41 patients, while there were 20 patients in the non-IAH group. The IAH group was characterized by severe disease, increased incidence of organ failure, increased requirement for drainage and surgery, prolonged hospital and intensive care unit stay. The mortality was not significantly different between the two groups. On univariate analysis, the CT features that were found to be significantly different between the two groups were the presence of collection ( p = 0.036), the maximum dimension of collection ( p = 0.004), volume of collection ( p = 0.019), biliary dilatation ( p = 0.011), and the presence of moderate-to-severe pleural effusion ( p = 0.009). On multivariate analysis, all these parameters except biliary dilatation were found to be statistically significant. Conclusion  CT findings in patients with AP may suggest IAH. This can be used as an additional marker for severity of AP.

Early on-demand drainage or standard management for acute pancreatitis patients with acute necrotic collections and persistent organ failure: A pilot randomized controlled trial

BACKGROUND/PURPOSE

The current standard care for acute pancreatitis with acute necrotic collections (ANC) is to postpone invasive intervention for 4 weeks when indicated. However, in patients with persistent organ failure (POF), this delayed approach may prolong organ failure. In this study, we aimed to assess the feasibility and safety of earlier drainage for acute pancreatitis patients with ANC and POF.

METHODS

A single-center, randomized controlled trial was conducted. Eligible patients were randomly assigned to either the early on-demand (EOD) group or the standard management (SM) group. Within 21 days of randomization, early drainage was triggered by unremitted or worsening organ failure in the EOD group. The primary endpoint was a composite of major complications/death during 90-days follow-up.

RESULTS

Thirty patients were randomized. Within 21 days of randomization, eight of the 15 patients (53%) in the EOD group underwent percutaneous drainage compared to four of the 15 patients (27%) in the SM group (P = 0.26). The primary outcome occurred in three of the 15 (20%) patients in the EOD group and seven of the 15(46.7%) in the controls (P = 0.25, relative risk 0.43, 95%CI 0.14 to 1.35).

CONCLUSIONS

Although the EOD approach did not result in significant differences between groups, the primary outcome assessed in this trial demonstrated the potential for clinical benefits favoring early drainage.

Management of abdominal compartment syndrome in acute pancreatitis

Abdominal compartment syndrome (ACS), defined by the presence of increased intra-abdominal pressure>20mmHg in association with failure of at least one organ system, is a common and feared complication that may occur in the early phase of severe acute pancreatitis (AP). This complication can lead to patient death in the very short term. The goal of this review is to provide the surgeon and intensivist with objective information to help them in their decision-making. In the early phase of severe AP, it is essential to monitor intra-vesical pressure (iVP) to allow early diagnosis of intra-abdominal hypertension or ACS. The treatment of ACS is both medical and surgical requiring close collaboration between the surgical and resuscitation teams. Medical treatment includes vascular volume repletion, prokinetic agents, effective curarization and percutaneous drainage of large-volume ascites. If uncontrolled respiratory or cardiac failure develops or if maximum medical treatment fails, most teams favor performing an emergency xipho-pubic decompression laparotomy with laparostomy. This procedure follows the principles of abbreviated laparotomy as described for abdominal trauma.

Effect of Clostridium butyricum and Butyrate on Intestinal Barrier Functions: Study of a Rat Model of Severe Acute Pancreatitis With Intra-Abdominal Hypertension

BACKGROUND/AIMS

Severe acute pancreatitis (SAP) is associated with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), but treatment of these conditions is difficult. We studied a rat model of SAP + IAH to determine the effect of oral administration of Clostridium butyricum and butyrate (its major metabolite) on intestinal barrier functions.

METHODS

A total of 48 rats were assigned to four groups, with 12 rats per group: Sham, SAP+IAH, SAP+IAH+C. butyricum, and SAP + IAH + butyrate. SAP was induced by sodium taurocholate infusion into the biliopancreatic duct, intra-abdominal pressure (IAP), mortality was measured 24 h later, and then rats were euthanized. The plasma levels of several markers [amylase, diamine oxidase (DAO), fluorescein isothiocyanate (FITC)-dextran, tumor necrosis factor alpha (TNF-α), interleukin (IL)-6, IL-1β, IL-12, lipopolysaccharide (LPS)] and fecal butyric acid level were determined. The pancreas and intestine were examined using histology, and RT-PCR and Western blotting of intestinal tissues were used to measure the expression of six markers {tight junction proteins [zonula occludens protein-1 (ZO-1), claudin-1, claudin-2, occluding], matrix metalloproteinase 9 [MMP9], and TNF-α}. The gut flora of the rats was examined by 16S rRNA sequencing.

RESULTS

Induction of SAP + IAH altered several functions of the intestinal barrier, and enhanced intestinal permeability, decreased the levels of ZO-1, claudin-1, occludin, the richness and diversity of the microflora community, the relative abundance (RA) of Firmicutes, and the number of probiotic organisms. However, induction of SAP+IAH increased the expression of claudin-2, MMP9, and TNF-α, and the RA of Proteobacteria and pathogens in the feces. Rats that received oral C. butyricum or butyrate had reduced intestinal injury and plasma levels of DAO, LPS, and inflammatory cytokines.

CONCLUSION

This study of rats with SAP+IAH indicated that oral dosing of C. butyricum or butyrate reduced intestinal injury, possibly by altering the functions of the intestinal mucosal barrier.

Early Rapid Fluid Therapy Is Associated with Increased Rate of Noninvasive Positive-Pressure Ventilation in Hemoconcentrated Patients with Severe Acute Pancreatitis

BACKGROUND/AIMS

Hematocrit is a widely used biomarker to guide early fluid therapy for patients with acute pancreatitis (AP), but there is controversy over whether early rapid fluid therapy (ERFT) should be used in hemoconcentrated patients. This study investigated the association of hematocrit and ERFT with clinical outcomes of patients with AP.

METHODS

Data from prospectively maintained AP database and retrospectively collected fluid management details were stratified according to actual severity defined by revised Atlanta classification. Hemoconcentration and "early" were defined as hematocrit > 44% and the first 6 h of general ward admission, respectively, and "rapid" fluid rate was defined as ≥ 3 ml/kg/h. Patients were allocated into 4 groups for comparisons: group A, hematocrit ≤ 44% and fluid rate < 3 ml/kg/h; group B, hematocrit ≤ 44% and fluid rate ≥ 3 ml/kg/h; group C, hematocrit > 44% and fluid rate < 3 ml/kg/h; and group D, hematocrit > 44% and fluid rate ≥ 3 ml/kg/h. Primary outcome was rate of noninvasive positive-pressure ventilation (NPPV).

RESULTS

A total of 912 consecutive AP patients were analyzed. ERFT has no impact on clinical outcomes of hemoconcentrated, non-severe or all non-hemoconcentrated AP patients. In hemoconcentrated patients with severe AP (SAP), ERFT was accompanied with increased risk of NPPV (odds ratio 5.96, 95% CI 1.57-22.6). Multivariate regression analyses confirmed ERFT and hemoconcentration were significantly and independently associated with persistent organ failure and mortality in patients with SAP.

CONCLUSIONS

ERFT is associated with increased rate of NPPV in hemoconcentrated patients with SAP.

Evaluation and Management of Abdominal Compartment Syndrome in the Emergency Department

BACKGROUND

Abdominal compartment syndrome is a potentially deadly condition that can be missed in the emergency department setting.

OBJECTIVE

The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of abdominal compartment syndrome with a focus on emergency clinicians.

DISCUSSION

Abdominal compartment syndrome is caused by excessive pressure within the abdominal compartment due to diminished abdominal wall compliance, increased intraluminal contents, increased abdominal contents, or capillary leak/fluid resuscitation. History and physical examination are insufficient in isolation, and the gold standard is intra-abdominal pressure measurement. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of end-organ injury. Management involves increasing abdominal wall compliance (e.g., analgesia, sedation, and neuromuscular blocking agents), evacuating gastrointestinal contents (e.g., nasogastric tubes, rectal tubes, and prokinetic agents), avoiding excessive fluid resuscitation, draining intraperitoneal contents (e.g., percutaneous drain), and decompressive laparotomy in select cases. Patients are critically ill and often require admission to a critical care unit.

CONCLUSIONS

Abdominal compartment syndrome is an increasingly recognized condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Mortality predictors of patients suffering of acute pancreatitis and development of intraabdominal hypertension

Background/aim

Intraabdominal hypertension (IAH) occurs frequently in patients with acute pancreatitis and adds to their morbidity and mortality. The main aim of the study was to identify the determination of the predictive factors connected to IAH that influence the evolution of acute pancreatitis.

Materials and methods

The prospective cohort study was conducted on 100 patients who had acute pancreatitis. According to obtained intraabdominal pressure (IAP) values, the patients were divided into two groups: one group (n = 40) with normal IAP values and the other (IAH group, n = 60) with increased IAP values. Deceased patients were specially analyzed within the IAH group in order to determine mortality predictors.

Results

Statistical significance of IAP (P = 0.048), lactates (P = 0.048), peak pressure (P = 0.043), abdominal perfusion pressure (P = 0.05), and mean arterial pressure (P = 0.041) was greater for deceased than for surviving patients in the IAH group. High mortality appears for patients younger than 65 years old, with lactate level higher than 3.22 mmol/L and filtration gradient (GF) lower than 67 mmHg.

Conclusion

Age, lactates, GF, and APACHE II score are determined as mortality predictors for patients suffering from acute pancreatitis who developed IAH. The mortality rate is higher when the level of GF is decreasing and the level of lactate increasing.

Development and validation of a multivariate prediction model for patients with acute pancreatitis in Intensive Care Medicine

BACKGROUND/OBJECTIVES

Development and validation of a multivariate prediction model for patients with acute pancreatitis (AP) admitted in Intensive Care Units (ICU).

METHODS

A prospective multicenter observational study, in 1 year period, in 46 international ICUs (EPAMI study).

PATIENTS

adults admitted to an ICU with AP and at least one organ failure.

INTERVENTIONS

Development of a multivariate prediction model, using the worst data of the stay in ICU, based in multivariate analysis, simple imputation in a development cohort. The model was validated in another cohort.

RESULTS

374 patients were included (mortality of 28.9%). Variables with statistical significance in multivariate analysis were age, no alcoholic and no biliary etiology, development of shock, development of respiratory failure, need of continuous renal replacement therapy, and intra-abdominal pressure. The model created with these variables presented an AUC of ROC curve of 0.90 (CI 95% 0.81-0.94) in the validation cohort. We developed a multivariable prediction model, and AP cases could be classified as low mortality risk (between 2 and 9.5 points, mortality of 1.35%), moderate mortality risk (between 10 and 12.5 points, 28.92% of mortality), and high mortality risk (13 points of more, mortality of 88.37%). Our model presented better AUC of ROC curve than APACHE II (0.91 vs 0.80) and SOFA in the first 24 h (0.91 vs 0.79).

CONCLUSIONS

We developed and validated a multivariate prediction model, which can be applied in any moment of the stay in ICU, with better discriminatory power than APACHE II and SOFA in the first 24 h.

Diaphragmatic dysfunction in sepsis due to severe acute pancreatitis complicated by intra-abdominal hypertension

Objective

This study aimed to examine the mechanism of diaphragmatic dysfunction in sepsis due to severe acute pancreatitis (SAP) with intra-abdominal hypertension (IAH) in a rat model.

Methods

The rats were assigned at random to four groups: (1) control (n = 5), (2) SAP (n = 5), (3) SAP+IAH (n = 5), and (4) SAP+IAH+SS-31 (n = 5). Length and force output of the diaphragm were analysed in vivo. Histopathological examinations were performed by haematoxylin–eosin. Oxidative stress levels related to protease in diaphragmatic mitochondria were detected with a colorimetric technique.

Results

In the septic rat model due to SAP complicated by IAH, myofibres were increased. Muscle contractile function was significantly lower in the SAP+IAH group compared with the SAP and control groups. Glutathione peroxidase and superoxide dismutase levels were significantly lower and malondialdehyde levels were higher in the SAP and SAP+IAH groups compared with the control group. Notably, SS-31 could reverse atrophy of myofibres in SAP+IAH rats, as well as contractile dysfunction and mitochondrial dysfunction in the diaphragm.

Conclusions

Diaphragmatic structure and biomechanics are altered in septic rats due to SAP and IAH. This finding is mainly due to an increase in release of mitochondrial reactive oxygen species.

The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis: A retrospective cohort study

PURPOSE

To explore clinical characteristics and long-term quality of life (QOL) in severe acute pancreatitis (SAP) patients with persistent inflammation-immunosuppression and catabolism syndrome (PICS).

MATERIALS AND METHODS

SAP patients admitted to ICU were eligible for the retrospective cohort study if they needed prolonged intensive care (>14days). Post-ICU QOL was assessed by a questionnaire, including 36-item Short Form Health Survey (SF-36) and record of re-work in a long-term follow-up.

RESULTS

214 SAP patients were enrolled, in which 149 (69.6%) patients met the criteria of PICS. PICS patients had more complications and ICU days compared to non-PICS patients (P<0.001), and their post-ICU mortality was higher (P=0.046). When adjusted for confounders, PICS was independently associated with higher post-ICU mortality (hazard ratio 4.5; 95% CI, 1.2 to 16.3; P=0.024). The 36-item Short Form Health Survey (SF-36) score was lower for PICS group in six subscales (P<0.001). Only 28.8% patients in the PICS group returned to work compared to 60% patients in the non-PICS group (P=0.001) CONCLUSIONS: SAP patients with prolonged ICU stay had a high morbidity of PICS, which was a risk factor for the post-ICU mortality and poor long-term QOL.

Visceral Adiposity Predicts Severity of Acute Pancreatitis

OBJECTIVES

The aim of this study was to determine the association of visceral adiposity with severe outcomes in acute pancreatitis (AP).

METHODS

This retrospective study included consecutive patients with AP admitted to a tertiary care hospital between January 2010 and January 2015 who underwent a computed tomography scan. The visceral adipose tissue (VAT) volume was estimated using the method of Linder and colleagues. Multivariable logistic regression analysis was conducted to assess VAT as a predictor of severe AP compared with other validated predictors of severity.

RESULTS

Five hundred and seventy four patients were admitted during the study period, of which 252 had a computed tomography scan available. Patients with severe AP had a larger VAT area compared with those with mild or moderate AP (mean: 184.9 cm vs 79.9 cm, P = 0.006). Patients who developed multisystem organ failure or had acute necrotic collections had a larger VAT area than those who did not (150.6 cm vs 91.0 cm, P = 0.004 and 174.0 cm vs 91.9 cm, P = 0.003, respectively). Visceral adipose tissue area demonstrated superior discrimination of severe AP compared with other severity predictors.

CONCLUSIONS

Increased VAT area is a strong predictor of severe pancreatitis, necrosis, and multisystem organ failure.

Prevalence and predictors of intra-abdominal hypertension and compartment syndrome in surgical patients in critical care units at Kenyatta National Hospital

BACKGROUND

Intra-abdominal hypertension (IAH) affects almost every organ sytem.If it is not detected early and corrected, mortality would be high. The prevalence of IAH and abdominal compartment syndrome (ACS) at Kenyatta National Hospital (KNH) critical care units is not known. The aim of this sudy was to determine the prevalence and factors associated with development of IAH/ACS among critically ill surgical patients.

METHODS

This was a cross sectional descriptive study involving surgical patients in critical care units at KNH, carried out from March 2015 to October 2015. One hundred and thirteen critically ill and ventilated patients 13 years or older were recruited into the study. Krohn's intravesical method was used to measure intra- abdominal pressure (IAP). Measurements were done at first contact, then at 12 and 24 h. Additional parameters recorded included: laboratory tests such as serum bilirubin and total blood count as well as clinical parameters such as urine output, vital signs and peak airway pressure, among others. Frequency, means and standard deviation were used to describe the data. Categorical variables e.g. age, were analysed using Chi square test and continous variables using student 't' test and Mann Whitney test as appropriate RESULT: A total of 113 consecutive surgical patients admitted to the critical care units were recruited. Of our study population, 71.7% (by IAP max) and 67.3% (by IAP mean) had IAH. Abdominal compartment syndrome (ACS) developed in 4.4% of the population. The following factors were significant determinants of risk of IAH : amount of IV fluids over 24 h (3949.6 vs 2931.1, p = 0.003, adjusted OR 1.0 [1.0-1.002]), haemoglobin values at admission (9.9 vs 12.0, p = <0.012, adjusted OR 0.6 [0.4-0.9]), peak airway pressure (28.4 vs 17.3; p = 0.018, adjusted OR 1.6 [1.1-2.4]) and synchronised intermittent mandatory ventilation (SIMV) (60 vs 32; p = 0.041, adjusted OR 1.4 [0.78-2.04]). Of those who had IAH; age, amount of iv fluids over 24 h, fluid balance and ventilator mode were significant determinants of risk of progression to ACS .

CONCLUSION

The prevalence of intraabdominal hypertension and abdominal compartment syndrome at KNH is high. Clinical parameters pertaining to fluids administration and ventilator mode are siginificant determinants.

Influence of Ventilation Parameters on Intraabdominal Pressure

Introduction

Intraabdominal pressure monitoring is not routinely performed because the procedure assumes some invasiveness and, like other invasive procedures, it needs to have a clear indication to be performed. The causes of IAH are various. Mechanically ventilated patients have numerous parameters set in order to be optimally ventilated and it is important to identify the ones with the biggest interference in abdominal pressure. Although it was stated that mechanical ventilation is a potential factor of high intraabdominal pressure the set parameters which may lead to this diagnostic are not clearly named.

Objectives

To evaluate the relation between intraabdominal pressure and ventilator parameters in patients with mechanical ventilation and to determine the correlation between intraabdominal pressure and body mass index.

Material and method

This is an observational study which enrolled 16 invasive ventilated patients from which we obtained 61 record sheets. The following parameters were recorded twice daily: ventilator parameters, intraabdominal pressure, SpO2, Partial Oxygen pressure of arterial blood. We calculated the Body Mass Index (BMI) for each patient and the volume tidal/body weight ratio for every recorded data point.

Results

We observed a significant correlation between intraabdominal pressure (IAP) and the value of PEEP (p=0.0006). A significant statistical correlation was noted regarding the tidal volumes used for patient ventilation. The mean tidal volume was 5.18 ml/kg. Another significant correlation was noted between IAP and tidal volume per kilogram (p=0.0022). A positive correlation was found between BMI and IAP (p=0.0049), and another one related to the age of the enrolled patients. (p=0.0045).

Conclusions

The use of positive end-expiratory pressures and high tidal volumes during mechanical ventilation may lead to the elevation of intraabdominal pressure, a possible way of reducing this risk would be using low values of PEEP and also low volumes for the setting of ventilation parameters. There is a close positive correlation between the intraabdominal pressure levels and body mass index.

Intra-abdominal pressure: Time ripe to revise management guidelines of acute pancreatitis?

AIM

To systematically review evidence on pathophysiology of intra-abdominal pressure (IAP) in acute pancreatitis (AP) with its clinical correlates.

METHODS

Systematic review of available evidence in English literature with relevant medical subject heading terms on PubMed, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved.

RESULTS

Intra-abdominal hypertension (IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital (prevalence increasing to 50% in those with severe disease). Abdominal compartment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-Biliary-Pancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums (such as fluid therapy, nutrition and antibiotic prophylaxis) with potential to further individualize treatment in AP.

CONCLUSION

We suggest that IAP be given its due place in future practice guidelines and that recommendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH.

Early Predictors of Fluid Sequestration in Acute Pancreatitis: A Validation Study

OBJECTIVES

The primary aim of this retrospective study was to externally validate predictors of increased fluid sequestration at 48 hours (FS⁴⁸) in acute pancreatitis (AP).

METHODS

Patients admitted between January 10 and February 13 with a diagnosis of AP were evaluated. The FS⁴⁸ was calculated as difference between total fluid input and output in the first 48 hours. Predictors of FS⁴⁸, such as young age, alcoholic etiology, hemoconcentration, hyperglycemia, and systemic inflammatory response syndrome (SIRS), and outcomes in AP, such as increased length of stay, acute fluid collection(s), necrosis, and persistent organ failure (POF), were defined in accordance with the previous study. Linear regression analysis was performed to evaluate the association between predictors and outcome.

RESULTS

Two hundred twenty-seven AP patients (mean age, 48 years; 54% men) with a median FS⁴⁸ of 4.2 L were evaluated. Age younger than 40 years, alcoholic etiology, hemoconcentration, and SIRS independently predicted increased FS⁴⁸ (P < 0.05). Increased FS⁴⁸ was associated with persistent SIRS and POF (P < 0.01). There was a significant trend between number of predictors and FS (P < 0.001). The presence of 4 predictors or more was associated with higher rates of persistent SIRS and POF (P < 0.01).

CONCLUSIONS

Our study validated 4 of 5 predictors of increased FS⁴⁸ from the previous study. Presence of 4 predictors or more and increased FS⁴⁸ are both associated with persistent SIRS and POF.

Efficacy of early application of enteral nutrition combined with probiotics in treatment of severe acute pancreatitis

AIM: To assess the efficacy of early enteral nutrition and probiotics in the treatment of severe acute pancreatitis.

METHODS: A retrospective analysis was performed of the clinical data for patients with severe acute pancreatitis treated at our hospital during from January 2011 to December 2014. All patients were given basic treatments such as fasting, gastrointestinal decompression, inhibition of pancreatic secretion, and improving the balance of water and electrolyte. According to the method of nutrition supply, the patients were divided into two groups: an enteral nutrition (EN) group and an enteral nutrition+probiotics (EN + P) group. Inflammatory indicators, nutritional indicators, and the incidence of complications were compared between the two groups.

RESULTS: The patients' general situation and blood tests of the two groups were not significantly different. albumin was significantly higher, and C-reactive protein, C-reactive protein, totalparenteralnutrtion, pancreatic amylase, white blood cell, and endotoxin were significantly lower after treatment than before treatment in both groups (P < 0.05). These changes were significantly better in the EN + P group than in the EN group (P < 0.05). The incidence rates of infection and multiple organ dysfunction were significantly lower in the EN+P group than in the EN group (P < 0.05). The average length of hospital stay and cost were also significantly lower in the EN+P group than in the EN group (P < 0.05).

CONCLUSION: Early enteral nutrition combined with probiotics can not only improve the nutritional status, promote the recovery of gastrointestinal function and reduce the incidence of complications such as infection and multiple organ dysfunction in patients with severe acute pancreatitis, but also shorten the length of hospital stay and reduce the cost.

Clinical update on fluid therapy and nutritional support in acute pancreatitis

BACKGROUND/OBJECTIVES

The aim of this focused review is to provide a valuable and updated source of information for clinical practice on fluid therapy (FT) and nutritional support in acute pancreatitis (AP).

METHODS

The review encompasses important new clinical information that has become available for understanding and offering these specific treatments since the 2013 publication of two guidelines, both the joint International Association of Pancreatology and American Pancreatic Association and the American College of Gastroenterology. The 2015 Revised Japanese Guideline is discussed selectively. To this end, the review is divided into 7 sections, including timing and cause of mortality; severity classification systems; predicting severity; response to treatment; nutritional support; fluid therapy and steps for further research.

CONCLUSIONS

In mild AP, begin oral feeding when nausea, vomiting and abdominal pain are improving. In (predicted) severe AP, feeding decisions should commence by 72 h, offering oral feeding if GI symptoms improve or enteral feeding if patients are symptomatic and/or intolerant to orals. All patients should be offered goal-directed FT during the first 6-12 h of presentation. Cautious FT is advised in those age >55 years or with preexisting organ failure or predictors of developing fluid sequestration.

Abnormal Expression of Urea Transporter Protein in a Rat Model of Hepatorenal Syndrome Induced by Succinylated Gelatin

BACKGROUND

Hepatorenal syndrome (HRS) is a serious complication of advanced chronic liver disease. Abdominal compartment syndrome (ACS) occurs with dysfunction of multiple organs when abdominal pressure increases. Here, we report on a novel model of ACS with ascites and a model of HRS in rats to observe the urea transporter protein (UT) expression in the 2 models.

MATERIAL AND METHODS

A liver cirrhosis model was induced by CCl4. After changes of liver histopathology were observed, rats were injected intraperitoneally with succinylated gelatin to establish a model of ACS and HRS. Then, changes in BUN, Cr, and renal histopathology were detected. Moreover, the UT in ACS and HRS were also quantified.

RESULTS

The surfaces of liver in the cirrhotic group became coarse, with visible small nodules and became yellow and greasy. The normal structure of the hepatic lobules were destroyed, and hyperplasia of fibrotic tissue and pseudo-lobe was observed. The levels of BUN and Cr were significantly increased in rats suffering from ACS and HRS, respectively, compared to their control groups. In addition, the mRNA levels of UT-A2 and UT-A3 decreased in rats with HRS compared to cirrhotic rats. However, there was no significant difference between the mRNA levels of UT-A2, UT-A3, and UT-B in rats with ACS vs. normal rats.

CONCLUSIONS

It is feasible to model ACS in rats by injecting succinylated gelatin into the abdominal cavity. Increasing the intra-abdominal pressure by succinylated gelatin is also a novel approach for modeling HRS in cirrhotic rats. Compared with control rats, there is an abnormal mRNA expression of UT in ACS rats and HRS rats.

Consensus guidelines on severe acute pancreatitis

This Position Paper contains clinically oriented guidelines by the Italian Association for the Study of the Pancreas (AISP) for the diagnosis and treatment of severe acute pancreatitis. The statements were formulated by three working groups of experts who searched and analysed the most recent literature; a consensus process was then performed using a modified Delphi procedure. The statements provide recommendations on the most appropriate definition of the complications of severe acute pancreatitis, the diagnostic approach and the timing of conservative as well as interventional endoscopic, radiological and surgical treatments.

Inverted U-Shaped Relationship between Central Venous Pressure and Intra-Abdominal Pressure in the Early Phase of Severe Acute Pancreatitis: A Retrospective Study

OBJECTIVE

Many studies have indicated that intra-abdominal pressure (IAP) is positively correlated with central venous pressure (CVP) in severe cases. However, although elevated IAP is common in patients with severe acute pancreatitis (SAP), its relationship with CVP remains unclear. Our study aimed to investigate the association of IAP with CVP in early-phase SAP patients.

METHODS

In total, 116 SAP patients were included in this retrospective study. On the first day of hospitalization, blood samples were collected for biochemical examination and cytokine concentration monitoring. Additionally, a urinary catheter and right subclavian vein catheter were inserted for IAP and CVP measurement, respectively. Other routine clinical data were also recorded.

RESULTS

Within 24 hours after hospitalization, CVP fluctuated and increased with increasing IAP up to 15.7 mmHg (P = 0.054) but decreased with increasing IAP when the IAP was > 15.7 mmHg (P < 0.001). After adjusting for abdominal perfusion pressure (APP) and mean arterial pressure (MAP), a similar distribution was observed. An inverted U-shaped trend between IAP and CVP was also present in the groups classified according to the patient's sex, local complications, ascites, and serum amylase levels.

CONCLUSIONS

CVP and IAP have an inverted U-shaped relationship, with a peak at an IAP of 15.7 mmHg in the early phase of SAP. After this peak, CVP decreases as IAP increases. These results have crucial implications for clinical fluid resuscitation in SAP patients. In particular, because one CVP value might be correlated with different IAP values in patients with the same CVP, the volume of fluid needed might be different.

Correlation between expression of 1 α -hydroxylase and hypocalcaemia in rats with severe pancreatitis

OBJECTIVE

To investigate the essential biochemical indices like 1 -hydroxylase and hypocalcaemia in the rats with severe acute pancreatitis and explore the correlation between them.

METHODS

A total of 120 SPF grade Wistar male rats which were in similar physiological status were selected and randomly divided into two groups: sham group (SO group) and severe acute pancreatitis group (SAP group). Then they were divided into 1 h, 3 h, 6 h, and 12 h subgroups according to the killing time. The severe acute pancreatitis model was established by retrograde injection of 5% sodium taurocholate. Serum calcium, serum creatinine, serum urea nitrogen and serum amylase were measured at different time. Serum 1, 25 dihydroxy vitamin D3 level was determined by enzyme linked immunosorbentassay. The expression of 1-hydroxylase protein in the kidney tissue was determined with Western blotting and immunohistochemistry to observe its location. The pathologic features of the kidney tissue section was observed under light microscope and submicroscopic structure of the proximal convoluted tubule epithelial cell was observed under transmission electron microscope.

RESULTS

Compared with the SO group, rats in the SAP group showed continuous pathological injury as time went by. There was significant increase in serum creatinine, serum urea nitrogen and serum amylase in SAP group compared with the SO group 1, 3, 6, 12 hours after the operation (P<0.05). There was significant decrease in serum calcium and 1, 25 dihydroxy vitamin D3 3, 6, 12 hours after the operation (P<0.05). It also showed that the expression of the 1-hydroxylase protein in kidney tissues was upregulated at 1 h, 3 h and decreased at 6 h, 12 h compared with the SO group. The serum calcium, 1, 25 dihydroxy vitamin D3 and the expression of the 1-hydroxylase protein in kidney tissues of the SAP group showed sustaining decrease. Western blotting showed positive correlation between the 1-hydroxylase expression and serum calcium at 3 h, 6 h and 12 h (r=0.976, P<0.001; r=0.948, P<0.001; r=0.742, P=0.001) and also positive correlation between the 1-hydroxylase expression and serum 1, 25 dihydroxy vitamin D3 at 1 h, 3 h, 6 h and 12 h (r=0.935, P<0.001; r=0.952, P<0.001; r=0.917, P<0.001; r=0.874, P<0.001).

CONCLUSIONS

At the early stage of the kidney injury, the expression of 1-hydroxylase in the kidney tissue is reduced with the progress of the disease and the decrease in its activity has a correlation with the hypocalcaemia.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Melanocortin-4 receptor agonists alleviate intestinal dysfunction in secondary intra-abdominal hypertension rat model

BACKGROUND

Intra-abdominal hypertension (IAH) is a potentially life-threatening disease. Melanocortin-4 (MC4) receptor activation exhibits life-saving properties. The aim of the present study was to examine whether treatment with the MC4 receptor agonist RO27-3225 ameliorates intestinal injury in IAH rats.

METHODS

A total of 72 male Sprague-Dawley rats were randomized into six groups. Group 1 was the sham group. Group 2, the sham + RO group, received RO27-3225 (180 μg/kg, intraperitoneally). IAH was induced in group 3, the IAH group, by blood draw (mean arterial pressure = 30 mm Hg for 90 min) followed by shed blood and/or Ringer solution reinfusion. Intra-abdominal pressure was increased to 20 mm Hg by injecting air into the peritoneal cavity. Group 4, the RO group, was administered RO27-3225 at 5 min after blood draw. Groups 5 and 6 were the chlorisondamine (Chl) and HS024 groups, in which the rats were pretreated with the nicotinic acetylcholine receptor antagonist Chl or selective MC4 receptor antagonist (HS024), respectively, at 2 min before RO27-3225 was administered.

RESULTS

RO27-3225 restored mean arterial pressure, reduced tumor necrosis factor-α, and interleukin-1β messenger RNA expression increased by IAH, alleviated histologic damage, and improved superoxide dismutase activity in the intestine. Compared with the IAH group, the levels of intestinal fatty acid-binding protein, intestinal edema and intestinal permeability were lower in the RO group. Furthermore, the RO27-3225 treatment increased the expression of Rho-associated coiled-coil-containing protein kinase 1 and phosphorylated myosin light chain. Chl and HS024 abrogated the protective effects of RO27-3225.

CONCLUSIONS

These data indicate that the MC4 receptor agonist counteracts the intestinal inflammatory response, ameliorating intestinal injury in experimental secondary IAH by MC4 receptor-triggered activation of the cholinergic anti-inflammatory pathway. It may represent a promising strategy for the treatment of IAH in the future.

Fluid balance in sepsis and septic shock as a determining factor of mortality

OBJECTIVE

The objective was to assess whether fluid balance had a determinant impact on mortality rate in a cohort of critically ill patients with severe sepsis or septic shock.

DESIGN

A prospective and observational study was carried out on an inception cohort.

SETTING

The setting was an intensive care unit of a university hospital.

PATIENTS

Patients admitted consecutively in the intensive care unit who were diagnosed with severe sepsis or septic shock were included.

INTERVENTIONS

Demographic, laboratory, and clinical data were registered, as well as time of septic shock onset, illness severity (Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment), and comorbidities. Daily and accumulated fluid balance was registered at 24, 48, 72, and 96 hours. Survival curves representing 28-day mortality were built according to the Kaplan-Meier method.

RESULTS

A total of 42 patients were included in the analysis: men, 64.3%; mean age, 61.8±15.9 years. Septic shock was predominant in 69% of the cases. Positive blood cultures were obtained in 17 patients (40.5%). No age, sex, Sepsis-related Organ Failure Assessment, creatinine, lactate, venous saturation of O2, and troponin differences were observed upon admission between survivors and nonsurvivors. However, higher Simplified Acute Physiology Score II was observed in nonsurvivors, P=.016. Nonsurvivors also showed higher accumulated positive fluid balance at 48, 72, and 96 hours with statistically significant differences. Besides, significant differences (P=.02) were observed in the survival curve with the risk of mortality at 72 hours between patients with greater than 2.5 L and less than 2.5 L of accumulated fluid balance.

CONCLUSIONS

Fluid administration at the onset of severe sepsis or septic shock is the first line of hemodynamic treatment. However, the accumulated positive fluid balance in the first 48, 72, and 96 hours is associated with higher mortality in these critically ill patients.

Predictors of critical acute pancreatitis: a prospective cohort study

Critical acute pancreatitis (CAP) has recently emerged as the most ominous severity category of acute pancreatitis (AP). As such there have been no studies specifically designed to evaluate predictors of CAP. In this study, we aimed to evaluate the accuracy of 4 parameters (Acute Physiology and Chronic Health Evaluation [APACHE] II score, C-reactive protein [CRP], D-dimer, and intra-abdominal pressure [IAP]) for predicting CAP early after hospital admission. During the study period, data on patients with AP were prospectively collected and D-dimer, CRP, and IAP levels were measured using standard methods at admission whereas the APACHE II score was calculated within 24 hours of hospital admission. The receiver-operating characteristic (ROC) curve analysis was applied and the likelihood ratios were calculated to evaluate the predictive accuracy. A total of 173 consecutive patients were included in the analysis and 47 (27%) of them developed CAP. The overall hospital mortality was 11% (19 of 173). APACHE II score ≥11 and IAP ≥13 mm Hg showed significantly better overall predictive accuracy than D-dimer and CRP (area under the ROC curve-0.94 and 0.92 vs. 0.815 and 0.667, correspondingly). The positive likelihood ratio of APACHE II score is excellent (9.9) but of IAP is moderate (4.2). The latter can be improved by adding CRP (5.8). In conclusion, of the parameters studied, APACHE II score and IAP are the best available predictors of CAP within 24 hours of hospital admission. Given that APACHE II score is rather cumbersome, the combination of IAP and CRP appears to be the most practical way to predict critical course of AP early after hospital admission.

Small intestinal smooth muscle cell apoptosis in rats with severe acute pancreatitis

AIM: To investigate whether small intestinal smooth muscle cell apoptosis occurs in rats with severe acute pancreatitis (SAP) and the underlying mechanism.

METHODS: Male SD rats were randomly divided into a sham operation group (SO) and an SAP group. SAP was induced by injecting 3.8% sodium taurocholate solution into the subcapsular region of the pancreas of SD rats. Rats in the SO group were injected with 1 mL/kg normal saline. Forty-eight hours later, pancreatic pathological changes and the transit rate of the small bowel were determined. Cell apoptosis, expression of adenine nucleotide translocator (ANT) mRNA, mitochondrial membrane potential, and cytochrome C (Cyt-C) protein expression in the small intestinal smooth muscle were determined by TUNEL method, RT-PCR, flow cytometry and immunohistochemistry, respectively.

RESULTS: Compared with rats in the SO group, rats in the SAP group developed typical SAP symptoms, with a higher pancreatic pathology score (6.85 ± 1.21 vs 1.13 ± 0.91, P < 0.001). Compared with rats in the SO group, the transit rate of the small intestine was significantly lower (55.91% ± 2.93% vs 68.9% ± 5.69%, P < 0.05), the apoptosis of smooth muscle cells in the small intestine increased significantly (0.056 ± 0.184 vs 0.029 ± 0.038, P < 0.05), the expression of ANT mRNA and Cyt-C protein (0.024 ± 0.001 vs 0.057 ± 0.168, P < 0.001) in the smooth muscle of the small intestine increased significantly, and the mitochondrial membrane potential decreased significantly (5.07 ± 0.92 vs 2.40 ± 0.50, P < 0.05) in the SAP group.

CONCLUSION: The mitochondrial signal transduction pathway contributes to smooth muscle cell apoptosis in the small intestine, which may play a role in small intestinal motility dysfunction in SAP rats.

Abdominal compartment syndrome in severe acute pancreatitis treated with percutaneous catheter drainage

Acute pancreatitis is one of the main causes of intra-abdominal hypertension (IAH). IAH contributes to multiple physiologic alterations and leads to the development of abdominal compartment syndrome (ACS) that induces multiorgan failure. We report a case of ACS in a patient with severe acute pancreatitis. A 44-year-old man who was admitted in a drunk state was found to have severe acute pancreatitis. During management with fluid resuscitation in an intensive care unit, drowsy mentality, respiratory acidosis, shock requiring inotropes, and oliguria developed in the patient, with his abdomen tensely distended. With a presumptive diagnosis of ACS, abdominal decompression through percutaneous catheter drainage was performed immediately. The intraperitoneal pressure measured with a drainage catheter was 31 mm Hg. After abdominal decompression, the multiorgan failure was reversed. We present a case of ACS managed with percutaneous catheter decompression.

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis - an opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.

Early factors associated with fluid sequestration and outcomes of patients with acute pancreatitis

BACKGROUND & AIMS

Predicting level of fluid sequestration could help identify patients with acute pancreatitis (AP) who need more or less aggressive fluid resuscitation. We investigated factors associated with level of fluid sequestration in the first 48 hours after hospital admission in patients with AP and effects on outcome.

METHODS

We analyzed data from consecutive adult patients with AP admitted to the Brigham and Women's Hospital in Boston, Massachusetts, from June 2005 to December 2007 (n = 266) or the Alicante University General Hospital in Spain from September 2010 to December 2012 (n = 137). Level of fluid sequestration in the first 48 hours after hospital admission was calculated by subtracting the total amount of fluid administered and lost in the first 48 hours of hospitalization. Demographic and clinical variables obtained in the emergency department were analyzed to identify factors associated with level of fluid sequestration in the first 48 hours after hospital admission. Outcome assessed included length of hospital stay, acute fluid collection(s), pancreatic necrosis, persistent organ failure, and mortality.

RESULTS

The median level of fluid sequestration in the first 48 hours after hospital admission was 3.2 L (1.4-5 L). The simple and multiple linear regression models showed that younger age, alcohol etiology, hematocrit, glucose, and systemic inflammatory response syndrome were significantly associated with increased levels of fluid sequestration in the first 48 hours after hospital admission. Increased level of fluid sequestration in the first 48 hours was significantly associated with longer hospital stays and higher rates of acute fluid collection, pancreatic necrosis, and persistent organ failure. There was a nonsignificant trend toward a higher level of fluid sequestration in the first 48 hours among patients who died.

CONCLUSION

Age, alcoholic etiology of AP, hematocrit, glucose, and presence of systemic inflammatory response syndrome in the emergency department were independent predictors of increased levels of fluid sequestration in the first 48 hours after hospital admission. These patients have higher risks of local and systemic complications and longer hospital stays.

Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study

BACKGROUND

To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP).

METHODS

Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded.

RESULTS

Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved.

CONCLUSIONS

Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3-4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.

A minimally invasive management for abdominal compartment syndrome in severe acute pancreatitis

Three patients with severe acute pancreatitis (SAP) developed into overt abdominal compartment syndrome (ACS) and confirmed or suspected infection of necrotic tissue. We successfully treated these patients by minimally invasive decompression with the assist of laparoscope after the failures of intensive care treatments. This technique we report here may be another safe and effective management for ACS in SAP.

Severe acute pancreatitis complicated with gastrointestinal dysfunction: Pathogenesis, diagnosis and treatment

Severe acute pancreatitis (SAP) is often associated with gastrointestinal dysfunction, leading to gastrointestinal motility disorders and even gastrointestinal failure, which has an important effect on SAP progression and prognosis, directly influences the outcome of treatment, is an important cause of death in patients with SAP, and moreover, has been one of the important prognostic factors for SAP. This review aims to discuss the pathophysiology, pathogenesis, diagnosis and treatment of SAP with gastrointestinal dysfunction.

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis

Introduction

Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis.

Methods

We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis.

Results

Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients.

Conclusions

Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.

Fluid balance and cardiac function in septic shock as predictors of hospital mortality

INTRODUCTION

Septic shock is a major cause of morbidity and mortality throughout the world. Unfortunately, the optimal fluid management of septic shock is unknown and currently is empirical.

METHODS

A retrospective analysis was performed at Barnes-Jewish Hospital (St. Louis, Missouri). Consecutive patients (n = 325) hospitalized with septic shock who had echocardiographic examinations performed within 24 hours of shock onset were enrolled.

RESULTS

A total of 163 (50.2%) patients with septic shock died during hospitalization. Non-survivors had a significantly larger positive net fluid balance within the 24 hour window of septic shock onset (median (IQR): 4,374 ml (1,637 ml, 7,260 ml) vs. 2,959 ml (1,639.5 ml, 4,769.5 ml), P = 0.004). The greatest quartile of positive net fluid balance at 24 hours and eight days post-shock onset respectively were found to predict hospital mortality, and the greatest quartile of positive net fluid balance at eight days post-shock onset was an independent predictor of hospital mortality (adjusted odds ratio (AOR), 1.66; 95% CI, 1.39 to 1.98; P = 0.004). Survivors were significantly more likely to have mild left ventricular dysfunction as evaluated by bedside echocardiography and non-survivors had slightly elevated left ventricular ejection fraction, which was also found to be an independent predictor of outcome.

CONCLUSIONS

Our data confirms the importance of fluid balance and cardiac function as outcome predictors in patients with septic shock. A clinical trial to determine the optimal administration of intravenous fluids to patients with septic shock is needed.

Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Purpose

To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).

Methods

We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear).

Results

In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation.

Conclusion

Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-013-2906-z) contains supplementary material, which is available to authorized users.

The importance of timing of decompression in severe acute pancreatitis combined with abdominal compartment syndrome

BACKGROUND

Surgical decompression is widely considered as an important treatment in patients with severe acute pancreatitis (SAP) and abdominal compartment syndrome (ACS). Until now, the indication and optimal time of decompression remain unknown, and no experimental data exist, although extremely high mortality has been repeatedly reported in these patients. The aim of this study was to evaluate the effects of three different time points for decompression in a 24-hour lasting porcine model.

METHODS

Following baseline registrations, 32 animals were divided into four groups (8 animals each group) as follows: one SAP-alone group and three SAP + ACS groups, which received decompression at 6, 9, and 12 hours. We used a N2 pneumoperitoneum to increase the intra-abdominal pressure to 25 mm Hg and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and serum biochemical parameters of the animals were studied. At the end of the experiment, histologic examination of the intestine and lung was performed.

RESULTS

The survival time of the 12-hour group was significantly shortened (p = 0.037 vs. 9 hours and p = 0.008 vs. 6 hours). In SAP + ACS animals, decompression at 6 hours restored systemic hemodynamics, oxygen-derived parameters, organ function, and inflammatory intensity to a level comparable with that of the SAP-alone group. In contrast, animals in the 9 hours and 12 hours developed more severe hemodynamic and organ dysfunction. The histopathologic analyses also revealed higher grade injury of the intestine and lung in animals receiving delayed decompression.

CONCLUSION

Well-timed decompression in a porcine model of SAP incorporating 25-mm Hg intra-abdominal hypertension/ACS was associated with significantly reduced mortality, improved systemic hemodynamics and organ function, as well as alleviated histologic injury and inflammatory intensity. According to our results and previous reports, both too early and too late decompression should be avoided owing to significant morbidity for the former and unfavorable outcomes for the latter.

Video-assisted Laparoscopic Débridement for Retroperitoneal Pancreatic Collections: A Reliable Step-up Approach

Several minimal access routes have been implemented as a step-up approach to treat infected pancreatic necrosis. We evaluate our experience with a series of consecutive patients with pancreatic collections treated with video-assisted retroperitoneal débridement (VARD). Seven patients were consecutively treated with VARD: five patients after acute necrotizing pancreatitis, one chronic pancreatitis, and one patient with perforation after endoscopic sphincterotomy. The indication for VARD was: development of sepsis, positive direct culture of the necrosis, and compartment syndrome. The procedure was performed under general anesthesia and modified lateral decubitus. There were four left, two right, and one bilateral VARD. Mean hospital stay since admission to VARD procedure was 30 days (range, 12 to 72 days). Mean operative time was 63 minutes. There were no intraoperative complications. Two patients needed a second procedure to control sepsis. Most patients had a long intensive care unit (ICU) stay with 6.1 days (range, 2 to 22 days) mean postoperative ICU stay. One patient had a hypernatremia as a consequence of saline lavage and three patients presented pancreatic fistula that were managed with conservative treatment. There was no mortality. VARD approach is a recommended step-up approach to treat infected pancreatic necrosis, and its indication may be extended to treat other retroperitoneal collections.