Abdominal compartment syndrome and decompressive laparotomy in children: a 9-year single-center experience

Monitoring and Management of Intra-abdominal Pressure in Critically Ill Children

BACKGROUND

Intra-abdominal hypertension is a comorbid condition in critically ill children, is an independent predictor of mortality, and has harmful effects on multiple organ systems through renal, pulmonary or hemodynamic damage. Intra-abdominal pressure monitoring is widely used in clinical practice because it is a safe, accurate, inexpensive, and rapid method for the clinical diagnosis of intra-abdominal hypertension.

OBJECTIVE

To improve pediatric critical care nurses' understanding of and ability to perform intra-abdominal pressure monitoring and provide a reference for standardizing intra-abdominal pressure monitoring in clinical practice.

METHODS

A literature review was performed using the following keywords: intra-abdominal pressure, bladder pressure, vesicular pressure, measurement, monitoring, critically ill children, pediatric intensive care, pediatric, and children. Four hundred fifty-four articles were initially identified and screened; 24 were included.

RESULTS

The monitoring and management of intra-abdominal pressure should include appropriate and clinically proven intra-abdominal pressure measurement techniques, appropriate patients, the proper frequency of measurement, and a repeatable intra-abdominal pressure measurement method.

CONCLUSIONS

Knowledge of intra-abdominal pressure monitoring in critically ill children enhances the ability of nurses in clinical practice to accurately measure intra-abdominal pressure to improve the timeliness and accuracy of clinical identification of intra-abdominal hypertension and guide decompression interventions.

Incidence and Mortality of Pediatric Abdominal Compartment Syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is the presence of intra-abdominal hypertension with systemic, multiorgan effects and is associated with high mortality, yet the national incidence and mortality rates of pediatric ACS remain unknown. The aim of this study is to evaluate the incidence and mortality of pediatric ACS over a 13-year period across multiple children's hospitals and between individual children's hospitals in the United States.

METHODS

We performed a retrospective cohort study on children (aged < 18 y) with ACS in the Pediatric Health Information Systems database from 2007 to 2019. We identified ACS patients by International Classification of Diseases codes in the ninth and 10th revision. The primary outcomes were incidence and mortality, which were analyzed by year, age, and hospital of admission.

RESULTS

Across 49 children's hospitals, we identified 2887 children with ACS from 2007 to 2019 in the Pediatric Health Information Systems database. The overall incidence of ACS was 0.17% and the overall mortality was 48.87%. There was no significant difference in annual incidence (P = 0.12) or mortality (P = 0.39) over the study period. There was no difference in incidence across age group (P = 0.38); however, mortality in patients 0-30 d old (58.61%) was significantly higher than older age groups (P < 0.0001). The hospital-specific incidence (0.04%-0.46%) and mortality (28.57%-71.43%) varied widely.

CONCLUSIONS

The annual incidence and mortality of pediatric ACS are unchanged from 2007 to 2019. ACS mortality remains high, especially in neonatal intensive care unit patients. No obvious correlation is seen between incidence rates and mortality. Differing hospital-specific incidence and mortality could suggest inconsistencies between institutions that affect pediatric ACS care, perhaps with respect to recognition and diagnosis.

Awareness and diagnosis for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in neonatal (NICU) and pediatric intensive care units (PICU) - a follow-up multicenter survey

BACKGROUND

Constantly elevated intra-abdominal pressure (IAH) can lead to abdominal compartment syndrome (ACS), which is associated with organ dysfunction and even multiorgan failure. Our 2010 survey revealed an inconsistent acceptance of definitions and guidelines among pediatric intensivists regarding the diagnosis and treatment of IAH and ACS in Germany. This is the first survey to assess the impact of the updated guidelines on neonatal/pediatric intensive care units (NICU/PICU) in German-speaking countries after WSACS published those in 2013.

METHODS

We conducted a follow-up survey and sent 473 questionnaires to all 328 German-speaking pediatric hospitals. We compared our findings regarding awareness, diagnostics and therapy of IAH and ACS with the results of our 2010 survey.

RESULTS

The response rate was 48% (n = 156). The majority of respondents was from Germany (86%) and working in PICUs with mostly neonatal patients (53%). The number of participants who stated that IAH and ACS play a role in their clinical practice rose from 44% in 2010 to 56% in 2016. Similar to the 2010 investigations, only a few neonatal/pediatric intensivists knew the correct WSACS definition of an IAH (4% vs 6%). Different from the previous study, the number of participants who correctly defined an ACS increased from 18 to 58% (p < 0,001). The number of respondents measuring intra-abdominal pressure (IAP) increased from 20 to 43% (p < 0,001). Decompressive laparotomies (DLs) were performed more frequently than in 2010 (36% vs. 19%, p < 0,001), and the reported survival rate was higher when a DL was used (85% ± 17% vs. 40 ± 34%).

CONCLUSIONS

Our follow-up survey of neonatal/pediatric intensivists showed an improvement in the awareness and knowledge of valid definitions of ACS. Moreover, there has been an increase in the number of physicians measuring IAP in patients. However, a significant number has still never diagnosed IAH/ACS, and more than half of the respondents have never measured IAP. This reinforces the suspicion that IAH and ACS are only slowly coming into the focus of neonatal/pediatric intensivists in German-speaking pediatric hospitals. The goal should be to raise awareness of IAH and ACS through education and training and to establish diagnostic algorithms, especially for pediatric patients. The increased survival rate after conducting a prompt DL consolidates the impression that the probability of survival can be increased by timely surgical decompression in the case of full-blown ACS.

Intra-Abdominal Hypertension and Compartment Syndrome after Pediatric Liver Transplantation: Incidence, Risk Factors and Outcome

In pediatric liver transplantation (pLT), the risk for the manifestation and relevance of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) is high. This observational study aimed to evaluate the incidence, relevance and risk factors for IAH and ACS by monitoring the intra-abdominal pressure (IAP), macro- and microcirculation (near-infrared spectroscopy (NIRS)), clinical and laboratory status and outcomes of 27 patients (16 female) after pLT (median age at pLT 35 months). Of the patients, 85% developed an elevated IAP, most of them mild. However, 17% achieved IAH° 3, 13% achieved IAH° 4 and 63% developed ACS. A multiple linear regression analysis identified aortal hepatic artery anastomosis and cold ischemia time (CIT) as risk factors for increased IAP and longer CIT and staged abdominal wall closure for ACS. ACS patients had significantly longer mechanical ventilation (p = 0.004) and LOS-PICU (p = 0.003). No significant correlation between NIRS or biliary complications and IAH or ACS could be shown. IAH and ACS after pLT were frequent. NIRS or grade of IAH alone should not be used for monitoring. A longer CIT is an important risk factor for higher IAP and ACS. Therefore, approaches such as the ex vivo machine perfusion of donor organs, reducing CIT effects on them, have great potential. Our study provides important basics for studying such approaches.

Intrauterine intestinal volvulus without malrotation presenting neonatal abdominal compartment syndrome

Introduction

Fetal intestinal volvulus without malrotation is extremely rare, and early prenatal diagnosis is challenging because the signs and symptoms are non-specific. However, without proper management, it can cause massive bowel necrosis.

Presentation of case

A woman experienced a dilated fetal bowel at 34 weeks of pregnancy and noticed a decrease in fetal movements at 36 weeks; however, she did not visit a hospital. Her newborn developed severe abdominal distension and was diagnosed with neonatal abdominal compartment syndrome with respiratory distress immediately after emergency caesarean section at 36 weeks and 5 days of pregnancy. The neonate underwent emergency exploratory laparotomy. This revealed a volvulus of the small bowel with extensive necrosis and no findings of congenital malrotation. While the patient required massive necrotic bowel resection, 80 cm of the small intestine was preserved.

Discussion

Fetal intestinal volvulus without malrotation can cause abdominal compartment syndrome with rapid respiratory distress. Therefore, it should be considered in the differential diagnosis of fetal intestinal dilatation. Volvulus exacerbation risk increases from 30 weeks of pregnancy to late preterm delivery. However, the time lag between the mother's awareness of decreased fetal movement and caesarean section makes early diagnosis challenging, resulting in a life-threatening condition for the neonate.

Conclusion

When a fetal ultrasound examination shows intestinal dilatation between gestational week 30 and late preterm, the mother must be fully informed about the possibility that the foetus has intestinal volvulus and the potential risk of massive fetal intestinal necrosis.

•

Volvulus without malrotation should be considered in fetal bowel dilatation.

•

This can cause abdominal compartment syndrome, resulting in respiratory distress.

•

Fetal bowel dilatation without polyhydramnios is a key finding for early diagnosis.

•

There is a risk of massive fetal bowel necrosis around the late preterm period.

•

Early recognition and informed consent are essential for a good neonatal prognosis.

Case Report: Tachycardia, Hypoxemia and Shock in a Severely Burned Pediatric Patient

Background

Severely burned children are at high risk of secondary intraabdominal hypertension and abdominal compartment syndrome (ACS). ACS is a life-threatening condition with high mortality and requires an effective, minimally invasive treatment to improve the prognosis when the condition is refractory to conventional therapy.

Case presentation

A 4.5-year-old girl was admitted to our hospital 30 h after a severe burn injury. Her symptoms of burn shock were relieved after fluid resuscitation. However, her bloating was aggravated, and ACS developed on Day 5, manifesting as tachycardia, hypoxemia, shock, and oliguria. Invasive mechanical ventilation, vasopressors, and percutaneous catheter drainage were applied in addition to medical treatments (such as gastrointestinal decompression, diuresis, sedation, and neuromuscular blockade). These treatments did not improve the patient's condition until she received continuous renal replacement therapy. Subsequently, her vital signs and laboratory data improved, which were accompanied by decreased intra-abdominal pressure, and she was discharged after nutrition support, antibiotic therapy, and skin grafting.

Conclusion

ACS can occur in severely burned children, leading to rapid deterioration of cardiopulmonary function. Patients who fail to respond to conventional medical management should be considered for continuous renal replacement therapy.

Botulinum Toxin Type A Injection Improves the Intraperitoneal High Pressure in Rats Treated with Abdominal Wall Plasty

The aim of the study is mainly to study the subject of BoNT-A injection to improve IAH in rats undergoing abdominal angioplasty. The study problem in surgery, especially in ICU, burn, and trauma centers, intra-abdominal hypertension (IAH), and abdominal compartment syndrome (ACS) are common complications. At present, there are various treatments for IAH. The intramuscular injection of Botulinum toxin type A (BoNT-A) into the abdominal wall has received a lot of attention. Based on this, this study proposes a method for measuring abdominal pressure, applies BoNT-A to reduce abdominal pressure in the IAH state of abdominal wall angioplasty, and explores a way to increase the compliance of the abdominal wall under the premise of maintaining the sealing of the abdominal cavity, so as to realize the expansion of the abdominal cavity. A method is achieved to reduce intra-abdominal pressure and eliminate or alleviate ACS. The results of the experiment showed that when the rats in the control group were injected with the same amount of normal saline as the rats in the experimental group, the IAP was significantly higher than that in the experimental group (P < 0.05). This shows that BoNT-A increases the compliance of the abdominal wall while maintaining the closure of the abdominal cavity, thereby increasing the volume of the abdominal cavity and alleviating the state of IAH in rats.

Awareness and management of intra-abdominal hypertension and abdominal compartment syndrome by paediatric intensive care physicians: a national survey

INTRODUCTION

This study aimed to evaluate the current awareness and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) among paediatric intensivists.

MATERIAL AND METHODS

A web-based electronic survey was sent to all physicians working in paedia-tric intensive care units (PICUs) in Saudi Arabia. The survey questions obtained information regarding awareness of ACS and IAH, recognition criteria, monitoring of intra-abdominal pressure (IAP), and experience in managing ACS.

RESULTS

A total of 79 physicians responded to the survey (response rate: 53%). Among respondents 48% were consultants. 85% of respondents were familiar with IAP/IAH/ACS. Only 35% and 10% were aware of the Abdominal Compartment Society consensus definitions for IAH and ACS in the paediatric population, respectively. Most respondents considered the cut-off for IAH to be ≥ 15 mm Hg, and approximately two-thirds thought that the cut-off for ACS was higher than the currently suggested consensus definition (10 mm Hg). More than two-thirds of respondents monitored IAP in the PICU, and it was measured almost exclusively via the bladder (96%); the majority (70%) reported that they instilled volumes well above the current recommendations. Medical management was the most frequent therapeutic approach to treat IAH/ACS, while surgical decompression was the least attempted option. Decisions to decompress the abdomen were predominantly based on the presence of organ dysfunction (74.4%).

CONCLUSIONS

This survey showed that although most responding physicians claim to be familiar with IAH and ACS, their knowledge of published consensus definitions, measurement techniques, and clinical management must be updated.