Outcomes in surgical versus medical patients with the secondary abdominal compartment syndrome

Interrelationship between endotoxicosis and syndrome of intraabdominal hypertension in pathogenesis of abdominal sepsis

Objective. Studying of mutual role of the main pathogenetic factors of abdominal sepsis – the inflammation origin and intraabdominal hypertension, from the one side, endotoxicosis and the abdominal compression syndrome (ACS), from the other side. Materials and methods. Into the investigation 196 patients with abdominal sepsis were included, in whom after the certain preliminary preparation the operative procedure was done. The levels of neutrophils, macrophages, interleukin–6, interleukin–10 in peritoneal exudate were studied as indices of the inflammation source for abdominal cavity. These indices were characteristic for systemic answer on general reaction, the degree of which have determined the abdominal sepsis course and result. Determination of intraabdominal pressure was applied for estimation the intraabdominal hypertension role in abdominal sepsis. Results. The ratio of the endotoxicosis and the ACS indices in the complications structure, not dependent on some differences due to the complication type present, was practically similar. Conclusion. The results of the investigation conducted, witnesses the presence of interrelationship of roles of endotoxicosis and the abdominal compression syndrome in pathogenesis of abdominal sepsis, their indices changes are characterized by mutual activity strengthening, accompanied by clinical manifestations of the organs dysfunction, determining the severity of course and result of pathological process in the organism.

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.

Abdominal compartment syndrome: Current concepts and management

Abdominal compartment syndrome occurs when 2 or more anatomic compartments have a sustained intra-abdominal pressure >20mmHg, associated with organ failure. Incidence is 2% and prevalence varies from 0% to 36.4%. A literature search was conducted utilizing different databases. Articles published from 1970 to 2018 were included, in English or Spanish, to provide the concepts, classifications, and comprehensive management in the approach to abdominal compartment syndrome, for its treatment and the prevention of severe complications associated with the entity. Intravesical pressure measurement is the standard diagnostic method. Treatment is based on evacuation of the intraluminal content, identification and treatment of intra-abdominal lesions, improvement of abdominal wall compliance, and optimum administration of fluids and tissue perfusion. Laparotomy is generally followed by temporary abdominal wall closure 5 to 7 days after surgery. Reconstruction is performed 6 to 12 months after the last operation. Abdominal compartment syndrome should be diagnosed and operated on before organic damage from the illness occurs. Kidney injury can frequently progress and is a parameter for considering abdominal decompression. Having a biomarker for early damage would be ideal. Surgical treatment is successful in the majority of cases. A multidisciplinary focus is necessary for the intensive care and reconstructive needs of the patient. Thus, efforts must be made to define and implement strategies for patient quality of life optimization.

Timing of Laparotomy and Closure in Burn Patients with Abdominal Compartment Syndrome: Effects on Survival

BACKGROUND

Survival of burn patients with abdominal compartment syndrome (ACS) is uniformly reported to be poor, averaging just 16% after laparotomy. We hypothesize that better outcomes can be achieved with a strategy of immediate laparotomy and early fascial closure.

STUDY DESIGN

Patients with burn injury who were diagnosed with ACS between 2005 and 2016 were identified through a search of databases. Data were gathered from electronic medical records. Timing of laparotomy and closure were calculated for each patient. Patients were stratified into predefined groups based on timing of laparotomy, cause of ACS, patient age, and timing of abdominal closure. Survival rates were calculated and compared.

RESULTS

Forty-six patients with burn injury and ACS were identified. Abdominal compartment syndrome developed during initial resuscitation in 27 patients, during perioperative resuscitation in 5 patients, and during an episode of sepsis in 13 patients. Overall survival was 56%. Mean time to laparotomy from diagnosis of ACS was 1 hour 8 minutes (SD 59 minutes). When ACS developed in patients during initial resuscitation, the mean time to laparotomy from hospital admission was 13 hours (SD 7 hours). Survival rate in this group was 70%, and survival rate in patients treated for ACS later in their hospital course was 33% (p = 0.03). Survival among patients whose laparotomy was closed within 48 hours was 100%, and survival among patients whose laparotomy was not closed within 48 hours was 48% (p = 0.01).

CONCLUSIONS

Immediate laparotomy resulted in much higher survival rates than previously reported in burn patients with ACS. Survival was higher when ACS was diagnosed during initial resuscitation. Fascial closure within 48 hours was associated with improved survival compared with later fascial closure.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival

BACKGROUND

Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications.

METHODS

Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway.

RESULTS

The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived.

CONCLUSION

Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Intraabdominal Hypertension, Abdominal Compartment Syndrome, and the Open Abdomen

Abdominal compartment syndrome (ACS) is the end point of a process whereby massive interstitial swelling in the abdomen or rapid development of a space-filling lesion in the abdomen (such as ascites or a hematoma) leads to pathologically increased pressure. This results in so-called intraabdominal hypertension (IAH), causing decreased perfusion of the kidneys and abdominal viscera and possible difficulties with ventilation and maintenance of cardiac output. These effects contribute to a cascade of ischemia and multiple organ dysfunction with high mortality. A few primary disease processes traditionally requiring large-volume crystalloid resuscitation account for most cases of IAH and ACS. Once IAH is recognized, nonsurgical steps to decrease intraabdominal pressure (IAP) can be undertaken (diuresis/dialysis, evacuation of intraluminal bowel contents, and sedation), although the clinical benefit of such therapies remains largely conjectural. Surgical decompression with midline laparotomy is the standard ultimate treatment once ACS with organ dysfunction is established. There is minimal primary literature on the pathophysiological underpinnings of IAH and ACS and few prospective randomized trials evaluating their treatment or prevention; this concise review therefore provides only brief summaries of these topics. Many modern studies nominally dealing with IAH or ACS are simply epidemiologic surveys on their incidence, so this paper summarizes the incidence of IAH and ACS in a variety of disease states. Especially emphasized is the fact that modern critical care paradigms emphasize rational limitations to fluid resuscitation, which may have contributed to an apparent decrease in ACS among critically ill patients.

Nutrition Support in the Open Abdomen

Early provision of enteral nutrition (EN) in critically ill and injured patients has become standard practice in surgical intensive care units (ICUs) due to its proven role in reducing septic complications. Increasingly, intensivists are confronted with patients with an open abdomen due to the use of damage control surgery and the recognition of the abdominal compartment syndrome; the role and timing of EN in these challenging patients continue to be debated. Patients with an open abdomen are often among the sickest in the ICU and hence could benefit from early nutrition support. However, the exposed abdominal viscera can understandably create anxiety regarding the initiation of EN; there is theoretic concern over exacerbation of bowel distention with resultant inability to close the abdomen and an increased aspiration risk due to paralytic ileus. Recent studies have investigated the utility of EN in the patient with an open abdomen, addressing these clinical concerns. The goal of this clinical review is to provide guidance to physicians caring for these complex patients.

Postinjury abdominal compartment syndrome: from recognition to prevention

Postinjury abdominal compartment syndrome (ACS) is an example of a deadly clinical occurrence that was eliminated by strategic research and focused preventions. In the 1990s, the syndrome emerged with the widespread use of damage control surgery and aggressive crystalloid-based resuscitation. Patients who previously exsanguinated on the operating table made it to intensive care units, but then developed highly lethal hyperacute respiratory, renal, and cardiac failure due to increased abdominal pressure. Among many factors, delayed haemorrhage control and preload driven excessive use of crystalloid resuscitation were identified as modifiable predictors. The surrogate effect of preventive strategies, including the challenge of the 40-year-old standard of large volume crystalloid resuscitation for traumatic shock, greatly reduced cases of ACS. The discoveries were rapidly translated to civilian and military trauma surgical practices and fundamentally changed the way trauma patients are resuscitated today with substantially improved outcomes.

Management of hemodynamically unstable pelvic trauma: results of the first Italian consensus conference (cooperative guidelines of the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology -Section of Vascular and Interventional Radiology- and the World Society of Emergency Surgery)

Hemodynamically Unstable Pelvic Trauma is a major problem in blunt traumatic injury. No cosensus has been reached in literature on the optimal treatment of this condition. We present the results of the First Italian Consensus Conference on Pelvic Trauma which took place in Bergamo on April 13 2013. An extensive review of the literature has been undertaken by the Organizing Committee (OC) and forwarded to the Scientific Committee (SC) and the Panel (JP). Members of them were appointed by surgery, critical care, radiology, emergency medicine and orthopedics Italian and International societies: the Italian Society of Surgery, the Italian Association of Hospital Surgeons, the Multi-specialist Italian Society of Young Surgeons, the Italian Society of Emergency Surgery and Trauma, the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care, the Italian Society of Orthopaedics and Traumatology, the Italian Society of Emergency Medicine, the Italian Society of Medical Radiology, Section of Vascular and Interventional Radiology and the World Society of Emergency Surgery. From November 2012 to January 2013 the SC undertook the critical revision and prepared the presentation to the audience and the Panel on the day of the Conference. Then 3 recommendations were presented according to the 3 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on a email debate took place until December 2013 to reach a unanimous consent. We present results on the 3 following questions: which hemodynamically unstable patient needs an extraperitoneal pelvic packing? Which hemodynamically unstable patient needs an external fixation? Which hemodynamically unstable patient needs emergent angiography? No longer angiography is considered the first therapeutic maneuver in such a patient. Preperitoneal pelvic packing and external fixation, preceded by pelvic binder have a pivotal role in the management of these patients.

Hemodynamically Unstable Pelvic Trauma is a frequent death cause among people who sustain blunt trauma. We present the results of the First Italian Consensus Conference.

Evaluation of the relationship between pelvic fracture and abdominal compartment syndrome in traumatic patients

INTRODUCTION

An increase in abdominal pressure can lead to so-called intra-abdominal compartment syndrome (ACS). Multiple factors such as an increase in retroperitoneal volume due to pancreatitis, bleeding and edema as a result of pelvic fracture can lead to compartment syndrome. Prevention is better than cure in compartment syndrome. By measuring the intra-abdominal pressure (IAP) through the bladder, a quick and accurate assessment of abdominal pressure is achieved. Therefore, this study aimed to evaluate the relationship between pelvic fracture and ACS in traumatic patients.

MATERIALS AND METHODS

This research was a descriptive-analytical study conducted on 100 patients referring to the Shiraz Nemazee Hospital in 2010. IAP was monitored every 4 h in patients suspected to be at high risk for ACS, e.g., those undergoing severe abdominal trauma and pelvic fracture. The IAP was measured via the urinary bladder using the procedure described by Kron et al. Data collected were analyzed using SPSS software.

RESULTS

The findings showed that ACS occurred in 28 of 100 patients. With regard to the associated injuries with abdominal trauma, 19% of all patients and 46/42% of the patients with ACS had pelvic fracture. Chi-square test revealed a significant relationship between pelvic fracture and incidence rate of ACS (P < 0.001).

CONCLUSIONS

According to the collected data, pelvic fracture due to a trauma can be one of the important causes of an increase in IAP and ACS. In this lethal condition, prevention is better than cure. Therefore, serial measurement of IAP through the bladder in high-risk patients (those with pelvic fracture by trauma) is recommended to the nurses to diagnose this condition and to decrease the incidence of mortality.

Abdominal catastrophes in the intensive care unit setting

Patients in the setting of the intensive care unit can develop intra-abdominal complications that may worsen outcome. Clinical suspicion of such complications coupled with early diagnosis and treatment may reduce morbidity and mortality associated with these processes. This article addresses the diagnosis and management of some of the common causes of intra-abdominal catastrophes.

Advanced age may limit the survival benefit of open abdominal decompression

Open abdominal decompression (OAD) and temporary abdominal closure (TAC) are widely performed for the treatment of intra-abdominal hypertension and/or abdominal compartment syndrome. During 2005 to 2009, 405 consecutive patients required OAD/TAC (trauma 68%, surgery 24%, medicine 5%, burn 3%). Overall patient survival to hospital discharge was 65 per cent regardless of age and was significantly decreased among patients older than 70 years of age (P < 0.0001). Survival by decade of life exceeded 50 per cent through the eighth decade but decreased to 19 per cent for the ninth decade (older than 80 years of age). Survival varied significantly by service (trauma 72%, surgical 56%, burns 55%, medical 33%) (P < 0.0001). Successful definitive fascial closure rates (range, 75 to 100%) were equivalent among all age groups (P = 0.78). Survival after OAD/TAC varies by decade of life and mechanism of injury/illness. Age alone should not negate the use of OAD/TAC. Reasonable survival rates may be expected for patients younger than 80 years of age.

Early Diagnosis and Evidence-Based Care of Surgical Sepsis

Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.

Intra-abdominal hypertension: detecting and managing a lethal complication of critical illness

Intra-abdominal hypertension occurs in 50% of all patients admitted to the intensive care unit and is associated with significant morbidity and mortality. Intra-abdominal hypertension is defined as a sustained, pathologic rise in intra-abdominal pressure to 12 mm Hg or more. Patients with intra-abdominal hypertension may progress to abdominal compartment syndrome. Early identification and treatment of this condition will improve patient outcome. Patients at risk for intra-abdominal hypertension include those with major traumatic injury, major surgery, sepsis, burns, pancreatitis, ileus, and massive fluid resuscitation. Predisposing factors include decreased abdominal wall compliance, increased intraluminal contents, increased peritoneal cavity contents, and capillary leak/fluid resuscitation.

Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival?

OBJECTIVE

The diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome have changed significantly over the past decade with improved understanding of the pathophysiology and appropriate treatment of these disease processes. Serial intra-abdominal pressure measurements, nonoperative pressure-reducing interventions, and early abdominal decompression for refractory intra-abdominal hypertension or abdominal compartment syndrome are all key elements of this evolving strategy.

DESIGN

Prospective, observational study.

SETTING

Tertiary referral/level I trauma center.

PATIENTS

Four hundred seventy-eight consecutive patients requiring an open abdomen for the management of intra-abdominal hypertension or abdominal compartment syndrome.

INTERVENTIONS

Patients were managed by a defined group of surgical intensivists using established definitions and an evidence-based management algorithm. Both univariate and multivariate analyses were performed to identify patient and management factors associated with improved survival.

MEASUREMENTS AND MAIN RESULTS

Whereas patient demographics and severity of illness remained unchanged over the 6-yr study period, the use of a continually revised intra-abdominal hypertension/abdominal compartment syndrome management algorithm significantly increased patient survival to hospital discharge from 50% to 72% (p = .015). Clinically significant decreases in resource utilization and an increase in same-admission primary fascial closure from 59% to 81% were recognized. Development of abdominal compartment syndrome, prophylactic use of an open abdomen to prevent development of intra-abdominal hypertension/abdominal compartment syndrome, and use of a multi-modality surgical/medical management algorithm were identified as independent predictors of survival.

CONCLUSIONS

A comprehensive evidence-based management strategy that includes early use of an open abdomen in patients at risk significantly improves survival from intra-abdominal hypertension/abdominal compartment syndrome. This improvement is not achieved at the cost of increased resource utilization and is associated with an increased rate of primary fascial closure.

Semi-recumbent position and body mass percentiles: effects on intra-abdominal pressure measurements in critically ill children

PURPOSE

Patient position and body mass index (BMI) affect intra-abdominal pressure (IAP) measured by the intra-vesical method in adults. We sought to determine effects of patient position and BMI on IAP in children because accurate measurement and interpretation of IAP are important for patient management.

METHODS

Seventy-seven mechanically ventilated children (<18 years) admitted to a PICU were prospectively studied. IAP was taken with the head of the bed at 0 degrees and 30 degrees every 6 h over a 24-h period. Statistical methods included descriptives, univariate statistics to identify potential confounding variables and multivariable analysis to assess the impact of position on IAP after adjusting for the significant covariates.

RESULTS

Seventy-seven patients had 290-paired IAP measurements. Mean IAP at 30 degrees was 10.6 +/- 4.0 compared to 8.4 +/- 4.0 at 0 degrees , which was significantly higher (p = 0.026) even after adjusting for age, gender and length. There was no correlation between IAP and actual BMI or BMI percentiles.

CONCLUSION

Patient position should be considered when interpreting IAP. BMI did not influence IAP measurements in children.

[Importance of abdominal compartment syndrome in Germany: a questionnaire]

BACKGROUND

The abdominal compartment syndrome (ACS) is a life-threatening condition and may affect any critically ill patient. Little is known about the recognition and management of the ACS in Germany.

METHODS

A postal questionnaire was sent to departments of surgery and anesthesia of German hospitals with more than 450 beds.

RESULTS

From the 222 eligible hospitals a total of 113 replies were received. Most respondents (95%) indicated that the ACS plays a role in their clinical practice. Measurement of intra-abdominal pressure (IAP) is not performed by 26% while it is routinely done by 30%. Intra-abdominal pressure is mostly (94%) assessed via the bladder pressure. Of the respondents 41% measure IAP only in those patients thought likely to develop ACS. Risk factors of the ACS would lead to IAP monitoring in 10-23% of cases. The majority (86%) would require signs of organ dysfunction together with exceeding the IAD threshold in order to opt for a surgical decompression. The attitude towards the critical threshold (>20 mmHg or >25 mmhg) divided respondents into two groups of similar size (39% compared to 47%, respectively).

CONCLUSIONS

German anesthesiologists and surgeons are familiar with the ACS. However, about one-quarter never measure IAP and there is a considerable variance as to which patients are at risk to develop ACS and how often IAP should be measured in these patients. This could indicate a lack of acceptance or simply a persisting need for more data concerning the avoidance and treatment of the ACS.

Abdominal compartment syndrome

Increased intra-abdominal pressure (IAP) has received growing attention in critically ill patients. Pathophysiologically, it deranges cardiovascular haemodynamics, respiratory and renal functions and may eventually lead to multi-organ failure. It is primarily seen in surgical intensive care units and is frequently associated with abdominal trauma but also occurs after elective abdominal surgery. Non-surgical intensivists ought to be aware that the syndrome is also seen in a wide spectrum of medical conditions, e.g. acute pancreatitis. An expert panel has recently set up definitions of intra-abdominal hypertension (IAH, sustained or repeated pathological elevation in IAP > or = 12 mmHg) and abdominal compartment syndrome (ACS, sustained IAP > 20 mmHg associated with a new organ dysfunction or failure). As clinical signs of IAH are unreliable, IAP should be measured non-invasively by the 'bladder technique'. It is hoped that the consensus definitions will contribute to a broader recognition and effective treatment of this life-threatening syndrome.