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Dukkipati SS, Puranik AK, Meena SP, Badkur M, Lodha M, Kompally PV, Chaudhary R, Rodha MS, Sharma N. An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study. Cureus 2024; 16:e59736. [PMID: 38841048 PMCID: PMC11151994 DOI: 10.7759/cureus.59736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis. PURPOSE OF THE STUDY The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP). MATERIALS AND METHODS The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery. RESULTS The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027). CONCLUSION Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.
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Affiliation(s)
| | - Ashok K Puranik
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Satya Prakash Meena
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Mayank Badkur
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | - Mahendra Lodha
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | | | - Ramkaran Chaudhary
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
| | | | - Naveen Sharma
- General Surgery, All India Institute of Medical Sciences, Jodhpur, Jodhpur, IND
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Li Z, Wang H, Lu F. The development, feasibility and credibility of intra-abdominal pressure measurement techniques: A scoping review. PLoS One 2024; 19:e0297982. [PMID: 38512833 PMCID: PMC10956852 DOI: 10.1371/journal.pone.0297982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/14/2024] [Indexed: 03/23/2024] Open
Abstract
AIM To provide a comprehensive overview on emerging direct and alternative methods for intra-abdominal pressure (IAP) measurement techniques. METHODS This was a scoping review study following Arksey and Malley's framework. The PubMed, EMBASE, Web of Science, EBSCO, Scopus and ProQuest databases were searched, and we only considered studies published from 2000 as we have extended the data from two previous reviews. Original studies that reported on the development, feasibility and credibility of IAP measurement techniques were included. RESULTS Forty-two of 9954 screened articles were included. IAP measurement techniques include three major categories: direct, indirect and less invasive measurement techniques. Agreement analyses were performed in most studies, and some explored the safety, time expenditure and reproducibility of IAP measurement techniques. CONCLUSIONS Clinical data assessing the validation of new IAP measurement techniques or the reliability of established measurement techniques remain lacking. Considering the cost and invasiveness, direct measurement is not recommended as a routine method for IAP measurement and should be preserved for critically ill patients where standard techniques are contraindicated or could be inaccurate. The measurement accuracy, reliability and sensitivity of the transrectal and transfemoral vein methods remain insufficient and cannot be recommended as surrogate IAP measures. Transvesical measurement is the most widely used method, which is the potentially most easy applicable technique and can be used as a reliable method for continuous and intermittent IAP measurement. Wireless transvaginal method facilitates the quantitative IAP measurement during exercise and activity, which laying the foundations for monitoring IAP outside of the clinic environment, but the accuracy of this technique in measuring absolute IAP cannot be determined at present. Less invasive technology will become a new trend to measure IAP and has substantial potential to replace traditional IAP measurement technologies, but further validation and standardization are still needed. Medical professionals should choose appropriate measurement tools based on the advantages and disadvantages of each IAP technique in combination with assessing specific clinical situations.
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Affiliation(s)
- ZhiRu Li
- Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - HuaFen Wang
- Nursing Department, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - FangYan Lu
- Hepatobiliary and pancreatic surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Wise R, Rodseth R, Párraga-Ros E, Latorre R, López Albors O, Correa-Martín L, M. Sánchez-Margallo F, Eugenia Candanosa-Aranda I, Poelaert J, Castellanos G, L. N. G. Malbrain M. The pathophysiological impact of intra-abdominal hypertension in pigs. PLoS One 2023; 18:e0290451. [PMID: 37639437 PMCID: PMC10461824 DOI: 10.1371/journal.pone.0290451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Intra-abdominal hypertension and abdominal compartment syndrome are common with clinically significant consequences. We investigated the pathophysiological effects of raised IAP as part of a more extensive exploratory animal study. The study design included both pneumoperitoneum and mechanical intestinal obstruction models. METHODS Forty-nine female swine were divided into six groups: a control group (Cr; n = 5), three pneumoperitoneum groups with IAPs of 20mmHg (Pn20; n = 10), 30mmHg (Pn30; n = 10), 40mmHg (Pn40; n = 10), and two mechanical intestinal occlusion groups with IAPs of 20mmHg (MIO20; n = 9) and 30mmHg (MIO30; n = 5). RESULTS There were significant changes (p<0.05) noted in all organ systems, most notably systolic blood pressure (SBP) (p<0.001), cardiac index (CI) (p = 0.003), stroke volume index (SVI) (p<0.001), mean pulmonary airway pressure (MPP) (p<0.001), compliance (p<0.001), pO2 (p = 0.003), bicarbonate (p = 0.041), hemoglobin (p = 0.012), lipase (p = 0.041), total bilirubin (p = 0.041), gastric pH (p<0.001), calculated glomerular filtration rate (GFR) (p<0.001), and urine output (p<0.001). SVV increased progressively as the IAP increased with no obvious changes in intravascular volume status. There were no significant differences between the models regarding their impact on cardiovascular, respiratory, renal and gastrointestinal systems. However, significant differences were noted between the two models at 30mmHg, with MIO30 showing worse metabolic and hematological parameters, and Pn30 and Pn40 showing a more rapid rise in creatinine. CONCLUSIONS This study identified and quantified the impact of intra-abdominal hypertension at different pressures on several organ systems and highlighted the significance of even short-lived elevations. Two models of intra-abdominal pressure were used, with a mechanical obstruction model showing more rapid changes in metabolic and haematological changes. These may represent different underlying cellular and vascular pathophysiological processes, but this remains unclear.
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Affiliation(s)
- Robert Wise
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
| | - Reitze Rodseth
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Ester Párraga-Ros
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Rafael Latorre
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Octavio López Albors
- Department of Anatomy and Comparative Pathology, Veterinary Faculty, University of Murcia, Murcia, Spain
| | - Laura Correa-Martín
- Laparoscopy Department Jesus Uson Minimally Invasive Surgery Centre, Caceres, Spain
| | | | - Irma Eugenia Candanosa-Aranda
- Highlands Teaching and Research Farm, Faculty of Veterinary Medicine, National Autonomous University of Mexico, Queretaro. Mexico
| | - Jan Poelaert
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Gregorio Castellanos
- Department of General Surgery, Virgen de la Arrixaca General University Hospital, Murcia, Spain
| | - Manu L. N. G. Malbrain
- First Department of Anaesthesiology and Intensive Care Medicine, Medical University of Lublin, Lublin, Poland
- Medical Director (CMO), Medical Data Management, Medaman, Geel, Belgium
- International Fluid Academy, Lovenjoel, Belgium
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Stojanović M, Đurić M, Nenadić I, Dimić N, Bojić S, Stevanović P. Evaluation of Intra-Abdominal Hypertension Parameters in Patients with Acute Pancreatitis. Life (Basel) 2023; 13:1227. [PMID: 37374010 DOI: 10.3390/life13061227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 06/29/2023] Open
Abstract
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.
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Affiliation(s)
- Maja Stojanović
- Department of Anesthesiology and Intensive Care, University Medical Center "Zvezdara", 11000 Belgrade, Serbia
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
| | - Marko Đurić
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Clinical Center of "Dr Dragiša Mišović", 11000 Belgrade, Serbia
| | - Irina Nenadić
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Clinical Center of "Dr Dragiša Mišović", 11000 Belgrade, Serbia
| | - Nemanja Dimić
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Clinical Center of "Dr Dragiša Mišović", 11000 Belgrade, Serbia
| | - Suzana Bojić
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Clinical Center of "Dr Dragiša Mišović", 11000 Belgrade, Serbia
| | - Predrag Stevanović
- Medical Faculty, University of Belgrade, 11000 Belgrade, Serbia
- Department of Anesthesiology and Intensive Care, Clinical Center of "Dr Dragiša Mišović", 11000 Belgrade, Serbia
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Łagosz P, Sokolski M, Biegus J, Tycinska A, Zymlinski R. Elevated intra-abdominal pressure: A review of current knowledge. World J Clin Cases 2022; 10:3005-3013. [PMID: 35647129 PMCID: PMC9082714 DOI: 10.12998/wjcc.v10.i10.3005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/20/2021] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Elevated intra-abdominal pressure (IAP) is a known cause of increased morbidity and mortality among critically ill patients. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome can lead to rapid deterioration of organ function and the development of multiple organ failure. Raised IAP affects every system and main organ in the human body. Even marginally sustained IAH results in malperfusion and may disrupt the process of recovery. Yet, despite being so common, this potentially lethal condition often goes unnoticed. In 2004, the World Society of the Abdominal Compartment Syndrome, an international multidisciplinary consensus group, was formed to provide unified definitions, improve understanding and promote research in this field. Simple, reliable and nearly costless standardized methods of non-invasive measurement and monitoring of bladder pressure allow early recognition of IAH and timely optimized management. The correct, structured approach to treatment can have a striking effect and fully restore homeostasis. In recent years, significant progress has been made in this area with the contribution of surgeons, internal medicine specialists and anesthesiologists. Our review focuses on recent advances in order to present the complex underlying pathophysiology and guidelines concerning diagnosis, monitoring and treatment of this life-threatening condition.
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Affiliation(s)
- Piotr Łagosz
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw 50-367, Poland
- Institute of Heart Diseases, University Clinical Hospital, Wroclaw 50-556, Poland
| | - Mateusz Sokolski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw 50-367, Poland
- Institute of Heart Diseases, University Clinical Hospital, Wroclaw 50-556, Poland
| | - Jan Biegus
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw 50-367, Poland
- Institute of Heart Diseases, University Clinical Hospital, Wroclaw 50-556, Poland
| | - Agnieszka Tycinska
- Department of Cardiology, Medical University of Bialystok, Bialystok 15-089, Poland
| | - Robert Zymlinski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw 50-367, Poland
- Institute of Heart Diseases, University Clinical Hospital, Wroclaw 50-556, Poland
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6
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Ramser M, Glauser PM, Glass TR, Weixler B, Grapow MTR, Hoffmann H, Kirchhoff P. Abdominal Decompression after Cardiac Surgery: Outcome of 42 Patients with Abdominal Compartment Syndrome. World J Surg 2021; 45:1242-1251. [PMID: 33481080 DOI: 10.1007/s00268-020-05917-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Up to 50% of patients in intensive care units develop intraabdominal hypertension (IAH) in the course of medical treatment. If not detected on time and treated adequately, IAH may develop into an abdominal compartment syndrome (ACS) which is associated with a high mortality rate. Patients undergoing cardiac surgery are especially prone to develop ACS due to several risk factors including intraoperative hypothermia, fluid resuscitation and acidosis. We investigated patients who developed ACS after cardiac surgery and analyzed potential risk factors, treatment and outcome. METHODS From 2011 to 2016, patients with ACS after cardiac surgery requiring decompressive laparotomy were prospectively recorded. Patient characteristics, details on the cardiac surgery, mortality rate and type of treatment of the open abdomen were analyzed. RESULTS Incidence of ACS in cardiac surgery patients was 1.0% (n = 42/4128), with a mortality rate of 57%. Ejection fraction, Euroscore2 as well as the perfusion time are independent risk factors for the development of ACS. The outcome of patients with ACS was independent of elective versus emergency surgery, gender, age, BMI or ASA score. In the 18 surviving patients, fascial closure was achieved in 72% after a median of 9 days. CONCLUSION Abdominal compartment syndrome is a rare but serious complication after cardiac surgery with a high mortality rate. Independent risk factors for ACS were identified. Negative pressure wound therapy seems to promote and allow early fascia closure of the abdomen and represents therefore a likely benefit for the patient.
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Affiliation(s)
- Michaela Ramser
- Department of Surgery, University Hospital Basel, Basel, Switzerland. .,Department of Surgery, Solothurner Spitäler, Kantonsspital Olten, Olten, Switzerland.
| | - Philippe M Glauser
- Department of Surgery, University Hospital Basel, Basel, Switzerland.,Department of Surgery, Solothurner Spitäler, Spital Dornach, Dornach, Switzerland
| | - Tracy R Glass
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Benjamin Weixler
- University of Basel, Basel, Switzerland.,Department of Surgery, Charité University Hospital Berlin, Berlin, Germany
| | - Martin T R Grapow
- Department of Cardiac Surgery, University Hospital Basel, Basel, Switzerland.,Hirslanden Klinik Zürich, HerzZentrum, Zürich, Switzerland
| | - Henry Hoffmann
- University of Basel, Basel, Switzerland.,Center for Hernia Surgery & Proctology, ZweiChirurgen, Basel, Switzerland
| | - Philipp Kirchhoff
- University of Basel, Basel, Switzerland.,Center for Hernia Surgery & Proctology, ZweiChirurgen, Basel, Switzerland
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7
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Lee RK, Gallagher JJ, Ejike JC, Hunt L. Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society. Crit Care Nurse 2020; 40:13-26. [PMID: 32006038 DOI: 10.4037/ccn2020772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.
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Affiliation(s)
- Rosemary K Lee
- Rosemary K. Lee is an acute care nurse practitioner and clinical nurse specialist at Baptist Health South Florida, Coral Gables, Florida
| | - John J Gallagher
- John J. Gallagher is a clinical nurse specialist and trauma program coordinator, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Janeth Chiaka Ejike
- Janeth Chiaka Ejike is an associate professor of pediatrics, pediatric critical care medicine practitioner, and Program Director of the Pediatric Critical Care Medicine Fellowship at Loma Linda University Children's Hospital, Loma Linda, California
| | - Leanne Hunt
- Leanne Hunt is a senior lecturer at Western Sydney University and a registered nurse at Liverpool Hospital, Sydney, Australia
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Nansubuga P, Kavuma Mwanje A, Kizito S, Obua D, Sendagire C, Kwizera A. The prevalence, incidence and mortality associated with intra-abdominal hypertension among patients in intensive care units of a low-income country: a cohort study. AAS Open Res 2020. [DOI: 10.12688/aasopenres.13101.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: Intra-abdominal hypertension (IAH) is sustained increase in intra-abdominal pressure (IAP) ≥12 mmHg in adults and ≥10 mmHg in children. IAH has been noted to be associated with increased morbidity and mortality among critically ill patients. Measurement of IAP is common among at risk patients in the developed world. However, it has not received due attention in the majority of intensive care units (ICUs) in low-income countries, Uganda being one of these. This is evidenced by paucity of data and lack of protocols from the Ugandan Ministry of Health. This multi-center study was thus conducted to assess the prevalence, incidence and mortality associated with IAH among patients admitted to Ugandan ICUs.Methods:A multi-center prospective cohort study was conducted from September 2017 to February 2018 at three ICUs in Uganda. We consecutively enrolled 126 patients into the study. IAP was measured using the Harrahil manometer technique. Categorical variables were analyzed using the Chi square test and continuous variables analyzed using the t-test and Man Whitney test. The prevalence and incidence were determined using proportions and mortality was determined using survival analysis.Results:The median age was 33 years (26-48.5) for the patients without IAH and 42 years (29-55) for those with IAH. The majority of the patients were male and 9.6% of the patients were below 18 years. The prevalence of IAH was 62.7 (CI 54.1-71.3), whereas the 24 hour and 72 hour incidence of IAH was 9.3% (CI 1.3-17.2) and 14.3 % (CI 4.1-24.4), respectively. Mortality was higher in patients with IAH compared to those without (p-value 0.003 and 0.028, mean and maximum IAP, respectively). Conclusion:We found a high prevalence and incidence of IAH among critically ill patients, associated with a high mortality. Routine screening for IAH can preempt management strategies to mitigate this.
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Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 2. Ultrasound J 2020; 12:15. [PMID: 32166639 PMCID: PMC7067962 DOI: 10.1186/s13089-020-00160-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/06/2020] [Indexed: 12/18/2022] Open
Abstract
Assessing heart and diaphragm function constitutes only one of the steps to consider along the weaning path. In this second part of the review, we will deal with the more systematic evaluation of the pulmonary parenchyma—often implicated in the genesis of respiratory failure. We will also consider the other possible causes of weaning failure that lie beyond the cardio-pulmonary-diaphragmatic system. Finally, we will take a moment to consider the remaining unsolved problems arising from mechanical ventilation and describe the so-called protective approach to parenchyma and diaphragm ventilation.
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Reis ACV, Kusamura S, Azmi N, Fumagalli L, Piccioni F, Valenza F, Baratti D, Guaglio M, Cavalleri A, Garrone G, Barretta F, Deraco M. Hemodynamic and respiratory implications of high intra-abdominal pressure during HIPEC. Eur J Surg Oncol 2020; 46:1896-1901. [PMID: 32147425 DOI: 10.1016/j.ejso.2020.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/05/2020] [Accepted: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND cytoreduction surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is currently the standard of care for some peritoneal surface malignancies. There is experimental evidence supporting that high Intra Abdominal Pressure (IAP) during HIPEC could enhance the uptake of drugs by tumor tissues. However, few papers are describing the hemodynamic and respiratory effects of increased IAP during HIPEC. AIMS to evaluate the hemodynamic and respiratory association with different IAPs during HIPEC. METHODS This is part of an IRB board approved prospective randomized controlled trial conducted at The National Tumor Institute of Milan from 2014 to 2017 (NCT0294979). Patients diagnosed with Pseudomyxoma (PMP) or Peritoneal Metastasis of Colorectal Cancer (PM-CRC) were submitted to CRS and then randomized to receive low IAP (8-12 mmHg) or high IAP (18-22 mmHg) HIPEC. Hemodynamic and respiratory data were collected in eight different time-points during the whole procedure. RESULTS 33 patients (n low = 15, n high = 18) with PM-CRC and PMP were analysed. The mean IAP in the low IAP HIPEC group was 11.4 mmHg (SD: 2.5) and 18.1 mmHg (SD: 2.5) in the high IAP HIPEC group (p«0.001). There was no difference in the hemodynamic parameters between both groups, except for the central venous pressure (CVP) that was significantly higher in the high IAP group (p = 0.006). High IAP was well tolerated in the experimental arm with no hemodynamic and ventilation instability observed during the intervention. CONCLUSION We conclude that high IAP at the level of 18-22 mmHg during HIPEC has no significant hemodynamic parameters difference, being feasible and safe in our study.
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Affiliation(s)
- Artur C V Reis
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy; Irmandade Santa Casa de Misericórdia de São José Dos Campos, Department of Gastrointestinal Surgery, São Paulo, Brazil.
| | - Shigeki Kusamura
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Norfarizan Azmi
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Luca Fumagalli
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Federico Piccioni
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy
| | - Franco Valenza
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Anesthesiology Unit, Italy; University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Dario Baratti
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Marcello Guaglio
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy
| | - Adalberto Cavalleri
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Giulia Garrone
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Laboratory of Department of Preventive and Predictive Medicine, Italy
| | - Francesco Barretta
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Department of Clinical Epidemiology and Trial Organization, Milan, Italy
| | - Marcello Deraco
- Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Peritoneal Surface Malignancies Unit, Italy.
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Evaluation and Management of Abdominal Compartment Syndrome in the Emergency Department. J Emerg Med 2019; 58:43-53. [PMID: 31753758 DOI: 10.1016/j.jemermed.2019.09.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 12/12/2022]
Abstract
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.
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Bordejé ML, Montejo JC, Mateu ML, Solera M, Acosta JA, Juan M, García-Córdoba F, García-Martínez MA, Gastaldo R. Intra-Abdominal Pressure as a Marker of Enteral Nutrition Intolerance in Critically Ill Patients. The PIANE Study. Nutrients 2019; 11:nu11112616. [PMID: 31683850 PMCID: PMC6893696 DOI: 10.3390/nu11112616] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 12/26/2022] Open
Abstract
To determine whether elevated intra-abdominal pressure (IAP) is associated with a higher rate of enteral nutrition-related gastrointestinal (GI) complications; to assess the value of IAP as a predictor of enteral nutrition (EN) intolerance. Intensive Care Unit (ICU) patients on mechanical ventilation requiring at least 5 days of EN were recruited for a prospective, observational, non-interventional, multicenter study. EN was performed and GI complications were managed with an established protocol. IAP was determined via a urinary catheter. Patients who developed any GI complications were considered as presenting EN intolerance. Variables related to EN, IAP and GI complications were monitored daily. Statistical analysis compared patients without GI complications (group A) vs. GI complications (group B). 247 patients were recruited from 28 participating ICUs (group A: 119, group B: 128). No differences between groups were recorded. Patients in group B (p < 0.001) spent more days on EN (8.1 ± 8.4 vs. 18.1 ± 13.7), on mechanical ventilation (8.0 ± 7.7 vs. 19.3 ± 14.9) and in the ICU (12.3 ± 11.4 vs. 24.8 ± 17.5). IAP prior to the GI complication was (14.3 ± 3.1 vs. 15.8 ± 4.8) (p < 0.003). The best IAP value identified for EN intolerance was 14 mmHg but it had low sensitivity and specificity. Although a higher IAP was associated with EN intolerance, IAP alone did not emerge as a good predictor of EN intolerance in critically ill patients.
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Affiliation(s)
- M Luisa Bordejé
- ICU, Hospital Universitario Germans Trias i Pujol, Carretera del Canyet s/n, 08916 Badalona, Spain.
| | - Juan C Montejo
- ICU, Hospital Universitario 12 de Octubre, Glorieta de Málaga s/n, 28041 Madrid, Spain.
| | - M Lidón Mateu
- ICU, Hospital General Universitario de Castellón, Avda. Benicassim s/n, 12004 Castellon, Spain.
| | - Manuel Solera
- ICU, Hospital San Francisco de Borja Pg. les Germanies 71, 46702 Gandía, Valencia, Spain.
| | - Jose A Acosta
- ICU, Hospital General Unversitario de Alicante, C/Maestro Alonso 109, 03010 Alicante, Spain.
| | - Mar Juan
- ICU, Hospital Clínico Universitario de Valencia, Av. de Blasco Ibáñez, 17, 46010 Valencia, Spain.
| | - Francisco García-Córdoba
- ICU, Hospital Universitario Los Arcos del Mar Menor, Paraje Torre Octavio s/n, 30739 Pozo Aledo-San Javier, Murcia, Spain.
| | - Miguel A García-Martínez
- ICU, Hospital Universitario de Torrevieja. Carretera CV-95 s/n, 03186 Torrevieja, Alicante, Spain.
| | - Rosa Gastaldo
- ICU, Hospital de Manacor Alcudia s/n, 07500 Manacor, Islas Baleares, Spain.
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STOJANOVIC M, SVORCAN P, KARAMARKOVIC A, LADJEVIC N, JANKOVIC R, STEVANOVIC P. Mortality predictors of patients suffering of acute pancreatitis and development of intraabdominal hypertension. Turk J Med Sci 2019; 49:506-513. [PMID: 30997789 PMCID: PMC7018200 DOI: 10.3906/sag-1809-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Maja STOJANOVIC
- Department of Anesthesiology and Intensive Care, “Zvezdara” University Medical Center, BelgradeSerbia
- * To whom correspondence should be addressed. E-mail:
| | - Petar SVORCAN
- Faculty of Medicine, University of Belgrade, BelgradeSerbia
- Department of Gastroenterology and Hepatology, “Zvezdara” University Medical Center, BelgradeSerbia
| | - Aleksandar KARAMARKOVIC
- Faculty of Medicine, University of Belgrade, BelgradeSerbia
- Department of Surgery, “Zvezdara” University Medical Center, BelgradeSerbia
| | - Nebojsa LADJEVIC
- Faculty of Medicine, University of Belgrade, BelgradeSerbia
- Department of Anesthesiology and Intensive Care, Clinical Center of Serbia, BelgradeSerbia
| | - Radmilo JANKOVIC
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Niš, NišSerbia
| | - Predrag STEVANOVIC
- Faculty of Medicine, University of Belgrade, BelgradeSerbia
- Department of Anesthesiology and Intensive Care, Clinical Center of “Dr Dragiša Mišović”, BelgradeSerbia
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Gray S, Christensen M, Craft J. The gastro-renal effects of intra-abdominal hypertension: Implications for critical care nurses. Intensive Crit Care Nurs 2018; 48:69-74. [PMID: 29937073 DOI: 10.1016/j.iccn.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/16/2018] [Accepted: 06/01/2018] [Indexed: 12/29/2022]
Abstract
Intra-abdominal hypertension is classified as either primary or secondary - primary occurs due to intra-abdominal or retro-peritoneal pathophysiology, whereas secondary results in alterations in capillary fluid dynamics due to factors, such as massive fluid resuscitation and generalised inflammation. The renal and gastro-intestinal effects occur early in the progression of intra-abdominal hypertension, and may lead to poor patient outcomes if not identified. As a direct response to intra-abdominal hypertension, renal function is reduced with remarkable impairment from pressures of around 10 mmHg, oliguria developing at 15 mmHg and anuria developing at 30 mmHg. Intestinal micro-circulation is significantly reduced by up to 50% with intra-abdominal pressures as low as 15 mmHg. Mucosal and submucosal tissue hypo-perfusion causes considerable damage to the intestinal cells, potentially resulting in bacterial translocation, endotoxin release, sepsis and multiple organ failure. The critical care nurse plays an important role in the early identification of intra-abdominal hypertension however, without this essential knowledge base and comprehension of intra-abdominal hypertension, clinical signs and symptoms may go unnoticed or be misinterpreted as signs of other critical illnesses.
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Affiliation(s)
- Sherree Gray
- School of Nursing, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
| | - Martin Christensen
- Centre for Applied Nursing Research (CANR), Western Sydney University, South Western Sydney Local Health District (SWSLHD), Locked Bag 7103, Liverpool, NSW 1871, Australia.
| | - Judy Craft
- School of Biomedical Sciences, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
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Reduction of Intra-abdominal Hypertension Is Associated with Increase of Cardiac Output in Critically Ill Patients Undergoing Mechanical Ventilation. JOURNAL OF INTERDISCIPLINARY MEDICINE 2018. [DOI: 10.2478/jim-2018-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objective: To demonstrate the relationship between intra-abdominal hypertension (IAH) and cardiac output (CO) in mechanically ventilated (MV), critically ill patients.
Material and methods: This was a single-center, prospective study performed between January and April 2016, on 30 mechanically ventilated patients (mean age 67.3 ± 11.9 years), admitted in the Intensive Care Unit (ICU) of the Emergency County Hospital of Tîrgu Mureș, Romania, who underwent measurements of intra-abdominal pressure (IAP). Patients were divided into two groups: group 1 – IAP <12 mmHg (n = 21) and group 2 – IAP >12 mmHg (n = 9). In 23 patients who survived at least 3 days post inclusion, the variation of CO and IAP between baseline and day 3 was calculated, in order to assess the variation of IAP in relation to the hemodynamic status.
Results: IAP was 8.52 ± 1.59 mmHg in group 1 and 19.88 ± 8.05 mmHg in group 2 (p <0.0001). CO was significantly higher in group 1 than in the group with IAH: 6.96 ± 2.07 mmHg (95% CI 6.01–7.9) vs. 4.57 ± 1.23 mmHg (95% CI 3.62–5.52) (p = 0.003). Linear regression demonstrated an inverse correlation between CO and IAP (r = 0.48, p = 0.007). Serial measurements of CO and IAP proved that whenever accomplished, the decrease of IAP was associated with a significant increase in CO (p = 0.02).
Conclusions: CO is significantly correlated with IAP in mechanically ventilated patients, and IAH reduction is associated with increase of CO in these critically ill cases.
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Michel P, Wähnert D, Freistühler M, Laukoetter MG, Rehberg S, Raschke MJ, Garcia P. Acute transfusion-related abdominal injury in trauma patients: a case report. J Med Case Rep 2016; 10:294. [PMID: 27760561 PMCID: PMC5070412 DOI: 10.1186/s13256-016-1075-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 09/22/2016] [Indexed: 11/24/2022] Open
Abstract
Background Secondary abdominal compartment syndrome is well known as a life-threatening complication in critically ill patients in an intensive care unit. Massive crystalloid fluid resuscitation has been identified as the most important risk factor. The time interval from hospital admittance to the development of manifest abdominal compartment syndrome is usually greater than 24 hours. In the absence of any direct abdominal trauma, we observed a rapidly evolving secondary abdominal compartment syndrome shortly after hospital admittance associated with massive transfusion of blood products and only moderate crystalloid resuscitation. Case presentation We report the case of an acute secondary abdominal compartment syndrome developing within 3 to 4 hours in a 74-year-old polytraumatized white woman. Although multiple fractures of her extremities and a B-type pelvic ring fracture were diagnosed by a full body computed tomography scan, no intra-abdominal injury could be detected. Hemorrhagic shock with a drop in her hemoglobin level to 5.7 g/dl was treated by massive transfusion of blood products and high doses of catecholamines. Shortly afterwards, her pulmonary gas exchange progressively deteriorated and mechanical ventilation became almost impossible with peak airway pressures of up to 60 cmH2O. Her abdomen appeared rigid and tense accompanied by a progressive hemodynamic decompensation necessitating mechanic cardiopulmonary resuscitation. Although preoperative computed tomography scans showed no signs of intra-abdominal fluid, a decompressive laparotomy under cardiopulmonary resuscitation conditions was performed and 2 liters of ascites-like fluid disgorged. Her hemodynamics and pulmonary ventilation improved immediately. Conclusions This case report describes for the first time acute secondary abdominal compartment syndrome in a trauma patient, evolving in a very short time period. We hypothesize that the massive transfusion of blood products along with high doses of catecholamines triggered the acute development of abdominal compartment syndrome. Trauma teams need to consider a rapidly developing secondary abdominal compartment syndrome to be a potential cause of hemodynamic decompensation not only in the later phase of treatment but also in the emergency phase of treatment.
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Affiliation(s)
- P Michel
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms University Muenster, Waldeyer Str. 1, 48149, Muenster, Germany.
| | - D Wähnert
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms University Muenster, Waldeyer Str. 1, 48149, Muenster, Germany
| | - M Freistühler
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms University Muenster, Waldeyer Str. 1, 48149, Muenster, Germany
| | - M G Laukoetter
- Department of General and Visceral Surgery, Westfaelische Wilhelms University Muenster, Muenster, Germany
| | - S Rehberg
- Department of Anesthesiology, Anesthesia, Intensive Care, Emergency and Pain Medicine, University Medicine Greifswald, Greifswald, Germany
| | - M J Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms University Muenster, Waldeyer Str. 1, 48149, Muenster, Germany
| | - P Garcia
- Department of Trauma-, Hand- and Reconstructive Surgery, Westfaelische Wilhelms University Muenster, Waldeyer Str. 1, 48149, Muenster, Germany
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Kuteesa J, Kituuka O, Namuguzi D, Ndikuno C, Kirunda S, Mukunya D, Galukande M. Intra-abdominal hypertension; prevalence, incidence and outcomes in a low resource setting; a prospective observational study. World J Emerg Surg 2015; 10:57. [PMID: 26604981 PMCID: PMC4657315 DOI: 10.1186/s13017-015-0051-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/19/2015] [Indexed: 12/02/2022] Open
Abstract
Background Intra-abdominal hypertension (IAH) is defined as a sustained elevation in intra-abdominal pressure (IAP) greater than or equal to 12 mmHg. IAH has been shown to cause organ derangements and dysfunction in the body. Objective screening of IAH is neither done early enough nor at all thus leading to significant morbidity and mortality among surgical patients. The epidemiology and outcome of IAH among surgical patients has not been documented in Uganda. The aim of this study was to determine the prevalence, incidence and outcome of intra-abdominal hypertension among patients undergoing emergency laparotomy. Methodology Prospective observational study, conducted from January to April 2015 among patients undergoing emergency laparotomy. Inclusion criteria was; age >7 yrs, scheduled for emergency laparotomy, able to lie supine. Exclusion Criteria: pregnant, failed urethral catheterization, known cardiac, renal and respiratory disorders. Consecutive sampling was used. IAP, blood pressure, heart rate, respiratory rate, Sp02, Serum creatinine, Serum urea, and Urine output were measured preoperatively and postoperatively at 0, 6, 24 and 48 h. IAH was defined as IAP > 12 mmHg on three consecutive readings 3 min apart. Results In total 192 patients were enrolled. Mean age ± SD was 14.25 (±3.16) yrs in the paediatrics and 34.4(±13.72) yrs in the adults with male preponderance 65 and 80.7 % respectively. The prevalence of IAH was 25 % paediatrics and 17.4 % adults and the cumulative incidence after surgery was 20 % paediatrics and 21 % adults. In paediatrics, IAH was associated with mortality at 0 h postoperatively, RRR = 1:24, 95 % CI (1.371–560.178), p-value 0.048. In adults, the statistically significant outcomes associated with IAH were respiratory system dysfunction RRR1:2.783, p-value 0.023, 95 % CI (1.148–6.744) preoperatively and mortality RRR 1:2.933, p-value 0.034, 95 % CI (1.017–8.464) at 6 h, RRR 1:3.769, p-value 0.033, 95 % CI (1.113–12.760) at 24 h postoperatively. Conclusion The prevalence and incidence of IAH in the paediatrics and adults group in our study population were high. IAH was associated with mortality in both adult and paediatrics groups and respiratory system dysfunction in adult group. This calls for objective monitoring of intraabdominal pressure in patients undergoing emergency laparotomy with the aim of reducing associated mortality.
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Affiliation(s)
- Job Kuteesa
- Department of Surgery, College of Health Sciences, Makerere University, Mulago Hill road, P.O Box 7072, Kampala, Uganda East Africa ; Department of Surgery, School of Medicine, College of Health Sciences, Makerere University, P.O Box 7072 Kampala, Uganda
| | - Olivia Kituuka
- Department of Surgery, College of Health Sciences, Makerere University, Mulago Hill road, P.O Box 7072, Kampala, Uganda East Africa
| | - Dan Namuguzi
- Department of Surgery, College of Health Sciences, Makerere University, Mulago Hill road, P.O Box 7072, Kampala, Uganda East Africa
| | - Cynthia Ndikuno
- Department of Nursing, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Samuel Kirunda
- Department of Surgery, College of Health Sciences, Makerere University, Mulago Hill road, P.O Box 7072, Kampala, Uganda East Africa
| | - David Mukunya
- Department of Paediatrics, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses Galukande
- Department of Surgery, College of Health Sciences, Makerere University, Mulago Hill road, P.O Box 7072, Kampala, Uganda East Africa
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