Abdominal compartment syndrome

Botulinum Toxin and Progressive Pneumoperitoneum in Loss of Domain Ventral Hernias: A Systematic Review

Introduction: Preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTX) have been used together in the preoperative preparation of patients with loss of domain hernias. This study aims to evaluate the efficacy and safety of the combined use of PPP and BTX. Methods: A systematic electronic search was performed according to the PRISMA criteria. A literature search of scientific articles was conducted up to December 2023. Articles were chosen based on the reference to BTX and PPP in loss of domain ventral hernias with a defect width greater than 10 cm before surgery. The GRADE methodology and the modified Newcastle-Ottawa scale were used to assess the quality of the studies. Results: The research yielded seven articles, with 217 patients analysed in total. BTX was performed 29.5 ± 1.7 days before surgery and PPP was inflated 14.8 ± 5.8 days before surgery. PPP complications were reported in 25.6% of patients, The average reduction of the volume of hernia (VH)/volume of the abdominal cavity (VAC) ratio was 7.6% (range 0.9%-15%). Only 40 patients (18.4%) required a PCS or TAR to repair the loss of domain hernias. The SSI and SSO rates were 17.5% and 26.2%, respectively. No differences in SSI and SSO rates were found between the different repair techniques. The recurrence rate was 5.9% (13/217). Recurrence was significantly higher in patients who underwent IPOM repair than other techniques (p < 0.001). Conclusion: BTX and PPP may be useful tools for the management of loss of domain hernias presenting lower SSI and SSO. The combination of BTX and PPP reduces the use of more invasive repair techniques.

Intra-abdominal Pressure Measurement as a Predictor of Postoperative Wound Complications in Patients Undergoing Emergency Laparotomy: A Prospective Observational Study

Introduction Elevated intra-abdominal pressure (IAP) hampers the effective functioning of intra- and extra-abdominal organs. Despite the abundance of knowledge, routine measurement of IAP still needs to be widely incorporated in managing at-risk patients. The present study intends to assess the need for IAP measurement on abdominal wound healing in emergency laparotomy patients. Methods This prospective study was carried out over 24 months in patients undergoing emergency laparotomy. The IAP was measured at admission, immediately after surgery, and during the early postoperative period at 6, 12, 24, 48, and 72 hours. The patients were evaluated for the development of wound-related complications over a follow-up period of three months post-operatively. Results Seventy-two patients were enrolled. At admission, 54 (75%) patients had intra-abdominal hypertension (IAH), of which three patients had evidence of abdominal compartment syndrome. Thirty-one (43%) patients developed postoperative wound infections. The overall incidence of wound infection was significantly higher in patients with IAH (54.3% vs. 24%, p-value = 0.04, Pearson's Chi-squared test). The frequency of wound dehiscence was greater (19.6 % vs. 4.3 %, p-value 0.14, Fischer's exact test) in patients with IAH. The median duration of hospital stay (13 vs. 8 days, p-value 0.02, Mann-Whitney U test) and healing time (30.5 vs. 18 days, p-value 0.02, Mann-Whitney U test) was significantly higher in patients with IAH. Conclusion Measurement of IAP is a relatively simple procedure that should be incorporated into the routine postoperative care of surgical patients. The presence of elevated IAP can identify the subset of patients at risk of increased postoperative wound complications.

Management of Pancreatic Fluid Collections: An Evidence-based Approach

Managing pancreatic fluid collections (PFCs) remains a challenge for many clinicians. Recently, significant progress has been made in the therapy of PFCs, including improvements in technology and devices, as well as in the development of minimally invasive endoscopic techniques, many of which are proven less traumatic when compared with surgical options and more efficacious when compared with percutaneous techniques. This review will explore latest developments in the management of PFCs and how they incorporate into the current treatment algorithm.

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

Risk factors for abdominal compartment syndrome in trauma – A review

" Background and Aim: Abdominal compartment syndrome is a life-threatening complication that can occur in trauma patients and greatly increase their mortality. Although there is a better scientific understanding of the general phenomena involved in the pathogenesis of this complication, the particular risk factors and their implications in the trauma patient population are yet to be deciphered. Methods: The authors conducted research through 3 electronic databases (PubMed, Scopus, and ScienceDirect) using the following search formula: “(ACS OR abdominal compartment syndrome) AND (*trauma*) AND (risk factor)”. Subsequently, additional search formulas were used, including the risk factors taken into consideration (i.e. “shock”, “hypotension”, “acidosis”, “base deficit”, ”coagulopathy”, “retroperitoneal hematoma”, “HOB elevation”, “fluid resuscitation”, “damage control laparotomy”). Results: Throughout the 41 articles analyzed in this paper, 7 risk factors transcended and were further discussed: head of bed elevation/patient positioning, fluid resuscitation, the “lethal triad” of acidosis hypothermia and coagulopathy, Damage Control Laparotomy, shock/hypotension, retroperitoneal hematoma and demographics (age, gender, and race). Conclusions: To summarize, many potential risk factors were evaluated for the envisagement of the present paper, but the ones that prevailed the most were excessive fluid resuscitation, shock/hypotension, retroperitoneal hematomas, and the lethal triad. Consistent with other studies, no connection was found between age, gender, or race and the development of ACS. Further studies should focus more on the likely involvement of damage control laparotomy and patient positioning, as well as hypocalcemia, in the unfolding of ACS in trauma patients"

Abdominal compartment syndrome after endoscopic combined intrarenal surgery

Introduction

We report a case of abdominal compartment syndrome due to hydroperitoneum after endoscopic combined intrarenal surgery.

Case presentation

A 56-year-old woman with a left staghorn calculus underwent endoscopic combined intrarenal surgery as a two-staged procedure and developed a distended abdomen, cyanosis of both legs, and hypotension immediately after the second operation. A computed tomography scan showed hydroperitoneum. We performed urgent laparotomy and evacuated approximately 2 L of nearly transparent fluid. No peritoneal injury was detected. Postoperatively, she required intensive care for shocked liver and acute kidney injury.

Conclusion

Hydroperitoneum after endoscopic combined intrarenal surgery is a rare complication and may lead to abdominal compartment syndrome or a condition where intra-abdominal pressure exceeds 20 mmHg, causing impaired organ perfusion. Delayed drainage can be fatal.

Treatment outcomes of penetrating abdominal injury requiring laparotomy at Hiwot Fana Specialized University Hospital, Harar, Ethiopia

Background

Penetrating abdominal injury (PAI) is a public health problem and accounts for significant mortality and disability in both developing and developed countries. It often causes damage to internal organs, resulting in shock and infection. In this study, we assessed the outcomes of PAI and factors associated with post-surgical outcomes including surgical site infection (SSI) and in-hospital death.

Methods

An institution-based cross-sectional study was conducted from 15 January to January 30, 2020, using a standard checklist to review the clinical charts of patients who presented to Hiwot Fana Specialized University Hospital (HFSUH) with PAI and underwent laparotomy between January 2015 and September 2019. Descriptive statistics were used to describe the characteristics of patients, and odds ratios (ORs) with a 95% confidence interval (CI) were reported for factors included in binary logistic regression. The statistical significance was declared at a P-value <0.05.

Results

A total of 352 charts of patients with PAI were reviewed. A majority of them (84.9%) were males and the mean age was 26.5 years. The anterior abdomen was the most common site of injury, accounting for 285 patients (81%), 329 patients (93.5%) suffered organ injury, 204 (62%) had a single organ injury, and 125 (38%) had more than one organ injury. The leading injured organs were small intestines 194 (55.1%), followed by the colon 88 (25%) and liver 40 (11.4%). The magnitude of SSI and hospital death was 84 (23.9%) and 12 (3.4%), respectively. Patients above 45 years of age (AOR = 2.9, 95% CI: 1.2, 9.2), with fluid collection (AOR = 2.7, 95% CI: 1.2, 5.9), colostomy (AOR = 3.9, 95% CI: 1.9, 7.8), body temperature >37.5 °C (AOR = 3.8,95% CI:1.9,7.6), and Hgb < 10 mg/dl (AOR = 7.4, 95% CI: 3.4,16.1) had a higher likelihood of SSI. Those patients admitted to the intensive care unit (AOR = 21.3, 95% CI: 1.1, 412.3) and who underwent damage control surgery (AOR = 9.6, 95% CI: 1.3, 73.3) had a higher likelihood of mortality.

Conclusions

SSI and death among patients with PAI were high. Age, fluid collection, colostomy, body temperature, and hemoglobin level were statistically associated with SSI, and intensive care unit and damage control surgery were statistically associated with death. Therefore, health professionals working in surgical wards should consider these factors to alleviate SSI and prevent death. Broadly speaking, the guidelines of the World Society of Emergency Surgery (WSES) should consider these factors in their recommendations.

Low-Flow Acute Kidney Injury: The Pathophysiology of Prerenal Azotemia, Abdominal Compartment Syndrome, and Obstructive Uropathy

AKI is a syndrome, not a disease. It results from many different primary and/or secondary etiologies and is often multifactorial, especially in the hospitalized patient. This review discusses the pathophysiology of three etiologies that cause AKI, those being kidney hypoperfusion, abdominal compartment syndrome, and urinary tract obstruction. The pathophysiology of these three causes of AKI differs but is overlapping. They all lead to a low urine flow rate and low urine sodium initially. In all three cases, with early recognition and correction of the underlying process, the resulting functional AKI can be rapidly reversed. However, with continued duration and/or increased severity, cell injury occurs within the kidney, resulting in structural AKI and a longer and more severe disease state with increased morbidity and mortality. This is why early recognition and reversal are critical.

Gastric and urinary bladder pressures correlate with intra-abdominal pressure in patients with morbid obesity

Intra-abdominal pressure (IAP) affects cardio-respiratory and hemodynamic parameters and can be measured directly or indirectly by measuring gastric or urinary bladder pressure. The aim of this study was to investigate the correlation between IAP, gastric pressure and urinary bladder pressure in patients with morbid obesity, at normal and elevated levels of IAP in two positions. As well, to examine the effects of increasing IAP and patient's position on hemodynamic and respiratory parameters. Twelve patients undergoing laparoscopic bariatric surgery were included. IAP, gastric pressure, and urinary bladder pressure were measured while patients were in the supine position and after 45° anti-Trendelenburg tilt. Mean inspiratory pressure, peak inspiratory pressure, and tidal volume were recorded and assessed. In supine position; directly measured IAP was 9.1 ± 1.8 mmHg, compared to 10 ± 3.6 and 8.9 ± 2.9 mmHg in the stomach and bladder, respectively. Increasing IAP to 15 mmHg resulted in an increased gastric pressure of 17 ± 3.8 mmHg, and urinary bladder pressure of 14.8 ± 3.9 mmHg. Gastric and urinary bladder pressures strongly correlated with IAP (R = 0.875 and 0.847, respectively). With 45° anti-Trendelenburg tilt; directly measured IAP was 9.4 ± 2.2 mmHg, and pressures of 10.8 ± 3.8 mmHg and 9.2 ± 3.8 mmHg were measured in the stomach and the bladder, respectively. Increasing IAP to 15 mmHg resulted in elevating gastric and bladder pressures to 16.6 ± 5.3 and 13.3 ± 4 mmHg, respectively. Gastric and urinary bladder pressures had good correlation with IAP (R = 0.843 and 0.819, respectively). Changing patient position from supine to 45° anti-Trendelenburg position resulted in decreased mean and peak inspiratory pressures, and increased tidal volume. Basal IAP is high in patients with morbid obesity. IAP shows positive correlation to gastric and urinary bladder pressures at both normal and elevated levels of IAP. Anti-Trendelenburg tilt of mechanically ventilated morbidly obese patients resulted in favorable effects on respiratory parameters.

Trial Registration: The study was retrospectively registered in the NIH registry. Registration number is pending.

Early intra-abdominal hypertension: A reliable bedside prognostic marker for severe acute pancreatitis

Background and Aim

Severe acute pancreatitis (SAP) is commonly associated with intra-abdominal hypertension (IAH). This acute increase of intra-abdominal pressure (IAP) may be attributed to early organ dysfunction, leading to an increased morbidity and mortality. To assess the incidence of raised IAH and its correlation with other prognostic indicators and various outcomes in SAP.

Methods and Results

This was a prospective observational study in patients of SAP between July 2009 and December 2010. All patients of SAP who were admitted to the hospital within 2 weeks of onset of pain were included in the study. A total of 35 patients with SAP were included in the study. Among these, 25 (71.4%) were males. All our patients had raised IAP; however, IAH was present in 51.4% (18/35). Patients with IAH were found to have a higher APACHE II score (88.9 vs 5.9%; P < 0.001), infectious complications (72.2 vs 5.9%; P < 0.001), circulatory failure (88.9 vs 0%; P < 0.001), and respiratory failure (100 vs 41.2%; P < 0.001). All the eight (22.8%) patients who succumbed to sepsis had IAH. Patients with IAH were found to have a significantly longer intensive care unit (ICU) stay (17.72 vs 12.29 days) and in-hospital stay (24.89 vs 12.29 days).

Conclusion

IAH is a good negative prognostic marker in SAP, seen in up to 51.4%. IAH was found to have a significant negative impact on the outcome in terms of increased mortality, morbidity, in-hospital stay, and ICU stay among the patients of SAP.

Current Approach to the Evaluation and Management of Abdominal Compartment Syndrome in Pediatric Patients

Abdominal compartment syndrome is an emergent condition caused by increased pressure within the abdominal compartment. It can be caused by a number of etiologies, which are associated with decreased abdominal wall compliance, increased intraluminal or intraperitoneal contents, or edema from capillary leak or fluid resuscitation. The history and physical examination are of limited utility, and the criterion standard for diagnosis is intra-abdominal pressure measurement, which is typically performed via an intravesical catheter. Management includes increasing abdominal wall compliance, evacuating gastrointestinal or intraperitoneal contents, avoiding excessive fluid resuscitation, and decompressive laparotomy in select cases.

Gender differences in response to abdominal compartment syndrome in rats

Objective

Our study aims to emphasize the novelty of female rats in regard to their hemodynamic changes in response to abdominal compartment syndrome. A group of 64 rats was randomly divided into 4 subgroups for each gender. Except for the control, intra-abdominal pressure was increased to 10, 20, 30 mmHg. Survival time, mean arterial pressure, pH and lactate were determined at different time intervals.

Results

As IAP was 20 mmHg, a statistically difference was seen between the male group and the female group starting from 15 min (126 ± 9.7 mmHg, 124 ± 14.7 mmHg respectively, p < 0.02) and lasting 2 h. At 30 mmHg, a statistically difference was seen between 30 to 60 min (p < 0.05). Only group 2 presented results with statistical power both at 30 and at 60 min concerning pH (p = 0.003, p < 0.001 respectively). In the lactate measurements at IAP of 10 mmHg, at 60 min male lactate level was 3.93 ± 1.13 and 2.25 ± 0.33 in female rats (p = 0.034). Female rats that were subjected to IAP of 20 mmHg and 30 mmHg had significantly better survival than male rats that were subjected to the same pressure (p < 0.05 and p < 0.01, respectively). We concluded that female rats have better preserved their hemodynamic and metabolic parameters during ACS than male rats.

Management Strategies for Intracranial Pressure Crises in Subarachnoid Hemorrhage

Objectives: Standard management strategies for lowering intracranial pressure (ICP) in traumatic brain injury has been well-studied, but the use of lesser known interventions for ICP in subarachnoid hemorrhage (SAH) remains elusive. Searches were performed in PubMed and EBSCO Host to identify best available evidence for evaluation and management of medically refractory ICP in SAH. The role of standard management strategies such as head elevation, hyperventilation, mannitol and hypertonic saline as well as lesser known management such as sodium bicarbonate, indomethacin, tromethamine, decompressive craniectomy, decompressive laparotomy, hypothermia, and barbiturate coma are reviewed. We also included dose concentrations, dose frequency, infusion volume, and infusion rate for these lesser known strategies. Nonetheless, there is still a gap in the evidence to recommend optimal dosing, timing and its role in the improvement of outcomes but early diagnosis and appropriate management reduce adverse outcomes.

Abdominal compartment syndrome and ruptured aortic aneurysm: Validation of a predictive test (SCA-AAR)

BACKGROUND

The abdominal compartment syndrome (ACS) has been clearly identified as being one of the main causes of mortality after ruptured abdominal aortic aneurysm (rAAA). The ACS is defined as a sustained intra-abdominal pressure > 20 mm Hg associated with a new organ dysfunction or failure. A pilot study was conducted and found that the threshold of 3 among 8 selected criteria, we would predict an ACS occurrence with a 54% positive predictive value and a 92% negative predictive value. But a multicentric prospective study was clearly needed to confirm these results. The outcome of this new study is to assess the qualities of a predictive test on occurrence of the ACS after rAAA surgery.

METHODS

This is a 30 months prospective cohort study conducted in 12 centers and 165 patients will be included. All patients with a rAAA will be consecutively included, whatever the surgical treatment. At the end of surgery, all patients have an abdominal closure and a monitoring of intrabladder pressure will be established every 3 to 4 hours. Decompressive laparotomy will be indicated when ACS occurs. Follow-up period is 1 month. Eight pre- and per-operative criteria will be studied: anemia, hypotension, cardiac arrest, obesity, massive fluid resuscitation, transfusion, hypothermia, and acidosis.

DISCUSSION

In the literature, there is no recommendation about prophylactic decompression, but early decompressive laparotomy appears to improve survival. This study should make it possible to establish a predictive test, detect the ACS early, and consider a prophylactic decompression in the operating room.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02859662, Registered on 4 August 2016.

The Influence of Carbon Dioxide Pneumoperitoneum on Systemic Inflammatory Response Syndrome and Bacterial Translocation in Patients With Bacterial Peritonitis Caused by Acute Appendicitis

OBJECTIVE

To explore the influence of carbon dioxide pneumoperitoneum (CDP) on system inflammatory response syndrome (SIRS) and bacterial translocation (BT) in patients with bacterial peritonitis (BP) caused by acute appendicitis (AA).

METHODS

Eighty-six consecutive subjects were randomly divided into the laparoscopy and laparotomy groups (n = 44 and n = 42, respectively). The levels of white blood cells (WBC), C-reactive protein (CRP), tumor necrosis factor α (TNF-α), and interleukin 6 (IL-6) of the 2 groups were tested preoperatively and at days 1, 2, and 4 after surgery. Blood and secretion culture was performed to verify whether septicemia or incision infection occurred, respectively. And the abdominal ultrasound or computed tomography scanning was used to diagnose peritoneal abscess for the suspected patients. The essential risk factors related to the aggravation of SIRS were analyzed through analysis of variance and binary logistic regression.

RESULTS

The postoperative blood levels of WBC, CRP, TNF-α, and IL-6 on day 4 in the laparoscopy group were significantly lower than those in the control group (all Ps < .05). The differences in incidence rates of septicemia and peritoneal abscess between the CDP and control groups were not statistically significant ( P > .05). Nevertheless, the incision infection rate in the laparoscopy group was apparently lower than that in the control group (4.55% vs 19.04%, P = .047). Analysis of variance and binary logistic regression showed that the non-pneumoperitoneum, pathological type of appendicitis, and multidrug resistant infections were the 3 major risk factors for SIRS (the P values were .001, .019, and .012, respectively).

CONCLUSION

It was found that CDP is safe for BP and could be a potential protective factor to mitigate BP effectively, indicating that the performance of laparoscopy operation under CDP is feasible to control SIRS; at the same time, CDP would not raise the incidence rate of BT.

Early Definitive Closure of the Open Abdomen: A Quiet Revolution

Contrary to the management strategy recommended only 2-3 years ago, temporarily covering the open abdomen with an absorbable mesh or a plastic sheath without preserving the peritoneal space is no longer considered in the patient's best interest. The use of the vacuum pack, in conjunction with vacuum-assisted wound management and new biological prostheses now offer patients with an open abdomen a better and simpler alternative to the giant "planned ventral hernia". With very few exceptions in the most critically ill patients, the survivors of damage control surgery or infected pancreatic necrosis should not be sent home with a huge defect only to undergo a complex reconstruction a year later. Simpler and better alternatives exist. The new concepts and technologies presented in this review, when widely adopted, will rapidly translate into safer and better management of the patient with an open abdomen.

Assessment of intensivists' knowledge on abdominal compartment syndrome

BACKGROUND AND OBJECTIVES

: Early recognition of abdominal compartment syndrome (ACS) is essential, as delay in the diagnosis may induce a negative impact on prognosis. However, there are some evidences suggesting a low level of knowledge concerning ACS in intensive care units (ICU). The aim of this study was to evaluate the intensivist's knowledge on ACS.

METHODS

We distributed 49 questionnaires, with 13 multiple choice questions, in seven ICU, which addressed the concept, diagnosis, and management of ACS.

RESULTS

Thirty-two questionnaires were answered. Forty-seven percent of respondents have more than 16 years of medical practice and spend more than 50% of their time in ICU. Although 75% reported having knowledge of ACS' concept, only 34% had measured intra-abdominal pressure (IAP). The most used method for measurements was urinary catheterization (91%). For 37%, the frequency of measurement should be based on clinical data rather than IAP values. Regarding the indication to IAP monitoring, the choices were performing the measurement after urgent laparotomy (25%), in massive volemic replacement (18%) and in other hazardous conditions (57%). The lack of information about measurement techniques was the main reason for not measuring IAP. Most respondents (90%) suggested the measurement of IAP as a routine in ICU.

CONCLUSION

Intensivists' knowledge on ACS was low, as most were not able to measure, interpret the results and recognize important risk factors for IAP. These data demonstrate that educational efforts concerning ACS are necessary in order to standardize the measurement of IAP in populations at risk, aiming at a better outcome in critically ill patients.

Does Diastasis Width Influence the Variation of the Intra-Abdominal Pressure After Correction of Rectus Diastasis?

BACKGROUND

It has been demonstrated that there is an increase of intra-abdominal pressure (IAP) after correction of rectus diastasis.

OBJECTIVE

To evaluate the correlation between the diastasis width and IAP variation after the plication of the anterior rectus sheath.

METHODS

Seventeen patients met the inclusion criteria and were selected. The diastasis width was measured at three levels: 3 cm above the umbilicus, 2 cm above the umbilicus, and 2 cm below the umbilicus. Rectus sheath plication was performed in two layers: the first layer with separate stitches, and the second with continuous suture. The IAP was measured at two stages: before and after the correction of rectus diastasis. The distance between the iliac spines (IS) and that between the xiphoid process and pubic symphysis (XP) were measured. The abdominal surface index (ASI) was calculated using the formula: ASI = (IS × XP)/2. This index was used to determine the individual abdominal surface. The relative diastasis coefficient (RDC) was calculated using the formula: RDC = diastasis/ASI. These measurements were correlated to the IAP variation. The results of the IAP measurements obtained in each stage and the RDC values were compared, using the Pearson's linear correlation coefficient.

RESULTS

There was no statistically significant correlation between the IAP variation and the RDC values at the three levels studied.

CONCLUSIONS

The diastasis width does not interfere with the increase of the IAP when a plication of the anterior aponeurosis is performed.

LEVEL OF EVIDENCE

3 Diagnostic.

Compartment syndrome in patients with haemophilia

BACKGROUND

Acute compartment syndrome (ACS) is an uncommon but potentially devastating condition.

METHODS AND RESULTS

There are scattered case reports and case series in the literature of ACS in persons with haemophilia (PWH), and even fewer in PWH and inhibitors. The management of compartment syndrome in these scenarios is controversial and often anecdotal. In addition haematological outcomes are frequently quoted but functional outcomes are generally overlooked. This article aims to provide an overview of ACS and its contemporary management. We also review the literature and outcomes of patients with haemophilia who develop ACS in an effort to assess the best treatment modality.

CONCLUSION

In the majority of cases ACS settles with normalisation of the clotting cascade. Specialist haematological input is mandatory before surgical intervention should be considered, especially in PWH and inhibitors.

The increase of intra-abdominal pressure can affect intraocular pressure

Objective. This study aims to explore the usage of intraocular pressure measurements as the early indicator of the increase in intra-abdominal pressure. Methods. In this prospective study, 40 patients undergoing elective surgery were included. Patients were divided into four groups of 10 patients. The control group (Group C) was not subjected to laparoscopic intervention. Laparoscopic surgery was, respectively, performed with an intra-abdominal pressure of 9, 12, and 15 mmHg in Groups L (low), M (medium), and H (high pressure). Intraocular pressure was measured binocularly in each patient at three different times (before, during, and end of surgery) using a contact tonometer. Results. Patients' gender, age, body mass index (BMI), American Society of Anesthesiology (ASA) class, and operative times were not different among the groups. No complications occurred with either the surgery or measurement of intraocular pressure. Intubation was associated with a severe rise in IOP (P < 0.05). An increase in intraocular pressure was seen in groups M and H (P < 0.05). Conclusion. Intraocular pressure was increased in the groups with an intra-abdominal pressure of 12 mmHg or more. Measuring the intraocular pressure might be a useful method to estimate the intra-abdominal pressure. This trial is registered with NCT02319213.

Pulmonary Function After Pedicled Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction

Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, have been shown to increase intra-abdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled TRAM flap breast reconstruction.A prospective clinical trial was conducted involving 22 women undergoing unilateral or bilateral pedicled TRAM flap breast reconstruction. Pulmonary function testing was conducted 1 week before the operation, 24 hours postoperatively, and 2 months postoperatively. The patients were stratified by age (<50 years vs ≥50 years), type of TRAM flap (unilateral vs bilateral), tobacco use (smoker vs nonsmoker), and body mass index. Changes were analyzed using 1-way repeated-measures analysis of variance and paired t tests. All comparisons used a 2-tailed test at the 0.05 level of significance.Other than residual volume, the 24-hour postoperative values were significantly lower than the preoperative values. The smokers had less change in functional residual capacity, total lung capacity, and forced vital capacity values than the nonsmokers at 24 hours postoperatively; however, they were noted to have decreased pulmonary function at baseline. The patients 50 years or older had significantly greater decline in functional residual capacity and residual volume compared with the younger cohort. No significant difference in pulmonary function testing values existed between those undergoing bilateral versus unilateral pedicled TRAM flap reconstruction. Pulmonary function tests returned to baseline at 2-month follow-up.Pulmonary function test values were significantly decreased at 24 hours after pedicled TRAM flap breast reconstruction.

The pathophysiology, diagnosis and current management of acute compartment syndrome

Acute compartment syndrome (ACS) is a surgical emergency warranting prompt evaluation and treatment. It can occur with any elevation in interstitial pressure in a closed osseo-fascial compartment. Resultant ischaemic damage may be irreversible within six hours and can result in long-term morbidity and even death. The diagnosis is largely clinical with the classical description of ‘pain out of proportion to the injury’. Compartment pressure monitors can be a helpful adjunct where the diagnosis is in doubt. Initial treatment is with the removal of any constricting dressings or casts, avoiding hypotension and optimizing tissue perfusion by keeping the limb at heart level. If symptoms persist, definitive treatment is necessary with timely surgical decompression of all the involved compartments. This article reviews the pathophysiology, diagnosis and current management of ACS.

New developments in abdominal wall reconstruction after abdominal compartment syndrome decompression

The acute abdominal compartment syndrome (ACS) is most often treated with surgical abdominal decompression. After the acute phase, primary closure of the abdominal wall may not be possible, due to tissue loss and retraction of the abdominal wall and its musculofascial components. This article gives an update of the reconstructive ladder for abdominal wall defects. Because of improved intensive care treatment and wound dressing, reconstruction can usually be delayed until infection and oedema have settled. Recent developments in bioprosthetics and new surgical techniques like component separation make better results with less donor site morbidity possible. However, there is still a place for local and distant flaps.

Outcomes of children with abdominal compartment syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations.

OBJECTIVE

To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS.

SETTING

25 bed tertiary pediatric intensive care unit.

PATIENTS

PATIENTS less than 50 kg on mechanical ventilation and a urethral catheter.

MEASUREMENTS

Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored.

MAIN RESULTS

14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondary ACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17 - 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of ≥17 were predictive of developing ACS.

CONCLUSIONS

ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Clinical awareness of intra-abdominal hypertension and abdominal compartment syndrome in 2007

INTRODUCTION

There has been an exponentially increasing interest in intra-abdominal hypertension (IAH). The aim of this review is to evaluate the evolution in clinical awareness of this syndrome.

METHODS

A PubMed (U.S. National Library of Medicine) search and a ScienceDirect (Elsevier B.V.) search of recent literature were performed in order to assess clinical awareness of IAH and abdominal compartment syndrome (ACS).

RESULTS

In total, 489 articles and 8 clinical surveys have been identified. The results of the landmark papers and the surveys will be briefly discussed in this review.

CONCLUSION

Clinical awareness of ACS is steadily increasing. It is time to pay attention to ACS, but further, it is time to move forward with therapeutic bundles in a multi-centered, outcome trial on IAH/ACS therapy in order to elevate IAH/ACS management to an international standard of care.

Management of open abdomen

Non-closure of abdominal fascia and the resultant open abdomen after laparotomy has become a major advance in the management of critically ill or injured patients. The benefits of open abdomen are many and include the prevention of intra-abdominal hypertension and the consequent abdominal compartment syndrome. Appropriately and exquisitely managed, it can provide all the benefits and prevent highly morbid complications of leaving the abdomen open. This review will provide some insights into such management.

Hepatic function and non-invasive hepatosplanchnic monitoring in patients with abdominal hypertension

A better understanding of intra-abdominal hypertension with relation to the liver is vital to the management of all forms of liver pathophysiology. Supporting good hepatic function within the critically ill patient is important not only in maintaining synthetic function, but also in avoiding the multi-organ complications of liver dysfunction. The resulting reduction in hepato-splanchnic blood flow (HSBF) observed with increasing intra-abdominal pressure has been clearly documented and seen to be exaggerated in animals with established liver disease. Unfortunately the tools required to measure this, remain difficult to apply routinely in the clinical setting and as such goal directed therapy to specifically improve the hepatosplanchnic circulation remains elusive. Given the documented effects of IAP on HSBF and the relatively high incidence of intra-abdominal hypertension and the abdominal compartment syndrome within "liver patients" as a whole, close attention to IAP and timely correction by appropriate medical or surgical means would appear to be essential.

Effects of doxycycline on intestinal ischemia reperfusion injury induced by abdominal compartment syndrome in a rat model

BACKGROUND

Abdominal compartment syndrome (ACS) refers to organ dysfunction and ischemia resulting from intra-abdominal hypertension (IAH). Ischemia of the gut results in the triggering of a systemic inflammatory response by releasing cytokines which, in turn, causes capillary leakage leading to bowel edema, further increasing intra-abdominal pressure and resulting in a morbid cycle of ischemia and edema.

OBJECTIVE

The aim of this study was to determine the effects of doxycycline on intestinal ischemia reperfusion (I/R) injury in a rat model of ACS.

METHODS

Sprague-Dawley rats were divided into 5 equal groups. In groups 1 and 2, saline (1 cc IP) was administered during induction of ACS and intestinal samples were removed at 1 and 24 hours, respectively, after decompression. In groups 3 and 4, doxycycline (10 mg/kg IP) was injected during induction of ACS and, similarly, intestinal samples were removed at 1 and 24 hours after decompression. In the control group (group 5), intestinal samples were collected without induction of ACS. Malon-dialdehyde (MDA), interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, matrix metalloproteinase-2 (MMP-2), and tissue inhibitor of metalloproteinase-1 were studied and the apoptotic cells were enumerated histopathologically. Apoptosis and β-cell lymphoma 2 (βcl-2) expression were assessed immunohistochemically.

RESULTS

Thirty-five rats were evenly divided into 5 groups of 7 rats each. MDA, IL-1β, IL-6, TNF-α, and MMP-2 levels were significantly higher in group 1 one hour after the reperfusion period compared with the control group (P < 0.001, P < 0.001, P < 0.05, P < 0.001, and P < 0.01, respectively). The same parameters were significantly lower in group 3, in which doxycycline was administered, than in group 1 (P < 0.001, P < 0.05, P < 0.05, P < 0.001, and P < 0.01, respectively). However, there was no significant difference between groups 2 and 4 in the 24th hour (all, P > 0.05). The mean (SD) number of apoptotic cells and the expression of βcl-2 was highest in group 2 at 24 hours after the reperfusion period (92.5 [11.4] and 35.9 [5.0], respectively) and significantly greater than that in group 4 (P < 0.001 and P < 0.05, respectively).

CONCLUSION

Doxycycline was associated with protective effects against I/R injury through decreasing apoptosis via attenuating the response of proinflammatory cytokines and inhibiting the activity of MMP-2 in this rat model.

Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures

INTRODUCTION

Transcatheter arterial embolization (TAE) is usually necessary in the management of hemodynamically unstable patients with concomitant pelvic fractures. Given the critical conditions of such patients, TAE is at times performed only according to the results of a primary evaluation without computed tomographic (CT) imaging. Therefore, the evaluation of associated intra-abdominal injuries (IAIs) might be insufficient. Clinically, some patients have required post-TAE laparotomy due to further deterioration. In this study, we attempted to determine a feasible protocol for post-TAE observation.

MATERIALS AND METHODS

This study focused on patients who received TAE to achieve hemostasis of retroperitoneal hemorrhage and who did not undergo CT imaging due to their unstable hemodynamics. The characteristics of patients with and without associated IAIs requiring post-TAE laparotomy were compared. We also analyzed the effects of the timing of post-TAE CT imaging on patients with IAIs requiring surgery.

RESULTS

A total of 41 patients were enrolled in the study. Of these patients, all of whom underwent primary TAE without preprocedure CT imaging; 15 patients (15/41, 36.6%) required post-TAE laparotomy due to further deterioration. Comparisons between the 2 patient groups revealed no significant differences in the rate of endotracheal intubation (80.0% vs 65.4%, P=.480), loss of consciousness (66.7% vs 73.1%, P=.730), or abdominal symptoms (20.0% vs 23.1%, P=1.000).

CONCLUSION

In the management of hemodynamically unstable patients with concomitant pelvic fractures, greater attention should be paid to associated IAIs. Early CT imaging is encouraged after the patient's hemodynamic status is stabilized with TAE.

Intestinal permeability, systemic endotoxemia, and bacterial translocation after open or laparoscopic resection for colon cancer: a prospective randomized study

PURPOSE

In this prospective randomized study, we investigated the effect of surgery on intestinal permeability (IP), endotoxemia, and bacterial translocation (BT) in patients undergoing elective colectomy for colon cancer by comparing the laparoscopic with the open approach.

METHODS

Seventy-two consecutive patients underwent colectomy for colon cancer: 35 cases open resection and 37 cases laparoscopic resection. IP was measured preoperatively and at days 1 and 3 after surgery. Serial venous blood sample were taken at 0, 30, 60, 90, 120, and 180 min and at 12, 24, and 48 h after surgery for endotoxin measurement. Tissue sample were taken from the liver, spleen, and mesenteric lymph nodes and were weighed under sterile conditions.

RESULTS

IP was significantly increased in the open and closed group at day 1 compared with the preoperative level (p < 0.05), but no difference was found between laparoscopic and open surgery group. The concentration endotoxin systemic increased significantly in the both group during the course of surgery but returned to baseline levels at the second day 2. No difference was found between laparoscopic and open surgery. A significant correlation was observed between the maximum systemic endotoxin concentration and IP measured at D1 in the open group and in the laparoscopic group. The incidence of BT increased in laparoscopic and open group after bowel mobilization, compared with the before mobilization (p < 0.05). There was not a statistically significant difference in BT value between the two groups.

CONCLUSION

An increase in IP, systemic endotoxemia, and BT were observed during the open and laparoscopic resection for colon cancer, without significant statistically difference between the two groups.

Ventilatory function and intra-abdominal pressure in patients who underwent abdominoplasty with plication of the external oblique aponeurosis

BACKGROUND

After correction of rectus diastasis there is a change in the values obtained by spirometry in the first few postoperative days. In specific cases, a plication of the external oblique aponeurosis in addition to plication of the anterior rectus sheath is indicated. Therefore, the aim of this study was to evaluate ventilatory function and intra-abdominal pressure (IAP) in patients who underwent abdominoplasty with the plication of the anterior rectus sheath, associated with an "L-shaped" plication of the external oblique aponeurosis.

METHODS

Eighteen female patients, classified as Nahas type III or B, were selected. Spirometry was performed preoperatively and on the 2nd, 7th, and 15th days after surgery. Intraoperatively, the IAP was measured at five points in the surgical procedure: (1) before skin incision, (2) after the plication of the rectus abdominis muscle, (3) after the L-plication of the aponeurosis of the external oblique, (4) after skin closure, and (5) after the use of a compressive garment.

RESULTS

There was a significant reduction in spirometry values after surgery. There was no correlation between body mass index (BMI), pain, the increase of IAP, and the width of diastasis and changes in spirometry (p ≤ 0.05) in any of the postoperative evaluations.

CONCLUSION

Spirometric parameters change on the 2nd and 7th postoperative days and tend to normalize on the 15th day. Postoperative pain, BMI, and increased IAP are not related to these changes. The use of compressive garments increases the IAP.

Traumatic appendicitis: a case report and literature review

Appendicitis and trauma may exist together, which causes an interesting debate whether trauma has led to appendicitis. We report a case of appendicitis after an abdominal trauma. Our patient developed acute appendicitis following a stab wound in the right iliac fossa. Surgical exploration confirmed the traumatic origin of appendicitis, appendectomy was performed and our patient made an excellent recovery. In non operative management of abdominal trauma, physical examinations and radiological explorations should be repeated in order to diagnose traumatic appendicitis.

Biochemical and histopathological changes of intra-abdominal hypertension on the kidneys: Experimental study in rats

OBJECTIVE

This study aimed to evaluate the effects of experimentally induced intra-abdominal hypertension on renal functions, with the combination of biochemical and histopathological properties.

MATERIAL AND METHODS

Thirty male Wistar albino rats were used in this experimental study. Rats were divided into four groups. Group 1 (control group, n=6) only received anesthesia. After the induction of anesthesia, a 20 G catheter was introduced intraperitoneally to Group 2 (sham group, n=8), Group 3 (n=8) and Group 4 (n=8). The intra-abdominal pressure was not increased in Group 2. We applied 20 mmHg intra-peritoneal pressure to Group 3 and 30 mmHg to Group 4 for 3 hours. After withdrawing 3 mL intracardiac blood from all groups, the kidneys were removed for histopathological examination. Serum urea and creatinine levels were measured in all groups.

RESULTS

Biochemical examination showed that blood urea and creatinine levels were statistically different among all groups (p<0.05). Serum creatinine levels in Group 3 and serum urea and creatinine levels in Group 4 were significantly increased. In the histopathological examination, the kidneys in Group 1 and Group 2 were classified as normal. In Group 3, areas with congestion were detected in the glomeruli and interstitial regions. In addition to these findings seen in Group 3, dilatation of the pelvi-caliceal structures and proximal ureters were noticed in Group 4.

CONCLUSION

The levels of serum urea and creatinine are elevated when intra-abdominal pressure is increased due to kidney damage. Foci of hemorrhage in the interstitial area, dilatations in the proximal ureter, renal pelvis, and lymphatics were the pathologic findings seen in the kidneys under such circumstances.

[Evolution of US military transfusion support for resuscitation of trauma and hemorrhagic shock]

Military conflicts create a dynamic medical environment in which the number of severe trauma cases is compressed in both time and space. In consequence, lessons are learned at a rapid pace. Because the military has an effective organizational structure at its disposal and the logistical capacity to rapidly disseminate new ideas, adoption of novel therapies and protective equipment occurs quickly. The recent conflicts in Iraq and Afghanistan are no exception: more than three dozen new clinical practice guidelines were implemented by the US Armed Forces, with attendant survival benefits, in response to observation and research by military physicians. Here we review the lessons learned by coalition medical personnel regarding resuscitation of severe trauma, integrating knowledge gained from massive transfusion, autopsies, and extensive review of medical records contained in the Joint Theater Trauma Registry. Changes in clinical care included the shift to resuscitation with 1:1:1 component therapy, use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding. Future research will focus on emerging concepts regarding coagulopathy of trauma and evaluation of promising new blood products for far-forward resuscitation. New strategies aimed at reducing mortality on the battlefield will focus on resuscitation in the pre-hospital setting where hemorrhagic death continues to be a major challenge.

Clinical evidences, personal experiences, recent applications

Management of difficult wounds can be a complex, challenging and expensive task, especially for wounds showing a slow healing process. Topical negative pressure (TNP) therapy has greatly improved difficult wounds treatment. It allows to treat patient on an outpatient management, to reduce the complication rate with shorter hospital stay, to avoid frequent dressings with expensive advanced materials and allow a lower commitment of health professionals. Vacuum Assisted Closure^® (VAC^®) system is a therapeutic device based on the administration of a controlled TNP introduced by Morykwas and Argenta in 1997. It is indicated in different kinds of wound, but clinical evidences are present only for few of them. In this work we summarize indications and recommendations for VAC^® therapy and we analyze the actual better choice of treatment based on evidences and personal experience in order to stimulate further studies. Finally we introduce recent applications of VAC^® system such as Prevena^®, VAC Instill^® and VAC Via^®. Prevena^® is a system based on TNP indicated in the management of closed wounds that present risk factors for dehiscence. VAC Instill^® is a system that allows to associate TNP and topical administration of solutions, such as antibiotics or disinfectants, to treat specific type of wounds. VAC Via^® is a device based on TNP, characterized by little dimension and a preset system that allow the treatment of little wounds for 7 d, with no impairment for the patient. The aim of our paper is to describe a report of VAC^® therapy use in order to stimulate further studies and to define the level of evidence of VAC^® therapy.

Abdominal decompression in children

Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.

Intra-abdominal hypertension and abdominal compartment syndrome in association with ruptured abdominal aortic aneurysm in the endovascular era: vigilance remains critical

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are common complications of ruptured abdominal aortoiliac aneurysms (rAAAs) and other abdominal vascular catastrophes even in the age of endovascular therapy. Morbidity and mortality due to systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) are significant. Recognition and management of IAH are key critical care measures which may decrease morbidity and improve survival in these vascular patients. Two strategies have been utilized: expectant management with prompt decompressive laparotomy upon diagnosis of threshold levels of IAH versus prophylactic, delayed abdominal closure based upon clinical parameters at the time of initial repair. Competent management of the abdominal wound with preservation of abdominal domain is also an important component of the care of these patients. In this review, we describe published experience with IAH and ACS complicating abdominal vascular catastrophes, experience with ACS complicating endovascular repair of rAAAs, and techniques for management of the abdominal wound. Vigilance and appropriate management of IAH and ACS remains critically important in decreasing morbidity and optimizing survival following catastrophic intra-abdominal vascular events.