Abdominal compartment syndrome

Abdominal Compartment Syndrome Secondary to Bulimia Nervosa: A Case Report and Systematic Review of Published Cases

BACKGROUND

Abdominal compartment syndrome (ACS) is typically attributed to critically unwell patients with trauma, burns, post surgery, and massive ascites. A rare but fatal cause of ACS is bulimia nervosa (BN), which is an eating disorder characterized by bingeing, followed by methods to avoid weight gain, including purging.

CASE REPORT

We present a case of a 20-year-old woman who presented with abdominal pain and distension after consuming a large quantity of food the previous night and was unable to purge. She was initially managed conservatively and discharged home, but returned subsequently on the same day with clinical features of ACS secondary to acute gastric distension. Decompression resulted in life-threatening reperfusion injury with critical electrolyte abnormalities and fatal cardiac arrest in the operating theatre. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A systematic review of the literature found only 11 case reports of ACS secondary to BN, of which only 6 patients survived due to early diagnosis and decompression. Inability to purge and lower limb ischemia appeared to be associated with increased mortality. As BN is a common emergency presentation, the case and systematic review highlights the need to consider ACS as a potentially life-threatening complication of binge eating, particularly when there is unsuccessful purging.

Abdominal Compartment Syndrome Following Paraesophageal and Diaphragmatic Hernia Repair

Abdominal compartment syndrome (ACS) is defined as a sustained intra-abdominal pressure ≥ 20 mm Hg, associated with new organ dysfunction. Postoperative ACS can occur following repair of hernias with loss-of-domain. Such loss-of-domain hernias are well described involving incisional hernias, less described involving Bochdalek congenital diaphragmatic hernias (CDHs), but not yet described involving paraesophageal hernias (PEHs) or Morgagni CDHs. We describe a case of postoperative ACS following laparoscopic repair of a PEH and Morgagni CDH. This case demonstrates that prophylactic omentectomy should be considered in select patients undergoing repair of large PEHs or CDHs, as ACS is a rare but potential complication.

[Successful treatment of severe purulent peritonitis against the background of intraperitoneal hypertension syndrome (clinical case)]

Traditional surgical treatment of widespread purulent peritonitis has some disadvantages that emphasizes the need for new approaches to postoperative care. The authors present successful treatment of diffuse purulent peritonitis using a combination of 'open abdomen' technology and VAC therapy. This approach reduces abdominal inflammation and intra-abdominal pressure. Combination of 'open abdomen' technology and VAC therapy provides effective control of inflammation and stabilization of patients with purulent peritonitis.

Uterine Leiomyomata as a Cause of Abdominal Compartment Syndrome in the Postpartum Period

Uterine leiomyomas are common benign smooth muscle tumors that often occur during the reproductive years. Although many cases may not result in significant complications, negative pregnancy outcomes have been associated with the size and location of the fibroids. Degeneration of fibroids can occur as early as the late first trimester when they undergo significant volumetric growth, contributing to pain during pregnancy. While myomectomy is typically avoided during pregnancy, conservative management with anti-inflammatory medications may be effective. Surgical removal or preterm delivery may be necessary if symptoms persist. Abdominal compartment syndrome (ACS) is a rare condition characterized by sustained elevated intra-abdominal pressure leading to organ failure. Although ACS resulting from large-volume leiomyomas in the postpartum period has not been previously described, we present a case of a 25-year-old patient with massive uterine fibroids who required indicated preterm delivery via primary cesarean section at 25 weeks gestation. Her postpartum course was complicated by ACS, requiring emergent surgical decompression. When a large fibroid burden is present during pregnancy or in the postpartum period, ACS should be considered in the differential diagnosis. Early diagnosis and timely surgical decompression are necessary to prevent organ dysfunction and worsening maternal outcomes.

Avoiding High Pressure Abdominal Closure of Congenital Abdominal Wall Defects-One Step Further to Improve Outcomes

The main goal of surgical treatment for gastroschisis and omphalocele is the reduction of viscera in the abdominal cavity and closure of the abdomen, but the challenge is to succeed without the detrimental effects of increased intraabdominal pressure. In this regard, we performed a retrospective study for all patients admitted for gastroschisis and omphalocele to the Neonatal Intensive Care Unit of 'Marie Sklodowska Curie' Emergency Clinical Hospital for Children, from January 2011 until June 2021. Our aim was to highlight the presence of postoperative abdominal compartment syndrome. We observed that six out of forty-seven patients developed clinical signs of abdominal compartment syndrome, five associated with primary closure and one with staged closure with a polyvinyl chloride patch. Following the results, we decided to implement the trans-bladder measurement of intraabdominal pressure to avoid closing the abdomen at pressures higher than 10 mmHg in order to prevent the development of abdominal compartment syndrome. We consider that there is still place for the improvement of congenital abdominal wall defects management and that the measurement of intraabdominal pressure might help us reach our goal.

Acute Abdominal Compartment Syndrome complicating a chronic mesenteric ischemia revascularization

BACKGROUND

Abdominal Compartment Syndrome (ACS) is a pathological condition that results from an increase in pressure within the abdomen associated with organ failure. It can be acute or chronic, primary or secondary. ACS poses a serious diagnostic challenge for physicians as the clinical presentation is varied and can mimic other medical pathologies. To prevent a multi-organ failure and ultimately death due to this disease, the World Society of Abdominal Compartment Syndrome (WSACS) suggested clinical criteria and biology tests to facilitate an early diagnosis of acute ACS.

CASE PRESENTATION

We report a case of 61 year-old man diagnosed with chronic mesenteric ischemia that has been successfully treated by prosthetic bypass. The postoperative period was eventual, the patient presented complications corresponding essentially to a manifest acute ACS. The treatment consisted on abdominal decompression and resuscitation measures.

CONCLUSIONS

An early diagnosis of ACS disease for an appropriate therapeutic initiation is mandatory to prevent its complications and save the patient's life prognosis.

Factors associated with increased intra-abdominal pressure in patients undergoing cardiac surgery

Background

The aim of this study was to investigate the intra-abdominal pressure changes and risk factors associated with increased intra-abdominal pressure in patients undergoing cardiac surgery.

Methods

Between July 2016 and January 2017, a total of 100 patients (74 males, 26 females; mean age 55.9±14.3 years; range, 19 to 75 years) who underwent cardiac surgery under cardiopulmonary bypass were included in the study. Patients" data including demographic and clinical characteristics and intra- and postoperative data were recorded. Intra-abdominal pressure was measured via a urinary catheter after anesthesia induction, on admission to the intensive care unit, and at postoperative 12 and 24 h. The patients were divided into two groups according to the intraabdominal pressure as Group 1 (≥12 mmHg; n=49) and Group 2 (<12 mmHg; n=51).

Results

In the univariate regression analysis, high intra-abdominal pressure was related to intra-abdominal pressure measured after anesthesia induction (Odds Ratio =0.70, p=0.001), age (odds ratio=0.95, p=0.004), hypertension (odds ratio=4.51, p=0.0001), duration of cardiopulmonary bypass (odds ratio=0.97, p=0.0001), intraoperative lactate levels (odds ratio=0.53, p=0.0001), use of red blood cells (odds ratio=0.24, p=0.0001), use of dopamine (odds ratio=0.21, p=0.002), dobutamine (odds ratio=0.28, p=0.005), use of noradrenaline (odds ratio=0.25, p=0.016), postoperative lactate levels (odds ratio=0.60, p=0.0001), duration of cross-clamp (odds ratio=0.97, p=0.0001), atrial fibrillation (odds ratio=5.89, p=0.004), and acute kidney injury (odds ratio=8.33, p=0.048). In the multivariate analysis, the intra-abdominal pressure at baseline (odds ratio=0.70, p=0.045), age (odds ratio=0.93, p=0.032), hypertension (odds ratio=6.87, p=0.023), duration of cardiopulmonary bypass (odds ratio=0.98, p=0.062), intraoperative lactate levels (odds ratio=0.57, p=0.035), and use of red blood cells (odds ratio=0.19, p=0.003) remained statistically significant.

Conclusion

Our study results suggest that age, hypertension, duration of cardiopulmonary bypass, intraoperative lactate levels, and use of red blood cells are risk factors associated with elevated intra-abdominal pressure in patients undergoing cardiac surgery. Increased awareness of these risk factors and the addition of intra-abdominal pressure measurement to the standard follow-up scheme in patients with variable hemodynamics, low cardiac output, and high lactate levels in the intensive care unit may be useful in early diagnosis of complications and in decreasing morbidity.

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.

Intraabdominal pressure in non-laboring preeclamptic vs normotensive patients undergoing cesarean section: A prospective observational study

INTRODUCTION

It is hypothesized that increased intraabdominal pressure (IAP) may be a cause of preeclampsia. There is, however, a paucity of clinical data regarding IAP in preeclamptics. We evaluated and compared the IAP and its effects on organ functions, in normotensive and preeclamptic patients.

MATERIAL AND METHODS

Previously healthy non-laboring patients with a singleton pregnancy scheduled for elective cesarean section under subarachnoid block were enrolled (preeclamptic and normotensive; n = 29 each). IAP was measured using an indwelling Foley catheter, and compared in both cohorts at four predefined time points: just before subarachnoid block, immediately after the onset of sensory block to T₆ dermatomal level, just after surgery, and 2 hours later. In addition, the presence of organ dysfunction for respiratory, cardiovascular, renal, hepatic, hematopoietic and central nervous systems were evaluated for association with IAP.

RESULTS

Although age, body mass index, gravidity, parity, serum bilirubin, serum creatinine, PaO₂ /FiO₂ ratio and Glasgow coma score of the preeclamptic and normotensive patients were similar, the mean blood pressure was significantly higher (P < 0.001), the period of gestation less (P = 0.003) and the platelet count lower (P = 0.020) in the former. The IAP was significantly higher in the preeclamptic group at all four time points: respectively, 15.1 (1.0) vs 14.2 (0.9) mm Hg (P = 0.002); 14.9 (0.9) vs 14.1 (1.0) mm Hg (P = 0.002), 10.4 (1.0) vs 9.5 (1.3) mm Hg (P = 0.008) and 10.2 (0.8) vs 9.2 (1.2) mm Hg (P = 0.001). There was no correlation between the IAP and various organ dysfunctions.

CONCLUSIONS

Preeclampsia is associated with a significantly higher IAP in patients undergoing a cesarean section. The clinical relevance of this finding needs further investigation.

Intensive management of severe acute pancreatitis

To investigate an optimal management bundle to improve the survival rate of severe acute pancreatitis (SAP). We constructed a treatment bundle based on our clinical investigation, literature, and empirical practice. Intensive management during the acute response stage and infection stage comprised eight main issues: etiology, diagnosis, fluid resuscitation, support of organ function, abdominal compartment syndrome (ACS), enteral nutrition, intestinal function, and antibiotics. The intensive management plan included a time-dependent plan for the eight main issues and goal-directed therapy. The plan must be started within the prescribed time (time-dependent endeavors) and must involve the right strategies, right sequence, and right ward for each individual. Effective goal-directed therapy and essential treatment measures must be performed within a specified period of time, and treatment efficacy should be regularly assessed. In 2010, intensive management was initiated in China. Intensive management has significant effects on SAP. This strategy was adopted by 36 hospitals in China, resulting in significant improvements in prognoses. Some criteria of intensive management were adopted by the International Association of Pancreatology (IAP)/American Pancreatic Association Working Group Acute Pancreatitis Guidelines in 2013. Intensive management is an important efficacy-based treatment strategy that can significantly ameliorate prognoses.

Intra-Abdominal Pressure as a Marker of Enteral Nutrition Intolerance in Critically Ill Patients. The PIANE Study

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.

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.

Predicting Fluid Responsiveness in Acute Liver Failure: A Prospective Study

BACKGROUND

The profound hemodynamic changes seen in acute liver failure (ALF) resemble the hyperdynamic state found in the later stages of septic shock. Vasopressor support frequently is required after initial volume therapy. Markers of preload dependency have not been studied in this patient group. Dynamic maneuvers such as passive leg raising or end-expiratory hold, which have shown good predictive accuracy in a general intensive care unit population, cannot be considered safe in this cohort because of the concerns of intracranial hypertension.

METHODS

Mechanically ventilated patients with ALF admitted to a tertiary specialist intensive care unit in shock and multiorgan failure were enrolled. Markers of fluid responsiveness derived from transpulmonary thermodilution, pulse contour analysis, and echocardiography were compared between responders (cardiac index ≥15%) and nonresponders to a colloid fluid challenge (5 mL/kg predicted body weight). The ability to predict fluid responsiveness of stroke volume variation, pulse pressure variation (PPV), and respiratory change in peak (delta V peak) left ventricular outflow tract velocity for preload dependency were analyzed.

RESULTS

Thirty-five patients (mean ± SD age, 38 [14] years, 13 male, 22 female]) were assessed after a single fluid challenge. Ten patients (29%) were fluid responders. Changes in cardiac index and stroke volume index in the cohort of 35 patients were correlated (R = 0.726 [99% confidence interval, 0.401-0.910]; P < .001). PPV predicted fluid responsiveness (area under the receiver operating characteristic curve [AUROC], 0.752 [95% confidence interval, 0.565-0.889]; P = .005; cutoff >9%). The AUROC for stroke volume variation was 0.678 ([95% confidence interval, 0.499-0.825]; P = .084; cutoff >11%). The AUROC for [delta] V peak before fluid bolus was 0.637 (95% confidence interval, 0.413-0.825; P = .322).

CONCLUSIONS

PPV based on pulse contour analysis predicted fluid responsiveness in ALF.

Acute Abdominal Compartment Syndrome following Extraperitoneal Bladder Perforation

Extraperitoneal bladder perforation is a known complication of a commonly performed rigid cystoscopy. If unrecognized, this complication can lead to continuous intra-abdominal fluid leakage with consequent organ function impairment and symptoms. This is the first case report in literature of a transurethral bladder perforation causing an acute abdominal compartment syndrome, which was subsequently managed conservatively with supportive management only. Case Presentation. We describe a clinical course of a 73-year-old Caucasian female whose initial acute presentation involved urinary symptoms. Surgery and general anaesthesia during rigid cystoscopy were complicated by an initially unrecognized extraperitoneal bladder perforation, resulting in fluid extravasation. This extravasation resulted in transurethral bladder resection syndrome with acute intra-abdominal free fluid accumulation. This complication caused acute abdominal compartment syndrome resulting in respiratory end-organ compromise and immediate postextubation respiratory failure. Patient required an emergency reintubation. During the management, diagnosis was considered through the use of the point of care abdominal ultrasound. Postoperatively, patient was managed conservatively in intensive care. Postoperative course included an approximate nine liters of urinary diuresis and supportive ventilation for four days. Conclusion. There is equipoise in the clinical management of abdominal compartment syndrome with regard to supportive medical management alone or invasive surgical treatment.

Rhubarb vs. glycerin enema for treatment of critically ill patients with intra-abdominal hypertension

Rhubarb has been used as an evacuant for thousands of years. However, recent research has indicated that rhubarb inhibits inflammation and protects organ function. In the current study, the use of rhubarb was investigated in patients with intra-abdominal hypertension (IAH). Specifically, its dual role in attenuating lung and bowel injury by catharsis and inhibiting inflammation was evaluated. Patients in the glycerin group (n=56) received 110 ml of glycerin enema by coloclysis once daily for 7 to 9 days. Patients in the rhubarb group (n=56) were treated with a mixture of 0.3 g/kg body weight rhubarb powder in 100 ml warm water. The Acute Physiology and Chronic Health Evaluation II (APACHE II), Sepsis-Related Organ Failure Assessment (SOFA), intra-abdominal pressure, procalcitonin (PCT), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and interleukin (IL)-6 levels were recorded. The duration of mechanical ventilation (MV), respiratory parameters, first day of enteral nutrition (EN), intensive care unit (ICU) hospital stay and 30-day mortality were also recorded. The APACHE II scores were significantly lower in the rhubarb group compared with the glycerin group from day 3 to 9 (P<0.05 at day 3 and 4; P<0.01 at day 5, 7 and 9). The SOFA scores were significantly lower in the rhubarb group compared with the glycerin group from day 5 to 9 (P<0.05). PCT levels were significantly lower from day 4 to 9 (P<0.05) and the CRP level was significantly lower from day 3 to 9 (P<0.05) in the rhubarb group compared with the glycerin group. The TNF-α and IL-6 were significantly lower in the rhubarb group compared with the glycerin group from day 3 to 9 (P<0.05 at day 3 and 4, P<0.01 at day 5, 7 and 9). The positive end-expiratory pressure and peak inspiratory pressure were significantly lower in the rhubarb group compared with the glycerin group at day 3, 5 and 7 (P<0.05 at day 3 and 5, P<0.01 at day 7), while the oxygenation index (P<0.05) and alveolar-arterial partial pressure of oxygen (P<0.05 at day 3 and 5, P<0.01 at day 7) were significantly improved. Significantly shorter durations of MV and ICU hospital stay, and earlier EN, were observed in the rhubarb group compared with the glycerin group (all P<0.05). Rhubarb treatment was indicated to be beneficial in IAH, by inhibiting inflammation and restoring intestinal function.

Abdominal compartment syndrome in trauma patients: New insights for predicting outcomes

Context:

Abdominal compartment syndrome (ACS) is associated with high morbidity and mortality among trauma patients. Several clinical and laboratory findings have been suggested as markers for ACS, and these may point to different types of ACS and complications.

Aims:

This study aims to identify the strength of association of clinical and laboratory variables with specific adverse outcomes in trauma patients with ACS.

Settings and Design:

A 5-year retrospective chart review was conducted at three Level I Trauma Centers in the City of Chicago, IL, USA.

Subjects and Methods:

A complete set of demographic, pre-, intra- and post-operative variables were collected from 28 patient charts.

Statistical Analysis:

Pearson's correlation coefficient was used to determine the strength of association between 29 studied variables and eight end outcomes.

Results:

Thirty-day mortality was associated strongly with the finding of an initial intra-abdominal pressure >20 mmHg and moderately with blunt injury mechanism. A lactic acid >5 mmol/L on admission was moderately associated with increased blood transfusion requirements and with acute renal failure during the hospitalization. Developing ACS within 48 h of admission was moderately associated with increased length of stay in the Intensive Care Unit (ICU), more ventilator days, and longer hospital stay. Initial operative intervention lasting more than 2 h was moderately associated with risk of developing multi-organ failure. Hemoglobin level <10 g/dL on admission, ongoing mechanical ventilation, and ICU stay >7 days were moderately associated with a disposition to long-term support facility.

Conclusions:

Clinical and lab variables can predict specific adverse outcomes in trauma patients with ACS. These findings may be used to guide patient management, improve resource utilization, and build capacity within trauma centers.

Permissible Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction

BACKGROUND

Repair of hernias with loss of domain can lead to elevated intraabdominal pressure. The authors aimed to characterize the effects of elective hernia repair on intraabdominal pressure, as well as its predictors and association with negative outcomes.

METHODS

Patients undergoing elective hernia repair requiring myofascial release had intraabdominal and pulmonary plateau pressures measured preoperatively, postoperatively, and on the morning of the first postoperative day. Loss of domain was measured by preoperative computed tomography. Outcome measures included predictors of an increase in plateau pressure, respiratory complications, and acute kidney injury.

RESULTS

Following 50 consecutive cases, diagnoses of intraabdominal hypertension (92 percent), abdominal compartment syndrome (16 percent), and abdominal perfusion pressure less than 60 mmHg (24 percent) were determined. Changes in intraabdominal pressure (preoperative, 12.7 ± 4.0 mmHg; postoperative, 18.2 ± 5.4 mmHg; postoperative day 1, 12.9 ± 5.2 mmHg) and abdominal perfusion pressure (preoperative, 74.7 ± 15.7; postoperative, 70.0 ± 14.4; postoperative day 1, 74.9 ± 11.6 mmHg) consistently resolved by postoperative day 1, and were not associated with respiratory complications or acute kidney injury. Patients who remained intubated postoperatively for an elevation in pulmonary plateau pressure (≥6 mmHg) all demonstrated an improvement in plateau pressure by postoperative day 1 (preoperative, 18.9 ± 4.5 mmHg; postoperative, 27.4 ± 4.0 mmHg; postoperative day 1, 20.1 ± 3.7 mmHg), and could be identified preoperatively as having a hernia volume of greater than 20 percent of the abdominal cavity (p < 0.001), but were still more likely to have postoperative respiratory events (p = 0.01).

CONCLUSIONS

Elevated intraabdominal pressure following elective hernia repair requiring myofascial releases is common but transient. Change in plateau pressure by 6 mmHg or more following repair can be expected with a loss of domain greater than 20 percent and is a more useful surrogate than intraabdominal pressure measurements with regard to predicting postoperative pulmonary complications. The perception and management of elevated intraabdominal pressure should be considered distinct and "permissible" in this context.

Inferior vena cava collapsibility loses correlation with internal jugular vein collapsibility during increased thoracic or intra-abdominal pressure

PURPOSE

Point-of-care ultrasound evaluates inferior vena cava (IVC) and internal jugular vein (IJV) measurements to estimate intravascular volume status. The reliability of the IVC and IJV collapsibility index during increased thoracic or intra-abdominal pressure remains unclear.

METHODS

Three phases of sonographic scanning were performed: spontaneous breathing phase, increased thoracic pressure phase via positive pressure ventilation (PPV) phase, and increased intra-abdominal pressure (IAP) phase via laparoscopic insufflation to 15 mmHg. IVC measurements were done at 1-2 cm below the diaphragm and IJV measurements were done at the level of the cricoid cartilage during a complete respiratory cycle. Collapsibility index was calculated by (max diameter - min diameter)/max diameter × 100 %. Chi square, t test, correlation procedure (CORR) and Fisher's exact analyses were completed.

RESULTS

A total of 144 scans of the IVC and IJV were completed in 16 patients who underwent laparoscopic surgery. Mean age was 46 ± 15 years, with 75 % female and 69 % African-American. IVC and IJV collapsibility correlated in the setting of spontaneous breathing (r (2) = 0.86, p < 0.01). IVC collapsibility had no correlation with the IJV in the setting of PPV (r (2) = 0.21, p = 0.52) or IAP (r (2) = 0.26, p = 0.42). Maximal IVC diameter was significantly smaller during increased IAP (16.5 mm ± 4.9) compared to spontaneous breathing (20.6 mm ± 4.8, p = 0.04) and PPV (21.8 mm ± 5.6, p = 0.01).

CONCLUSION

IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.

Effect of Negative Pressure Therapy on the Inflammatory Response of the Intestinal Microenvironment in a Porcine Septic Model

In a swine model of ischemia/reperfusion injury coupled with sepsis, we have previously shown attenuation of secondary organ injury and decreased mortality with negative pressure therapy (NPT). We hypothesized that NPT modulates the intestinal microenvironment by mediating the innate immune system. Sepsis was induced in 12 anesthetized female pigs. Group 1 (n = 6) was decompressed at 12 hrs after injury (T₁₂) and treated with standard of care (SOC), and group 2 (n = 6) with NPT for up to T₄₈. Immunoparalysis was evident as lymphocytopenia at T₂₄ in both groups; however, survival was improved in the NPT group versus SOC (Odds ratio = 4.0). The SOC group showed significant reduction in lymphocyte numbers compared to NPT group by T₄₈ (p < 0.05). The capacity of peritoneal fluid to stimulate a robust reactive oxygen species response in vitro was greater for the NPT group, peaking at T₂₄ for both M1 (p = 0.0197) and M2 macrophages (p = 0.085). Plasma elicited little if any effect which was confirmed by microarray analysis. In this septic swine model NPT appeared to modulate the intestinal microenvironment, facilitating an early robust, yet transient, host defense mediated by M1 and M2 macrophages. NPT may help overcome immunoparalysis that occurs during inflammatory response to septic injury.

A case report of abdominal compartment syndrome caused by malposition of a femoral venous catheter

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Venous catheter malposition is a rare event with potential catastrophic consequences.

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Catheter malposition can occur on induction or late.

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Ultrasound guided insertion offers extra safety in combination with clinical blood back-flow confirmation of intravascular placement.

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Periodical and systematic check of intravascular lines prior to their use can confirm positioning during patient transfers.

Introduction

Venous catheter malposition is a rare event with potential catastrophic consequences. To our knowledge we describe one of the first case reports of an adult presenting with a rare late complication of femoral venous catheter malposition: abdominal compartment syndrome.

Presentation of case

A 39 year-old female sustained severe cerebral injury in a road traffic accident. During initial resuscitation a femoral venous catheter was inserted without ultrasound guidance with no immediate concerns. After 48 h whilst in intensive care unit the patient developed progressive abdominal distension. Bedside investigations revealed raised intra-abdominal pressures associated with new organ failure. Subsequent an emergency laparotomy and on-table intravenous contrast radiographs revealed extravasation of contrast into the peritoneal space from the malposition of the catheter into the abdominal cavity.

Discussion

Complications of central venous catheterization are associated with adverse events with significant morbidity to the patient as well as having cost implications. Mechanical complications are underreported but are potentially preventable through ultrasound-guided insertion, in accordance with international guidelines.

Conclusion

This case report highlights the importance of safe methods of catheter insertion, the need for increased awareness of late femoral catheter malposition and its potential catastrophic consequences.

Pathophysiology and management of acute kidney injury in the setting of abdominal compartment syndrome

Abdominal compartment syndrome (ACS) is defined as an organ dysfunction caused by intra-abdominal hypertension (IAH). Up to 4.2% of the patients in intensive care unit may develop IAH with it being an independent predictor of mortality. However, overall, it still remains a relatively underdiagnosed condition, part in because physical examination alone is very unreliable. Acute kidney injury is one of the most consistently described organ dysfunctions with oliguria being one of the earliest clinical signs of IAH. We recommend that any patient with evidence of new onset oliguria in the setting of distended abdomen, unexplained respiratory failure, with or without hypotension should be suspected of having IAH/ACS. Intravesicular pressure measurement represents a safe, rapid, and cost-effective method of diagnosing IAH. We hereby review the pathophysiology, diagnosis, and management of ACS and its association with acute kidney injury.

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.

ICU management of the patient with intra-abdominal hypertension: what to do, when and to whom?

INTRODUCTION

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognised to be a contributing cause of organ dysfunction and mortality in critically ill patients. The number of publications describing and researching this phenomenon is increasing exponentially but there are still very limited data about treatment and outcome.

METHODS

This review will focus on the available literature from the last years. A Medline and PubMed search was performed using the search terms "abdominal compartment syndrome" and "treatment".

RESULTS

This search yielded 437 references, most of which were not relevant to the subject of this paper. The remaining abstracts were screened and selected on the basis of relevance, methodology and number of cases. Full text articles of the selected abstracts were used to supplement the authors' expert opinion and experience. The abdomino-thoracic transmission of pressure has direct clinical consequences on the cardiovascular, respiratory and central nervous systems in terms of monitoring and management. These interactions are discussed and treatment recommendations are made. IAH-induced renal dysfunction is addressed as a separate issue. Finally, an overview of non-invasive measures to decrease IAP is given.

CONCLUSION

This paper describes current insights on management of IAP induced organ dysfunction and lists the most widely used and published non-invasive techniques to decrease IAP with their limitations and pitfalls.

Acs in paediatrics

Abdominal Compartment Syndrome (ACS) occurs relatively infrequent in a paediatric population when compared with adults. Overall mortality is still high. Also, the pathophysiologic mechanism that leads to ACS is different in children. In this review, we will present an overview on ACS in children admitted to a paediatric intensive care unit.

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.

Abdominal compartment syndrome in children

Abdominal compartment syndrome is defined as sustained intra-abdominal pressure greater than 20 mm Hg (with or without abdominal perfusion pressure <60 mm Hg) associated with new organ failure or dysfunction. The syndrome is associated with 90% to 100% mortality if not recognized and treated in a timely manner. Nurses are responsible for accurately measuring intra-abdominal pressure in children with abdominal compartment syndrome and for alerting physicians about important changes. This article provides relevant definitions, outlines risk factors for abdominal compartment syndrome developing in children, and discusses an instructive case involving an adolescent with abdominal compartment syndrome. Techniques for measuring intra-abdominal pressure, normal ranges, and the importance of monitoring in the critical care setting for timely identification of intra-abdominal hypertension and abdominal compartment syndrome also are discussed.

Are standard intra-abdominal pressure values different during pregnancy?

Background

Measurement of intra-abdominal pressure (IAP) is an important parameter in the surveillance of intensive care unit patients. Standard values of IAP during pregnancy have not been well defined. The aim of this study was to assess IAP values in pregnant women before and after cesarean delivery.

Methods

This prospective study, carried out from January to December 2011 in a French tertiary care centre, included women with an uneventful pregnancy undergoing elective cesarean delivery at term. IAP was measured through a Foley catheter inserted in the bladder under spinal anaesthesia before cesarean delivery, and every 30 minutes during the first two hours in the immediate postoperative period.

Results

The study included 70 women. Mean IAP before cesarean delivery was 14.2 mmHg (95%CI: 6.3–23). This value was significantly higher than in the postoperative period: 11.5 mmHg (95%CI: 5–19.7) for the first measurement (p = 0.002). IAP did not significantly change during the following two postoperative hours (p = 0.2). Obese patients (n = 25) had a preoperative IAP value significantly higher than non-obese patients: 15.7 vs. 12.4; p = 0.02.

Conclusion

In term pregnancies, IAP values are significantly higher before delivery than in the post-partum period, where IAP values remain elevated for at least two hours at the level of postoperative classical abdominal surgery. The knowledge of these physiological changes in IAP values may help prevent organ dysfunction/failure when abdominal compartment syndrome occurs after cesarean delivery.

The relevance of congestion in the cardio-renal syndrome

Worsening renal function (WRF) during the treatment of acute decompensated heart failure (ADHF) occurs in up to a third of patients and is associated with worse survival. Venous congestion is increasingly being recognized as a key player associated with WRF in ADHF. Understanding the hemodynamic effects of venous congestion and the interplay between venous congestion and other pathophysiological factors such as raised abdominal pressure, endothelial cell activation, anemia/ iron deficiency, sympathetic overactivity, and stimulation of the renin-angiotensin-aldosterone system will help in devising effective management strategies. Early recognition of venous congestion through novel techniques such as bioimpedance measurements and remote monitoring of volume status combined with customized diuretic regimens may prevent venous congestion and perhaps avoid significant WRF.

Characterizing peritoneal dialysis catheter use in pediatric patients after cardiac surgery

OBJECTIVE

Children who undergo cardiac surgery are at high risk for renal insufficiency and abdominal compartment syndrome. Peritoneal dialysis catheter (PDC) implantation is used in this population for abdominal decompression and access for dialysis. However, there is no consensus regarding PDC use, and the practice varies widely. This study was undertaken to assess associated factors, outcomes, and variability in the use of PDC in patients who have undergone cardiac surgery.

METHODS

The cohort was obtained from the Kids' Inpatient Database, years 2006 and 2009. Patients who underwent cardiac surgery were included and the subset that underwent PDC implantation during the same hospitalization was identified. Univariable and multivariable analyses assessed factors associated with PDC and survival.

RESULTS

A cohort of 28,259 patients underwent cardiac surgery, of whom 558 (2%) had PDCs placed. In the PDC group, 39.1% (n = 218) had acute renal failure whereas 3.5% or patients (n = 974) in the non-PDC group had acute renal failure. Among patients receiving PDC, mortality was 20.3% (n = 113; vs 3.4% overall mortality, n = 955). Excluding patients with acute renal failure, mortality remained 12% (n = 41) for the PDC group. Factors associated significantly with PDC placement in the overall cohort were younger age, greater surgical complexity, nonelective admission, hospital region, use of cardiopulmonary bypass, and acute renal failure.

CONCLUSIONS

Patients receiving PDC after cardiac surgery had 20% mortality, which remained 12% after excluding patients with acute renal failure. Given the variability in PDC use and poor outcomes, further research is needed to assess the possible benefit of earlier intervention for peritoneal access in this high-risk cohort.

Should we measure intra-abdominal pressures in every intensive care patient?

Intra-abdominal pressure (IAP) is seldom measured by default in intensive care patients. This review summarises the current evidence on the prevalence and risk factors of intra-abdominal hypertension (IAH) to assist the decision-making for IAP monitoring.IAH occurs in 20% to 40% of intensive care patients. High body mass index (BMI), abdominal surgery, liver dysfunction/ascites, hypotension/vasoactive therapy, respiratory failure and excessive fluid balance are risk factors of IAH in the general ICU population. IAP monitoring is strongly supported in mechanically ventilated patients with severe burns, severe trauma, severe acute pancreatitis, liver failure or ruptured aortic aneurysms. The risk of developing IAH is minimal in mechanically ventilated patients with positive end-expiratory pressure < 10 cmH2O, PaO2/FiO2 > 300, and BMI < 30 and without pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding or laparotomy and the use of vasopressors/inotropes on admission. In these patients, omitting IAP measurements might be considered.In conclusions, clear guidelines to select the patients in whom IAP measurements should be performed cannot be given at present. In addition to IAP measurements in at-risk patients, a clinical assessment of the signs of IAH should be a part of every ICU patient's bedside evaluation, leading to prompt IAP monitoring in case of the slightest suspicion of IAH development.

Pediatric critical care nurses' experience with abdominal compartment syndrome

BACKGROUND

Abdominal compartment syndrome (ACS) is a syndrome associated with multi-system effects of elevated intra-abdominal pressure (IAP) in critically ill children. It has a 90-100% mortality rate if not recognized and treated promptly. Measuring IAP helps identify patients developing intra-abdominal hypertension (IAH) which allows for timely intervention before progression to ACS. IAP helps identify ACS and guides its medical and surgical management. IAP is often measured by the bedside nurse in the intensive care unit. Pediatric critical care nurses (PCCN) play a key role in managing critically ill patients and recognizing potential causes for clinical deterioration such as ACS therefore should be knowledgeable about this entity.

OBJECTIVE

The aim of this study was to assess the awareness and current knowledge of ACS among PCCN.

METHODS

A ten-item written questionnaire was distributed at a National Critical Care Conference in 2006 and again in 2010. Participants of the conference voluntarily completed and immediately returned the survey. Results from the two questionnaires were compared.

RESULTS

Sixty-two percent of 691 questionnaires were completed. The awareness of ACS improved from 69.3% in 2006 to 87.8% in 2010 (p < 0.001) among PCCN. "Years in practice" influenced awareness of ACS. Nurses working for 5-10 and > 10 years were, respectively, 2.34 and 1.89 times more likely to be aware of ACS than those working for < 5 years. Hands-on experience managing a child with ACS by PCCN also improved from 49.1% to 67.9% (p < 0.001) but remains low. The number of participants who never measured IAP fell from 27.3% to 19.1% (p = 0.101). The most common method being used to measure IAP is the bladder method. Knowledge of the definition of ACS remains poor with only 13.2% associating the definition of ACS with organ dysfunction in 2010 which was even lower than in 2006.

CONCLUSIONS

There is increasing awareness of ACS and experience in its management among PCCN. However, few PCCN correctly understand the definition of ACS. Since recognition of IAH and early intervention can reduce morbidity and mortality in critically ill patients, further educational efforts should be directed toward improving the knowledge and recognition of ACS by PCCN.

Utility of measurements of abdominal perfusion pressure as a measure of isovolemic status and intestinal perfusion in patients with ruptured aortic aneurysm

Ruptured abdominal aorta aneurysm of ten results in intraabdominal hypertension (IAH). When IAH exceeds 20 mm Hg, intestinal ischemia can result that is a common cause of severe postoperative complications, including death.

THE AIM OF THE STUDY

was to evaluate utility of measurement of abdominal perfusion pressure (APP) to estimate intestinal perfusion and isovolemic status in patients undergoing surgical treatment for ruptured abdominal aorta aneurysm.

MATERIAL AND METHODS

A group of 40 patients of either sex, aged 47-93 years (average age 70 ± 10) was treated at an Intensive Care Unit after surgical reconstruction of abdominal aorta due to ruptured aortic aneurysm. The study was prospective. The following were measured: parameters of intraabdominal pressure (intraabdominal pressure - IAP, abdominal perfusion pressure - APP); parameters of intestinal perfusion - tonometric (intramucosal gastric carbon dioxide partial pressure PgCO(2), intramucosal-arterial difference in carbon dioxide partial pressure - Pg-aCO(2)); hemodynamic parameters (mean arterial pressure - MAP, central venous pressure - CVP).

RESULTS

A statistically significant correlation was demonstrated between parameters of visceral perfusion and abdominal perfusion pressure. Pearson correlation coefficient for APP/PgCO(2) and APP/Pg-aCO(2) was negative and was -0.4664 and -0.3498, respectively.

CONCLUSIONS

Abdominal perfusion pressure is an useful parameter in the evaluation of intestinal perfusion in IAH patients after surgical treatment of ruptured aortic aneurysm. MAP reflects current physiological body reserves at a critical stage of the disease, informing about possibility to provide visceral perfusion and indirectly, about adequacy of fluid replacement therapy. In intraabdominal hypertension, CVP is falsely elevated, making it of low utility in the evaluation of volemic status and intestinal perfusion.

Pulmonary complications of renal disorders

To manage patients with diseases of the lungs and the kidneys, one must first understand the relationship between respiratory and renal function. In treating acute renal failure (ARF), the clinician often must contend with respiratory manifestations of volume overload and metabolic acidosis. Mechanical ventilation in patients with renal failure (RF) can be challenging, particularly with lung protective ventilation and weaning. Patients with chronic renal failure (CRF) experience several respiratory complications. Hypoxaemia during dialysis is now understood to be a predictable effect of the loss of CO(2) into the dialysate. Critical illness of any primary cause predisposes patients not only to acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) but also to the development of ARF. Meanwhile, the potential for ventilator-induced renal injury has increasingly become the subject of active investigation.

Relationship between Abdominal Pressure, Pulmonary Compliance, and Cardiac Preload in a Porcine Model

Rationale. Elevated intra-abdominal pressure (IAP) may compromise respiratory and cardiovascular function by abdomino-thoracic pressure transmission. We aimed (1) to study the effects of elevated IAP on pleural pressure, (2) to understand the implications for lung and chest wall compliances and (3) to determine whether volumetric filling parameters may be more accurate than classical pressure-based filling pressures for preload assessment in the setting of elevated IAP. Methods. In eleven pigs, IAP was increased stepwise from 6 to 30 mmHg. Hemodynamic, esophageal, and pulmonary pressures were recorded. Results. 17% (end-expiratory) to 62% (end-inspiratory) of elevated IAP was transmitted to the thoracic compartment. Respiratory system compliance decreased significantly with elevated IAP and chest wall compliance decreased. Central venous and pulmonary wedge pressure increased with increasing IAP and correlated inversely (r = -0.31) with stroke index (SI). Global end-diastolic volume index was unaffected by IAP and correlated best with SI (r = 0.52). Conclusions. Increased IAP is transferred to the thoracic compartment and results in a decreased respiratory system compliance due to decreased chest wall compliance. Volumetric filling parameters and transmural filling pressures are clearly superior to classical cardiac filling pressures in the assessment of cardiac preload during elevated IAP.

Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing

Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.

Can chronic intra-abdominal hypertension cause oxidative stress to the abdominal wall muscles? An experimental study

BACKGROUND

The aim of this study was to test the hypothesis that intra-abdominal hypertension alone could trigger such changes to the rectus abdominis muscle that would lead to an imbalance between oxidant production and antioxidant protection.

MATERIALS AND METHODS

Forty-five New Zealand white rabbits were divided into three groups and a rubber bag was implanted into their peritoneal cavity. In group A (n = 15), the bag was empty. In group B (n = 15), it was filled with normal saline to achieve an intra-abdominal pressure of over 12 mm Hg. In group C (n = 15), it was filled with lead equiponderant to the mean weight of the normal saline injected in group B. After 8 weeks, we measured in rectus abdominis muscle biopsies the lipid peroxidation products, the protein carbonyl content, the total glutathione and superoxide dismutase (SOD) concentration, the activity of glutathione reductase and glutathione peroxidase, and the pro-oxidant-antioxidant balance.

RESULTS

The lipid peroxidation products were significantly higher in group B compared with both group A (P = 0.026) and group C (P < 0.001). The total protein carbonyl content was significantly higher in group B compared with both group A (P = 0.006) and group C (P < 0.001). No difference was found between the three groups in total glutathione (P = 0.735) and SOD (P = 0.410) concentration. Glutathione peroxidase activity was higher in groups B and C compared with group A (P = 0.05 and P = 0.003, respectively). Glutathione reductase activity was higher in group B compared with group A (P = 0.005) and group C (P = 0.001). The pro-oxidant antioxidant balance was higher in group B compared with the group A (P = 0.012).

CONCLUSIONS

Maintaining the IP over 12 mm Hg for 8 wk caused increased oxidative damage to both lipids and proteins with an increased pro-oxidant-antioxidant balance. In an attempt to compensate for this damage the muscle fibers increased their glutathione reductase and glutathione peroxidase activity.

A modified model of the abdominal compartment syndrome

BACKGROUND

To develop an animal model in rats and to investigate whether an intra-abdominal pressure (IAP) of 20 mm Hg will lead to a condition comparable with the abdominal compartment syndrome in humans.

METHODS

Forty Sprague-Dawley rats were used. In the study group, IAP was increased to 20 mm Hg using a nitrogen gas pneumoperitoneum for 4 hours. We also observed the next reperfusion period for another 4 hours. In the controls, IAP remained unchanged. Hemodynamic readings, peak inspiratory pressure, renal function parameters, and blood gas were obtained. Additionally, histopathologic examinations were performed.

RESULTS

In the presence of intra-abdominal hypertension (IAH), mean arterial pressure was reduced, whereas central venous pressure was increased significantly. Peak inspiratory pressure remained >35 mbar in the 4 hours of IAH and recovered after decompression. Arterial Po(2) decreased substantially while Pco(2) increased soon after IAH. IAH caused a metabolic acidosis, which was further complicated by the respiratory acidosis. Decompression resulted in normocapnia but the metabolic acidosis persisted. Renal blood flow and urine output decreased obviously, whereas little change was found in blood urea nitrogen and creatinine. The histopathologic study revealed parenchymal injury in lung and intestine.

CONCLUSIONS

This animal model was simple and easily reproducible. An IAP of 20 mm Hg can lead to a condition comparable with the abdominal compartment syndrome in humans.

Acute kidney injury: not just acute renal failure anymore?

Until recently, no uniform standard existed for diagnosing and classifying acute renal failure. To clarify diagnosis, the Acute Dialysis Quality Initiative group stated its consensus on the need for a clear definition and classification system of renal dysfunction with measurable criteria. Today the term acute kidney injury has replaced the term acute renal failure, with an understanding that such injury is a common clinical problem in critically ill patients and typically is predictive of an increase in morbidity and mortality. A classification system, known as RIFLE (risk of injury, injury, failure, loss of function, and end-stage renal failure), includes specific goals for preventing acute kidney injury: adequate hydration, maintenance of renal perfusion, limiting exposure to nephrotoxins, drug protective strategies, and the use of renal replacement therapies that reduce renal injury.

Acute renal dysfunction in patients with alcoholic hepatitis

Acute renal dysfunction is common in patients with alcoholic hepatitis (AH). Its presence leads to higher mortality in these patients. Despite advances in medical care, the outcome has changed little over the past decades. Studies using Pentoxifylline and molecular adsorbent recirculation system have shown encouraging data in small studies. Further larger well designed studies are needed to assess these modalities of treatment for the treatment of AH.