The abdominal compartment syndrome in patients with burn injury

Abdominal Compartment Syndrome-When Is Surgical Decompression Needed?

Compartment syndrome occurs when increased pressure inside a closed anatomical space compromises tissue perfusion. The sudden increase in pressure inside these spaces requires rapid decompression by means of surgical intervention. In the case of abdominal compartment syndrome (ACS), surgical decompression consists of a laparostomy. The aim of this review is to identify the landmarks and indications for the appropriate moment to perform decompression laparotomy in patients with ACS based on available published data. A targeted literature review was conducted on indications for decompression laparotomy in ACS. The search was focused on three conditions characterized by a high ACS prevalence, namely acute pancreatitis, ruptured abdominal aortic aneurysm and severe burns. There is still a debate around the clinical characteristics which require surgical intervention in ACS. According to the limited data published from observational studies, laparotomy is usually performed when intra-abdominal pressure reaches values ranging from 25 to 36 mmHg on average in the case of acute pancreatitis. In cases of a ruptured abdominal aortic aneurysm, there is a higher urgency to perform decompression laparotomy for ACS due to the possibility of continuous hemorrhage. The most conflicting recommendations on whether surgical treatment should be delayed in favor of other non-surgical interventions come from studies involving patients with severe burns. The results of the review must be interpreted in the context of the limited available robust data from observational studies and clinical trials.

Acute kidney injury after burn surgery: Preoperative neutrophil/lymphocyte ratio as a predictive factor

BACKGROUND

Severe inflammation and acute kidney injury (AKI) are serious adverse events after burn injuries. The neutrophil/lymphocyte ratio (NLR) is a marker of inflammation. We evaluated the independent risk factors for postoperative AKI, including NLR, in burn-injured patients.

METHODS

The preoperative, intraoperative, and postoperative variables of 473 burn-injured patients were collected. The risk factors for AKI after burn surgery were evaluated using univariate and multivariate logistic regression analyses. The receiver operating characteristic (ROC) curve analysis of preoperative NLR was performed. The 3-month mortality after surgery was also compared between AKI and non-AKI groups using Kaplan-Meier analysis with a log-rank test.

RESULTS

Postoperative AKI occurred in 71 of 473 (15.0%) burn patients. The total body surface area burned (odds ratio (OR), 1.013; 95% confidence interval (CI), 1.001-1.026; P = 0.037), inhalation injury (OR, 1.821; 95% CI, 1.008-3.292; P = 0.047), and preoperative NLR (OR, 1.094; 95% CI, 1.064-1.125; P < 0.001) were risk factors for AKI after surgery. The area under the ROC curve was 0.767, with an optimal cut-off value of 11.7. Moreover, the 3-month mortality after surgery was significantly higher in the AKI group than in the non-AKI group (49.3% vs 14.9%, P < 0.001).

CONCLUSION

Total body surface area burned, inhalation injury, and preoperative NLR are risk factors for AKI after burn surgery, which is associated with early postoperative mortality. Preoperative NLR can provide useful information for the early detection of postoperative AKI and subsequent mortality in burn-injured patients.

The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation

Burn trauma in the current age of medical care still portends a 3% to 8% mortality. Of patients who die from their burn injuries, 58% of deaths occur in the first 72 hours after injury, indicating death from the initial burn shock is still a major cause of burn mortality. Significant thermal injury incites an inflammatory response, which distinguishes burns from other trauma. This article focuses on the current understanding of the pathophysiology of burn shock, the inflammatory response, and the direction of research and targeted therapies to improve resuscitation, morbidity, and mortality.

Outcome of acute kidney injury in severe burns: a systematic review and meta-analysis

PURPOSE

The main objective of this review was to analyse the prevalence and outcome of acute kidney injury (AKI) in patients with severe burn injury. AKI is a common complication in patients with severe burn injury and one of the major causes of death (often combined with other organ dysfunctions). Several definitions of AKI have been used, but the RIFLE 'consensus' classification is nowadays considered the gold standard, enabling a more objective comparison of populations.

METHODS

We performed a systematic literature search (1960-2009), involving PubMed, the Web of Science, the search engine Google and textbooks. Reference lists and the Science Citation Index search were also consulted. Attributable mortality was assessed by performing a meta-analysis.

RESULTS

This search yielded 57 articles and abstracts with relevant epidemiologic data of AKI in the burn population. Of these, 30 contained complete mortality data of the burn and control population, which revealed a 3- to 6-fold higher mortality for AKI patients in univariate analysis, depending on the applied definition. When defined by the RIFLE consensus classification, AKI occurred in one quarter of patients with severe burn injury (median mortality of 34.9%), and when defined by the need for renal replacement therapy (RRT), AKI occurred in 3% (median mortality of 80%). The prevalence of AKI slightly increased, but AKI-RRT decreased. However, the outcome in both groups improved.

CONCLUSION

Despite the wide variation of the analysed burn populations and definitions of AKI, this review clearly showed that AKI remains prevalent and is associated with increased mortality in patients with severe burn injury.

Abdominal decompression for intra-abdominal hypertension after simultaneous pancreas-kidney transplantation

Intra-abdominal hypertension (IAH) is increasingly recognized in critically ill patients and can result in respiratory, hemodynamic or renal dysfunction. We report the case of a patient suffering from diabetic nephropathy who underwent simultaneous pancreas-kidney transplantation. Within 12 h after the operation, the patient developed IAH resulting in oliguria and a rise in serum creatinine. Surgical abdominal decompression was performed, resulting in immediate restoration of kidney graft function.

Abdominal compartment syndrome: a concise clinical review

OBJECTIVE

There has been an increased awareness of the presence and clinical importance of abdominal compartment syndrome. It is now appreciated that elevations of abdominal pressure occur in a wide variety of critically ill patients. Full-blown abdominal compartment syndrome is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction resulting from elevated intra-abdominal pressure. This review provides a current, clinically focused approach to the diagnosis and management of abdominal compartment syndrome, with a particular emphasis on intensive care.

METHODS

Source data were obtained from a PubMed search of the medical literature, with an emphasis on the time period after 2000. PubMed "related articles" search strategies were likewise employed frequently. Additional information was derived from the Web site of the World Society of the Abdominal Compartment Syndrome (http://www.wsacs.org).

SUMMARY AND CONCLUSIONS

The detrimental impact of elevated intra-abdominal pressure, progressing to abdominal compartment syndrome, is recognized in both surgical and medical intensive care units. The recent international abdominal compartment syndrome consensus conference has helped to define, characterize, and raise awareness of abdominal compartment syndrome. Because of the frequency of this condition, routine measurement of intra-abdominal pressure should be performed in high-risk patients in the intensive care unit. Evidence-based interventions can be used to minimize the risk of developing elevated intra-abdominal pressure and to aggressively treat intra-abdominal hypertension when identified. Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of intra-abdominal hypertension and abdominal compartment syndrome.

Intra-abdominal hypertension and the effect on renal function

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are increasingly recognized in critically-ill patients. They are independently associated with mortality and organ dysfunction. The kidney is especially vulnerable to the effect of increased intra-abdominal pressure (IAP) due to its anatomical position and blood supply. Several animal and human studies have provided insights into the mechanism of renal dysfunction in IAH. It is now also accepted that the adverse effects of elevated IAP on renal function can occur at lower levels of IAP, long before development of overt ACS. The mechanism of renal impairment in ACS is not yet completely understood, but there is evidence available that renal blood flow and/or altered hormone levels are involved.