Intra-abdominal hypertension in patients with severe acute pancreatitis

Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) play a pivotal role in the pathophysiology of severe acute pancreatitis (SAP) and contribute to new-onset and persistent organ failure. The optimal management of ACS involves a multi-disciplinary approach, from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure (IAP). A targeted literature search from January 1, 2000, to November 30, 2022, revealed 20 studies and data was analyzed on the type and country of the study, patient demographics, IAP, type and timing of surgical procedure performed, post-operative wound management, and outcomes of patients with ACS. There was no randomized controlled trial published on the topic. Decompressive laparotomy is effective in rapidly reducing IAP (standardized mean difference = 2.68, 95% confidence interval: 1.19-1.47, P < 0.001; 4 studies). The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but, potentially lethal ACS. Disease-specific patient selection and the role of less-invasive decompressive measures, like subcutaneous linea alba fasciotomy or component separation techniques, is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS. This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP. However, there is a lack of high-quality evidence on patient selection, timing, and modality of surgical decompression. Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to 60% and ACS in 15% to 30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiology of IAH/ACS development in patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and the management of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

[Socioeconomic impact of the current management of severe biliary acute pancreatitis: comparative study]

OBJETIVE

Acute pancreatitis of biliary origin is a common gastrointestinal pathology, in which timely management still is the most important. The aims of this research is establish the socioeconomic impact in the current management of severe acute pancreatitis of biliary origin comparing two centers of the third level, one of high socioeconomic population and another of low in Bogotá, Colombia.

MATERIALS AND METHODS

A retrospective, cross-sectional comparative study was conducted between January 2012 and December 2017, in two hospitals of Bogotá DC. We evaluated their socioeconomic characteristics, gender, time of evolution at the time of consultation, Marshall score, ICU stay, hospital stay, complications, surgical management and mortality.

RESULTS

101 patients from two different socioeconomic strata (high and low) were analyzed, where a 10 times higher risk of requiring a surgical procedure in the group of patients with low stratum was found, as well as a higher mortality compared with those of high stratum. (11.3% Vs 4.2%). There were also more complications in the low socioeconomic group with respect to the high, as in the exocrine failure (81.1% vs 31.3%) and the compartment syndrome (35.8% vs 4.2%).

CONCLUSION

There is greater morbidity and mortality in patients of low socioeconomic status in the context of this pathology. This study can guide new research that increases the clarity of the socioeconomic impact on the outcomes of severe acute pancreatitis.

Optimising the measurement of intra-bladder pressure in patients with predicted severe acute pancreatitis

BACKGROUND

Measuring intra-abdominal pressure (IAP) is important for management of patients with severe acute pancreatitis (SAP). Intra-bladder pressure (IBP) is an indirect index that reflects IAP, but measuring techniques vary. We sought to optimise IBP measuring techniques in predicted SAP patients.

METHODS

Predicted SAP patients consecutively admitted between June 2018 and January 2020 were scrutinised. Eligible patients had their IBP monitored for the first 72 h at 6-h intervals, and were then sequentially allocated into three research scenarios: (1) in the supine position along with head of bed elevation(HoBE)of 0, 15 and 30° at various points including the iliac crest the midaxillary line, pubic symphysis, and right atrium level, instilled with 25 mL normal saline (NS) at room temperature (RT); (2) NS instillation volume from 0, 10, 25, 40-50 mL at the iliac crest with HoBE15 at RT; and (3) NS instillation (25 mL) at either RT or 37 °C with HoBE15.

RESULTS

The dynamic IBP values measured at the pubic symphysis and iliac crest were fairly similar between HoBE0 and HoBE15 (all P > 0.05), but greatly increased at HoBE30 (all P < 0.01). IBP was significantly increased with escalating instillation volumes of NS (all P < 0.01 versus 0 mL NS), while there was no significant difference between 25 mL and 10 mL (P = 0.055). IBP was similar between NS at RT and under 37 °C (P = 0.643).

CONCLUSION

In predicted SAP patients, measuring IBP at the iliac crest with HoBE15 after instilling 10 mL of NS seems to be appropriate for monitoring IAP.

Incidence and risk factors of nasogastric feeding intolerance in moderately-severe to severe acute pancreatitis

Background

The importance of enteral nutrition (EN) in acute pancreatitis (AP) has been emphasised. Nasogastric (NG) feeding has been the preferred route for EN delivery in most AP patients intolerant to oral intake. However, gastric feeding intolerance (GFI) was frequently reported, especially in patients with more severe diseases. This study aimed to investigate the incidence and risk factors for GFI in moderately-severe to severe AP.

Methods

This is a single-centre, retrospective study. All the data were extracted from an electronic database from April 2020 to May 2021. Data were prospectively collected during hospitalisation. Patients diagnosed with moderately-severe to severe AP and admitted within seven days from the onset of abdominal pain were assessed for eligibility. Patients who showed signs of intolerance to gastric feeding and required switching to nasojejunal (NJ) feeding were deemed GFI. Multivariable logistic regression was performed to assess potential risk factors of GFI.

Results

A total of 93 patients were analysed, of whom 24 were deemed GFI (25.8%), and the rest tolerated NG feeding well (n = 69). In patients with GFI, the median time of switching to NJ feeding was five days (interquartile range: 4–7 days) after admission. The multivariable analysis showed that respiratory failure (odds ratio = 3.135, 95% CI: 1.111–8.848, P = 0.031) was an independent risk factor for GFI.The mean daily energy delivery in the following three days after switching to NJ feeding was significantly higher than the first three days after initiation of NG feeding in patients with GFI [920.83 (493.33–1326) vs. 465 (252.25–556.67) kcal, P < 0.001].

Conclusion

GFI is common in moderately-severe to severe AP patients with an incidence of 25.8%, and the presence of respiratory failure may increase the risk of GFI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02403-w.

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.

Ultrasound-Assisted versus Endoscopic Nasojejunal Tube Placement for Acute Pancreatitis: A Retrospective Feasibility Study

Objective

The optimal technique for nasojejunal tube (NJT) placement in terms of facilitating early enteral nutrition (EN) in patients with acute pancreatitis (AP) is unclear. In this study, we aimed to evaluate the impact of two common techniques on EN implementation and clinical outcomes in a group of AP patients.

Methods

This is a retrospective study. All the data were extracted from an electronic database from August 2015 to October 2017. Patients with a diagnosis of AP requiring NJT placement were retrospectively analyzed. The primary outcome was the successful procedural rate.

Results

A total of 53 eligible patients were enrolled, of whom 30 received an ultrasound-assisted technique and the rest received the endoscopy method (n = 23). There was no difference in success rates of initial placement procedures between the two groups (93.3% and 95.7% in the ultrasound-assisted group and endoscopy group, respectively). The mean amount of EN delivery within the first three days after NJT placement was significantly higher in the ultrasound-assisted group (841.4 kcal (95% CI: 738.8, 944 kcal) vs. 652.5 kcal (95% CI: 562.5, 742.6 kcal), P = 0.018). Moreover, a slight increased postprocedural intra-abdominal pressure (IAP) was observed in patients undergoing endoscopic procedures, but not in the ultrasound-assisted group, especially at 6 hours after NJT placement (0.35 vs. -2.01 from baseline, P < 0.05). For clinical outcomes, we observed no difference between groups.

Conclusion

Compared with endoscopic procedures, ultrasound-assisted NJT placement possesses the acceptable success rates of initial placement procedures.

The impact of fluid resuscitation via colon on patients with severe acute pancreatitis

Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan–Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.

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.

Machine Learning Models of Acute Kidney Injury Prediction in Acute Pancreatitis Patients

Background. Acute kidney injury (AKI) has long been recognized as a common and important complication of acute pancreatitis (AP). In the study, machine learning (ML) techniques were used to establish predictive models for AKI in AP patients during hospitalization. This is a retrospective review of prospectively collected data of AP patients admitted within one week after the onset of abdominal pain to our department from January 2014 to January 2019. Eighty patients developed AKI after admission (AKI group) and 254 patients did not (non-AKI group) in the hospital. With the provision of additional information such as demographic characteristics or laboratory data, support vector machine (SVM), random forest (RF), classification and regression tree (CART), and extreme gradient boosting (XGBoost) were used to build models of AKI prediction and compared to the predictive performance of the classic model using logistic regression (LR). XGBoost performed best in predicting AKI with an AUC of 91.93% among the machine learning models. The AUC of logistic regression analysis was 87.28%. Present findings suggest that compared to the classical logistic regression model, machine learning models using features that can be easily obtained at admission had a better performance in predicting AKI in the AP patients.

Portal Vein Thrombosis and Intra-Abdominal Hypertension Presenting as Complications of Hypertriglyceridemia-Induced Severe Acute Pancreatitis

A 44-year-old male without any significant past medical history presented to the emergency department (ED) with the chief complaint of severe constant epigastric pain for three hours. On physical examination, the abdomen was distended and tender, particularly in the epigastric region. The lab work showed an elevation of the lipase (12,405 U/L) and triglycerides (5,837 mg/dL). An abdominal CT scan with contrast was ordered, which revealed non-necrotic pancreatitis. In addition, the liver ultrasound showed no evidence of gallstones. Subsequently, fluid infusion, meropenem, pain medication, and an insulin drip were started, and the patient was transferred to the intensive care unit (ICU). After six hours in the ICU, he complained of abdominal pain despite taking a high hydromorphone dose.

On further physical examination, the abdomen was tender and distended but without rebound tenderness. The gastric distention on kidneys, ureter, and bladder (KUB) and a bladder pressure of 34 mmHg raised the suspicion for intra-abdominal hypertension (IAH), which led us to place a nasogastric tube (NGT) and consult the surgical team. The patient's symptoms and bladder pressure were closely followed and showed significant improvement. On day seven in the ICU, the patient responded well to medications; feeding through the Dobhoff tube was started, and his triglycerides decreased to approximately 1,000 mg/dL. Despite his general improvement and meropenem regimen, the patient spiked a fever of 38.5 °C. Due to the possibility of pancreatitis complications, a CT abdomen with contrast was ordered, which showed partial portal vein thrombosis (PVT). Subsequently, enoxaparin was started, and the patient was closely observed for gastrointestinal bleeding. Eventually, after 17 days in the ICU, the patient was transferred to the floor and then discharged from the hospital with normal lab tests and without evidence of portal thrombosis on abdominal CT.

In this report, we illustrate and discuss a case of hypertriglyceridemia (HTG)-induced pancreatitis (HTGP), which progressed to PVT and IAH. Physicians should be aware that patients with HTG are inclined to have severe pancreatitis. In addition, the degree of triglyceride elevation is correlated with the severity of acute pancreatitis.

Abdominal Compartment Syndrome is an Early, Lethal Complication of Acute Pancreatitis

Data defining the optimal management of abdominal compartment syndrome resulting from acute pancreatitis are lacking. We investigated the outcomes of patients with acute pancreatitis who underwent surgery for treatment of abdominal compartment syndrome at a tertiary referral center. An electronic database was searched to identify patients with acute pancreatitis who underwent laparotomy between January 1, 2000, and December 31, 2009, for treatment of abdominal compartment syndrome. Twelve patients underwent decompressive laparotomy for abdominal compartment syndrome. The median interval between onset of pancreatitis and laparotomy was 4.5 days. Nine patients underwent a laparotomy within seven days of onset of pancreatitis. As a result of cardiopulmonary instability, four decompressive laparotomies were performed in the intensive care unit. In 11 patients, cardiopulmonary improvement was observed. Statistically significant improvements were seen across multiple physiologic parameters. Despite this initial improvement, six patients (50%) died from multisystem organ failure. Two patients survived without need for pancreatic débridement. Abdominal compartment syndrome is an uncommon but likely underrecognized and highly lethal complication of acute pancreatitis that should be considered in patients who become critically ill early in the course of their pancreatitis. Prompt recognition and decompressive laparotomy may rescue some of these patients and does not mandate future débridement.

Reduction of intra-abdominal pressure after percutaneous catheter drainage of pancreatic fluid collection predicts survival

OBJECTIVE

Intra-abdominal hypertension (IAH) can adversely affect the outcome in patients of acute pancreatitis (AP). Effect of percutaneous drainage (PCD) on IAH has not been studied. We studied the effect of PCD on IAH in patients with acute fluid collections.

MATERIAL AND METHODS

Consecutive patients of AP undergoing PCD between Jan 2016 and May 2018 were evaluated for severity markers, clinical course, hospital and ICU stay, and mortality. Patients were divided into two groups: with IAH and with no IAH (NIAH). The two groups were compared for severity scores, organ failure, hospital and ICU stay, reduction in IAP and mortality.

RESULTS

Of the 105 patients, IAH was present in 48 (45.7%) patients. Patients with IAH had more often severe disease, BISAP ≥2, higher APACHE II scores and computed tomography severity index (CTSI). IAH group had more often OF (87.5% vs. 70.2%, p = 0.033), prolonged ICU stay (12.5 vs. 6.75 days, p = 0.007) and higher mortality (52.1% vs. 15.8%, p < 0.001). After PCD, IAP decreased significantly more in the IAH group (21.85 ± 4.53 mmHg to 12.5 ± 4.42 mmHg) than in the NIAH group (12.68 ± 2.72 mmHg to 8.32 ± 3.18 mmHg), p = <0.001. Reduction of IAP in patients with IAH by >40% at 48 h after PCD was associated with better survival (63.3% vs. 36.7%, p = 0.006).

CONCLUSION

We observed that patients with IAH have poor outcome. PCD decreases IAP and a fall in IAP >40% of baseline value predicts a better outcome after PCD in patients with acute fluid collections.

Role of Static and Dynamic Intra-abdominal Pressure Monitoring in Acute Pancreatitis: A Prospective Study on Its Impact

OBJECTIVE

This study was aimed to determine the relationship between static and dynamic intra-abdominal pressure (IAP) with the mortality and outcome of acute pancreatitis.

METHODS

From July 2017 to December 2018, 150 patients admitted at the Institute of Gastrosciences and Liver and diagnosed as acute pancreatitis were included in the study. Intra-abdominal pressure was measured for the first few days, and mean value of day 1 (static IAP) and highest value on day 2 and day 3 (dynamic IAP) were calculated and categorized into intra-abdominal hypertension and abdominal compartment syndrome.

RESULTS

A statistical relationship was observed between static and dynamic IAP with the severity and mortality of acute pancreatitis. Both static and dynamic IAPs tended to be higher in nonsurvivors (83.33% and 88.88%, respectively) compared with survivors (51.51% and 63.63%, respectively). Higher IAP had more severe disease. However, IAP did not correlate with the evidence of sepsis or serum procalcitonin levels.

CONCLUSION

Determination of static IAP is an easy, useful, and inexpensive method to determine and predict the mortality of acute pancreatitis. Prevention and/or early detection of intra-abdominal hypertension helps in reducing the mortality in acute pancreatitis.

Evaluation of the Severity of Hyperlipidemia Pancreatitis Using CT-measured Visceral Adipose Tissue

BACKGROUND

Computed tomography-measured visceral adipose tissue (VAT) and the distribution of VAT are highly correlated with the severity and prognosis of acute pancreatitis (AP). To date, all available data are from the overall AP patient population; no subgroup analysis has been conducted to evaluate patients with moderately severe AP or patients with hyperlipidemia acute pancreatitis (HLAP) as independent populations. Currently, studies on the relationship between VAT and HLAP are lacking.

MATERIALS AND METHODS

A total of 235 patients with moderately severe AP or severe acute pancreatitis were divided into 2 groups according to whether hyperlipidemia was present: the HLAP group and the non-HLAP group. The general inpatient information was collected, and computed tomography was used to measure VAT, subcutaneous adipose tissue (SAT), total adipose tissue, and VAT/SAT (V/S). The data were subjected to t test, χ test, matrix scatter plot, logistic regression, and receiver operating characteristic analyses to evaluate the relationship between VAT and HLAP severity.

RESULTS

Significant differences were observed in VAT, SAT, total adipose tissue, and triglycerides (TGs) between the HLAP group and the non-HLAP group (P<0.001). Significant correlations were observed between VAT and body mass index (r=0.425, P=0.017) and between VAT and TG (r=0.367, P=0.042). In the HLAP group, VAT, V/S, TG, and local complications may have significant effects on disease severity. The receiver operating characteristic curves showed that VAT and V/S were more reliable than TGs in evaluating disease severity [area under the curve (AUC) of VAT: 0.819, P<0.001; AUC of V/S: 0.855, P<0.001; AUC of TG: 0.671, P=0.04]. Disease severity was reliably evaluated at 139 cm, the cut-off value of VAT. The cut-off value of V/S was 1.145; high V/S was associated with extended intensive care unit stay. VAT and its distribution had no significant effects on mortality.

CONCLUSIONS

For patients with moderately severe to severe HLAP, VAT was correlated with body mass index and TG. VAT and V/S were valuable factors for evaluating disease severity and prognosis. However, VAT had no effect on mortality, and VAT could not be used to evaluate patients with moderately severe to severe non-HLAP.

The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis: A retrospective cohort study

PURPOSE

To explore clinical characteristics and long-term quality of life (QOL) in severe acute pancreatitis (SAP) patients with persistent inflammation-immunosuppression and catabolism syndrome (PICS).

MATERIALS AND METHODS

SAP patients admitted to ICU were eligible for the retrospective cohort study if they needed prolonged intensive care (>14days). Post-ICU QOL was assessed by a questionnaire, including 36-item Short Form Health Survey (SF-36) and record of re-work in a long-term follow-up.

RESULTS

214 SAP patients were enrolled, in which 149 (69.6%) patients met the criteria of PICS. PICS patients had more complications and ICU days compared to non-PICS patients (P<0.001), and their post-ICU mortality was higher (P=0.046). When adjusted for confounders, PICS was independently associated with higher post-ICU mortality (hazard ratio 4.5; 95% CI, 1.2 to 16.3; P=0.024). The 36-item Short Form Health Survey (SF-36) score was lower for PICS group in six subscales (P<0.001). Only 28.8% patients in the PICS group returned to work compared to 60% patients in the non-PICS group (P=0.001) CONCLUSIONS: SAP patients with prolonged ICU stay had a high morbidity of PICS, which was a risk factor for the post-ICU mortality and poor long-term QOL.

Predicting and evaluation the severity in acute pancreatitis using a new modeling built on body mass index and intra-abdominal pressure

OBJECT

Acute pancreatitis (AP) keeps as severe medical diagnosis and treatment problem. Early evaluation for severity and risk stratification in patients with AP is very important. Some scoring system such as acute physiology and chronic health evaluation-II (APACHE-II), the computed tomography severity index (CTSI), Ranson's score and the bedside index of severity of AP (BISAP) have been used, nevertheless, there're a few shortcomings in these methods. The aim of this study was to construct a new modeling including intra-abdominal pressure (IAP) and body mass index (BMI) to evaluate the severity in AP.

METHODS

The study comprised of two independent cohorts of patients with AP, one set was used to develop modeling from Jinling hospital in the period between January 2013 and October 2016, 1073 patients were included in it; another set was used to validate modeling from the 81st hospital in the period between January 2012 and December 2016, 326 patients were included in it. The association between risk factors and severity of AP were assessed by univariable analysis; multivariable modeling was explored through stepwise selection regression. The change in IAP and BMI were combined to generate a regression equation as the new modeling. Statistical indexes were used to evaluate the value of the prediction in the new modeling.

RESULTS

Univariable analysis confirmed change in IAP and BMI to be significantly associated with severity of AP. The predict sensitivity, specificity, positive predictive value, negative predictive value and accuracy by the new modeling for severity of AP were 77.6%, 82.6%, 71.9%, 87.5% and 74.9% respectively in the developing dataset. There were significant differences between the new modeling and other scoring systems in these parameters (P < 0.05). In addition, a comparison of the area under receiver operating characteristic curves of them showed a statistically significant difference (P < 0.05). The same results could be found in the validating dataset.

CONCLUSIONS

A new modeling based on IAP and BMI is more likely to predict the severity of AP.

Comparison of the clinical characteristics and prognosis of primary versus secondary acute gastrointestinal injury in critically ill patients

BACKGROUND

This prospective study compared clinical characteristics and prognosis between primary (P) and secondary (S) acute gastrointestinal injury (AGI) (P-AGI)/(S-AGI) in critically ill patients.

METHODS

This was a prospective, single-center observational study. Patients were included if they had been hospitalized for at least 72 h before the AGI diagnosis. Patients were classified according to severity of gastrointestinal dysfunction, while P-AGI or S-AGI were defined according to whether the gastrointestinal system was directly or indirectly involved. Clinical characteristics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and Sepsis-related Organ Failure Assessment (SOFA) scores after inclusion and 28-day mortality were recorded.

RESULTS

Altogether, 282 patients were included: P and S groups enrolled 100 and 182 patients, respectively. The S group patients were older and showed increased morbidities and higher APACHE II and SOFA scores. Compared to the S group, the P group had a higher prevalence in abdominal distention and enteroparalysis and fewer patients at AGI grade I, while more patients at grade III or IV. The S group patients had the higher 28-day mortality. Multiple logistic regression analysis showed AGI grades, APACHE II score, and S-AGI independently predicted the odds of 28-day mortality.

CONCLUSIONS

Comparing to the P-AGI patients, the S group patients were older, with higher APACHE II and SOFA scores. AGI grade, APACHE II score, and S-AGI independently predicted the odds of 28-day mortality in AGI patients.

Outcome benefit of abdominal paracentesis drainage for severe acute pancreatitis patients with serum triglyceride elevation by decreasing serum lipid metabolites

Background

Our previous reports demonstrated that abdominal paracentesis drainage (APD) exerts a beneficial effect on severe acute pancreatitis (SAP) patients. However, the underlying mechanisms for this effectiveness are not well understood.

Methods

A retrospective cohort of 132 consecutive non-hypertriglyceridemia (HTG)-induced SAP patients with triglyceride (TG) elevation and pancreatitis-associated ascitic fluid (PAAF) was recruited from May 2010 to May 2015 and included in this study. The patients were divided into two groups: the APD group (n = 68) and the non-APD group (n = 64). The monitored parameters mainly included mortality, hospital stay, the incidence of further intervention, levels of serum lipid metabolites and inflammatory factors, parameters related to organ failure and infections, and severity scores.

Results

The demographic data and severity scores were comparable between the two groups. Compared with the non-APD group, the primary outcomes (including mortality, hospital stay and the incidence of percutaneous catheter drainage) in the APD group were improved. The serum levels of lipid metabolites were significantly lower in the APD group after 2 weeks of treatment than in the non-APD group. Logistic regression analysis indicated that the decreased extent of free fatty acid (FFA)(odds ratio, 1.435; P = 0.015) was a predictor of clinical improvement after 2 weeks of treatment.

Conclusion

Treatment with APD benefits non-HTG-induced SAP patients with serum TG elevation by decreasing serum levels of FFA.

Minimally invasive percutaneous catheter drainage versus open laparotomy with temporary closure for treatment of abdominal compartment syndrome in patients with early-stage severe acute pancreatitis

This study aimed to examine the clinical efficacy of minimally invasive percutaneous catheter drainage (PCD) versus open laparotomy with temporary closure in the treatment of abdominal compartment syndrome (ACS) in patients with early-stage severe acute pancreatitis (SAP). Clinical data of 212 patients who underwent PCD and 61 patients who were given open laparotomy with temporary closure in our hospital over the last 10-year period were retrospectively analyzed, and outcomes were compared, including total and post-decompression intensive care unit (ICU) and hospital stays, physiological data, organ dysfunction, complications, and mortality. The results showed that the organ dysfunction scores were similar between the PCD and open laparotomy groups 72 h after decompression. In the PCD group, 134 of 212 (63.2%) patients required postoperative ICU support versus 60 of 61 (98.4%) in the open laparotomy group (P<0.001). Additionally, 87 (41.0%) PCD patients experienced complications as compared to 49 of 61 (80.3%) in the open laparotomy group (P<0.001). There were 40 (18.9%) and 32 (52.5%) deaths, respectively, in the PCD and open laparotomy groups (P<0.001). In conclusion, minimally invasive PCD is superior to open laparotomy with temporary closure, with fewer complications and deaths occurring in PCD group.

Intra-Abdominal Pressure Reduction After Percutaneous Catheter Drainage Is a Protective Factor for Severe Pancreatitis Patients With Sterile Fluid Collections

OBJECTIVES

Severe acute pancreatitis (SAP) is a fatal disease with natural course of early SAP (ESAP) and late SAP (LSAP) phases. Peripancreatic percutaneous catheter drainage (PCD) is effective in management of LSAP. Although our previous study indicates that intra-abdominal PCD ahead of peripancreatic PCD benefits ESAP patients with sterile fluid collections, the mechanism is still uncovered.

METHODS

According to therapeutic results, 452 SAP patients who underwent PCD were divided into sterile group (248 cases), secondary infection group (145 cases), and primary infection group (59 cases).

RESULTS

The mortality was 4.1%, 10.9%, and 18.6%, respectively. Logistic-regression analysis indicated that multiorgan dysfunction syndrome (odds ratio [OR], 1.717; 95% confidence interval [95% CI], 1.098-2.685; P = 0.018), catheters located intra-abdominally (OR, 0.511; 95% CI, 0.296-0.884; P = 0.016), and intra-abdominal hypertension (OR, 1.534; 95% CI, 1.016-2.316; P = 0.042) were predictors for infection after PCD. Receiver operating characteristics curve delineated that decrease of intra-abdominal pressure (IAP) of more than 6.5 mm Hg after PCD had the ability to predict infection with sensitivity of 84.0% and specificity of 79.5%.

CONCLUSIONS

Intra-abdominal PCD for acute sterile fluid collections seems to be an effective option rather than peripancreatic PCD. Patients with a significant decrease of IAP had a lower incidence of infection and better alleviation of organ failure.

Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective

Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative treatment.

The Decrease of Peripheral Blood CD4+ T Cells Indicates Abdominal Compartment Syndrome in Severe Acute Pancreatitis

OBJECTIVE

Few data are available on the role of T lymphocytes and inflammatory cytokines in abdominal compartment syndrome (ACS) in severe acute pancreatitis (SAP). We conducted a retrospective study to assess the risk factors associated with ACS in SAP.

METHODS

A total of 76 SAP patients who were admitted within 24 hours after symptom onset in our study. There were 36 patients suffering from ACS and 40 from intra-abdominal hypertension (IAH). On the 1st, 3rd and 7th days after hospital admission, the following variables were assessed: serum value of C-reactive protein (CRP), and the proportions of peripheral CD4+ and CD8+ T lymphocytes. Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and computed tomography severity index (CTSI) score were assessed on days 1 and 7 after hospitalization.

RESULTS

Compared with the patients with IAH, ACS patients showed statistically higher CRP value on 7th day after hospital admission, proportions of CD4+ T cells on days 1, 3, 7 and CD4+/CD8+ ratio on day 1 were significantly lower (P < 0.05, respectively). A CD4+ T cell proportion of 30.3% on the 1st day indicated ACS with an area under the curve (AUC) of 0.774, a sensitivity with 82.5% and specificity with 72.0%, respectively. Sensitivity/specificity for predicting ACS in SAP patients on day 1 was 70.0%/68.0% for CD4+/CD8+ ratio, 72.2%/65.0% for APACHE II score.

CONCLUSIONS

The reduction of peripheral blood CD4+ T lymphocytes is associated with ACS in SAP, and may act as a potential predictor of ACS in SAP.

The open abdomen, indications, management and definitive closure

The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure.

Inverted U-Shaped Relationship between Central Venous Pressure and Intra-Abdominal Pressure in the Early Phase of Severe Acute Pancreatitis: A Retrospective Study

OBJECTIVE

Many studies have indicated that intra-abdominal pressure (IAP) is positively correlated with central venous pressure (CVP) in severe cases. However, although elevated IAP is common in patients with severe acute pancreatitis (SAP), its relationship with CVP remains unclear. Our study aimed to investigate the association of IAP with CVP in early-phase SAP patients.

METHODS

In total, 116 SAP patients were included in this retrospective study. On the first day of hospitalization, blood samples were collected for biochemical examination and cytokine concentration monitoring. Additionally, a urinary catheter and right subclavian vein catheter were inserted for IAP and CVP measurement, respectively. Other routine clinical data were also recorded.

RESULTS

Within 24 hours after hospitalization, CVP fluctuated and increased with increasing IAP up to 15.7 mmHg (P = 0.054) but decreased with increasing IAP when the IAP was > 15.7 mmHg (P < 0.001). After adjusting for abdominal perfusion pressure (APP) and mean arterial pressure (MAP), a similar distribution was observed. An inverted U-shaped trend between IAP and CVP was also present in the groups classified according to the patient's sex, local complications, ascites, and serum amylase levels.

CONCLUSIONS

CVP and IAP have an inverted U-shaped relationship, with a peak at an IAP of 15.7 mmHg in the early phase of SAP. After this peak, CVP decreases as IAP increases. These results have crucial implications for clinical fluid resuscitation in SAP patients. In particular, because one CVP value might be correlated with different IAP values in patients with the same CVP, the volume of fluid needed might be different.

The duration of intra-abdominal hypertension strongly predicts outcomes for the critically ill surgical patients: a prospective observational study

INTRODUCTION

Intra-abdominal hypertension (IAH) is associated with morbidity and mortality in critically ill patients. The present study analyzed the clinical significance of IAH in surgical patients with severe sepsis.

METHODS

This was a prospective study carried out in the surgical intensive care unit (SICU). Intra-abdominal pressure (IAP) was measured three times a day via a urinary catheter filled with 25 mL of saline. IAH was defined as an IAP ≥ 12 mmHg, and the peak IAP was recorded as the IAP for the day. Data were analyzed in terms of IAH development and the IAH duration.

RESULTS

Of the 46 patients enrolled in the study, 42 developed IAH while in the SICU. The development of IAH aggravated the clinical outcomes; such as longer SICU stay, requirement of ventilator support, and delayed initiation of enteral feeding (EF). The IAH duration showed a significant correlation with pulmonary, renal, and cardiovascular function, and enteral feeding. The IAH duration was an independent predictor of 60-day mortality (odds ratio: 1.196; p = 0.014).

CONCLUSIONS

The duration of IAH is a more important prognostic factor than the development of IAH; thus every effort should be made to reduce the IAH duration in critically ill patients.

TRIAL REGISTRATION

NCT01784458.

Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015

BACKGROUND

Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines.

METHODS

A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines.

RESULTS

Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles.

CONCLUSIONS

The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.

Measurement of Intra-abdominal Pressure in Critically-ill Children

INTRODUCTION

It is being increasingly recognized that intra-abdominal hypertension is an important cause of organ dysfunction. This pilot study was done to determine the feasibility of measuring intra-abdominal pressures (IAP) in critically-ill children using simple inexpensive equipment available in the PICU.

MATERIALS AND METHODS

This was a prospective study done in the paediatric intensive care unit (PICU) of a tertiary care general hospital. Thirty-two consecutive patients admitted to the PICU, staying for more than 24 h and requiring a urinary catheter were studied. IAP was measured by the intravesical method, using a disposable manometer, twice a day for seven days or till discharge/death, Risk factors associated with IAH were recorded.

RESULTS

The majority of the patients had an IAP less than 5 mm Hg. Three patients had grade 1 intra-abdominal hypertension (IAP>12 mm Hg).

CONCLUSION

It is feasible to measure IAP in paediatric patients without the use of sophisticated equipment.

Mesenteric lymphatic vessels adapt to mesenteric venous hypertension by becoming weaker pumps

Lymphangions, the segments of lymphatic vessels between two adjacent lymphatic valves, actively pump lymph. Acute changes in transmural pressure and lymph flow have profound effects on lymphatic pump function in vitro. Chronic changes in pressure and flow in vivo have also been reported to lead to significant changes in lymphangion function. Because changes in pressure and flow are both cause and effect of adaptive processes, characterizing adaptation requires a more fundamental analysis of lymphatic muscle properties. Therefore, the purpose of the present work was to use an intact lymphangion isovolumetric preparation to evaluate changes in mesenteric lymphatic muscle mechanical properties and the intracellular Ca(2+) in response to sustained mesenteric venous hypertension. Bovine mesenteric veins were surgically occluded to create mesenteric venous hypertension. Postnodal mesenteric lymphatic vessels from mesenteric venous hypertension (MVH; n = 6) and sham surgery (Sham; n = 6) animals were isolated and evaluated 3 days after the surgery. Spontaneously contracting MVH vessels generated end-systolic active tension and end-diastolic active tension lower than the Sham vessels. Furthermore, steady-state active tension and intracellular Ca(2+) concentration levels in response to KCl stimulation were also significantly lower in MVH vessels compared with those of the Sham vessels. There was no significant difference in passive tension in lymphatic vessels from the two groups. Taken together, these results suggest that following 3 days of mesenteric venous hypertension, postnodal mesenteric lymphatic vessels adapt to become weaker pumps with decreased cytosolic Ca(2+) concentration.

Predictors of critical acute pancreatitis: a prospective cohort study

Critical acute pancreatitis (CAP) has recently emerged as the most ominous severity category of acute pancreatitis (AP). As such there have been no studies specifically designed to evaluate predictors of CAP. In this study, we aimed to evaluate the accuracy of 4 parameters (Acute Physiology and Chronic Health Evaluation [APACHE] II score, C-reactive protein [CRP], D-dimer, and intra-abdominal pressure [IAP]) for predicting CAP early after hospital admission. During the study period, data on patients with AP were prospectively collected and D-dimer, CRP, and IAP levels were measured using standard methods at admission whereas the APACHE II score was calculated within 24 hours of hospital admission. The receiver-operating characteristic (ROC) curve analysis was applied and the likelihood ratios were calculated to evaluate the predictive accuracy. A total of 173 consecutive patients were included in the analysis and 47 (27%) of them developed CAP. The overall hospital mortality was 11% (19 of 173). APACHE II score ≥11 and IAP ≥13 mm Hg showed significantly better overall predictive accuracy than D-dimer and CRP (area under the ROC curve-0.94 and 0.92 vs. 0.815 and 0.667, correspondingly). The positive likelihood ratio of APACHE II score is excellent (9.9) but of IAP is moderate (4.2). The latter can be improved by adding CRP (5.8). In conclusion, of the parameters studied, APACHE II score and IAP are the best available predictors of CAP within 24 hours of hospital admission. Given that APACHE II score is rather cumbersome, the combination of IAP and CRP appears to be the most practical way to predict critical course of AP early after hospital admission.

Abdominal compartment syndrome in acute pancreatitis: a systematic review

Abdominal compartment syndrome (ACS) is a lethal complication of acute pancreatitis. We performed a systematic review to assess the treatment and outcome of these patients.A systematic literature search for cohorts of patients with acute pancreatitis and ACS was performed. The main outcomes were number of patients with ACS, radiologic and surgical interventions, morbidity, mortality, and methodological quality.After screening 169 articles, 7 studies were included. Three studies were prospective and 4 studies were retrospective. The overall methodological quality of the studies was moderate to low. The pooled data consisted of 271 patients, of whom 103 (38%) developed ACS. Percutaneous drainage of intraabdominal fluid was reported as first intervention in 11 (11%) patients. Additional decompressive laparotomy was performed in 8 patients. Decompressive laparotomy was performed in a total of 76 (74%) patients. The median decrease in intraabdominal pressure was 15 mm Hg (range, 33-18 mm Hg). Mortality in acute pancreatitis patients with ACS was 49% versus 11% without ACS. Morbidity ranged from 17% to 90%.Abdominal compartment syndrome during acute pancreatitis is associated with high mortality and morbidity. Studies are relatively small and have methodological shortcomings. The optimal timing and method of invasive interventions, as well as their effect on clinical outcomes, should be further evaluated.

Current concepts of the role of abdominal compartment syndrome in acute pancreatitis - an opportunity or merely an epiphenomenon

The association of acute pancreatitis (AP) with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) has only recently been recognized. The detrimental effects of raised intra-abdominal pressure in cardiovascular, pulmonary and renal systems have been well established. Although IAH was associated with a higher APACHE II score and multi-organ dysfunction syndrome (MODS) in severe acute pancreatitis, a causal relationship between ACS and MODS in SAP is yet to be established. It is therefore debatable whether IAH is a phenomenon causative of organ failure or an epiphenomenon seen in conjunction with other organ dysfunction. This review systemically examines the pathophysiological basis and clinical relevance of ACS in AP and summarizes all the available evidence in its management.

Abdominal compartment syndrome and acute pancreatitis

Significant visceral edema associated with massive fluid resuscitation, paralytic ileus and formation of pancreatic ascites in patients with severe acute pancreatitis (SAP) can lead to abdominal compartment syndrome (ACS) that can contribute to the early development of multiple organ dysfunction syndrome (MODS), especially in the early stages of the disease. The prevalence of intra-abdominal hypertension (IAH) in SAP is about 40% and a manifest ACS occurs in about 10% of the patients warranting close monitoring of intra-abdominal pressure (IAP) in all patients with the severe form of the disease. Although nonsurgical management utilizing percutaneous drainage of ascites or continuous hemodiafiltration may decrease IAP, most patients require decompressive laparostomy and temporary abdominal closure. The primary aim in managing the ensuing open abdomen is delayed fascial closure during initial hospitalization. On many occasions a planned hernia approach, either with early skin grafting over the exposed bowel or managing the ASC primarily with a subcutaneous linea alba fasciotomy, is the only available option. The development of ACS in patients with SAP seems to be associated with increased mortality.

Noosa, 2 years later… a critical analysis of recent literature

INTRODUCTION

Since the second World Congress on the Abdominal Compartment Syndrome (WCACS) in Noosa 2 years ago, interest and publications on intra-abdominal hypertension (IAH) and ACS have increased exponentially. This paper aimed to critically review recent publications and put this new data into the context of already acquired knowledge concerning IAH/ACS.

METHODS

A Medline and PubMed search was performed from January 2005 up to now using "intra-abdominal pressure (IAP)", "intra-abdominal hypertension (IAH)", "abdominal compartment syndrome (ACS)" and "decompressive laparotomy" as search items.

RESULTS

Although consensus definitions of IAH/ACS have been formulated recently, data on awareness are still disconcerting. Several groups refined current IAP measurement techniques and tested new direct IAP measurement devices for use in selected subpopulations. A series of recent publications identified specific patient subpopulations in IAH/ACS, like patients with burns or severe acute pancreatitis, with their specific pathophysiology and therapy. Although many studies already assessed the effect of elevated IAP on regional and micro-circulatory organ perfusion, a number of new publications attempted to unravel the link between elevated IAP and more "downstream" organ function or histology. Finally, therapy for IAH/ACS still reveals more questions than it answers. Global resuscitation does not necessarily equate with organ resuscitation. In fact, fluid-resuscitation may even induce IAH/ACS.

CONCLUSIONS

After publication of consensus guidelines on IAH/ACS, there is an urgent need for human intervention studies and, in parallel, clinically relevant animal models. Given moderately low incidence of ACS and the complex and interrelated pathologies of the critically ill patient with IAH/ACS, large animal models of pathology-induced IAH/ACS might create the opportunity to gain clinically relevant knowledge on the treatment of IAH/ACS.

Rational intraabdominal pressure monitoring: how to do it?

INTRODUCTION

Intraabdominal hypertension (IAH) is increasingly appreciated by intensivists as an important cause of organ dysfunction, even at pressure levels which were previously thought to be harmless. Therefore, the goal of this review is to describe the different methods commonly used in clinical practice for intraabdominal pressure (IAP) measurement, the advised methodology for each measurement method, and finally to give a rational approach for IAP monitoring in daily clinical practice.

METHODS

A Medline search of the English literature was performed using the term "intra abdominal pressure" and "measurement". This resulted in 194 studies, which were then analysed based on the title and abstract. Only clinical studies in human subjects with IAP measurement or related issues as the subject of the study, were considered for inclusion in the study. Reviews, animal experiments and case reports were excluded, while one specific review on IAP measurement and 3 large animal studies (domestic swine > 40 kg) were included in the analysis. This left us with 19 studies, published between 1984 and 2006: 1 specific review, 2 studies in children, 13 in adults and 3 in domestic swine. The references from these studies were searched for relevant articles that may have been missed in the primary search. These articles served as the basis for the recommendations below.

RESULTS

Clinical data regarding the validation of new IAP measurement methods or the reliability of established measurement techniques are scarce. The transvesical route, which has been studied most extensively, can be used as reliable route for intermittent IAP measurement, as long as instillation volumes below 25mL are used. Continuous IAP and APP monitoring can be done via a balloon-tipped catheter placed in the stomach or directly intraperitoneal.

CONCLUSIONS

Rational IAP monitoring should be based on a site specific protocol, based on known risk factors, the monitoring equipment available and nursing staff experience, and should be linked directly to a local treatment protocol.

The secondary and recurrent abdominal compartment syndrome

INTRODUCTION

The Secondary Abdominal Compartment Syndrome (SACS) refers to cases of the ACS that do not originate from the abdominopelvic region. With greater awareness of the physiologic consequences of raised intra-abdominal hypertension (IAH), cases of the SACS are being increasingly described. The prior treatment or the presence of a partially open abdomen does not preclude the ACS if the abdomen and viscera continue to swell or the clinician is not vigilant in monitoring intra-abdominal pressure (IAP). Such recurrent cases (RACS) have been defined as those which redevelop following the previous medical or surgical treatment of primary or SACS. Although there has been a diverse range of etiologies implicated, these cases seem to be linked by the common occurrence of severe shock requiring aggressive fluid resuscitation. The aim of this paper is to thus to review the historical background, awareness, definitions, pathophysiological implications and treatment options for SACS and RACS.

METHODS

This review will focus on the available literature regarding SACS and RACS. A Medline and Pubmed search was performed using the keywords; secondary abdominal compartment syndrome AND secondary AND tertiary AND recurrent AND abdominal compartment syndrome AND intra-abdominal pressure AND intra-abdominal hypertension. Bibliographies of recovered papers were hand-searched for other appropriate references. The resulting references were included in the current review on the basis of relevance and scientific merit Results: There has been remarkably little specific study of these entities outside of specific groups such as those injured by thermal or traumatic injury. The epidemiology, risk factors for, treatment of and most importantly, strategies for prevention all remain scientifically unknown and therefore based on opinion. Notable, although small, studies suggest that specific resuscitation practices may avert these conditions.

CONCLUSIONS

ACS can occur in any patient who is critically ill and subject to visceral and somatic swelling, regardless of whether the inciting pathology is extra-abdominal. The ACS may also reoccur with recurrent shock and swelling even if previous therapies had partially addressed IAH. Therefore IAP measurements should be considered a routine monitoring for the critically ill, especially those subjected to shock and requiring a subsequent resuscitation. Much further study is required to understand the differences in etiology, diagnosis, pathophysiology, and treatment for all cases of the ACS.

Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study

BACKGROUND

To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP).

METHODS

Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded.

RESULTS

Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved.

CONCLUSIONS

Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3-4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.

The abdomen in "thoracoabdominal" cannot be ignored: abdominal compartment syndrome complicating extracorporeal life support

Extracorporeal life support (ECLS) is an incredible life-saving measure that is being used ever more frequently in the care of the critically ill. Management of these patients requires extreme vigilance on the part of the care providers in recognizing and addressing the complications and challenges that may arise. We present a case of overt abdominal compartment syndrome (ACS) in a previously well young male on ECLS with a history of trauma, submersion, hypothermia, and no intra-abdominal injuries. The patient developed ACS soon after ECLS was initiated which resulted in drastically compromised flow rates. Taking into account the patient's critical status, an emergent laparotomy was performed in the intensive care unit which successfully resolved the ACS and restored ECLS flow. The patient had an unremarkable course following and was weaned off ECLS but unfortunately died from his original anoxic injury. This case highlights several salient points: first, care of patients on ECLS is challenging and multiple etiologies can affect our ability to manage these patients; second, intra-abdominal pressures should be monitored liberally in the critically ill, especially in patients on ECLS; third, protocols for emergent operative treatment outside of traditional operating rooms should be established and care providers should be prepared for these situations.

Elevation of intra-abdominal pressure by pneumoperitoneum decreases pancreatic perfusion in an in vivo porcine model

BACKGROUND

The goal of this study is to examine changes in pancreatic perfusion due to pneumoperitoneum using perfusion CT in vivo.

METHODS

Three pigs were studied. Under general anesthesia, pneumoperitoneum was induced to 16 mm Hg. Perfusion CT scans were acquired at a rate of 1 image per 2 seconds for 60 seconds. Scans were repeated 5 days later without pneumoperitoneum using the same protocol, in the same animals. The time density curve, color map, peak enhancement, time to peak, blood flow, blood volume, and permeability were evaluated.

RESULTS

In the presence of pneumoperitoneum, peak enhancement in radiodensity was decreased and time to peak was increased, and both blood flow and blood volume decreased. However, there was no consistent change in permeability observed.

CONCLUSION

This study demonstrates that pneumoperitoneum quantitatively results in decreased blood flow and blood volume to the pancreas in an in vivo animal model.

Planned re-laparotomy and the need for optimization of physiology and immunology

Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.

Expanded measurements of intra-abdominal pressure do not increase the detection rate of intra-abdominal hypertension: a single-center observational study

OBJECTIVE

Intra-abdominal hypertension may contribute to a poor outcome. Whether limiting intra-abdominal pressure measurements to preselected at-risk patients allows for sufficient detection of intra-abdominal hypertension is unclear. We aimed to clarify whether expanded intra-abdominal pressure monitoring results in an increased detection rate of intra-abdominal hypertension.

DESIGN

Retrospective observational study.

SETTING

General ICU of University Hospital.

PATIENTS

Consecutive adult ICU patients from 2004 to 2011.

INTERVENTIONS

Intra-abdominal pressure measurements in predefined at-risk patients.

MEASUREMENTS AND MAIN RESULTS

Prospectively collected data of 2,696 admissions were divided into three subgroups according to the intra-abdominal pressure measurement policy in different years: 1) 2004-2005, mechanically ventilated patients with at least one additional risk factor for intra-abdominal hypertension (multiple trauma, abdominal surgery, pancreatitis, post-cardiopulmonary resuscitation, fluid resuscitation > 5 L/24 hr, vasoactive or inotropic support, and renal replacement therapy); 2) 2006-2009, all mechanically ventilated patients expected to stay for more than or equal to 24 hours; and 3) 2010-2011, mechanically ventilated patients with a body mass index greater than 30 kg/m, positive end-expiratory pressure more than 10 cm H2O, PaO2/FIO2 less than 300, use of vasopressors/inotropes, pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding, or postlaparotomy. In all, 2,696 patients were studied, and 1,241 patients (46.0%) underwent intra-abdominal pressure monitoring. The intra-abdominal pressure was measured in 31.7%, 55.6%, and 41.1% of patients during the first, second, and third time periods (p < 0.001), and intra-abdominal hypertension (intra-abdominal pressure ≥ 12 mm Hg) occurred in 19.9%, 20.3%, and 20.1% of patients, respectively (p = 0.972). The mean intra-abdominal pressure at admission day was an independent predictor of mortality in patients with intra-abdominal pressure measurements started within the first 24 hours (odds ratio, 1.046 [95% CI, 1.019-1.072]). The mortality of patients with intra-abdominal hypertension was 29.8% versus 18.6% in those without intra-abdominal hypertension (p < 0.001).

CONCLUSIONS

Expanding the measurement of intra-abdominal pressure to more than 50% of intensive care admissions does not increase the detection rate of intra-abdominal hypertension. In patients with intra-abdominal pressure monitoring, the mean intra-abdominal pressure on the admission day is an independent predictor of mortality.

The effect of somatostatin, ulinastatin and Salvia miltiorrhiza on severe acute pancreatitis treatment

BACKGROUND

The aim of this study was to evaluate the efficacy of somatostatin, ulinastatin and Salvia miltiorrhiza for treatment of severe acute pancreatitis.

METHODS

Three hundred six patients with severe acute pancreatitis were divided randomly into 5 groups: basic treatment, somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza. Amount of time for resolution of abdominal pain/distention, recovery to normal heart and respiratory rates, amylase and blood glucose levels, Acute Physiology and Chronic Health Evaluation II scores, and levels of tumor necrosis factor-α, interleukin (IL)-6, and IL-10 were analyzed and recorded for all 5 subgroups.

RESULTS

Tumor necrosis factor-α and IL-6 levels on the fourth and seventh days, and Acute Physiology and Chronic Health Evaluation II scores on the seventh day after treatment showed significant decrease in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. IL-10 levels on the fourth and seventh days were significantly improved in the somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup. The incidences of pancreatic sepsis, multiple organ dysfunction syndrome and mortality were lower in the somatostatin, somatostatin + ulinastatin, somatostatin + S miltiorrhiza and somatostatin + ulinastatin + S miltiorrhiza subgroups compared with the basic treatment subgroup.

CONCLUSIONS

Somatostatin is effective for the treatment of acute pancreatitis and both ulinastatin and S miltiorrhiza demonstrate improvement in therapeutic benefits.

Observational study of intra-abdominal pressure monitoring in acute pancreatitis

BACKGROUND

Intra-abdominal hypertension (IAH) is predictive of adverse outcome in critically ill patients; however, its role in acute pancreatitis is unclear, and prospective studies are lacking. We aimed to determine the overall incidence and predictive value of IAH on mortality in acute pancreatitis.

METHODS

Transvesical IAP was measured on admission and every 4 hours within high-dependency unit/intensive care unit. Serum biochemistry and physiologic parameters permitted calculation of Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Imrie, and Ranson scores. The primary end point was 30-day mortality.

RESULTS

A total of 218 patients with acute pancreatitis were recruited; 30-day mortality was greater in patients with IAH (IAP ≥12 mmHg; 37%) than no IAH (2%; P < .001). A total of 14% of patients had IAH on admission; another 3% developed IAH in hospital. Mortality was greater in the latter group (37% vs 50%; P < .01). In the majority of cases IAH developed in line with other organ failure; however, there were several patients in whom the development of IAH appeared to be the sentinel event before rapid clinical decline. An IAP threshold of 9 mmHg had best predictive value for mortality (sensitivity 86%, specificity 87%; area under the ROC curve 0.91). This finding was comparable with other validated markers of severe pancreatitis (Imrie ≥3: sensitivity 51%, specificity 70%; Acute Physiology and Chronic Health Evaluation II: sensitivity 67%, specificity 96%; C-reactive protein >150: sensitivity 89%, specificity 83%).

CONCLUSION

IAP is a good predictor of mortality and organ failure in acute pancreatitis and compares favorably with other validated prognostic scores. Whether IAH is a phenomenon causative of organ failure or an epiphenomenon, occurring in conjunction with other organ dysfunction, remains unclear.

Surveillance of intra-abdominal pressure and intestinal barrier function in a rat model of acute necrotizing pancreatitis and its potential early therapeutic window

OBJECTIVES

To monitor intra-abdominal pressure (IAP) and intestinal barrier function in a rat model of acute necrotizing pancreatitis (ANP) to elucidate a potential relevant therapeutic window.

METHODS

Sprague-Dawley rats were randomly divided into experimental or control groups. The ANP group (n = 40) was injected with 4.5% sodium taurocholate into the pancreatic duct to induce ANP. The controls received only abdominal opening surgery (sham-operated, SO; n = 40) or no treatment or surgery (baseline; 0 h, n = 20). The SO and ANP groups were then randomly subdivided into 3, 6, 12 and 24 h groups (n = 10 each). IAP was measured at each time point and the rats were sacrificed to measure the weight of accumulated ascites fluid and the amylase, endogenous creatinine (Cr), total bilirubin (TB), tumor necrosis factor- alpha (TNF-alpha), diamine oxidase (DAO), and D-lactate. Mortality and the development of pathological changes in the pancreas and intestines were also monitored.

RESULTS

IAP showed a continuous upward trend in the ANP group, with values 2 to 3 times higher than those in the SO group at the corresponding time points and the rising rate was peaking at 6 h. The levels of plasma amylase, TNF-alpha, Cr, TB, DAO, and D-lactate also gradually increased in the ANP group over time and were significantly higher than in the SO group at 3, 6, 12 and 24 h (all P<0.05). Moreover, the rising rate of TNF-alpha, DAO, and D-lactate also peaked at 6 h.

CONCLUSIONS

The ANP-induced changes in IAP, inflammatory factors and intestinal barrier that we observed in the rat model were especially obvious at 6 h post-induction, suggesting an early therapeutic window for the treatment of ANP in humans.

Early management of acute pancreatitis

Acute pancreatitis is the most common gastro-intestinal indication for acute hospitalization and its incidence continues to rise. In severe pancreatitis, morbidity and mortality remains high and is mainly driven by organ failure and infectious complications. Early management strategies should aim to prevent or treat organ failure and to reduce infectious complications. This review addresses the management of acute pancreatitis in the first hours to days after onset of symptoms, including fluid therapy, nutrition and endoscopic retrograde cholangiography. This review also discusses the recently revised Atlanta classification which provides new uniform terminology, thereby facilitating communication regarding severity and complications of pancreatitis.

Intra-abdominal pressure in the early phase of severe acute pancreatitis: canary in a coal mine? Results from a rigorous validation protocol

Background/Aims

Intra-abdominal hypertension (IAH) is being increasingly reported in patients with severe acute pancreatitis (SAP) with worsened outcomes. The present study was undertaken to evaluate intra-abdominal pressure (IAP) as a marker of severity in the entire spectrum of acute pancreatitis and to ascertain the relationship between IAP and development of complications in patients with SAP.

Methods

IAP was measured via the transvesical route by measurements performed at admission, once after controlling pain and then every 4 hours. Data were collected on the length of the hospital stay, the development of systemic inflammatory response syndrome (SIRS), multiorgan failure, the extent of necrosis, the presence of infection, pleural effusion, and mortality.

Results

In total, 40 patients were enrolled and followed up for 30 days. The development of IAH was exclusively associated with SAP with an APACHE II score ≥8 and/or persistent SIRS, identifying all patients who were going to develop abdominal compartment syndrome (ACS). The presence of ACS was associated with a significantly increased extent of pancreatic necrosis, multiple organ failure, and mortality. The mean admission IAP value did not differ significantly from the value obtained after pain control or the maximum IAP measured in the first 5 days.

Conclusions

IAH is reliable marker of severe disease, and patients who manifest organ failure, persistent SIRS, or an Acute Physiology and Chronic health Evaluation II score ≥8 should be offered IAP surveillance. Severe pancreatitis is not a homogenous entity.