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

An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study

BACKGROUND

The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis.

PURPOSE OF THE STUDY

The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP).

MATERIALS AND METHODS

The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery.

RESULTS

The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027).

CONCLUSION

Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.

Abdominal compartment syndrome in critically ill patients

Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.

In Vitro Validation of a Novel Continuous Intra-Abdominal Pressure Measurement System (TraumaGuard)

Introduction: Intra-abdominal pressure (IAP) has been recognized as an important vital sign in critically ill patients. Due to the high prevalence and incidence of intra-abdominal hypertension in surgical (trauma, burns, cardiac) and medical (sepsis, liver cirrhosis, acute kidney injury) patients, continuous IAP (CIAP) monitoring has been proposed. This research was aimed at validating a new CIAP monitoring device, the TraumaGuard from Sentinel Medical Technologies, against the gold standard (height of a water column) in an in vitro setting and performing a comparative analysis among different CIAP measurement technologies (including two intra-gastric and two intra-bladder measurement devices). A technical and clinical guideline addressing the strengths and weaknesses of each device is provided as well. Methods: Five different CIAP measurement devices (two intra-gastric and three intra-vesical), including the former CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, were validated against the gold standard water column pressure in a bench-top abdominal phantom. The impacts of body temperature and bladder fill volume (for the intra-vesical methods) were evaluated for each system. Subsequently, 48 h of continuous monitoring (n = 2880) on top of intermittent IAP (n = 300) readings were captured for each device. Using Pearson's and Lin's correlations, concordance, and Bland and Altman analyses, the accuracy, precision, percentage error, correlation and concordance coefficients, bias, and limits of agreement were calculated for all the different devices. We also performed error grid analysis on the CIAP measurements to provide an overview of the involved risk level due to wrong IAP measurements and calculated the area under the curve and time above a certain IAP threshold. Lastly, the robustness of each system in tracking the dynamic variations of the raw IAP signal due to respirations and heartbeats was evaluated as well. Results: The TraumaGuard was the only technology able to measure the IAP with an empty artificial bladder. No important temperature dependency was observed for the investigated devices except for the Spiegelberg, which displayed higher IAP values when the temperature was increased, but this could be adjusted through recalibration. All the studied devices showed excellent ability for IAP monitoring, although the intra-vesical IAP measurements seem more reliable. In general, the TraumaGuard, Accuryn, and Serenno showed better accuracy compared to intra-gastric measurement devices. On average, biases of +0.71, +0.93, +0.29, +0.25, and -0.06 mm Hg were observed for the CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, respectively. All of the equipment showed percentage errors smaller than 25%. Regarding the correlation and concordance coefficients, the Serenno and TraumaGuard showed the best results (R2 = 0.98, p = 0.001, concordance coefficient of 99.5%). Error grid analysis based on the Abdominal Compartment Society guidelines showed a very low associated risk level of inappropriate treatment strategies due to erroneous IAP measurements. Regarding the dynamic tracings of the raw IAP signal, all the systems can track respiratory variations and derived parameters; however, the CiMON was slightly superior compared to the other technologies. Conclusions: According to the research guidelines of the Abdominal Compartment Society (WSACS), this in vitro study shows that the TraumaGuard can be used interchangeably with the gold standard for measuring continuous IAP, even in an empty artificial bladder. Confirmation studies with the TraumaGuard in animals and humans are warranted to further validate these findings.

Continuous passive paracentesis versus large-volume paracentesis in the prevention and treatment of intra-abdominal hypertension in the critically ill cirrhotic patient with ascites (COPPTRIAHL): study protocol for a randomized controlled trial

BACKGROUND

Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites.

METHODS

An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach.

DISCUSSION

This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04322201 . Registered on 20 December 2019.

Abdominal perfusion pressure in critically ill cirrhotic patients: a prospective observational study

In critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1-3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46-15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20-4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29-3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04-1.16, p < 0.001) and SAPS II score (aOR 1.07, CI 95% 1.03-1.11, p = 0.001). There was a high prevalence of AhP in critical cirrhotic patients. Abdominal hypoperfusion was independently associated with higher ACLF grade and baseline paracentesis. Risk factors for 28-day mortality included clinical severity and total bilirubin. The prevention and treatment of AhP in the high-risk cirrhotic patient is prudential.

Impact of Obesity on Clinical Outcomes of Patients with Intra-Abdominal Hypertension and Abdominal Compartment Syndrome

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with high morbidity and mortality. Obesity may result in increased intra-abdominal pressure (IAP) and affect clinical outcomes of patients with IAH and/or ACS. This study aims to establish the impact of obesity on the clinical outcomes of IAH and ACS patients. A systematic search of Medline, Embase, and Scopus was performed in August 2022. Nine studies comprising 9938 patients were included. There were 65.1% males (n = 6250/9596). Patient demographics, comorbidities, and morbidities were analyzed in correlation with obesity and IAP. Obese patients had a higher risk of IAH (OR 8.5, p < 0.001). Obesity was associated with the need for renal replacement therapy, intensive care unit-acquired infections, systemic inflammatory response syndrome, acute respiratory distress syndrome, length of hospital stay, and mortality. This review highlights the lacunae in the existing literature to underpin the direct impact of obesity, independent of obesity-associated comorbidities, on the clinical outcomes of IAH and ACS.

Intra-abdominal pressure during and after cardiac surgery: a single-centre prospective cohort study

PURPOSE

While intra-abdominal hypertension (IAH) has been associated with adverse outcomes in multiple settings, the epidemiology and clinical implications of IAH in the context of cardiac surgery are less known. In this study, we aimed to describe the prevalence of IAH in patients undergoing cardiac surgery and determine its association with patient characteristics and postoperative outcomes.

METHODS

We conducted a single-centre prospective cohort study in which intra-abdominal pressure was measured in the operating room after general anesthesia (T1), after the surgical procedure (T2), and two hours after intensive care unit (ICU) admission (T3) in a subset of patients. Intra-abdominal hypertension was defined as intra-abdominal pressure (IAP) ≥ 12 mm Hg. Postoperative outcomes included death, acute kidney injury (AKI), and length of stay in the ICU and hospital.

RESULTS

A total of 513 IAP measurements were obtained from 191 participants in the operating room and 131 participants in the ICU. Intra-abdominal hypertension was present in 105/191 (55%) at T1, 115/191 (60%) at T2, and 31/131 (24%) at T3. Intra-abdominal pressure was independently associated with body mass index, central venous pressure, and mean pulmonary artery pressure but was not associated with cumulative fluid balance. Intraoperative IAH was not associated with adverse outcomes including AKI.

CONCLUSIONS

Intra-abdominal hypertension is very common during cardiac surgery but its clinical implications are uncertain.

Intra-abdominal hypertension and abdominal compartment syndrome in the critically ill liver cirrhotic patient-prevalence and clinical outcomes. A multicentric retrospective cohort study in intensive care

Background

Liver cirrhosis and ascites are risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); however, data is scarce. We aimed to determine the prevalence of IAH/ACS in a population of critically ill cirrhotic patients with acute medical illness in intensive care and to assess for risk factors and clinical outcomes.

Methods

This was a multicentric retrospective cohort study including two general ICUs and pooled data from a multicentric study between January 2009 and October 2019.

Results

A total of 9,345 patients were screened, and 95 were included in the analysis. Mean age was 56.7±1.3 years, and 79% were male. Liver cirrhosis etiology included alcohol in 45.3% and alcohol plus hepatitis C virus in 9.5%. Precipitating events included infection in 26% and bleeding in 21% of cases. Mean severity score MELD and SAPS II were 26.2±9.9 and 48.5±15.3, respectively, at ICU admission. The prevalence of IAH and ACS was respectively 82.1% and 23.2% with a mean value of maximum IAP of 16.0±5.7 mmHg and IAH grades: absent 17.9%, I 26.3%, II 33.7%, III 17.9%, and IV 4.2%. Independent risk factors for IAH were alcoholic cirrhosis (p = 0.01), West-Haven score (p = 0.01), and PaO2/FiO2 ratio (p = 0.02); as well as infection (p = 0.048) for ACS. Overall, 28-day mortality was 52.6% associated with higher IAP and ACS, and independent risk factors were MELD (p = 0.001), white blood cell count (p = 0.03), PaO2/FiO2 ratio (p = 0.03), and lactate concentration (p = 0.04) at ICU admission.

Conclusions

This study demonstrates a very high prevalence of IAH/ACS in the critically ill cirrhotic patient in intensive care. Increased IAP and ACS were associated with severity of disease and adverse outcomes and independent risk factors for IAH were alcoholic cirrhosis, hepatic encephalopathy and PO2/FiO2 ratio, as well as infection for ACS. Early diagnosis, prevention, and treatment of IAH/ACS might improve outcome in critically ill cirrhotic patients.

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

The prevalence, incidence and mortality associated with intra-abdominal hypertension among patients in intensive care units of a low-income country: a cohort study

Background: Intra-abdominal hypertension (IAH) is sustained increase in intra-abdominal pressure (IAP) ≥12 mmHg in adults and ≥10 mmHg in children. IAH has been noted to be associated with increased morbidity and mortality among critically ill patients. Measurement of IAP is common among at risk patients in the developed world. However, it has not received due attention in the majority of intensive care units (ICUs) in low-income countries, Uganda being one of these. This is evidenced by paucity of data and lack of protocols from the Ugandan Ministry of Health. This multi-center study was thus conducted to assess the prevalence, incidence and mortality associated with IAH among patients admitted to Ugandan ICUs.Methods:A multi-center prospective cohort study was conducted from September 2017 to February 2018 at three ICUs in Uganda. We consecutively enrolled 126 patients into the study. IAP was measured using the Harrahil manometer technique. Categorical variables were analyzed using the Chi square test and continuous variables analyzed using the t-test and Man Whitney test. The prevalence and incidence were determined using proportions and mortality was determined using survival analysis.Results:The median age was 33 years (26-48.5) for the patients without IAH and 42 years (29-55) for those with IAH. The majority of the patients were male and 9.6% of the patients were below 18 years. The prevalence of IAH was 62.7 (CI 54.1-71.3), whereas the 24 hour and 72 hour incidence of IAH was 9.3% (CI 1.3-17.2) and 14.3 % (CI 4.1-24.4), respectively.  Mortality was higher in patients with IAH compared to those without (p-value 0.003 and 0.028, mean and maximum IAP, respectively). Conclusion:We found a high prevalence and incidence of IAH among critically ill patients, associated with a high mortality. Routine screening for IAH can preempt management strategies to mitigate this.

Effect of 2 Enteral Feeding Schedules on Intra-abdominal Pressure in Patients Receiving Mechanical Ventilation: A Randomized Controlled Trial

BACKGROUND

Elevated intra-abdominal pressure is associated with morbidity in critically ill patients. Enteral feeding is important for these patients but may cause complications.

OBJECTIVE

To compare the effects of 2 intermittent feeding schedules on intra-abdominal pressure in patients receiving mechanical ventilation.

METHODS

A single-blinded, prospective, parallel-group, randomized controlled trial was conducted in an intensive care unit in a teaching hospital in Egypt. Fifty adult patients requiring more than 48 hours of mechanical ventilation were enrolled. Patients were randomly sorted into 2 study groups. The intervention group received intermittent enteral feedings 5 times daily at 4-hour intervals. The control group received intermittent enteral feedings 10 times daily at 2-hour intervals. Both groups fasted for 8 hours overnight. Intra-abdominal pressure was measured 7 times: at admission and before and after the first 3 feedings on the third day of the intensive care unit stay.

RESULTS

One-way repeated-measures analysis of variance showed that mean intra-abdominal pressure was higher in the control group before the first feeding (t = 2.27, P = .03) but was higher in the intervention group after the second feeding (t = 2.51, P = .02) and after the third feeding (t = 2.41, P = .02). Vomiting and diarrhea were not significantly different between the groups. More constipation and abdominal distension occurred in the intervention group than in the control group.

CONCLUSION

Intra-abdominal pressure was not significantly affected by feeding interval. However, reducing the time interval between intermittent enteral feedings may minimize the risk for constipation and abdominal distension.

Preventing kidney injury by avoiding fluid overload in patients with sepsis

The global epidemiologic burden of sepsis is difficult to ascertain. Sepsis affects more than 31.5 million people worldwide every year, potentially resulting in 5 million deaths. Up to one-third of patients with sepsis also develop sepsis-associated acute kidney injury. This article describes the need for restraint in fluid resuscitation in patients with sepsis, in order to mitigate end-organ damage and ultimately to save lives.

A Clinician's Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Incidence of Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: A Systematic Review

OBJECTIVE

To determine the contemporary prevalence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome in critically ill patients.

DATA SOURCES

Medline, Embase, and Central databases.

STUDY SELECTION

Studies reporting on the prevalence of IAH in consecutively admitted critically ill patients using the World Society of Abdominal Compartment Syndrome (WSACS) consensus guidelines for intra-abdominal pressure (IAP) measurement.

DATA EXTRACTION

Duplicate independent review and data abstraction.

DATA SYNTHESIS

The search identified 2428 titles with 6 eligible studies (n = 1965). Reported prevalence ranged from 30% to 49%. Despite abiding by the WSACS guidelines for IAP measurement, studies varied in their definition of IAH, frequency and duration of IAP measurement, and reporting of outcomes. Three of 6 studies reported that IAH, especially at higher grades, was an independent predictor of mortality.

CONCLUSIONS

Intra-abdominal hypertension is a common finding in critically ill patients and may be associated with increased mortality, especially at higher grades. Further prospective research is required to examine the effect of screening and treatment of IAH on patient outcomes.

Abdominal compartment syndrome and intra-abdominal hypertension in critically ill patients: diagnostic value of computed tomography

AIMS

The aims of the present work were to reevaluate, prospectively, the diagnostic value of already-described computed tomography (CT) landmarks of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) and to study the diagnostic value of some undescribed CT signs for the diagnosis of IAH and ACS.

MATERIALS AND METHODS

Consecutive patients admitted to the intensive care unit (ICU) in shock for whom an abdominal CT was clinically indicated were included. CT examinations were reviewed and scored by two reviewers for the 12 proposed CT features of IAH and ACS. Intravesical pressure (IVP) was measured for each patient. Imaging features and clinical data of patients with IAH (IVP ≥ 12 mmHg) were compared to those of patients with normal intra-abdominal pressure (IVP < 12 mmHg).

RESULTS

Forty-one patients were included. Twenty-one patients (51%) presented IAH with an IVP value ≥ 12 mmHg. Four patients (10%) were considered to have ACS (10%). Only an increased peritoneal-to-abdominal height ratio (PAR) was associated with the presence of IAH (PAR = 0.45 [0.40-0.49] in patients with IVP < 12 mmHg and PAR = 0.52 [0.48-0.53] in patients with IVP ≥ 12 mmHg; p < 0.001). Increased PAR ≥ 0.52 had a specificity of 85% for IAH diagnosis.

CONCLUSION

The present study suggests that a PAR ≥ 0.52 could help radiologists to identify IAH on abdominal CT scan and could lead to adequate identification and/or treatment, even at early stages of IAH.

KEY POINTS

• CT is an efficient first-intention procedure to evaluate and follow up underlying conditions in critically ill patients at risk of IAH and ACS overcome. • Raising the possibility of an IAH on a CT examination is relevant information for the clinician. • The only factors associated with intra-abdominal hypertension were the peritoneal-to-abdominal height ratio (PAR) and the ratio of maximal anteroposterior to transverse abdominal diameter (which define the round belly sign when > 0.8).

Comparison of pressure-regulated volume control ventilation and pressure control ventilation in patients with abdominal compartment syndrome

Mechanical ventilation support is commonly required in abdominal compartment syndrome (ACS). In the present study, pressure-regulated volume control ventilation (PRVCV) was compared to pressure control ventilation (PCV) in patients with ACS. The prospective study included 40 patients with ACS who were randomized into the PCV or PRVCV groups and subjected to the different modes of ventilation. After 6 h of ventilation, arterial blood gas, respiratory mechanics and hemodynamics parameters, as well as the intra-abdominal pressure (IAP) and Sequential Organ Failure Assessment (SOFA) scores were calculated. Compared to the PCV mode, mechanical ventilation with PRVCV lead to a significant decrease in the partial pressure of carbon dioxide, the peak inspiratory pressure, the mean inspiratory pressure, the central venous pressure, the heart rate and the extravascular lung water index. In addition, a marked improvement in pH, partial pressure of oxygen, oxygenation index and pulmonary static compliance was noted. However, no significant differences in airway resistance, mean arterial pressure, or IAP and SOFA scores were obtained. In conclusion, the PRVCV mode is better than the PCV mode in ventilation patients with ACS, and should therefore be used as a lung protective strategy. The present study was registered at Chictr.org (no. ChiCTR1800016869).

The Duration of Intra-abdominal Hypertension and Increased Serum Lactate Level are Important Prognostic Markers in Critically Ill Surgical Patient's Outcome: A Prospective, Observational Study

Aim:

The present study analyzed the clinical significance of duration of intra-abdominal hypertension (IAH) associated with increased serum lactate in critically ill patients with severe sepsis.

Materials and Methods:

Our study was an observational, prospective study carried out in the Surgical Intensive Care Unit (ICU) at J.L.N Medical College, Ajmer, Rajasthan, India. In our study, we included a total of 100 patients and intra-abdominal pressure (IAP) was measured through intravesical route at the time of admission and after 6, 12, 24, 48, and 72 h via a urinary catheter filled with 25 ml of saline. Duration of ICU and hospital stay, need for ventilator support, initiation of enteral feeding, serum lactate level at time of admission and after 48 h, and 30-day mortality were noted as outcomes.

Results:

In our study, an overall incidence of IAH was 60%. Patients with cardiovascular surgery and renal and pulmonary dysfunction were 93.3%, 55%, and 60%, respectively, at the time of admission and 65%, 10%, and 10%, respectively, after 72 h of admission in the surgical ICU. Nonsurvivors had statistically significant higher IAP and serum lactate levels than survivors. Patients with longer duration of IAH had longer ICU and hospital stay, longer duration of vasopressors and ventilator support, and delayed enteral feeding.

Conclusion:

There is a strong relationship “risk accumulation” between duration of IAH associated with increased serum lactate and organ dysfunction. The duration of IAH was an independent predictor of 30-day mortality. Early recognition and prompt intervention for IAH and severe sepsis are essential to improve the patient outcomes.

Acute abdominal compartment syndrome: current diagnostic and therapeutic options

BACKGROUND

If untreated, the abdominal compartment syndrome (ACS) has a mortality of nearly 100 %. Thus, its early recognition is of major importance for daily rounds on surgical intensive care units. Intraabdominal hypertension (IAH) is a poorly recognized entity, which occurs if intraabdominal pressure arises >12 mmHg. Measurement of the intravesical pressure is the gold standard to diagnose IAH, which can be detected in about one fourth of surgical intensive care patients.

PURPOSE

The aim of this manuscript is to outline the current diagnostic and therapeutic options for IAH and ACS. While diagnosis of IAH and ACS strongly depends on clinical experience, new diagnostic markers could play an important role in the future. Therapy of IAH/ACS consists of five treatment "columns": intraluminal evacuation, intraabdominal evacuation, improvement of abdominal wall compliance, fluid management, and improved organ perfusion. If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. Thereafter, patients with an open abdomen require intensive care and are permanently threatened by the quadrangle of fluid loss, muscle proteolysis, heat loss, and an impaired immune function. As a consequence, complication rate dramatically increases after 8 days of open abdomen therapy.

CONCLUSION

Despite many efforts, the mortality of patients with ACS remains unacceptably high. Permanent clinical education and surgical trials will be necessary to improve the outcome of our critically ill surgical patients.