Intra-abdominal Hypertension and Abdominal Compartment Syndrome

Estimation of Physiologic Pressures: Invasive and Non-Invasive Techniques, AI Models, and Future Perspectives

The measurement of physiologic pressure helps diagnose and prevent associated health complications. From typical conventional methods to more complicated modalities, such as the estimation of intracranial pressures, numerous invasive and noninvasive tools that provide us with insight into daily physiology and aid in understanding pathology are within our grasp. Currently, our standards for estimating vital pressures, including continuous BP measurements, pulmonary capillary wedge pressures, and hepatic portal gradients, involve the use of invasive modalities. As an emerging field in medical technology, artificial intelligence (AI) has been incorporated into analyzing and predicting patterns of physiologic pressures. AI has been used to construct models that have clinical applicability both in hospital settings and at-home settings for ease of use for patients. Studies applying AI to each of these compartmental pressures were searched and shortlisted for thorough assessment and review. There are several AI-based innovations in noninvasive blood pressure estimation based on imaging, auscultation, oscillometry and wearable technology employing biosignals. The purpose of this review is to provide an in-depth assessment of the involved physiologies, prevailing methodologies and emerging technologies incorporating AI in clinical practice for each type of compartmental pressure measurement. We also bring to the forefront AI-based noninvasive estimation techniques for physiologic pressure based on microwave systems that have promising potential for clinical practice.

Interrelationship between endotoxicosis and syndrome of intraabdominal hypertension in pathogenesis of abdominal sepsis

Objective. Studying of mutual role of the main pathogenetic factors of abdominal sepsis – the inflammation origin and intraabdominal hypertension, from the one side, endotoxicosis and the abdominal compression syndrome (ACS), from the other side. Materials and methods. Into the investigation 196 patients with abdominal sepsis were included, in whom after the certain preliminary preparation the operative procedure was done. The levels of neutrophils, macrophages, interleukin–6, interleukin–10 in peritoneal exudate were studied as indices of the inflammation source for abdominal cavity. These indices were characteristic for systemic answer on general reaction, the degree of which have determined the abdominal sepsis course and result. Determination of intraabdominal pressure was applied for estimation the intraabdominal hypertension role in abdominal sepsis. Results. The ratio of the endotoxicosis and the ACS indices in the complications structure, not dependent on some differences due to the complication type present, was practically similar. Conclusion. The results of the investigation conducted, witnesses the presence of interrelationship of roles of endotoxicosis and the abdominal compression syndrome in pathogenesis of abdominal sepsis, their indices changes are characterized by mutual activity strengthening, accompanied by clinical manifestations of the organs dysfunction, determining the severity of course and result of pathological process in the organism.

Intra-Abdominal Pressure Measurement Devices: A Technologic Analysis

PURPOSE

The purpose of this Technologic Analysis is to review devices designed to measure intra-abdominal pressure (IAP); these devices are used to detect intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).

APPROACH

Published literature focusing on devices designed to measure IAP was reviewed, comparing the options available and outlining recommendations for appropriate use. Safety information regarding IAP measurement devices was derived from the Manufacturer and User Facility Device Experience (MAUDE) database.

CONCLUSIONS

Intra-abdominal hypertension is prevalent among critically ill patients of all ages and is linked to adverse consequences, such as abdominal compartment syndrome. The condition is often unrecognized due to the lack of overt clinical symptoms, supporting the need for devices to accurately measure IAP. Commercially available devices measure IAP indirectly, typically via the bladder or stomach. Additional research is needed to demonstrate the benefits of routine screening, further define risk factors for IAH/ACS development, and evaluate the impact of measures to reduce IAP in an effort to improve patient outcomes.

Role of intra-abdominal pressure in the outcomes of perforation peritonitis: A prospective observational study

OBJECTIVES

Intra-abdominal pressure (IAP) has been investigated for its role in causing morbidity and mortality, with various studies showing different degrees of correlation. There remains paucity of literature on this subject, applied to patients of perforation peritonitis, especially in the Indian subcontinent.

MATERIAL AND METHODS

It is a prospective observational study involving 40 patients of perforation peritonitis undergoing exploratory laparotomy. IAP was measured as per WSACS (World Society of Abdominal Compartment Syndrome) guidelines. APACHE II (Acute Physiology And Chronic Health Evaluation- II) and SOFA (Sequential Organ Failure Assessment) were calculated. Data was collected regarding occurrence of prolonged ileus, burst abdomen, duration of hospital stay, 30 day mortality, and was statistically analyzed to correlate with IAP.

RESULTS

At admission, mean IAP was 13.37 mmHg, and the incidence of IAH was 65%. IAH was seen in 17.9% and 7.6% at 24 h and 48 h post-operatively. Incidence of prolonged ileus and burst abdomen were 7.7% and 22.5% respectively. Mortality rate was 17.5%. Mean duration of hospital stay was 13.45 days. Post-operative IAP correlated with mortality (p: 0.014) and post-operative SOFA score (p <0.05). Statistically significant correlation was also seen with the occurrence of prolonged ileus (p: 0.006). IAP did not significantly correlate with APACHE II score, occurrence of burst abdomen, and duration of hospital stay.

CONCLUSION

Rise in IAP correlates with deterioration of SOFA score, and also with the occurrence of prolonged ileus. IAP is also a predictor of mortality. IAP measured post-operatively (24 and 48 hours) had a better correlation with these outcomes than the value measured at admission. No statistically significant correlation of IAP with the occurrence of burst abdomen and duration of hospital stay could be found, which warrants further studies with a larger population.

The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal

Intra-abdominal pressure (IAP) is a physiological parameter that has gained considerable attention during the last few decades. The incidence of complications arising from increased IAP, known as intra-abdominal hypertension (IAH) or abdominal compartment syndrome in critically ill patients, is high and its impact is significant. The effects of IAP in neurological conditions and during surgical procedures are largely unexplored. IAP also appears to be relevant during neurosurgical procedures (spine and brain) in the prone position, and in selected cases, IAH may affect cerebrospinal fluid drainage after a ventriculoperitoneal shunt operation. Furthermore, raised IAP is one of the contributors to intracranial hypertension in patients with morbid obesity. In traumatic brain injury, case reports described how abdominal decompression lowers intracerebral pressure. The anatomical substrate for transmission of the IAP to the brain and venous system of the spine is the extradural neural axis compartment; the first reports of this phenomenon can be found in anatomical studies of the sixteenth century. In this review, we summarize the available knowledge on how IAP impacts the cerebrospinal venous system and the jugular venous system via two pathways, and we discuss the implications for neurosurgical procedures as well as the relevance of IAH in neurological disorders.

MI: Not a Heart Attack but a Gut Attack

Mesenteric ischemia and infarction are infrequent but often deadly conditions in acute and critically ill patients. Mesenteric ischemia may be a primary admission diagnosis or may develop secondary to another diagnosis. Having a high index of suspicion for patients at risk of mesenteric ischemia and mesenteric infarction can alter a poor outcome. This article reviews the pathophysiology, risk factors, assessment, medical and nursing diagnoses, as well as collaborative management for mesenteric ischemia. Early identification of patients at risk and the appropriate diagnostic testing are stressed. Nurses armed with the knowledge of this condition are better able to provide safe care to their patients.

Intraperitoneal hypertension, a novel risk factor for sepsis-associated encephalopathy in sepsis mice

Sepsis associated encephalopathy (SAE), appears often indicates the deterioration of the sepsis disease and which have high risk of death. Although several mechanism and hypotheses have been proposed and studied, there is no breakthrough in the treatment of SAE. We performed a systematic research to evaluate the effect of intraperitoneal pressure on SAE. A mice model of sepsis was established by intraperitoneal injection of endotoxin. A total of 48 female BALB/c mouse (30 days old) were randomly divided into a control group (n = 12) and an injection of endotoxin referred to bacterial lipopolysaccharide (LPS) group (n = 12). Intraperitoneal hypertension (IAH) referred to IAH group (n = 12), and LPS + IAH group (n = 12). Following sepsis induction, diagnosis, the brains were analyzed for both function and ultrastructural morphology.We determined that IAH exacerbated sepsis induces sepsis-associated encephalopathy when examining low score of neurological function and more delta wave in EEG, increased neuronal edema in LPS + IAH group, as well as an escalation of Bax and Cleaved-caspase-3, Cleaved-parp, and reduction of Bcl-2 and Mfsd2a in LPS + IAH group. Therefore, IAH can exacerbate and increase incident rate of sepsis-related encephalopathy in sepsis mice by promoting neuronal apoptosis and destruction of the blood-brain barrier.

Intestinal histopathological changes in a porcine model of pneumoperitoneum-induced intra-abdominal hypertension

BACKGROUND

Low splanchnic perfusion is an immediate effect of pneumoperitoneum-induced intra-abdominal hypertension (IAH). Anatomical structure results in the intestinal mucosa being the area most sensitive to hypoperfusion. The relationship between intestinal injury and clinical parameters of tissue perfusion [abdominal perfusion pressure (APP), gastric intramucosal pH (pH_i) and lactic acid (Lc)] has not been previously studied. This study aimed to monitorize intestinal pathogenesis through sequential ileal biopsies and to measure APP, pH_i, and Lc levels at different pneumoperitoneum-induced intra-abdominal pressures (20, 30, and 40 mmHg) to evaluate the potential relationships between them.

MATERIALS AND METHODS

Fifty pigs were divided into four groups; a control group (C) and three experimental groups with different pneumoperitoneum-induced levels [20 mmHg (G20), 30 mmHg (G30), and 40 mmHg (G40)], that were maintained for 3 and 5 h. APP, pH_i, and Lc were measured and ileal biopsies taken laparoscopically every 30 min. The mucosal damage was graded using the standardized Park's Score and animals were classified as injured (I+) or uninjured (I-).

RESULTS

Different histopathological lesions were observed in groups G20, G30, and G40 but no damage observed in group C. A 33.3% of animals in G20 and G30 were I+ after 3 h, while 93.3% were injured in G40. After 5 h, histopathological lesions were no longer seen in some animals in G20 and only 10% were I+. Conversely, in G30 I+ pigs increased to 80% while those in G40 remained at 93.3% I+. The I+ animals had significantly lower APP and pH_i than those I-. Lc was the clinical parameter that showed the earliest differences, with significantly higher figures in I+ animals.

CONCLUSIONS

The evolution of intestinal injuries from pneumoperitoneum-induced IAH depends on the degree of IAP. These damages may be associated with decreases in APP and pH_i, and increases in Lc.

Nursing Assessment of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in the Neonate

BACKGROUND

Abdominal compartment syndrome in the surgical neonate is a low-frequency, high-risk occurrence that if overlooked is often accompanied with long-term sequelae and sometimes death. The importance of early detection of signs and symptoms through expert nursing assessment cannot be overstated.

PURPOSE

To review the components of nursing assessment as it applies to detection of abdominal compartment syndrome in the surgical neonate and its relationship to the pathophysiology.

METHODS/SEARCH STRATEGY

Detailed search of the nursing and medical literature.

IMPLICATIONS FOR PRACTICE

The purpose of this article is to describe the onset of abdominal compartment syndrome in the neonate. Early detection of this low-frequency, high-risk occurrence hinges on expert nursing assessment. Complications of abdominal compartment syndrome in the neonate involve bowel perforation, short bowel syndrome, and sometimes death. Components of this expert nursing assessment and its relationship to the pathophysiology of compartment syndrome are presented.

Adaptive Immune Cell Dysregulation and Role in Acute Pancreatitis Disease Progression and Treatment

Acute pancreatitis (AP) is an inflammation of the pancreas caused by various stimuli including excessive alcohol consumption, gallstone disease and certain viral infections. Managing specifically the severe form of AP is limited due to lack of an understanding of the complex immune events that occur during AP involving immune cells and inflammatory molecules such as cytokines. The relative abundance of various immune cells resulting from the immune dysregulation drives disease progression. In this review, we examine the literature on the adaptive immune cells in AP, the prognostic value of these cells in stratifying patients into appropriate care and treatment strategies based on cell frequency in different AP severities are discussed.

Educating Nurses in the Intensive Care Unit About Gastrointestinal Complications: Using an Algorithm Embedded into Simulation

It can be a challenge to prepare intensive care unit (ICU) nurses to recognize and care for the complex needs of deteriorating patients, especially in patients with gastrointestinal (GI) complications, who often present with vague but serious issues. Tools such as the sequential organ failure assessment tool and the GI failure tool have been used to assist nurses in decision making. This article discusses how to incorporate such tools into an algorithm for simulation training for ICU nurses that integrates a clinical judgment model to shape care for patients with GI complications.

The cardio-respiratory effects of intra-abdominal hypertension: Considerations for critical care nursing practice

Intra-abdominal hypertension can be classified as either primary or secondary. Primary intra-abdominal hypertension is often associated through trauma or diseases of the abdominopelvic region such as pancreatitis or abdominal surgery, while secondary intra-abdominal hypertension is the result of extra-abdominal causes such as sepsis or burns. The critically ill patient offers some challenges in monitoring in particular secondary intra-abdominal hypertension because of the effects of fluid resuscitation, the use of inotropes and positive pressure ventilation. Recent work suggests that intensive care unit nurses are often unaware of the secondary effects of intra-abdominal pressure and therefore this is not monitored effectively. Therefore being aware of the cardio-respiratory effects may alert theintensive care nurse nurse to the development of intra-abdominal hypertension. The aim of this paper is to discuss the pathophysiology associated with the cardio-respiratory effects seen with intra-abdominal hypertension in the critically ill. In particular it will discuss how intra-abdominal hypertension can inadvertently be overlooked because of the low flow states that it produces which could be misconstrued as something else. It will also discuss how intra-abdominal hypertension impedes ventilation and respiratory mechanics which can often result in a non-cardiogenic pulmonary oedema. To close, the paper will offer some implications for critical care nursing practice.

Role of the Open Abdomen in Critically Ill Patients

An open abdomen is common used in critically ill patients to temporize permanent abdominal closure. The most common reason for leaving the abdomen open by reopening a laparotomy, not closing, or creating a fresh laparotomy is the abdominal compartment syndrome. The open abdomen technique is also used in damage control operations and intra-abdominal sepsis. Negative pressure wound therapy may be associated with better outcomes than other temporary abdominal closure techniques. The open abdomen is associated with many early and late complications, including infections, gastrointestinal fistulas, and ventral hernias. Clinicians should be vigilant regarding the development of these complications.

Practical Considerations in Sepsis Resuscitation

BACKGROUND

Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment.

OBJECTIVE

This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment.

DISCUSSION

Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario.

CONCLUSIONS

The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.

Postoperative Care of a Liver Transplant Recipient Using a Classification System: Type A (Stable) Versus Type B (Unstable)

Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B).

Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: An Underappreciated Cause of Acute Kidney Injury

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are increasingly recognized in both medical and surgical critically ill patients and are predictive of death and the development of acute kidney injury. Although there are many risk factors for the development of IAH, in the era of goal-directed therapy for shock, brisk volume resuscitation and volume overload are the most common contributors. Abdominal examination is an unreliable predictor of intra-abdominal pressure (IAP), but IAP can be easily measured in a reproducible and reliable manner by a number of simple bedside techniques. Prompt recognition and intervention to decrease IAP and improve vital organ perfusion are essential to minimize the negative effects of IAH on somatic and visceral organ functions.

Intra-abdominal pressure: an integrative review

There is a growing request for measuring intra-abdominal pressure in critically ill patients with acute abdominal pain to be clarified. Summarizing the research results on measurement of vesical intra-abdominal pressure and analyzing the level of evidence were the purposes of this integrative literature review, carried out based on the databases LILACS, MEDLINE and PubMed, from 2005 to July 2012. Twenty articles were identified, in that, 12 literature reviews, 4 descriptive and exploratory studies, 2 expert opinions, one prospective cohort study and one was an experience report. The vesical intra-abdominal pressure measurement was considered gold standard. There are variations in the technique however, but some common points were identified: complete supine position, in absence of abdominal contracture, in the end of expiration and expressed in mmHg. Most research results indicate keeping the transducer zeroed at the level of the mid-axillary line at the iliac crest level, and instill 25mL of sterile saline. Strong evidence must be developed.

Mechanical Intestinal Obstruction in a Porcine Model: Effects of Intra-Abdominal Hypertension. A Preliminary Study

INTRODUCTION

Mechanical intestinal obstruction is a disorder associated with intra-abdominal hypertension and abdominal compartment syndrome. As the large intestine intraluminal and intra-abdominal pressures are increased, so the patient's risk for intestinal ischaemia. Previous studies have focused on hypoperfusion and bacterial translocation without considering the concomitant effect of intra-abdominal hypertension. The objective of this study was to design and evaluate a mechanical intestinal obstruction model in pigs similar to the human pathophysiology.

MATERIALS AND METHODS

Fifteen pigs were divided into three groups: a control group (n = 5) and two groups of 5 pigs with intra-abdominal hypertension induced by mechanical intestinal obstruction. The intra-abdominal pressures of 20 mmHg were maintained for 2 and 5 hours respectively. Hemodynamic, respiratory and gastric intramucosal pH values, as well as blood tests were recorded every 30 min.

RESULTS

Significant differences between the control and mechanical intestinal obstruction groups were noted. The mean arterial pressure, cardiac index, dynamic pulmonary compliance and abdominal perfusion pressure decreased. The systemic vascular resistance index, central venous pressure, pulse pressure variation, airway resistance and lactate increased within 2 hours from starting intra-abdominal hypertension (p<0.05). In addition, we observed increased values for the peak and plateau airway pressures, and low values of gastric intramucosal pH in the mechanical intestinal obstruction groups that were significant after 3 hours.

CONCLUSION

The mechanical intestinal obstruction model appears to adequately simulate the pathophysiology of intestinal obstruction that occurs in humans. Monitoring abdominal perfusion pressure, dynamic pulmonary compliance, gastric intramucosal pH and lactate values may provide insight in predicting the effects on endorgan function in patients with mechanical intestinal obstruction.

Damage Control and the Open Abdomen: Challenges for the Nonsurgical Intensivist

BACKGROUND

As strategies in acute care surgery focus on damage control to restore physiology, intensivists spanning all disciplines care for an increasing number of patients requiring massive transfusion, temporary abdominal closures, and their sequelae.

OBJECTIVE

To equip the nonsurgical intensivist with evidence-based management principles for patients with an open abdomen after damage control surgery.

DATA SOURCE

Search of PubMed database and manual review of bibliographies from selected articles.

DATA SYNTHESIS AND CONCLUSIONS

Temporary abdominal closure improves outcomes in patients with abdominal compartment syndrome, hemorrhagic shock, and intra-abdominal sepsis but creates new challenges with electrolyte derangement, hypovolemia, malnutrition, enteric fistulas, and loss of abdominal wall domain. Intensive care of such patients mandates attention to resuscitation, sepsis control, and expedient abdominal closure.

The wicked question answered: positive deviance delivers patient-centered care

BACKGROUND

How nurses respond when faced with the dilemma of providing patient-centered care in the absence of patient-centered practice guidelines remains relatively unreported. Standards may not be available to guide nurses or may not be realistic for implementation at the point of care. Nurses may be forced to react creatively to meet the needs of their patients.

OBJECTIVES

The purpose was to understand nursing care when standard practice guidelines did not meet patient-specific care needs and to develop various viewpoints related to the use of positive deviance in providing patient-centered care.

METHODS

Complexity theory and the framework of a wicked question were used to guide a 3-round online national Delphi study from November 2011 to February 2012. The panel was accessed through the American Association of Critical Care Nurses to expose the care provided when standard practice guidelines were lacking.

RESULTS

Findings support the presence of positive deviance and expose care provided by nurses when standard practice guidelines lacked the ability to provide patient-centered care. Dominant themes of positive deviance are recommended as priorities for future research.

DISCUSSION

Better guidelines are needed that work for nurses, instead of against them, that would not force a nurse into actions that are not patient centered. Guidelines should guide practice and assist in allowing nurses to provide care that is centered on the best needs of the patient in the specific care situation.

Intra-abdominal hypertension does not predict renal recovery or in-hospital mortality in critically ill patients with acute kidney injury

BACKGROUND

Although emerging evidence suggests that intra-abdominal hypertension (IAH) is a predictor of the development of acute kidney injury (AKI), it remains unclear whether the presence of IAH is a predictor of prognosis in patients with AKI. The purpose of this study was to assess whether the presence of IAH could predict prognosis in critically ill patients with AKI. The prognostic value of urinary biomarkers was also determined.

METHODS

In this prospective observational study, we enrolled 57 patients with established AKI, who were admitted to the intensive care unit between February 2012 and June 2014. IAH was defined as a sustained elevation in intra-abdominal pressure of ≥12 mmHg, in three consecutive measurements performed daily on the first 3 days. Urinary neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid-binding protein, and simplified acute physiology score II score at the time of admission were also examined.

RESULTS

IAH was observed in 78.9% of patients. The in-hospital mortality was 21.1%, and renal recovery during hospitalization was achieved in 40.4% of patients. Although high urinary NGAL [odds ratio (OR), 1.015] and liver-type fatty acid-binding protein (OR, 1.003) were found to be independent predictors of renal recovery, IAH was not. High urinary NGAL (OR, 1.003) and a high simplified acute physiology score II score (OR, 1.102) were independent predictors of in-hospital mortality, while IAH or urinary liver-type fatty acid-binding protein was not.

CONCLUSION

Although IAH is prevalent in critically ill patients with AKI, it did not predict AKI prognosis. However, urinary NGAL was found to be a useful predictor of both renal recovery and in-hospital mortality.

Controlled peritoneal drainage improves survival in children with abdominal compartment syndrome

BACKGROUND

Children with massive ascites can develop abdominal compartment syndrome (ACS), which has been identified as an independent risk factor for mortality.

OBJECTIVES

The objective of this study was to assess the effectiveness of volume-controlled percutaneous catheter drainage (PCD) for treating children with massive ascites and ACS.

METHODS

A retrospective descriptive study was conducted; Comprising 12patients with ACS with massive ascites treated with volume-controlled PCD in a pediatric intensive care unitof a university hospital in southern China from April 2011 to June 2013.

RESULTS

The etiology of ascites in these children included abdominal tumor (8/12), capillary leak after liver or kidney transplantation (2/12) and urine leakage (2/12). Intra-abdominal hypertension was closely associated with multiple organ dysfunction and high mortality. Digestive and pulmonary functions were the most frequently affected by ACS, while the cerebrum was the least involved. Treatment with ultrasound-guided PCD significantly decreased intra-abdominal pressure, abdominal circumference, and indices of organ dysfunction. PCD treatment also significantly improved glomerular filtration rate and PaO2/FiO2. Complications of PCD included abdominal infection (1/12) and electrolyte imbalance (4/12). The mortality rate of patients treated with PCD was 25%, which was lower than previous reports.

CONCLUSIONS

Controlled peritoneal drainage is a minimally invasive and safe decompression method that is effective in patients with ACS, and should be considered in children with massive ascites.

The potential participation of abdominal pressure in preeclampsia

Preeclampsia is a major cause of maternal and perinatal mortality and morbidity. Regardless of susceptibility or predisposing conditions and risk factors, the degree of increase in abdominal pressure is directly related to the severity of preeclampsia, particularly in women with hydatidiform mole. When increased abdominal pressure is normalized by delivery, preeclampsia is cured. Recent genetic studies highlighted two leading risk factors for preeclampsia: chronic renal disease and T235 homozygosity for the AGT gene. Thus, while there is increased abdominal pressure in pregnancy, an imbalanced renin angiotensin system and renal injuries lead to a vicious cycle of increasing abdominal pressure and further renal injuries. A hypothesis for the potential participation of pressure in preeclampsia is described and the amelioration of preeclampsia through postural intervention and the possible therapeutic effect of angiotensin is suggested.

Nursing challenges with a severely injured patient in critical care

BACKGROUND

Patients with severe, multiple, traumatic injuries are challenging to manage in critical care. Early identification of injuries and optimal resuscitation is essential for favourable outcomes. Trauma-related haemorrhage can lead to the lethal triad of hypothermia, coagulopathy and acidosis. Many trauma patients require urgent haemorrhage control and structural fixation through operative intervention. However, metabolic derangement and cardiovascular instability may delay surgery, resulting in an ongoing cycle of deterioration. Damage control surgery (DCS) may be used as a temporizing measure until the patient is stabilized in critical care. The aim of this case study is to discuss the complex issues faced in the critical care management of a severely injured patient.

DESIGN

We conducted a patient case study, with analysis of care using published evidence. The key terms used to search for evidence were trauma, injury, damage control surgery, spinal fixation, critical/intensive care and nurse.

RESULTS

We report the care of a trauma patient with complex, conflicting injuries requiring management of the lethal triad and DCS. The delay in subsequent definitive repair of spinal column fractures provided many challenges for critical care nurses including restricted patient mobilization, positioning and pressure ulcer prevention. A review of contemporary evidence relating to DCS reveals that whilst this technique is used increasingly in trauma, the research focuses on single system injuries.

CONCLUSION

Evidence and guidelines are required to support DCS for critical care patients with multiple, conflicting injuries including spinal fractures. For patients with delayed surgical intervention, rotational bed therapy may assist critical care nurses in meeting needs.