The Correlation of Intraabdominal Pressure With Renal Resistive Index

BACKGROUND

To evaluate the correlation between intraabdominal pressure (IAP) measured via the bladder and renal resistive index (RRI) measured by Doppler ultrasonography (USG).

METHODS

Eighty consecutive surgical patients were included into this study. Before Doppler USG evaluation, IAP was measured by a Foley catheter via the bladder. The left and right RRI, the diameters of the inferior vena cava and portal vein were measured by colored Doppler USG. Spearman correlation analysis was used to evaluate the correlation between different measurements. Intraabdominal hypertension (IAH) was defined as of IAP ≥ 12 mmHg. Significantly different variables from the univariate analysis between patients with and without IAH were entered into backward stepwise binary logistic regression analysis of IAH as the dependent variable. P values < 0.05 were accepted as statistically significant.

RESULTS

In total, 80 patients were included into study. In 27 patients (34%) IAP was normal and in 53 patients (66%) IAH was diagnosed. The Spearman correlation analysis of IAP and the ultrasonographic measurements revealed a strong correlation between RRI and IAP (P < 0.001). Patients with IAH were more likely to be diabetic and had abdominal incisional hernia compared with patients with normal IAP (P < 0.05). The results of the multivariate logistic regression analysis revealed right RRI as the only independent predictor of IAH (B: 57.04, S. E.: 13.7, P < 0.001).

CONCLUSIONS

There is a strong correlation between IAP and RRI. RRI can be an alternative, noninvasive technique for the diagnosis and follow-up of IAH after further evaluations in different patient groups.

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.

Low intra-abdominal pressure and deep neuromuscular blockade laparoscopic surgery and surgical space conditions: A meta-analysis

BACKGROUND

Low intra-abdominal pressure (IAP) and deep neuromuscular blockade (NMB) are frequently used in laparoscopic abdominal surgery to improve surgical space conditions and decrease postoperative pain. The evidence supporting operations using low IAP and deep NMB is open to debate.

METHODS

The feasibility of the routine use of low IAP +deep NMB during laparoscopic surgery was examined. A meta-analysis is conducted with randomized controlled trials (RCTs) to compare the influence of low IAP + deep NMB vs. low IAP + moderate NMB, standard IAP +deep NMB, and standard IAP + moderate NMB during laparoscopic procedures on surgical space conditions, the duration of surgery and postoperative pain. RCTs were identified using the Cochrane, Embase, PubMed, and Web of Science databases from initiation to June 2019. Our search identified 9 eligible studies on the use of low IAP + deep NMB and surgical space conditions.

RESULTS

Low IAP + deep NMB during laparoscopic surgery did not improve the surgical space conditions when compared with the use of moderate NMB, with a mean difference (MD) of -0.09 (95% confidence interval (CI): -0.55-0.37). Subgroup analyses showed improved surgical space conditions with the use of low IAP + deep NMB compared with low IAP + moderate NMB, (MD = 0.63 [95% CI:0.06-1.19]), and slightly worse conditions compared with the use of standard IAP + deep NMB and standard IAP + moderate NMB, with MDs of -1.13(95% CI:-1.47 to 0.79) and -0.87(95% CI:-1.30 to 0.43), respectively. The duration of surgery did not improve with low IAP + deep NMB, (MD = 1.72 [95% CI: -1.69 to 5.14]), and no significant reduction in early postoperative pain was found in the deep-NMB group (MD = -0.14 [95% CI: -0.51 to 0.23]).

CONCLUSION

Low IAP +deep NMB is not significantly more effective than other IAP +NMB combinations for optimizing surgical space conditions, duration of surgery, or postoperative pain in this meta-analysis. Whether the use of low IAP + deep NMB results in fewer intraoperative complications, enhanced quality of recovery or both after laparoscopic surgery should be studied in the future.

Difference in Visceral Adipose Tissue in Pregnancy and Postpartum and Related Changes in Maternal Insulin Resistance

OBJECTIVE

To measure the difference between first-trimester and postpartum visceral adipose tissue (VAT), the agreement of this difference with change in body mass index, and whether a difference in VAT is associated with insulin resistance or glucose mishandling.

METHODS

Prospective study of 93 women with singleton pregnancies without a history of diabetes. Visceral adipose tissue depth was sonographically assessed at 11 to 14 weeks and at 6 to 12 weeks postpartum. Metabolic measures, sampled at 24 to 28 weeks and 6 to 12 weeks postpartum, included homeostatic model assessment of insulin resistance, insulin sensitivity index composite, and area under the 75-g oral glucose tolerance test curve.

RESULTS

First-trimester VAT depth explained only 37% (95% confidence interval [CI], 22-52) of the variation in postpartum VAT depth. There was limited agreement between the net change in postpartum minus first-trimester VAT depth and that same net change for body mass index (Cohen's kappa, 0.26; 95% CI, 0.05-0.47). Those with a net gain in VAT depth demonstrated poorer insulin sensitivity index postpartum than women with a net regression in VAT depth-a difference of -2.0 (95% CI, -3.3 to -0.69).

CONCLUSION

Sonographic assessment of postpartum VAT is feasible and may provide insight to metabolic changes between pregnancy and postpartum, beyond body mass index.

Improvised Laparostomy Pack to Manage Laparostomy for Injuries due to Improvised Explosive Devices (IEDs)

Splinters of improvised explosive devices [IEDs] cause multiple intestinal perforations and random pattern visceral injuries causing contamination of peritoneal cavity. This necessitates multiple peritoneal toilets and relook surgeries. Surgical management is to perform laparostomy to avoid life threatening complication, like abdominal compartment syndrome and fulminant sepsis. "Peshawar pack" is a three-layer temporary abdominal dressing pack for managing laparostomy. It is prepared in operation room and applied on patients with ease. Patients with abdominal injuries due to blasts of IEDs, managed with Peshawar pack during June 2014 to June 2016, were studied to determine the effectiveness and practical utility of Peshawar pack. Data was analysed by SPSS version 22. Total numbers, means +SD and frequencies with percentages were described. In fifty-five patients selected for the study, effective drainage of peritoneal cavity and control of peritoneal sepsis was achieved in all cases. Mobilisation out of bed was possible in 38 cases [70%] within 3-5 days and evisceration during mobilisation occurred in 02 cases [3.6%]. There was no case of iatrogenic gut injury. Complete fascial closure in staged manner was achieved in 53 cases [96%]. Peshawar pack is a simple, practical, and effective method for laparostomy care in abdominal injuries due to blast of IEDs.

[Comparative diagnostic value of various methods of intracavitary pressure measurement in abdominal compartment syndrome]

AIM

To investigate diagnostic value of various methods of biophysical somatic parameters (BSP) monitoring in peritonitis complicated by abdominal compartment syndrome.

MATERIAL AND METHODS

220 patients with advanced peritonitis complicated by compartment syndrome were enrolled. Sensitivity, specificity, diagnostic value of the measurement of intraabdominal, intraintestinal, intrathoracic pressure, paravulnar tissues tension depending on abdominal hypertension severity were determined.

RESULTS

BSP control including intraabdominal, intraintestinal, intrathoracic pressure and paravulnar tissues tension is effective for BPS disturbances diagnosis and abele to detect them significantly more often (p=0.037) compared with M. Cheatham's method alone.

The effect of crystalloid infusion on body water content and intra-abdominal pressure in patients undergoing orthopedic surgery under spinal anesthesia

BACKGROUND

Crystalloids are frequently used for the correction of spinal anesthesia-induced hypotension, intraoperative bleeding, or vaporisation from surgical wounds.

OBJECTIVES

The aim of this study was to observe the effect of perioperative crystalloid infusion on intraabdominal pressure (IAP), volume excess (VE), total body water (TBW), and extracellular body water (ECW) in patients undergoing elective orthopedic surgery under spinal anesthesia.

MATERIAL AND METHODS

Adult patients undergoing hip or knee replacement were studied. Changes in VE, TBW, ECW, and IAP were observed in patients who received restrictive fluid therapy (group R) and in patients who received liberal fluid therapy (group L). IAP was measured in the urinary bladder. All parameters were measured at 4 points in time: just before anesthesia (baseline value, A); just after surgery (B); 3 h after surgery (C); and on the morning of postoperative day 1 (D). Additionally, IAP was measured after anesthesia, just before surgery (A1).

RESULTS

The mean baseline values of IAP, ECW, TBW, and VE were comparable between groups L and R. The induction of anesthesia reduced IAP in both groups (p < 0.001). IAP and VE increased in both groups after surgery. Significantly higher values of IAP, however, were noted in group L at time points B, C, and D. TBW and ECW increased after surgery in group L. In group R, ECW slightly increased only at time point C. IAP strongly correlated with ECW in group L (p < 0.001, r = 0.62).

CONCLUSIONS

Spinal anesthesia reduces IAP. A perioperative increase in body water content and IAP mainly depends on the volume of the infused crystalloids.

Predicting Factors for Failure of Percutaneous Drainage of Postoperative Intra-Abdominal Collection

OBJECTIVE

To determine the predictive factors for failure of percutaneous drainage (PD) of postoperative intra-abdominal collection, to better select the patients who might benefit from PD.

MATERIAL AND METHOD

From September 2011 to February 2013, the authors reviewed 42 patients with symptomatic postoperative intra-abdominal collection who had received PD at Ramathibodi Hospital. The PD was considered as failure when clinical sepsis persisted or subsequent surgery was needed. Univariate analysis was used to examine the relationships between failure of PD and the collection and drainage-related variables.

RESULTS

The success rate of PD in the present study was 80%. No major complication was detected. The overall mortality was 12%. Univariate analysis showed that the presence of biliary fistula (p = 0.012), subhepatic location (p = 0.040) and the drainage catheter size of 12F (p = 0.002) were significant predictive variables for failure of PD.

CONCLUSION

Image-guided PD of postoperative intra-abdominal collection was found to be a safe and effective procedure with few complications. Initial recognition of biliary fistula in the collection at subhepatic region or in patients underwent hepatobiliary surgery was the important prognostic factor for unsuccessful PD. These patients may be more beneficial for initial surgical drainage.

Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3-2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2-3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

Airway pressures as surrogate estimates of intra-abdominal pressure

Intra-abdominal pressure (IAP) measurements are essential to the diagnosis and management of patients with intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Peak inspiratory pressure (PIP), plateau pressure (Pplat), and mean airway pressure (Paw) are used by some surgeons as surrogate estimates of IAP during abdominal closure. Thirty mechanically ventilated surgical/trauma patients with risk factors for IAH/ACS underwent simultaneous triplicate measurements of PIP, Pplat, Paw, and IAP. PIP, Pplat, and Paw were compared with IAP using both coefficient of determination and Bland and Altman analysis. The coefficient of determination for each airway pressure in predicting change in IAP was: PIP 5 per cent (P = 0.24), Pplat 17 per cent (P = 0.02), and Paw 15 per cent (P = 0.03). Bland and Altman analysis identified that marked variability exists between airway pressure and IAP measurements: PIP 19.3 ± 18.7 mmHg, Pplat 11.1 ± 13.7 mmHg, and Paw 2.0 ± 9.8 mmHg. Airway pressures do not accurately reflect IAP and cannot be substituted for IAP measurements in patients at risk for IAH/ACS.

Effect of acute, slightly increased intra-abdominal pressure on intestinal permeability and oxidative stress in a rat model

Introduction

Intra-abdominal hypertension (IAH) is known as a common, serious complication in critically ill patients. Bacterial translocation and permeability changes are considered the pathophysiological bases for IAH-induced enterogenic endotoxemia and subsequent multiorgan failure. Nevertheless, the effects of slightly elevated intra-abdominal pressures (IAPs) on the intestinal mucosa and the associated mechanisms remain unclear.

Methods

To investigate the acute effects of different nitrogen pneumoperitoneum grades on colonic mucosa, male Sprague-Dawley rats were assigned to six groups with different IAPs (0 [control], 4, 8, 12, 16, and 20 mmHg, n = 6/group). During 90 min of exposure, we dynamically monitored the heart rate and noninvasive hemodynamic parameters. After gradual decompression, arterial blood gas analyses were conducted. Thereafter, structural injuries to the colonic mucosa were identified using light microscopy. Colon permeability was determined using the expression of tight junction proteins, combined with fluorescein isothiocyanate dextran (FD-4) absorption. The pro-oxidant-antioxidant balance was determined based on the levels of malondialdehyde (MDA) and antioxidant enzymes.

Results

IAH significantly affected the histological scores of the colonic mucosa, tight junction protein expression, mucosal permeability, and pro-oxidant-antioxidant balance. Interestingly, elevations of IAP that were lower than the threshold for IAH also showed a similar, undesirable effect. In the 8 mmHg group, mild hyponatremia, hypocalcemia, and hypoxemia occurred, accompanied by reduced blood and abdominal perfusion pressures. Mild microscopic inflammatory infiltration and increased MDA levels were also detected. Moreover, an 8-mm Hg IAP markedly inhibited the expression of tight junction proteins, although no significant differences in FD-4 permeability were observed between the 0- and 8-mmHg groups.

Conclusions

Acute exposure to slightly elevated IAP may result in adverse effects on intestinal permeability and the pro-oxidant-antioxidant balance. Therefore, in patients with critical illnesses, IAP should be dynamically monitored and corrected, as soon as possible, to prevent intestinal mucosal injury and subsequent gut-derived sepsis.

Intra-abdominal pressure measurements in term pregnancy and postpartum: an observational study

Objective

To determine intra-abdominal pressure (IAP) and to evaluate the reproducibility of IAP-measurements using the Foley Manometer Low Volume (FMLV) in term uncomplicated pregnancies before and after caesarean section (CS), relative to two different reference points and to non-pregnant values.

Design

Observational cohort study.

Setting

Secondary level referral center for feto-maternal medicine.

Population

Term uncomplicated pregnant women as the case-group and non-pregnant patients undergoing a laparoscopic assisted vaginal hysterectomy (LAVH) as control group.

Methods

IAP was measured in 23 term pregnant patients, before and after CS and in 27 women immediately after and 1 day after LAVH. The midaxillary line was used as zero-reference (IAP_MAL) in all patients and in 13 CS and 13 LAVH patients, the symphysis pubis (IAP_SP) was evaluated as additional zero-reference. Intraobserver correlation (ICC) was calculated for each zero-reference. Paired student's t-tests were performed to compare IAP values and Pearson's correlation was used to assess correlations between IAP and gestational variables.

Main outcome measures

ICC before and after surgery, IAP before and after CS, IAP after CS and LAVH.

Results

The ICC for IAP_MAL before CS was lower than after (0.71 versus 0.87). Both mean IAP_MAL and IAP_SP were significantly higher before CS than after: 14.0±2.6 mmHg versus 9.8±3.0 mmHg (p<0.0001) and 8.2±2.5 mmHg versus 3.5±1.9 mmHg (p = 0.010), respectively. After CS, IAP was not different from values measured in the LAVH-group.

Conclusion

IAP-measurements using FMLV is reproducible in pregnant women. Before CS, IAP is increased in the range of intra-abdominal hypertension for non-pregnant individuals. IAP significantly decreases to normal values after delivery.

[Monitoring of intra-abdominal pressure and abdominal perfusion pressure in urgent abdominal surgery]

GOALS OF THE STUDY

To evaluate the changes in intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) during perioperative period in urgent abdominal surgery and to assess the relationship of these parameters with gas exchange and tissue perfusion.

MATERIALS AND METHODS

Twenty-four patients undergoing emergency abdominal surgery were enrolled into a prospective observational study. We recorded IAP APP, mean arterial pressure, arterial and venous blood gases after induction of anesthesia, at the end of surgery, and 6, 12, 48 and 72 h postoperatively. LAP was measured by nasogastric tube using CiMON monitor (Pulsion Medical Systems, Germany). In addition, we studied the relationship of IAP and APP with blood gases parameters.

RESULTS

We observed perioperative increase of IAP (> 12 mm Hg) in 75% of enrolled patients, tendency to postoperative rise of IAP and transient increase of arterial lactate at 6 h after surgery. APP remained within normal values. We found positive correlation of APP with PaO2/FiO2 and ScvO2 at 72 hours after surgery.

CONCLUSION

Transient perioperative increase of IAP was observed in 75% patients undergoing urgent abdominal surgery; however in parallel with intensive care the abdominal perfusion pressure remained within normal values. Abdominal perfusion is related with arterial oxygenation and central venous saturation.

The length of anterior vaginal wall exposed to external pressure on maximal straining MRI: relationship to urogenital hiatus diameter, and apical and bladder location

INTRODUCTION AND HYPOTHESIS

In cystoceles, the distal anterior vaginal wall (AVW) bulges out through the introitus and is no longer in contact with the posterior vaginal wall or perineal body, exposing the pressure differential between intra-abdominal pressure and atmospheric pressure. The goal of this study is to quantify the length of the exposed vaginal wall length and to investigate its relationship with other factors associated with the AVW support, such as most dependent bladder location, apical location, and hiatus diameter, demonstrating its key role in cystocele formation.

METHODS

Fifty women were selected to represent a full spectrum of AVW support. Each underwent supine, dynamic MR imaging. Most dependent bladder location and apical location were measured relative to the average normal position on the mid-sagittal plane using the Pelvic Inclination Correction System . The length of the exposed AVW and the hiatus diameter were measured as well. The relationship between exposed AVW and most dependent bladder location, apical location, and hiatus diameter were examined.

RESULTS

A bilinear relationship has been observed between exposed vaginal wall length and most dependent bladder location (R(2) = 0.91, P < 0.001). When the bladder descents up to the inflection point (about 4.4 cm away from its normal position), there is little change in the exposed AVW length. With further descent, the exposed vaginal wall length increases significantly, with a 2 cm increase in exposed AVW length for every additional 1 cm of drop bladder location. A similar but weaker bilinear relationship exists between exposed AVW and apical location. Exposed vaginal wall length is also highly correlated with hiatus diameter (R(2) = 0.85, P < 0.001).

CONCLUSION

A bilinear relationship exists between exposed vaginal wall length and most dependent bladder location and apical location. It is when the bladder descent is beyond the inflection point that exposed vaginal wall length increases significantly.

[Determination of a safe level for the intestine of the intraabdominal pressure, taking into account preservation of a local blood circulation regulation]

In an acute experiment on the laboratory rabbits there was elaborated and introduced a method of a model simulation for a standard level of intraabdominal pressure (IAP) in values of 50, 100, 150, 200, 250, 300, 350 mm of a water column, using a stand of original construction. Local blood flow (LBF), dilatational (KpCO2) and constrictional (KpO2) reactivity of vessels were determined, using a hydrogen clearance method, as well as the oxygen pressure (pO2) in the intestinal wall tissues, using polarography method, exploiting the electrode blocks of own construction. Under the impact of the modeled level of IAP there were observed a slowing down of LBF, a KpCO2 inhibition, and more, KpO2, and a pO2 lowering. Velocity of these changes occurrence has certain phases, the ratio of which witnesses about reversible ischemic injury of tissues in intraabdominal hypertension syndrome (IAHS) stages 1 - 2 (in accordance to Classification of a II World Congress on IAHS) and occurrence of prognostically unfavorable changes for further intestinal survival in IAHS stages 3 - 4. The data obtained permit to recommend in IAHS stages 1 - 2 to conduct a conservative therapy or operative decompression, in IAHS stages 3 - 4 the possibility of intestinal resection conduction must be mentioned.

[Priority of endovideosurgery in treatment of diffuse purulent peritonitis with subcompensated polyorgan dysfunction]

An analysis of treatment results was made in 474 patients with a diffuse purulent peritonitis. It was shown, that a dynamics of indices of computer phonoenterography (preservation and aggravation of disturbed intestinal motility pattern) and gas-liquid chromatography (the invariable or increased level of acetic, propionic, butyric acid in blood and exudate) significantly supported an evidence objectification to staged sanitization of the abdominal cavity. Recurrent peritoneal lavage was performed in a case of polyorgan dysfunction evidence in the stage of subcompensation in 36, 7 patients. It could be carried out by endovideosurgical method in 82.2% of medical supervisions. The lethality consisted of 4.9% in a case of the application of staged laparoscopic sanitization of the abdominal cavity in complex treatment of patients with diffuse purulent peritonitis.

[Influence of immobilized forms of sodium hypochlorite on the immediate and long-term results of treatment of the patients with diffuse peritonitis]

An analysis of complex examination and results of treatment was made in 290 patients with diffuse peritonitis. The patients were divided into two groups according to way of sanation of the abdominal cavity. The sanation with 0.03% aqueous solution of sodium hypochlorite was used for the first group of 155 patients. The immobilized forms of sodium hypochlorite in carboxymethyl cellulose gel were applied in the second group. The rate of postoperative complications was decreased on 15.4%, the lethality--on 8.2% in the case of application of the immobilized forms of sodium hypochlorite. The developed technology allowed increasing of physical component of life quality of the patients in 1.3 times, though it didn't influence on psychical component.

[The particularities of acute surgical diseases treatment of abdominal cavity organs in patients with haemophilia]

The experience of treatment of 366 patients with haemophilia who were urgently hospitalized in hеmatological Scientific Center over the last 10 years is presented in the article. There were 114 (31.1%) patients with acute diseases of abdominal cavity organs, 150 (41%) patients with bleeding from upper gastrointestinal tract, 102 (27.9%) patients with acute hematomas of retroperitoneal space. Urgent operations were performed in 48 (22.2%) patients who were hospitalized with clinical symptoms of acute abdomen syndrome. It was developed the criteria of diagnosis and choice of treatment tactic on the basis of the received results. Application of presented algorithms led to improve the quality of urgent surgical care to patients with haemophilia.

[Immunological features of children with primary peritonitis]

An immunological research of the patients and control group with primary peritonitis was made. The main indices of immune response were in the range of age rates. However, the immune signs of foci of chronic inflammation were revealed in patients after operation. The consequences of disease (an abdominal cavity effusion) were eliminated during surgical interventions, but not the cause of the inflammation. Children with the primary peritonitis should be examined for detection of infection foci.

[Features of clinical course of primary peritonitis in children]

The article presents an analysis of the features of primary peritonitis in children. Medical reports of 182 patients with primary and appendicular peritonitis were analyzed. It was significant, that the sick girls aged 4-7 years often had the primary peritonitis after acute inflammatory processes, which took place a month earlier. Chronic infection foci were noted in these patients. The age-specific features of maturation of the immune and reproductive systems predisposed the disease.

Are standard intra-abdominal pressure values different during pregnancy?

Background

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

Methods

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

Results

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

Conclusion

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

[Role of heat flow generated by an abdominal cavity in monitoring of acute surgical pathology of abdominal organs]

Despite of significant development of modern surgery results of treatment of acute diffused peritonitis and acute intestinal obstruction are still unsatisfactory. Successful treatment of these conditions depends considerably on timely and adequate diagnosing as it gives a choice of optimal treatment tactics. Measuring of a human body heat flow in areas of organs affected by pathology in cases of acute diffused peritonitis and acute intestinal obstruction provides a possibility to improve the principles of early differential diagnosing, to form new approaches to treatment tactics and monitoring of general health status of a patient during early postoperative treatment. 47 patient suffering from acute diffused peritonitis and 42 patients suffering from acute intestinal obstruction have been examined; the patients were divided into groups based on abdominal cavity exudates character, intestinal obstruction type and intra-abdominal hypertension grade. Measurement of abdominal cavity heat flow was performed by a contact method with use of thermoelectric medical thermometer. Intra-abdominal hypertension was measured by generally used transvesical method. It has been established that abdominal cavity heat flow correlates with character of abdominal cavity exudates; this is also confirmed by reliable difference between serous peritonitis and fibrinopurulent peritonitis indices. Indices in case of acute intestinal obstruction are lower than ones in case of acute diffused peritonitis as there are no inflammatory changes of peritoneum. Development of intra-abdominal hypertension of grades 3-4 directly influences the heat flow extent; this is explained by accelerated and aggravated pathological changes of inner organs cased by the main disease. Thus, abdominal cavity heat flow fully reflects degree of purulent and inflammatory processes of abdominal cavity organs and can be used for additional diagnosing and clinical course monitoring.

[Changes of the intraabdominal pressure in patients with abdominal sepsis]

64 patients with abdominal sepsis were included in the study of the intraabdominal pressure changes before and after the operation. The study demonstrated that the use of the crystalloids alone leads to the development of the capillary leak syndrome in comparison with the therapy regimen using colloids. The aggressive fluid resuscitation, associated with high numbers of central venous pressure, increasing 1177Pa (120 mm H2O), was connected with the increase of the intraabdominal pressure.

[The influence of modern plasma substitutes on the course of abdominal compartment syndrome in patients with abdominal sepsis]

The changes of intra-abdominal pressure (IAP) were followed up in 244 patients with abdominal sepsis after operation. The influence of liquid "resuscitation" with different types of plasma substitutes on the rates of IAP was studied and the dependence of changes IAP from filling of vascular bed was investigated. The impedance technique was used to determine the circulating blood volume and its percentage from proper index was estimated according to the sex, age and constitution. The percentage of interstitial liquid in organism was calculated by analogy. The severity of manifestations of abdominal compartment syndrome (ACS) increases with the assessment of severity of the general condition to APACHE-II scale. The most severe ACS course was while using the crystalloid solutions in the complex of infusion therapy. The inclusion of colloids in the infusion therapy facilitated more full volume filling of vascular bed with the liquid, reduced the capillary leakage, accelerated the process of reduction of ACS. The advantage was shown by using the derivatives of hydroxyethylstarch, which promoted the elimination of deficiency of intravascular liquid in the best way.

Matching positive end-expiratory pressure to intra-abdominal pressure improves oxygenation in a porcine sick lung model of intra-abdominal hypertension

INTRODUCTION

Intra-abdominal hypertension (IAH) causes atelectasis, reduces lung volumes and increases respiratory system elastance. Positive end-expiratory pressure (PEEP) in the setting of IAH and healthy lungs improves lung volumes but not oxygenation. However, critically ill patients with IAH often suffer from acute lung injury (ALI). This study, therefore, examined the respiratory and cardiac effects of positive end-expiratory pressure in an animal model of IAH, with sick lungs.

METHODS

Nine pigs were anesthetized and ventilated (48 +/- 6 kg). Lung injury was induced with oleic acid. Three levels of intra-abdominal pressure (baseline, 18, and 22 mmHg) were randomly generated. At each level of intra-abdominal pressure, three levels of PEEP were randomly applied: baseline (5 cmH2O), moderate (0.5 × intra-abdominal pressure), and high (1.0 × intra-abdominal pressure). We measured end-expiratory lung volumes, arterial oxygen levels, respiratory mechanics, and cardiac output 10 minutes after each new IAP and PEEP setting.

RESULTS

At baseline PEEP, IAH (22 mmHg) decreased oxygen levels (-55%, P <0.001) and end-expiratory lung volumes (-45%, P = 0.007). At IAP of 22 mmHg, moderate and high PEEP increased oxygen levels (+60%, P = 0.04 and +162%, P <0.001) and end-expiratory lung volume (+44%, P = 0.02 and +279%, P <0.001) and high PEEP reduced cardiac output (-30%, P = 0.04). Shunt and dead-space fraction inversely correlated with oxygen levels and end-expiratory lung volumes. In the presence of IAH, lung, chest wall and respiratory system elastance increased. Subsequently, PEEP decreased respiratory system elastance by decreasing chest wall elastance.

CONCLUSIONS

In a porcine sick lung model of IAH, PEEP matched to intra-abdominal pressure led to increased lung volumes and oxygenation and decreased chest wall elastance shunt and dead-space fraction. High PEEP decreased cardiac output. The study shows that lung injury influences the effects of IAH and PEEP on oxygenation and respiratory mechanics. Our findings support the application of PEEP in the setting of acute lung injury and IAH.

[Effects of abdominal compartment syndrome on circulation and respiratory function in rabbits]

OBJECTIVE

To establish a rabbit model of abdominal compartment syndrome (ACS) and evaluate the impact of ACS on cardiovascular and respiratory functions and blood electrolyte levels in rabbits.

METHODS

Twenty-four New Zealand rabbits were randomly allocated into 4 equal groups, namely the normal control group, ACS(5>\) group [intra-abdominal pressure (IAP)=5 mmHg], ACS(10) group (IAP=10 mmHg) and ACS(20) group (IAP=20 mmHg). ACS model was established by intra- abdominal bleeding (IAB) with intra-abdominal hypertension (IAH). All the data were recorded 1 h after inducing IAH including cardiovascular parameters (LVSP, LVEDP, ∓dp/dt max, SP, DP, HR, CVP), respiratory function (RR, PaO(2), PaCO(2), [HCO(3)(-)]), blood pH, and electrolyte level ([K(+)]).

RESULTS

Compared with those in the normal control group, ACS20 group showed significantly decreased LVSP, LVEDP, ∓dp/dt max, SP, DP, HR, RR, PaO(2), [HCO(3)(-)], and blood pH but increased CVP, PaCO(2), and K(+) (P<0.05). In ACS(10) group, all the parameters except for RR and PaO(2) showed similar changes as seen in ACS(20) group (P<0.05) but with lower amplitudes of variations. In ACS(5) group, only LVSP and HR were reduced remarkably (P<0.05) while the other parameters showed no significant variations.

CONCLUSION

IAB plus IAH may cause damage to the cardiovascular and respiratory functions and lead to ACS in rabbits.

[Comparative capacities of radiation studies in the diagnosis of circumscribed peritonitis in case of duodenal microperforation at different stages of emergency medical care]

The results of ultrasound (US) and X-ray studies were retrospectively studied in the diagnosis of circumscribed peritonitis in case of microperforation from duodenal ulcers at different stages of emergency medical care. Analysis of the findings has demonstrated that on admission and in its first hours the most effective diagnostic method is plain radiography that enables free gas accumulation to be found under the diaphragm and US study is of low informative value. Repeat targeted US study using expert-class scanners, with the well stated task based on clinical laboratory findings, is a high-informative diagnostic technique for circumscribed peritonitis in case of duodenal perforations.

[The compartment syndrome. Review]

The abdominal cavity has its own dimensions: the enlargement of one of the abdominal cavity (AC) organs results in the increase of pressure in intra-abdominal cavity (abdominal hypertension). The increased intra-abdominal pressure (IAP) causes the disturbance of organs' physiological functions, decompensation of gastrointestinal tract functions up to lethal outcome. The clinicians choose three rates of abdominal hypertension (AH): 1) mild form AH - when intra-abdominal pressure is within 10-20 mm Hg: AH due to adequate course of physiological functions has no particular clinical signs: sometimes the use of non-surgical treatment measures is required. 2) Mean severity AH: IAP is continuously within 21-35 mm Hg: the treatment except some cases is conservative. 3) Severe form AH: persistent IAP exceeds 35 mm Hg: in this case surgical decompression is required. Some diseases (obesity, ascites, heart failure etc.) result in chronic AH. IAP can be measured through a direct and indirect way. The best convenient methods of indirect IAP measurement include a monometer, which is connected to the catheter inserted into the urinary bladder. The abdominal decompression (AD) is used to eliminate the pathophysiological disorders taking place as a result of AH. However, today the abdominal hypertension syndrome as a pathophysiological process is widely extended in clinic. And it is impossible to achieve good treatment results not studying the mechanism of its appearance, concomitant pathological changes and the ways of its elimination.

Measurement of intra-abdominal pressure in term pregnancy: a pilot study

BACKGROUND

This study was conducted to assess the feasibility of measuring intra-abdominal pressure in term parturients under spinal anesthesia.

METHODS

Intra-abdominal pressure was measured in 20 term parturients after spinal anesthesia for elective caesarean section. Pressure was measured in the supine and 10° left lateral tilt positions with a constant reference point throughout.

RESULTS

Intra-abdominal pressure measurement was feasible and safe to perform. Pressure was significantly lower in the left lateral tilt position than supine (10.9 mmHg ± 4.67 vs. 8.9 mmHg ± 4.87, P=0.0004). The range of intra-abdominal pressure in pregnancy was wide, from 2 to 20 mmHg, with >25% of patients resting with pressures above 12 mmHg in both positions.

CONCLUSIONS

Under spinal anesthesia, intra-abdominal pressure in >25% of healthy term parturients was > 12 mmHg, which has conventionally been defined as intra-abdominal hypertension. The intra-abdominal pressure in term pregnancy should be performed in the left lateral tilt position to avoid falsely elevated pressure measurements.

[Diagnostics of acute adhesive intestinal obstruction by the method of measuring intra-abdominal pressure]

Questions of diagnostics of acute adhesive intestinal obstruction (AIO) including erased picture of the disease are considered. The data of 120 patients with acute intestinal obstruction are presented in whom the intra-abdominal pressure (IAP) was investigated in dynamics. The questions of degree of IAP in acute intestinal obstruction of different genesis and with different levels of disturbed patency of the gastro-intestinal tract are discussed. The radiological data are compared with the parameters of IAP in acute intestinal obstruction. The algorithm of strategy of treatment of patients with acute intestinal obstruction based on the size of IAP is proposed.

[Extraperitoneal ligation herniorraphy by the acute infectious diseases of the abdominal cavity in children]

Surgery on the reason of the "acute abdomen" in children often reveals the persisting vaginal peritoneal defects, which further lead to hernia formation. 23 children (aged 4-15 years) were operated on the acute uncomplicated appendicitis (n=10), acute mesadenitis (n=3), appendicular local and pelvioperitonitis (n=9) and ovary apoplexia (n=1). Inguinal hernia was revealed in all patients during laparoscopy. After videoendoscopic sanation of the abdomen and appendectomy (if it was necessary) the extraperitoneal ligation herniorraphy in author's modification was performed. The were no cases of abdominal complications as well as hernia recurrence among the treated patients.

[The miniinvasive treatment of the aseptic fluid collections by the acute necrotizing pancreatitis]

The study aimed to state the indications to punctures and draining of the aseptic fluid collections by the acute necrotizing pancreatitis. Data of 82 patients were analyzed. The miniinvasive treatment proved to be preferable to the conservative treatment only in cases of the internal organs compression. Punctures and draining didn't provide the decrease of septic complications and pseudocyst formation. Poor result of miniinvasive procedures predict the high risk of pseudocyst formation.

[The videoendoscopic sanations of the abdominal cavity by the spread peritonitis]

The treatment results of 109 patients with the disseminated septic peritonitis were analyzed. All patients were divided in two statistically similar groups. The first group of patients was treated using the standart approach (open surgery, eliminating the cause of peritonitis followed by further endoscopic planned sanations of the abdominal cavity). Difference of the treatment approach among the patients of the second group (n=41) was in using the pulsing stream of anticeptic for fibrine onlays elimination and the use of 200 ml of immobilized form of sodium hypochlorite gel for the final sanation. The treatment results among these patients were significantly better (the endotoxicosis parameters were 1.5 times lower and the recovery of motor intestinal function was 2 times faster). The morbidity level was 9% lower and the lethality level was 4% lower in comparison with patients of the 1st group.

[The videoendoscopic sanation of the abdominal cavity by the diffuse septic peritonitis]

The 1st group consisted of 68 patients with the diffuse peritonitis, who were treated with the use of traditional approach, i.e., laparotomy, elimination of the peritonitis source, nasointestinal intubation, abdominal cavity sanation and drainage. Within 24--48 hours all these patients had videoendoscopic abdominal sanation with the injection of 200 ml 0.03% water solution of sodium hypochlorite. The 2nd group, consisted of 41 patients. The first treatment stage was the same, but during the videoendoscopic stage the pulsing stream of the antiseptic was used and the procedure ended with intraabdominal injection of 200 ml 0.03% water solution of sodium hypochlorite immobilized in gel. All patients of the 2nd group showed better recovery results.

Bloating in gastroparesis: severity, impact, and associated factors

OBJECTIVES

Bloating is commonly reported in gastroparesis, but its prevalence, impact, and associated factors are uninvestigated. We aimed to quantify the prevalence of bloating in gastroparesis and relate its severity to clinical factors and quality of life.

METHODS

Survey, examination, and scintigraphy data were compared in 335 gastroparesis patients from 6 centers of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Gastroparesis Clinical Research Consortium. Bloating severity was stratified using Gastroparesis Cardinal Symptom Index (GCSI) bloating subscale scores.

RESULTS

Bloating severity of at least mild (GCSI ≥2) and severe (GCSI ≥4) grades were reported by 76 and 41% of patients, respectively. Bloating severity related to female gender (P<0.0001) and overweight status (P=0.04) on regression analysis and correlated with intensity of nausea, postprandial fullness, visible distention, abdominal pain, and altered bowel function (P<0.05). Disease etiology, smoking status, and gastric emptying did not relate to bloating subset (P>0.05). Disease-specific quality of life and general measures of well-being were progressively impaired with increasing bloating severity (P=0.01). Probiotic use (P=0.03) and use of antidepressants with significant norepinephrine reuptake inhibitor activity (P=0.045) use related to bloating severity; antiemetic use trended higher with worsening bloating (P=0.06).

CONCLUSIONS

Bloating is prevalent in gastroparesis and is severe in many individuals. Bloating severity relates to female gender, body weight, and intensity of other symptoms. The symptom impairs quality of life but is not influenced by gastric emptying rates. Antiemetics, probiotics, and antidepressants with significant norepinephrine reuptake inhibitor activity may affect reports of bloating. These findings provide insight into this underappreciated symptom of gastroparesis.

Definitions and pathophysiological implications of intra-abdominal hypertension and abdominal compartment syndrome

For any syndrome or disease process, uniform definitions are essential to facilitate effective clinical communication as well as evaluation of the scientific literature and standardization of research. The following consensus definitions for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been proposed by the World Society of the Abdominal Compartment Syndrome and are now widely accepted around the world. The use of these definitions, and their subsequent revisions as new evidence becomes published, will further improve communication and future research in this area. This review briefly addresses the present definitions as well as the pathophysiological effects of IAH/ACS on end-organ function.

Effects of intra-abdominal pressure on liver function assessed with the LiMON in critically ill patients

BACKGROUND

Intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) are associated with significant morbidity and mortality in critically ill patients. Our aim was to assess the effects of IAH on liver function using the noninvasive liver function monitoring system LiMON and to assess the prognostic value of IAP in critically ill patients.

METHODS

We conducted a retrospective analysis of critically ill patients who were treated in the intensive care unit (ICU). The IAP and indocyanine green plasma disappearance rate (ICG-PDR) measurements were made within 24 hours after admission to the ICU and repeated 12 hours later. Intra-abdominal pressure was measured via a Foley bladder catheter, and ICG elimination tests were conducted concurrently using the LiMON.

RESULTS

We included 30 critically ill patients (17 women and 13 men aged 28-89 yr) in our analysis. Statistical analysis showed that the baseline IAP values were significantly higher among nonsurvivors than survivors (19.38 [standard deviation; SD 2.08] v. 13.07 [SD 0.99]). The twelfth-hour IAP values were higher than baseline measurements among nonsurvivors (21.50 [SD 1.96]) and lower than baseline measurements among survivors (11.71 [SD 1.54]); the difference between groups was significant (p < 0.001). The baseline ICG-PDR values were significantly lower among nonsurvivors than survivors (10.86 [SD 3.35] v. 24.51 [SD 6.78]), and the twelfth-hour ICGPDR values were decreased in all groups; the difference between groups was significant (p < 0.001).

CONCLUSION

Our results suggest that measurement of ICG-PDR with the LiMON is a good predictor of the effects of IAP on liver function and, thus, can be recommended for the evaluation of critically ill patients.

Identification, management and complications of intra-abdominal hypertension and abdominal compartment syndrome in neonatal intensive care unit (a single centre retrospective analysis)

The abdominal compartment syndrome (ACS) is a result of increased intra-abdominal pressure (IAP) due to tissue edema or free fluid collecting in the abdominal cavity. Elevated pressure in the abdomen is referred to as intra-abdominal hypertension (IAH). The end result of ACS, if undetected and untreated, is multisystem organ failure and patient death. Intra-abdominal pressure monitoring should be strongly considered in all patients with this clinical presentation. Normal intra-abdominal pressure is 0-5 mm Hg. Physiologic compromise begins when the pressure rises above 8-10 mm Hg. Once the pressures increase beyond 20 mm Hg irreversible tissue injury occurs, ultimately resulting in ACS and multiple organ failure. Early recognition of rising abdominal pressure is critically important, because it allows prompt intervention which will prevent ACS from developing, leading to a much better prognosis for the patient. The purpose of the research was to: 1) Detect abdominal compartment syndrome in newborns with clinically suspicious intra-abdominal hypertension; 2) Identify intra-abdominal pressure numbers presented with clinical manifestation; 3) Measure and detect intra-abdominal pressure numbers presented with abdominal compartment syndrome; 4) Find correlation between intra-abdominal hypertension grade and patient outcome. For completion of our goal we selected and reviewed medical records of 155 neonatal patients from 2008 to 2010, who stayed in surgical neonatal intensive care unit for more than 7 days. We monitored IAP in patients with suspected ACS and different clinical presentation. According to our research we may come to the following conclusion: Intra-abdominal hypertension was confirmed in most suspected cases. Intra-abdominal pressure of >10 mmHg in patients with clinical suspicion may be considered as intra-abdominal hypertension. Intra-abdominal hypertension is in close correlation with presence of fluid in abdominal cavity proved by ultrasound investigation. Intra-abdominal pressure of ≥20 mmHg can be considered as a point of development of abdominal compartment syndrome. The grade of hypertension is in close correlation with patient outcome.

[The application of immobilized forms of sodium hypochlorite in complex treatment of diffuse purulent peritonitis]

Complex examination and the following treatment of 380 patients with diffuse purulent peritonitis were analyzed. The patients were divided into 2 groups. The first group included 245 patients to whom the sanitization of the abdominal cavity used traditional antiseptics. The main group included 135 patients to whom the immobilized form of sodium hypochlorite in the carboxymethyl cellulose was introduced instead of aqueous solution. An original method of sanitization of the abdominal cavity allows 1.2-1.5 times decreased degree of endotoxicosis, 2-2.5 times improved the motor-evacuatory function of the intestine in different forms of treatment of peritonitis. In the main group of patients the number of postoperative complications was 10% less, lethality was 8.2% less.

[Relaparotomy and laparostomy in treatment of early postoperative complications]

The cause-and-effect analysis of early (within 3 weeks after the initial surgery) relaparotomy was made, using the experience of 5286 laparotomized patients, of whom 82 (1,55%) had relaparotomy. The main reason of intraabdominal complications was the initial generalized peritonitis in emergency patients (85,4%). In comparison with data of 30 years prescription, the portion of postoperative peritonitis and bleeding had increased, though the number of eventrations and postoperative ileus, on the contrary, decreased. The introduction of laparoscopy eliminated the necessity of diagnostic relaparotomies. The mortality rate after the repeated surgery had decreased from 38,0% to 30,5%.

[Effects of different reference point on intra-abdominal pressure measurement in critically ill patients: a clinical trial]

OBJECTIVE

To investigate the effects of different reference point on intra-abdominal pressure (IAP) measurement.

METHODS

Nine critically ill patients with risk of intra-abdominal hypertension (IAH) were studied from July 2008 to June 2010, all of the patients were equipped with abdominal cavity drain and urinary drainage tube. By which IAP was measured using direct and indirect methods respectively. The symphysis pubis, phlebostatic axis and the midaxillary line at the level of the iliac crest were defined as reference points. According to the different reference point, three sets of IAP measurements were obtained in the supine position with each method and kept as IAP(S), IAP(P), IAP(I). Bland-Altman method analysis and Pearson's correlation were performed to evaluate the relationships between results from different reference points with direct and indirect methods. Paired t-test was performed to evaluate the differences among different reference points.

RESULTS

Sixty measurements of IAP(S), IAP(P) and IAP(I) were obtained. In direct measurement through abdominal cavity drain, IAP(I) (13.8 ± 3.9) mmHg (1 mmHg = 0.133 kPa) was significantly higher than IAP(P) (12.8 ± 3.6) mmHg and IAP(S) (9.1 ± 3.6) mmHg, P < 0.05; while in indirect measurement through urinary drainage tube, IAP(I) (12.7 ± 3.2) mmHg was significantly higher than IAP(P) (11.7 ± 2.9) mmHg and IAP(S) (7.9 ± 3.0) mmHg too, P < 0.05. In either direct or indirect method, IAP(P) was higher than IAP(S), P < 0.05. And good correlations were found among IAP(S), IAP(P) and IAP(I).

CONCLUSIONS

In the supine position, pressure obtained via the bladder could reflect authentic IAP. But selection of reference point has great impact on IAP measurement.

[Monitoring of intraabdominal pressure in colonic obstruction]

Results of surgical treatment of 197 patients with acute colonic obstruction complicated by intraabdominal hypertension were analyzed. Monitoring of intraabdominal pressure was made in 101 patients at the pre- and postoperative periods. Compensated, sub- and decompensated forms of obstruction depending on the data of intraabdominal pressure were determined. The level and dynamics of the intraabdominal pressure are taken as criteria of severity of acute colonic obstruction, decision on the time and volume of surgical procedures. The medico-diagnostic algorithm of management of such patients is proposed. Lethality turned out to be decreased to 15.8% as compared with a control group (24%) due to the monitoring of intraabdominal pressure and improved surgical strategy.