Differential Effects of Intra-Abdominal Hypertension and ARDS on Respiratory Mechanics in a Porcine Model.

Background and Objectives: Intra-abdominal hypertension (IAH) and acute respiratory distress syndrome (ARDS) are common concerns in intensive care unit patients with acute respiratory failure (ARF). Although both conditions lead to impairment of global respiratory parameters, their underlying mechanisms differ substantially. Therefore, a separate assessment of the different respiratory compartments should reveal differences in respiratory mechanics. Materials and Methods: We prospectively investigated alterations in lung and chest wall mechanics in 18 mechanically ventilated pigs exposed to varying levels of intra-abdominal pressures (IAP) and ARDS. The animals were divided into three groups: group A (IAP 10 mmHg, no ARDS), B (IAP 20 mmHg, no ARDS), and C (IAP 10 mmHg, with ARDS). Following induction of IAP (by inflating an intra-abdominal balloon) and ARDS (by saline lung lavage and injurious ventilation), respiratory mechanics were monitored for six hours. Statistical analysis was performed using one-way ANOVA to compare the alterations within each group. Results: After six hours of ventilation, end-expiratory lung volume (EELV) decreased across all groups, while airway and thoracic pressures increased. Significant differences were noted between group (B) and (C) regarding alterations in transpulmonary pressure (TPP) (2.7 ± 0.6 vs. 11.3 ± 2.1 cmH2O, p < 0.001), elastance of the lung (EL) (8.9 ± 1.9 vs. 29.9 ± 5.9 cmH2O/mL, p = 0.003), and elastance of the chest wall (ECW) (32.8 ± 3.2 vs. 4.4 ± 1.8 cmH2O/mL, p < 0.001). However, global respiratory parameters such as EELV/kg bodyweight (-6.1 ± 1.3 vs. -11.0 ± 2.5 mL/kg), driving pressure (12.5 ± 0.9 vs. 13.2 ± 2.3 cmH2O), and compliance of the respiratory system (-21.7 ± 2.8 vs. -19.5 ± 3.4 mL/cmH2O) did not show significant differences among the groups. Conclusions: Separate measurements of lung and chest wall mechanics in pigs with IAH or ARDS reveals significant differences in TPP, EL, and ECW, whereas global respiratory parameters do not differ significantly. Therefore, assessing the compartments of the respiratory system separately could aid in identifying the underlying cause of ARF.

Randomized controlled trial: neostigmine for intra-abdominal hypertension in acute pancreatitis.

BACKGROUND: Intra-abdominal hypertension (IAH) in acute pancreatitis (AP) is associated with deterioration in organ function. This trial aimed to assess the efficacy of neostigmine for IAH in patients with AP. METHODS: In this single-center, randomized trial, consenting patients with IAH within 2 weeks of AP onset received conventional treatment for 24 h. Patients with sustained intra-abdominal pressure (IAP) ≥ 12 mmHg were randomized to receive intramuscular neostigmine (1 mg every 12 h increased to every 8 h or every 6 h, depending on response) or continue conventional treatment for 7 days. The primary outcome was the percent change of IAP at 24 h after randomization. RESULTS: A total of 80 patients were recruited to neostigmine (n = 40) or conventional treatment (n = 40). There was no significant difference in baseline parameters. The rate of decrease in IAP was significantly faster in the neostigmine group compared to the conventional group by 24 h (median with 25th-75th percentile: -18.7% [- 28.4 to - 4.7%] vs. - 5.4% [- 18.0% to 0], P = 0.017). This effect was more pronounced in patients with baseline IAP ≥ 15 mmHg (P = 0.018). Per-protocol analysis confirmed these results (P = 0.03). Stool volume was consistently higher in the neostigmine group during the 7-day observational period (all P < 0.05). Other secondary outcomes were not significantly different between neostigmine and conventional treatment groups. CONCLUSION: Neostigmine reduced IAP and promoted defecation in patients with AP and IAH. These results warrant a larger, placebo-controlled, double-blind phase III trial. Trial registration Clinical Trial No: NCT02543658 (registered August /27, 2015).

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis.

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors' own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric-rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

Intraabdominal pressure and its relation with organ dysfunction in patients scheduled for elective cesarean section: Effect of supine vs left lateral tilt position.

INTRODUCTION: Intraabdominal pressure (IAP) is related to clinical outcome of patients. It is measured as intravesical pressure through a Foley catheter in the supine position. During pregnancy, there are data showing elevated IAP and also a suggestion that it may be a false increase due to pressure on the urinary bladder by the gravid uterus in the supine position. Additionally, it is not known whether the elevated IAP during pregnancy is merely a physiological change or is associated with impairment of organ functions. We thus aimed to establish a normal value of IAP in supine (IAPsupine ) as well as 10° left lateral (IAPlateral-tilt ) positions, and their association with organ functions as well as certain maternal risk characteristics. MATERIAL AND METHODS: This prospective cross-sectional cohort study included 100 consenting parturients with term gestation posted for elective cesarean section under single-shot subarachnoid block. IAP was measured via an indwelling Foley catheter with a transducer connected to it, as per the recommended technique. Organ dysfunction was defined as Sequential Organ Failure Assessment (SOFA) subscore ≥1 for the particular system. TRIAL REGISTRATION: ctri.gov.in (CTRI/2017/11/010527). RESULTS: The IAPsupine was significantly higher than IAPlateral-tilt (13.8 ± 2.4 vs 12 ± 2.3 mm Hg) (P < .001). The incidence of intraabdominal hypertension as per conventional definition, that is, IAP ≥12 mm Hg, was also higher in the supine position (77% vs 55%) (P < .001). None of the patients had dysfunction of the cardiovascular, renal or central nervous system. The incidence of respiratory, hepatic and hematologic dysfunction was 2%, 15% and 32%, respectively. Receiver operating characteristic analysis showed insignificant association of IAPsupine and IAPlateral-tilt with various organ dysfunctions (P > .05). There was a significant correlation of intraabdominal hypertension when considering IAPsupine or IAPlateral-tilt , with obesity (P = .004 and .000, respectively), as well as preeclampsia (P = .006 and .000, respectively). CONCLUSIONS: In nonlaboring patients undergoing elective cesarean section, IAP is significantly higher in the supine vs 10° left lateral position. In neither position is IAP significantly associated with organ dysfunction. Thus, the usual recommendation of a supine position for measuring IAP to diagnose intraabdominal hypertension, formulated consequent to its pathological effects on organ functions, may not be applicable to pregnant patients and needs urgent validation studies.

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.

Intra-Abdominal Hypertension is a Risk Factor for Increased VAP Incidence: A Prospective Cohort Study in the ICU of a Tertiary Hospital.

BACKGROUND: Ventilator-associated pneumonia (VAP) might be increased in cases with intra-abdominal hypertension (IAH). However, despite animal experimentation and physiological studies on humans in favor of this hypothesis, there is no definitive clinical data that IAH is associated with VAP. We therefore aimed to study whether IAH is a risk factor for increased incidence of VAP in critical care patients. This 1-center prospective observational cohort study was conducted in the intensive care unit of the University Hospital of Larissa, Greece, during 2013 to 2015. Consecutive patients were recruited if they presented risk factors for IAH at admission and were evaluated systematically for IAH and VAP for a 28-day period. RESULTS: Forty-five (36.6%) of 123 patients presented IAH and 45 (36.6%) presented VAP; 24 patients presented VAP following IAH. Cox regression analysis showed that VAP was independently associated with IAH (1.06 [1.01-1.11]; P = .053), while there was an indication for an independent association between VAP and abdominal surgery (1.62 [0.87-3.03]; P = .11] and chronic obstructive pulmonary disease (1.79 [0.96-3.37]; P = .06). CONCLUSIONS: Intra-abdominal hypertension is an independent risk factor for increased VAP incidence in critically ill patients who present risk factors for IAH at admission to the ICU.

Basic Fibroblast Growth Factor (bFGF) Protects the Blood-Brain Barrier by Binding of FGFR1 and Activating the ERK Signaling Pathway After Intra-Abdominal Hypertension and Traumatic Brain Injury.

BACKGROUND Intra-abdominal hypertension (IAH) is associated with high morbidity and mortality. IAH leads to intra-abdominal tissue damage and causes dysfunction in distal organs such as the brain. The effect of a combined injury due to IAH and traumatic brain injury (TBI) on the integrity of the blood-brain barrier (BBB) has not been investigated. MATERIAL AND METHODS Intracranial pressure (ICP) monitoring, brain water content, EB permeability detection, immunofluorescence staining, real-time PCR, and Western blot analysis were used to examine the effects of IAH and TBI on the BBB in rats, and to characterize the protective effects of basic fibroblast growth factor (bFGF) on combined injury-induced BBB damage. RESULTS Combined injury from IAH and TBI to the BBB resulted in brain edema and increased intracranial pressure. The effects of bFGF on alleviating the rat BBB injuries were determined, indicating that bFGF regulated the expression levels of the tight junction (TJ), adhesion junction (AJ), matrix metalloproteinase (MMP), and IL-1ß, as well as reduced BBB permeability, brain edema, and intracranial pressure. Moreover, the FGFR1 antagonist PD 173074 and the ERK antagonist PD 98059 decreased the protective effects of bFGF. CONCLUSIONS bFGF effectively protected the BBB from damage caused by combined injury from IAH and TBI, and binding of FGFR1 and activation of the ERK signaling pathway was involved in these effects.

Influence of Elevated Intra-abdominal Pressure on Suture Tension Dynamics in a Porcine Model.

BACKGROUND: Inadequate suture tension is a risk factor for the failure of laparotomy closure. Suture tension dynamics in the abdominal wall are still obscure due to the lack of measuring devices. To answer the questions if intra-abdominal hypertension (IAH) influences suture tension in midline laparotomies and if IAH leads to a permanent loss of suture tension, microsensors were applied in a porcine model of IAH. MATERIAL AND METHODS: Microsensors measuring suture tension "on the thread" with a frequency of 1/s were developed and implanted in the suture lines of midline laparotomies in four pigs. During a 23-h experiment under general anesthesia, two intervals of IAH (30 mm Hg) were applied, interrupted by a 3-h interval without elevated intra-abdominal pressure. RESULTS: All sensors showed an immediate and reproducible response to changes of intra-abdominal pressure. The two 9-h periods of IAH resulted in a significant elevation of suture tension (P = 0.003 and P = 0.0009, respectively). Reducing the IAH lead to a significant loss of suture tension (P = 0.0005 and P = 0.0001, respectively). After the second interval with IAH, a complete loss of mean suture tension was observed. A statistically significant "recovery" of suture tension in the interval between the two phases with IAH was not observed. CONCLUSIONS: Intervals with elevated intra-abdominal pressure have a direct influence on suture tension in midline laparotomy wounds. Intervals with IAH lead to a significant loss of suture tension in the suture line and to a complete loss of mean suture tension at the end of this experiment. A subsequent gaping of the fascia might contribute to either acute or chronic failure of laparotomy closure.

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.

Current Approach to the Evaluation and Management of Abdominal Compartment Syndrome in Pediatric Patients.

Abdominal compartment syndrome is an emergent condition caused by increased pressure within the abdominal compartment. It can be caused by a number of etiologies, which are associated with decreased abdominal wall compliance, increased intraluminal or intraperitoneal contents, or edema from capillary leak or fluid resuscitation. The history and physical examination are of limited utility, and the criterion standard for diagnosis is intra-abdominal pressure measurement, which is typically performed via an intravesical catheter. Management includes increasing abdominal wall compliance, evacuating gastrointestinal or intraperitoneal contents, avoiding excessive fluid resuscitation, and decompressive laparotomy in select cases.

Analyzing the effect of laparoscopy duration time on peroperative gastroesophageal reflux

Background/aim: Intraabdominal pressure (IAP) is one of the main reasons for gastroesophageal reflux (GER). This study investigates whether IAP during laparoscopic surgery leads to GER in a time-dependent manner. Materials and methods: In a laparoscopy model, 15 mmHg IAP was created in 8 Wistar albino rats in the Trendelenburg position (TP). A 5 mm laparotomy was performed in the left lower abdominal region, and a 6 Fr catheter was placed intraabdominally. Air was insufflated into the abdominal cavity, and the pressure was kept constant at 15 mmHg. Esophageal pH alterations were measured by pH sticks for 4 h every 30 min. Results: The basal median esophageal pH value was 9 (8­10), the value after placing the catheter was 9 (7­10) (P = 0.47), and the median pH value after placing the subjects in TP was 9 (8­10) (P = 0.70). In our experimental model, esophageal pH values were found to decrease significantly at the 150th minute in TP and at 15 mmHg IAP (P < 0.05). Two rats died: one at the 120th minute and the other at the 240th minute (P > 0.05) Conclusion: Esophageal pH values decreased and continued to remain low following IAP increase and TP in this experimental rat model. Prolonged laparoscopic procedures can particularly lead to GER that requires instant recognition and rapid and appropriate intervention.

Carbon monoxide and hydrogen sulphide reduce reperfusion injury in abdominal compartment syndrome.

BACKGROUND: Carbon monoxide (CO)- and hydrogen sulphide-releasing molecules (CORM-3 and GYY4137, respectively) have been shown to be potent antioxidant and antiinflammatory agents at the tissue and systemic level. We hypothesized that both CORM-3 and GYY4137 would reduce the significant organ dysfunction associated with abdominal compartment syndrome (ACS). MATERIAL AND METHODS: Randomized trial was conducted where ACS was maintained for 2 hours in 27 rats using an abdominal plaster cast and intraperitoneal CO2 insufflation at 20 mmHg. Three experimental groups underwent ACS and received an experimental molecule at the time of decompression: inactive CORM-3, active CORM-3, and GYY4137, whereas three groups underwent no ACS to serve as a sham. Sinusoidal perfusion, inflammatory response and cell death were quantified in exteriorized livers. Respiratory, liver, and renal dysfunction was assessed biochemically. RESULTS: Hepatocellular death and the number of activated leukocytes within postsinusoidal venules were significantly increased in rats with ACS (16-fold increase, 17-fold leukocyte activation, respectively, P < 0.05). Administration of CORM-3 or GYY4137 resulted in a significant decrease of both parameters (P = 0.03 and P = 0.009). ACS resulted in an increase in markers of renal and liver injury; CORM-3 or GYY4137 partially restored levels to those seen in sham animals. Myeloperoxidase was significantly elevated in the ACS group in lung, liver, and small intestine (P = 0.0002, P = 0.01, and P = 0.08, respectively). CORM-3 treatment, but not GYY4137, was able to completely block the response (65 ± 11 U/ml and 92 ± 18 U/ml, respectively versus 110 ± 10U/ml in the ACS group, lung tissue). CONCLUSIONS: We have demonstrated the effect of two molecules, CO and hydrogen sulphide, on tempering the reperfusion-associated metabolic and organ derangements in ACS. CORM-3 demonstrated a greater effect than GYY4137 and was able to restore most of the measured parameters to levels comparable to sham.

Damage Control Surgery for Non-traumatic Abdominal Emergencies.

BACKGROUND: Damage control surgery (DCS) was a major paradigm change in the management of critically ill trauma patients and has gradually expanded in the general surgery arena, but data in this setting are still scarce. The study aim was to evaluate outcomes of DCS in patients with general surgery emergencies. METHODS: Between 2005 and 2015, 164 patients (104 men, age 66) underwent DCS for non-traumatic abdominal emergencies. The decision to perform DCS was triggered by the presence of at least one trauma DCS criterion: hypotension (<70 mmHg), hypothermia (<35 °C), acidosis (pH < 7.25), coagulopathy (INR ≥ 1.7) and massive (>5 RBC) transfusion. Statistical tests were performed to identify risk factors for operative mortality. Observed outcomes were compared to those predicted by commonly employed scores (APACHE II, POSSUM, P-POSSUM, SAPS II). RESULTS: DCS was performed for acute mesenteric ischemia (n = 68), peritonitis (n = 44), pancreatitis (n = 28), bleeding (n = 14) and other (n = 10). Abdominal compartment syndrome was associated in 52 patients (32%). Seventy-four (45%) patients died and 150 patients (91%) experienced complications. On multivariate analysis, age (p = 0.018) and INR ≥ 1.7 (p = 0.001) were independent predictors of mortality. Mortality was 24% (13/55), 48% (22/46) and 62% (39/63) in patients with one, two and ≥3 DCS criteria, respectively. Comparison of observed and score-predicted mortality suggested DCS use resulted in significant survival benefit of the whole cohort and of patients with pancreatitis and postoperative peritonitis. CONCLUSIONS: DCS can be lifesaving in critically ill patients with general surgery emergencies. Patients with peritonitis and acute pancreatitis are those who benefit most of the DCS approach.

Daily intra-abdominal pressure, Sequential Organ Failure Score and fluid balance predict duration of mechanical ventilation.

BACKGROUND: Elevated intra-abdominal pressure (IAP) is a common occurrence in mechanically ventilated patients in the intensive care unit (ICU). This study was undertaken to determine the relationship between IAP, pulmonary compliance and the duration of mechanical ventilation. METHODS: A prospective study of 220 consecutively enrolled mechanically ventilated patients admitted to a mixed surgical-medical ICU in a tertiary referral hospital. The IAP was measured at least twice daily, benchmarked against consensus guidelines. Dynamic pulmonary compliance was calculated together with admission Acute Physiology and Chronic Health Evaluation (APACHE III) score and daily Sequential Organ Failure Assessment (SOFA) score. RESULTS: No relationship between highest IAP for the day and pulmonary compliance (P = 0.61) was found. For each 5 mm Hg increase in IAP, the risk of remaining intubated increased 19% (HR = 1.19, 95% CI: 0.98-1.44); for each standard deviation increase in SOFA score (3.7 points), the risk of remaining intubated increased by 14% (HR = 1.14, 95% CI: 0.98-1.33); and for each 1 L increase in fluid balance, the risk of remaining intubated increased by 11% (HR = 1.11, 95% CI: 1.04-1.19). A nomogram was developed to predict the probability of extubation based on daily highest IAP for the day, SOFA score and fluid balance. CONCLUSION: IAPs did not correlate with pulmonary compliance in critically ill patients. Increased IAP was associated with a longer duration of mechanical ventilation. A nomogram integrating daily IAP, SOFA score and fluid balance may be used to predict the duration of mechanical ventilation.

Changes in spatial QRS-T angle and QTc interval in patients with traumatic brain injury with or without intra-abdominal hypertension.

Introduction: Traumatic brain injury (TBI) affects cardiac electrical function, and several extra-cerebral factors, including intra-abdominal pressure (IAP), might further modulate this brain-heart interaction. The purpose of this study was to investigate the impact of TBI, and of increased IAP during TBI, on cardiac electrical function as measured by vectorcardiographic (VCG) variables. Methods: Survival, IAP and changes in VCG variables including spatial QRS-T angle and QTc interval were measured in consecutive adult patients with either isolated TBI (iTBI), or with TBI accompanied by polytrauma to the abdomen and/or limbs (pTBI). For all patients, observations were performed just after the admission to the ICU (baseline) and at 24, 48, 72 and 96 h after admission. Results: 74 patients aged 45 ± 18 were studied. 44 were treated for iTBI and 30 for pTBI. In all patients, spatial QRS-T angle and QTc interval increased after TBI (p < 0.001), relatively more so in patients with pTBI. Compared to survivors, non-survivors also ultimately had greater widening of the spatial QRS-T angle (p < 0.001), most notably just before foraminal herniation. Wider spatial QRS-T angle and longer QTc interval were also noted in patients with IAP > 12 mmHg (p < 0.001), and with right compared to left hemispheric injury (p < 0.001). ST segment level at the J point decreased 24 and 48 h after TBI in leads I, II, III, aVR, aVF, V1, V2, V3 and V6, and increased in lead V1, especially in non-survivors. Conclusions: Spatial QRS-T angle and QTc interval increase after TBI. If foraminal herniation complicates TBI, further widening of the spatial QRS-T angle typically precedes it, followed by notable narrowing thereafter. Increased IAP also intensifies TBI-associated increases in spatial QRS-T angle and QTc interval.

Risk factors for and the prevention of acute kidney injury after abdominal surgery.

Postoperative acute kidney injury in patients undergoing abdominal surgery is not rare and often results in bad outcomes for patients. The incidence of postoperative acute kidney injury is hard to evaluate reliably due to its non-unified definitions in different studies. Risk factors for acute kidney injury specific to abdominal surgery include preoperative renal insufficiency, intraabdominal hypertension, blood transfusion, bowel preparation, perioperative dehydration, contrast agent and nephrotoxic drug use. Among these, preoperative renal insufficiency is the strongest predictor of acute kidney injury. The peri-operative management of high-risk patients should include meticulous selection of fluid solutions. Balanced crystalloid solutions and albumin are generally thought to be relatively safe, while the safety of hydroxyethyl starch solutions has been controversial. The purpose of the present review is to discuss the current knowledge regarding postoperative acute kidney injury in abdominal surgical settings to help surgeons make better decisions concerning the peri-operative management.

Emergent laparotomy and temporary abdominal closure for the cirrhotic patient.

BACKGROUND: Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients. METHODS: We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals. RESULTS: At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients. CONCLUSIONS: Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.

Valsalva maneuver exacerbates left atrial compression in patients with large hiatal hernia.

INTRODUCTION: Hiatal hernia (HH) can cause left atrial (LA) compression and impair LA filling. We evaluated the cardiac effects of preload reduction and abdominal strain induced by Valsalva maneuver (VM) in large HH patients. METHODS: LA and left ventricular (LV) dimensions were measured using 2D transthoracic echocardiography at rest and during VM in HH patients (n=55, 70±10 years) and controls (n=22, 67±6 years). Biplane LV volumes (n=39) and mitral inflow pulse-wave Doppler parameters (n=27) were also evaluated. In HH patients, resting LA compression was graded qualitatively (none-mild or moderate-severe). RESULTS: In both controls and HH patients, VM significantly decreased LA (controls, 19±2 vs 16±3 mm/m2 ; HH, 16±5 vs 9±5 mm/m2 ) and LV diameters (22±3 vs 19±3 mm/m2 ; 21±3 vs 17±3 mm/m2 ) and LV volume (38±8 vs 26±10 mL/m2 ; 31±8 vs 19±9 mL/m2 ) (P<.001 for all). VM decreased LA diameter significantly more in HH patients than controls (-42% vs -16%, P<.001). HH patients with none-mild resting LA compression exhibited significantly greater LA diameter reduction than controls (-38±23% vs -16±13% P=.0003) despite similar resting LA diameters. LV volumes were similarly decreased by VM in HH patients and controls irrespective of resting LA compression severity indicating relative preservation of LV filling. LA diameter correlated inversely with early diastolic filling velocity during VM in HH patients (R=-.43, P=.03) but not controls (R=.18, P=.43). CONCLUSION: VM can markedly exacerbate LA compression in HH patients; however, LV filling is relatively less affected possibly due to augmented early diastolic filling. Conditions associated with decreased preload and increased intra-abdominal pressure may exacerbate the cardiac effects of large HH.

[A case of progressive glaucoma against the background of chronic constipation]. / Sluchai prog-ressivnogo techeniia glaukomy na fone khronicheskoi obstipatsii.

The authors describe a case of severe glaucoma in the only seeing eye of a patient with venous circulation disturbance resulting from a chronic anal fissure complicated with progressive anal stenosis, severe sphincter spasm, and pain syndrome. The article presents the results of multiple clinical ophthalmological tests and instrumental examinations performed before and after surgical intervention that evidence the importance of venous circulation disturbances for glaucoma development.

[CORRECTION OF INTRAABDOMINAL PRESSURE IN RATS IN AN ACUTE PANCREATITIS, USING INFUSION OF MYORELAXANT OF A DURABLE ACTION PIPECURONIUM BROMIDE].

Impact of a durable action of myorelaxant pipecuronium bromide on intraabdominal pressure (IAP) in rats in experimentally simulated acute peritonitis was studied. In the rats in purulent pancreatitis, іnduced by L-аrginin, IAP was in 4,5 times high (p < 0.001), than in intact laboratory animals. Pipecuronium bromide have lowered IAP by 33.4%, witnessing efficacy of application of myorelaxants in treatment of intraabdominal hypertension in purulent pancreatitis.