Trends and clinical outcomes of abdominal compartment syndrome among intensive care hospitalizations.

BACKGROUND: Abdominal compartment syndrome has been shown to be a highly morbid condition among patients admitted to the intensive care unit. The present study sought to characterize trends as well as clinical and financial outcomes of patients with abdominal compartment syndrome. METHODS: The 2010 to 2020 National Inpatient Sample was used to identify adults (≥18 years) admitted to the intensive care unit. Standard mean differences were obtained to demonstrate effect size with >0.1 denoting significance. Hospitals were divided into tertiles based on annual institutional intensive care unit admissions. Multivariable regression models were used to evaluate the association of abdominal compartment syndrome on outcomes. The primary endpoint was in-hospital mortality, while complications, costs, and length of stay were secondarily considered. RESULTS: Of 11,804,585 patients, 19,644 (0.17%) developed abdominal compartment syndrome. Over the study period, the incidence of abdominal compartment syndrome (2010-0.19%, 2020-0.20%, P < .001) remained similar. Those with abdominal compartment syndrome were more commonly admitted for gastrointestinal (22.8% vs 8.4%) and cardiovascular (22.6% vs 14.9%) etiologies and were more frequently managed at urban teaching hospitals (77.7% vs 65.1%) as well as high-volume intensive care units (85.2% vs 79.1%) (all standard mean differences >0.1). After adjustment, abdominal compartment syndrome was associated with higher odds of mortality (adjusted odds ratio: 3.84, 95% confidence interval: 3.57-4.13, reference: non-abdominal compartment syndrome). Incremental length of stay (ß: +5.0 days, 95% confidence interval: 4.2-5.8) and costs (ß: $49.3K, 95% confidence interval: 45.3-53.4) were significantly higher in abdominal compartment syndrome compared to non-abdominal compartment syndrome. CONCLUSION: Abdominal compartment syndrome, while an uncommon occurrence among intensive care unit patients, remains highly morbid with significant resource burden. Further work exploring factors to mitigate its clinical and financial burden is needed.

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.

Editor's Choice - Abdominal Compartment Syndrome after Surgery for Abdominal Aortic Aneurysm: Subgroups, Risk Factors, and Outcome.

OBJECTIVES: Abdominal compartment syndrome (ACS) is a serious complication after abdominal aortic aneurysm (AAA) repair. The aim was to investigate outcome among subgroups and factors associated with outcome, with emphasis on the duration of intra-abdominal hypertension before treatment. METHODS: Since 2008, ACS and decompressive laparotomy (DL) after AAA repair are registered prospectively in the Swedish vascular registry (Swedvasc). Registry data and case records were reviewed. Subgroups were defined by main pathophysiological finding at DL, timing of DL after AAA repair, and treatment modality. RESULTS: During 2008-2015, 120 of 8765 patients undergoing surgery for infrarenal AAA developed post-operative ACS (1.4%). Eighty-three followed ruptured AAA (rAAA); 45 open surgical repairs (OSR) and 38 endovascular (EVAR), and thirty-seven after intact AAA (iAAA); 30 OSR and seven EVAR. The main pathophysiological findings at DL were bowel ischaemia in 27 (23.3%), post-operative bleeding in 34 (29.3%), and general oedema in 55 (47.4%). DL was performed <24 hours after AAA repair in 56 (48.7%), 24-48 hours in 30 (26.1%), and >48 hours in 29 patients (25.2%). The overall 90 day mortality was 50.0%, neither different depending on main pathophysiological finding, nor on the timing of DL. In multivariable regression analysis, age was a predictor of mortality (p = .017), while duration of intra-abdominal hypertension (IAH) prior to DL predicted the need for renal replacement therapy (RRT) (p = .033). DL was performed earlier after EVAR compared with OSR in rAAA (p < .001). CONCLUSIONS: Mortality in ACS was high, irrespective of the main pathophysiological finding and timing of DL. The duration of IAH prior to DL predicted the need for RRT. DL was performed earlier after EVAR than after OSR for rAAA, underlining the importance of monitoring IAP after EVAR for rAAA.

The relationship of abdominal perfusion pressure with mortality in critically ill pediatric patients.

PURPOSE: To the best of our knowledge, in the literature, there is no data regarding clinical utility of the abdominal perfusion pressure (APP) in critically ill children. Thus, in the present study, we aimed to investigate the clinical utility of APP in predicting of survival in critically ill children with IAH. DESIGN: A prospective cohort study of patients between 1 month to 18 years who had risk for intra-abdominal hypertension from June 2013 to January 2014. SETTING: Pediatric intensive care unit (PICU) at a tertiary university hospital. PATIENTS: Thirty-five (16 female) PICU patients who had risk for the development of IAH were included. Serial intraabdominal pressure (IAP) and mean arterial pressure (MAP) measurements were performed. Abdominal perfusion pressure was calculated using the formula (MAP-IAP). MEASUREMENTS AND MAIN RESULTS: Overall mortality rate was 49% (n = 17). The mortality rate in patients with IAP mean ≥10 mmHg (n = 27, 77%) was 55% (n = 15), while 53% (n = 16) in patients with IAP max ≥10 mmHg (n = 30, 86%) and 47% (n = 7) in patients with IAP min ≥ 10 mmHg (n = 15, 43%). Overall mean APP was 58 ±â€¯20 mmHg. Logistic regression analysis revealed that decrease in minAPP was associated with increased risk for mortality (Odds ratio for each 1 mmHg decrease in APP was 1.052 [CI 95%, 1.006-1.100], p < 0.05). ROC curve analysis revealed that, in predicting mortality, area under curve for minAPP was 0.765. The optimal cut-off point for APP was obtained as 53 mmHg with the 77.8% sensitivity and 70.6% specificity using the IU method. CONCLUSIONS: Our findings showed that APP seems to be a useful tool in predicting mortality. Interventions to improve APP may be associated with better outcomes in critically ill PICU patients. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Diagnostic.

Effects of temporary abdominal closure methods on mortality and morbidity in patients with open abdomen.

BACKGROUND: Open abdomen (OA) in which the abdomen is closed with temporary abdominal closure methods is the most effective in patients who develop severe abdominal sepsis or abdominal compartment syndrome. Major techniques used are Vacuum-Assisted Closure Method (VACM) and non-vacuum assisted closure method (NVACM). In the present study, the effects of different abdominal closure methods on morbidity and mortality were evaluated. METHODS: In the study, the temporary abdominal closure methods of the patients with OA during 2013-2016 were studied retrospectively. OA etiopathologies, mortality prediction scores, final abdominal closure periods and methods, hospitalization periods, complications (enteroatmospheric fistula, mesh infection, and incisional hernia), and mortality rates of patients who underwent VACM and NVACM were determined and compared. RESULTS: The present study included 123 patients who underwent VACM (n=65) and NVACM (n=58). There was no difference between the groups in terms of age, gender, and etiopathogenesis (p>0.05). The mean APACHE 4 and Multiple Organ Dysfunction Score (MODS) scores in the VACM/NVACM groups in treatment period were 47/63 and 11/14, respectively (p<0.05). The mean intensive care and hospitalization periods in the VACM/NVACM groups were 11/16 (days) and 22/28 (days), respectively (p<0.05). The collection and abscess development rates in the VACM and NVACM groups were 46.2% and 77.6%, respectively (p<0.05). The rate of enteroatmospheric fistula (EAF) development in the VACM and NVACM groups were 15.4% and 56.9%, respectively (p<0.05). The mean abdominal closure times in the VACM and NVACM groups were 13 and 17 days, respectively (p<0.05). Mortality rate in the VACM and NVACM groups were 18% (n=18) and 55% (n=32), respectively (p<0.05). CONCLUSION: In patients with OA, the temporary abdominal closure technique VACM has lower complication and mortality rates and shorter hospitalization period than other methods. Therefore, it is an effective and safe method for the treatment of OA.

Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU.

OBJECTIVES: To determine the prevalence of intra-abdominal hypertension in mixed medical-surgical critically ill patients using modern definitions and measurement techniques. Secondarily to determine variables associated with intra-abdominal hypertension and ICU mortality. DESIGN: A prospective observational study. SETTING: Single institution trauma, medical and surgical ICU in Canada. PATIENTS: Consecutive adult patients admitted to the ICU (n = 285). INTERVENTION: Intra-abdominal pressure measurements twice a day during admission to the ICU. MEASUREMENTS AND MAIN RESULTS: In 285 patients who met inclusion criteria, 30% were diagnosed with intra-abdominal hypertension at admission and a further 15% developed intra-abdominal hypertension during admission. The prevalence of abdominal compartment syndrome was 3%. Obesity, sepsis, mechanical ventilation, and 24-hour fluid balance (> 3 L) were all independent predictors for intra-abdominal hypertension. Intra-abdominal hypertension occurred in 28% of nonventilated patients. Admission type (medical vs surgical vs trauma) was not a significant predictor of intra-abdominal hypertension. Overall ICU mortality was 20% and was significantly higher for patients with intra-abdominal hypertension (30%) compared with patients without intra-abdominal hypertension (11%). Intra-abdominal hypertension of any grade was an independent predictor of mortality (odds ratio, 3.33; 95% CI, 1.46-7.57). CONCLUSIONS: Intra-abdominal hypertension is common in both surgical and nonsurgical patients in the intensive care setting and was found to be independently associated with mortality. Despite prior reports to the contrary, intra-abdominal hypertension develops in nonventilated patients and in patients who do not have intra-abdominal hypertension at admission. Intra-abdominal pressure monitoring is inexpensive, provides valuable clinical information, and there may be a role for its routine measurement in the ICU. Future work should evaluate the impact of early interventions for patients with intra-abdominal hypertension.

Postoperative Development of Abdominal Compartment Syndrome among Patients Undergoing Endovascular Aortic Repair for Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: Abdominal compartment syndrome (ACS) has a reported incidence of 9%-14% among trauma patients. However, in patients with similar hemodynamic changes, the incidence of ACS remains unclear. Our aim was to determine the incidence of ACS among patients undergoing endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) and to identify associated risk factors. METHODS: A retrospective review was performed for consecutive patients who underwent EVAR for rAAA from March 2010 to November 2016 at our institution. The development of ACS was diagnosed based on a variety of factors, including bladder pressure, laboratory abnormalities, hemodynamic monitoring, and clinical evaluation. Previously validated risk factors for ACS development in trauma and EVAR patients (preoperative hypotension, aggressive fluid resuscitation, postoperative anemia, use of an aorto-uniiliac graft, and placement of an aortic occlusive balloon) were analyzed. Association between patient characteristics and ACS development was analyzed using the Fisher's exact test. RESULTS: During the study period, 25 patients had image-confirmed rAAA and underwent emergent EVAR. Mortality rate was 28% (n = 7), and ACS incidence was 12% (n = 3). Of the analyzed risk factors, hypotension on arrival (P = 0.037), transfusion of 3 or more units of packed red blood cells (P = 0.037), and postoperative anemia (P = 0.02) were all significantly associated with postoperative ACS development. In addition, having greater than 3 of the studied risk factors was associated with increased odds of developing ACS (P = 0.015), and having greater than 4 of the studied risk factors showed the strongest association with ACS development (P = 0.0017). CONCLUSIONS: Overresuscitation should be avoided in patients with rAAA. In addition, patients who present with multiple risk factors for ACS should be monitored very closely with serial bladder pressures and may require decompression laparotomy immediately after EVAR.

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.

Analysis of treatment of large abdominal malignancies in children complicated with abdominal compartment syndrome: Report of six cases.

To explore effective treatment of large abdominal malignancies in children complicated with abdominal compartment syndrome (ACS).Six children with large abdominal malignancies complicated with ACS were admitted to our department from January 2013 to January 2016, and the changes in their breathing, heart rate, oxygen saturation, abdominal circumference, bladder pressure, and urine output, as well as the treatment measures and outcomes, were retrospectively analyzed.The 6 children included 1 child with bilateral nephroblastoma, 1 child with abdominal alveolar rhabdomyosarcoma, 1 child with right ovarian malignant teratoma complicated with abdominal glioma, 1 child with abdominal malignant teratoma, 1 child with right nephroblastoma, and 1 child with left adrenal gland neuroblastoma. All patients were treated in a timely manner. The first 4 children underwent abdominal cavity decompression through surgical resection of the tumor, and the ACS was successfully cured allowing for follow-up care, whereas the last 2 patients failed to receive emergency surgery and eventually died due to the gradual aggravation of ACS.Decompression through surgical resection of the tumor is the only effective measure for treating large abdominal malignancies in children complicated with ACS.

How much does decompressive laparotomy reduce the mortality rate in primary abdominal compartment syndrome?: A single-center prospective study on 66 patients.

Contribution of decompressive laparotomy within the framework of the complex therapeutic algorithm of abdominal compartment syndrome (ACS) is cited with an extremely heterogeneous percentage in terms of survival. The purpose of this study was to present new data regarding contribution of each therapeutic step toward decreasing the mortality of this syndrome.This is a longitudinal prospective study including 134 patients with risk factors for ACS. The intra-abdominal pressure was measured every hour indirectly based on transvesical approach and the appearance of organ dysfunction. Specific therapy for ACS was based on the 2013 World Society of Abdominal Compartment Syndrome guidelines, which include laparotomy decompression. Management of the temporarily open abdomen included an assisted vacuum wound therapy.Of 134 patients, 66 developed ACS. The average intra-abdominal pressure significantly decreased after therapy and decompression surgery. The overall rate of mortality was 27.3% with statistical significance in necrotizing infected pancreatitis. Surgical decompression performed within the first 24 hours after the onset of ACS had a protective role against mortality (odds ratio <1). The average time after which laparotomy decompression was performed was 16.23 hours. The complications occurred during TAC were 2 wound suppurations and 1 intestinal obstruction. Wound suppurations evolved favorably by using vacuum wound-assisted therapy associated with the general treatment, whereas for occlusion, resurgery was performed after which adhesions dissolved. The final closure of the abdomen was performed at a mean of 11.7 days (min. = 9, max. = 14). The closure type was primary suture of the musculoaponeurotic edges in 4 cases, and the use of dual mesh in the other 11 cases.The highest mortality rate in the study group was registered in patients with necrotizing pancreatitis and the lowest in trauma group. Surgical decompression within the framework of the complex algorithm treatment of ACS contributed to the reduction of mortality by 8.7%. It is extremely important that the elapsed time since the initiation of the ACS until the surgical decompression is minimal (under 24 hours).

How to identify patients at risk of abdominal compartment syndrome after surgical repair of ruptured abdominal aortic aneurysms in the operating room: A pilot study.

Objectives Abdominal compartment syndrome (ACS) is poorly identified in surgery for ruptured abdominal aortic aneurysm and an early management is crucial. The aim of this study was to validate how many risk factors were needed to predict ACS. Secondary objectives were to assess its prevalence and the 30-day mortality. Methods All patients operated for ruptured abdominal aortic aneurysm during 5 years were included. An independent committee performed a retrospective diagnosis of ACS. Eight criteria were selected from the literature, and corresponded to pre- and intraoperative period: anemia (hemoglobin lower than 10 g/dL), prolonged shock (systolic blood pressure <90 mmHg more than 18 min), preoperative cardiac arrest, obesity (body mass index > 30), massive fluid resuscitation (≥3500 mL per hour for at least 1 h) and transfusions (>10 units packed blood red cell since the beginning of the treatment), severe hypothermia (≤33℃), acidosis (pH < 7.2). Sensitivity and specificity were assessed for each number of criteria. Results Eight patients were ACS+ and 28 ACS-, with three criteria for ACS+ and 1.5 for ACS- ( p = 0.002). Three criteria among the eight selected criteria have the best cutoff for sensitivity and specificity (75% and 82%) with a positive predictive value of 54% and a negative predictive value of 92%. The prevalence of ACS was 17%. The 30-day mortality in ACS+ tended to be higher than in ACS- ( p = 0.108). Conclusion The present results suggest that patients with an ACS seemed to have higher mortality and the threshold of three factors among eight specific factors is enough to predict this.

Endovascular repair of ruptured abdominal aortic aneurysms with the endurant stent-graft: a combined experience from three centers.

BACKGROUND: Endovascular repair of ruptured abdominal aortic aneurysms (RAAAs) has been previously reported to reduce mortality rates compared to open repair. Newer stent-grafts may provide even better results with applicability in a larger number of patients. We present our experience with the Medtronic Endurant endograft over a three-year period. METHODS: Consecutive cases of RAAAs which have been managed with the Endurant stent-graft were recruited from three centers and were analyzed retrospectively. Twenty-three patients (22 males; mean age 74±9 years) were treated between June 2010 and May 2013. RESULTS: The technical success rate was 100% with no intraoperative endoleaks. Thirty-day mortality was 13% (3/23 patients). Two patients required prolonged hospitalization and mechanical ventilation. For the remaining 18 patients, the average hospitalization length was 5.5 days. Two major risk factors were found to be significantly associated with increased mortality: low systolic blood pressure on arrival at the hospital (63±6 vs. 99±22; P=0.01), and post-operative development of an abdominal compartment syndrome (Relative Risk - RR=13.3, 95% confidence interval - CI: 1.6-106; P=0.03). Other important clinical variables which did not significantly affect mortality included age (mean age 83±9 years in those who died vs. 73±9 years in the survivors; P=0.09), type of graft (bifurcated vs. aorto-uni-iliac; RR=2.2, 95% CI: 0.3-15; P=0.4), aneurysm diameter (11±4 cm vs. 9±2 cm; P=0.28), and proximal neck angulation (68±14 vs. 57±26 degrees; P=0.5). A proximal neck angulation >75° was not associated with a higher mortality rate (RR=1.33, 95% CI: 0.22-7.8; P=1). CONCLUSIONS: Endovascular repair of RAAAs resulted in high technical success and low mortality rates in this series of patients treated with the Endurant stent graft. Hypotension on arrival to the hospital and development of an abdominal compartment syndrome were predictive of increased risk of death. Patient age, aneurysm diameter and graft configuration did not negatively impact survival. Non-compliance with the device instructions for use (IFU) did not adversely affect results in this small patient series. Larger studies are needed to confirm our results.

Open Abdomen Treated with Negative Pressure Wound Therapy: Indications, Management and Survival.

BACKGROUND: Open abdomen treatment (OAT) is a significant burden for patients and is associated with considerable mortality. The primary aim of this study was to report survival and cause of mortality after OAT. Secondary aims were to evaluate length of stay (LOS) in intensive care unit (ICU) and in hospital, time to abdominal closure and major complications. METHODS: Retrospective review of prospectively registered patients undergoing OAT between October 2006 and June 2014 at Trondheim University Hospital, Norway. RESULTS: The 118 patients with OAT had a median age of 63 (20-88) years. OAT indications were abdominal compartment syndrome (ACS) (n = 53), prophylactic (n = 29), abdominal contamination/second look laparotomy (n = 22), necrotizing fasciitis (n = 7), hemorrhage packing (n = 4) and full-thickness wound dehiscence (n = 3). Eight percent were trauma patients. Vacuum-assisted wound closure (VAWC) with mesh-mediated traction (VAWCM) was used in 92 (78 %) patients, the remaining 26 (22 %) had VAWC only. Per-protocol primary fascial closure rate was 84 %. Median time to abdominal closure was 12 days (1-143). LOS in the ICU was 15 (1-89), and in hospital 29 (1-246) days. Eighty-one (68 %) patients survived the hospital stay. Renal failure requiring renal replacement therapy (RRT) (OR 3.9, 95 % CI 1.37-11.11), ACS (OR 3.1, 95 % CI 1.19-8.29) and advanced age (OR 1.045, 95 % CI 1.004-1.088) were independent predictors of mortality in multivariate analysis. The nine patients with an entero-atmospheric fistula (EAF) survived. CONCLUSION: Two-thirds of the patients treated with OAT survived. Renal failure with RRT, ACS and advanced age were predictors of mortality, whereas EAF was not associated with increased mortality.

Laparotomy during endovascular repair of ruptured abdominal aortic aneurysms increases mortality.

OBJECTIVE: Subset analyses from small case series suggest patients requiring laparotomy during endovascular repair of ruptured abdominal aortic aneurysms (REVAR) have worse survival than those undergoing REVAR without laparotomy. Most concomitant laparotomies are performed for abdominal compartment syndrome. This study used data from the American College of Surgeons National Surgical Quality Improvement Program to determine whether the need for laparotomy during REVAR is associated with increased mortality. METHODS: Data were obtained from the 2005 to 2013 National Surgical Quality Improvement Program participant user files based on Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases-9 Edition coding. Patient and procedure-related characteristics and 30-day postoperative outcomes were compared using Pearson χ2 tests for categoric variables and Wilcoxon rank sum tests for continuous variables. A backward-stepwise multivariable logistic regression model was used to identify patient- and procedure-related factors associated with increased death after REVAR. RESULTS: We identified 1241 patients who underwent REVAR, and 91 (7.3%) required concomitant laparotomy. The 30-day mortality was 60% in the laparotomy group and 21% in the standard REVAR group (P < .001). The major complication rate was also higher in the laparotomy group (88% vs 63%; P < .001). Multivariable analysis showed laparotomy was strongly associated with 30-day mortality (odds ratio, 5.91; 95% confidence interval, 3.62-9.62; P < .001). CONCLUSIONS: Laparotomy during REVAR is a commonly used technique for the management of elevated intra-abdominal pressure and abdominal compartment syndrome development. The results of this study strongly confirm findings from smaller studies that the need for laparotomy during REVAR is associated with significantly worse 30-day survival.

Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review.

BACKGROUND: Abdominal compartment syndrome (ACS) in severely injured patients is associated with high morbidity and mortality. Many efforts have been made to improve outcome of patients with ACS. A treatment algorithm for ACS patients was introduced on January 1, 2005 by the World Society of the Abdominal Compartment Syndrome. The aim of this study was to determine the prevalence and mortality rate of ACS among severely injured patients before and after January 1, 2005 using a systematic literature review. METHOD: Databases of Embase, Medline (OvidSP), Web of Science, CINAHL, CENTRAL, PubMed publisher, and Google Scholar were searched for terms related to severely injured patients and ACS. Original studies reporting ACS in trauma patients were considered eligible. Data on study design, population, definitions, prevalence, and mortality rates were extracted. Pooled prevalence and mortality of ACS among severely injured patients were calculated for both time periods using inversed variance weighting assuming a random effects model. Tests for heterogeneity were applied. RESULTS: A total of 80 publications were included. Prevalence of studies that finished enrolling patients before January 1, 2005 ranged from 0.5% to 36.4% and 0.0% to 28.0% in studies after that date. For severely injured patients admitted to the ICU, this range was 0.5% to 1.3% before 2005 and 0% in one publication in the second time period. For patients with visceral injuries, ACS prevalence ranged 1.0% to 20.0%; one study in the second time period reported 11.1%. The prevalence among severely injured patients who underwent trauma laparotomy ranged from 0.9% to 36.4% in the first time period. Two studies after January 1, 2005 reported ACS prevalence of 2.3% and 13.2%, respectively. The mortality rate in both time periods ranged between 0.0% and 100.0%. CONCLUSION: The overall prevalence of ACS ranged from 0.0% to 36.4%. Future studies are needed to measure the effect of improved trauma care and effectiveness of the World Society of the Abdominal Compartment Syndrome Consensus Statements. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.

Increased pressure within the abdominal compartment: intra-abdominal hypertension and the abdominal compartment syndrome.

PURPOSE OF REVIEW: This article reviews recent developments related to intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) and clinical practice guidelines published in 2013. RECENT FINDINGS: IAH/ACS often develops because of the acute intestinal distress syndrome. Although the incidence of postinjury ACS is decreasing, IAH remains common and associated with significant morbidity and mortality among critically ill/injured patients. Many risk factors for IAH include those findings suggested to be indications for use of damage control surgery in trauma patients. Medical management strategies for IAH/ACS include sedation/analgesia, neuromuscular blocking and prokinetic agents, enteral decompression tubes, interventions that decrease fluid balance, and percutaneous catheter drainage. IAH/ACS may be prevented in patients undergoing laparotomy by leaving the abdomen open where appropriate. If ACS cannot be prevented with medical or surgical management strategies or treated with percutaneous catheter drainage, guidelines recommend urgent decompressive laparotomy. Use of negative pressure peritoneal therapy for temporary closure of the open abdomen may improve the systemic inflammatory response and patient-important outcomes. SUMMARY: In the last 15 years, investigators have better clarified the pathogenesis, epidemiology, diagnosis, and appropriate prevention of IAH/ACS. Subsequent study should be aimed at understanding which treatments effectively lower intra-abdominal pressure and whether these treatments ultimately affect patient-important outcomes.

Decompressive laparotomy for abdominal compartment syndrome.

BACKGROUND: The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes. METHODS: This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28-day and 1-year all-cause mortality. Changes in intra-abdominal pressure (IAP) and organ function, and laparotomy-related morbidity were secondary endpoints. RESULTS: Thirty-three patients were included in the study (20 men). Twenty-seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20-32). Median IAP was 23 (21-27) mmHg before decompressive laparotomy, decreasing to 12 (9-15), 13 (8-17), 12 (9-15) and 12 (9-14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non-survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28-day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non-survivors were no different from survivors, except that they tended to be older and on mechanical ventilation. CONCLUSION: Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Secondary abdominal compartment syndrome after complicated traumatic lower extremity vascular injuries.

INTRODUCTION: Secondary abdominal compartment syndrome (ACS) can occur in trauma patients without abdominal injuries. Surgical management of patients presenting with secondary ACS after isolated traumatic lower extremity vascular injury (LEVI) continues to evolve, and associated outcomes remain unknown. METHODS: From January 2006 to September 2011, 191 adult trauma patients presented to the Ryder Trauma Center, an urban level I trauma center in Miami, Florida with traumatic LEVIs. Among them 10 (5.2 %) patients were diagnosed with secondary ACS. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: Mean age was 37.4 ± 18.0 years (range 16-66 years), and the majority of patients were males (8 patients, 80 %). There were 7 (70 %) penetrating injuries (5 gunshot wounds and 2 stab wounds), and 3 blunt injuries with mean Injury Severity Score (ISS) 21.9 ± 14.3 (range 9-50). Surgical management of LEVIs included ligation (4 patients, 40 %), primary repair (1 patient, 10 %), reverse saphenous vein graft (2 patients, 20 %), and PTFE interposition grafting (3 patients, 30 %). The overall mortality rate in this series was 60 %. CONCLUSIONS: The association between secondary ACS and lower extremity vascular injuries carries high morbidity and mortality rates. Further research efforts should focus at identifying parameters to accurately determine resuscitation goals, and therefore, prevent such a devastating condition.

Incidence and Prognostic Factors for Mortality of Abdominal Hypertension in Critically Ill Surgical Patients in THAI-SICU Study.

Objective: This study aimed to investigate the incidence and prognostic factors of mortality in intra-abdominal hypertension that developed during admission in the surgical intensive care units in Thailand. Material and Method: This was a prospective observational study in nine university-based surgical intensive care units in Thailand. (THAI-SICU) The suspected patients who had the intra-abdominal pressure more than 12 mmHg were defined as intra-abdominal hypertension (IAH). The patients were followed until discharge. Results: Among 4,652 cases, a total of 71 cases (1.5%) developed IAH. The average age was 53.05+20.26 years. The median APACHE II score was 13 (9-15). Eighteen patients received surgical decompression as treatment. Metabolic acidosis (pH <7.2) and abdominal aortic surgery were the significant factors for mortality in intra-abdominal hypertension patients. Conclusion: The incidence of intra-abdominal hypertension in the critical surgical care units was low in this cohort. Intraabdominal hypertension in patients who previously received abdominal aortic surgery and who had concomitant acidosis was the independent risk factor of mortality.

Factors associated with failure-to-rescue in patients undergoing trauma laparotomy.

INTRODUCTION: Quality improvement initiatives have focused primarily on preventing in-hospital complications. Patients developing complications are at a greater risk of mortality; however, factors associated with failure-to-rescue (death after major complication) in trauma patients remain undefined. The aim of this study was to identify risk factors associated with failure-to-rescue in patients undergoing trauma laparotomy. METHODS: An -8-year, retrospective analysis of patients undergoing trauma laparotomy was performed. Patients who developed major in-hospital complications were included. Major complications were defined as respiratory, infectious, cardiac, renal, or development of compartment syndrome. Regression analysis was performed to identify independent factors associated with failure-to-rescue after we adjusted for demographics, mechanism of injury, abdominal abbreviated injury scale, initial vital signs, damage control laparotomy, and volume of crystalloids and blood products administered. RESULTS: A total of 1,029 patients were reviewed, of which 21% (n = 217) patients who developed major complications were included. The mean age was 39 ± 18 years, 82% were male, 61% had blunt trauma, and median abdominal abbreviated injury scale was 25 [16-34, interquartile range]. Respiratory complications (n = 77) followed by infectious complications (n = 75) were the most common complications. The failure-to-rescue rate was 15.7% (n = 34/217). Age, blunt trauma, severe head injury, uninsured status, and blood products administered on the second day were independent predictor for failure-to-rescue. CONCLUSION: When major complications develop, age, uninsured status, severity of head injury, and prolonged resuscitation are associated independently with failure-to-rescue, whereas initial resuscitation, coagulopathy, and acidosis did not predict failure to rescue. Quality-of-care programs focus in patient level should be on improving the patient's insurance status, preventing secondary brain injury, and further development of resuscitation guidelines.