Abdominal compartment syndrome: A review.

OBJECTIVES: The aims of this review were to summarize a) the consensus definitions of normal and pathologic intra-abdominal pressure (IAP); b) the techniques to measure IAP; c) the risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); d) the pathophysiology of ACS; and e) the current recommendations for management and prevention of ACS. DATA SOURCES: PubMed was searched using the following terms: ACS, IAH, IAP, and abdominal decompression. DATA SYNTHESIS: ACS represents the natural progression of end-organ dysfunction caused by increased IAP and develops if IAH is not recognized and treated appropriately. Although the reported incidence of ACS is relatively low in critically ill children (0.6%-4.7%) it may be under-recognized and under-reported. The diagnosis of IAH/ACS depends on a high index of suspicion and the accurate and frequent measurement of IAP in patients at risk. Mortality from ACS remains high (50%-60%) even when decompression of the abdomen is performed early, which highlights the importance of detection and treatment of elevated IAP before end-organ damage occurs. CONCLUSIONS: A widespread awareness of the recognition and current approach to management and prevention of IAH and ACS is needed among pediatric intensivists, so outcome of these life-threatening disease processes might be improved.

Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock.

PURPOSE: The objective of this article is to study the cumulative incidence of intra-abdominal hypertension (IAH) in septic shock (SS) patients during the first 72 hours of intensive care unit (ICU) admission and to determine if the presence and severity of IAH are associated with sepsis morbidity and mortality. MATERIALS AND METHODS: Eighty-one consecutive SS patients admitted to a surgical-medical ICU of an academic university hospital (January 2005 to January 2006) were included. Intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) were measured every 6 h (intermittently) for 72 h. Intra-abdominal pressure was registered as minimal, mean, and maximal values per day, during shock and throughout the study period. Intra-abdominal hypertension was diagnosed if IAP remained 12 mm Hg or higher on 2 consecutive measurements and stratified according to the most recent consensus definition (www.wsacs.org). RESULTS: According to maximal and mean IAP values, 67 (82.7%) and 62 (76.5%) of the patients developed IAH during the study period, respectively. Mean IAP values remained stable throughout the study period. Surgical patients had a higher incidence of IAH than medical patients (93% vs 73%, P < .009). Maximal IAPs were normally distributed, with nonsurvivors exhibiting significantly higher IAP levels during shock (survivors, 17.2 +/- 5.3; nonsurvivors, 19.9 +/- 5.6 mm Hg; P < .04). Patients with IAH exhibited significantly lower values of APP and diuresis, higher values of lactate and creatinine, and higher maximal norepinephrine doses, and were more frequently mechanically ventilated (P < .05 for all). Increasing degrees of IAH and the development of the abdominal compartment syndrome were associated with lower APP and higher maximal serum creatinine levels (P < .03 for both). CONCLUSIONS: Septic shock patients have a very high incidence of IAH, which seems to be associated with the severity of shock and could be related to the development of organ dysfunctions, particularly renal dysfunction. Intra-abdominal pressure should be routinely monitored during the course of SS.

Incidence and clinical effects of intra-abdominal hypertension in critically ill patients.

OBJECTIVE: The objective of this study was to determine the epidemiology and outcomes of intra-abdominal hypertension in a heterogeneous intensive care unit population. DESIGN: This was a prospective cohort study. SETTING: This study was conducted at a medical-surgical intensive care unit in a university hospital. PATIENTS: Study patients included all those consecutively admitted during 9 months, staying > 24 hrs, and requiring bladder catheterization. MEASUREMENTS AND MAIN RESULTS: On admission, epidemiologic data and risk factors for intra-abdominal hypertension were studied; then, daily maximal and mean intra-abdominal pressures (IAP(max) and IAP(mean)), abdominal perfusion pressure, fluid balances, filtration gradient, and sequential organ failure assessment score, were registered. IAPs were recorded through a bladder catheter every 6 hrs until death, discharge, or along 7 days. Intra-abdominal hypertension was defined as IAP > or = 12 mm Hg. Abdominal compartment syndrome was defined as IAP > or = 20 mm Hg plus > or = 1 new organ failure. Main outcome measure was hospital mortality. Of 83 patients, considering IAP(max), 31% had intra-abdominal hypertension on admission and another 33% developed it after (23% and 31% with IAP(mean)). Main risk factors were mechanical ventilation, acute respiratory distress syndrome, and fluid resuscitation (relative risk, 5.26, 3.19, and 2.50, respectively). Patients with intra-abdominal hypertension were sicker, had higher mortality (53% vs. 27%, p = .02), and consistently showed higher total and renal sequential organ failure assessment score, daily and cumulative fluid balances, and lower filtration gradient. Nonsurvivors had higher IAP(max), IAP(mean), and fluid balances and lower abdominal perfusion pressure. Abdominal compartment syndrome developed in 12%; 20% survived. Logistic regression identified IAP(max) as an independent predictor of mortality (odds ratio, 1.17; 95% confidence interval, 1.05-1.30; p = .003) after adjusting with Acute Physiology and Chronic Health Evaluation II and comorbidities (odds ratio, 1.15; 95% confidence interval, 1.06-1.25; p = .001; and odds ratio, 2.68; 95% confidence interval, 1.27-5.67; p = .013, respectively). Models with IAP(mean) and abdominal perfusion pressure also performed well. Areas under receiver operating characteristic curves were .81 and .83. CONCLUSIONS: Intra-abdominal hypertension, diagnosed either with IAP(max) or IAP(mean), was frequent and showed an independent association with mortality. Intra-abdominal hypertension was significantly associated with more severe organ failures, particularly renal and respiratory, and a prolonged intensive care unit stay.

[Early diagnosis and risk factors associated with abdominal compartment syndrome]. / Detección temprana y factores de riesgo asociados al síndrome compartimental abdominal.

INTRODUCTION: Abdominal compartment syndrome (ACS) is a clinical entity that develops after sustained and uncontrolled intraabdominal hypertension (IAHT). The ACS is clinically characterized by a massively distended abdomen and respiratory, cardiovascular, neurologic, and renal dysfunction. OBJECTIVE: The goal of this study was to demonstrate the benefit of early diagnosis of intra-abdominal hypertension and ACS and to identify risk factors associated with mortality. MATERIAL AND METHODS: We used a prospective study that included all patients admitted to Hospital de Especialidades Miguel Hidalgo with known ACS risk factors between January 2002 and December 2003. All patients were submitted to systematic measurements of intra-abdominal pressure (IAP). Those patients with grade III-IV IAHT were treated with decompressive laparotomy. RESULTS: Included in the study were 32 patients (23 males and 9 females). Mean age was 45.0 +/- 18.34 years. Twenty three patients developed IAHT grade I-II (group I) and nine developed grade IIIIV (group II). All group II patients were treated with abdominal decompression. The most common clinical entities associated were closed abdominal trauma (28%), hernias (15%), intestinal occlusions: (12.5%), acute pancreatitis (9.4%) and mesenteric ischemia (6.3%). Grade III-IV IAHT was statistically associated with reoperation (p = 0.038), acidosis (p = 0.003), anuria (p < 0.001) and sustained arterial hypotension (p = 0.004). The significant variables associated to mortality were anuria (p = 0.024) and grade III-IV IAHTA (0.017). CONCLUSIONS: It is possible to make an early diagnosis of IAHT and ACS with an indirect measurement of IAP. The most important factors related to mortality are anuria and IAHT.