Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions

Non-invasive and continuous intra-abdominal pressure assessment using MC sensors

Monitoring intra-abdominal pressure (IAP) in critical care patients is crucial for preventing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), with their severe consequences. The muscle contraction sensor (MC) introduced in this study offers a novel, non-invasive method with promising accuracy based on previous findings. This study further evaluates the MC accuracy and reproducibility and examines its correlation with objective IAP measurements obtained through a CO2 insufflator. We enrolled 41 patients undergoing elective laparoscopic gallbladder removal under general anesthesia with complete muscle relaxation. Two MC sensors were placed on the right and left sides of the abdomen, and elevated IAP was induced by insufflating CO2 into the peritoneal cavity. IAP measurements from the MC sensors were compared to the randomized IAP values set on the CO2 insufflator. Data from both methods were analyzed to assess the accuracy and agreement with the insufflator measurements. The MC sensor provided continuous and accurate detection of IAP changes. A Pearson correlation coefficient of 0.963 indicated a strong positive linear correlation between the MC sensor readings and the IAP values set on the insufflator. The coefficient of determination (R2) was 0.927, showing that the model explains 92.7% of the variation in IAP values based on the MC sensor signals. Receiver operating characteristic analysis demonstrated that the MC sensor system performed exceptionally well in identifying both IAH and ACS cases, with an area under the curve of 0.996 for IAH and 0.981 for ACS. The study introduces a transcutaneous pressure measuring device as an innovative, non-invasive method for assessing IAP. The system strongly correlates with IAP values measured by CO2 insufflation, indicating its accuracy. It thus could present an alternative to conventional IAP measurement in the future. The MC capability to deliver real-time, continuous data holds substantial potential for proactive patient care. By incorporating advanced analytics like machine learning, the system could detect trends and provide early warnings of dangerous IAP changes, enabling timely, targeted interventions to enhance outcomes for critically ill patients.

Elevated IAP in critically ill patients associated with increased AKI incidence: a cohort study from the MIMIC-IV database

Elevated intra-abdominal pressure can engender a spectrum of adverse physiological repercussions in patients, but further research is needed to ascertain whether elevated intra-abdominal pressure exerts significant effects on renal function. The study used MIMIC-IV database to identify critical patients with IAP monitoring. Patients were categorized into Low-IAP and High-IAP groups based on the results of the restricted cubic splines curve, with HR = 1 set at IAP = 16 mmHg. The primary outcome of the study was the occurrence of AKI within 72 h of ICU admission, and secondary outcomes including the rate of CRRT utilization and 28-day all-cause mortality. Cox proportional hazards regression analysis was employed to clarify the relationship between IAP and AKI. A total of 1746 patients were included in our study. Restricted cubic spline analysis demonstrated an increased risk of AKI with higher IAP. Multivariable Cox proportional hazards analysis uncovered a notable correlation between elevated IAP and AKI incidence (HR: 1.40(1.14-1.71)). After adjusting for confounding factors, patients with elevated IAP remained significantly related with AKI (HR: 1.23(1.01-1.52)). The Kaplan-Meier survival curves indicated a significant superior 28-day survival rate for Low-IAP group (the log-rank test p-value was 0.001) and the cumulative risk curve showed a higher demand for CRRT in the High-IAP group (the log-rank test p-value was 0.0028). Augmented intra-abdominal pressure (above 16 mmHg) is significantly associated with a higher incidence of acute kidney injury (AKI) in critically ill patients, along with an increased need for continuous renal replacement therapy (CRRT) and a higher 28-day mortality rate.

Acute Kidney Injury Secondary to Abdominal Compartment Syndrome: Biomarkers, Pressure Variability, and Clinical Outcomes

Background and Objectives: Abdominal compartment syndrome (ACS) is a severe clinical condition caused by intra-abdominal hypertension (IAH), often observed in surgical and trauma patients. However, ACS can also develop in non-surgical patients with massive ascites, leading to acute kidney injury (AKI) due to renal hypoperfusion. This study investigates the association between intra-abdominal pressure (IAP) changes, renal biomarkers, and mortality in patients with ACS-related AKI. Materials and Methods: A prospective cohort study was conducted on 24 hospitalized patients with ascites due to malignancy, cirrhosis, or heart failure. IAP was measured via the trans-vesical method on the first and seventh days of hospitalization. Serum and urinary biomarkers, including kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-6 (IL-6), were assessed for their correlation with IAP changes. The primary outcome was in-hospital mortality, and the secondary outcomes included AKI progression and the effect of paracentesis on IAP reduction. Results: The overall in-hospital mortality rate was 50%. Patients who survived had significantly lower IAP on the seventh day compared to those who died (14.9 ± 3.5 mmHg vs. 20.2 ± 5.6 mmHg, p = 0.01). A 25% reduction in IAP was associated with improved kidney function and increased survival (p < 0.001). Urinary KIM-1 and serum NGAL levels showed a moderate correlation with IAP (r = 0.55, p = 0.02 and r = 0.61, p = 0.018, respectively), while IL-6 levels were significantly higher in non-survivors (p = 0.03). Paracentesis was associated with improved survival outcomes (p = 0.04). Conclusions: ACS is a critical but often overlooked cause of AKI in non-surgical patients with massive ascites. Lowering IAP significantly improves renal function and reduces mortality. Urinary KIM-1 and serum NGAL may serve as useful biomarkers for monitoring IAP changes. The early identification and management of IAH through timely interventions such as paracentesis and volume control strategies could improve patient outcomes.

Abdominal Hypoperfusion and Acute Kidney Injury in the Critically Ill Patient with Liver Cirrhosis: A Prospective Cohort Study

Background

Reduced abdominal perfusion pressure (APP) is an underdiagnosed potential pathophysiological mechanism for acute kidney injury (AKI) in the patient with liver cirrhosis and ascites. This study aimed to analyze the prevalence of abdominal hypoperfusion (AhP) (APP <60 mm Hg) and the impact of APP on AKI in critically ill patients with liver cirrhosis.

Methods

This was a post hoc analysis from a prospective cohort study set in a general ICU at a tertiary university hospital. Patients were recruited between October 2016 and December 2021. Acute renal failure (ARF) was defined by stage 3 AKI according to the International Club of Ascites.

Results

Fifty-eight patients where included, with a mean age of 57 (±8.4) years, 79% were male, and 93% had acute-on-chronic liver failure at admission. The prevalence of AhP reached 75%, and 29% of cases had persisting AhP during the first week of ICU stay. Patients with baseline AhP had a higher 28-day mortality compared to those without AhP (respectively, 76% vs. 49%, p = 0.03). Acute renal failure developed in 48% of patients. Higher serum urea (aOR: 1.01, 95% CI: 1.00-1.02, p = 0.04) and white blood cell count (aOR: 1.1, 95% CI: 1.01-1.2, p = 0.02) at ICU admission, as well as low persisting APP (aOR: 0.9, 95% CI: 0.86-0.98, p = 0.02) were independent risk factors for ARF.

Conclusion

Critically ill patients with liver cirrhosis presented a high prevalence of ARF, independently associated with higher baseline serum urea and WBC, and lower persisting APP. A structured clinical approach to optimize APP may reduce renal dysfunction in high-risk patients with cirrhosis.

Prone Positioning in a Pregnant Woman With Severe Acute Respiratory Distress Syndrome: A Case Report

INTRODUCTION

Prone ventilation is a standard treatment for acute respiratory distress syndrome, and its clinical benefits are well established. However, implementing prone positioning safely and effectively is challenging in patients who are pregnant, have intra-abdominal hypertension, or are in other high-risk groups.

CLINICAL FINDINGS AND DIAGNOSIS

A patient in the third trimester of pregnancy (28 weeks and 6 days of gestation) developed a body temperature of 39 °C and severe respiratory distress. She was transferred to the intensive care unit, received noninvasive ventilation, and ultimately underwent endotracheal intubation. Because her oxygenation index remained below 100, she received a diagnosis of severe acute respiratory distress syndrome.

INTERVENTIONS

The patient was safely placed in the prone position with a swim ring while receiving venovenous extracorporeal membrane oxygenation. During this period, her intra-abdominal pressure did not increase significantly.

OUTCOMES

The fetus was delivered by cesarean birth, and the patient was transferred to the general ward after extubation.

CONCLUSION

This case report describes the use of prone positioning in a pregnant patient. The report offers critical care nurses insights into the clinical management of patients who are pregnant or have intra-abdominal hypertension.

Assessing gastrointestinal system dysfunction in intensive care

PURPOSE OF REVIEW

To summarize the current knowledge on the assessment of gastrointestinal dysfunction.

RECENT FINDINGS

Clinical assessment is becoming more structured but remains largely subjective. Some instrumental tools to assess gastrointestinal motility have been developed but not yet widely applied in clinical practice. Imaging techniques offer a good method for static (i.e. nonfunctional) diagnostics but a standardized dynamic assessment at the bedside is currently unavailable. Recent studies on biomarkers have not provided convincing results for accurate evaluation of gastrointestinal function.

SUMMARY

Clinical assessment remains the main tool for assessing gastrointestinal dysfunction. A single sign or symptom does not reflect gastrointestinal dysfunction adequately, and a set of variables might be needed. Studies on tools reflecting gastrointestinal motility and biomarkers for response to enteral nutrients, including absorption, are warranted.

Feasibility and accuracy of continuous intraabdominal pressure monitoring with a capsular device in human pilot trial

BACKGROUND

Intrabdominal pressure (IAP) is an important parameter. Elevated IAP can reduce visceral perfusion, lead to intraabdominal hypertension, and result in life-threatening abdominal compartment syndrome. While ingestible capsular devices have been used for various abdominal diagnoses, their application in continuous IAP monitoring remains unproven.

METHOD

We conducted a prospective clinical trial to evaluate the feasibility of IAP measurement using a digital capsule PressureDOT, an ingestible capsule equipped with wireless transmission capability and a pressure sensor, then compared its reliability with conventional intravesical method. Patients undergoing laparoscopic or robotic surgeries were recruited. During surgery, we created pneumoperitoneum by inflating CO2 into the peritoneal cavity and IAP was simultaneously monitored using both the ingestible capsules and intravesical measurements from Foley catheter. We assessed the feasibility of signal transmission and the accuracy of pressure measurements.

RESULTS

Six patients were enrolled in this pilot study. No adverse events were reported, and the average first-intake time was within 24 h. All capsules were successfully expelled, with an average excretion time of 81 h. In the summarized data, the mean IAPdot is 0.6 mmHg lower than the IAPivp, with a standard deviation of 1.68 mmHg. However, capsule measurements showed excellent correlation with intravesical IAP measurements, with an intraclass correlation coefficient of 0.916 (95% CI: 0.8821-0.9320).

CONCLUSION

Our study demonstrates the feasibility and safety of using digital capsules for continuous IAP monitoring, providing the agreement between IAP measurements from digital capsules and conventional intravesical measurement within a near-normal pressure.

Towards a better understanding of abdominal wall biomechanics: In vivo relationship between dynamic intra-abdominal pressure and magnetic resonance imaging measurements

BACKGROUND

In vivo mechanical behaviour of the abdominal wall has been poorly characterised and important details are missing regarding the occurrence and post-operative recurrence rate of hernias which can be as high as 30 %. This study aimed to assess the correlation between abdominal wall displacement and intra-abdominal pressure, as well as abdominal compliance.

METHODS

Eighteen healthy participants performed audio-guided passive (breathing) and active (coughing, Valsalva maneuver) exercises. Axial dynamic changes of abdominal muscles and visceral area were measured using MRI, and intra-abdominal pressure with ingested pressure sensor.

FINDINGS

Correlations between abdominal wall displacement and intra-abdominal pressure were specific to participant, exercise, and varying between rectus abdominis and lateral muscles. Strong correlations were found between rectus abdominis displacement and intra-abdominal pressure during breathing (r = 0.92 ± 0.06), as well as lateral muscles displacement with intra-abdominal pressure during coughing and Valsalva maneuver (r = -0.98 ± 0.03 and - 0.94 ± 0.05 respectively). The abdominal pseudo-compliance varied greatly among participants during muscular contraction, the coefficient of variation reaching up to 70 %.

INTERPRETATION

The combination of intra-abdominal pressure and dynamic MRI measurements enables the identification of participant-specific behaviour pattern. Intra-abdominal pressure and abdominal wall dynamic undergo consistent and predictable interactions. However, this relationship is subject-specific and may not be extrapolated to other individuals. Therefore, both intra-abdominal pressure and abdominal wall motion must be measured in the same participant in order to accurately characterise the abdominal wall behaviour. These results are of great importance for mesh design, surgical decision-making, and personalised healthcare.

Abdominal perfusion pressure is critical for survival analysis in patients with intra-abdominal hypertension: mortality prediction using incomplete data

BACKGROUND

Abdominal perfusion pressure (APP) is a salient feature in the design of a prognostic model for patients with intra-abdominal hypertension (IAH). However, incomplete data significantly limits the size of the beneficiary patient population in clinical practice. Using advanced artificial intelligence methods, the authors developed a robust mortality prediction model with APP from incomplete data.

METHODS

The authors retrospectively evaluated the patients with IAH from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Incomplete data were filled in using generative adversarial imputation nets (GAIN). Lastly, demographic, clinical, and laboratory findings were combined to build a 7-day mortality prediction model.

RESULTS

The authors included 1354 patients in this study, of which 63 features were extracted. Data imputation with GAIN achieved the best performance. Patients with an APP <60 mmHg had significantly higher all-cause mortality within 7-90 days. The difference remained significant in long-term survival even after propensity score matching (PSM) eliminated other mortality risks between groups. Lastly, the built machine learning model for 7-day modality prediction achieved the best results with an AUC of 0.80 in patients with confirmed IAH outperforming the other four traditional clinical scoring systems.

CONCLUSIONS

APP reduction is an important survival predictor affecting the survival prognosis of patients with IAH. The authors constructed a robust model to predict the 7-day mortality probability of patients with IAH, which is superior to the commonly used clinical scoring systems.

Effects of 24-hour urine-output trajectories on the risk of acute kidney injury in critically ill patients with cirrhosis: a retrospective cohort analysis

BACKGROUND

Acute kidney injury (AKI) is one of the most common complications for critically ill patients with cirrhosis, but it has remained unclear whether urine output fluctuations are associated with the risk of AKI in such patients. Thus, we explored the influence of 24-h urine-output trajectory on AKI in patients with cirrhosis through latent category trajectory modeling.

MATERIALS AND METHODS

This retrospective cohort study examined patients with cirrhosis using the MIMIC-IV database. Changes in the trajectories of urine output within 24 h after admission to the intensive care unit (ICU) were categorized using latent category trajectory modeling. The outcome examined was the occurrence of AKI during ICU hospitalization. The risk of AKI in patients with different trajectory classes was explored using the cumulative incidence function (CIF) and the Fine-Gray model with the sub-distribution hazard ratio (SHR) and the 95% confidence interval (CI) as size effects.

RESULTS

The study included 3,562 critically ill patients with cirrhosis, of which 2,467 (69.26%) developed AKI during ICU hospitalization. The 24-h urine-output trajectories were split into five classes (Classes 1-5). The CIF curves demonstrated that patients with continuously low urine output (Class 2), a rapid decline in urine output after initially high levels (Class 3), and urine output that decreased slowly and then stabilized at a lower level (Class 4) were at higher risk for AKI than those with consistently moderate urine output (Class 1). After fully adjusting for various confounders, Classes 2, 3, and 4 were associated with a higher risk of AKI compared with Class 1, and the respective SHRs (95% CIs) were 2.56 (1.87-3.51), 1.86 (1.34-2.59), and 1.83 1.29-2.59).

CONCLUSIONS

The 24-h urine-output trajectory is significantly associated with the risk of AKI in critically ill patients with cirrhosis. More attention should be paid to the dynamic nature of urine-output changes over time, which may help guide early intervention and improve patients' prognoses.

Safety and effectiveness of laparoscopic renal biopsy: a single-center review and meta-analysis

BACKGROUND

While renal biopsy remains the preferred diagnostic method for assessing proteinuria, hematuria, or renal failure, laparoscopic renal biopsy (LRB) can serve as an alternative for high-risk patients when percutaneous kidney biopsy (PKB) is not recommended. This study was aimed to evaluate the safety of LRB.

METHODS

In study 1, Fourteen patients from January 2021 to January 2023 had a LRB taken for various indications, such as morbid obesity, abnormal kidney construction, uncontrolled hypertension, and coagulopathy. We also conducted a Meta-analysis of the success rate and complication rate of previous LRB in study 2.

RESULTS

All the patients completed biopsies and adequate renal tissues were obtained. The success rate was 100%. The median number of glomeruli obtained was 22.5 (range:12.0, 45.0). The complication rate was 7.1% (urinary tract infection). There were no significant differences between levels of hemoglobin, serum creatinine, and urinary NAGL before and after surgery. In the meta-analysis, the success rate of operation, satisfactory rate of sample, and complication rate of surgery were 99.9%, 99.1%, and 2.6% respectively.

CONCLUSION

LRB can achieve a good success rate and specimen retrieval and does not increase the risk of complications for high-risk patients. It can present as one of the alternative methods for patients with glomerular diseases.

International cross-sectional survey on current and updated definitions of intra-abdominal hypertension and abdominal compartment syndrome

BACKGROUND

The Abdominal Compartment Society (WSACS) established consensus definitions and recommendations for the management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in 2006, and they were last updated in 2013. The WSACS conducted an international survey between 2022 and 2023 to seek the agreement of healthcare practitioners (HCPs) worldwide on current and new candidate statements that may be used for future guidelines.

METHODS

A self-administered, online cross-sectional survey was conducted under the auspices of the WSACS to assess the level of agreement among HCPs over current and new candidate statements. The survey, distributed electronically worldwide, collected agreement or disagreement with statements on the measurement of intra-abdominal pressure (IAP), pathophysiology, definitions, and management of IAH/ACS. Statistical analysis assessed agreement levels, expressed in percentages, on statements among respondents, and comparisons between groups were performed according to the respondent's education status, base specialty, duration of work experience, role (intensivist vs non-intensivist) and involvement in previous guidelines. Agreement was considered to be reached when 80% or more of the respondents agreed with a particular statement.

RESULTS

A total of 1042 respondents from 102 countries, predominantly physicians (73%), of whom 48% were intensivists, participated. Only 59% of HCPs were aware of the 2013 WSACS guidelines, and 41% incorporated them into practice. Despite agreement in most statements, significant variability existed. Notably, agreement was not reached on four new candidate statements: "normal intra-abdominal pressure (IAP) is 10 mmHg in critically ill adults" (77%), "clinical assessment and estimation of IAP is inaccurate" (65.2%), "intragastric can be an alternative to the intravesical route for IAP measurement" (70.4%), and "measurement of IAP should be repeated in the resting position after measurement in a supine position" (71.9%). The survey elucidated nuances in clinical practice and highlighted areas for further education and standardization.

CONCLUSION

More than ten years after the last published guidelines, this worldwide cross-sectional survey collected feedback and evaluated the level of agreement with current recommendations and new candidate statements. This will inform the consensus process for future guideline development.

Phlegmonous Gastritis With Streptococcal Toxic Shock Syndrome: A Rare Complication After Endoscopy

Phlegmonous gastritis is a rare, suppurative bacterial infection of the gastric wall and one of the rarest complications after upper gastrointestinal endoscopy. The pathogenesis is not fully clear, but multiple risk factors have been described in literature as mucosal injury and achlorhydria. We report a case of a 76-year-old male with vomiting and epigastric pain, two days after an upper endoscopy, who presented in septic shock. The diagnostics with computed tomography showed diffuse thickening of the gastric wall, and the differential diagnosis of phlegmonous gastritis was made. Subsequently, he developed abdominal compartment syndrome and clinically deteriorated, necessitating open partial gastric resection. This case of a rare complication after upper gastrointestinal endoscopy with a potentially fatal outcome illustrates septic shock and abdominal compartment syndrome as severe complications. In this case, a combination of early antibiotic treatment and calculated surgical interventions showed a favorable outcome. Only a limited number of cases of phlegmonous gastritis after endoscopy have been published, and to the best of our knowledge, this is the second case of phlegmonous gastritis with subsequent abdominal compartment syndrome as a complication.

Sequential Fasciotomies for Managing Abdominal Compartment Syndrome: Porcine Experimental Study

INTRODUCTION

Abdominal compartment syndrome (ACS) poses a significant clinical challenge, with high morbidity and mortality rates. Conventional treatment via decompressive laparotomy with open abdomen and temporary closure presents significant drawbacks. This experimental study evaluates the efficacy of open minimally invasive sequential fasciotomy in managing simulated ACS in a porcine model.

METHODS

Ten adult pigs were included in this prospective experimental investigation, wherein a mechanical model of abdominal hypertension was induced by pneumoperitoneum via a Veres needle. Open minimally invasive sequential fasciotomy, involving bilateral external oblique muscles (EOMs) and linea alba (LA), was performed. Physiological parameters were recorded preprocedure and postprocedure.

RESULTS

In our study, 70% of pigs completed the fasciotomy sequence. Unilateral EOM fasciotomy significantly reduced intravesical pressure and femoral venous pressure by 18% and 16%, respectively. Bilateral EOM fasciotomies led to a 35.7% decrease in both parameters. Following re-establishment of intra-abdominal pressure to 20 mmHg, LA fasciotomy resulted in a 47% drop in intravesical pressure and femoral venous pressure. Significant increases in tidal volume and abdominal perimeter were observed after each fasciotomy.

CONCLUSIONS

This study establishes that open minimally invasive sequential fasciotomy of bilateral EOM and LA is an effective strategy for managing simulated ACS in a porcine model. Each fasciotomy resulted in a significant reduction in intra-abdominal pressure. These findings suggest that sequential fasciotomy techniques offer a promising alternative to decompressive laparotomy in ACS management. Further research is essential to validate these outcomes in human subjects.

Relevance of intra-abdominal pressure monitoring in non-operative management of patients with blunt liver and splenic injuries

PURPOSE

Non-operative management (NOM) has been validated for blunt liver and splenic injuries. Literature on continuous intra-abdominal pressure (IAP) monitoring as a part of NOM remains to be equivocal. The study aimed to find any correlation between clinical parameters and IAP, and their effect on the NOM of patients with blunt liver and splenic injury.

METHOD

A prospective cross-sectional study conducted at a level I trauma center from October 2018 to January 2020 including 174 patients who underwent NOM following blunt liver and splenic injuries. Hemodynamically unstable patients or those on ventilators were excluded, as well as patients who suffered significant head, spinal cord, and/or bladder injuries. The study predominantly included males (83.9%) with a mean age of 32.5 years. IAP was monitored continuously and the relation of IAP with various parameters, interventions, and outcomes were measured. Data were summarized as frequency (percentage) or mean ± SD or median (Q1, Q3) as indicated. χ2 or Fisher's exact test was used for categorical variables, while for continuous variables parametric (independent t-test) or nonparametric tests (Wilcoxon rank sum test) were used as appropriate. Clinical and laboratory correlates of IAP < 12 with p < 0.200 in the univariable logistic regression analysis were included in the multivariable analysis. A p < 0.05 was used to indicate statistical significance.

RESULTS

Intra-abdominal hypertension (IAH) was seen in 19.0% of the study population. IAH was strongly associated with a high injury severity score (p < 0.001), and other physiological parameters like respiratory rate (p < 0.001), change in abdominal girth (AG) (p < 0.001), and serum creatinine (p < 0.001). IAH along with the number of solid organs involved, respiratory rate, change in AG, and serum creatinine was associated with the intervention, either operative or non-operative (p = 0.001, p = 0.002, p < 0.001, p < 0.001, p = 0.013, respectively). On multivariable analysis, IAP (p = 0.006) and the mean change of AG (p = 0.004) were significantly associated with the need for intervention.

CONCLUSION

As a part of NOM, IAP should be monitored as a continuous vital. However, the decision for any intervention, either operative or non-operative cannot be guided by IAP values alone.

Early and Midterm Outcomes of Chimney Endovascular Aortic Repair for Ruptured Abdominal Aortic Aneurysms

PURPOSE

To compare the outcomes of endovascular aortic aneurysm repair using a chimney technique (ch-EVAR) with those of the standard EVAR (st-EVAR) for ruptured abdominal aortic aneurysms (RAAA).

MATERIALS AND METHODS

We implemented ch-EVAR for juxtarenal RAAA based on obvious anatomical indications after converting the strategy for RAAA from open repair to EVAR. A retrospective, cohort-based study was conducted on patients with RAAA who were treated using EVAR in our hospital between July 2011 and March 2022. EVAR cases were extracted, and outcomes were compared between ch-EVAR and st-EVAR. Patient clinical status, anatomical variables, treatment, and follow-up data were evaluated.

RESULTS

A total of 56 (82%) and 12 (18%) patients were treated by st-EVAR and ch-EVAR, respectively. Thirty-day mortality rates were comparable between the 2 groups [8.9% in st-EVAR vs 8.3% in ch-EVAR (p= 0.95)]. Short-term outcomes showed that no type Ia endoleak occurred in either group. Midterm outcomes, including sac enlargement [7.5% in st-EVAR vs 0% in ch-EVAR (p= 0.37)], shrinkage [77.5% in st-EVAR vs 80.0% in ch-EVAR (p= 0.86)], and overall survival and freedom from aneurysm-related reintervention at 3 years [64.7% and 96.4% in the EVAR group vs 91.7% and 100% in the ch-EVAR group, respectively (p= 0.30 and 0.52)], were not significantly different between the 2 groups.

CONCLUSION

Ch-EVAR for RAAA showed remarkably excellent outcomes, comparable to those of st-EVAR. Ch-EVAR is considered technically feasible in experienced centers. The indications for EVAR for RAAA may be further expanded using the chimney technique, resulting in overall improved outcomes for RAAA.

CLINICAL IMPACT

This is a retrospective, single-center analysis of 68 patients with ruptured abdominal aortic aneurysms (RAAAs) treated by endovascular repair (EVAR) to investigate the efficacy of the chimney technique for juxtarenal RAAA. Thirty-day mortality rate was 8.3% for the chimney EVAR group, which was equivalent to that in the standard EVAR group. Mid-term outcomes including sac enlargement/shrinkage, overall survival, and freedom from aneurysm-related reintervention were comparable between the two groups. This report suggests the possibility of broadening the selection criteria of the current endovascular strategy using the chimney technique.

Open Abdominal Management for Damage Control in Liver Transplantation: A Single-center Experience

Background

Patients undergoing liver transplantation are in a state of coagulopathy before surgery because of liver failure. Intraoperative hemorrhage, massive transfusions, and post-reperfusion syndrome further contribute to coagulopathy, acidosis, and hypothermia. In such situations, temporary cessation of surgery with open abdominal management and resuscitation in the intensive care unit (ICU), which is commonly used as a damage control strategy in trauma care, may be effective. We assessed the outcomes of open abdominal management in liver transplantation and the corresponding complication rates.

Methods

We retrospectively reviewed the outcomes of patients undergoing open abdominal management among 250 consecutive liver transplantation cases performed at our institution from 2009 to 2022.

Results

Open abdominal management was indicated in 16 patients. The open abdomen management group had higher Model for End-stage Liver Disease scores (24 versus 16, P < 0.01), a higher incidence of previous upper abdominal surgery (50% versus 18%, P < 0.01), more pretransplant ICU treatment (31% versus 10%, P = 0.03), and more renal replacement therapy (38% versus 12%, P = 0.01). At the time of the damage control decision, coagulopathy (81%), acidosis (38%), hypothermia (31%), and a high-dose noradrenaline requirement (75%) were observed. The abdominal wall was closed in the second operation in 75% of patients, in the third operation in 19%, and in the fourth operation in 6%. Postoperatively, the frequency of early allograft dysfunction was predominantly higher in the open abdominal management group (69%), whereas the frequency of vascular complications and intra-abdominal infection was the same as in other patients.

Conclusions

Open abdominal management can be a crucial option in cases of complex liver transplant complicated by conditions such as hypothermia, acidosis, coagulopathy, and hemodynamic instability. Damage control management minimizes deterioration of the patient's condition during surgery, allowing completion of the planned procedure after stabilizing the patient's overall condition in the ICU.

Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion

Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.

Spontaneous bacterial peritonitis in patients with portal hypertension

Background. Spontaneous bacterial peritonitis (SBP) is a life-threatening infection in patients with portal hypertension (PH) and ascites. Its prevention and treatment are vital to improve the prognosis in decompensated PH. Alterations in gut microbiota, gut permeability, and systemic immune dysfunction are cornerstones in the development of SBP in patients with PH. This contributes to the translocation of bacteria from the intestinal lumen to the mesenteric lymph nodes, and then to the portal and systemic circulation from where the ascitic fluid can be colonized with the subsequent development of peritonitis. The purpose was to monitor the course of the disease and determine the possibility of correcting pathological factors of SBP such as bacterial contamination and volume of ascitic fluid, nature of bacterial contamination, increased intra-abdominal pressure, hypoalbuminemia, and to evaluate the role of antibacterial therapy, paracentesis in the treatment of patients with SBP in decompensated PG. Materials and methods. Examination and treatment of 242 patients with ascites who were admitted for emergency medical care were carried out. Diagnostic paracentesis was performed to examine ascitic fluid, which allowed to detect neutrophilia > 250 cells in 1 mm3 in 194 (80.2 %) patients and indicated the presence of SBP. These patients made up the first group of observation. In the second group, there were 48 (19.8 %) patients with no clinical and laboratory signs of SBP at the time of hospitalization. Methodology of analysis of actual research material: to find a statistical difference between the distribution of nominal data of patients in this study, we used Pearson’s χ2 test. To establish the strength of the relationship between variables, we determined the polychoric correlation coefficient. When a statistically significant difference was detec-ted, a stratification analysis was performed with determination of the 95% confidence interval of the odds ratio (Clopper-Pearson method) and the risk ratio for the development of complications in PH. Results. Empiric antibacterial therapy, which was carried out from the moment of receiving information about SBP and began with the use of broad-spectrum antibiotics, was successful in 41 % of cases that was confirmed by repeated examination of ascitic fluid. In antibiotic resistance, determining the sensitivity of ascitic microflora led to a delay in an effective anti-inflammatory treatment and affected the results. In the first group, 39 (20.1 %) patients died, in the second group, 22 (50 %), total mortality was 25.2 %. Conclusions. Diagnostic paracentesis combined with the assessment of bacterial contamination of ascitic fluid, evaluation of intra-abdominal pressure, state of osmoregulation based on albumin concentration is a safe and informative method of diagnosing the severity of pathological process in patients with complicated PH. Treatment of SBP requires urgent care, both in terms of elimination of the infectious factor, and normalization of the disturbed mechanisms of reabsorption regulation by peritoneal and hepatorenal processes. High mortality in patients with SBP is due to the development of inflammation in the abdominal cavity against the background of progressive hepatorenal insufficiency and the inability to correct decompensated PH.

Early Autocalibrated Arterial Waveform Analysis for the Management of Burn Shock-A Cohort Study

Adequate fluid therapy is crucial for resuscitation after major burns. To adapt this to individual patient demands, standard is adjustment of volume to laboratory parameters and values of enhanced hemodynamic monitoring. To implement calibrated parameters, patients must have reached the intensive care unit (ICU). The aim of this study was, to evaluate the use of an auto-calibrated enhanced hemodynamic monitoring device to improve fluid management before admission to ICU. We used PulsioflexProAqt® (Getinge) during initial treatment and burn shock resuscitation. Analysis was performed regarding time of measurement, volume management, organ dysfunction, and mortality. We conducted a monocentre, prospective cohort study of 20 severely burned patients, >20% total body surface area (TBSA), receiving monitoring immediately after admission. We compared to 57 patients, matched in terms of TBSA, age, sex, and existence of inhalation injury out of a retrospective control group, who received standard care. Hemodynamic measurement with autocalibrated monitoring started significantly earlier: 3.75(2.67-6.0) hours (h) after trauma in the study group versus 13.6(8.1-17.5) h in the control group (P < .001). Study group received less fluid after 6 h: 1.7(1.2-2.2) versus 2.3(1.6-2.8) ml/TBSA%/kg, P = .043 and 12 h: 3.0(2.5-4.0) versus 4.2(3.1-5.0) ml/TBSA%/kg, P = .047. Dosage of norepinephrine was higher after 18 h in the study group: 0.20(0.12-0.3) versus 0.08(0.02-0.18) µg/kg/min, P = .014. The study group showed no adult respiratory distress syndrome versus 21% in the control group, P = .031. There was no difference in other organ failures, organ replacement therapy, and mortality. The use of auto-calibrated enhanced hemodynamic monitoring is a fast and feasible way to guide early fluid therapy after burn trauma. It reduces the time to reach information about patient's volume capacity. Management of fluid application changed to a more restrictive fluid use in the early period of burn shock and led to a reduction of pulmonary complications.

Is There a Direct Effect Between the Plication of the Myoaponeurotic Layer and the Force of Inspiratory and Expiratory Muscles After Abdominoplasty?

OBJECTIVE

Abdominoplasty may generate an increase in the intra-abdominal pressure (IAP) and consequently an alteration in the pulmonary ventilation. The purpose of this study was to evaluate the potential alterations in the maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP) after abdominoplasty.

METHODS

Thirty-three female patients, aged between 18 and 60, with type III/B Nahas abdominal deformity that underwent abdominoplasty with plication of the anterior rectus and external oblique aponeurosis were selected. The MIP and MEP were measured using a mouthpiece. This is a simple way to indirectly gauge inspiratory and expiratory muscle strength. Measurements were performed before surgery and on the 2nd, 7th, 15th, and 180th postoperative day. In addition, IAP was measured before abdominoplasty and after the placement of compression garment. The MIP and MEP were compared using analysis of variance, followed by the Bonferroni multiple comparison test pairing the different points in time. Paired Student's t test was used for comparing IAP measurements. Pearson's correlation test was used to compare MIP and MEP variations with IAP variation. Results were considered statistically significant when P ≤ 0.05.

RESULTS

A decrease was observed in MEP on the 2nd day, with a return close to normal values on the 15th day. In opposition MIP had a surprisingly increase on the 15th postoperative day (129 cmH2O), normalizing 180 days after the operation. A leap in IAP values was revealed at the end of the surgical procedure. It was not possible to establish a positive correlation between the increase of IAP and the alterations of MIP and MEP.

CONCLUSIONS

There is a decrease in maximum expiratory pressure on the very early postoperative day (2nd postoperative day) and an increase in maximum inspiratory pressure on the 15th postoperative day in patients who underwent abdominoplasty. There was no correlation between the IAP and maximum respiratory pressure variations, both inspiratory and expiratory.

Musculoskeletal spine modeling in large patient cohorts: how morphological individualization affects lumbar load estimation

Introduction: Achieving an adequate level of detail is a crucial part of any modeling process. Thus, oversimplification of complex systems can lead to overestimation, underestimation, and general bias of effects, while elaborate models run the risk of losing validity due to the uncontrolled interaction of multiple influencing factors and error propagation. Methods: We used a validated pipeline for the automated generation of multi-body models of the trunk to create 279 models based on CT data from 93 patients to investigate how different degrees of individualization affect the observed effects of different morphological characteristics on lumbar loads. Specifically, individual parameters related to spinal morphology (thoracic kyphosis (TK), lumbar lordosis (LL), and torso height (TH)), as well as torso weight (TW) and distribution, were fully or partly considered in the respective models according to their degree of individualization, and the effect strengths of these parameters on spinal loading were compared between semi- and highly individualized models. T-distributed stochastic neighbor embedding (T-SNE) analysis was performed for overarching pattern recognition and multiple regression analyses to evaluate changes in occurring effects and significance. Results: We were able to identify significant effects (p < 0.05) of various morphological parameters on lumbar loads in models with different degrees of individualization. Torso weight and lumbar lordosis showed the strongest effects on compression (β ≈ 0.9) and anterior-posterior shear forces (β ≈ 0.7), respectively. We could further show that the effect strength of individual parameters tended to decrease if more individual characteristics were included in the models. Discussion: The induced variability due to model individualization could only partly be explained by simple morphological parameters. Our study shows that model simplification can lead to an emphasis on individual effects, which needs to be critically assessed with regard to in vivo complexity. At the same time, we demonstrated that individualized models representing a population-based cohort are still able to identify relevant influences on spinal loading while considering a variety of influencing factors and their interactions.

Abdominal Compartment Syndrome Secondary to Bulimia Nervosa: A Case Report and Systematic Review of Published Cases

BACKGROUND

Abdominal compartment syndrome (ACS) is typically attributed to critically unwell patients with trauma, burns, post surgery, and massive ascites. A rare but fatal cause of ACS is bulimia nervosa (BN), which is an eating disorder characterized by bingeing, followed by methods to avoid weight gain, including purging.

CASE REPORT

We present a case of a 20-year-old woman who presented with abdominal pain and distension after consuming a large quantity of food the previous night and was unable to purge. She was initially managed conservatively and discharged home, but returned subsequently on the same day with clinical features of ACS secondary to acute gastric distension. Decompression resulted in life-threatening reperfusion injury with critical electrolyte abnormalities and fatal cardiac arrest in the operating theatre. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A systematic review of the literature found only 11 case reports of ACS secondary to BN, of which only 6 patients survived due to early diagnosis and decompression. Inability to purge and lower limb ischemia appeared to be associated with increased mortality. As BN is a common emergency presentation, the case and systematic review highlights the need to consider ACS as a potentially life-threatening complication of binge eating, particularly when there is unsuccessful purging.

Review article: Evaluation and care of the critically ill patient with cirrhosis

BACKGROUND

The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients.

AIM

Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care.

METHODS

We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care.

RESULTS

Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource.

CONCLUSIONS

Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.

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.

Acute Gastrointestinal Injury in Critically Ill Patients in a South Indian Intensive Care Unit: A Prospective, Observational, Preliminary Study

Introduction The acute gastrointestinal injury (AGI) score was proposed by the Working Group on Abdominal Problems of the European Society of Intensive Care Medicine (ESICM) as a tool to define and grade gut dysfunction. There have not been any studies in India to validate this tool. The objective of this preliminary study was primarily to study the frequency of AGI in the first week of ICU stay in critically ill patients in our intensive care unit (ICU). We also sought to determine the risk factors predisposing to the development of AGI and to determine the prognostic implication of gastrointestinal (GI) injury in critically ill patients. Materials and methods A prospective, observational, preliminary, single-center study was conducted on critically ill patients (APACHE II > 8) who were on enteral tube feeds and admitted to a mixed ICU of a tertiary care hospital. Anthropometric data, admission diagnosis, APACHE II score, and comorbidities were recorded. Data of daily heart rate, mean arterial pressure, dose of vasopressors, intra-abdominal pressure, fluid balance, feeding intolerance, mechanical ventilation, and laboratory tests were noted for the first seven days of ICU stay or till ICU discharge, whichever was earlier. The occurrence of AGI score (1-4) during the first seven days of critical illness was the primary outcome of interest. Patient outcome at 28 days was recorded and the impact of the occurrence of AGI on patient outcome was analyzed using the Chi-square test. The patient characteristics associated with AGI were characterized as risk factors and analyzed using a multivariate model. Results Data were collected from 33 patients over 201 patient days. The frequency of acute GI dysfunction in the first seven days of ICU stay in our group of patients was 45.45% (15/33). APACHE II, fluid balance, creatinine, and lactate were identified as possible predictors of GI injury based on existing literature. These four variables were entered into an ordinal logistic regression model to assess their ability to predict the occurrence of GI Injury. When fitted into a predictive model, only fluid balance and creatinine were predictive of the final model (p-value < 0.05). A greater fluid balance was predictive in the final model of the development of GI injury; however, it showed negligible clinical significance (OR: 1.00033, 95% CI: 1.000051-1.00061). Lower creatinine levels were predictive in the final model of the development of AGI Injury, as demonstrated by the negative coefficient. Creatinine also had a greater clinical significance (OR: 0.63, 95% CI: 0.44-0.90) in the development of AGI. The impact of the AGI scores on mortality was analyzed. The number of patient days with higher AGI scores was significantly associated with increased mortality at 28 days (p-value < 0.001). Conclusion The study showed that nearly half of the critically ill patients included in the study developed acute GI dysfunction. We could not identify any predictors of GI injury based on our results. The result suggested an association between the severity of GI dysfunction and mortality at 28 days.

An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study

BACKGROUND

The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis.

PURPOSE OF THE STUDY

The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP).

MATERIALS AND METHODS

The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery.

RESULTS

The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027).

CONCLUSION

Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.

Abdominal Compartment Syndrome Following Paraesophageal and Diaphragmatic Hernia Repair

Abdominal compartment syndrome (ACS) is defined as a sustained intra-abdominal pressure ≥ 20 mm Hg, associated with new organ dysfunction. Postoperative ACS can occur following repair of hernias with loss-of-domain. Such loss-of-domain hernias are well described involving incisional hernias, less described involving Bochdalek congenital diaphragmatic hernias (CDHs), but not yet described involving paraesophageal hernias (PEHs) or Morgagni CDHs. We describe a case of postoperative ACS following laparoscopic repair of a PEH and Morgagni CDH. This case demonstrates that prophylactic omentectomy should be considered in select patients undergoing repair of large PEHs or CDHs, as ACS is a rare but potential complication.

The development, feasibility and credibility of intra-abdominal pressure measurement techniques: A scoping review

AIM

To provide a comprehensive overview on emerging direct and alternative methods for intra-abdominal pressure (IAP) measurement techniques.

METHODS

This was a scoping review study following Arksey and Malley's framework. The PubMed, EMBASE, Web of Science, EBSCO, Scopus and ProQuest databases were searched, and we only considered studies published from 2000 as we have extended the data from two previous reviews. Original studies that reported on the development, feasibility and credibility of IAP measurement techniques were included.

RESULTS

Forty-two of 9954 screened articles were included. IAP measurement techniques include three major categories: direct, indirect and less invasive measurement techniques. Agreement analyses were performed in most studies, and some explored the safety, time expenditure and reproducibility of IAP measurement techniques.

CONCLUSIONS

Clinical data assessing the validation of new IAP measurement techniques or the reliability of established measurement techniques remain lacking. Considering the cost and invasiveness, direct measurement is not recommended as a routine method for IAP measurement and should be preserved for critically ill patients where standard techniques are contraindicated or could be inaccurate. The measurement accuracy, reliability and sensitivity of the transrectal and transfemoral vein methods remain insufficient and cannot be recommended as surrogate IAP measures. Transvesical measurement is the most widely used method, which is the potentially most easy applicable technique and can be used as a reliable method for continuous and intermittent IAP measurement. Wireless transvaginal method facilitates the quantitative IAP measurement during exercise and activity, which laying the foundations for monitoring IAP outside of the clinic environment, but the accuracy of this technique in measuring absolute IAP cannot be determined at present. Less invasive technology will become a new trend to measure IAP and has substantial potential to replace traditional IAP measurement technologies, but further validation and standardization are still needed. Medical professionals should choose appropriate measurement tools based on the advantages and disadvantages of each IAP technique in combination with assessing specific clinical situations.

Effect of opioids on constipation in critically ill patients: A meta-analysis

OBJECTIVES

This meta-analysis evaluated the effect of opioids on constipation in ICU patients.

REVIEW METHOD USED

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang DATA databases.

REVIEW METHODS

Random or fixed-effects meta-analyses were used. Subgroup analysis was performed according to the definition of constipation (three vs. six days), opioids (fentanyl vs. morphine), study design (prospective vs. retrospective), adjustment of confounders (No vs. Yes), and patient's age (adults vs. children). We used sensitivity analysis to test the robustness of results with significant statistical heterogeneity.

RESULTS

Seven studies (2264 patients) were included. Opioid use in ICU patients was associated with an increased risk of constipation (relative risk [RR]=1.14; 95% confidence interval [CI]=1.05 to 1.24; I2=49.8%). Subgroup analysis further showed that adjustment form, category of opioid, study design, and patient's age significantly influenced the relationship between opioid use and the risk of constipation. Sensitivity analysis confirmed the robustness of pooled results.

CONCLUSION

Opioids significantly increase the risk of constipation in critically ill patients, especially children. It is worth noting that the adjustment of the constipation definition used for ICU significantly influenced the relationship between opioid use and the risk of constipation. Therefore, It is necessary to clearly define ICU constipation and conduct time-based layered treatment. Additional prospective studies are needed to investigate the consistent definition of ICU constipation.

Anaesthesia Management for Giant Intraabdominal Tumours: A Case Series Study

BACKGROUND

Due to a lack of randomised controlled trials and guidelines, and only case reports being available in the literature, there is no consensus on how to approach anaesthetic management in patients with giant intraabdominal tumours.

METHODS

This study aimed to evaluate the literature and explore the current status of evidence, by undertaking an observational research design with a descriptive account of characteristics observed in a case series referring to patients with giant intraabdominal tumours who underwent anaesthesia.

RESULTS

Twenty patients diagnosed with giant intraabdominal tumours were included in the study, most of them women, with the overall pathology being ovarian-related and sarcomas. Most of the patients were unable to lie supine and assumed a lateral decubitus position. Pulmonary function tests, chest X-rays, and thoracoabdominal CT were the most often performed preoperative evaluation methods, with the overall findings that there was no atelectasis or pleural effusion present, but there was bilateral diaphragm elevation. The removal of the intraabdominal tumour was performed under general anaesthesia in all cases. Awake fiberoptic intubation or awake videolaryngoscopy was performed in five cases, while the rest were performed with general anaesthesia with rapid sequence induction. Only one patient was ventilated with pressure support ventilation while maintaining spontaneous ventilation, while the rest were ventilated with controlled ventilation. Hypoxemia was the most reported respiratory complication during surgery. In more than 50% of cases, there was hypotension present during surgery, especially after the induction of anaesthesia and after tumour removal, which required vasopressor support. Most cases involved blood loss with subsequent transfusion requirements. The removal of the tumor requires prolonged surgical and anaesthesia times. Fluid drainage from cystic tumour ranged from 15.7 L to 107 L, with a fluid extraction rate of 0.5-2.5 L/min, and there was no re-expansion pulmonary oedema reported. Following surgery, all the patients required intensive care unit admission. One patient died during hospitalization.

CONCLUSIONS

This study contributes to the creation of a certain standard of care when dealing with patients presenting with giant intraabdominal tumour. More research is needed to define the proper way to administer anaesthesia and create practice guidelines.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Uterine Leiomyomata as a Cause of Abdominal Compartment Syndrome in the Postpartum Period

Uterine leiomyomas are common benign smooth muscle tumors that often occur during the reproductive years. Although many cases may not result in significant complications, negative pregnancy outcomes have been associated with the size and location of the fibroids. Degeneration of fibroids can occur as early as the late first trimester when they undergo significant volumetric growth, contributing to pain during pregnancy. While myomectomy is typically avoided during pregnancy, conservative management with anti-inflammatory medications may be effective. Surgical removal or preterm delivery may be necessary if symptoms persist. Abdominal compartment syndrome (ACS) is a rare condition characterized by sustained elevated intra-abdominal pressure leading to organ failure. Although ACS resulting from large-volume leiomyomas in the postpartum period has not been previously described, we present a case of a 25-year-old patient with massive uterine fibroids who required indicated preterm delivery via primary cesarean section at 25 weeks gestation. Her postpartum course was complicated by ACS, requiring emergent surgical decompression. When a large fibroid burden is present during pregnancy or in the postpartum period, ACS should be considered in the differential diagnosis. Early diagnosis and timely surgical decompression are necessary to prevent organ dysfunction and worsening maternal outcomes.

Assessment of the Smartpill, a Wireless Sensor, as a Measurement Tool for Intra-Abdominal Pressure (IAP)

Background: The SmartPill, a multisensor ingestible capsule, is marketed for intestinal motility disorders. It includes a pressure sensor, which could be used to study intra-abdominal pressure (IAP) variations. However, the validation data are lacking for this use. Material and Methods: An experimental study was conducted on anesthetized pigs with stepwise variations of IAP (from 0 to 15 mmHg by 3 mmHg steps) generated by laparoscopic insufflation. A SmartPill, inserted by endoscopy, provided intragastric pressure data. These data were compensated to take into account the intrabdominal temperature. They were compared to the pressure recorded by intragastric (IG) and intraperitoneal (IP) wired sensors by statistical Spearman and Bland-Altmann analysis. Results: More than 4500 pressure values for each sensor were generated on two animals. The IG pressure values obtained with the SmartPill were correlated with the IG pressure values obtained with the wired sensor (respectively, Spearman ρ coefficients 0.90 ± 0.08 and 0.72 ± 0.25; bias of -28 ± -0.3 mmHg and -29.2 ± 0.5 mmHg for pigs 1 and 2). The intragastric SmartPill values were also correlated with the IAP measured intra-peritoneally (respectively, Spearman ρ coefficients 0.49 ± 0.18 and 0.57 ± 0.30; bias of -29 ± 1 mmHg and -31 ± 0.7 mmHg for pigs 1 and 2). Conclusions: The SmartPill is a wireless and painless sensor that appears to correctly monitor IAP variations.

Abdominal Compartment Syndrome Secondary to Constipation in an Adult Patient With Cerebral Palsy

The majority of patients with constipation can often be treated conservatively with laxatives, suppositories, or enemas in mild cases. However, endoscopic decompression or surgical intervention may be required in some instances. Abdominal compartment syndrome as a result of constipation is rarely seen in the literature. We report a case of faecal impaction, which led to abdominal compartment syndrome in an adult patient with cerebral palsy. With increasing life expectancy, such cases may be increasingly encountered in the adult population. Severe complications of constipation should not be overlooked, especially in this at-risk population. Early recognition of abdominal compartment syndrome is key in its management.

Prone restraint death: Possible role of the Valsalva maneuver

There is an on-going debate about the safety of prone restraint and the exact role of the prone position in physical restraint death. Cardiac arrest in prone restraint death is essentially the end-result of a violent physical altercation wherein a combative individual suddenly loses consciousness while trying to counteract an opposing force. The direct correlations of increased static weight force with decreased inferior vena cava diameter, decreased cardiac output, and decreased stroke volume in prone restraint studies suggest that decreased venous return and decreased cardiac output could have a significant role to play in prone restraint death. Although the degree of changes observed in those studies might not be sufficient to cause cardiac arrest, they could predispose people who instinctively try to free themselves of the restraints to severe complications. The Valsalva maneuver, or forceful expiration against a closed airway, is frequently performed spontaneously in daily activities involving straining and resistance exercise, but has never been considered in restraint death. Pre-existing diminished venous return could increase the risk of major complications in individuals performing the Valsalva maneuver. A substantial decrease in venous return and cardiac output could increase the risk of cerebral hypoperfusion, loss of consciousness, hypoventilation, and sudden death. By increasing the risk of increased intra-abdominal pressure and its negative effect on venous return, high body mass index may be a significant risk factor in prone restraint death. The Valsalva maneuver may have different roles in prone restraint cardiac arrest and might be overlooked in prone restraint death.

The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure

PURPOSE OF THE REVIEW

An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients.

RECENT FINDINGS

Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.

Study protocol for a multicenter randomized controlled pilot study on decompressive laparotomy vs. decompressive craniectomy for intractable intracranial pressure after traumatic brain injury: The SCALPEL study

Introduction

Decompressive craniectomy (DC) is the ultimate intervention to lower intracranial pressure (ICP) following severe traumatic brain injury (TBI). However, this intervention is associated with considerable adverse events and a higher proportion of survivors with poor functional outcomes.

Research question

In a multicompartment system ICP is associated with intraabdominal pressure (IAP) due to cerebral venous outflow from the brain. This is the rationale for decompressive laparotomy (DL) to control ICP after TBI as reported by experimental and retrospective clinical data. The safety profile of DL is superior to DC. This study aims to randomly assign patients with intractable high ICP after severe TBI to DL or DC.

Material and methods

Among other inclusion criteria, ICP must be above 20 mmHg (1-12 h) despite sedation and all other measures according to current guidelines. The primary outcome is the Extended Glasgow Outcome Scale assessed after twelve months. Further secondary outcome measures are compartmental pressure values, complications, etc. After 20 initial patients, results will be reviewed by the ethics committees and safety monitoring board to decide on the enrolment of 80 additional patients.

Results

The study is designed to provide not only high-quality prospective data for the first time on this treatment approach, its two-stage design (20 + 80 pts) also provides maximum patient safety. This protocol conforms with the SPIRIT 2013 Statement. Ethics approval was granted by our but also 5 other university ethics committees (registration 473/18S).

Conclusion

Registration was performed prior to study initiation in November 2021 (registration number NCT05115929).

Avoiding High Pressure Abdominal Closure of Congenital Abdominal Wall Defects-One Step Further to Improve Outcomes

The main goal of surgical treatment for gastroschisis and omphalocele is the reduction of viscera in the abdominal cavity and closure of the abdomen, but the challenge is to succeed without the detrimental effects of increased intraabdominal pressure. In this regard, we performed a retrospective study for all patients admitted for gastroschisis and omphalocele to the Neonatal Intensive Care Unit of 'Marie Sklodowska Curie' Emergency Clinical Hospital for Children, from January 2011 until June 2021. Our aim was to highlight the presence of postoperative abdominal compartment syndrome. We observed that six out of forty-seven patients developed clinical signs of abdominal compartment syndrome, five associated with primary closure and one with staged closure with a polyvinyl chloride patch. Following the results, we decided to implement the trans-bladder measurement of intraabdominal pressure to avoid closing the abdomen at pressures higher than 10 mmHg in order to prevent the development of abdominal compartment syndrome. We consider that there is still place for the improvement of congenital abdominal wall defects management and that the measurement of intraabdominal pressure might help us reach our goal.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Incidence and risk factors of abdominal compartment syndrome in pediatric oncology patients: a prospective cohort study

Abdominal compartment syndrome (ACS) has been the subject of increasing research over the past decade owing to its effects on morbidity and mortality in critically ill patients. This study aimed to determine the incidence and risk factors of ACS in patients in an onco-hematological pediatric intensive care unit in a middle-income country and to analyze patient outcomes. This prospective cohort study was conducted between May 2015 and October 2017. Altogether, 253 patients were admitted to the PICU, and 54 fulfilled the inclusion criteria for intra-abdominal pressure (IAP) measurements. IAP was measured using the intra-bladder indirect technique with a closed system (AbViser AutoValve®, Wolfle Tory Medical Inc., USA) in patients with clinical indications for indwelling bladder catheterization. Definitions from the World Society for ACS were used. The data were entered into a database and analyzed. The median age was 5.79 years, and the median pediatric risk of mortality score was 7.1. The incidence of ACS was 27.7%. Fluid resuscitation was a significant risk factor for ACS in the univariate analysis. The mortality rates in the ACS and non-ACS groups were 46.6% and 17.9%, respectively (P < 0.05). This is the first study of ACS in critically ill children with cancer.   Conclusion: The incidence and mortality rates were high, justifying IAP measurement in children with ACS risk factors.

Albumin infusion may decrease the mortality of hypoalbuminemia patients with severe acute pancreatitis: a retrospective cohort study

BACKGROUND

At present, the relationship between severe acute pancreatitis (SAP) and albumin infusion is not clear. We aimed to identify the impact of serum albumin on the prognosis of SAP and the association between albumin infusions and mortality for hypoalbuminemia patients.

METHODS

This was a retrospective cohort study that analyzed 1000 patients with SAP who were admitted to the First Affiliated Hospital of Nanchang University between January 2010 and December 2021 using data from a prospectively maintained database. Multivariate logistic regression analysis was conducted to reveal the relationship between serum albumin within 1 week after admission and poor prognosis of SAP. Propensity score matching (PSM) analysis was adopted to evaluate the effect of albumin infusion for hypoalbuminemia patients with SAP.

RESULTS

The prevalence of hypoalbuminemia (≤ 30 g/L) was 56.9% within 1 week after admission. Multivariate logistic regression identified that age (OR: 1.02; 95% CI: 1.00-1.04; P = 0.012), serum urea (OR: 1.08; 95% CI: 1.04-1.12; P < 0.001), serum calcium (OR: 0.27; 95% CI: 0.14-0.50; P < 0.001), lowest albumin level within 1 week after admission (OR: 0.93; 95% CI: 0.89-0.97; P = 0.002), and APACHE II score ≥ 15 (OR: 1.73; 95% CI: 1.19-2.51; P = 0.004) were independently associated with mortality. The PSM analysis demonstrated that mortality (OR: 0.52, 95% CI: 0.29-0.92, P = 0.023) was less common in albumin-infused than non-albumin-infused hypoalbuminemia patients. In subgroup analyses, doses > 100 g within 1 week after admission for hypoalbuminemia patients with albumin infusions was associated with lower mortality than doses ≤ 100 g (OR: 0.51, 95% CI: 0.28-0.90, P = 0.020).

CONCLUSIONS

Hypoalbuminemia in early-stage SAP is significantly related to poor prognosis. However, albumin infusions could significantly decrease mortality in hypoalbuminemia patients with SAP. Additionally, infusing sufficient albumin within a week after admission may decrease mortality in hypoalbuminemia patients.

Fluid Management for Critically Ill Patients with Acute Kidney Injury Receiving Kidney Replacement Therapy: An International Survey

BACKGROUND

In critically ill patients receiving KRT, high ultrafiltration rates and persistent fluid accumulation are associated with adverse outcomes. The purpose of this international survey was to evaluate current practices and evidence gaps related to fluid removal with KRT in critically ill patients.

METHODS

This was a multinational, web-based survey distributed by seven networks comprising nephrologists and intensivists. Physicians involved in the care of critically ill patients were invited to complete a 39-question survey about fluid management practices on KRT. The survey was distributed from September 2021 to December 2021.

RESULTS

There were 757 respondents from 96 countries (response rate of 65%). Most respondents practiced adult medicine (89%) and worked in an academic center (69%). The majority (91%) reported aiming for a 0.5- to 2-L negative fluid balance per day when fluid removal is indicated, although there was important variability in what respondents considered a safe maximal target. Intensivists were more likely than nephrologists to use adjunct volume status assessment methods ( i.e. , ultrasound, hemodynamic markers, and intra-abdominal pressure), while nephrologists were more likely to deploy cointerventions aimed at improving tolerance to fluid removal ( i.e. , osmotic agents and low-temperature dialysate). There was a broad consensus that rapid decongestion should be prioritized when fluid accumulation is present, but the prevention of hypotension was also reported as a competing priority. A majority (77%) agreed that performing trials that compare fluid management strategies would be ethical and clinically relevant.

CONCLUSIONS

We have identified multiple areas of variability in current practice of fluid management for patients receiving KRT. Most nephrologists and intensivists agreed that several knowledge gaps related to fluid removal strategies should be investigated in future randomized controlled trials.

Abdominal perfusion pressure in critically ill cirrhotic patients: a prospective observational study

In critical patients, abdominal perfusion pressure (APP) has been shown to correlate with outcome. However, data from cirrhotic patients is scarce. We aimed to characterize APP in critically ill cirrhotic patients, analyze the prevalence and risk factors of abdominal hypoperfusion (AhP) and outcomes. A prospective cohort study in a general ICU specialized in liver disease at a tertiary hospital center recruited consecutive cirrhotic patients between October 2016 and December 2021. The study included 101 patients, with a mean age of 57.2 (± 10.4) years and a female gender proportion of 23.5%. The most frequent etiology of cirrhosis was alcohol (51.0%), and the precipitant event was infection (37.3%). ACLF grade (1-3) distribution was 8.9%, 26.7% and 52.5%, respectively. A total of 1274 measurements presented a mean APP of 63 (± 15) mmHg. Baseline AhP prevalence was 47%, independently associated with paracentesis (aOR 4.81, CI 95% 1.46-15.8, p = 0.01) and ACLF grade (aOR 2.41, CI 95% 1.20-4.85, p = 0.01). Similarly, AhP during the first week (64%) had baseline ACLF grade (aOR 2.09, CI 95% 1.29-3.39, p = 0.003) as a risk factor. Independent risk factors for 28-day mortality were bilirubin (aOR 1.10, CI 95% 1.04-1.16, p < 0.001) and SAPS II score (aOR 1.07, CI 95% 1.03-1.11, p = 0.001). There was a high prevalence of AhP in critical cirrhotic patients. Abdominal hypoperfusion was independently associated with higher ACLF grade and baseline paracentesis. Risk factors for 28-day mortality included clinical severity and total bilirubin. The prevention and treatment of AhP in the high-risk cirrhotic patient is prudential.

Evaluation of Intra-Abdominal Hypertension Parameters in Patients with Acute Pancreatitis

BACKGROUND

Patients with acute pancreatitis develop numerous complications and organ damage due to increased intra-abdominal pressure (IAP). These extrapancreatic complications determine the clinical outcome of the disease.

MATERIALS AND METHODS

A total of 100 patients with acute pancreatitis were included in the prospective cohort study. Observed patients were divided into two groups according to their mean values of IAP (normal IAP values and elevated IAP values), which were compared with examined variables. Patients with intra-abdominal hypertension (IAH) were divided into four groups by IAP values, and those groups of patients were also compared with the examined variables.

RESULTS

Differences between body mass index (BMI) (p = 0.001), lactates (p = 0.006), and the Sequential Organ Failure Assessment (SOFA) score (p = 0.001) were statistically significant within all examined IAH groups. Differences between the mean arterial pressure (MAP) (p = 0.012) and filtration gradient (FG) (p < 0.001) were statistically significant between the first and second IAH groups in relation to the fourth. Differences in diuresis per hour (p = 0.022) showed statistical significance in relation to the first and third groups of IAH patients.

CONCLUSIONS

Changes in IAP values lead to changes in basic vital parameters MAP, APP, FG, diuresis per hour, and lactate levels in patients with acute pancreatitis. Early recognition of changes in the SOFA score accompanying an increase in the IAP value is essential.

Infected pancreatic necrosis: outcomes and clinical predictors of mortality. A post hoc analysis of the MANCTRA-1 international study

The identification of high-risk patients in the early stages of infected pancreatic necrosis (IPN) is critical, because it could help the clinicians to adopt more effective management strategies. We conducted a post hoc analysis of the MANCTRA-1 international study to assess the association between clinical risk factors and mortality among adult patients with IPN. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality. We identified 247 consecutive patients with IPN hospitalised between January 2019 and December 2020. History of uncontrolled arterial hypertension (p = 0.032; 95% CI 1.135-15.882; aOR 4.245), qSOFA (p = 0.005; 95% CI 1.359-5.879; aOR 2.828), renal failure (p = 0.022; 95% CI 1.138-5.442; aOR 2.489), and haemodynamic failure (p = 0.018; 95% CI 1.184-5.978; aOR 2.661), were identified as independent predictors of mortality in IPN patients. Cholangitis (p = 0.003; 95% CI 1.598-9.930; aOR 3.983), abdominal compartment syndrome (p = 0.032; 95% CI 1.090-6.967; aOR 2.735), and gastrointestinal/intra-abdominal bleeding (p = 0.009; 95% CI 1.286-5.712; aOR 2.710) were independently associated with the risk of mortality. Upfront open surgical necrosectomy was strongly associated with the risk of mortality (p < 0.001; 95% CI 1.912-7.442; aOR 3.772), whereas endoscopic drainage of pancreatic necrosis (p = 0.018; 95% CI 0.138-0.834; aOR 0.339) and enteral nutrition (p = 0.003; 95% CI 0.143-0.716; aOR 0.320) were found as protective factors. Organ failure, acute cholangitis, and upfront open surgical necrosectomy were the most significant predictors of mortality. Our study confirmed that, even in a subgroup of particularly ill patients such as those with IPN, upfront open surgery should be avoided as much as possible. Study protocol registered in ClinicalTrials.Gov (I.D. Number NCT04747990).

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Is it feasible to measure intra-abdominal pressure using a balloon-tipped rectal catheter? Results of a validation study

The gold standard to measure intra-abdominal pressure (IAP) is intra-vesical measurement via the urinary bladder. However, this technique is restricted in ambulatory settings because of the risk of iatrogenic urinary tract infections. Rectal IAP measurements (IAP_rect) may overcome these limitations, but requires validation. This validation study compares the IAP_rect technique against gold standard intra-vesical IAP measurements (IAP_ves). IAP_rect using an air-filled balloon catheter and IAP_ves using Foley Manometer Low Volume were measured simultaneously in sedated and ventilated patients. Measurements were performed twice in different positions (supine and HOB 45° elevated head of bed) and with an external abdominal pressure belt. Sixteen patients were included. Seven were not eligible for analysis due to unreliable IAP_rect values. IAP_rect was significantly higher than IAP_ves for all body positions (p < 0.01) and the correlation between IAP_ves and IAP_rect was poor and not significant in each position (p ≥ 0.25, R² < 0.6, Lin's CCC < 0.8, bias - 8.1 mmHg and precision of 5.6 mmHg with large limits of agreement between - 19 to 2.9 mmHg, high percentage error 67.3%, and low concordance 86.2%). Repeatability of IAP_rect was not reliable (R = 0.539, p = 0.315). For both techniques, measurements with the external abdominal pressure belt were significantly higher compared to those without (p < 0.03). IAP_rect has important shortcomings making IAP estimation using a rectal catheter unfeasible because the numbers cannot be trusted nor validated.