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Kirkpatrick AW, Coccolini F, Tolonen M, Minor S, Catena F, Gois E, Doig CJ, Hill MD, Ansaloni L, Chiarugi M, Tartaglia D, Ioannidis O, Sugrue M, Colak E, Hameed SM, Lampela H, Agnoletti V, McKee JL, Garraway N, Sartelli M, Ball CG, Parry NG, Voght K, Julien L, Kroeker J, Roberts DJ, Faris P, Tiruta C, Moore EE, Ammons LA, Anestiadou E, Bendinelli C, Bouliaris K, Carroll R, Ceresoli M, Favi F, Gurrado A, Rezende-Neto J, Isik A, Cremonini C, Strambi S, Koukoulis G, Testini M, Trpcic S, Pasculli A, Picariello E, Abu-Zidan F, Adeyeye A, Augustin G, Alconchel F, Altinel Y, Hernandez Amin LA, Aranda-Narváez JM, Baraket O, Biffl WL, Baiocchi GL, Bonavina L, Brisinda G, Cardinali L, Celotti A, Chaouch M, Chiarello M, Costa G, de'Angelis N, De Manzini N, Delibegovic S, Di Saverio S, De Simone B, Dubuisson V, Fransvea P, Garulli G, Giordano A, Gomes C, Hayati F, Huang J, Ibrahim AF, Huei TJ, Jailani RF, Khan M, Luna AP, Malbrain MLNG, Marwah S, McBeth P, Mihailescu A, Morello A, Mulita F, Murzi V, Mohammad AT, Parmar S, Pak A, Wong MPK, Pantalone D, Podda M, Puccioni C, Rasa K, Ren J, Roscio F, Gonzalez-Sanchez A, Sganga G, Scheiterle M, Slavchev M, Smirnov D, Tosi L, Trivedi A, Vega JAG, Waledziak M, Xenaki S, Winter D, Wu X, Zakaria AD, Zakaria Z. The unrestricted global effort to complete the COOL trial. World J Emerg Surg 2023; 18:33. [PMID: 37170123 DOI: 10.1186/s13017-023-00500-z.pmid:] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/13/2023] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. METHODS The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. DISCUSSION OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. TRIAL REGISTRATION National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).
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Affiliation(s)
- Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, EG23T2N 2T9, Canada.
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Samuel Minor
- Departments of Critical Care Medicine and Surgery, Dalhousie University, Halifax, NS, Canada
| | - Fausto Catena
- Department of Surgery, Bufalini Hospital, Cesena, Italy
| | - Emanuel Gois
- Department of Surgery, Londrina State University, and National COOL Coordinator for Brazil, Londrina, Brazil
| | - Christopher J Doig
- Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Luca Ansaloni
- General Surgery I, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Massimo Chiarugi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Dario Tartaglia
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Orestis Ioannidis
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Elif Colak
- University of Samsun, Samsun Training and Research Hospital, Samsun, Turkey
| | - S Morad Hameed
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Hanna Lampela
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Espoo, Finland
| | | | - Jessica L McKee
- Global Project Manager, COOL Trial and the TeleMentored Ultrasound Supported Medical Interventions Research Group, Calgary, AB, Canada
| | - Naisan Garraway
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Global Alliance for Infections in Surgery, Macerata, Italy
| | - Chad G Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Neil G Parry
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kelly Voght
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa Julien
- Department of Surgery, NSHA-Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Jenna Kroeker
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery and School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | | | - Elissavet Anestiadou
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Konstantinos Bouliaris
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | | | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Favi
- Chirurgia Generale E d'Urgenza, Ospedale M. Bufalini - Cesena, AUSL Della Romagna, Cesena, Italy
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Joao Rezende-Neto
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Arda Isik
- General Surgery Department, Istanbul Medeniyet University School of Medicine Istanbul, Istanbul, Turkey
| | - Camilla Cremonini
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Silivia Strambi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Georgios Koukoulis
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Sandy Trpcic
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Erika Picariello
- General Surgery Unit, Ospedale M. Buffalini Di Cesena, Cesena, Italy
| | - Fikri Abu-Zidan
- College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ademola Adeyeye
- Division of Surgical Oncology, Afe Babalola University Multisystem Hospital, Ado-Ekiti, Nigeria
| | - Goran Augustin
- University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Felipe Alconchel
- Virgen de la Arrixaca University Hospital IMIB-Arrixaca, Ctra. Madrid-Cartagena, S/N, Murcia, Spain
| | - Yuksel Altinel
- Bagcilar Research and Training Hospital, Istanbul, Turkey
| | - Luz Adriana Hernandez Amin
- Nurse Master of Nursing, Professor and Coordinator of the teaching-service relationship, Faculty of Health Sciences, University of Sucre, Sincelejo, Colombia
| | - José Manuel Aranda-Narváez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | | | | | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Bonavina
- Department of Surgery, University of Milan Medical School, Milan, Italy
| | - Giuseppe Brisinda
- Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Luca Cardinali
- Department of Surgery, General Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
| | - Andrea Celotti
- General Surgery Unit, UO Chirurgia Generale - Ospedale Maggiore Di Cremona, Cremona, Italy
| | - Mohamed Chaouch
- Department of Visceral and Digestive Surgery, Monastir University, Monastir, Tunisia
| | - Maria Chiarello
- Department of Surgery, Azienda Sanitaria Provinciale Di Cosenza, Cosenza, Italy
| | - Gianluca Costa
- Fondazione Policlinico Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Nicola de'Angelis
- Colorectal and Digestive Surgery Unit-DIGEST Department, Beaujon University Hospital AP-HP, University Paris Cité, Clichy, France
| | - Nicolo De Manzini
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Samir Delibegovic
- Department of Proctology, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy
| | - Belinda De Simone
- Unit of Digestive and Metabolic Minimally Invasive Surgery, Clinique Saint Louis, Poissy, Poissy, Ile de France, France
- Unit of Emergency and General Surgery, Guastalla Hospital, AUSL Reggio Emilia, Guastalla, Italy
| | - Vincent Dubuisson
- Chirurgie Digestive, Service de Chirurgie Vasculaire Et, Générale University Hospital of Bordeaux FR, Bordeaux, France
| | | | | | - Alessio Giordano
- Emergency and General Consultant Surgeon, Nuovo Ospedale "S. Stefano", Azienda ASL Toscana Centro, Prato, Italy
| | - Carlos Gomes
- Surgery Unit, Hospital Universitário Terezinha de Jesus, SUPREMA, Juiz de Fora, Brazil
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | | | | | | | - Mansoor Khan
- General Surgery, University Hospitals, Sussex, UK
| | | | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Sanjay Marwah
- Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | | | - Alessia Morello
- Department of General Surgery, Madonna del Soccorso Hospital - San Benedetto del Tronto, Italy, Italy
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Rio, Greece
| | - Valentina Murzi
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | | | | | - Ajay Pak
- Department of General Surgery, King George's Medical University, Lucknow, UP, India
| | - Michael Pak-Kai Wong
- School of Medical Sciences & Hospital, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Kemal Rasa
- Department of General Surgery, Hüseyin Kemal Raşa, Anadolu Medical Center, Kocaeli, Turkey
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Francesco Roscio
- Division of General and Minimally Invasive Surgery, ASST Valle Olona, Busto Arsizio, Italy
| | - Antonio Gonzalez-Sanchez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Maximilian Scheiterle
- Emergency Surgery Unit and Trauma Team, Careggi University Hospital, Florence, Italy
| | | | - Dmitry Smirnov
- Department of Surgery, South Ural State Medical University, Chelyabinsk City, Russia
| | - Lorenzo Tosi
- Department of General Surgery, University of Bologna, Bologna, Italy
| | | | | | | | - Sofia Xenaki
- Department of General Surgery, University Hospital of Heraklion, Crete, Greece
| | | | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Andee Dzulkarnean Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
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2
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Kirkpatrick AW, Coccolini F, Tolonen M, Minor S, Catena F, Gois E, Doig CJ, Hill MD, Ansaloni L, Chiarugi M, Tartaglia D, Ioannidis O, Sugrue M, Colak E, Hameed SM, Lampela H, Agnoletti V, McKee JL, Garraway N, Sartelli M, Ball CG, Parry NG, Voght K, Julien L, Kroeker J, Roberts DJ, Faris P, Tiruta C, Moore EE, Ammons LA, Anestiadou E, Bendinelli C, Bouliaris K, Carroll R, Ceresoli M, Favi F, Gurrado A, Rezende-Neto J, Isik A, Cremonini C, Strambi S, Koukoulis G, Testini M, Trpcic S, Pasculli A, Picariello E, Abu-Zidan F, Adeyeye A, Augustin G, Alconchel F, Altinel Y, Hernandez Amin LA, Aranda-Narváez JM, Baraket O, Biffl WL, Baiocchi GL, Bonavina L, Brisinda G, Cardinali L, Celotti A, Chaouch M, Chiarello M, Costa G, de'Angelis N, De Manzini N, Delibegovic S, Di Saverio S, De Simone B, Dubuisson V, Fransvea P, Garulli G, Giordano A, Gomes C, Hayati F, Huang J, Ibrahim AF, Huei TJ, Jailani RF, Khan M, Luna AP, Malbrain MLNG, Marwah S, McBeth P, Mihailescu A, Morello A, Mulita F, Murzi V, Mohammad AT, Parmar S, Pak A, Wong MPK, Pantalone D, Podda M, Puccioni C, Rasa K, Ren J, Roscio F, Gonzalez-Sanchez A, Sganga G, Scheiterle M, Slavchev M, Smirnov D, Tosi L, Trivedi A, Vega JAG, Waledziak M, Xenaki S, Winter D, Wu X, Zakaria AD, Zakaria Z. The unrestricted global effort to complete the COOL trial. World J Emerg Surg 2023; 18:33. [PMID: 37170123 PMCID: PMC10173926 DOI: 10.1186/s13017-023-00500-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/13/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. METHODS The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. DISCUSSION OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. TRIAL REGISTRATION National Institutes of Health ( https://clinicaltrials.gov/ct2/show/NCT03163095 ).
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Affiliation(s)
- Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, EG23T2N 2T9, Canada.
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Matti Tolonen
- Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Samuel Minor
- Departments of Critical Care Medicine and Surgery, Dalhousie University, Halifax, NS, Canada
| | - Fausto Catena
- Department of Surgery, Bufalini Hospital, Cesena, Italy
| | - Emanuel Gois
- Department of Surgery, Londrina State University, and National COOL Coordinator for Brazil, Londrina, Brazil
| | - Christopher J Doig
- Departments of Critical Care Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neuroscience and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Luca Ansaloni
- General Surgery I, San Matteo Hospital Pavia, University of Pavia, Pavia, Italy
| | - Massimo Chiarugi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Dario Tartaglia
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Orestis Ioannidis
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Elif Colak
- University of Samsun, Samsun Training and Research Hospital, Samsun, Turkey
| | - S Morad Hameed
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Hanna Lampela
- Department of Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Espoo, Finland
| | | | - Jessica L McKee
- Global Project Manager, COOL Trial and the TeleMentored Ultrasound Supported Medical Interventions Research Group, Calgary, AB, Canada
| | - Naisan Garraway
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Massimo Sartelli
- Department of Surgery, Macerata Hospital, Global Alliance for Infections in Surgery, Macerata, Italy
| | - Chad G Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Neil G Parry
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Kelly Voght
- Departments of Surgery and Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lisa Julien
- Department of Surgery, NSHA-Queen Elizabeth II Health Sciences Center, Dalhousie University, Halifax, NS, Canada
| | - Jenna Kroeker
- Departments of Surgery and Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery and School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | | | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | | | - Elissavet Anestiadou
- 4th Department of Surgery, Medical School, Aristotle University of Thessaloniki, General Hospital "George Papanikolaou", Thessaloniki, Greece
| | | | - Konstantinos Bouliaris
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | | | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Francesco Favi
- Chirurgia Generale E d'Urgenza, Ospedale M. Bufalini - Cesena, AUSL Della Romagna, Cesena, Italy
| | - Angela Gurrado
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Joao Rezende-Neto
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Arda Isik
- General Surgery Department, Istanbul Medeniyet University School of Medicine Istanbul, Istanbul, Turkey
| | - Camilla Cremonini
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Silivia Strambi
- Emergency Surgery and Trauma Center, University of Pisa, Pisa, Italy
| | - Georgios Koukoulis
- General Surgery Department of Koutlimbaneio, Triantafylleio General Hospital of Larissa, Larissa, Thessaly, Greece
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Sandy Trpcic
- Trauma and Acute Care Surgery, General Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Alessandro Pasculli
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery "V. Bonomo", University of Bari "A. Moro", Bari, Italy
| | - Erika Picariello
- General Surgery Unit, Ospedale M. Buffalini Di Cesena, Cesena, Italy
| | - Fikri Abu-Zidan
- College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ademola Adeyeye
- Division of Surgical Oncology, Afe Babalola University Multisystem Hospital, Ado-Ekiti, Nigeria
| | - Goran Augustin
- University Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia
| | - Felipe Alconchel
- Virgen de la Arrixaca University Hospital IMIB-Arrixaca, Ctra. Madrid-Cartagena, S/N, Murcia, Spain
| | - Yuksel Altinel
- Bagcilar Research and Training Hospital, Istanbul, Turkey
| | - Luz Adriana Hernandez Amin
- Nurse Master of Nursing, Professor and Coordinator of the teaching-service relationship, Faculty of Health Sciences, University of Sucre, Sincelejo, Colombia
| | - José Manuel Aranda-Narváez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | | | | | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Bonavina
- Department of Surgery, University of Milan Medical School, Milan, Italy
| | - Giuseppe Brisinda
- Department of Surgery, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Luca Cardinali
- Department of Surgery, General Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
| | - Andrea Celotti
- General Surgery Unit, UO Chirurgia Generale - Ospedale Maggiore Di Cremona, Cremona, Italy
| | - Mohamed Chaouch
- Department of Visceral and Digestive Surgery, Monastir University, Monastir, Tunisia
| | - Maria Chiarello
- Department of Surgery, Azienda Sanitaria Provinciale Di Cosenza, Cosenza, Italy
| | - Gianluca Costa
- Fondazione Policlinico Campus Bio-Medico, University Campus Bio-Medico of Rome, Rome, Italy
| | - Nicola de'Angelis
- Colorectal and Digestive Surgery Unit-DIGEST Department, Beaujon University Hospital AP-HP, University Paris Cité, Clichy, France
| | - Nicolo De Manzini
- Department of General Surgery, Cattinara University Hospital, Trieste, Italy
| | - Samir Delibegovic
- Department of Proctology, Clinic for Surgery, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
| | - Salomone Di Saverio
- Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy
| | - Belinda De Simone
- Unit of Digestive and Metabolic Minimally Invasive Surgery, Clinique Saint Louis, Poissy, Poissy, Ile de France, France
- Unit of Emergency and General Surgery, Guastalla Hospital, AUSL Reggio Emilia, Guastalla, Italy
| | - Vincent Dubuisson
- Chirurgie Digestive, Service de Chirurgie Vasculaire Et, Générale University Hospital of Bordeaux FR, Bordeaux, France
| | | | | | - Alessio Giordano
- Emergency and General Consultant Surgeon, Nuovo Ospedale "S. Stefano", Azienda ASL Toscana Centro, Prato, Italy
| | - Carlos Gomes
- Surgery Unit, Hospital Universitário Terezinha de Jesus, SUPREMA, Juiz de Fora, Brazil
| | - Firdaus Hayati
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | | | | | | | - Mansoor Khan
- General Surgery, University Hospitals, Sussex, UK
| | | | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Sanjay Marwah
- Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | | | | | - Alessia Morello
- Department of General Surgery, Madonna del Soccorso Hospital - San Benedetto del Tronto, Italy, Italy
| | - Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Rio, Greece
| | - Valentina Murzi
- Department of Surgical Science, Cagliari State University, Cagliari, Italy
| | | | | | - Ajay Pak
- Department of General Surgery, King George's Medical University, Lucknow, UP, India
| | - Michael Pak-Kai Wong
- School of Medical Sciences & Hospital, Universiti Sains Malaysia, Kelantan, Malaysia
| | | | - Mauro Podda
- Department of Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Caterina Puccioni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Kemal Rasa
- Department of General Surgery, Hüseyin Kemal Raşa, Anadolu Medical Center, Kocaeli, Turkey
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Francesco Roscio
- Division of General and Minimally Invasive Surgery, ASST Valle Olona, Busto Arsizio, Italy
| | - Antonio Gonzalez-Sanchez
- Trauma and Emergency Surgery Unit. General, Digestive and Transplantation Surgery Department, University Regional Hospital of Málaga, Malaga, Spain
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Maximilian Scheiterle
- Emergency Surgery Unit and Trauma Team, Careggi University Hospital, Florence, Italy
| | | | - Dmitry Smirnov
- Department of Surgery, South Ural State Medical University, Chelyabinsk City, Russia
| | - Lorenzo Tosi
- Department of General Surgery, University of Bologna, Bologna, Italy
| | | | | | | | - Sofia Xenaki
- Department of General Surgery, University Hospital of Heraklion, Crete, Greece
| | | | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Andee Dzulkarnean Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences and Hospital USM, Universiti Sains Malaysia, Georgetown, Malaysia
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3
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Suphatheerawatr N, Jaturapisanukul S, Prommool S, Kurathong S, Pongsittisak W. Intra-abdominal hypertension among medical septic patients associated with worsening kidney outcomes (IAH-WK study). Medicine (Baltimore) 2023; 102:e32807. [PMID: 36705348 PMCID: PMC9875967 DOI: 10.1097/md.0000000000032807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
High intra-abdominal pressure (IAP) is associated with acute kidney injury (AKI). However, the relationship between intra-abdominal hypertension (IAH) and AKI in medical septic patients is still inconclusive. This prospective cohort study enrolled patients admitted in the Medical Intensive Care Unit from April 2020 to February 2021. Demographic, therapeutic, and laboratory data were obtained upon admission. The evaluation of IAP was performed via the intra-vesical method during the first and second 24 hours of admission. Kidney function was evaluated on the first 3 days and at least on the 7th day of enrollment. Among 79 patients, 30 (38%) developed IAH, while 50 (63.3%) developed AKI within 7 days. On the first day, the mean IAP was 15.4 (interquartile range [IQR], 4) and 7.0 (IQR, 3.7) mm Hg in the IAH and non-IAH groups, respectively. A total of 52 patients (65.8%) developed the primary outcome (i.e., a composite outcome including AKI, treatment with kidney replacement therapy, or death). On Cox proportional-hazards model between IAH and outcomes, after adjustment for multiple covariates, IAH was associated with a composite outcome (hazard ratio [HR], 6.5; 95% confidence interval [CI], 2.3-18.6; P < .005) and the development of AKI (HR, 6.5; 95% CI, 2.3-18.8; P < .005). IAH was associated with a composite outcome of AKI, treatment with kidney replacement therapy, or death in medical septic patients. thaiclinicaltrial.org, Identifier: TCTR20200531001, Registered May 24, 2020.
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Affiliation(s)
- Nitcha Suphatheerawatr
- Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Solos Jaturapisanukul
- Nephrology and Renal Replacement Therapy division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Bangkok, Thailand
| | - Surazee Prommool
- Nephrology and Renal Replacement Therapy division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Sathit Kurathong
- Nephrology and Renal Replacement Therapy division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Bangkok, Thailand
| | - Wanjak Pongsittisak
- Nephrology and Renal Replacement Therapy division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
- Vajira Renal-Rheumatology-Autoimmune Disease Research Group, Bangkok, Thailand
- * Correspondence: Wanjak Pongsittisak, Nephrology and Renal Replacement Therapy division, Department of Internal Medicine, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok 10400, Thailand (e-mail: )
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4
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Bachmann KF, Regli A, Mändul M, Davis W, Reintam Blaser A. Impact of intraabdominal hypertension on kidney failure in critically ill patients: A post-hoc database analysis. J Crit Care 2022; 71:154078. [PMID: 35738182 DOI: 10.1016/j.jcrc.2022.154078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/02/2022] [Accepted: 05/18/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess whether intraabdominal hypertension (IAH) may influence kidney failure as well as mortality. METHODS This post-hoc analysis of two databases (IROI and iSOFA study) tested the independent association between IAH and kidney failure. Mortality was assessed using four prespecified groups (IAH present, kidney failure present, IAH and kidney failure present and no IAH or kidney failure present). RESULTS Of 825 critically ill patients, 302 (36.6%) developed kidney failure and 192 (23.7%) died during the first 90 days. Only 'Cumulative days with IAH grade II or more' was significantly associated with kidney failure (OR 1.29 (1.08-1.55), p = 0.003) while 'cumulative days with IAH grade I or more' (p = 0.135) or highest daily IAP (p = 0.062) was not. IAH combined with kidney failure was independently associated with 90-day mortality (OR 2.20 (1.20-4.05), p = 0.011), which was confirmed for higher grades of IAH (grade II or more) alone (OR 2.14 (1.07-4.30), p = 0.032) and combined with kidney failure (OR 3.25 (1.72-6.12), p < 0.001). CONCLUSIONS This study suggest that duration as well as higher grades of IAH are associated with kidney failure and may increase mortality.
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Affiliation(s)
- Kaspar F Bachmann
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland; Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia.
| | - Adrian Regli
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia; Medical School, The University of Western Australia, Perth, WA, Australia; Medical School, The University of Notre Dame, Fremantle, WA, Australia
| | - Merli Mändul
- Institute of Mathematics and Statistics, University of Tartu, Tartu, Estonia; Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Wendy Davis
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Annika Reintam Blaser
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland; Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
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5
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Molitoris BA. Low-Flow Acute Kidney Injury: The Pathophysiology of Prerenal Azotemia, Abdominal Compartment Syndrome, and Obstructive Uropathy. Clin J Am Soc Nephrol 2022; 17:1039-1049. [PMID: 35584927 PMCID: PMC9269622 DOI: 10.2215/cjn.15341121] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
AKI is a syndrome, not a disease. It results from many different primary and/or secondary etiologies and is often multifactorial, especially in the hospitalized patient. This review discusses the pathophysiology of three etiologies that cause AKI, those being kidney hypoperfusion, abdominal compartment syndrome, and urinary tract obstruction. The pathophysiology of these three causes of AKI differs but is overlapping. They all lead to a low urine flow rate and low urine sodium initially. In all three cases, with early recognition and correction of the underlying process, the resulting functional AKI can be rapidly reversed. However, with continued duration and/or increased severity, cell injury occurs within the kidney, resulting in structural AKI and a longer and more severe disease state with increased morbidity and mortality. This is why early recognition and reversal are critical.
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Affiliation(s)
- Bruce A Molitoris
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, and Department of Anatomy, Cell Biology and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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6
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Makhija N, Magoon R, Das D, Saxena AK. Haemodynamic predisposition to acute kidney injury: Shadow and light! J Anaesthesiol Clin Pharmacol 2022; 38:353-359. [PMID: 36505192 PMCID: PMC9728413 DOI: 10.4103/joacp.joacp_547_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/30/2021] [Accepted: 05/11/2021] [Indexed: 11/06/2022] Open
Abstract
Acute kidney injury (AKI) could well be regarded as a sentinel complication given it is relatively common and associated with a substantial risk of subsequent morbidity and mortality. On the aegis of 'prevention is better than cure', there has been a wide interest in evaluating haemodynamic predisposition to AKI so as to provide a favourable renoprotective haemodynamic milieu to the subset of patients presenting a significant risk of developing AKI. In this context, the last decade has witnessed a series of evaluation of the hypotension value and duration cut-offs associated with risk of AKI across diverse non-operative and operative settings. Nevertheless, a holistic comprehension of the haemodynamic predisposition to AKI has been a laggard with only few reports highlighting the potential of elevated central venous pressure, intra-abdominal hypertension and high mean airway pressures in considerably attenuating the effective renal perfusion, particularly in scenarios where kidneys are highly sensitive to any untoward elevation in the afterload. Despite the inherent autoregulatory mechanisms, the effective renal perfusion pressure (RPP) can be modulated by a number of haemodynamic factors in addition to mean arterial pressure (MAP) as the escalation of renal interstitial pressure, in particular hampers kidney perfusion which in itself is a dynamic interplay of a number of innate pressures. The present article aims to review the subject of haemodynamic predisposition to AKI centralising the focus on effective RPP (over and above the conventional 'tunnel-vision' for MAP) and discuss the relevant literature accumulating in this area of ever-growing clinical interest.
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Affiliation(s)
- Neeti Makhija
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Magoon
- Department of Cardiac Anaesthesia, Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Devishree Das
- Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, New Delhi, India
| | - Ashok Kumar Saxena
- Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India,Address for correspondence: Dr. Ashok Kumar Saxena, Professor and Head, Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, Delhi - 110 095, India. E-mail:
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7
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Lee RK, Gallagher JJ, Ejike JC, Hunt L. Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society. Crit Care Nurse 2020; 40:13-26. [PMID: 32006038 DOI: 10.4037/ccn2020772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intra-abdominal hypertension has been identified as an independent risk factor for death in critically ill patients. Known risk factors for intra-abdominal hypertension indicate that intra-abdominal pressures should be measured and monitored. The Abdominal Compartment Society has identified medical and surgical interventions to relieve intra-abdominal hypertension or to manage the open abdomen if abdominal compartment syndrome occurs. The purpose of this article is to describe assessments and interventions for managing intra-abdominal hypertension and open abdomen that are within the scope of practice for direct-care nurses. These guidelines provide direction to critical care nurses caring for these patients.
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Affiliation(s)
- Rosemary K Lee
- Rosemary K. Lee is an acute care nurse practitioner and clinical nurse specialist at Baptist Health South Florida, Coral Gables, Florida
| | - John J Gallagher
- John J. Gallagher is a clinical nurse specialist and trauma program coordinator, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Janeth Chiaka Ejike
- Janeth Chiaka Ejike is an associate professor of pediatrics, pediatric critical care medicine practitioner, and Program Director of the Pediatric Critical Care Medicine Fellowship at Loma Linda University Children's Hospital, Loma Linda, California
| | - Leanne Hunt
- Leanne Hunt is a senior lecturer at Western Sydney University and a registered nurse at Liverpool Hospital, Sydney, Australia
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8
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Khot Z, Murphy PB, Sela N, Parry NG, Vogt K, Ball IM. Incidence of Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: A Systematic Review. J Intensive Care Med 2019; 36:197-202. [PMID: 31808368 DOI: 10.1177/0885066619892225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the contemporary prevalence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome in critically ill patients. DATA SOURCES Medline, Embase, and Central databases. STUDY SELECTION Studies reporting on the prevalence of IAH in consecutively admitted critically ill patients using the World Society of Abdominal Compartment Syndrome (WSACS) consensus guidelines for intra-abdominal pressure (IAP) measurement. DATA EXTRACTION Duplicate independent review and data abstraction. DATA SYNTHESIS The search identified 2428 titles with 6 eligible studies (n = 1965). Reported prevalence ranged from 30% to 49%. Despite abiding by the WSACS guidelines for IAP measurement, studies varied in their definition of IAH, frequency and duration of IAP measurement, and reporting of outcomes. Three of 6 studies reported that IAH, especially at higher grades, was an independent predictor of mortality. CONCLUSIONS Intra-abdominal hypertension is a common finding in critically ill patients and may be associated with increased mortality, especially at higher grades. Further prospective research is required to examine the effect of screening and treatment of IAH on patient outcomes.
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Affiliation(s)
- Zaid Khot
- Division of General Surgery, Department of Surgery, 70384Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Patrick B Murphy
- Division of General Surgery, Department of Surgery, 70384Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Acute Care Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nathalie Sela
- Division of General Surgery, Department of Surgery, 70384Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Transplantation Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Neil G Parry
- Division of General Surgery, Department of Surgery, 70384Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Division of Critical Care, Department of Medicine, 215470Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Trauma Program, London Health Sciences Centre, London, Ontario, Canada
| | - Kelly Vogt
- Division of General Surgery, Department of Surgery, 70384Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Trauma Program, London Health Sciences Centre, London, Ontario, Canada
| | - Ian M Ball
- Division of Critical Care, Department of Medicine, 215470Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Trauma Program, London Health Sciences Centre, London, Ontario, Canada
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9
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Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU. Crit Care Med 2019; 46:958-964. [PMID: 29578878 DOI: 10.1097/ccm.0000000000003122] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine the prevalence of intra-abdominal hypertension in mixed medical-surgical critically ill patients using modern definitions and measurement techniques. Secondarily to determine variables associated with intra-abdominal hypertension and ICU mortality. DESIGN A prospective observational study. SETTING Single institution trauma, medical and surgical ICU in Canada. PATIENTS Consecutive adult patients admitted to the ICU (n = 285). INTERVENTION Intra-abdominal pressure measurements twice a day during admission to the ICU. MEASUREMENTS AND MAIN RESULTS In 285 patients who met inclusion criteria, 30% were diagnosed with intra-abdominal hypertension at admission and a further 15% developed intra-abdominal hypertension during admission. The prevalence of abdominal compartment syndrome was 3%. Obesity, sepsis, mechanical ventilation, and 24-hour fluid balance (> 3 L) were all independent predictors for intra-abdominal hypertension. Intra-abdominal hypertension occurred in 28% of nonventilated patients. Admission type (medical vs surgical vs trauma) was not a significant predictor of intra-abdominal hypertension. Overall ICU mortality was 20% and was significantly higher for patients with intra-abdominal hypertension (30%) compared with patients without intra-abdominal hypertension (11%). Intra-abdominal hypertension of any grade was an independent predictor of mortality (odds ratio, 3.33; 95% CI, 1.46-7.57). CONCLUSIONS Intra-abdominal hypertension is common in both surgical and nonsurgical patients in the intensive care setting and was found to be independently associated with mortality. Despite prior reports to the contrary, intra-abdominal hypertension develops in nonventilated patients and in patients who do not have intra-abdominal hypertension at admission. Intra-abdominal pressure monitoring is inexpensive, provides valuable clinical information, and there may be a role for its routine measurement in the ICU. Future work should evaluate the impact of early interventions for patients with intra-abdominal hypertension.
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10
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Kirkpatrick AW, Coccolini F, Ansaloni L, Roberts DJ, Tolonen M, McKee JL, Leppaniemi A, Faris P, Doig CJ, Catena F, Fabian T, Jenne CN, Chiara O, Kubes P, Manns B, Kluger Y, Fraga GP, Pereira BM, Diaz JJ, Sugrue M, Moore EE, Ren J, Ball CG, Coimbra R, Balogh ZJ, Abu-Zidan FM, Dixon E, Biffl W, MacLean A, Ball I, Drover J, McBeth PB, Posadas-Calleja JG, Parry NG, Di Saverio S, Ordonez CA, Xiao J, Sartelli M. Closed Or Open after Source Control Laparotomy for Severe Complicated Intra-Abdominal Sepsis (the COOL trial): study protocol for a randomized controlled trial. World J Emerg Surg 2018; 13:26. [PMID: 29977328 PMCID: PMC6015449 DOI: 10.1186/s13017-018-0183-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/10/2018] [Indexed: 12/29/2022] Open
Abstract
Background Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. Principles of treatment include early antibiotic administration and operative source control. A further therapeutic option may be open abdomen (OA) management with active negative peritoneal pressure therapy (ANPPT) to remove inflammatory ascites and ameliorate the systemic damage from SCIAS. Although there is now a biologic rationale for such an intervention as well as non-standardized and erratic clinical utilization, this remains a novel therapy with potential side effects and clinical equipoise. Methods The Closed Or Open after Laparotomy (COOL) study will constitute a prospective randomized controlled trial that will randomly allocate eligible surgical patients intra-operatively to either formal closure of the fascia or use of the OA with application of an ANPTT dressing. Patients will be eligible if they have free uncontained intra-peritoneal contamination and physiologic derangements exemplified by septic shock OR a Predisposition-Infection-Response-Organ Dysfunction Score ≥ 3 or a World-Society-of-Emergency-Surgery-Sepsis-Severity-Score ≥ 8. The primary outcome will be 90-day survival. Secondary outcomes will be logistical, physiologic, safety, bio-mediators, microbiological, quality of life, and health-care costs. Secondary outcomes will include days free of ICU, ventilation, renal replacement therapy, and hospital at 30 days from the index laparotomy. Physiologic secondary outcomes will include changes in intensive care unit illness severity scores after laparotomy. Bio-mediator outcomes for participating centers will involve measurement of interleukin (IL)-6 and IL-10, procalcitonin, activated protein C (APC), high-mobility group box protein-1, complement factors, and mitochondrial DNA. Economic outcomes will comprise standard costing for utilization of health-care resources. Discussion Although facial closure after SCIAS is considered the current standard of care, many reports are suggesting that OA management may improve outcomes in these patients. This trial will be powered to demonstrate a mortality difference in this highly lethal and morbid condition to ensure critically ill patients are receiving the best care possible and not being harmed by inappropriate therapies based on opinion only. Trial registration ClinicalTrials.gov, NCT03163095.
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Affiliation(s)
- Andrew W. Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- The Trauma Program, University of Calgary, Calgary, Alberta Canada
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesena, Italy
| | - Derek J. Roberts
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Matti Tolonen
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Jessica L. McKee
- Regional Trauma Services, Foothills Medical Centre, Calgary, Alberta Canada
| | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Peter Faris
- Research Facilitation Analytics (DIMR), University of Calgary, Calgary, Alberta Canada
| | - Christopher J. Doig
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Fausto Catena
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Timothy Fabian
- Surgery, University of Tennessee Health Sciences Center Memphis, Memphis, TN USA
| | - Craig N. Jenne
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
| | - Osvaldo Chiara
- General Surgery and Trauma Team Niguarda Hospital Milano, Milan, Italy
| | - Paul Kubes
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta Canada
- Department of Physiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
| | - Braden Manns
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
- Department of Medicine, University of Calgary, Calgary, Alberta Canada
- Libin Cardiovascular Institute and O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta Canada
| | | | - Gustavo P. Fraga
- Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Bruno M. Pereira
- Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
| | - Jose J. Diaz
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
| | - Ernest E. Moore
- Trauma and Critical Care Research, University of Colorado, Denver, CO USA
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chad G. Ball
- General, Acute Care, and Hepatobiliary Surgery, and Regional Trauma Services, University of Calgary, Calgary, Alberta Canada
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda, CA USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA USA
| | - Zsolt J. Balogh
- John Hunter Hospital and Hunter New England Health District, Newcastle, NSW Australia
- Surgery and Traumatology, University of Newcastle, Newcastle, NSW Australia
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
- Surgical Oncology, University of Calgary, Calgary, Alberta Canada
- City Wide Section of General Surgery, University of Calgary, Calgary, Alberta Canada
| | - Walter Biffl
- Scripps Memorial Hospital La Jolla, La Jolla, California USA
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
| | - Ian Ball
- Department of Medicine, Western University, London, Ontario Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario Canada
| | - John Drover
- Department of Critical Care Medicine, Queen’s University, Kingston, Ontario Canada
- Department of Surgery, Queen’s University, Kingston, Ontario Canada
| | - Paul B. McBeth
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- The Trauma Program, University of Calgary, Calgary, Alberta Canada
| | | | - Neil G. Parry
- Department of Surgery, Western University, Victoria Hospital, London Health Sciences Centre, London, Ontario Canada
- Department of Critical Care, Western University, Victoria Hospital, London Health Sciences Centre, London, Ontario Canada
| | - Salomone Di Saverio
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili and Universidad Del Valle, Cali, Colombia
| | - Jimmy Xiao
- Regional Trauma Services, Foothills Medical Centre, Calgary, Alberta Canada
| | | | - for The Closed Or Open after Laparotomy (COOL) after Source Control for Severe Complicated Intra-Abdominal Sepsis Investigators
- Department of Surgery, University of Calgary, Calgary, Alberta Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta Canada
- The Trauma Program, University of Calgary, Calgary, Alberta Canada
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
- Unit of General and Emergency Surgery, Bufalini Hospital of Cesena, Cesena, Italy
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
- Regional Trauma Services, Foothills Medical Centre, Calgary, Alberta Canada
- Research Facilitation Analytics (DIMR), University of Calgary, Calgary, Alberta Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
- Surgery, University of Tennessee Health Sciences Center Memphis, Memphis, TN USA
- General Surgery and Trauma Team Niguarda Hospital Milano, Milan, Italy
- Calvin, Phoebe and Joan Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Alberta Canada
- Department of Physiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta Canada
- Department of Medicine, University of Calgary, Calgary, Alberta Canada
- Libin Cardiovascular Institute and O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta Canada
- Rambam Health Care Campus, Haifa, Israel
- Division of Trauma Surgery, University of Campinas, Campinas, SP Brazil
- Department of Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School on Medicine, Baltimore, MD USA
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- Trauma and Critical Care Research, University of Colorado, Denver, CO USA
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- General, Acute Care, and Hepatobiliary Surgery, and Regional Trauma Services, University of Calgary, Calgary, Alberta Canada
- Riverside University Health System Medical Center, Loma Linda, CA USA
- Department of Surgery, Loma Linda University School of Medicine, Loma Linda, CA USA
- John Hunter Hospital and Hunter New England Health District, Newcastle, NSW Australia
- Surgery and Traumatology, University of Newcastle, Newcastle, NSW Australia
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
- Surgical Oncology, University of Calgary, Calgary, Alberta Canada
- City Wide Section of General Surgery, University of Calgary, Calgary, Alberta Canada
- Scripps Memorial Hospital La Jolla, La Jolla, California USA
- Department of Medicine, Western University, London, Ontario Canada
- Department of Epidemiology and Biostatistics, Western University, London, Ontario Canada
- Department of Critical Care Medicine, Queen’s University, Kingston, Ontario Canada
- Department of Surgery, Queen’s University, Kingston, Ontario Canada
- Department of Surgery, Western University, Victoria Hospital, London Health Sciences Centre, London, Ontario Canada
- Department of Critical Care, Western University, Victoria Hospital, London Health Sciences Centre, London, Ontario Canada
- Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, Fundación Valle del Lili and Universidad Del Valle, Cali, Colombia
- Department of Surgery, Macerata Hospital, Macerata, Italy
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Braha B, Mahmutaj D, Maxhuni M, Neziri B, Krasniqi S. Correlation of Procalcitonin and C-Reactive Protein with Intra-Abdominal Hypertension in Intra-Abdominal Infections: Their Predictive Role in the Progress of the Disease. Open Access Maced J Med Sci 2018; 6:479-484. [PMID: 29610604 PMCID: PMC5874369 DOI: 10.3889/oamjms.2018.112] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 01/17/2023] Open
Abstract
AIM To analyse the correlation of procalcitonin (PCT) and C-reactive protein (CRP) values with increased intra-abdominal pressure and to evaluate their predictive role in the progression of Intra-abdominal infections. MATERIALS AND METHODS A non-randomized prospective study conducted in the group of 80 patients. We have measured the PCT, CRP and intra-abdominal pressure (IAP). RESULTS According to IAH grades (G), there was a significant difference of PCT values: G I 3.6 ± 5.1 ng/ml, G II 10.9 ± 22.6 ng/ml, G III 15.2 ± 30.2 ng/ml (p = 0.045) until: CRP values were increased in all IAH groups but without distinction between the groups: GI 183 ± 64.5, GII 196 ± 90.2, GIII 224 ± 96.3 (p = 0.17). According to the severity of the infection, we yielded increased values of PCT, IAP and CRP in septic shock, severe sepsis and SIRS/sepsis resulting in significant differences of PCT and IAP. CONCLUSION Based on the results of our research, we conclude that the correlation of PCT values with IAH grades is quite significant while the CRP results remain high in IAH but without significant difference between the different grades of IAH.
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Affiliation(s)
- Bedri Braha
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Dafina Mahmutaj
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Mehmet Maxhuni
- Clinic of Surgery, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Burim Neziri
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
| | - Shaip Krasniqi
- Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
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Increased pressure within the abdominal compartment: intra-abdominal hypertension and the abdominal compartment syndrome. Curr Opin Crit Care 2016; 22:174-85. [PMID: 26844989 DOI: 10.1097/mcc.0000000000000289] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW This article reviews recent developments related to intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) and clinical practice guidelines published in 2013. RECENT FINDINGS IAH/ACS often develops because of the acute intestinal distress syndrome. Although the incidence of postinjury ACS is decreasing, IAH remains common and associated with significant morbidity and mortality among critically ill/injured patients. Many risk factors for IAH include those findings suggested to be indications for use of damage control surgery in trauma patients. Medical management strategies for IAH/ACS include sedation/analgesia, neuromuscular blocking and prokinetic agents, enteral decompression tubes, interventions that decrease fluid balance, and percutaneous catheter drainage. IAH/ACS may be prevented in patients undergoing laparotomy by leaving the abdomen open where appropriate. If ACS cannot be prevented with medical or surgical management strategies or treated with percutaneous catheter drainage, guidelines recommend urgent decompressive laparotomy. Use of negative pressure peritoneal therapy for temporary closure of the open abdomen may improve the systemic inflammatory response and patient-important outcomes. SUMMARY In the last 15 years, investigators have better clarified the pathogenesis, epidemiology, diagnosis, and appropriate prevention of IAH/ACS. Subsequent study should be aimed at understanding which treatments effectively lower intra-abdominal pressure and whether these treatments ultimately affect patient-important outcomes.
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Zhang HY, Liu D, Tang H, Sun SJ, Ai SM, Yang WQ, Jiang DP, Zhou J, Zhang LY. Prevalence and diagnosis rate of intra-abdominal hypertension in critically ill adult patients: A single-center cross-sectional study. Chin J Traumatol 2016; 18:352-6. [PMID: 26917027 DOI: 10.1016/j.cjtee.2015.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To investigate the prevalence and diagnosis rate of intra-abdominal hypertension (IAH) in a mixed-population intensive care unit (ICU), and to investigate the knowledge of ICU staff regarding the guidelines published by the World Society of Abdominal Compartment Syndrome (WSACS) in 2013. METHODS A one-day cross-sectional study based on the WSACS 2013 guidelines was conducted in the general ICU of a tertiary teaching hospital in Chongqing, China. The included patients were divided into intravesical pressure (IVP) measured group and IVP unmeasured group. The epidemiologic data were recorded, and potential IAH risk factors (RFs) were collected based on the guidelines. IVP measurements were conducted by investigators every 4 h and the result was compared to that measured by the ICU staff to evaluate the diagnosis rate. Besides, a questionnaire was used to investigate the understanding of the guidelines among ICU staff. RESULTS Thirty-two patients were included, 14 in the IVP measured group and 18 in the IVP unmeasured group. The prevalence of IAH during the survey was 15.63% (5/32), 35.71% (5/14) in IVP measured group. Only one case of IAH had been diagnosed by the ICU physician and the diagnosis rate was as low as 20.00%. Logistic regression analysis showed that sequential organ failure assessment (SOFA) score was an independent RF for IAH (OR: 1.532, 95% CI: 1.029-2.282, p=0.036. Fourteen doctors and 5 nurses were investigated and the response rate was 67.86%. The average scores of the doctors and nurses were 27.14±20.16 and 16.00±8.94 respectively. None of them had studied the WSACS 2013 guidelines thoroughly. CONCLUSION Patients with a higher SOFA score has a higher incidence of IAH. The IAH prevalence in 14 ICU patients with indwelling catheter was 35.71%. Strengthening the wide and rational use of WSACS guideline is important to improve the diagnosis of IAH.
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Affiliation(s)
- Hua-Yu Zhang
- Trauma Center, State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing 400042, China
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Patel DM, Connor MJ. Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: An Underappreciated Cause of Acute Kidney Injury. Adv Chronic Kidney Dis 2016; 23:160-6. [PMID: 27113692 DOI: 10.1053/j.ackd.2016.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 02/26/2016] [Accepted: 03/04/2016] [Indexed: 02/06/2023]
Abstract
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are increasingly recognized in both medical and surgical critically ill patients and are predictive of death and the development of acute kidney injury. Although there are many risk factors for the development of IAH, in the era of goal-directed therapy for shock, brisk volume resuscitation and volume overload are the most common contributors. Abdominal examination is an unreliable predictor of intra-abdominal pressure (IAP), but IAP can be easily measured in a reproducible and reliable manner by a number of simple bedside techniques. Prompt recognition and intervention to decrease IAP and improve vital organ perfusion are essential to minimize the negative effects of IAH on somatic and visceral organ functions.
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Zamani MM, Keshavarz-Fathi M, Fakhri-Bafghi MS, Hirbod-Mobarakeh A, Rezaei N, Bahrami A, Nader ND. Survival benefits of dexmedetomidine used for sedating septic patients in intensive care setting: A systematic review. J Crit Care 2016; 32:93-100. [DOI: 10.1016/j.jcrc.2015.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/08/2015] [Accepted: 11/10/2015] [Indexed: 12/15/2022]
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Maddison L, Starkopf J, Reintam Blaser A. Mild to moderate intra-abdominal hypertension: Does it matter? World J Crit Care Med 2016; 5:96-102. [PMID: 26855899 PMCID: PMC4733462 DOI: 10.5492/wjccm.v5.i1.96] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 11/18/2015] [Accepted: 12/03/2015] [Indexed: 02/06/2023] Open
Abstract
This review summarizes the epidemiology, pathophysiological consequences and impact on outcome of mild to moderate (Grade I to II) intra-abdominal hypertension (IAH), points out possible pitfalls in available treatment recommendations and focuses on tasks for future research in the field. IAH occurs in about 40% of ICU patients. Whereas the prevalence of abdominal compartment syndrome seems to be decreasing, the prevalence of IAH does not. More than half of IAH patients present with IAH grade I and approximately a quarter with IAH grade II. However, most of the studies have addressed IAH as a yes-or-no variable, with little or no attention to different severity grades. Even mild IAH can have a negative impact on tissue perfusion and microcirculation and be associated with an increased length of stay and duration of mechanical ventilation. However, the impact of IAH and its different grades on mortality is controversial. The influence of intra-abdominal pressure (IAP) on outcome most likely depends on patient and disease characteristics and the concomitant macro- and microcirculation. Therefore, management might differ significantly. Today, clear triggers for interventions in different patient groups with mild to moderate IAH are not defined. Further studies are needed to clarify the clinical importance of mild to moderate IAH identifying clear triggers for interventions to lower the IAP.
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Chadi SA, Abdo H, Bihari A, Parry N, Lawendy AR. Hepatic microvascular changes in rat abdominal compartment syndrome. J Surg Res 2015; 197:398-404. [DOI: 10.1016/j.jss.2015.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 12/24/2014] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
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Chopra SS, Wolf S, Rohde V, Freimann FB. Pressure Measurement Techniques for Abdominal Hypertension: Conclusions from an Experimental Model. Crit Care Res Pract 2015; 2015:278139. [PMID: 26113992 PMCID: PMC4465705 DOI: 10.1155/2015/278139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/24/2015] [Indexed: 11/17/2022] Open
Abstract
Introduction. Intra-abdominal pressure (IAP) measurement is an indispensable tool for the diagnosis of abdominal hypertension. Different techniques have been described in the literature and applied in the clinical setting. Methods. A porcine model was created to simulate an abdominal compartment syndrome ranging from baseline IAP to 30 mmHg. Three different measurement techniques were applied, comprising telemetric piezoresistive probes at two different sites (epigastric and pelvic) for direct pressure measurement and intragastric and intravesical probes for indirect measurement. Results. The mean difference between the invasive IAP measurements using telemetric pressure probes and the IVP measurements was -0.58 mmHg. The bias between the invasive IAP measurements and the IGP measurements was 3.8 mmHg. Compared to the realistic results of the intraperitoneal and intravesical measurements, the intragastric data showed a strong tendency towards decreased values. The hydrostatic character of the IAP was eliminated at high-pressure levels. Conclusion. We conclude that intragastric pressure measurement is potentially hazardous and might lead to inaccurately low intra-abdominal pressure values. This may result in missed diagnosis of elevated abdominal pressure or even ACS. The intravesical measurements showed the most accurate values during baseline pressure and both high-pressure plateaus.
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Affiliation(s)
- Sascha Santosh Chopra
- Department of General, Visceral and Transplantation Surgery, Charité-University Medicine Berlin, 13353 Berlin, Germany
| | - Stefan Wolf
- Department of Neurosurgery, Charité-University Medicine Berlin, 13353 Berlin, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medicine Göttingen, Georg-August University, 37099 Göttingen, Germany
| | - Florian Baptist Freimann
- Department of Neurosurgery, University Medicine Göttingen, Georg-August University, 37099 Göttingen, Germany
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Arabadzhiev GM, Tzaneva VG, Peeva KG. Intra-abdominal hypertension in the ICU - a prospective epidemiological study. ACTA ACUST UNITED AC 2015; 88:188-95. [PMID: 26528070 PMCID: PMC4576776 DOI: 10.15386/cjmed-455] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/06/2015] [Indexed: 12/19/2022]
Abstract
The aim of this prospective study is to examine the frequency and the severity of intra-abdominal hypertension in a mixed ICU of the University hospital.
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Affiliation(s)
- Georgi M Arabadzhiev
- Department of Pediatric Surgery, Anesthesia and Emergency Medicine, Trakia University, Medical Faculty, Stara Zagora, Bulgaria
| | - Valentina G Tzaneva
- Department of Infection Diseases and Epidemiology, Trakia University, Medical Faculty, Stara Zagora, Bulgaria
| | - Katya G Peeva
- Department of Social Medicine and Health Management, Trakia University, Medical Faculty, Stara Zagora, Bulgaria
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Singhal J, Shanbag P. Measurement of Intra-abdominal Pressure in Critically-ill Children. J Clin Diagn Res 2015; 8:PC06-7. [PMID: 25653998 DOI: 10.7860/jcdr/2014/10435.5345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 09/23/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION It is being increasingly recognized that intra-abdominal hypertension is an important cause of organ dysfunction. This pilot study was done to determine the feasibility of measuring intra-abdominal pressures (IAP) in critically-ill children using simple inexpensive equipment available in the PICU. MATERIALS AND METHODS This was a prospective study done in the paediatric intensive care unit (PICU) of a tertiary care general hospital. Thirty-two consecutive patients admitted to the PICU, staying for more than 24 h and requiring a urinary catheter were studied. IAP was measured by the intravesical method, using a disposable manometer, twice a day for seven days or till discharge/death, Risk factors associated with IAH were recorded. RESULTS The majority of the patients had an IAP less than 5 mm Hg. Three patients had grade 1 intra-abdominal hypertension (IAP>12 mm Hg). CONCLUSION It is feasible to measure IAP in paediatric patients without the use of sophisticated equipment.
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Affiliation(s)
- Jyoti Singhal
- Assistant Professor, Department of Pediatrics, Bharati Vidyapeeth Medical College , Pune, India
| | - Preeti Shanbag
- Assistant Professor, Department of Pediatrics, Bharati Vidyapeeth Medical College , Pune, India
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Aik-Yong C, Ye-Xin K, Yi NS, Hway WT. Abdominal compartment syndrome: Incidence and prognostic factors influencing survival in Singapore. Indian J Crit Care Med 2014; 18:648-52. [PMID: 25316974 PMCID: PMC4195194 DOI: 10.4103/0972-5229.142173] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim of Study: Abdominal compartment syndrome (ACS) is a distinct clinical entity in the critically ill-patient, which leads to end-organ dysfunction. However, data on the incidence of ACS is scarce, and this is also likely contributed by under-diagnosis of this clinical condition. This study reports all cases of ACS in a tertiary institution in Singapore over 10 years, and evaluates prognostic factors affecting survival. Materials and Methods: This retrospective clinical study included 17 patients with ACS, of which 13 underwent decompressive laparotomy, over a 10 years period. Univariate and multivariate analyses of prognostic factors predicting mortality was performed using Chi-square or Fisher-exact test as appropriate. Results: Mean arterial pressure was significantly improved postoperatively, and intra-abdominal pressure and positive end-expiratory pressure significantly decreased. Overall mortality was 47.1%. Advanced age of more than 65 years, gender, large volume resuscitation of more than 3.5 L over 24 h, three or more co-morbidities, requirement of inotropes, usage of mechanical ventilation, and the presence of concurrent lung and renal dysfunction were not adverse prognostic indicators of poorer outcome. The occurrence of multiple relook laparotomies was shown to be the only independent prognostic factor predicting a favorable outcome among these patients on univariate and multivariate analyses. The incidence of ACS accounts for only 0.1% of all Intensive Care Unit admissions during the study period of 10 years, likely due to under-diagnosis. Conclusion: We believe that a protocol for a focused measurement in high-risk groups will increase the diagnostic yield of this condition. Multiple laparotomies for abdominal decompression can lead to improved survival.
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Affiliation(s)
- Chok Aik-Yong
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Koh Ye-Xin
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Ng Shin Yi
- Department of Anaesthesia and Critical Care, Singapore General Hospital, Singapore
| | - Wong Ting Hway
- Department of General Surgery, Singapore General Hospital, Singapore
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Hernandez G, Luengo C, Bruhn A, Kattan E, Friedman G, Ospina-Tascon GA, Fuentealba A, Castro R, Regueira T, Romero C, Ince C, Bakker J. When to stop septic shock resuscitation: clues from a dynamic perfusion monitoring. Ann Intensive Care 2014; 4:30. [PMID: 25593746 PMCID: PMC4273696 DOI: 10.1186/s13613-014-0030-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 08/06/2014] [Indexed: 12/15/2022] Open
Abstract
Background The decision of when to stop septic shock resuscitation is a critical but yet a relatively unexplored aspect of care. This is especially relevant since the risks of over-resuscitation with fluid overload or inotropes have been highlighted in recent years. A recent guideline has proposed normalization of central venous oxygen saturation and/or lactate as therapeutic end-points, assuming that these variables are equivalent or interchangeable. However, since the physiological determinants of both are totally different, it is legitimate to challenge the rationale of this proposal. We designed this study to gain more insights into the most appropriate resuscitation goal from a dynamic point of view. Our objective was to compare the normalization rates of these and other potential perfusion-related targets in a cohort of septic shock survivors. Methods We designed a prospective, observational clinical study. One hundred and four septic shock patients with hyperlactatemia were included and followed until hospital discharge. The 84 hospital-survivors were kept for final analysis. A multimodal perfusion assessment was performed at baseline, 2, 6, and 24 h of ICU treatment. Results Some variables such as central venous oxygen saturation, central venous-arterial pCO2 gradient, and capillary refill time were already normal in more than 70% of survivors at 6 h. Lactate presented a much slower normalization rate decreasing significantly at 6 h compared to that of baseline (4.0 [3.0 to 4.9] vs. 2.7 [2.2 to 3.9] mmol/L; p < 0.01) but with only 52% of patients achieving normality at 24 h. Sublingual microcirculatory variables exhibited the slowest recovery rate with persistent derangements still present in almost 80% of patients at 24 h. Conclusions Perfusion-related variables exhibit very different normalization rates in septic shock survivors, most of them exhibiting a biphasic response with an initial rapid improvement, followed by a much slower trend thereafter. This fact should be taken into account to determine the most appropriate criteria to stop resuscitation opportunely and avoid the risk of over-resuscitation.
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Affiliation(s)
- Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Cecilia Luengo
- Unidad de Pacientes Críticos, Hospital Clínico, Universidad de Chile, Santos Dumont 999, Santiago 8380456, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Gilberto Friedman
- Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Porto Alegre-RS, 90035-903, Brazil
| | - Gustavo A Ospina-Tascon
- Intensive Care Unit, Fundación Valle del Lili, Av. Simón Bolívar Cra 98 # 18-49, Cali, Valle del Cauca, Colombia
| | - Andrea Fuentealba
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Ricardo Castro
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Tomas Regueira
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Carlos Romero
- Unidad de Pacientes Críticos, Hospital Clínico, Universidad de Chile, Santos Dumont 999, Santiago 8380456, Chile
| | - Can Ince
- Department of Intensive Care Adults, Erasmus MC University Medical Centre, Doctor Molewaterplein 50-60, Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Centre, Doctor Molewaterplein 50-60, Rotterdam, the Netherlands
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Expanded measurements of intra-abdominal pressure do not increase the detection rate of intra-abdominal hypertension: a single-center observational study. Crit Care Med 2014; 42:378-86. [PMID: 24145841 DOI: 10.1097/ccm.0b013e3182a6459b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Intra-abdominal hypertension may contribute to a poor outcome. Whether limiting intra-abdominal pressure measurements to preselected at-risk patients allows for sufficient detection of intra-abdominal hypertension is unclear. We aimed to clarify whether expanded intra-abdominal pressure monitoring results in an increased detection rate of intra-abdominal hypertension. DESIGN Retrospective observational study. SETTING General ICU of University Hospital. PATIENTS Consecutive adult ICU patients from 2004 to 2011. INTERVENTIONS Intra-abdominal pressure measurements in predefined at-risk patients. MEASUREMENTS AND MAIN RESULTS Prospectively collected data of 2,696 admissions were divided into three subgroups according to the intra-abdominal pressure measurement policy in different years: 1) 2004-2005, mechanically ventilated patients with at least one additional risk factor for intra-abdominal hypertension (multiple trauma, abdominal surgery, pancreatitis, post-cardiopulmonary resuscitation, fluid resuscitation > 5 L/24 hr, vasoactive or inotropic support, and renal replacement therapy); 2) 2006-2009, all mechanically ventilated patients expected to stay for more than or equal to 24 hours; and 3) 2010-2011, mechanically ventilated patients with a body mass index greater than 30 kg/m, positive end-expiratory pressure more than 10 cm H2O, PaO2/FIO2 less than 300, use of vasopressors/inotropes, pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding, or postlaparotomy. In all, 2,696 patients were studied, and 1,241 patients (46.0%) underwent intra-abdominal pressure monitoring. The intra-abdominal pressure was measured in 31.7%, 55.6%, and 41.1% of patients during the first, second, and third time periods (p < 0.001), and intra-abdominal hypertension (intra-abdominal pressure ≥ 12 mm Hg) occurred in 19.9%, 20.3%, and 20.1% of patients, respectively (p = 0.972). The mean intra-abdominal pressure at admission day was an independent predictor of mortality in patients with intra-abdominal pressure measurements started within the first 24 hours (odds ratio, 1.046 [95% CI, 1.019-1.072]). The mortality of patients with intra-abdominal hypertension was 29.8% versus 18.6% in those without intra-abdominal hypertension (p < 0.001). CONCLUSIONS Expanding the measurement of intra-abdominal pressure to more than 50% of intensive care admissions does not increase the detection rate of intra-abdominal hypertension. In patients with intra-abdominal pressure monitoring, the mean intra-abdominal pressure on the admission day is an independent predictor of mortality.
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Moderate intra-abdominal hypertension leads to anaerobic metabolism in the rectus abdominis muscle tissue of critically ill patients: a prospective observational study. BIOMED RESEARCH INTERNATIONAL 2014; 2014:857492. [PMID: 24745026 PMCID: PMC3973001 DOI: 10.1155/2014/857492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/11/2014] [Indexed: 12/31/2022]
Abstract
Purpose. We hypothesize that intra-abdominal hypertension (IAH) is associated with the presence of anaerobic metabolism in the abdominal rectus muscle (RAM) tissue of critically ill patients. Methods. We included 10 adult, critically ill patients with intra-abdominal pressure (IAP) above 12 mmHg. Microdialysis catheters (CMA 60) were inserted into the RAM tissue. The samples were collected up to 72 hours after enrollment. Results. The patients' median (IQR) APACHE II at inclusion was 29 (21–37); 7 patients were in shock. IAP was 14.5 (12.5–17.8) mmHg at baseline and decreased significantly over time, concomitantly with arterial lactate and vasopressors requirements. The tissue lactate-to-pyruvate (L/P) ratio was 49 (36–54) at the beginning of the study and decreased significantly throughout the study. Additionally, the tissue lactate, lactate-to-glucose (L/G) ratio, and glutamate concentrations changed significantly during the study. The correlation analysis showed that lower levels of pyruvate and glycerol were associated with higher MAP and abdominal perfusion pressures (APP) and that higher levels of glutamate were correlated to elevated IAP. Conclusions. Moderate IAH leads to RAM tissue anaerobic metabolism suggestive for hypoperfusion in critically ill patients. Correlation analysis supports the concept of using APP as the primary endpoint of resuscitation in addition to MAP and IAP.
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Verburgh P, Reintam-Blaser A, Kirkpatrick AW, De Waele JJ, Malbrain MLNG. Overview of the recent definitions and terminology for acute gastrointestinal injury, intra-abdominal hypertension and the abdominal compartment syndrome. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s13546-013-0819-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Maddison L, Karjagin J, Buldakov M, Mäll M, Kruusat R, Lillemäe K, Kirsimägi U, Starkopf J. Sublingual microcirculation in patients with intra-abdominal hypertension: a pilot study in 15 critically ill patients. J Crit Care 2013; 29:183.e1-6. [PMID: 24125769 DOI: 10.1016/j.jcrc.2013.08.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/07/2013] [Accepted: 08/27/2013] [Indexed: 01/18/2023]
Abstract
PURPOSE The purpose of the study is to clarify whether increased intra-abdominal pressure (IAP) is associated with sublingual microcirculatory alterations in intensive care patients. METHODS Fifteen adult, mechanically ventilated patients were included if their IAP was at least 12 mm Hg for at least 12 hours within the first 3 days after admission to the intensive care unit. Sublingual sidestream dark field (SDF) images were recorded twice a day for 7 days. RESULTS Median (interquartile range) IAP at inclusion was 14.5 (12.5-16.0) mm Hg. The total vascular density of small vessels at the sublingual area was 13.1 (10.6-14.3) per square millimeter at baseline; the proportion of perfused vessels, 78.9% (69.6%-86.2%); and perfused vessels density, 12.4 (10.8-13.8) per square millimeter. The calculated indices suggested relatively good blood flow in the capillaries, with a De Backer score of 9.0 (8.3-10.2) and a microvascular blood flow of 3.0 (2.9-3.0). Blood flow heterogeneity index was 0.3 (0.1-0.5) at study entry. Despite that IAP, vasopressors dose, and arterial lactate decreased significantly over time, no significant changes were observed in sublingual microvascular density or blood flow. Weak correlations of microvascular blood flow (positive) and heterogeneity index (negative) were detected with both mean arterial pressure and abdominal perfusion pressure. CONCLUSIONS Neither grade I or II intra-abdominal hypertension (IAP from 12 to 18 mm Hg) is associated with significant changes of sublingual microcirculation in intensive care patients. Correlation analysis indicates better microvascular blood flow at higher mean arterial pressure and abdominal perfusion pressure levels.
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Affiliation(s)
- Liivi Maddison
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia.
| | - Juri Karjagin
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Maksim Buldakov
- University of Tartu, Medical Faculty, Ravila 19, Tartu, Estonia
| | - Merilin Mäll
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Rein Kruusat
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Kadri Lillemäe
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Ulle Kirsimägi
- Department of Surgery, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
| | - Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu University Hospital, Puusepa 8, 51014 Tartu, Estonia
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Abstract
Patients in the setting of the intensive care unit can develop intra-abdominal complications that may worsen outcome. Clinical suspicion of such complications coupled with early diagnosis and treatment may reduce morbidity and mortality associated with these processes. This article addresses the diagnosis and management of some of the common causes of intra-abdominal catastrophes.
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Affiliation(s)
- Joao B Rezende-Neto
- Department of Surgery, St. Michael's Hospital, 30 Bond Street 16CC-044, Toronto, Ontario M5B1W8, Canada
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Malbrain ML, De laet IE, De Waele JJ, Kirkpatrick AW. Intra-abdominal hypertension: Definitions, monitoring, interpretation and management. Best Pract Res Clin Anaesthesiol 2013; 27:249-70. [DOI: 10.1016/j.bpa.2013.06.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 06/28/2013] [Indexed: 02/01/2023]
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Correa-Martín L, Castellanos G, García-Lindo M, Díaz-Güemes I, Sánchez-Margallo FM. Tonometry as a predictor of inadequate splanchnic perfusion in an intra-abdominal hypertension animal model. J Surg Res 2013; 184:1028-34. [PMID: 23688792 DOI: 10.1016/j.jss.2013.04.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 04/10/2013] [Accepted: 04/19/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND The gastrointestinal system is the most sensitive to the presence of intra-abdominal hypertension. We aimed to assess the early prognostic value of gastric air tonometry as a predictor of inadequate splanchnic perfusion and determine its relation with abdominal perfusion pressure (APP). METHODS Twenty-five Large White swine were used for this study. A control group and two study groups were included, in which intra-abdominal pressure (IAP) was elevated with Co2 to 20 and 30 mmHg during 5 h. We measured the intramucosal gastric pH (pHim) and determined gastric luminal PCO2 (PgCO2) and PgCO2gap (gastric luminal CO2-arterial CO2) to evaluate gastric acidity. APP was indirectly obtained through IAP and mean arterial pressure. Additionally, histopathologic samples of small intestine were obtained and analyzed. RESULTS pHim showed a decrease in IAP groups, with statistical significance in the 30 mmHg group, 90 min after stabilization period (P < 0.01). Serum lactate showed delayed alteration when compared with pHim, with significant increase, 180 min after stabilization (P < 0.05). The values of PgCO2 and PCO2gap were increased in IAP groups, being statistically significant in the 30 mmHg group, 120 and 150 min, respectively, after stabilization. In increased IAP groups, there was a time progressive decrease of APP, with statistically significant differences observed between groups at 20 min (P < 0.001). The histopathology study revealed parenchymal injury of the intestine at 30 mmHg. CONCLUSIONS Tonometry is sensitive to the increase in IAP and relates to the reduction of APP generated by splanchnic hypoperfusion.
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Affiliation(s)
- Laura Correa-Martín
- Department of Laparoscopy, Jesús Usón Minimally Invasive Surgery Center (JUMISC), Cáceres, Spain.
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Relationship of systemic, hepatosplanchnic, and microcirculatory perfusion parameters with 6-hour lactate clearance in hyperdynamic septic shock patients: an acute, clinical-physiological, pilot study. Ann Intensive Care 2012; 2:44. [PMID: 23067578 PMCID: PMC3488533 DOI: 10.1186/2110-5820-2-44] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
Background Recent clinical studies have confirmed the strong prognostic value of persistent hyperlactatemia and delayed lactate clearance in septic shock. Several potential hypoxic and nonhypoxic mechanisms have been associated with persistent hyperlactatemia, but the relative contribution of these factors has not been specifically addressed in comprehensive clinical physiological studies. Our goal was to determine potential hemodynamic and perfusion-related parameters associated with 6-hour lactate clearance in a cohort of hyperdynamic, hyperlactatemic, septic shock patients. Methods We conducted an acute clinical physiological pilot study that included 15 hyperdynamic, septic shock patients undergoing aggressive early resuscitation. Several hemodynamic and perfusion-related parameters were measured immediately after preload optimization and 6 hours thereafter, with 6-hour lactate clearance as the main outcome criterion. Evaluated parameters included cardiac index, mixed venous oxygen saturation, capillary refill time and central-to-peripheral temperature difference, thenar tissue oxygen saturation (StO2) and its recovery slope after a vascular occlusion test, sublingual microcirculatory assessment, gastric tonometry (pCO2 gap), and plasma disappearance rate of indocyanine green (ICG-PDR). Statistical analysis included Wilcoxon and Mann–Whitney tests. Results Five patients presented a 6-hour lactate clearance <10%. Compared with 10 patients with a 6-hour lactate clearance ≥10%, they presented a worse hepatosplanchnic perfusion as represented by significantly more severe derangements of ICG-PDR (9.7 (8–19) vs. 19.6 (9–32)%/min, p < 0.05) and pCO2 gap (33 (9.1-62) vs. 7.7 (3–58) mmHg, p < 0.05) at 6 hours. No other systemic, hemodynamic, metabolic, peripheral, or microcirculatory parameters differentiated these subgroups. We also found a significant correlation between ICG-PDR and pCO2 gap (p = 0.02). Conclusions Impaired 6-hour lactate clearance could be associated with hepatosplanchnic hypoperfusion in some hyperdynamic septic shock patients. Improvement of systemic, metabolic, and peripheral perfusion parameters does not rule out the persistence of hepatosplanchnic hypoperfusion in this setting. Severe microcirculatory abnormalities can be detected in hyperdynamic septic shock patients, but their role on lactate clearance is unclear. ICG-PDR may be a useful tool to evaluate hepatosplanchnic perfusion in septic shock patients with persistent hyperlactatemia. Trial registration ClinicalTrials.gov Identifier: NCT01271153
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Plante A, Ro E, Rowbottom JR. Hemodynamic and related challenges: monitoring and regulation in the postoperative period. Anesthesiol Clin 2012; 30:527-554. [PMID: 22989593 DOI: 10.1016/j.anclin.2012.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The clinician caring for patients in the immediate postoperative period must maintain a high index of suspicion for the development of complications. Evolving illness manifests itself throughout the continuum of care and must be recognized and aggressively managed to ensure optimal outcome. This article discusses common hemodynamic problems encountered in the postanesthesia care unit. These problems are presented in a clinical framework that is familiar to experienced practitioners and recognizable to trainees. This article reviews of these common problems including relevant physiologic principles; effects on hemodynamics; and a logical approach to evaluation, monitoring, and management of a complex postoperative patient.
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Affiliation(s)
- Andrew Plante
- Department of Anesthesiology & Perioperative Medicine, University Hospitals, Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
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Jacobs FM. Relation between mean arterial pressure and renal function in the early phase of shock: a prospective, explorative cohort study. Crit Care 2012; 15:442. [PMID: 21939565 PMCID: PMC3334739 DOI: 10.1186/cc10417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Starkopf J, Tamme K, Blaser AR. Should we measure intra-abdominal pressures in every intensive care patient? Ann Intensive Care 2012; 2 Suppl 1:S9. [PMID: 22873425 PMCID: PMC3390289 DOI: 10.1186/2110-5820-2-s1-s9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Intra-abdominal pressure (IAP) is seldom measured by default in intensive care patients. This review summarises the current evidence on the prevalence and risk factors of intra-abdominal hypertension (IAH) to assist the decision-making for IAP monitoring.IAH occurs in 20% to 40% of intensive care patients. High body mass index (BMI), abdominal surgery, liver dysfunction/ascites, hypotension/vasoactive therapy, respiratory failure and excessive fluid balance are risk factors of IAH in the general ICU population. IAP monitoring is strongly supported in mechanically ventilated patients with severe burns, severe trauma, severe acute pancreatitis, liver failure or ruptured aortic aneurysms. The risk of developing IAH is minimal in mechanically ventilated patients with positive end-expiratory pressure < 10 cmH2O, PaO2/FiO2 > 300, and BMI < 30 and without pancreatitis, hepatic failure/cirrhosis with ascites, gastrointestinal bleeding or laparotomy and the use of vasopressors/inotropes on admission. In these patients, omitting IAP measurements might be considered.In conclusions, clear guidelines to select the patients in whom IAP measurements should be performed cannot be given at present. In addition to IAP measurements in at-risk patients, a clinical assessment of the signs of IAH should be a part of every ICU patient's bedside evaluation, leading to prompt IAP monitoring in case of the slightest suspicion of IAH development.
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Affiliation(s)
- Joel Starkopf
- Department of Anaesthesiology and Intensive Care, University of Tartu, 8 L. Puusepa Str, 51014, Tartu, Estonia
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, 8 L. Puusepa Str, 51014, Tartu, Estonia
| | - Kadri Tamme
- Department of Anaesthesiology and Intensive Care, University of Tartu, 8 L. Puusepa Str, 51014, Tartu, Estonia
- Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, 8 L. Puusepa Str, 51014, Tartu, Estonia
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, 8 L. Puusepa Str, 51014, Tartu, Estonia
- Department of Intensive Care Medicine, University Hospital (Inselspital) and University of Bern, 3010 Bern, Switzerland
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Sánchez-Miralles A, Castellanos G, Badenes R, Conejero R. [Abdominal compartment syndrome and acute intestinal distress syndrome]. Med Intensiva 2012; 37:99-109. [PMID: 22244213 DOI: 10.1016/j.medin.2011.11.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/18/2011] [Accepted: 11/22/2011] [Indexed: 12/19/2022]
Abstract
Seriously ill patients frequently present intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as complications, and the associated mortality is very high. This review offers an update on the most controversial aspects of these entities: factors favoring their appearance, the most common causes, prognosis, and methods of measuring intra-abdominal pressure (IAP), physiopathological consequences in relation to the different organs and systems, and the currently accepted treatment measures (medical and/or surgical). Simultaneously to the strictly physical mechanisms of injury, such as direct compression of intra-abdominal organs and vessels, the transmission of IAP to other compartments, and the drop in cardiac output, a series of immune-inflammatory mediators generated in the intestine itself may also intervene. Hypoperfusion, sustained ischemia and the ischemia-reperfusion phenomenon, would act upon the microbiota, intestinal epithelium and intestinal immune system, triggering a systemic inflammatory response and multiorgan dysfunction that appears in the final stages of ACS.
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Affiliation(s)
- A Sánchez-Miralles
- Servicio de Medicina Intensiva, Hospital Universitario San Juan de Alicante, Alicante, España
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36
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Kim IB, Prowle J, Baldwin I, Bellomo R. Incidence, Risk Factors and Outcome Associations of Intra-Abdominal Hypertension in Critically Ill Patients. Anaesth Intensive Care 2012; 40:79-89. [DOI: 10.1177/0310057x1204000107] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are significantly associated with morbidity and mortality. We performed a prospective observational study and applied recently published consensus criteria to measure and describe the incidence of IAH and ACS, identify risk factors for their development and define their association with outcomes. We studied 100 consecutive patients admitted to our general intensive care unit. We recorded relevant demographic, clinical data and maximal (max) and mean intra-abdominal pressure (IAP). We measured and defined IAH and ACS using consensus guidelines. Of our study patients, 42% (by IAPmax) and 38% (by IAPmean) had IAH. Patients with IAH had greater mean body mass index (30.4±9.6 vs 25.4±5.6 kg/m2, P=0.005), Acute Physiology and Chronic Health Evaluation III score (78.2±28.5 vs 65.5±29.2, P=0.03) and central venous pressure (12.8±4.8 vs 9.2±3.5 mmHg, P <0.001), lower abdominal perfusion pressure (67.6±13.5 vs 79.3±17.3 mmHg, P <0.001) and lower filtration gradient (51.2±14.8 vs 71.6±17.7 mmHg; P <0.001). Risk factors associated with IAH were body mass index ≥30 (P <0.001), higher central venous pressure (P <0.001), presence of abdominal infection (P=0.005) and presence of sepsis on admission (P=0.035). Abdominal compartment syndrome developed in 4% of patients. IAP was not associated with an increased risk of mortality after adjusting for other confounders. We conclude that, in a general population of critically ill patients, using consensus guidelines, IAH was common and significantly associated with obesity and sepsis on admission. In a minority of patients, IAH was associated with abdominal compartment syndrome. In this cohort IAH was not associated with an increased risk of mortality.
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Affiliation(s)
- I. B. Kim
- Intensive Care Unit, Austin Health, Austin Hospital, Melbourne, Victoria, Australia
| | - J. Prowle
- Intensive Care Unit, Austin Health, Austin Hospital, Melbourne, Victoria, Australia
| | - I. Baldwin
- Intensive Care Unit, Austin Health, Austin Hospital, Melbourne, Victoria, Australia
| | - R. Bellomo
- Intensive Care Unit, Austin Health, Austin Hospital, Melbourne, Victoria, Australia
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The effect of different temporary abdominal closure materials on the growth of granulation tissue after the open abdomen. ACTA ACUST UNITED AC 2011; 71:961-5. [PMID: 21378579 DOI: 10.1097/ta.0b013e3181fa2932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Temporary abdominal closure (TAC) is often performed after an open abdomen to prevent postoperative complications. Reducing the time of TAC and performing a skin grafting as early as possible would improve the outcome of open abdomen. This study was designed to evaluate the effects of different TAC materials and topically applied exogenous growth factors on the growth of granulation tissue covered on the wound areas after the open abdomen. METHODS Healthy Sprague-Dawley rats were randomly assigned to four groups of six animals each. Twenty-four hours after induction of peritonitis and intra-abdominal hypertension by intraperitoneal injection of nitrogen, relaparotomies were done. The abdomen was then closed with polyethylene sheet or polypropylene mesh plus growth factor (or not). On the seventh day after TAC surgery, TAC materials were removed, and granulation tissue on the wound surface was assessed microscopically. Microvascular densities, thickness of granulation tissue, and fibroblast counts were also measured. RESULTS Microvascular densities, thickness of granulation tissue, and fibroblast counts were the highest for polypropylene mesh closure plus recombinant bovine basic fibroblast growth factor (rbFGF) followed by polypropylene mesh plus recombinant human growth hormone (rhGH) and polypropylene mesh alone, with polyethylene sheet alone being the least. CONCLUSIONS Polypropylene mesh could promote the growth of granulation tissue after the open abdomen. Topical application of rhGH or rbFGF further hastens the process, with the effect of rbFGF being the greatest.
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Yi M, Leng Y, Bai Y, Yao G, Zhu X. The evaluation of the effect of body positioning on intra-abdominal pressure measurement and the effect of intra-abdominal pressure at different body positioning on organ function and prognosis in critically ill patients. J Crit Care 2011; 27:222.e1-6. [PMID: 22033056 DOI: 10.1016/j.jcrc.2011.08.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 08/09/2011] [Accepted: 08/09/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Current literatures confirmed the widespread and frequent development of both intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) among the critically ill with a significant associated risk of organ failure and increased mortality. The 2004 International ACS Consensus Conference committee proposed that intra-abdominal pressure (IAP) be measured in complete supine position; however, the supine position of intensive care unit (ICU) patients (<30° of bed increase) presented a significant risk for ventilator-associated pneumonia. Therefore, the potential contribution of head of bed (HOB) position in elevating IAP should be considered. The purpose of this study was to evaluate the effect of body positioning on IAP measurement and the effect of IAP at different body positions on organ function and prognosis in critically ill patients. MATERIALS AND METHODS A prospective cohort study to investigate the effect of different patient positioning on IAP, organ function, and prognosis was conducted on 88 patients admitted to a medical-surgical ICU. On admission, patients' epidemiological data and risk factors for IAH were studied; daily mean IAPs, abdominal perfusion pressure, filtration gradient, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, and multiple organ dysfunction scores were registered; next, conventional hemodynamic variables, intrathoracic blood volume index, global end-diastolic volume index and extravascular lung water using the pulse contour cardiac output system were recorded. Intra-abdominal pressures were recorded through a bladder catheter every 4 hours on the first day. Intra-abdominal pressure was measured with the patient HOB increases from 0° to 45°. Mean arterial pressure was recorded simultaneously, whereas abdominal perfusion pressure and filtration gradient (FG) were also calculated simultaneously. RESULTS The main results of this study were the incidence of IAH (28.4%) and ACS (2.3%) in ICU patients; the significant and independent relationship between IAP and HOB increases. Considering the absolute numbers of IAP, the HOB of 10° and 20° showed slight differences, whereas that of 30° and 45° showed clinically significant differences; HOB elevation was associated with clinically significant decreases in abdominal perfusion pressure and FG; patients with IAH were prone to the development of shock and multiple organ dysfunction syndrome and exhibited significantly lower intrathoracic blood volume index and global end-diastolic volume index and higher extravascular lung water. CONCLUSIONS There is a significant and independent relationship between IAP and HOB positioning in critically ill patients, with the HOB of 30° and 45° showing significant difference. Abdominal perfusion pressure and FG are significantly decreased when the patient's HOB is elevated. The potential contribution of body position in elevating IAP should be considered in critically ill patients with the risk of IAH and ACS.
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Affiliation(s)
- Min Yi
- Department of Intensive Care Medicine, Peking University Third Hospital, Beijing 100191, PR China.
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Liu C, Wang YM, Fan K. Epidemiological and clinical features of hepatitis B virus related liver failure in China. World J Gastroenterol 2011; 17:3054-9. [PMID: 21799653 PMCID: PMC3132258 DOI: 10.3748/wjg.v17.i25.3054] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 06/20/2011] [Accepted: 06/27/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the epidemiologic and clinical characteristics of hepatitis B virus (HBV) related liver failure in patients in China.
METHODS: This study was conducted with a retrospective design to examine 1066 patients with HBV-related liver failure in the southwest of China.
RESULTS: There were more male than female patients. Young and middle-aged people comprised most of the patients. Farmers and laborers comprised the largest proportion (63.09%). Han Chinese accounted for 98.12%, while minority ethnic groups only accounted for 0.88% of patients. A total of 43.47% patients had a family history of HBV-related liver failure and 56.66% patients had a history of drinking alcohol. A total of 42.59% patients with HBV-related liver failure had definite causes. With regard to the clinical manifestation of HBV-related liver failure, the symptoms were: hypodynamia, anorexia and abdominal distension. Total bilirubin (TBIL) and alanine aminotransferase (ALT) levels were altered in 46.23% of patients with evident damage of the liver. Univariate logistic regression analysis showed that the patients’ prognoses were correlated with ALT, aspartate aminotransferase, albumin, TBIL, prothrombin activity (PTA), and alpha-fetoprotein levels, and drinking alcohol, ascites, hepatorenal syndrome, infection and ≥ 2 complications. Multifactor logistic regression analysis showed that the activity of thrombinogen and the number of complications were related to the prognosis.
CONCLUSION: Alcohol influences the patients’ prognosis and condition. PTA and complications are independent factors that can be used for estimating the prognosis of HBV-related liver failure.
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Ruiz Ferrón F, Tejero Pedregosa A, Ruiz García M, Ferrezuelo Mata A, Pérez Valenzuela J, Quirós Barrera R, Rucabado Aguilar L. Presión intraabdominal y torácica en pacientes críticos con sospecha de hipertensión intraabdominal. Med Intensiva 2011; 35:274-9. [DOI: 10.1016/j.medin.2011.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 02/09/2011] [Accepted: 02/10/2011] [Indexed: 11/27/2022]
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Mohmand H, Goldfarb S. Renal dysfunction associated with intra-abdominal hypertension and the abdominal compartment syndrome. J Am Soc Nephrol 2011; 22:615-21. [PMID: 21310818 DOI: 10.1681/asn.2010121222] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Once considered mostly a postsurgical condition, intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are now thought to increase morbidity and mortality in many patients receiving medical or surgical intensive care. Animal data and human observational studies indicate that oliguria and acute kidney injury are early and frequent consequences of IAH/ACS and can be present at relatively low levels of intra-abdominal pressure (IAP). Among medical patients at particular risk are those with septic shock and severe acute pancreatitis, but the adverse effects of IAH may also be seen in cardiorenal and hepatorenal syndromes. Factors predisposing to IAH/ACS include sepsis, large volume fluid resuscitation, polytransfusion, mechanical ventilation with high intrathoracic pressure, and acidosis, among others. Transduction of bladder pressure is the gold standard for measuring intra-abdominal pressure, and several nonsurgical methods can help reduce IAP. The role of renal replacement therapy for volume management is not well defined but may be beneficial in some cases. IAH/ACS is an important possible cause of acute renal failure in critically ill patients and screening may benefit those at increased risk.
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Affiliation(s)
- Hashim Mohmand
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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42
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Sonographic assessment of abdominal vein dimensional and hemodynamic changes induced in human volunteers by a model of abdominal hypertension*. Crit Care Med 2011; 39:344-8. [DOI: 10.1097/ccm.0b013e3181ffe0d2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Heart-kidney interactions have been increasingly recognized by clinicians and researchers who study and treat heart failure and kidney disease. A classification system has been developed to categorize the different manifestations of cardiac and renal dysfunction. Work has highlighted the significant negative prognostic effect of worsening renal function on outcomes for individuals with heart failure. The etiology of concomitant cardiac and renal dysfunction remains unclear; however, evidence supports alternatives to the established theory of underfilling, including effects of venous congestion and changes in intra-abdominal pressure. Conventional therapy focuses on blockade of the renin-angiotensin-aldosterone system with expanding use of direct renin and aldosterone antagonists. Novel therapeutic interventions using extracorporeal therapy and antagonists of the adenosine pathway show promise and require further investigation.
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Affiliation(s)
- Suneel M Udani
- Department of Medicine, University of Chicago, IL 60637, USA
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Dauplaise DJN, Barnett SJ, Frischer JS, Wong HR. Decompressive abdominal laparotomy for abdominal compartment syndrome in an unengrafted bone marrow recipient with septic shock. Crit Care Res Pract 2010; 2010:102910. [PMID: 20948887 PMCID: PMC2951079 DOI: 10.1155/2010/102910] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Accepted: 04/29/2010] [Indexed: 11/18/2022] Open
Abstract
Objective. To describe a profoundly immunocompromised (panleukopenia) child with septic shock who developed abdominal compartment syndrome (ACS) and was successfully treated with surgical decompression. Design. Individual case report. Setting. Pediatric intensive care unit of a tertiary children's hospital. Patient. A 32-month-old male with Fanconi anemia who underwent bone marrow transplantation (BMT) 5 days prior to developing septic shock secondary to Streptococcus viridans and Escherichia coli ACS developed after massive fluid resuscitation, leading to cardiopulmonary instability. Interventions. Emergent surgical bedside laparotomy and silo placement. Measurements and Main Results. The patient's cardiopulmonary status stabilized after decompressive laparotomy. The abdomen was closed and the patient survived to hospital discharge without cardiac, respiratory, or renal dysfunction. Conclusions. The use of laparotomy and silo placement in an unengrafted BMT patient with ACS and septic shock did not result in additional complications. Surgical intervention for ACS is a reasonable option for high risk, profoundly immunocompromised patients.
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Affiliation(s)
- Derrick J. N. Dauplaise
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2005, Cincinnati, OH 45229, USA
| | - Sean J. Barnett
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2005, Cincinnati, OH 45229, USA
| | - Jason S. Frischer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2005, Cincinnati, OH 45229, USA
| | - Hector R. Wong
- Division of Critical Care Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC 2005, Cincinnati, OH 45229, USA
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Evaluation of Intraabdominal Presure changes after large Abdominal hernia Surgeries. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Sepsis is physiologically viewed as a proinflammatory and procoagulant response to invading pathogens. There are three recognized stages in the inflammatory response with progressively increased risk of end-organ failure and death: sepsis, severe sepsis, and septic shock. Patients with cirrhosis are prone to develop sepsis, sepsis-induced organ failure, and death. There is evidence that in cirrhosis, sepsis is accompanied by a markedly imbalanced cytokine response ("cytokine storm"), which converts responses that are normally beneficial for fighting infections into excessive, damaging inflammation. Molecular mechanisms for this excessive proinflammatory response are poorly understood. In patients with cirrhosis and severe sepsis, high production of proinflammatory cytokines seems to play a role in the worsening of liver function and the development of organ/system failures such as shock, renal failure, acute lung injury or acute respiratory distress syndrome, coagulopathy, or hepatic encephalopathy. In addition, these patients may have sepsis-induced hyperglycemia, defective arginine-vasopressin secretion, adrenal insufficiency, or compartmental syndrome. In patients with cirrhosis and spontaneous bacterial peritonitis (SBP), early use of antibiotics and intravenous albumin administration decreases the risk for developing renal failure and improves survival. There are no randomized studies that have been specifically performed in patients with cirrhosis and severe sepsis to evaluate treatments that have been shown to improve outcome in patients without cirrhosis who have severe sepsis or septic shock. These treatments include recombinant human activated C protein and protective-ventilation strategy for respiratory failure. Other treatments should be evaluated in the cirrhotic population with severe sepsis including the early use of antibiotics in "non-SBP" infections, vasopressor therapy, hydrocortisone, renal-replacement therapy and liver support systems, and selective decontamination of the digestive tract or oropharynx.
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Affiliation(s)
- Thierry Gustot
- INSERM, U773, Centre de Recherche Bichat-Beaujon CRB3, Paris 75018, France.
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Alam HB, Fricchione GL, Guimaraes ASR, Zukerberg LR. Case records of the Massachusetts General Hospital. Case 31-2009. A 26-year-old man with abdominal distention and shock. N Engl J Med 2009; 361:1487-96. [PMID: 19812406 DOI: 10.1056/nejmcpc0900643] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Hasan B Alam
- Department of Surgery, Massachusetts General Hospital, and Harvard Medical School, USA
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Lapointe V, Jocov D, Denault A. Hemodynamic instability in septic shock. Can J Anaesth 2009; 56:864-7. [DOI: 10.1007/s12630-009-9168-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 08/05/2009] [Indexed: 11/28/2022] Open
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