Emergent abdominal decompression with patch abdominoplasty in the pediatric patient

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

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

Outcomes of Abdominal Firearm Injury and Damage Control Laparotomy in the Pediatric Population

INTRODUCTION

Firearm injuries (GSW) in the pediatric population is a public health crisis. Little is known about the outcomes of damage control laparotomy (DCL) following abdominal GSW. This study aims to evaluate outcomes from abdominal GSWs in the pediatric population.

METHODS

The trauma registry from an urban Level 1 trauma was queried for pediatric (0-18 y) GSW was queried from September 2013 to June 2020. Demographics, clinical variables, outcomes, readmissions, and recidivism were analyzed.

RESULTS

Abdominal GSW were identified in 83 patients (17% of all GSW). The median age was 16 [15-17], 84% were male and 86% Black. Violent intent accounted for 90% of GSW. The injury severity score was 16 [9-26] and 80% went directly from the resuscitation bay to the operating room. Laparotomy was required in 87% of patients, and surgery was not required in any patient initially managed nonoperatively. The most common complications were intraabdominal infection (20%), other infections (13%), and small bowel obstruction (8%). DCL with temporary abdominal closure was performed in 16% of laparotomies and was associated with a longer length of stay, more infections, but similar rates of readmission and mortality. Overall mortality was 13%, with all but one patient expiring in the resuscitation bay or the operating room. All patients who underwent DCL survived to discharge.

CONCLUSIONS

Abdominal firearm injuries have high morbidity and mortality in the pediatric population. Damage control operations for abdominal GSWs are a valuable surgical option with similar outcomes to primary abdominal closure after initial injury survival.

Intra-abdominal Hypertension and the Open Abdomen: Nursing Guidelines From the Abdominal Compartment Society

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.

Utilization of Vicryl Bridging Mesh in Orthotopic Liver Transplantation to Achieve Tension-Free Abdominal Wall Closure: A Case Series

Difficulty in primary fascial closure of the abdomen in transplant patients is a common challenge. Abdominal wall tension may have detrimental effects on the newly transplanted graft due to compression, and blood flow hindrance, potentially leading to ischemia or thrombosis and possibly graft failure. Furthermore, patients will be at risk of developing fascial ischemia and dehiscence. Myocutaneous flaps, temporary closure with silastic mesh, abdominal wall transplants, and even graft reduction, bowel resection, and splenectomies have been practiced with varying degrees of success. In this study, we present four cases of patients who underwent orthotopic liver transplantation (OLT) with bridging Vicryl knitted mesh (ETHICON VKML VICRYL-Polyglactin 910-30 × 30 cm) to relieve the tension during the closure. Our results show that these patients, despite having a high average Model End-Stage Liver Disease (MELD) score of 25, had a good liver function at the time of discharge and continue to upon follow-up. They had a relatively short length of stay (LOS) in both the intensive care unit (ICU) and in the hospital, an average of 3.5 days and 9 days, respectively. Our case series successfully show that utilizing a bridging Vicryl knitted mesh is a reasonable approach to attain tension-free abdominal closure in OLT with satisfying results.

Intra-abdominal hypertension and abdominal compartment syndrome in pediatrics. A review

PURPOSE

To consolidate pediatric intensivists' understanding of the pathophysiology, definition, incidence, monitoring, and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); and to highlight the characteristics related to the pediatric population.

METHODS

This is a narrative review article that utilized a systematic search of the medical literature published in the English language between January 1990 and august 2016. Studies were identified by conducting a comprehensive search of Pub Med databases. Search terms included "intra-abdominal hypertension and child", "intra-abdominal hypertension and pediatrics", "abdominal compartment syndrome and child", and "abdominal compartment syndrome and pediatrics".

RESULTS

Intra-abdominal hypertension and ACS are associated with a number of pathophysiological disturbances and increased morbidity and mortality. These conditions have been well described in critically ill adults. In children, the IAH and the ACS have a reported incidence of 13% and 0.6 to 10% respectively; they carry similar prognostic impact but are still under-diagnosed and under-recognized by pediatric health care providers.

CONCLUSIONS

Intra-abdominal hypertension and ACS are conditions that are regularly encountered in critically ill children. They are associated with an increased morbidity and mortality. Early recognition, prevention and timely management of this critical condition are necessary to improve its outcome.

Damage control laparotomy for abdominal trauma in children

BACKGROUND

Damage control laparotomy (DCL) is not well studied in the pediatric trauma population. The purpose of this study was to develop a surrogate definition of DCL compatible with national and administrative data sources so that the rate and outcomes of DCL in pediatric trauma patients could be determined.

METHODS

Using the 2010-2014 National Trauma Data Bank, children ≤18 with an abdominal AIS ≥ 3 who underwent a laparotomy within 3 h of arrival were identified (n = 2989). DCL was defined as occurring in children who underwent a second laparotomy within 5-48 h from the index laparotomy (n = 360). Children meeting these criteria were compared to those children who had the initial definitive operative management (n = 2174) and those who died prior to 48 h (n = 455).

RESULTS

DCL occurred in 12% of children with operative abdominal trauma. Children who underwent DCL had a greater median ISS (25 vs 18) and heart rate (112 vs 100), lower systolic blood pressure (104 vs 113), and GCS (12 vs 13), and were more likely to receive a preoperative blood transfusion (19 vs 11%) than those who had definitive initial operative management (all p < .05). Median length of stay (17 vs 8 days) and mortality (9 vs 2%) were greater following DCL than definitive initial operative management (p < .001). No differences in rate of DCL were seen based on ACS pediatric verification (p = .07).

CONCLUSIONS

Few children with operative abdominal trauma undergo DCL. DCL was associated with worse physiology rather than anatomic injury severity in this study. As expected, outcomes were worse following DCL.

Outcomes of children with abdominal compartment syndrome

INTRODUCTION

Abdominal compartment syndrome (ACS) is a problem across all critical care scenarios and is associated with a high mortality. It has not been well described in pediatric populations.

OBJECTIVE

To describe the occurrence of ACS in a subset of critically ill pediatric patients and determine its effects on mortality and length of pediatric intensive care stay (PICU LOS). We also aimed to find predictors of mortality and development of ACS.

SETTING

25 bed tertiary pediatric intensive care unit.

PATIENTS

PATIENTS less than 50 kg on mechanical ventilation and a urethral catheter.

MEASUREMENTS

Intra-abdominal pressures (IAP) were monitored using the intra-vesical technique. ACS was defined as IAP of >12mmHg associated with new organ dysfunction or failure. Demographics, physiologic measures of organ dysfunction, PICU LOS and mortality were monitored.

MAIN RESULTS

14 (4.7%) of 294 eligible patients had ACS. Mortality was 50% among those with ACS versus 8.2% without (p<.001). PICU LOS stay did not differ between groups. No difference in mortality or PICU LOS was seen in primary versus secondary ACS or in patients who underwent abdominal decompression compared to those without decompression. IAP and ACS were independent predictors of mortality (odds ratio 1.53, 95% CI, 1.17 - 1.99 and 9.09, 95% CI, 1.07 - 76.84) respectively. IAP and a PRISM score of ≥17 were predictive of developing ACS.

CONCLUSIONS

ACS is a clinical problem that increases the risk of mortality in critically ill children. IAP and PRISM scores may help identify children likely to develop ACS.

Abdominal decompression in children

Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.

Abdominal compartment syndrome caused by massive pyonephrosis in an infant with primary obstructive megaureter

The authors report a case of abdominal compartment syndrome caused by massive pyonephrosis in an infant with primary obstructive megaureter successfully treated with emergency surgical decompression.

Abdominal compartment syndrome in childhood: diagnostics, therapy and survival rate

PURPOSE

The abdominal compartment syndrome (ACS) in childhood is a rare but dire disease if diagnosed delayed and treated improperly. The mortality amounts up to 60% (Beck et al. in Pediatr Crit Care Med 2:51-56, 2001). ACS is defined by a sustained rise of the intraabdominal pressure (IAP) together with newly developed organ dysfunction. The present study reports on 28 children with ACS to evaluate its potential role in the diagnosis, treatment and outcome of ACS.

METHODS

Retrospectively, medical reports and outcome of 28 children were evaluated who underwent surgical treatment for ACS. The diagnosis of ACS was established by clinical signs, intravesical pressure-measurements and concurrent organ dysfunction.

RESULTS

Primary ACS was found in 25 children (89.3%) predominantly resulting from polytrauma and peritonitis. Three children presented secondary ACS with sepsis (2 cases) and combustion (1 case) being the underlying causative diseases. Therapy of choice was the decompression of the abdominal cavity with implantation of an absorbable Vicryl(®) mesh. In 18 cases the abdominal cavity could be closed later, while in the other ten cases granulation of the mesh was allowed. The overall survival rate was 78.6% (22 of 28 children). The cause of death in the remaining six cases (21.4%) was sepsis with multiorgan failure.

CONCLUSION

Our results suggest that early establishment of the specific diagnosis of ACS followed by swift therapy with reduction of intraabdominal hypertension is essential in order to further reduce the high mortality rate associated with this condition.

Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late

PURPOSE

Abdominal compartment syndrome (ACS) in children is an infrequently reported, rapidly progressive, and often lethal condition underappreciated in the pediatric population. This underrecognition can result in a critical delay in diagnosis causing increased morbidity and mortality. This study examines the clinical course of patients treated for ACS at our institution.

METHODS

A review of children requiring an emergency laparotomy (n = 264) identified 26 patients with a diagnosis of ACS. ACS was defined as sustained intraabdominal hypertension (bladder pressure >12 mm Hg) that was associated with new onset organ dysfunction or failure.

RESULTS

Patients ranged in age from 3 months to 17 years old and were cared for in the pediatric intensive care unit (PICU). Twenty-seven percent (n = 7) were transferred from referring hospitals, 50% (n = 13) were admitted directly from the emergency department, and 23% (n = 6) were inpatients before being transferred to PICU. Admission diagnoses included infectious enterocolitis (n = 12), postsurgical procedure (n = 10), and others (n = 4). Patients progressed to ACS rapidly, with most requiring decompressive laparotomy within 8 hours of PICU admission (range, <1-96 hours). Preoperatively, all patients had maximum ventilatory support and oliguria, 85% (n = 22) required vasopressors/inotropes, and 31% (n = 8) required hemodialysis. Mean bladder pressure was 25 mm Hg (range, 12-44 mm Hg). In 42% (n = 11), cardiac arrest preceeded decompressive laparotomy. All patients showed evidence of tissue ischemia before decompressive laparotomy with an average preoperative lactate of 8 (range, 1.2-20). Decompressive laparotomy was done at the bedside in the PICU in 13 patients and in the operating room in 14 patients. Abdominal wounds were managed with open vacuum pack or silastic silo dressings. Physiologic data including fluid resuscitation, oxygen index, mean airway pressure, vasopressor score, and urine output were recorded at 6-hour intervals beginning 12 hours before decompressive laparotomy and extending 12 hours after operation. The data demonstrate improvement of all physiologic parameters after decompressive laparotomy except for urine output, which continued to be minimal 12 hours post intervention. Mortality was 58% (n = 15) overall. The only significant factor related to increased mortality was bladder pressure (P = .046; odds ratio, 1.258). Cardiac arrest before decompressive laparotomy, need for hemodialysis, and transfer from referring hospital also trended toward increased mortality but did not reach significance.

CONCLUSION

Abdominal compartment syndrome in children carries a high mortality and may be a consequence of common childhood diseases such as enterocolitis. The diagnosis of ACS and the potential need for emergent decompressive laparotomy may be infrequently discussed in the pediatric literature. Increased awareness of ACS may promote earlier diagnosis, treatment, and possibly improve outcomes.

Early Fascial Closure of the Damage Control Abdomen in Children

Traditional staged closure of the damage control abdomen frequently results in a ventral hernia, need for delayed abdominal wall reconstruction, and risk of multiple complications. We examined the potential benefits in children of early fascial closure of the damage control abdomen using human acellular dermal matrix (HADM). We reviewed our experience with five consecutive children sustaining intra-abdominal catastrophe and managed with damage control celiotomy. To accomplish early definitive abdominal closure, HADM was sewn in place as a fascial substitute; the skin and subcutaneous layers were approximated over silicone drains. The five patients ranged in age from 1 month to 19 years at the time of presentation. Intra-abdominal catastrophes included complex bowel injuries after blunt trauma in two children, necrotizing pancreatitis and gastric perforation in one teenager, necrotizing enterocolitis in one premature infant, and perforated typhlitis in one adolescent. All damage control wounds were dirty. Time range from initial celiotomy to definitive abdominal closure was 6 to 9 days. After definitive closure, one child developed a superficial wound infection. No patient developed a ventral hernia. After damage control celiotomy in children, early abdominal wall closure using HADM may minimize complications associated with delayed closure techniques and the need for additional procedures.

Preformed Silastic Silos in the Management of Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is sometimes complicated by abdominal compartment syndrome, a clinical syndrome characterized by multiple organ dysfunction that arises as a consequence of increased intra-abdominal pressure. The evolving clinical picture of NEC sometimes requires “second-look” operations done after initial abdominal exploration to more accurately gauge the optimal extent of surgery. Placing intestines in a preformed, spring-loaded, transparent Silastic silo, traditionally used in the staged treatment of gastroschisis, addresses both situations: decompression of the abdomen and allowing periodic inspection of the intestines. Standard silos were used in three infants with advanced (Bell Class 3) NEC without perforation before definitive surgery. Clinical indices and laboratory values were recorded during the patients’ hospital courses. All three infants had extensive areas of intestinal ischemia and necrosis. FiO2, acidosis, and urinary output remained stable or improved in two patients. Silo placement corrected abdominal compartment syndrome in the third patient. Intestinal resection was required in all infants, each achieving surgical resolution of NEC. Two patients ultimately died from respiratory and neurologic complications. Application of a silo addresses abdominal compartment syndrome as a complication of NEC and allows continual inspection of the intestines. Physiological indices may improve the patient's overall clinical status.

Abdominal compartment syndrome: A review

OBJECTIVES

The aims of this review were to summarize a) the consensus definitions of normal and pathologic intra-abdominal pressure (IAP); b) the techniques to measure IAP; c) the risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); d) the pathophysiology of ACS; and e) the current recommendations for management and prevention of ACS.

DATA SOURCES

PubMed was searched using the following terms: ACS, IAH, IAP, and abdominal decompression.

DATA SYNTHESIS

ACS represents the natural progression of end-organ dysfunction caused by increased IAP and develops if IAH is not recognized and treated appropriately. Although the reported incidence of ACS is relatively low in critically ill children (0.6%-4.7%) it may be under-recognized and under-reported. The diagnosis of IAH/ACS depends on a high index of suspicion and the accurate and frequent measurement of IAP in patients at risk. Mortality from ACS remains high (50%-60%) even when decompression of the abdomen is performed early, which highlights the importance of detection and treatment of elevated IAP before end-organ damage occurs.

CONCLUSIONS

A widespread awareness of the recognition and current approach to management and prevention of IAH and ACS is needed among pediatric intensivists, so outcome of these life-threatening disease processes might be improved.

Abdominal compartment syndrome: a concise clinical review

OBJECTIVE

There has been an increased awareness of the presence and clinical importance of abdominal compartment syndrome. It is now appreciated that elevations of abdominal pressure occur in a wide variety of critically ill patients. Full-blown abdominal compartment syndrome is a clinical syndrome characterized by progressive intra-abdominal organ dysfunction resulting from elevated intra-abdominal pressure. This review provides a current, clinically focused approach to the diagnosis and management of abdominal compartment syndrome, with a particular emphasis on intensive care.

METHODS

Source data were obtained from a PubMed search of the medical literature, with an emphasis on the time period after 2000. PubMed "related articles" search strategies were likewise employed frequently. Additional information was derived from the Web site of the World Society of the Abdominal Compartment Syndrome (http://www.wsacs.org).

SUMMARY AND CONCLUSIONS

The detrimental impact of elevated intra-abdominal pressure, progressing to abdominal compartment syndrome, is recognized in both surgical and medical intensive care units. The recent international abdominal compartment syndrome consensus conference has helped to define, characterize, and raise awareness of abdominal compartment syndrome. Because of the frequency of this condition, routine measurement of intra-abdominal pressure should be performed in high-risk patients in the intensive care unit. Evidence-based interventions can be used to minimize the risk of developing elevated intra-abdominal pressure and to aggressively treat intra-abdominal hypertension when identified. Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome, but nonsurgical measures can often effectively affect lesser degrees of intra-abdominal hypertension and abdominal compartment syndrome.

Management of abdominal compartment syndrome during extracorporeal life support

OBJECTIVE

To describe the successful use of a peritoneal dialysis catheter for emergent decompression of abdominal compartment syndrome during extracorporeal life support for septic shock.

DESIGN

Case report.

SETTING

Pediatric intensive care unit at a freestanding tertiary children's hospital.

PATIENT

Two-year-old toddler with influenza A complicated by methicillin-resistant Staphylococcus aureus pneumonia and septic shock.

INTERVENTIONS

Placement of peritoneal dialysis catheter.

MEASUREMENTS AND MAIN RESULTS

Changes in hemodynamic and respiratory parameters. Improvement in extracorporeal membrane oxygenation venous drainage with subsequent survival.

CONCLUSIONS

Although the standard therapy for abdominal compartment syndrome is decompressive laparotomy, a minimally invasive percutaneous approach may be effective and should be considered in selected patients.

Hemodynamic changes during acute elevation of intra-abdominal pressure in rabbits

BACKGROUND

The intra-abdominal pressure (IAP) may be increased during pneumoperitoneum for minimally invasive surgery, after high tension repairs of congenital abdominal wall defects, major abdominal surgery, liver transplantation, abdominal trauma, peritonitis or ileus. The aim of this study was to investigate hemodynamic changes during elevation of IAP using an experimental setting, which mirrors anatomical and physiological conditions of neonates and small infants as closely as possible.

METHODS

In five fasted, anesthetized, mechanically ventilated and multicatheterized New Zealand rabbits, the IAP was gradually increased by intra-abdominal infusion of normal saline (total volume 1000 ml). At baseline and after each infusion of 100 ml normal saline cardiac output (CO, transcardiopulmonary thermodilution), pressure in the superior (SVCP) and inferior vena cava (IVCP), mean arterial pressure (MAP), peak airway pressure (PAP) and IAP was recorded.

RESULTS

During the study, IAP, SVCP and IVCP increased significantly. IVCP was significantly higher than SVCP from timepoint 200 ml to study end. After abdominal decompression IAP, SVCP and IVCP decreased to baseline levels. Changes in MAP were not significant. CO increased significantly from baseline to timepoint 200 ml (peak value), remained nearly constant until timepoint 800 ml and decreased thereafter until the abdominal infusion ceased. After abdominal decompression CO returned to baseline level. SVCP, IVCP and PAP correlated significantly with IAP (SVCP, r = 0.73; IVCP, r = 0.97; PAP, r = 0.94; P < 0.0001).

CONCLUSIONS

The hemodynamic changes caused by increased IAP cannot be recognized by routine monitoring of arterial blood pressure and transcutaneous oxygen saturation. The increase in central venous pressure may be misinterpreted as an elevation of cardiac preload. One major effect of a prolonged increase in IAP is a decreased CO.

Damage control surgery in children

Whilst the principles of damage control are the same in paediatric surgery as in adults the unique qualities of children must be appreciated. Children are more susceptible to hypothermia and multiple trauma. Technical aspects of the damage control laparotomy specific to children are outlined. Lessons learnt from damage control in neonatal surgery are transferable to paediatric trauma.

Defense mechanisms of the peritoneal cavity

The peritoneal cavity contains resident and migratory cell populations, which play crucial roles in the local defensive response against bacterial invasion. Although mononuclear phagocytes predominate in the peritoneal cavity of healthy subjects, recent attention has been focused on mesothelial and dendritic cells. Kinetic analysis of inflammatory mediators has derived from experimental models of peritonitis, but advances in the understanding of the roles of molecules such as lipocortins, PAF, leukotriene B4, PPAR gamma agonists, and chemokines has also been made. Little is known about the peritoneal response to physical trauma in the context of the abdominal compartment syndrome. Studies on the cellular and molecular pathology of intra-abdominal abscesses, peritoneal sclerosis, and other less frequent clinical entities (e.g., tertiary peritonitis) are needed. Biological therapy may contribute to improved clinical management of such diseases.