Abdominal compartment syndrome: pathophysiology and definitions

Incidence, implications and predictors of abdominal compartment syndrome in acute pancreatitis: A nationwide analysis

BACKGROUND

Acute pancreatitis (AP) often presents with varying severity, with a small fraction evolving into severe AP, and is associated with high mortality. Complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are intricately associated with AP.

OBJECTIVE

To assess the clinical implications and predictors of ACS in AP patients.

METHODS

We conducted a retrospective study using the National Inpatient Sample (NIS) database on adult AP patients, further stratified by the presence of concurrent ACS. The data extraction included demographics, underlying comorbidities, and clinical outcomes. Multivariate linear and logistic regression analyses were performed using STATA (v.14.2).

RESULTS

Of the 1,099,175 adult AP patients, only 1,090 (0.001%) exhibited ACS. AP patients with ACS had elevated inpatient mortality and all major complications, including septic shock, acute respiratory distress syndrome (ARDS), requirement for total parenteral nutrition (TPN), and intensive care unit (ICU) admission (P < 0.01). These patients also exhibited increased odds of requiring pancreatic drainage and necrosectomy (P < 0.01). Predictor analysis identified blood transfusion, obesity (BMI ≥30), and admission to large teaching hospitals as factors associated with the development of ACS in AP patients. Conversely, age, female gender, biliary etiology of AP, and smoking were found less frequently in patients with ACS.

CONCLUSION

Our study highlights the significant morbidity, mortality, and healthcare resource utilization associated with the concurrence of ACS in AP patients. We identified potential factors associated with ACS in AP patients. Significantly worse outcomes in ACS necessitate the need for early diagnosis, meticulous monitoring, and targeted therapeutic interventions for AP patients at risk of developing ACS.

Pediatric Profound Dengue Shock Syndrome and Use of Point-of-Care Ultrasound During Mechanical Ventilation to Guide Treatment: Single-Center Retrospective Study, 2013-2021

OBJECTIVES

Profound dengue shock syndrome (DSS) complicated by severe respiratory failure necessitating mechanical ventilation (MV) accounts for high case fatality rates among PICU-admitted patients. A major challenge to management is the assessment of intravascular volume, which can be hampered by severe plasma leakage and the use of MV.

DESIGN

Retrospective cohort, from 2013 to 2021.

PATIENTS

Sixty-seven children with profound DSS supported by MV, some of whom underwent bedside point-of-care ultrasound (POCUS) for assessment and monitoring of hemodynamics and fluid administration.

SETTING

PICU of the tertiary Children's Hospital No. 2 in Vietnam.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed data clinical and laboratory data during PICU stay. In particular, during use of MV (i.e., at times 0-, 6-, and 24-hr after commencement) and fluid resuscitation. The primary study outcome was 28-day in-hospital mortality, and the secondary outcomes were associations with changes in hemodynamics, blood lactate, and vasoactive-inotrope score (VIS). Patients had a median age of 7 years (interquartile range, 4-9). Use of POCUS during fluid management (39/67), as opposed to not using (28/67), was associated with lower mortality (6/39 [15%] vs. 18/28 [64%]; difference 49 % [95% CI, 28-70%], p < 0.001). Use of POCUS was associated with lower odds of death (adjusted odds ratio 0.17 [95% CI, 0.04-0.76], p = 0.02). The utilization of POCUS, versus not, was associated with greater use of resuscitation fluid, and reductions in VIS and pediatric logistic organ dysfunction (PELOD-2) score at 24 hours after MV and PICU discharge.

CONCLUSIONS

In our experience of pediatric patients with profound DSS and undergoing MV (2013-2021), POCUS use was associated with lower odds of death, a higher volume of resuscitation fluid, and improvements in the blood lactate levels, VIS, and PELOD-2 score.

Correlation of cerebral microvascular circulation with vital signs in cerebral compression and the validity of three concepts: vasodilation, autoregulation, and terminal rise in arterial pressure

Background

Vasodilation, autoregulation, and rising arterial pressure are three common concepts in cerebral compression, believed to improve cerebral blood flow to maintain the brain's nutrition. However, these concepts are unclear, unproven, and based on assumptions. This study aimed to correlate cerebral circulation with alterations of vital signs and to evaluate the above concepts based on physics and hemodynamics.

Methods

Without new animal experiments, a large amount of data: recording of vital signs, long movies of cerebral circulation, and numerous photos of histological examination and microvessels obstruction in cerebral compression in cats was studied, and only partial and preliminary results were reported in 1970. The experiments were supported by an NIH grant for head injury, done before the 1985 Institutional Animal Care and Use Committee requirement. The advent of digital technology facilitated digitizing and stepwise correlating them and evaluating the validity of the above concepts.

Results

As cerebral compression increased intracranial pressure (ICP), veins dilated, not arteries, and arterial microvessels obstructed, diminished, and stopped cerebral circulation. Simultaneously, vital signs deteriorated, and pupils became fixed and dilated. There was no evidence for what is believed as autoregulation.

Conclusion

In cerebral compression, rising ICP obstructs cerebral arterial microvessels while simultaneously deteriorating vital signs. There is no evidence for dilatation of the arteries; only veins dilate, best-called venodilation. There is no evidence of autoregulation; what occurs is a cerebral compartmental syndrome. The terminal rise of arterial pressure is the hemodynamic result of cerebral circulation cessation, overloading the aorta. None of the concepts benefit the brain's nutrition.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient

BACKGROUND

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known.

AIM

The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction.

MATERIALS AND METHOD

By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24 h after abdominal skin closure, for 13 patients.

RESULTS

The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p = 0.007)] and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p = 0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n = 3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12 mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24 h. One patient developed a non-fatal lung embolism.

CONCLUSION

The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 h after the closure of the skin.

Abdominal compartment syndrome: what radiologist needs to know

The intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are life-threatening conditions with a significant rate of mortality; therefore, early detection is paramount in their optimal management. IAH is diagnosed when the intra-abdominal pressure (IAP) is more than 12 mmHg. It can occur when the intra-abdominal volume increases (ileus, ascites, trauma, pancreatitis, etc.) and/or the abdominal wall compliance decreases. IAH can cause decreased venous flow, low cardiac output, renal impairment, and decreased respiratory compliance. Consequently, these complications can lead to multiple organ failure and induce the abdominal compartment syndrome (ACS) when IAP rises above 20 mmHg. The diagnosis is usually made with intravesical pressure measurement. However, this measurement was not always possible to obtain; therefore, alternative diagnostic techniques should be considered. In this setting, computed tomography (CT) may play a crucial role, allowing the detection and characterization of pathological conditions that may lead to IAH. This review is focused on the pathogenesis, clinical features, and radiological findings of ACS, because their presence allows radiologists to raise the suspicion of IAH/ACS in critically ill patients, guiding the most appropriate treatment.

Mammoth Bilateral Ovarian Serous Cyst Adenomas in a Postmenopausal Woman: A Rare Case Report

Serous cyst adenomas account for about 40% of all ovarian tumors and most commonly are diagnosed in middle-aged women. The aim of this publication is to present an extremely rare case of mammoth bilateral cyst adenomas in a postmenopausal woman, occupying the pelvis and the most of abdominal cavity. A 67-year-old obese woman was presented to our emergency department with abdominal pain. Ultrasound and computed tomography of the abdomen verified two huge cystic masses. Exploration of the abdominal cavity by laparotomy established two intact giant cystic masses with ovarian origin. The cysts were removed by bilateral salpingo-oophorectomy and hysterectomy was performed. Histological examination revealed that both cystic masses were ovarian serous cyst adenomas. The woman was discharged with an uneventful recovery. We present a case of the largest gigantic bilateral ovarian cyst adenomas in the oldest woman ever reported.

Prone restraint death: Possible role of the Valsalva maneuver

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

In Vitro Validation of a Novel Continuous Intra-Abdominal Pressure Measurement System (TraumaGuard)

Introduction: Intra-abdominal pressure (IAP) has been recognized as an important vital sign in critically ill patients. Due to the high prevalence and incidence of intra-abdominal hypertension in surgical (trauma, burns, cardiac) and medical (sepsis, liver cirrhosis, acute kidney injury) patients, continuous IAP (CIAP) monitoring has been proposed. This research was aimed at validating a new CIAP monitoring device, the TraumaGuard from Sentinel Medical Technologies, against the gold standard (height of a water column) in an in vitro setting and performing a comparative analysis among different CIAP measurement technologies (including two intra-gastric and two intra-bladder measurement devices). A technical and clinical guideline addressing the strengths and weaknesses of each device is provided as well. Methods: Five different CIAP measurement devices (two intra-gastric and three intra-vesical), including the former CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, were validated against the gold standard water column pressure in a bench-top abdominal phantom. The impacts of body temperature and bladder fill volume (for the intra-vesical methods) were evaluated for each system. Subsequently, 48 h of continuous monitoring (n = 2880) on top of intermittent IAP (n = 300) readings were captured for each device. Using Pearson's and Lin's correlations, concordance, and Bland and Altman analyses, the accuracy, precision, percentage error, correlation and concordance coefficients, bias, and limits of agreement were calculated for all the different devices. We also performed error grid analysis on the CIAP measurements to provide an overview of the involved risk level due to wrong IAP measurements and calculated the area under the curve and time above a certain IAP threshold. Lastly, the robustness of each system in tracking the dynamic variations of the raw IAP signal due to respirations and heartbeats was evaluated as well. Results: The TraumaGuard was the only technology able to measure the IAP with an empty artificial bladder. No important temperature dependency was observed for the investigated devices except for the Spiegelberg, which displayed higher IAP values when the temperature was increased, but this could be adjusted through recalibration. All the studied devices showed excellent ability for IAP monitoring, although the intra-vesical IAP measurements seem more reliable. In general, the TraumaGuard, Accuryn, and Serenno showed better accuracy compared to intra-gastric measurement devices. On average, biases of +0.71, +0.93, +0.29, +0.25, and -0.06 mm Hg were observed for the CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, respectively. All of the equipment showed percentage errors smaller than 25%. Regarding the correlation and concordance coefficients, the Serenno and TraumaGuard showed the best results (R2 = 0.98, p = 0.001, concordance coefficient of 99.5%). Error grid analysis based on the Abdominal Compartment Society guidelines showed a very low associated risk level of inappropriate treatment strategies due to erroneous IAP measurements. Regarding the dynamic tracings of the raw IAP signal, all the systems can track respiratory variations and derived parameters; however, the CiMON was slightly superior compared to the other technologies. Conclusions: According to the research guidelines of the Abdominal Compartment Society (WSACS), this in vitro study shows that the TraumaGuard can be used interchangeably with the gold standard for measuring continuous IAP, even in an empty artificial bladder. Confirmation studies with the TraumaGuard in animals and humans are warranted to further validate these findings.

Gastrointestinal Stromal Tumor Masquerading As Acute Decompensated Heart Failure: A Challenging Diagnosis

Gastrointestinal stromal tumors (GISTs) are rare lesions of the gastrointestinal tract that have a strong predisposition to the stomach and small intestine. We present a case of an 89-year-old female who initially presented to the emergency room with signs and symptoms of acute decompensated heart failure (HF) and was later discovered to have a 23-centimeter GIST in her abdominal cavity. This case emphasizes the implications of large intraperitoneal neoplasms and the unique constellation of symptoms they may present with.

Abdominal Wall Movements Predict Intra-Abdominal Pressure Changes in Rats: A Novel Non-Invasive Intra-Abdominal Pressure Detection Method

(1) Background: As increases in intra-abdominal pressure (IAP) result in irreversible tissue damage, monitoring IAP in critically ill patients using the common urinary bladder catheter method is essential. However, this method can result in complications and is not suitable for very low birth weight neonates. The aim of this study was to establish a non-invasive and accurate method to detect IAP changes using an animal model. (2) Methods: IAP changes via intra-abdominal air application (up to 20 mmHg) were measured in 19 Wistar rats via an intra-abdominally placed intracranial pressure probe. Concurrently, abdominal surface tension was measured using a Graseby capsule (GC). (3) Results: A high correlation between abdominal wall distension and IAP (r = 0.9264, CI 0.9249-0.9279) was found for all subjects. (4) Conclusions: IAP changes in rats can be detected non-invasively using a GC. However, further studies are necessary to assess whether IAP changes can be measured using a GC in the neonatal population.

Estimation of Physiologic Pressures: Invasive and Non-Invasive Techniques, AI Models, and Future Perspectives

The measurement of physiologic pressure helps diagnose and prevent associated health complications. From typical conventional methods to more complicated modalities, such as the estimation of intracranial pressures, numerous invasive and noninvasive tools that provide us with insight into daily physiology and aid in understanding pathology are within our grasp. Currently, our standards for estimating vital pressures, including continuous BP measurements, pulmonary capillary wedge pressures, and hepatic portal gradients, involve the use of invasive modalities. As an emerging field in medical technology, artificial intelligence (AI) has been incorporated into analyzing and predicting patterns of physiologic pressures. AI has been used to construct models that have clinical applicability both in hospital settings and at-home settings for ease of use for patients. Studies applying AI to each of these compartmental pressures were searched and shortlisted for thorough assessment and review. There are several AI-based innovations in noninvasive blood pressure estimation based on imaging, auscultation, oscillometry and wearable technology employing biosignals. The purpose of this review is to provide an in-depth assessment of the involved physiologies, prevailing methodologies and emerging technologies incorporating AI in clinical practice for each type of compartmental pressure measurement. We also bring to the forefront AI-based noninvasive estimation techniques for physiologic pressure based on microwave systems that have promising potential for clinical practice.

Diagnosis and Management of Acute Pancreatitis in Pregnancy

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.

Analysis of Incidence, Risk Factors and Outcomes Associated With Abdominal Hypertension in Major Burn Patients

The objective of this study is to analyze incidence and risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in major burn patients. Aprospective cohort study was conducted at a Burns Treatment Center, including all patients with a burned body surface area ≥20% admitted from August 2015 to January 2018. Intra-abdominal pressure was measured periodically during the first week of ICU stay. Sixty-four patients were analyzed, with median age of 39 years (interquartile range ITQ: 28-53) and 66% were male. Median burned body surface area was 30% (ITQ: 20-46). Twenty-eight (56%) patients presented criteria for IAH and seven (14%) developed clinical signs compatible with ACS. Burn severity was greater in the group that developed IAH, represented by the ABSI score. This group also presented higher values of creatinine and positive fluid balance. The group of patients with ACS showed a higher frequency of alterations in renal and respiratory functions. The organ systems most frequently affected in groups with diagnostic criteria for IAH and ACS were renal, cardiovascular and respiratory. Mortality rate at hospital outcome was 56%. In conclusion, the incidence of IAH during the study period was high in patients with extensive burns. The occurrence of ACS was associated with organic dysfunctions of the respiratory, cardiovascular and renal systems. The factors associated with intra-abdominal hypertension were age, extension of burned body surface, inhalation injury, and need for mechanical ventilation.

Fatal complication caused by laxative suppository agent on pediatric patient with hydrocephalus on ventriculo-peritoneal shunt: a case report

INTRODUCTION

Laxative suppository agent is oftenly used for patient with constipation due to its effectiveness and rapid onset. However, beside the benefit of the drugs, it could cause several side effects which could lead to life-threatening complication. In this report, we present a rare case of laxative's side effect that leads to fatal complication in pediatric patient with history of hydrocephalus and ventriculo-peritoneal (VP) shunt placement.

CASE REPORT

An 11 years old boy admitted with general weakness, low nutrition intake, and constipation for 4 days. Patient had a history of VP shunt surgery at half months old due to congenital hydrocephalus. Abdominal X-ray found colon dilatation and fecal material collection. Laxative suppository agent was given to the patient. An hour after the treatment, patient had an abdominal pain followed by defecation, and 30 min after defecation, patient was unresponsive with irregular breathing followed by cardiac arrest. Code blue was activated and resuscitation was done for about 40 min, and patient did not respond to resuscitation and pronounced dead 2.5 h after drug's administration.

DISCUSSION

The pathophysiology of this complication is related with elevated intraabdominal pressure that caused abdominal compartment syndrome (ACS), and this condition could lead to several organ dysfunction such as cardiopulmonary and abdominal organ dysfunction inducing central nervous system impairment through raised intracranial pressure (ICP). Pediatric patient with history of hydrocephalus on VP shunt could have a low brain compliance and very susceptible to fatal complication due to acute raised of ICP.

CONCLUSION

Laxative suppository agent on pediatric patient with hydrocephalus on VP shunt could lead to fatal complication through ACS and acute elevated ICP pressure. Oral laxative agent should be chosen in constipated patient with neurologic preexisting condition, and patient should be closely monitored if suppository agent is given.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Postoperative Acute Kidney Injury

Postoperative AKI is a common complication of major surgery and is associated with significant morbidity and mortality. The Kidney Disease Improving Global Outcomes AKI definition allows consensus classification and identification of postoperative AKI through changes in serum creatinine and/or urine output. However, such conventional diagnostic criteria may be inaccurate in the postoperative period, suggesting a potential to refine diagnosis by application of novel diagnostic biomarkers. Risk factors for the development of postoperative AKI can be thought of in terms of preoperative, intraoperative, and postoperative factors and, as such, represent areas that may be targeted perioperatively to minimize the risk of AKI. The treatment of postoperative AKI remains predominantly supportive, although application of management bundles may translate into improved outcomes.

Elevated intra-abdominal pressure: A review of current knowledge

Elevated intra-abdominal pressure (IAP) is a known cause of increased morbidity and mortality among critically ill patients. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome can lead to rapid deterioration of organ function and the development of multiple organ failure. Raised IAP affects every system and main organ in the human body. Even marginally sustained IAH results in malperfusion and may disrupt the process of recovery. Yet, despite being so common, this potentially lethal condition often goes unnoticed. In 2004, the World Society of the Abdominal Compartment Syndrome, an international multidisciplinary consensus group, was formed to provide unified definitions, improve understanding and promote research in this field. Simple, reliable and nearly costless standardized methods of non-invasive measurement and monitoring of bladder pressure allow early recognition of IAH and timely optimized management. The correct, structured approach to treatment can have a striking effect and fully restore homeostasis. In recent years, significant progress has been made in this area with the contribution of surgeons, internal medicine specialists and anesthesiologists. Our review focuses on recent advances in order to present the complex underlying pathophysiology and guidelines concerning diagnosis, monitoring and treatment of this life-threatening condition.

Abdominal compartment syndrome: an often overlooked cause of acute kidney injury

Abdominal compartment syndrome (ACS) is defined as any organ dysfunction caused by intra-abdominal hypertension (IAH), referred as intra-abdominal pressure (IAP) ≥ 12 mm Hg according to the World Society of Abdominal Compartment Syndrome. Abdominal compartment syndrome develops in most cases when IAP rises above 20 mmHg. Abdominal compartment syndrome, while being a treatable and even preventable condition if detected early in the stage of intra-abdominal hypertension, is associated with high rates of morbidity and mortality if diagnosis is delayed: therefore, early detection is essential. Acute kidney injury (AKI) is a common comorbidity, affecting approximately one in every five hospitalized patients, with a higher incidence in surgical patients. AKI in response to intra-abdominal hypertension develops as a result of a decline in cardiac output and compression of the renal vasculature and renal parenchyma. In spite of the high incidence of intra-abdominal hypertension, especially in surgical patients, its potential role in the pathophysiology of AKI has been investigated in very few clinical studies and is commonly overlooked in clinical practice despite being potentially treatable and reversible. Aim of the present review is to illustrate the current evidence on the pathophysiology, diagnosis and therapy of intra-abdominal hypertension and abdominal compartment syndrome in the context of AKI.

Effect of Orogastric Acetazolamide on Optic Nerve Sheath Diameter in Patients Undergoing Laparoscopic Donor Nephrectomies: A Randomized, Double-Blind Trial

Introduction Laparoscopic Live Donor Nephrectomy(LLDN) is becoming an increasingly frequent procedure. The rise in intracranial pressure(ICP) during LLDN has not been measured yet. ICP can be evaluated by measuring ultrasonographic optic nerve sheath diameter(ONSD). Acetazolamide has been found to provide effective analgesia following LLDN. It also helps lowering the raised ICP. Therefore, we planned to study effect of orogastric Acetazolamide on ONSD in patients undergoing LLDN. Methods Forty Donors scheduled for LLDN were randomized preoperatively either into Group A receiving acetazolamide 5mg/kg or Group S receiving normal saline. ONSD was measured at time points:Time 0: In supine position before induction of GA, Time 1: 5 minutes after induction of GA but before giving orogastric acetazolamide, Time 2: 10 minutes after creating pneumoperitoneum, Time 3: 60 minutes after creating pneumoperitoneum, Time 4: Towards end of surgery, just before taking out specimen in modified flank position, Time 5: after extubating in supine position. Results Mean ONSD of left eye(4.42 ± 0.48) in Group S was significantly more than mean ONSD of left eye(4.16 ± 0.15; p-0.036) in Group A at 10 mins after creating pneumoperitoneum in modified flank position. Mean ONSD showed significant increase in group S at 10 and 60 minutes(4.374 ± 0.433mm in group S vs 4.151 ± 0.168 in group A; p-0.042 at 10 mins and 4.336 ± 0.301mm in group S vs 4.149 ± 0.282mm in group A; p-0.050 at 60 mins) after creating pneumoperitoneum as compared to group A. Conclusion Orogastric acetazolamide 5 mg/kg was found to be beneficial in preventing rise in ONSD from 10 minutes to 1 hour of creating pneumoperitoneum in patients undergoing laparoscopic donor nephrectomy under general anaesthesia. Acetazolamide was also found to be effective in reducing postoperative pain.

Gut Microbiota Was Involved in the Process of Liver Injury During Intra-Abdominal Hypertension

Background: Intestinal damage caused by intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) can lead to the ectopic gut microbiota, which can contribute to liver injury via portal veins. Therefore, it is speculated that gut microbiota disorder caused by IAH/ACS may result in liver injury. The relationship between gut microbiota and IAH/ACS-related liver injury was investigated in this study.

Methods: A model of IAH was established in rats, and 16S rRNA sequencing was analyzed for gut microbiota in the feces of rats. The elimination of gut microbiota was completed by antibiotics gavage, and fecal microbiota transplantation (FMT) was used to change the composition of gut microbiota in rats.

Results: In addition to the traditional cause of liver blood vessel compression, liver injury caused by IAH was also associated with gut microbiota dysbiosis. Gut microbiota clearance can relieve liver injury caused by IAH, while FMT from IAH-intervened rats can aggravate IAH-related liver injury.

Conclusion: The gut microbiota was one of the most important factors contributing to the IAH-related liver injury, and the JNK/p38 signaling pathway was activated in this process.

[Intra-abdominal pressure measurement]

An elevated intra-abdominal pressure (IAP) above 12 mmHg is a pathological finding in critically ill patients. IAP are classified into different degrees of intra-abdominal hypertension and, in the presence of associated organ failure, as abdominal compartment syndrome. Both disease entities represent an underestimated factor in intensive care patients and are associated with increased mortality and prolonged intensive care and hospital stay. The measurement of intra-abdominal pressure in critically ill patients in intensive care units is not widely established and there is often considerable uncertainty regarding measurement conditions and methods. If risk factors are present, intra-abdominal pressure should be monitored every 4 hours. Bladder pressure measurement is the gold standard for determining intra-abdominal pressure. The measurement is a non-invasive, cost-effective, easy to perform bedside and safe method for the patient.

Role of intra-abdominal pressure in the outcomes of perforation peritonitis: A prospective observational study

OBJECTIVES

Intra-abdominal pressure (IAP) has been investigated for its role in causing morbidity and mortality, with various studies showing different degrees of correlation. There remains paucity of literature on this subject, applied to patients of perforation peritonitis, especially in the Indian subcontinent.

MATERIAL AND METHODS

It is a prospective observational study involving 40 patients of perforation peritonitis undergoing exploratory laparotomy. IAP was measured as per WSACS (World Society of Abdominal Compartment Syndrome) guidelines. APACHE II (Acute Physiology And Chronic Health Evaluation- II) and SOFA (Sequential Organ Failure Assessment) were calculated. Data was collected regarding occurrence of prolonged ileus, burst abdomen, duration of hospital stay, 30 day mortality, and was statistically analyzed to correlate with IAP.

RESULTS

At admission, mean IAP was 13.37 mmHg, and the incidence of IAH was 65%. IAH was seen in 17.9% and 7.6% at 24 h and 48 h post-operatively. Incidence of prolonged ileus and burst abdomen were 7.7% and 22.5% respectively. Mortality rate was 17.5%. Mean duration of hospital stay was 13.45 days. Post-operative IAP correlated with mortality (p: 0.014) and post-operative SOFA score (p <0.05). Statistically significant correlation was also seen with the occurrence of prolonged ileus (p: 0.006). IAP did not significantly correlate with APACHE II score, occurrence of burst abdomen, and duration of hospital stay.

CONCLUSION

Rise in IAP correlates with deterioration of SOFA score, and also with the occurrence of prolonged ileus. IAP is also a predictor of mortality. IAP measured post-operatively (24 and 48 hours) had a better correlation with these outcomes than the value measured at admission. No statistically significant correlation of IAP with the occurrence of burst abdomen and duration of hospital stay could be found, which warrants further studies with a larger population.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Acute Right Ventricular Dysfunction Secondary to Hereditary Angioedema Exacerbation

This is a case report of a 31-year-old woman with past medical history of hereditary angioedema (HAE) who developed acute right ventricular dysfunction. The patient presented to the emergency department with complaints of acute abdominal pain and swelling. Her electrocardiogram demonstrated sinus tachycardia and T wave inversion in leads V1-V3, otherwise without findings suggestive of ischemia. Troponin was elevated at 1.83 ng/mL. A transthoracic echocardiogram showed normal left ventricular function with ejection fraction of 65-70%, but the right ventricle (RV) was dilated and severely hypokinetic and there was moderate tricuspid regurgitation. Patient was managed symptomatically for her HAE exacerbation. Her abdominal swelling resolved, troponins continued to trend down, and she was discharged home after three days. A follow up echocardiogram done six months later demonstrated normal RV function. 

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome (ACS) develops when organ failure arises secondary to an increase in intraabdominal pressure. The abdominal pressure is determined by multiple factors such as blood pressure, abdominal compliance, and other factors that exert a constant pressure within the abdominal cavity. Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction. Among surgical and trauma patients, aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS. Other conditions that have also been identified as risk factors are ascites, hemoperitoneum, bowel distention, and large tumors. All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension (IAH). Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery, abdominal aortic aneurysm repair, and liver transplantation among others. Close monitoring of organ function and intra-abdominal pressure (IAP) allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP. Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction. There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

Acute Abdominal Compartment Syndrome complicating a chronic mesenteric ischemia revascularization

BACKGROUND

Abdominal Compartment Syndrome (ACS) is a pathological condition that results from an increase in pressure within the abdomen associated with organ failure. It can be acute or chronic, primary or secondary. ACS poses a serious diagnostic challenge for physicians as the clinical presentation is varied and can mimic other medical pathologies. To prevent a multi-organ failure and ultimately death due to this disease, the World Society of Abdominal Compartment Syndrome (WSACS) suggested clinical criteria and biology tests to facilitate an early diagnosis of acute ACS.

CASE PRESENTATION

We report a case of 61 year-old man diagnosed with chronic mesenteric ischemia that has been successfully treated by prosthetic bypass. The postoperative period was eventual, the patient presented complications corresponding essentially to a manifest acute ACS. The treatment consisted on abdominal decompression and resuscitation measures.

CONCLUSIONS

An early diagnosis of ACS disease for an appropriate therapeutic initiation is mandatory to prevent its complications and save the patient's life prognosis.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Percutaneous catheter drainage of secondary abdominal compartment syndrome: A case report

Abdominal compartment syndrome can be a lethal entity when not treated in a timely fashion. Current standard of care involves emergent decompressive laparotomy by the surgical team. In this case, a 52-year-old male who developed abdominal compartment syndrome secondary to hemoperitoneum underwent emergent drain placement as decompressive laparotomy was not an optimal option for management. Little literature exists on the utility of drain placement or paracentesis for decompression in overall patient morbidity and mortality. However, when necessary, drain placement shows similar outcomes when compared to the standard of care. Interventional radiologists are uniquely positioned to provide drainage guided management for abdominal compartment syndrome in emergent settings.

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.

Evaluation of the effects of intraabdominal hypertension on equine central venous pressure

OBJECTIVE

To evaluate the effect of changes in intraabdominal pressure (IAP) on central venous pressure (CVP) in normal horses.

DESIGN

Experimental, in vivo study.

SETTING

University Teaching Hospital.

ANIMALS

Convenience sample of 7 mixed breed horses-5 geldings and 2 mares.

INTERVENTIONS

Pneumoperitoneum was induced in horses under standing sedation with carbon dioxide gas using a laparoscopic insufflator for a total of 60 minutes to simulate clinical elevation in IAP. Pressure was increased stepwise to 20 mm Hg over 30 minutes, and maintained at that pressure for 30 minutes to evaluate the effect of sustained intraabdominal hypertension. CVP was obtained from the cranial vena cava, concurrent with pressure obtained from the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

CVP increased as IAP increased up to 12 mm Hg, and declined as IAP increased further. The changes in CVP over time were significantly different (P < 0.03). Repeated measures correlation was positive, and highest, for mean CVP as IAP increased from 0 to 12 mm Hg (r = .70; 95% CI, .43-.85; P < 0.0001). Correlation of mean CVP with insufflation pressure became negative as IAP increased further from 15 to 20 mm Hg (r = -.47; 95% CI, -.66 to -.21; P = 0.0006).

CONCLUSIONS

This report provides preliminary data demonstrating a biphasic trend in equine CVP caused by changes in IAP, similar to that observed in other species. Further investigations are needed to evaluate this trend and to confirm these results in clinical patients.

Intra-abdominal Fluid Extravasation: Is Endoscopic Deep Gluteal Space Exploration a Risk Factor?

Background

The extravasation of fluid into the intra-abdominal space is recognized as a possible complication of hip arthroscopic surgery/endoscopy. The exposure of anatomic areas to elevated pump pressures and high volumes of irrigation fluid increases the risk of fluid leakage into anatomic spaces around the hip joint, especially to the abdomen and pelvis.

Purpose

To estimate the incidence and risk factors related to intra-abdominal fluid extravasation (IAFE) after hip endoscopy or arthroscopic surgery.

Study Design

Cohort study; Level of evidence, 2.

Methods

A prospective study was carried out between June 2017 and June 2018. A total of 106 hip procedures (endoscopy or arthroscopic surgery) performed for extra- or intra-articular abnormalities were included. Before and after surgery, in the operating room, ultrasound was performed by a trained anesthesiologist to detect IAFE. The hepatorenal (Morison pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. Patients were monitored for 3 hours after surgery to assess for abdominal pain. The data collected included maximum pump pressure, duration and volume of irrigation fluid (Ringer lactate), total surgical time, and traction time.

Results

The incidence of IAFE was 31.1% (33/106; 95% CI, 23.1%-40.5%). The frequency of IAFE was 52.9% (9/17) in cases with isolated extra-articular abnormalities and 15.9% (7/44) in cases with isolated femoroacetabular impingement; in cases with both extra- and intra-articular abnormalities, the frequency was 37.8% (17/45). An intervention in the subgluteal space was identified as a risk factor for IAFE (odds ratio, 3.62 [95% CI, 1.47-8.85]). There was no statistically significant difference between groups (with vs without IAFE) regarding total surgical time, maximum pump pressure, or fluid volume. Postoperative abdominal pain was found in 36.4% (n = 12) of cases with IAFE compared with 2.7% (n = 2) of cases without extravasation (P < .001). No patient with IAFE developed abdominal compartment syndrome.

Conclusion

IAFE was a frequent finding after hip arthroscopic surgery/endoscopy in patients with extra-articular abnormalities. Exploration of the subgluteal space may increase the risk of IAFE. Pain and abdominal distension during the immediate postoperative period were early warning signs for IAFE. These results reinforce the need for careful intraoperative and postoperative monitoring by the surgeon and anesthesiologist to identify and avoid complications related to IAFE.

Hydrops fetalis and neonatal abdominal compartment syndrome continuum from immature gastric teratoma: a case report

Background

Hydrops fetalis as well as abdominal compartment syndrome (ACS) are conditions that are associated with high mortality rates. A rare case of immature gastric teratoma causing fetal hydrops and subsequent ACS is presented. The related pathophysiologic mechanisms are discussed, and the importance of timely recognition and appropriate interventions are highlighted.

Case presentation

The male patient was born preterm, weighing 3.9 kg., by Cesarean section. Prior prenatal ultrasounds were normal, but a scan done just before delivery had findings indicating polyhydramnios, fetal ascites, and meconium peritonitis. Upon delivery, the patient had respiratory distress, anasarca and a massively distended abdomen. Resuscitation measures, including ventilatory support, were instituted. Imaging studies showed ascites as well as a large, complex intra-abdominal lesion with calcifications. In the succeeding hours, anuria persisted, anasarca worsened, the abdomen became more distended, and inotrope requirements increased. The occurrence of ACS, from what was presumed to be a retroperitoneal teratoma, was therefore considered. Laparotomy was done on the 28th hour of life, with en bloc excision of a massive tumor and attached section of the greater curvature of the stomach. Passage of urine occurred intra-operatively, and the patient was soon after weaned off inotropes and ventilator support. The histopathologic result was immature gastric teratoma. No chemotherapy was given, and the patient’s serum AFP is at normal levels 15 months following surgery.

Conclusion

The presence of a massive intra-abdominal lesion can result in the pathophysiologic continuum of hydrops fetalis and neonatal ACS. The early recognition of such an association can enable appropriate expectant management of similarly affected neonates, including emergent decompression laparotomy.

Comparison of right lateral versus left lateral versus sternal recumbence intra-abdominal pressure measurements in normal dogs

OBJECTIVE

To determine if there is a difference in intra-abdominal pressure (IAP) among 3 anatomic body positions (right lateral, left lateral, and sternal recumbence) in apparently healthy dogs.

DESIGN

Prospective, observational study.

SETTING

University Veterinary Medical Teaching Hospital.

ANIMALS

Fourteen apparently healthy male dogs.

MEASUREMENTS AND MAIN RESULTS

After mild sedation with dexmedetomidine, a water manometer attached to a Foley urinary catheter was used to measure IAP in 3 different body positions in each dog. There was no significant difference in IAP between right lateral (3.87± 3.16 cm H₂ O), left lateral (4.45 ± 3.22 cm H₂ O), and sternal recumbence (4.04 ± 3.57 cm H₂ O).

CONCLUSIONS

Based on data from these 14 apparently healthy dogs, these 3 body positions can be used interchangeably for monitoring an individual dog. However, more research in dogs is needed to see if this conclusion holds true when IAP is abnormal.

Intra-abdominal Pressure Screening of Horses With Colic

The objective of this study was to evaluate changes in intra-abdominal pressure (IAP) in horses with colic by associating the underlying etiologies with directly acquired IAP values and survival rate. This is a 2-year cohort study (2014-2016). Horses with clinical signs of colic were admitted to the veterinary teaching hospital during the period 2014-2016. Twenty-eight horses, of different breeds, males (stallions and geldings) and females, aged between 2 and 20 years, and weighing from 300 to 450 kg presenting with clinical signs of colic, were included in the study. IAP was directly acquired at the right flank (standing under sedation) and at the linea alba (supine position under general anesthesia). Twenty IAP measurements were recorded at end expiration for each recording site. IAP values >0.0 mmHg, obtained at the upper right flank in the standing position, were associated with surgical treatment (P < .05). In these cases, signs of colic were associated with strangulated obstructions of the large colon, and a greater likelihood of death as a result of colic (P < .001). Intra-abdominal pressure varied considerably in horses with colic, even for the same underlying etiologies. Horses with colic related to strangulating obstructions of the large intestine had IAP >.0 mmHg, at the upper right flank. These horses were also considerably more likely to require surgical intervention (P < .05) and death/euthanasia was more likely in this group of horses (P < .001).

Effects of low versus standard pressure pneumoperitoneum on renal syndecan-1 shedding and VEGF receptor-2 expression in living-donor nephrectomy: a randomized controlled study

Background

Laparoscopic nephrectomy is a preferred technique for living kidney donation. However, positive-pressure pneumoperitoneum may have an unfavorable effect on the remaining kidney and other distant organs due to inflamed vascular endothelium and renal tubular cell injury in response to increased systemic inflammation. Early detection of vascular endothelial and renal tubular response is needed to prevent further kidney injury due to increased intraabdominal pressure induced by pneumoperitoneum. Transperitoneal laparoscopic living donor nephrectomy represented a human model of mild increasing intraabdominal pressure. This study aimed to assess the effect of increased intraabdominal pressure on vascular endothelium and renal tubular cells by comparing the effects of low and standard pressure pneumoperitoneum on vascular endothelial growth factor receptor-2 (VEGFR-2) expression and the shedding of syndecan-1 as the early markers to a systemic inflammation.

Methods

We conducted a prospective randomized study on 44 patients undergoing laparoscopic donor nephrectomy. Subjects were assigned to standard (12 mmHg) or low pressure (8 mmHg) groups. Baseline, intraoperative, and postoperative plasma interleukin-6, syndecan-1, and sVEGFR-2 were quantified by ELISA. Syndecan-1 and VEGFR-2 expression were assessed immunohistochemically in renal cortex tissue. Renal tubule and peritubular capillary ultrastructures were examined using electron microscopy. Perioperative hemodynamic changes, end-tidal CO₂, serum creatinine, blood urea nitrogen, and urinary KIM-1 were recorded.

Results

The low pressure group showed lower intra- and postoperative heart rate, intraoperative plasma IL-6, sVEGFR-2 levels and plasma syndecan-1 than standard pressure group. Proximal tubule syndecan-1 expression was higher in the low pressure group. Proximal-distal tubules and peritubular capillary endothelium VEGFR-2 expression were lower in low pressure group. The low pressure group showed renal tubule and peritubular capillary ultrastructure with intact cell membranes, clear cell boundaries, and intact brush borders, while standard pressure group showed swollen nuclei, tenuous cell membrane, distant boundaries, vacuolizations, and detached brush borders.

Conclusion

The low pressure pneumoperitoneum attenuated the inflammatory response and resulted in reduction of syndecan-1 shedding and VEGFR-2 expression as the renal tubular and vascular endothelial proinflammatory markers to injury due to a systemic inflammation in laparoscopic nephrectomy.

Trial registration

ClinicalTrials.gov NCT:03219398, prospectively registered on July 17th, 2017.

Intraoperative Monitoring and Intra-abdominal Fluid Extravasation During Hip Arthroscopy

OBJECTIVE

To evaluate the relationship between the intraoperative monitoring factors with intra-abdominal fluid extravasation (IAFE) in patients who underwent hip arthroscopy. The secondary purpose was to describe the main intraoperative variables between cases with and without IAFE.

METHODS

We carried out a prospective observational study of 106 hip arthroscopies between June 2017 and June 2018. Within procedures, 54 cases with deep gluteal syndrome (DGS) were included. Ultrasonography was performed by a trained anesthesiologist before and after the surgery to identify the presence of fluid. The hepatorenal (Morison's pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. During the surgery, the blood pressure, heart rate, temperature, peak inspiratory pressure (PIP), pulmonary compliance, oxygen saturation, and end-tidal carbon dioxide were registered.

RESULTS

The incidence of IAFE was 31.1% (33/106; 95% confidence interval 23.0%-40.5%). IAFE in cases with isolated FAI was 15.9% (7/44) in comparison with 52.9% (9/17) of the cases with isolated DGS. Maximum values of PIP greater than 20 mm Hg were associated with fluid extravasation (odds ratio 3.22; 95% confidence interval 1.07-9.68). No statistically significant relationship was found in blood pressure, heart rate, temperature, oxygen saturation, end-tidal carbon dioxide, and pulmonary compliance between cases with and without IAFE.

CONCLUSIONS

Asymptomatic IAFE, as measured by ultrasound, is a frequent event in patients who underwent hip arthroscopy, mainly in cases with DGS. PIP was found to be a useful intraoperative monitoring parameter for the early identification of IAFE in hip arthroscopy.

LEVEL OF EVIDENCE

Level II, observational prospective cohort study.

Abdominal Compartment Syndrome: Improving Outcomes With A Multidisciplinary Approach - A Narrative Review

Abdominal compartment syndrome (ACS) refers to a severe increase in intra-abdominal pressure associated with single or multiorgan failure. ACS with specific pathophysiological processes and detrimental outcomes may occur in a variety of clinical conditions. Patients with ACS are predominantly managed in critical care settings, however, a wide range of multidisciplinary interventions are frequently required from medical, surgical, radiological and nursing specialties. The medical management, aiming to prevent the progression of intra-abdominal hypertension to ACS, is extensively reviewed. Timing and techniques of surgical decompression techniques, as well as management of open abdomen, are outlined. In summary, the current narrative review provides data on history, definitions, epidemiology and pathophysiology of the syndrome and highlights the importance of multidisciplinary approach in the management of ACS in adults.

Current Approach to the Evaluation and Management of Abdominal Compartment Syndrome in Pediatric Patients

Abdominal compartment syndrome is an emergent condition caused by increased pressure within the abdominal compartment. It can be caused by a number of etiologies, which are associated with decreased abdominal wall compliance, increased intraluminal or intraperitoneal contents, or edema from capillary leak or fluid resuscitation. The history and physical examination are of limited utility, and the criterion standard for diagnosis is intra-abdominal pressure measurement, which is typically performed via an intravesical catheter. Management includes increasing abdominal wall compliance, evacuating gastrointestinal or intraperitoneal contents, avoiding excessive fluid resuscitation, and decompressive laparotomy in select cases.

Evaluation and Management of Abdominal Compartment Syndrome in the Emergency Department

BACKGROUND

Abdominal compartment syndrome is a potentially deadly condition that can be missed in the emergency department setting.

OBJECTIVE

The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of abdominal compartment syndrome with a focus on emergency clinicians.

DISCUSSION

Abdominal compartment syndrome is caused by excessive pressure within the abdominal compartment due to diminished abdominal wall compliance, increased intraluminal contents, increased abdominal contents, or capillary leak/fluid resuscitation. History and physical examination are insufficient in isolation, and the gold standard is intra-abdominal pressure measurement. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of end-organ injury. Management involves increasing abdominal wall compliance (e.g., analgesia, sedation, and neuromuscular blocking agents), evacuating gastrointestinal contents (e.g., nasogastric tubes, rectal tubes, and prokinetic agents), avoiding excessive fluid resuscitation, draining intraperitoneal contents (e.g., percutaneous drain), and decompressive laparotomy in select cases. Patients are critically ill and often require admission to a critical care unit.

CONCLUSIONS

Abdominal compartment syndrome is an increasingly recognized condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Filho D, Amaral GPD, Ferraz GC, Ferraudo AS, Canola JC. Intrabladder pressure as predictor of intra-abdominal pressure in horses

OBJECTIVES

To investigate effects of postural changes and bladder distention on intrabladder pressure whilst estimating intra-abdominal pressure in horses.

DESIGN

Two-year cohort study. Patients admitted for elective surgical procedures unrelated to gastrointestinal or genitourinary tract.

SETTING

School of Agricultural and Veterinarian Sciences, Jaboticabal, SP, Brazil.

ANIMALS

20 adult horses, 11 males (stallions and geldings) and 9 females; between 3.5 and 12 years, weighing 350 to 500 kg.

INTERVENTIONS

Intra-abdominal pressure was directly-recorded through abdominocentesis at the ventral midline with a fluid-filled system. Intrabladder pressure was obtained from a bladder catheter with the fluid-filled system zeroed at the level of the tuber ischia with patients in dorsal recumbency or pubic symphysis if in lateral recumbency.

MEASUREMENTS AND MAIN RESULTS

Body position directly influenced intra-abdominal pressure. In dorsal recumbency, intra-abdominal pressure differed (p < 0.05) from intrabladder pressure at end-inspiration and end-expiration regardless of whether the bladder was empty or distended. There was no correlation nor association between the two pressures in this body position. In lateral recumbency a difference (p <0.05) between intra-abdominal pressure and intrabladder pressure was recorded at end-inspiration with the bladder distended with 25 ml, and at end-expiration for distension volumes of 25 ml and 50 ml. There was a strong correlation between both pressures for left and right lateral recumbency, regardless of the distension volume. Ordinary least product (OLP) regression analysis showed no fixed or proportional bias between both pressures for distension volume of 50 ml, at both end-inspiration and end-expiration.

CONCLUSIONS

Indirect assessment of equine intra-abdominal pressure cannot be made in dorsal recumbency. For that purpose, patients should be in left lateral recumbency with the bladder distended with 50 ml. Values can be recorded at end-inspiration or end-expiration.

RESTRICTION

Occlusion of the catheter tip by the bladder wall when minimally distended.

Experimentally Induced Open Pneumothorax in Horses

The objective of this study was to evaluate clinical and cardiovascular parameters and pleural and intra-abdominal pressures of horses after experimentally induced unilateral open pneumothorax. Prospective, experimental study-animals: seven healthy adult horses, 4 females and 3 males. Left hemithorax thoracotomy was carried out to create an open pneumothorax for 60 minutes. Pleural pressure (P_pl) was directly obtained at the midpoint of the left eighth intercostal space before thoracotomy. Esophageal pressure (P_es), arterial blood gas analysis, left ventricular function, and ultrasonographic assessment of pneumothorax extent/resolution were performed at the baseline, and 5, 10, 15, 30, 45, and 60 minutes after thoracotomy, and on the first, second, third, fifth, and seventh days postoperatively. Intra-abdominal pressure was only recorded while the pneumothorax was present. There was moderate correlation (Spearman's rs = 0.404; R² = 0.8; P < .00001; Bland-Altman bias = -2.59; s.d. = 2.11) between P_es and P_pl. Esophageal pressure increased (P < .05) after open pneumothorax until the fifth day postoperatively. Partial pressure of oxygen in arterial blood reduced (P < .05) until the third day postoperatively when it returned to the baseline. No significant variations in P_aCO₂, pH in arterial blood, and in left ventricular function were appreciated. The extent of the pneumothorax was assessed by thoracic ultrasonography. Esophageal pressure, in association with blood gas analysis and thoracic ultrasonography, could be used to aid diagnosis of pneumothorax in horses. Horses tolerate open pneumothorax, with minimum cardiovascular impairment, even without aspiration of free air from within pleural space to restore thoracic wall integrity.

Abdominal compartment syndrome following posterior lumbar fusion in a patient with previous abdominal surgery

Introduction

Perioperative complications associated with spinal fusion have been investigated steadily to reduce morbidity and mortality. Although there are several reports reviewing abdominal complications occurring with anterior spinal fusion, complications related to posterior spinal fusion (PSF) are rare. However, abdominal compartment syndrome (ACS) after PSF could be the most fatal and unpredictable complication in spinal surgery.

Case presentation

This 73-year-old man with body mass index (BMI) of 23.02, and surgical history of appendectomy 10 years prior complained of severe nausea and vomiting on the second postoperative day of L4-5 transforaminal lumbar interbody fusion (TLIF). By postoperative day 4, he presented with dyspnea and fever, and the first diagnostic impression suggested aspiration pneumonia due to vomiting. Physical examination revealed severe abdominal distention and tenderness to palpation at most of the abdomen. Computed tomography (CT) scan of abdomen and chest revealed left inguinal hernia of the small bowel with incarceration suggesting intra-abdominal hypertension (IAH), and multifocal peri-bronchial consolidation in both lungs, respectively. His respiratory symptoms progressed to respiratory failure, and he was finally mechanically ventilated in conjunction with antibiotics. After 2 weeks of intensive care, the patient's symptom had improved, and finally he was transferred to a nursing facility.

Discussion

IAH and ACS rarely occur as abdominal complications of PSF. We suggest several risk factors including body mass index, abdominal surgical history, and long segment fusion for development of abdominal complications.

The value of combined hemodynamic, respiratory and intra-abdominal pressure monitoring in predicting acute kidney injury after major intraabdominal surgeries

Background: The incidence of postoperative acute kidney injury (AKI) is predominantly determined by renal hemodynamics. Beside arterial blood pressure, the role of factors causing a deterioration of venous congestion (intraabdominal pressure, central venous pressure, mechanical ventilation) has emerged. The value of combined hemodynamic, respiratory and intra-abdominal pressure (IAP) monitoring in predicting postoperative acute kidney injury has received only limited exploration to date.

Methods: Data were collected for adult patients admitted after major abdominal surgery at nine Hungarian ICUs. Hemodynamic parameters were compared in AKI vs. no-AKI patients at the time of admission and 48 h thereafter. Regarding ventilatory support, we tested mean airway pressures (Pmean). Effective renal perfusion pressure (RPP) was calculated as MAP−(IAP + CVP + Pmean). The Mann–Whitney U and the chi-square tests were carried out for statistical analysis with forward stepwise logistic regression for AKI as a dependent outcome.

Results: A total of 84 patients (34 ventilated) were enrolled in our multicenter observational study. The median values of MAP were above 70 mmHg, IAP not higher than 12 mmHg and CVP not higher than 8 mmHg at all time-points. When we combined those parameters, even those belonging to the ‘normal’ range with Pmean, we found significant differences between no-AKI and AKI groups only at 12 h after ICU admission (median and IQR: 57 (42–64) vs. 40 (36–52); p < .05). Below it’s median (40.7 mmHg) on admission, AKI developed in all patients. If above 40.7 mmHg on admission, they were protected against AKI, but only if it did not decrease within the first 12 h.

Conclusions: Calculated effective RPP with the novel formula MAP−(IAP + CVP + Pmean) may predict the onset of AKI in the surgical ICU with a great sensitivity and specificity. Maintaining effective RPP appears important not only at ICU admission but during the next 12 h, as well. Additional, larger studies are needed to explore therapeutic interventions targeting this parameter.

Abdominal Compartment Syndrome as a Multidisciplinary Challenge. A Literature Review

Abdominal Compartment Syndrome (ACS), despite recent advances in medical and surgical care, is a significant cause of mortality. The purpose of this review is to present the main diagnostic and therapeutic aspects from the anesthetical and surgical points of view. Intra-abdominal hypertension may be diagnosed by measuring intra-abdominal pressure and indirectly by imaging and radiological means. Early detection of ACS is a key element in the ACS therapy. Without treatment, more than 90% of cases lead to death and according with the last reports, despite all treatment measures, the mortality rate is reported as being between 25 and 75%. There are conflicting reports as to the importance of a conservative therapy approach, although such an approach is the central to treatment guidelines of the World Society of Abdominal Compartment Syndrome, Decompressive laparotomy, although a backup solution in ACS therapy, reduces mortality by 16-37%. The open abdomen management has several variants, but negative pressure wound therapy represents the gold standard of surgical treatment.

Liver function assessment by indocyanine green plasma disappearance rate in patients with intra-abdominal hypertension after "non-hepatic" abdominal surgery

BACKGROUND AND OBJECTIVE

Liver function assessment in patients with intra-abdominal hypertension (IAH) after major abdominal surgery is complex and often confounding. Elevated intra-abdominal pressure (IAP) often occurs after major abdominal surgery, and is associated with decreased abdominal blood flow and organ dysfunction, and it could cause abdominal compartment syndrome (ACS), which is a life-threatening condition. Plasma disappearance rate (PDR) of indocyanine green (ICG) and ICG retention rate after 15 min (R15) were used to evaluate liver function and as a prognostic parameter after major abdominal surgery.

METHODS

In this prospective/observational study, 51 patients were followed in the surgical intensive care unit after major abdominal surgery (operation of the small and large intestine, stomach, pancreas, spleen, or resection of the abdominal aorta), 29 had IAH. The PDR-ICG and R15 were analyzed 24 h after surgery concurrently with IAP, APP, bilirubin, AST, ALT, prothrombin time, albumin, cardiac index, arterial lactate, oxygen delivery, MAP (mean arterial pressure), APACHE II (acute physiology and chronic health evaluation), SOFA (sequential organ failure assessment), and SAPS II (simplified acute physiology score). IAH has been defined as a peak intra-abdominal pressure (IAP) value of ≥12 mmHg, at a minimum, as two standardized measurements obtained 1-6 h apart.

RESULTS

The PDR-ICG measured 24 h after surgery was not different among groups (20.95% [SD = 10.34] vs 25.40% [SD = 7.42]), p = .094. ICG R15 was significantly higher in patients with IAH, 11.10% [SD = 13.82] vs 8.30 [SD = 11.46], p < .05, respectively. The PDR/ICG value was significantly lower in non-survivors than survivors (16.82 [SD = 10.87] vs 24.35 [SD = 8.48], p < .05).

CONCLUSIONS

The results suggest that PDR/ICG and ICG R15 are useful dynamic tests for evaluation of complex liver function and survival prediction after major abdominal surgery in patients with IAH.

Successful non-operative management of intraabdominal hypertension and abdominal compartment syndrome after complex ventral hernia repair: a case series

BACKGROUND

Intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are devastating complications of surgery. Patients who undergo complex ventral hernia repair (CVHR) may be at risk for IAH and ACS.

METHODS

We performed a retrospective review of 175 patients who underwent CVHR by a single surgeon. Body mass index (BMI), prior hernia repair, operative time, bladder pressure, serum creatinine, sedation, paralytic therapy, and ventilator support were reviewed.

RESULTS

IAH was identified in 33 patients; 11 patients developed ACS. Paralytic therapy was employed in 29 patients for an average of 1.4 days. Elevated BMI was independently associated with an increased risk of IAH (p = 0.006) and ACS (p = 0.02).

CONCLUSION

Patients who undergo CVHR are at risk of developing IAH and ACS in the postoperative period. Elevated BMI and longer operative time are independent risk factors for the development of IAH. IAH and ACS can be successfully managed with surgical critical care.