Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units

Abdominal Compartment Syndrome Secondary to Delayed Retroperitoneal Hemorrhage After Renal Biopsy: A Case Report

Abdominal compartment syndrome (ACS) is a severe clinical condition characterized by increased intra-abdominal pressure, potentially leading to organ dysfunction and high mortality. This report describes a rare case of ACS resulting from delayed retroperitoneal hemorrhage following a renal biopsy. The patient was successfully managed through repeated interventional radiology (IVR) embolization procedures, followed by prompt surgical evacuation of the hematoma. This case underscores the critical role of coordinated intervention between IVR and surgical teams in achieving hemostasis and controlling intra-abdominal hypertension. The collaborative approach highlights the importance of timely, multidisciplinary decision-making in managing biopsy-related hemorrhagic complications, particularly in high-risk patients with coagulopathies.

Barriers and facilitators in implementing intra-abdominal pressure measurement by nurses in paediatric intensive care units: A qualitative study

BACKGROUND

Intra-abdominal hypertension has been proven to be an independent risk factor for death in critically ill patients. Accurate monitoring of intra-abdominal pressure is of great significance for early identification and timely intervention of intra-abdominal hypertension to prevent further progression to abdominal compartment syndrome. Paediatric critical care nurses play an important role in constant observation and recognition of subtle and dynamic changes in intra-abdominal pressure of critically ill children.

OBJECTIVES

The objective of this study was to explore paediatric critical care nurses's views on the barriers and facilitators in clinical practice of intra-abdominal pressure measurement.

METHODS

A qualitative, open-ended, and exploratory study was conducted in the paediatric intensive care unit of a tertiary hospital in China. Semistructured interviews were conducted with nurses and nursing managers who were involved in the management of intra-abdominal pressure. The interview guide was developed using the Theoretical Domains Framework to explore the barriers and facilitators to intra-abdominal pressure measurement in the paediatric intensive care unit. Data analysis followed the framework approach, drawing on the Theoretical Domains Framework.

RESULTS

Fourteen participants (10 nurses and four nursing managers) were interviewed. We identified seven domains related to intra-abdominal pressure measurement mapping to six "barrier" domains and four "facilitator" domains. The six "barrier" domains were knowledge, social influences, behavioural regulation, beliefs about consequences, beliefs about capabilities, and environmental context and resources, and the four "facilitator" domains were social influences, beliefs about consequences, environmental context and resources, and social/professional role and identity.

CONCLUSIONS

The findings confirm the need for interventions to support paediatric critical care nurses in their intra-abdominal pressure measurement practices, with a particular focus on increasing knowledge, improving skills and measurement equipment, promoting nurse-physician interprofessional collaboration, providing a standardised measurement process, and establishing a supportive environment. Using the Theoretical Domains Framework will enhance the design of a targeted intervention, which should facilitate the standardised management of intra-abdominal pressure in the paediatric intensive care unit.

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

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

Application of bridging mesh repair in giant ventral incisional hernia

Achieving ideal abdominal wall reconstruction in giant ventral incisional hernia has been a challenging for surgeons. This study aimed to verify the safety and efficacy of bridging repair by comparing it with primary fascial closure (PFC) repair in the treatment of giant ventral incisional hernia. We retrospectively analyzed the clinical data of 92 patients with giant ventral incisional hernia who underwent mesh repair at our medical institution from January 1, 2014 to December 31, 2020. Patients were divided into 2 groups: the bridging repair group with 40 patients in whom repair was completed using the bridging technique and the PFC group with 52 patients in whom primary fascial closure was achieved and all patients underwent mesh reinforcement during the operation. The main outcome measures were recurrence rate and morbidity, especially intra-abdominal hypertension (IAH). Follow-up time of both groups lasted at least 24 months after surgery. After a median of 46 months and 65 months of follow-up, respectively, in the two groups, bridging repair did not increase the long-term recurrence rate (2.56%) in the larger defect area group compared to the PFC group (1.96%). There were no significant differences in perioperative morbidity, IAH, incidence of postoperative chronic pain, and sensory impairment of the abdominal wall between both groups. The application of bridging surgery in the treatment of complex giant ventral incisional hernias is safe and effective and does not significantly increase the postoperative recurrence rate.

Combined effect of intermittent hemostasis and a modified external hemorrhage control device in a lethal swine model

Background

Non-compressible torso hemorrhage (NCTH) presents the ultimate challenge in pre-hospital care. While external hemorrhage control devices (EHCDs) such as the Abdominal Aortic and Junctional Tourniquet (AAJT) and SAM Junctional Tourniquet (SJT) have been invented, the current design and application strategy requires further improvement. Therefore, researchers devised a novel apparatus named Modified EHCD (M-EHCD) and implemented intermittent hemostasis (IH) as a preventive measure against ischemia-reperfusion injury. The objective of this study was to ascertain the combined effect of M-EHCD and IH on the hemostatic effect of NCTH.

Methods

Eighteen swine were randomized to M-EHCD, AAJT or SJT. The NCTH model was established by inducing Class Ⅲ hemorrhagic shock and performing a hemi-transection of common femoral artery (CFA). EHCDs were rapidly fastened since the onset of free bleeding (T0min). The IH strategy was implemented by fully releasing M-EHCD at T40min, T70min and T100min, respectively, whereas AAJT and SJT maintained continuous hemostasis (CH) until T120min. All groups underwent CFA bridging at T110min, and EHCDs were removed at T120min. Reperfusion lasted for 60 min, after which euthanasia was performed. Hemodynamics, intra-vesical pressure (IVP), and blood samples were collected periodically. Histological examinations were also conducted.

Results

M-EHCD demonstrated the fastest application time (M-EHCD: 26.38 ± 6.32s vs. SJT: 30.84 ± 5.62s vs. AAJT: 54.28 ± 5.45s, P < 0.001) and reduced free blood loss (M-EHCD: 17.77 ± 9.85g vs. SJT: 51.80 ± 33.70g vs. AAJT: 115.20 ± 61.36g, P = 0.011) compared to SJT and AAJT. M-EHCD exhibited inhibitory effects on heart rate (M-EHCD: 91.83 ± 31.61bpm vs. AAJT: 129.00 ± 32.32bpm vs. SJT: 135.17 ± 21.24bpm, P = 0.041) and shock index. The device's external pressure was lowest in M-EHCD and highest in SJT (P = 0.001). The resultant increase in IVP were still the lowest in M-EHCD (M-EHCD: -0.07 ± 0.45 mmHg vs. AAJT: 27.04 ± 5.03 mmHg vs. SJT: 5.58 ± 2.55 mmHg, P < 0.001). Furthermore, M-EHCD caused the least colonic injury (M-EHCD: 1.17 ± 0.41 vs. AAJT: 2.17 ± 0.41 vs. SJT: 2.17 ± 0.41, P = 0.001). The removal of M-EHCD showed the slightest impact on pH (P < 0.001), while AAJT group was more susceptible to the lethal triad based on the arterial lactate and thrombelastogram results.

Conclusions

M-EHCD + IH protected the organs and reduced the risk of the lethal triad by decreasing disruptions to IVP, hemodynamics, acid-base equilibrium and coagulation. M-EHCD + IH was superior to the hemostatic safety and efficacy of AAJT/SJT + CH.

Earthquake victims in focus: a cross-sectional examination of trauma and management in intensive care unit

BACKGROUND

After the Kahramanmaras earthquake of February 6, 2023, the disaster of the century, a significant number of victims were admitted to intensive care units (ICUs). In this study, we aimed to share the characteristics and management of critical earthquake victims and shed light on our experiences as intensivists in future earthquakes.

METHODS

The study included 62 earthquake victims in two tertiary ICUs. Demographic characteristics, laboratory findings, clinical characteristics, trauma and disease severity scores, treatments administered to patients, and the clinical course of the patients were recorded retrospectively. The patients were divided into two groups, survivors and nonsurvivors, according to 7-day mortality and into two groups according to the duration of their stay under the rubble: those who remained under the rubble for 72 hours or less and those who remained under the rubble for more than 72 hours. A receiver operating characteristic (ROC) curve analysis was used to determine the best cutoff value for the 'Circulation, Respiration, Abdomen, Motor, and Speech' (CRAMS) score.

RESULTS

The median age of the 62 patients included in the study was 35.5 (23-53) years. The median length of stay under the rubble for the patients was 30.5 (12-64.5) hours. The patient was transferred to the ward with a maximum duration of 222 hours under the rubble. The limb (75.8%) was the most common location of trauma in patients admitted to the ICU. Crush syndrome developed in 96.8% of the patients. There was a positive correlation between the development of acute kidney injury (AKI) and myoglobin, serum lactate, and uric acid levels (r = 0.372, p = 0.003; r = 0.307, p = 0.016; r = 0.428, p = 0.001, respectively). The best cutoff of the CRAMS score to predict in-7-day mortality was < 4.5 with 0.94 area under the curve (AUC); application of this threshold resulted in 75% sensitivity and 96.3% specificity.

CONCLUSION

Search and rescue operations should continue for at least ten days after an earthquake. The CRAMS score can be used to assess trauma severity and predict mortality in critically ill earthquake victims.

Abdominal compartment syndrome as a complication of endoscopic carbon dioxide insufflation in a patient with malignant bowel obstruction: a case report

BACKGROUND

A self-expandable metal stent is often placed as a bridge to elective surgical treatment of left-sided malignant obstruction of the colon because it allows for primary anastomosis without the need for a temporary stoma, which has a positive impact on the patient's quality of life. However, although a relatively safe procedure, colonic stenting can have complications that require emergency surgery. This case report describes a rare case of abdominal compartment syndrome that occurred as a complication of endoscopic insufflation during colonic stenting.

CASE PRESENTATION

The patient was a 72-year-old woman who presented complaining of several days of constipation and loss of appetite. Computed tomography of the abdomen revealed obstruction of the sigmoid colon by a tumor. There were no symptoms or computed tomography findings to suggest perforation. Therefore, an attempt was made to insert a self-expandable metal stent. Acute respiratory disturbance and a change in consciousness occurred during the stenting procedure, with marked abdominal distention. Abdominal compartment syndrome was diagnosed and treated by decompressive laparotomy.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of abdominal compartment syndrome as a complication of endoscopic insufflation during colonic stenting. The possibility of abdominal compartment syndrome should be considered if acute respiratory disturbance or altered consciousness occurs during endoscopic procedure in a patient with malignant bowel obstruction.

Stable Gastric Pentadecapeptide BPC 157 Therapy: Effect on Reperfusion Following Maintained Intra-Abdominal Hypertension (Grade III and IV) in Rats

Given in reperfusion, the use of stable gastric pentadecapeptide BPC 157 is an effective therapy in rats. It strongly counteracted, as a whole, decompression/reperfusion-induced occlusion/occlusion-like syndrome following the worst circumstances of acute abdominal compartment and intra-abdominal hypertension, grade III and grade IV, as well as compression/ischemia-occlusion/occlusion-like syndrome. Before decompression (calvariectomy, laparotomy), rats had long-lasting severe intra-abdominal hypertension, grade III (25 mmHg/60 min) (i) and grade IV (30 mmHg/30 min; 40 mmHg/30 min) (ii/iii), and severe occlusion/occlusion-like syndrome. Further worsening was caused by reperfusion for 60 min (i) or 30 min (ii/iii). Severe vascular and multiorgan failure (brain, heart, liver, kidney, and gastrointestinal lesions), widespread thrombosis (peripherally and centrally) severe arrhythmias, intracranial (superior sagittal sinus) hypertension, portal and caval hypertension, and aortal hypotension were aggravated. Contrarily, BPC 157 therapy (10 µg/kg, 10 ng/kg sc) given at 3 min reperfusion times eliminated/attenuated venous hypertension (intracranial (superior sagittal sinus), portal, and caval) and aortal hypotension and counteracted the increases in organ lesions and malondialdehyde values (blood ˃ heart, lungs, liver, kidney ˃ brain, gastrointestinal tract). Vascular recovery promptly occurred (i.e., congested inferior caval and superior mesenteric veins reversed to the normal vessel presentation, the collapsed azygos vein reversed to a fully functioning state, the inferior caval vein-superior caval vein shunt was recovered, and direct blood delivery returned). BPC 157 therapy almost annihilated thrombosis and hemorrhage (i.e., intracerebral hemorrhage) as proof of the counteracted general stasis and Virchow triad circumstances and reorganized blood flow. In conclusion, decompression/reperfusion-induced occlusion/occlusion-like syndrome counteracted by BPC 157 therapy in rats is likely for translation in patients. It is noteworthy that by rapidly counteracting the reperfusion course, it also reverses previous ischemia-course lesions, thus inducing complete recovery.

A nomogram for predicting the risk of intra-abdominal hypertension in critically ill patients based on ultrasound and clinical data

Background

Intra-abdominal hypertension (IAH) is a common complication in critically ill patients. This study aimed to identify independent risk factors for IAH and generate a nomogram to distinguish IAH from non-IAH in these patients.

Methods

We retrospectively analyzed 89 critically ill patients and divided them into an IAH group [intra-abdominal pressure (IAP) ≥12 mmHg] and a non-IAH group (IAP <12 mmHg) based on the IAP measured from their bladders. Ultrasound and clinical data were also measured. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for IAH. The correlation between IAP and independent risk factors was also assessed.

Results

Of these 89 patients, 45 (51%) were diagnosed with IAH. Univariate analysis showed there were significant differences in the right renal resistance index (RRRI) of the interlobar artery, the right diaphragm thickening rate (RDTR), and lactic acid (Lac) between IAH and non-IAH groups (P<0.001). Multivariate logistic regression analysis revealed that increasing RRRI, RDTR, and Lactic acid (Lac) were independent risk factors for IAH (P=0.001, P=0.001, and P=0.039, respectively). IAP was significantly correlated with RRRI, RDTR, and Lac (r=0.741, r=-0.774, and r=0.396, respectively; P<0.001). The prediction model based on regression analysis results was expressed as follows: predictive score = -17.274 + 31.125 × RRRI - 29.074 × RDTR + 0.621 × Lac. Meanwhile, the IAH nomogram prediction model was established with an area under the receiver operating characteristic (ROC) curve of 0.956 (95% confidence interval: 0.909-1.000). The nomogram showed good calibration for IAH with the Hosmer-Lemeshow test (P=0.864) and was found to be applicable within a wide threshold probability range, especially that higher than 0.40.

Conclusions

The noninvasive nomogram based on ultrasound and clinical data has good diagnostic efficiency and can predict the risk of IAH. This nomogram may provide valuable guidance for clinical interventions to reduce IAH morbidity and mortality in critically ill patients.

Intra-abdominal hypertension and abdominal compartment syndrome in acute pancreatitis

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are underrecognized entities in patients of acute pancreatitis (AP). IAH develops in 30% to 60% and ACS in 15% to 30% of all AP patients and they are markers of severe disease with high morbidity and mortality. The detrimental effect of increased IAP has been recognized in several organ systems, including the central nervous system, cardiovascular, respiratory, renal and gastrointestinal systems. The pathophysiology of IAH/ACS development in patients with AP is multifactorial. Pathogenetic mechanisms include over-zealous fluid management, visceral edema, ileus, peripancreatic fluid collections, ascites and retroperitoneal edema. Laboratory and imaging markers are neither sensitive nor specific enough to detect IAH/ACS and intra-abdominal pressure (IAP) monitoring is vital for early diagnosis and the management of patients of AP with IAH/ACS. The treatment of IAH/ACS requires a multi-modality approach with both medical and surgical attention. Medical management consists of nasogastric/rectal decompression, prokinetics, fluid management and diuretics or hemodialysis. If conservative management is not effective, percutaneous drainage of fluid collection or ascites is necessary. Despite medical management, if IAP worsens, surgical decompression is warranted. The review discusses the relevance of IAH/ACS in patients of AP and its management.

Intraabdominal hypertension and Abdominal Compartment Syndrome in patients with COVID-19: an integrative review

The first cases of COVID-19 were diagnosed in China, rapidly evolving with worldwide spread, turning into a pandemic. A percentage of these patients develop the severe form of the disease and progress to respiratory distress syndrome, requiring support in Intensive Care Units. Intra-abdominal Hypertension and Abdominal Compartment Syndrome are characterized by increased intra-abdominal pressure, and are subject to several predisposing factors, such as mechanical ventilation assistance, extracorporeal membrane oxygenation, elevated PEEP, intestinal obstructions, excessive fluid replacement, major burns and coagulopathies. Hence, for the management of patients with severe COVID-19, there are numerous risk factors for the development of intra-abdominal hypertension and abdominal compartment syndrome. Therefore, this study proposes to analyze the variables that directly interfere with the increase in intra-abdominal pressure in patients with COVID-19, as well as the changes in the organic systems caused, through an integrative literature review.

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.

Pneumoperitoneum and Acute Kidney Injury-An Integrative Clinical Concept Review

An increased intraabdominal pressure, particularly when occurring during periods of hemodynamic instability or fluid overload, is regarded as a major contributor to acute kidney injury (AKI) in intensive care units. During abdominal laparoscopic procedures, intraoperative insufflation pressures up to 15 mmHg are applied, to enable visualization and surgical manipulation but with the potential to compromise net renal perfusion. Despite the widely acknowledged renal arterial autoregulation, net arterial perfusion pressure is known to be narrow, and the effective renal medullary perfusion is disproportionately impacted by venous and lymphatic congestion. At present, the potential risk factors, mitigators and risk-stratification of AKI during surgical pneumoperitoneum formation received relatively limited attention among nephrologists and represent an opportunity to look beyond mere blood pressure and intake-output balances. Careful charting and reporting duration and extent of surgical pneumoperitoneum represents an opportunity for anesthesia teams to better communicate intraoperative factors affecting renal outcomes for the postoperative clinical teams. In this current article, the authors are integrating preclinical data and clinical experience to provide a better understanding to optimize renal perfusion during surgeries. Future studies should carefully consider intrabdominal insufflation pressure as a key variable when assessing outcomes and blood pressure goals in these settings.

Intra-abdominal hypertension among medical septic patients associated with worsening kidney outcomes (IAH-WK study)

High intra-abdominal pressure (IAP) is associated with acute kidney injury (AKI). However, the relationship between intra-abdominal hypertension (IAH) and AKI in medical septic patients is still inconclusive. This prospective cohort study enrolled patients admitted in the Medical Intensive Care Unit from April 2020 to February 2021. Demographic, therapeutic, and laboratory data were obtained upon admission. The evaluation of IAP was performed via the intra-vesical method during the first and second 24 hours of admission. Kidney function was evaluated on the first 3 days and at least on the 7th day of enrollment. Among 79 patients, 30 (38%) developed IAH, while 50 (63.3%) developed AKI within 7 days. On the first day, the mean IAP was 15.4 (interquartile range [IQR], 4) and 7.0 (IQR, 3.7) mm Hg in the IAH and non-IAH groups, respectively. A total of 52 patients (65.8%) developed the primary outcome (i.e., a composite outcome including AKI, treatment with kidney replacement therapy, or death). On Cox proportional-hazards model between IAH and outcomes, after adjustment for multiple covariates, IAH was associated with a composite outcome (hazard ratio [HR], 6.5; 95% confidence interval [CI], 2.3-18.6; P < .005) and the development of AKI (HR, 6.5; 95% CI, 2.3-18.8; P < .005). IAH was associated with a composite outcome of AKI, treatment with kidney replacement therapy, or death in medical septic patients. thaiclinicaltrial.org, Identifier: TCTR20200531001, Registered May 24, 2020.

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.

Intra-Abdominal Pressure Measurement Devices: A Technologic Analysis

PURPOSE

The purpose of this Technologic Analysis is to review devices designed to measure intra-abdominal pressure (IAP); these devices are used to detect intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).

APPROACH

Published literature focusing on devices designed to measure IAP was reviewed, comparing the options available and outlining recommendations for appropriate use. Safety information regarding IAP measurement devices was derived from the Manufacturer and User Facility Device Experience (MAUDE) database.

CONCLUSIONS

Intra-abdominal hypertension is prevalent among critically ill patients of all ages and is linked to adverse consequences, such as abdominal compartment syndrome. The condition is often unrecognized due to the lack of overt clinical symptoms, supporting the need for devices to accurately measure IAP. Commercially available devices measure IAP indirectly, typically via the bladder or stomach. Additional research is needed to demonstrate the benefits of routine screening, further define risk factors for IAH/ACS development, and evaluate the impact of measures to reduce IAP in an effort to improve patient outcomes.

Chryseobacterium Indologenes Sepsis and Acute Renal Failure Secondary to Abdominal Compartment Syndrome in a Confirmed COVID-19 Patient

Sepsis due to nosocomial pathogens markedly increases morbidity and mortality in the critically ill patient. The SARS-CoV-2 (COVID-19) pandemic has increased the number of patients requiring intensive care unit (ICU) in-patient management. Chryseobacterium indologenes (C. indologenes) is a group of multiresistant gram-negative bacteria associated with in-hospital environment and catheter-associated infections of increasing importance in the ICU. SARS-CoV-2 severe infection in the critically ill patient increases the risk of abdominal compartment syndrome (ACS) and acute kidney injury (AKI). We hereby report a case of a patient with SARS-CoV-2 severe infection, C. indologenes sepsis, abdominal compartment syndrome, and secondary renal failure.

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.

Abdominal Compartment Syndrome: A Life-Threatening Condition in Air Medical Transportation of Multiple Trauma Patients

A 41-year-old male farmer was injured in a land mine explosion. After initial resuscitation, the emergency physician coordinated with the hospital and air medical crew for the patient's evacuation. The evacuation was started by a Bell 214C helicopter, and the patient's clinical condition deteriorated during flight with increased abdominal pain and distension, tachycardia, tachypnea, hypotension, and loss of consciousness. Intra-abdominal (vesical) pressure of 23 mm Hg, findings of in-flight bedside ultrasound, and echocardiography indicated intra-abdominal hypertension with abdominal compartment syndrome. The emergency physician started medical management quickly based on the World Society of Abdominal Compartment Syndrome, but after 15 minutes the intra-abdominal pressure was still > 20 mm Hg. Despite the in-flight difficult condition, the risk of vascular or neural damages, and infection, the emergency physician performed a midline decompression laparotomy and, when the intra-abdominal pressure reached about 11 mm Hg, temporarily covered the wound with a Bogota bag. After the patient's intra-abdominal pressure stabilized, permanent abdominal wound repair was performed by the surgeon, and he was discharged from the hospital.

Awareness and management of intra-abdominal hypertension and abdominal compartment syndrome by paediatric intensive care physicians: a national survey

INTRODUCTION

This study aimed to evaluate the current awareness and management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) among paediatric intensivists.

MATERIAL AND METHODS

A web-based electronic survey was sent to all physicians working in paedia-tric intensive care units (PICUs) in Saudi Arabia. The survey questions obtained information regarding awareness of ACS and IAH, recognition criteria, monitoring of intra-abdominal pressure (IAP), and experience in managing ACS.

RESULTS

A total of 79 physicians responded to the survey (response rate: 53%). Among respondents 48% were consultants. 85% of respondents were familiar with IAP/IAH/ACS. Only 35% and 10% were aware of the Abdominal Compartment Society consensus definitions for IAH and ACS in the paediatric population, respectively. Most respondents considered the cut-off for IAH to be ≥ 15 mm Hg, and approximately two-thirds thought that the cut-off for ACS was higher than the currently suggested consensus definition (10 mm Hg). More than two-thirds of respondents monitored IAP in the PICU, and it was measured almost exclusively via the bladder (96%); the majority (70%) reported that they instilled volumes well above the current recommendations. Medical management was the most frequent therapeutic approach to treat IAH/ACS, while surgical decompression was the least attempted option. Decisions to decompress the abdomen were predominantly based on the presence of organ dysfunction (74.4%).

CONCLUSIONS

This survey showed that although most responding physicians claim to be familiar with IAH and ACS, their knowledge of published consensus definitions, measurement techniques, and clinical management must be updated.

Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting

In the second part of the Society of Cardiovascular Anesthesiologists Extracorporeal Membrane Oxygenation (ECMO) working group expert consensus statement, venoarterial (VA) and venovenous (VV) ECMO management and troubleshooting in the operating room are discussed. Expert consensus statements are provided about intraoperative monitoring, anesthetic drug dosing, and management of intraoperative problems in VA and VV ECMO patients.

[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.

Comparison of Intra-Abdominal Pressure Measurements in Critically Ill Patients Using Intravesical Normal Saline at 15°C, 25°C, and 35°C

Background

The incidence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in intensive care units is high. Dynamic monitoring of intra-abdominal pressure (IAP) is important to treat patients with these conditions. The World Society of Abdominal Compartment Syndrome revised IAP measurement and treatment guidelines in 2013. IAP is measured by instilling ≤25 mL of sterile saline into the bladder, but there is no requirement for the saline to be at a specific temperature. Many doctors presume that using cold saline will trigger bladder muscle spasms, resulting in measurement error. In the present study, we investigated the effect of body-temperature saline on IAP measurements.

Material/Methods

A single-center study was conducted in 12 patients with IAH over a 2-year period. IAP was measured via the bladder with instillation of sterile saline at temperatures of 35°C, 25°C, and 15°C. We analyzed the data using R software, version 4.1.0. Paired t tests were used for comparisons between groups. A Spearman rank correlation analysis was performed to compare groups. Analysis results were plotted using the R packages ggplot2, ggpubr, and BlandAltmanLeh. P<0.05 was considered statistically significant.

Results

There was a significant difference in IAP measurement between the 15°C and 35°C groups (t=−2.55, P=0.027). There was no significant difference between the 25°C and 35°C groups (t=0.73, P=0.48). Bland-Altman analysis showed that IAP was consistent in the 25°C and 35°C groups.

Conclusions

Although it is preferable to measure IAP with saline at body temperature (35°C), a temperature >25°C is associated with accurate results. Using saline at <15°C should be avoided.

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.

A New Device for Measuring Abdominal Wall Tension and Its Value in Screening Abdominal Infection

OBJECTIVE

This study is the largest clinical study of noninvasive Abdominal wall tension (AWT) measurement with a tensiometer to date. It also initially applies a polynomial regression equation to analyze the correlation between AWT measurement and intravesical pressure (IVP) measurement and remarkably finds interesting changes between different IVP intervals and AWT.

METHODS

Critically ill patients who were treated in the intensive care unit (ICU) of Daping Hospital, Army Medical University, from August 30, 2018, to June 30, 2020, and met the inclusion criteria were prospectively included in this study. The patients were divided into an intra-abdominal hypertension group and a non-intra-abdominal hypertension group and an abdominal infection group and no abdominal infection group. AWT and IVP were measured at 9 points on the abdominal wall on the first day after admission to the ICU. The correlations between AWTs and IVP were analyzed, and the role of AWT in the diagnosis of complications of abdominal infection and the prediction of adverse prognosis were analyzed.

RESULTS

A total of 127 patients were included. The average AWT and IVP were 2.77±0.38 N/mm and 12.31±7.01 mmHg, respectively, on the first day of admission. There was a positive correlation between AWT and IVP (correlation coefficient r = 0.706, p < 0.05). The polynomial regression model was AWT= -1.616×10-3 IVP2 +8.323×10-2 IVP+2.094. The cutoff value of the sensitivity and specificity of AWT for the diagnosis of abdominal infection was 2.57 N/mm. Furthermore, AWT = 2.57 N/mm had the best diagnostic efficiency, which was better than that of IAH and lactate.

CONCLUSION

There was a correlation between AWT and IVP. AWT measurement was helpful in the diagnosis of IAH and abdominal infection complications and can therefore serve as a new method for the clinical diagnosis of IVP and abdominal infection.

Phlegmonous gastritis complicated by abdominal compartment syndrome: a case report

BACKGROUND

Phlegmonous gastritis (PG) is a rare, suppurative bacterial infection of the gastric wall, which may rapidly evolve into fatal septicemia. The etiology and pathogenesis are poorly understood; however, multiple risk factors have been cited in current literature. Most cases have been diagnosed at autopsy, and occasionally at laparotomy, as the clinical presentation is often variable.

CASE PRESENTATION

We report a case of a 67-year-old male presenting with intractable nausea, vomiting, and epigastric pain following an uneventful upper gastrointestinal (GI) endoscopy. Diagnostic workup including contrast tomography (CT) and endoscopic assessment was in keeping with PG. This was subsequently followed by development of abdominal compartment syndrome (ACS) and clinical deterioration necessitating surgical resection of the stomach.

CONCLUSION

This case emphasizes the importance of early diagnosis of this potentially fatal infection that can follow endoscopic procedures and illustrates ACS and septic shock as serious complications. There is currently no consensus on the proper management of PG; however, in this case, a combination of surgery and antibiotics provided a favourable outcome. Limited number of cases of PG have been reported in literature, and to our knowledge, this is the first reported case of PG with subsequent ACS as an acute complication.

INTRAABDOMINAL HYPERTENSION SYNDROME: CURRENT STATE OF THE PROBLEM

Syndrome of intra-abdominal hypertension (SIAH) is a dangerous complication that can occur in patients with a surgical profile after surgery in the abdominal cavity. Only in the past 25 years has the SIAH been recognized. According to W. Ertel et al., In one third of patients with peritonitis, pancreatic necrosis, injuries of the abdominal cavity and after extensive surgery, there is an increase in intra-abdominal pressure (IAP), while SIAH develops in 5.5% of such patients. Mortality in SIAH is 42–68%. The reason for the development of so many deaths is the presence of diagnostic, preventive and therapeutic measures, as well as differences in the interpretation of terms. Today, much attention is paid to the study of SIAH, official attempts are being made to standardize and define terms and recommended methods of treatment, but this problem needs further study. The review presents data on the current state of the problem, current trends in the diagnosis, prevention and treatment of patients with IAP and SIAH, their use in practical research.