Hemodynamic effects of increased intra-abdominal pressure in critically ill children

Abstract Objective: To evaluate the influence of intra-abdominal pressure on the cardiac index (CI) at different intra-abdominal hypertension grades achieved when performing an abdominal compression maneuver (ACM). Evaluating the effectiveness of the ACM in distending the left internal jugular vein (LIJV). Methods: Prospective observational study conducted in the PICU of a quaternary care teaching hospital. Participants underwent the ACM and the IAP was measured with an indwelling urinary catheter. At each IAH grade reached during the ACM, the CI was measured by transthoracic echocardiography and the LIJV cross-sectional area (CSA) was determined by ultrasonography. Results: Twenty-four children were included (median age and weight of 3.5 months and 6.37 kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65 L/min/m2 (IQR 3.12−4.03), 3.38 L/min/m2 (IQR 3.04−3.73), 3.16 L/min/m2 (IQR 2.70−3.53), 2.89 L/min/m2 (IQR 2.38−3.22), and 2.42 L/min/m2 (IQR 1.91−2.79), respectively. A 25% increase in the LIJV CSA area was achieved in 14 participants (58%) during the ACM. Conclusion: The ACM significantly increases IAP, causing severe reversible impairment in the cardiovascular system and is effective in distending the LIJV in just over half of the subjects. Even low levels of HIA can result in significant cardiac dysfunction in children. Therefore, health professionals should be aware of the negative hemodynamic repercussions caused by the increased IAP.

Hipertensão intra-abdominal e síndrome compartimental abdominal: repercussões e tratamento clínico no paciente crítico / Intra-abdominal hypertension and abdominal compartment syndrome: repercussions and clinical treatment in critically ill patients

A hipertensão intra-abdominal e a síndrome compartimental abdominal foram durante muitas décadas mal compreendidas e dissociadas de suas repercussões clínicas. Trata-se de um distúrbio que pode levar à disfunção de múltiplos órgãos devido ao desequilíbrio circulatório desencadeado pelo aumento de pressão no compartimento abdominal. As manifestações envolvem os sistemas cardiovascular, respiratório, renal, nervoso e gastrintestinal e estão largamente relacionadas com o fator de morbimortalidade no paciente crítico. A despeito da importância clínica, a hipertensão intra-abdominal e à síndrome compartimental abdominal ainda são temas pouco dominados pelos médicos, e fazem-se necessários o reconhecimento precoce e o estabelecimento de estratégias clínicas objetivas no contexto de uma síndrome com desfecho tão desfavorável. Portanto, foi realizada uma revisão da literatura não sistematizada com objetivo de compreender os principais pontos sobre definições, prevalência, fatores de risco, fisiopatologia, diagnóstico e tratamento acerca da hipertensão intra-abdominal e a síndrome compartimental abdominal.

Intra-abdominal hypertension and abdominal compartment syndrome have been, for many decades, poorly understood and dissociated from their clinical repercussions. It is a disorder that can lead to organ dysfunction due to circulatory impairment triggered by increased pressure in the abdominal compartment. The manifestations involve cardiovascular, respiratory, renal, nervous, and gastrointestinal systems, and are widely associated with significant morbidity and mortality in critically ill patients. Despite their clinical importance, intra-abdominal hypertension and abdominal compartment syndrome are still not sufficiently known by physicians and, early recognition and the establishment of objective clinical strategies for managing these highly morbid syndromes are required. Therefore, a non-systematized review was carried out to understand the main points about definitions, prevalence, risk factors, pathophysiology, diagnosis, and treatment of intra-abdominal hypertension and abdominal compartment syndrome.

Caracterización del síndrome compartimental abdominal en pacientes críticos / Characterization of abdominal compartment syndrome in critical patients

RESUMEN Introducción: el síndrome compartimental abdominal es una entidad clínica sistémica desencadenada por incremento en la presión intraabdominal, caracterizada clínicamente por distensión abdominal y alteraciones de las funciones respiratoria, cardiovascular, neurológica y renal. Objetivo: caracterizar el comportamiento del síndrome compartimental abdominal en los pacientes críticos que ingresaron en la unidad de cuidados intensivos del Hospital Provincial "José Ramón López Tabrane". Materiales y método: se realizó un estudio prospectivo, descriptivo, y longitudinal que tuvo como universo los pacientes adultos con factores de riesgo conocidos para síndrome compartimental abdominal, tratados entre enero de 2014 a diciembre de 2015. Se le realizó medición sistemática de la presión intraabdominal transvesical y fueron sometidos a descompresión quirúrgica en caso de hipertensión intraabdominal grados III y IV. Resultados: los valores de presión intraabdominal sostenidamente elevados, son directamente proporcionales al desarrollo del síndrome compartimental abdominal y trae aparejado disfunciones en los diferentes sistemas de órganos; en estos casos apareció complicaciones, las cuales se presentaron combinadas para todos los pacientes, y fueron mayoritarias para el grupo con presión intraabdominal grado IV. La mortalidad se comportó en un número bastante elevado lo cual estuvo relacionado con los niveles de presión intraabdominal, así como la posibilidad de que fueran reintervenidos quirúrgicamente estos pacientes. Conclusiones: se debe protocolizar en todo paciente con sospecha de desarrollar un síndrome compartimental abdominal la medición periódica de la presión intraabdominal (AU).

SUMMARY Introduction: the abdominal compartment syndrome is a systemic clinical entity triggered by an increase of the intra abdominal pressure, clinically characterized by abdominal distension and the alteration of the renal, neurological, cardiovascular and respiratory functions. Objective: to characterize the behavior of the abdominal compartment syndrome in critical patients from the intensive care unit of the provincial hospital "Jose Ramon Lopez Tabrane". Materials and methods: a longitudinal, descriptive and prospective study was carried out in a universe of adult patients with risk factors known as abdominal compartment syndrome, treated in the period of time from January 2014 to December 2015. Their transvesical intraabdominal pressure was systematically measured and they underwent surgical decompression in cases of intraabdominal hypertension grades iii and iv. Results: the values of intraabdominal pressure steadily increased are directly proportional to the development of the abdominal compartment syndrome and entails dysfunctions in the different systems of organs; in these cases complications were found, that were combined for all patients and mainly in the group with intraabdominal pressure grade iv. Mortality was present in a certainly increased group, and was related to the levels of intraabdominal pressure, and also to the possibility these patients undergoing surgical treatments again. Conclusions: it should be standardized the periodical measure of the intraabdominal pressure in any patient suspected of developing an abdominal compartment syndrome (AU).

Síndrome compartimental abdominal / Abdominal compartment syndrome

Resumen El síndrome compartimental abdominal (SCA) se define como la disfunción orgánica causada por la hipertensión intraabdominal (HIA). Ambas son complicaciones frecuentes en pacientes graves ingresados en las unidades de cuidados intensivos (UCI). Las manifestaciones clínicas asociadas suelen ser inespecíficas, por lo que dichas entidades deben ser sospechadas ante pacientes críticos con factores de riesgo. El diagnóstico de la HIA se realiza midiendo de forma indirecta la presión intraabdominal (PIA), generalmente por medio de una sonda vesical. El tratamiento consiste en medidas de soporte, y en algunos casos es necesaria la descompresión abdominal quirúrgica. En esta revisión se presenta la fisiopatología de ambas entidades, así como el enfoque diagnóstico y terapéutico.

Abstract Abdominal compartment syndrome (ACS) is defined as an organ dysfunction caused by intra-abdominal hypertension (IAH). Both are common complications in severe patients admitted to intensive care units. The associated clinical manifestations are usually non-specific and, therefore, such entities should be suspected in critical patients with risk factors. The diagnosis of IAH is made by indirectly measuring intrabdominal pressure, usually by means of a urinary catheter. Treatment consists of supportive measures and, in some cases, surgical abdominal decompression. In this review the physiopathology of both entities is described, as well as the diagnostic and therapeutic approach.

Intracranial Hypertension and Intra-abdominal Pressure. Is it Worth Measuring?

Patients with refractory intracranial hypertension who have already undergone all the measures recommended by the current guidelines can benefit from having their intraabdominal pressure monitored since its increase generates hemodynamic repercussions and secondary elevation of intracranial pressure. In this context, a bibliographic research was performed on PubMed with the terms intra-abdominal pressure, abdominal compartment syndrome, intracranial pressure, intracranial hypertension. Altogether, 146 articles were observed, 87 of which were from the year 2000, and only 15 articles were considered relevant to the topic. These studies indicate that patients with refractory intracranial hypertension can benefit fromthe measurement of intraabdominal pressure, since there is evidence that an increase in this pressure leads to organic dysfunctions with an indirect impact on cerebral venous return and, consequently, an increase in intracranial pressure. In thosewho underwent decompression laparotomy, direct effectswere observed in reducing intracranial hypertension and survival.

Hipertensión intraabdominal y síndrome compartimental abdominal en el paciente grave / Intra-abdominal hypertension and abdominal compartment syndrome in the severe patient / Hipertensão intra-abdominal e síndrome do compartimento abdominal no paciente grave

RESUMEN Introducción: La hipertensión intraabdominal y el síndrome compartimental abdominal implican un grave pronóstico. Objetivo: Sistematizar contenidos esenciales relacionados con el diagnóstico y el tratamiento de estas emergencias médicas. Método: En la Facultad de Ciencias Médicas Guantánamo, entre enero y julio de 2019 se hizo una revisión narrativa sobre el tema a través de una búsqueda en bases de datos electrónicas (Biblioteca Virtual en Salud): LILACS, PubMed, SciELO, ClinicalKey, REDALYC, Scopus, Cochrane. Resultados: Se localizaron 125 documentos, y se eligieron 25 relevantes para el objetivo de la revisión. La información se estructuró en los siguientes aspectos: definición, fisiopatología, etiología, diagnóstico y tratamiento. Conclusiones: Se elaboró un referente teórico útil a estudiantes y médicos generales para prepararse sobre el tema. Se identificaron controversias sobre la efectividad del uso de fármacos sedantes, analgésicos, procinéticos, albúmina y diuréticos, la terapia de reemplazo renal y la descompresión gástrica y colónica para el tratamiento médico, el impacto de los tratamientos quirúrgicos en la supervivencia de pacientes y el efecto de la comorbilidad del paciente, la enfermedad causal, la ventana temporal diagnóstico-tratamiento en los resultados terapéuticos de estas emergencias médicas.

ABSTRACT Introduction: Intra-abdominal hypertension and abdominal compartment syndrome imply a serious prognosis. Objective: Systematize essential contents related to the diagnosis and treatment of these medical emergencies. Method: In the Faculty of Medical Sciences Guantanamo, between January and July 2019, a narrative review on the subject was made through a search in electronic databases (Virtual Health Library): LILACS, PubMed, SciELO, ClinicalKey, REDALYC, Scopus, Cochrane. Results: 125 documents were located, and 25 relevant for the purpose of the review were chosen. The information was structured in the following aspects: definition, pathophysiology, etiology, diagnosis and treatment. Conclusions: A useful theoretical reference to students and general practitioners was prepared to prepare on the subject. Controversies were identified about the effectiveness of the use of sedative, analgesic, prokinetic, albumin and diuretic drugs, renal replacement therapy and gastric and colonic decompression for medical treatment, the impact of surgical treatments on patient survival and the effect of the patient's comorbidity, the causative disease, the diagnostic-treatment time window in the therapeutic results of these medical emergencies.

RESUMO Introdução: Hipertensão intra-abdominal e síndrome do compartimento abdominal implicam um prognóstico sério. Objetivo: Sistematizar conteúdos essenciais relacionados ao diagnóstico e tratamento dessas emergências médicas. Método: Na Faculdade de Ciências Médicas de Guantánamo, entre janeiro e julho de 2019, foi realizada uma revisão narrativa sobre o assunto, através de uma busca em bases de dados eletrônicas (Biblioteca Virtual em Saúde): LILACS, PubMed, SciELO, ClinicalKey, REDALYC, Scopus, Cochrane. Resultados: Foram localizados 125 documentos e escolhidos 25 relevantes para a finalidade da revisão. As informações foram estruturadas nos seguintes aspectos: definição, fisiopatologia, etiologia, diagnóstico e tratamento. Conclusões: Foi preparado um referencial teórico útil para estudantes e médicos de clínica geral para se preparar sobre o assunto. Foram identificadas controvérsias sobre a eficácia do uso de medicamentos sedativos, analgésicos, procinéticos, albumina e diuréticos, terapia de reposição renal e descompressão gástrica e colônica para tratamento médico, o impacto dos tratamentos cirúrgicos na sobrevida dos pacientes e o efeito da comorbidade do paciente, da doença causadora, da janela do tempo de diagnóstico e tratamento nos resultados terapêuticos dessas emergências médicas.

Protocolos para diagnóstico e manejo da hipertensão intra-abdominal em centros de tratamento intensivo / Protocols for diagnosis and management of intra-abdominal hypertension in intensive care units

RESUMO Objetivo: A hipertensão intra-abdominal (HIA) é uma condição mórbida comum em pacientes críticos. A síndrome compartimental abdominal (SCA) é condição grave de tratamento cirúrgico que ocorre como evolução da HIA não diagnosticada e não tratada. O objetivo deste trabalho é disseminar evidências e propor protocolos de rastreio e condutas em casos de HIA e SCA para centros de terapia intensiva (CTI) Métodos: Foram realizadas buscas sobre o tema nas principais bases de dados e utilizadas as evidências e protocolos recomendadas pela World Society of the Abdominal Compartment Syndrome. Resultados: Apresentamos protocolos sobre investigação, aferição, manejo e controle da HIA, adequadas à realidade brasileira. Conclusão: Neste trabalho, apresentamos em detalhes os principais fatos e evidências sobre o manejo em casos de suspeita de HIA e como aferir a pressão intra-abdominal (PIA), de forma simples e reproduzível para qualquer CTI do nosso país.

ABSTRACT Objectives: Intra-abdominal hypertension (IAH) is a common morbid condition in critically ill patients. Abdominal compartment syndrome (ACS) is a severe condition that requires surgical treatment, and it is an evolution of undiagnosed and untreated IAH. This study aims to highlight the importance of clinical evidence, and proposes screening as well as medical protocols for IAH and ACS, in intensive care units. Methods: Database searches were performed and the recommended World Society of the Abdominal Compartment Syndrome standards and protocols were used. Results: Protocols for IAH and ACS investigation, measurements, management and control, tailored for the Brazilian ICU reality, were indicated. Conclusion: We extensively detailed IAH medical evidence, using the most up-to-date literature about IAH care and how to measure intra-abdominal pressure (IAP), which can be easily reproduced in any intensive care unit.

Síndrome compartimental abdominal en el paciente pediátrico: una revisión de la literatura / Abdominal compartment syndrome in the pediatric patient: a review of the literature

Resumen El presente artículo tiene como finalidad realizar una revisión bibliográfica acerca del síndrome compartimental abdominal en el paciente pediátrico, para actualizar a la población médica general respecto al tema en cuestión; debido a que no hay actualmente estudios de peso estadístico en cuanto a la patología; además, no hay estudios recientes a nivel nacional. El síndrome compartimental abdominal es una condición clínica seria, que presenta una mortalidad elevada sobre todo en la población pediátrica. El desconocimiento de la patología es el principal factor determinante en la mortalidad; ya que, es fundamental la sospecha médica oportuna para inicio de medidas terapéuticas evitando disfunción orgánica y muerte. Por lo tanto, en el siguiente trabajo, se desarrollarán los puntos fundamentales sobre su incidencia, presentación clínica, factores de riesgo, fisiopatología, abordaje diagnóstico y los distintos abordajes terapéuticos, tanto médicos como quirúrgicos; así como, complicaciones y pronósticos. Sin olvidar el punto clave que es conocer la técnica para la medición de la presión intraabdominal, lo que posibilita la detección precoz de complicaciones y consecuentemente, un accionar terapéutico oportuno.

Abstract The purpose of this article is to carry out a bibliographic review about abdominal compartment syndrome in the pediatric patient, to update the medical population about this topic, because currently there are no studies with enough statistical weight about this pathology. Furthermore, there aren´t recent studies at the national level. Abdominal compartment syndrome is a serious clinical condition that has an elevated mortality rate, especially in the pediatric population. The ignorance of the pathology it is the main determining factor in mortality because it is fundamentally the timely medical suspicion to start therapeutic measures avoiding organ dysfunction and death. Therefore, in the following work, the fundamental points will be developed about its incidence, clinical presentation, risk factors, pathophysiology, diagnosis, approach and the different therapeutic approaches medical and surgical as well as complications and prognosis. Without forgetting the key point which is knowing the technique for the measurement of intra abdominal pressure, which will allow the early detection of complications and consequently, a timely therapeutic action.

Cirugía de control de daños abdominopélvica. Experiencia en un hospital de 3er Nivel / Abdominopelvic damage control surgery

La cirugía de control de daños (CCD), surge con el afán de mejorar los pobres resultados obtenidos con el abordaje quirúrgico tradicional en traumatismos abdominales graves y exanguinantes en pacientes críticos con escasa reserva fisiológica. Se define con una "cirugía por etapas", con un primer tiempo quirúrgico corto para controlar el sangrado y la contaminación con cierre temporario abdominal, seguido de un período de reanimación en unidad de cuidados intensivos y, finalmente, de reparación definitiva de las lesiones. Se revisaron las histrias clínicas de 41 pacientes sometidos a éste tipo de cirugía en el período comprendido entre marzo de 2011 y octubre de 2017 en el Hospital Municipal de Urgencias de la ciudad de Córdoba, 29 hombres y 12 mujeres, en cuanto al mecanismo lesional 23 casos fueron por trauma cerrado y 18 penetrantes. La edad promedio fue de 30 años, 28 pacientes presentaron lesiones asociadas, siendo las más frecuentes las torácicas en 14 pacientes y la mortalidad global de la serie del 41% (17 pacientes). El grupo etario involucrado, la distribución por sexo, y la mortalidad de nuestra serie no difiere de la bibliografía consultada

Damaage control surgery (CCD) arises with the aim of imporving the poor results obtained with the traditional surgical approach in severe and exanguinating abdominal trauma in critically ill patients with scarce physiological reserve. It is defined as a "step surgery", with a short surgical first time to control bleeding and contamination with temporary abdominal closure, followed by a period of resuscitation in the intensive care unit and, finally, definitive repair of the injuries. We revierwed the medical rcords of 41 patients undergoing this type of surgery in the period between arch 2011 and October 2017 at the Municipal Emergenci Hospital of the city of Córdoba, 29 men and 12 women, regarding the mechanism of injury 23 cases were due to closed trauma and 18 penetrating. The average age was 30 years, 28 patients had associated injuries, the most frequent being thoracic in 14 patients and the overall mortality of the series of 41% (17 patients). The age group involved, the distributin by sex, and the mortality of our series does not differ from the bibliography consulted

The duration of intra-abdominal hypertension and increased serum lactate level are important prognostic markers in critically ill surgical patient's outcome: a prospective, observational study

The present study analyzed the clinical significance of duration of intra-abdominal hypertension (IAH) associated with increased serum lactate in critically ill patients with severe sepsis. Materials and Methods: Our study was an observational, prospective study carried out in the Surgical Intensive Care Unit (ICU) at J.L.N Medical College, Ajmer, Rajasthan, India. In our study, we included a total of 100 patients and intra-abdominal pressure (IAP) was measured through intravesical route at the time of admission and after 6, 12, 24, 48, and 72 h via a urinary catheter filled with 25 ml of saline. Duration of ICU and hospital stay, need for ventilator support, initiation of enteral feeding, serum lactate level at time of admission and after 48 h, and 30-day mortality were noted asoutcomes.Results:In our study, an overall incidence of IAH was 60%. Patients with cardiovascular surgery and renal and pulmonary dysfunction were 93.3%, 55%, and 60%, respectively, at the time of admission and 65%, 10%, and 10%, respectively, after 72 h of admission in the surgical ICU. Nonsurvivors had statistically significant higher IAP and serum lactate levels than survivors. Patients with longer duration of IAH had longer ICU and hospital stay, longer duration of vasopressors and ventilator support, and delayed enteral feeding.Conclusion:There is a strong relationship "risk accumulation" between duration of IAH associated with increased serum lactate and organdysfunction. The duration of IAH was an independent predictor of 30-day mortality. Early recognition and prompt intervention for IAH and severe sepsis are essential to improve the patient outcomes

Successful case of veno-venous extracorporeal membrane oxygenation in an abdominal trauma patient: A case report

A 37-year-old male visited the hospital with multiple trauma after traffic accident. Fractures of ribs, left femur, and right humerus and spleen rupture with hemoperitoneum were founded on image studies. He was moved to operation room and general anesthesia was performed for splenectomy. During the operation, excessive high peak inspiratory pressure was observed. After abdominal closure, hypoxia, hypercapnia, and respiratory acidosis were worsened. Veno-venous extracorporeal membrane oxygenation (ECMO) was initiated after the operation. Status of the patient were improved after the application of ECMO. The patient was discharged without significant complication. Despite of several limitations in applying ECMO to patients with abdominal compartment syndrome (ACS) and multiple trauma, severe pulmonary dysfunction in ACS patients may be rescued without open abdomen treatment.

Early experiences of endovascular aneurysm repair for ruptured abdominal aortic aneurysms

PURPOSE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea. METHODS: We retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed. RESULTS: We identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS. CONCLUSION: Despite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Management of an Open Abdomen Considering Trauma and Abdominal Sepsis: A Single-Center Experience

PURPOSE: To describe the experience of patients over a 7-year period who have had open abdomen (OA) surgery, at a tertiary university hospital.METHODS: The medical records of 59 patients, who were managed with OA after a laparotomy between March 2009 and December 2015, were reviewed retrospectively. The data collected included demographics, indication for OA, abdominal closure methods, abdominal closure rate, the intensive care unit stay duration, mechanical ventilation duration, hospital stay duration, and complications.RESULTS: Forty-seven patients (37 males, 78.7%) with a mean age of 52.2 ± 16.7 years were reviewed in the study. The indications for OA were traumatic intra-abdominal bleeding in 23 patients (48.9%), non-traumatic bowel perforation in 10 (21.3%), non-traumatic bleeding in 7 (14.9%), and bowel infarction in 6 (12.8%). The abdominal wall was closed in 38 patients (80.9%). Primary closures and fascial closure using an artificial mesh were performed on 21 (44.7%) and 12 patients (25.5%), respectively. The median number of dressing changes was 0 (interquartile range 0 – 1). The median duration of the intensive care unit and hospital stays were 12.0 and 32.0 days, respectively. The median interval to abdominal closure was 4 days (interquartile range 2 – 10.3 days). Twenty-seven patients developed complications, including uncontrolled sepsis (21.3%), entero-atmospheric fistula (19.1%), ventral hernia (8.5%), bleeding (4.3%), and lateralization (4.3%). The mortality rate was 44.7% with sepsis being the main cause of death (61.9%).CONCLUSION: Traumatic intra-abdominal bleeding was a common indication for OA. Primary closure was performed in most patients, and frequent complications resulted in poor patient outcomes.

Síndrome compartimental abdominal: uma entidade ainda desconhecida pelos médicos? / Abdominal compartment syndrome: an entity still unknown by doctors?

RESUMO Objetivo: avaliar o conhecimento dos médicos com relação à síndrome compartimental abdominal e identificar fatores que possam dificultar aferição rotineira da pressão intra-abdominal nos pacientes que necessitam dessa monitorização. Métodos: estudo descritivo, observacional, transversal, avaliando o conhecimento dos médicos envolvidos no atendimento de pacientes críticos. Utilizamos um questionário composto por 16 perguntas abordando conceitos básicos relacionados à síndrome compartimental. Resultados: 97 médicos participaram deste estudo, sendo 56 (57,7%) residentes e 41 (42,2%) assistentes. A minoria dos avaliados demonstrou conhecimento teórico adequado a respeito da definição de hipertensão intra-abdominal e de síndrome compartimental abdominal, do diagnóstico dessas condições, do volume a ser infundido no balão intravesical para aferição, e dos fatores de risco associados à hipertensão intra-abdominal. Comparando-se as respostas entre residentes e assistentes, apenas as respostas sobre a classificação de hipertensão intra-abdominal (57,1% vs. 34,1%, p=0,02) e sobre o grau de hipertensão intra-abdominal relacionado ao início da síndrome compartimental (60,7% vs. 36,5%, p = 0,01) foram diferentes. A maioria os participantes considera importante a criação de um protocolo institucional sobre o tema. Conclusão: a maioria dos médicos estudados demonstrou não ter conhecimento básico a respeito da hipertensão intra-abdominal. Medidas educativas e de atualização são necessárias a fim de incrementar o conhecimento dos médicos que assistem pacientes críticos. Palavras-chave: Hipertensão intra-abdominal. Síndrome compartimental abdominal. Conhecimentos, atitudes e prática em saúde

Presión intraabdominal y ventilación artificial mecánica. Hospital "Arnaldo Milián Castro". 2014-2015 / Intra-abdominal pressure and mechanical artificial ventilation. Arnaldo Milián Castro Hospital. 2014-2015

Introducción: La cavidad abdominal y la caja torácica se encuentran separadas por el diafragma, por lo que las variaciones en las presiones dentro de una, repercuten sobre las presiones de la otra. La hipertensión intraabdominal es hoy una entidad frecuente en el paciente crítico en el que constituye un factor de riesgo importante de complicaciones y mortalidad, ya que influye sobre órganos y sistemas. Objetivo: Relacionar la presión intraabdominal con presiones de la ventilación artificial mecánica y parámetros de la función respiratoria, cardiovascular y renal. Material y Métodos: Se realizó un estudio descriptivo y prospectivo de la presión intraabdominal en pacientes sometidos a ventilación mecánica, con enfermedades clínicas y quirúrgicas, en las Unidades de Cuidados Intensivos del Hospital Clínico Quirúrgico Arnaldo Milán Castro, durante el período comprendido entre enero 2014 hasta diciembre 2015. Resultados: Los pacientes clínicos con presiones de la vía aérea elevadas mostraron valores más altos de presión intraabdominal, y aquellos pacientes postquirúrgicos que cursaron con niveles altos de presión dentro del abdomen también presentaron los valores más elevados de presión pico y media registradas en el ventilador mecánico. Conclusiones: La tensión arterial media, el ritmo diurético y la saturación periférica de oxígeno disminuyeron, mientras que la presión venosa central, la presión parcial de dióxido de carbono en sangre y la creatinina aumentó ante los aumentos de la presión dentro del abdomen(AU)

Introduction: The abdominal cavity and the thoracic cage are separated by the diaphragm; therefore, the variations in the pressures within one of them have an effect on the pressures of the other. At present, intra-abdominal hypertension is a frequent entity in the critically ill patient, which constitutes an important risk factor for complications and mortality since it influences on different organs and systems. Objective: To relate intra-abdominal pressure with mechanical artificial ventilation pressures and parameters of respiratory, cardiovascular and renal function. Material and Methods: A descriptive prospective study of intra-abdominal pressure was conducted in patients undergoing mechanical ventilation with clinical and surgical diseases in the Intensive Care Units of the Arnaldo Milán Castro Hospital, during the period between January 2014 until December 2015. Results: Clinical patients with high values of airway pressures showed higher values of intra-abdominal pressure, and those post-surgical patients who presented with high levels of pressure inside the abdomen indicated the highest values of peak and average pressure recorded in the mechanical ventilator. Conclusions: Mean arterial pressure, diuretic rate and peripheral oxygen saturation decreased, whereas the central venous pressure, the partial pressure of carbon dioxide in blood, and creatinine increased due to raises in pressure within the abdomen(AU)

Injúria renal aguda e hipertensão intra-abdominal em paciente queimado em terapia intensiva / Acute kidney injury and intra-abdominal hypertension in burn patients in intensive care

RESUMO Objetivo: Avaliar a frequência de hipertensão intra-abdominal no paciente grande queimado e sua associação com a ocorrência de injúria renal aguda. Métodos: Estudo de coorte prospectivo, com população de pacientes queimados internados nos leitos de unidade de terapia intensiva especializada. Realizada amostragem de conveniência de pacientes adultos internados no período de 1º de agosto de 2015 a 31 de outubro de 2016. Foram coletados dados clínicos e da queimadura, além de medidas seriadas da pressão intra-abdominal. O nível de significância utilizado foi de 5%. Resultados: Foram analisados 46 pacientes. Evoluíram com hipertensão intra-abdominal 38 pacientes (82,6%). A mediana da maior pressão intra-abdominal foi 15,0mmHg (intervalo interquartílico: 12,0 - 19,0). Desenvolveram injúria renal aguda 32 (69,9%) pacientes. A mediana do tempo para desenvolvimento de injúria renal aguda foi de 3 dias (intervalo interquartílico: 1 - 7). A análise individual de fatores de risco para injúria renal aguda apontou associação com hipertensão intra-abdominal (p = 0,041), uso de glicopeptídeos (p = 0,001), uso de vasopressor (p = 0,001) e uso de ventilação mecânica (p = 0,006). Foi evidenciada associação de injúria renal aguda com maior mortalidade em 30 dias (log-rank, p = 0,009). Conclusão: Ocorreu hipertensão intra-abdominal em grande parte dos pacientes estudados, predominantemente nos graus I e II. Os fatores de risco identificados para ocorrência de injúria renal aguda foram hipertensão intra-abdominal, uso de glicopeptídeos, vasopressor e ventilação mecânica. Injúria renal aguda esteve associada à maior mortalidade em 30 dias.

ABSTRACT Objective: To evaluate the frequency of intra-abdominal hypertension in major burn patients and its association with the occurrence of acute kidney injury. Methods: This was a prospective cohort study of a population of burn patients hospitalized in a specialized intensive care unit. A convenience sample was taken of adult patients hospitalized in the period from 1 August 2015 to 31 October 2016. Clinical and burn data were collected, and serial intra-abdominal pressure measurements taken. The significance level used was 5%. Results: A total of 46 patients were analyzed. Of these, 38 patients developed intra-abdominal hypertension (82.6%). The median increase in intra-abdominal pressure was 15.0mmHg (interquartile range: 12.0 to 19.0). Thirty-two patients (69.9%) developed acute kidney injury. The median time to development of acute kidney injury was 3 days (interquartile range: 1 - 7). The individual analysis of risk factors for acute kidney injury indicated an association with intra-abdominal hypertension (p = 0.041), use of glycopeptides (p = 0.001), use of vasopressors (p = 0.001) and use of mechanical ventilation (p = 0.006). Acute kidney injury was demonstrated to have an association with increased 30-day mortality (log-rank, p = 0.009). Conclusion: Intra-abdominal hypertension occurred in most patients, predominantly in grades I and II. The identified risk factors for the occurrence of acute kidney injury were intra-abdominal hypertension and use of glycopeptides, vasopressors and mechanical ventilation. Acute kidney injury was associated with increased 30-day mortality.

Síndrome compartimental abdominal: análise do conhecimento da equipe médica de um Hospital Universitário de Curitiba / Abdominal compartment syndrome: knowledge of the medical staff of a University Hospital in Curitiba

RESUMO Objetivo: identificar o conhecimento dos médicos com relação à hipertensão intra-abdominal e síndrome compartimental abdominal e compará-lo com a conduta estabelecida na literatura. Métodos: estudo quantitativo descritivo, observacional, transversal. Foram entrevistados 38 médicos por meio de um questionário auto-aplicado composto por perguntas objetivas. O estudo foi realizado em um hospital universitário, de referência terciária, localizado em Curitiba, Paraná. Resultados: a média de idade dos participantes foi de 28 anos, 60,5% era do sexo feminino e o tempo médio de experiência médica foi de 3,5 anos. Em relação ao conhecimento sobre o tema, 57,9% considerou que a síndrome compartimental abdominal se inicia com a hipertensão intra-abdominal grau III, 50% considerou a pressão de perfusão abdominal o método mais fidedigno para determinar hipertensão intra-abdominal, 89,4% considerou a técnica de aferição intravesical como a mais utilizada, 71,1% considerou a oligúria o sinal precoce de síndrome compartimental abdominal. Não mensurou a pressão intra-abdominal 81,6% dos entrevistados, por não haver protocolo definido pelo serviço. Setenta e nove por cento dos entrevistados afirmou não conhecer as definições do consenso do World Society of the Abdominal Compartment Syndrome (WSACS). Conclusão: metade dos médicos foi capaz de classificar hipertensão intra-abdominal e indicar o início de um quadro de síndrome compartimental abdominal corretamente.

ABSTRACT Objective: to assess the physicians' knowledge regarding intra-abdominal hypertension and abdominal compartment syndrome and to compare it with the established literature. Methods: we conducted a descriptive, observational, cross-sectional, quantitative study. We interviewed 38 physicians through a self-administered questionnaire composed of objective questions. We carried out the study in a tertiary reference university hospital, located in Curitiba, Paraná. Results: the mean age of the participants was 28 years, 60.5% were female and the mean time of medical experience was 3.5 years. Regarding the knowledge on the subject, 57.9% considered that abdominal compartment syndrome starts with intra-abdominal grade III hypertension, 50% considered abdominal perfusion pressure the most reliable method to determine intra-abdominal hypertension, 89.4% considered the intravesical measuring technique as the most used, 71.1% considered oliguria to be the early sign of abdominal compartment syndrome. Of the interviewees, 81.6% did not measure intra-abdominal pressure because there was no protocol defined by the service. Seventy-nine percent of respondents said they did not know the definitions of the consensus of the World Society of the Abdominal Compartment Syndrome (WSACS). Conclusion: half of the physicians were able to classify intra-abdominal hypertension and indicate the onset of abdominal compartment syndrome correctly.

Repeated gastric dilatations leading to fatal abdominal compartment syndrome in a patient with bulimia nervosa

Cases of repeated acute gastric dilatations after binge eating in one patient are rarely reported. We report here a case of repeated acute gastric dilatations in a 22-year-old woman with bulimia nervosa. Her repeated acute gastric dilatations seem to have been related to superior mesenteric artery syndrome. On her last visit due to acute gastric dilatation, she underwent emergency gastric decompression surgery because of abdominal compartment syndrome; however, she eventually died because of ischemia reperfusion injury. Emergency physicians should be aware of the need to manage acute gastric dilatation in patients with eating disorder and should pay attention to the signs and distinctive clinical features of abdominal compartment syndrome.