[Emergency expert consensus on diagnosis and treatment of intra-abdominal hypertension and abdominal compartment syndrome in adults in China (2024)].

Patients with emergent conditions are prone to develop intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), which are closely associated with adverse outcomes. Currently, there is a lack of guiding documents for the management of IAH/ACS in the emergency departments in China. Based on a systematic review of recent researches and clinical experiences in emergency departments, the Emergency Medicine Branch if Chinese Medical Association and other professional organizations have jointly formulated the Emergency expert consensus on diagnosis and treatment of intra-abdominal hypertension and abdominal compartment syndrome in adults in China (2024) to enhance the diagnostic and therapeutic capabilities of emergency physicians regarding adult IAH/ACS. The consensus particularly emphasizes the importance of early identification, continuous monitoring, and timely treatment of IAH/ACS in the emergency settings. The consensus recommends routine intra-abdominal pressure (IAP) measurement for emergency patients with risk factors for IAH/ACS and suggests adjusting the monitoring frequency based on IAP levels. In terms of treatment, the consensus highlights a comprehensive approach that includes both non-surgical and surgical interventions, with additional recommendations for traditional Chinese medicine (TCM) treatments. The consensus also stresses the importance of fluid resuscitation, organ support, and preventive measures, proposing nutritional therapy and preventive strategies. The consensus provides more precise and practical guidance for the clinical diagnosis and treatment of emergency patients with IAH/ACS, which is conducive to improving clinical outcomes.

Increasing Use of Prophylactic Open Abdomen Therapy With Vacuum Assisted Wound Closure and Mesh Mediated Fascial Traction After Repair of Ruptured Abdominal Aortic Aneurysm.

OBJECTIVE: Open abdomen therapy (OAT) is commonly used to prevent or treat abdominal compartment syndrome (ACS) in patients with ruptured abdominal aortic aneurysms (rAAAs). This study aimed to evaluate the incidence, treatment, and outcomes of OAT after rAAA from 2006 to 2021. Investigating data on resuscitation fluid, weight gain, and cumulative fluid balance could provide a more systematic approach to determining the timing of safe abdominal closure. METHODS: This was a single centre observational cohort study. The study included all patients treated for rAAA followed by OAT from October 2006 to December 2021. RESULTS: Seventy-two of the 244 patients who underwent surgery for rAAA received OAT. The mean age was 72 ± 7.85 years, and most were male (n = 61, 85%). The most frequent comorbidities were cardiac disease (n = 31, 43%) and hypertension (n = 31, 43%). Fifty-two patients (72%) received prophylactic OAT, and 20 received OAT for ACS (28%). There was a 25% mortality rate in the prophylactic OAT group compared with the 50% mortality in those who received OAT for ACS (p = .042). The 58 (81%) patients who survived until closure had a median of 12 (interquartile range [IQR] 9, 16.5) days of OAT and 5 (IQR 4, 7) dressing changes. There was one case of colocutaneous fistula and two cases of graft infection. All 58 patients underwent successful abdominal closure, with 55 (95%) undergoing delayed primary closure. In hospital survival was 85%. Treatment trends over time showed the increased use of prophylactic OAT (p ≤ .001) and fewer ACS cases (p = .03) assessed by Fisher's exact test. In multivariable regression analysis fluid overload and weight reduction predicted 26% of variability in time to closure. CONCLUSION: Prophylactic OAT after rAAA can be performed safely, with a high rate of delayed primary closure even after long term treatment.

Abdominal Compartment Syndrome Secondary to Bulimia Nervosa: A Case Report and Systematic Review of Published Cases.

BACKGROUND: Abdominal compartment syndrome (ACS) is typically attributed to critically unwell patients with trauma, burns, post surgery, and massive ascites. A rare but fatal cause of ACS is bulimia nervosa (BN), which is an eating disorder characterized by bingeing, followed by methods to avoid weight gain, including purging. CASE REPORT: We present a case of a 20-year-old woman who presented with abdominal pain and distension after consuming a large quantity of food the previous night and was unable to purge. She was initially managed conservatively and discharged home, but returned subsequently on the same day with clinical features of ACS secondary to acute gastric distension. Decompression resulted in life-threatening reperfusion injury with critical electrolyte abnormalities and fatal cardiac arrest in the operating theatre. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A systematic review of the literature found only 11 case reports of ACS secondary to BN, of which only 6 patients survived due to early diagnosis and decompression. Inability to purge and lower limb ischemia appeared to be associated with increased mortality. As BN is a common emergency presentation, the case and systematic review highlights the need to consider ACS as a potentially life-threatening complication of binge eating, particularly when there is unsuccessful purging.

The development, feasibility and credibility of intra-abdominal pressure measurement techniques: A scoping review.

AIM: To provide a comprehensive overview on emerging direct and alternative methods for intra-abdominal pressure (IAP) measurement techniques. METHODS: This was a scoping review study following Arksey and Malley's framework. The PubMed, EMBASE, Web of Science, EBSCO, Scopus and ProQuest databases were searched, and we only considered studies published from 2000 as we have extended the data from two previous reviews. Original studies that reported on the development, feasibility and credibility of IAP measurement techniques were included. RESULTS: Forty-two of 9954 screened articles were included. IAP measurement techniques include three major categories: direct, indirect and less invasive measurement techniques. Agreement analyses were performed in most studies, and some explored the safety, time expenditure and reproducibility of IAP measurement techniques. CONCLUSIONS: Clinical data assessing the validation of new IAP measurement techniques or the reliability of established measurement techniques remain lacking. Considering the cost and invasiveness, direct measurement is not recommended as a routine method for IAP measurement and should be preserved for critically ill patients where standard techniques are contraindicated or could be inaccurate. The measurement accuracy, reliability and sensitivity of the transrectal and transfemoral vein methods remain insufficient and cannot be recommended as surrogate IAP measures. Transvesical measurement is the most widely used method, which is the potentially most easy applicable technique and can be used as a reliable method for continuous and intermittent IAP measurement. Wireless transvaginal method facilitates the quantitative IAP measurement during exercise and activity, which laying the foundations for monitoring IAP outside of the clinic environment, but the accuracy of this technique in measuring absolute IAP cannot be determined at present. Less invasive technology will become a new trend to measure IAP and has substantial potential to replace traditional IAP measurement technologies, but further validation and standardization are still needed. Medical professionals should choose appropriate measurement tools based on the advantages and disadvantages of each IAP technique in combination with assessing specific clinical situations.

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.

Prevalence of increased intra-abdominal pressure and its impact on renal function in acute decompensated heart failure: A prospective pilot study.

BACKGROUND: Intra-abdominal pressure (IAP) is a frequently overlooked aspect in clinical assessment that can have a significant impact on organ dysfunction in patients with acute decompensated heart failure (ADHF). AIMS: We aimed to investigate dynamics of IAP in patients with ADHF and its impact on diuretic response. METHODS: We conducted a prospective observational pilot study on a group consisting of 30 patients admitted for ADHF. In every individual IAP measurement, blood and urine samples were taken upon admission, on the second and third days of hospitalization. RESULTS: The study showed a high (63.3%) prevalence of intra-abdominal hypertension (IAH) defined as IAP ≥12 mm Hg upon admission, while only roughly 13% had signs of ascites. We observed poorer diuresis on the first day of hospitalization in the IAH group (P = 0.03). IAP was negatively correlated with urine output (P = 0.01) and positively correlated with urine osmolality (P = 0.03) on the first day of hospitalization. During follow-up, there was a significant decrease in IAP in patients with IAH upon admission who received standard decongestive therapy. CONCLUSIONS: The study shows a high prevalence of IAH in patients admitted for ADHF, even in individuals who do not present symptoms of abdominal congestion. Established correlation between IAP, reduced diuresis, and increased urine osmolality, despite achieving target natriuresis, contributes novel insights into the understanding of pathomechanisms underlying diuretic resistance in ADHF.

A Custom-Tailored Multichannel Pressure Monitoring System Designed for Experimental Surgical Model of Abdominal Compartment Syndrome.

In experimental medicine, a wide variety of sensory measurements are used. One of these is real-time precision pressure measurement. For comparative studies of the complex pathophysiology and surgical management of abdominal compartment syndrome, a multichannel pressure measurement system is essential. An important aspect is that this multichannel pressure measurement system should be able to monitor the pressure conditions in different tissue layers, and compartments, under different settings. We created a 12-channel positive-negative sensor system for simultaneous detection of pressure conditions in the abdominal cavity, the intestines, and the circulatory system. The same pressure sensor was used with different measurement ranges. In this paper, we describe the device and major experiences, advantages, and disadvantages. The sensory systems are capable of real-time, variable frequency sampling and data collection. It is also important to note that the pressure measurement system should be able to measure pressure with high sensitivity, independently of the filling medium (gas, liquid). The multichannel pressure measurement system we developed was well suited for abdominal compartment syndrome experiments and provided data for optimizing the method of negative pressure wound management. The system is also suitable for direct blood pressure measurement, making it appropriate for use in additional experimental surgical models.

Effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure in severe burn patients: A prospective randomized clinical trial.

INTRODUCTION: Massive burn patients are at risk of developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as a complication of resuscitation. OBJECTIVE: This study aimed to evaluate the effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure (IAP) in massive burn patients. METHODS: This was a prospective randomized clinical trial carried on at Ain Shams University (ASU) burn unit for 2 years. Where adult patients with burns more than 20% of TBSA were equally randomized into HES group or albumin group. RESULTS: Fifty-two patients were equally randomized into 2 groups. We found no difference in age, sex, weight, type of burn, and TBSA between the two groups. The mean total resuscitation fluid volume in the first 48 h was 213 ml/kg and 206.2 ml/kg for the HES group and the albumin group respectively (p = 0.674). IAP statistically was non-significantly higher in the HES group. We found no statistical difference between the two groups as regards the renal function tests. CONCLUSION: Both HES and 5% albumin solution are effective and safe colloids for burn resuscitation. As regards the IAP, it seems that both 5% albumin and HES have comparable effect regarding IAH in severely burn patients. Both HES and 5% albumin were partially equal in terms of renal involvement and vital data stability.

Using a Fluid Resuscitation Algorithm to Reduce the Incidence of Abdominal Compartment Syndrome in the Burn Intensive Care Unit.

BACKGROUND: Patients with large burns must be carefully resuscitated to balance adequate tissue perfusion with the risk of end-organ damage. One devastating complication of overresuscitation is abdominal compartment syndrome. Reducing the volume of fluids given during resuscitation may reduce the incidence of abdominal compartment syndrome and improve outcomes. OBJECTIVE: To determine whether decreasing fluid resuscitation volume in a burn center reduced the incidence of abdominal compartment syndrome. METHODS: This retrospective cohort study involved all patients with severe burns (total body surface area ≥20%) who were admitted to a burn intensive care unit over 4 years (n = 166). Primary outcomes were required fluid volume, whether differences in the patient characteristics measured affected outcomes, rate of abdominal compartment syndrome, and incidence of abdominal hypertension. After the first 2 years, the Parkland fluid resuscitation algorithm was modified to decrease the volume goal, and patients were assessed for the incidence of abdominal compartment syndrome and related complications such as kidney failure, abdominal hypertension, and ventilator days. RESULTS: A total of 16% of patients resuscitated using the Parkland equation experienced abdominal compartment syndrome compared with 10% of patients resuscitated using the modified algorithm, a difference of 6 percentage points (P = .39). Average volume administered was 11.8 L using the Parkland formula and 9.4 L using the modified algorithm (P = .03). CONCLUSION: Despite a significant decrease in the amount of fluid administered, no significant difference was found in incidence of abdominal compartment syndrome or urine output. Matched prospective studies are needed to improve resuscitation care for patients with large burns.

Evaluation of the TraumaGuard Balloon-in-Balloon Catheter Design for Intra-Abdominal Pressure Monitoring: Insights from Pig and Human Cadaver Studies.

Introduction: Intra-abdominal pressure (IAP) monitoring is crucial for the detection and prevention of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). In the 1970s, air-filled catheters (AFCs) for urodynamic studies were introduced as a solution to overcome the limitations of water-perfused catheters. Recent studies have shown that for correct IAP measurement with traditional AFC, the bladder needs to be primed with 25 mL of saline solution to allow pressure wave transmission to the transducer outside of the body, which limits continuous IAP monitoring. Methods: In this study, a novel triple balloon, air-filled TraumaGuard (TG) catheter system from Sentinel Medical Technologies (Jacksonville, FL, USA) with a unique balloon-in-balloon design was evaluated in a porcine and cadaver model of IAH via laparoscopy (IAPgold). Results: In total, 27 and 86 paired IAP measurements were performed in two pigs and one human cadaver, respectively. The mean IAPTG was 20.7 ± 10.7 mmHg compared to IAPgold of 20.3 ± 10.3 mmHg in the porcine study. In the cadaver investigation, the mean IAPTG was 15.6 ± 10.8 mmHg compared to IAPgold of 14.4 ± 10.4 mmHg. The correlation, concordance, bias, precision, limits of agreement, and percentage error were all in accordance with the WSACS (Abdominal Compartment Society) recommendations and guidelines for research. Conclusions: These findings support the use of the TG catheter for continuous IAP monitoring, providing early detection of elevated IAP, thus enabling the potential for prevention of IAH and ACS. Confirmation studies with the TraumaGuard system in critically ill patients are warranted to further validate these findings.

The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review.

BACKGROUND: The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS: A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS: The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION: Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

The association between maternal intra-abdominal pressure and hypertension in pregnancy.

INTRODUCTION: Pregnancy leads to a state of chronically increased intra-abdominal pressure (IAP) caused by a growing fetus, fluid, and tissue. Increased intra-abdominal pressure is leading to state of Intra-Abdominal Hypertension (IAH) and Abdominal Compartment Syndrome. Clinical features and risk factors of preeclampsia is comparable to abdominal compartment syndrome. IAP may be associated with the hypertension in pregnancy (HIP). OBJECTIVES: The study aimed to determine the antepartum and postpartum IAP levels in women undergoing caesarean delivery (CD) and association between hypertension in pregnancy, and antepartum and postpartum IAP levels in women undergoing CD. METHOD: Seventy pregnant women (55 normotensive, 15 HIP) undergoing antepartum, non-emergency CD, had their intravesical pressure measured before and after the CD, the intravesical pressure measurements obtained with the patient in the supine position were considered to correspond to the IAP. Multivariable linear regression models were used to study associations between intraabdominal pressure and baseline characteristics in normotensive pregnancies and hypertensive pregnancies. RESULTS: In normotensive pregnancies at mean gestation age of 38.2 weeks (95%CI 37.9 to 38.6), mean antepartum IAP was 12.7 mmHg(95%CI 11.6 to 13.8) and the mean postpartum IAP was 7.3 mmHg (95% CI 11.6 to 13.8). Multivariable linear regression models showed HIP group antepartum IAP positively associated with coefficient value of 1.617 (p = 0.268) comparing with normotensive pregnancy group. Postpartum IAP in HIP group positively associated with coefficient value of 2.519 (p = 0.018) comparing with normotensive pregnancy group. IAP difference is negatively associated with HIP (coefficient -1.013, p = 0.179). CONCLUSION: In normotensive pregnancies at term, the IAP was in the IAH range of the non-pregnant population. Higher Antepartum IAP and Postpartum IAP are associated with HIP. Reduction of IAP from antepartum period to postpartum period was less with HIP.

Supine transfer test-induced changes in cardiac index predict fluid responsiveness in patients without intra-abdominal hypertension.

BACKGROUND: The reversible maneuver that mimics the fluid challenge is a widely used test for evaluating volume responsiveness. However, passive leg raising (PLR) does have certain limitations. The aim of the study is to determine whether the supine transfer test could predict fluid responsiveness in adult patients with acute circulatory failure who do not have intra-abdominal hypertension, by measuring changes in cardiac index (CI). METHODS: Single-center, prospective clinical study in a 25-bed surgery intensive care unit at the Fudan University Shanghai Cancer Center. Thirty-four patients who presented with acute circulatory failure and were scheduled for fluid therapy. Every patient underwent supine transfer test and fluid challenge with 500 mL saline for 15-30 min. There were four sequential steps in the protocol: (1) baseline-1: a semi-recumbent position with the head of the bed raised to 45°; (2) supine transfer test: patients were transferred from the 45° semi-recumbent position to the strict supine position; (3) baseline-2: return to baseline-1 position; and (4) fluid challenge: administration of 500 mL saline for 15-30 min. Hemodynamic parameters were recorded at each step with arterial pulse contour analysis (ProAQT/Pulsioflex). A fluid responder was defined as an increase in CI ≥ 15% after fluid challenge. The receiver operating characteristic curve and gray zone were defined for CI. RESULTS: Seventeen patients were fluid challenge. The r value of the linear correlations was 0.73 between the supine transfer test- and fluid challenge-induced relative CI changes. The relative changes in CI induced by supine transfer in predicting fluid responsiveness had an area under the receiver operating characteristic curve of 0.88 (95% confidence interval 0.72-0.97) and predicted a fluid responder with 76.5% (95% confidence interval 50.1-93.2) sensitivity and 88.2% (95% confidence interval 63.6-98.5) specificity, at a best threshold of 5.5%. Nineteen (55%) patients were in the gray zone (CI ranging from -3 and 8 L/min/m2). CONCLUSION: The supine transfer test can potentially assist in detecting fluid responsiveness in patients with acute circulatory failure without intra-abdominal hypertension. Nevertheless, the small threshold and the 55% gray zone were noteworthy limitation. TRIAL REGISTRATION: Predicting fluid responsiveness with supine transition test (ChiCTR2200058264). Registered 2022-04-04 and last refreshed on 2023-03-26, https://www.chictr.org.cn/showproj.html?proj=166175 .

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.

The pathophysiological impact of intra-abdominal hypertension in pigs.

BACKGROUND: Intra-abdominal hypertension and abdominal compartment syndrome are common with clinically significant consequences. We investigated the pathophysiological effects of raised IAP as part of a more extensive exploratory animal study. The study design included both pneumoperitoneum and mechanical intestinal obstruction models. METHODS: Forty-nine female swine were divided into six groups: a control group (Cr; n = 5), three pneumoperitoneum groups with IAPs of 20mmHg (Pn20; n = 10), 30mmHg (Pn30; n = 10), 40mmHg (Pn40; n = 10), and two mechanical intestinal occlusion groups with IAPs of 20mmHg (MIO20; n = 9) and 30mmHg (MIO30; n = 5). RESULTS: There were significant changes (p<0.05) noted in all organ systems, most notably systolic blood pressure (SBP) (p<0.001), cardiac index (CI) (p = 0.003), stroke volume index (SVI) (p<0.001), mean pulmonary airway pressure (MPP) (p<0.001), compliance (p<0.001), pO2 (p = 0.003), bicarbonate (p = 0.041), hemoglobin (p = 0.012), lipase (p = 0.041), total bilirubin (p = 0.041), gastric pH (p<0.001), calculated glomerular filtration rate (GFR) (p<0.001), and urine output (p<0.001). SVV increased progressively as the IAP increased with no obvious changes in intravascular volume status. There were no significant differences between the models regarding their impact on cardiovascular, respiratory, renal and gastrointestinal systems. However, significant differences were noted between the two models at 30mmHg, with MIO30 showing worse metabolic and hematological parameters, and Pn30 and Pn40 showing a more rapid rise in creatinine. CONCLUSIONS: This study identified and quantified the impact of intra-abdominal hypertension at different pressures on several organ systems and highlighted the significance of even short-lived elevations. Two models of intra-abdominal pressure were used, with a mechanical obstruction model showing more rapid changes in metabolic and haematological changes. These may represent different underlying cellular and vascular pathophysiological processes, but this remains unclear.

Continuous passive paracentesis versus large-volume paracentesis in the prevention and treatment of intra-abdominal hypertension in the critically ill cirrhotic patient with ascites (COPPTRIAHL): study protocol for a randomized controlled trial.

BACKGROUND: Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites. METHODS: An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach. DISCUSSION: This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites. TRIAL REGISTRATION: ClinicalTrials.gov NCT04322201 . Registered on 20 December 2019.

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.

Abdominal compartment syndrome caused by severe acute gastric distension in a patient with COVID-19: A case report.

RATIONALE: The clinical manifestation of coronavirus disease 2019 (COVID-19) ranges from asymptomatic to critical. The gastrointestinal (GI) tract is involved in the early stages of the disease and is recognized as an important entry site for the virus. Consequently, GI manifestations are common in patients with COVID-19; however, the GI presentation of COVID-19 in relation to bowel dilatation has rarely been reported. Here, we report a case of acute severe gastric distension resulting in aortic compression and abdominal compartment syndrome (ACS) in a patient with COVID-19. PATIENT CONCERNS: A 72-year-old male presented to the emergency department (ED) with severe abdominal distension. The patient had been confirmed to have COVID-19 5 days prior to the visit. DIAGNOSES: Computed tomography revealed critical abdominal distension with severe gastric dilatation, accompanied by compression of the abdominal aorta and distal thrombosis formation. INTERVENTIONS: Intravenous fluid resuscitation and support with inotropic agents were initiated immediately, and a large amount of gastric content was evacuated via a nasogastric (NG) tube. OUTCOME: Finally, the patient was discharged after 12 days of admission without obvious complications. LESSONS: ACS is critical, which can be caused by a severe degree of acute gastric distension (AGD). Evacuation of the intraluminal contents is the most efficient management strategy. Prognosis is poor, and most previous studies of the transition from AGD to ACS have reported unfavorable outcomes.

Ruptured abdominal aorto-iliac aneurysms: Diagnosis, treatment, abdominal compartment syndrome, and role of simulation-based training.

Ruptured abdominal aortic aneurysms (rAAA), with or without iliac involvement, are a life-threatening scenario with high mortality even after surgical therapy. Several factors have contributed to improving perioperative outcomes in recent years, including the progressive use of endovascular aortic repair (EVAR) and intraoperative balloon occlusion of the aorta, a dedicated treatment algorithm with centralization of care to high-volume centres, and optimized perioperative management protocols. Nowadays, EVAR is applicable in the majority of scenarios even in the emergency setting. Among the factors that influence the postoperative course of rAAA patients, abdominal compartment syndrome (ACS) is a rare but life-threatening complication. As its early clinical diagnosis is often missed but crucial to initiate an emergent surgical decompression therapy, dedicated surveillance protocols and transvesical measurement of the intraabdominal pressure are key for prompt diagnosis and immediate treatment of ACS. Further improvement of rAAA patients' outcome may be achieved by the implementation of simulation-based training (of both technical and non-technical skills for surgeons as well as all involved healthcare personnel in multidisciplinary teams) and by transfer of all rAAA patients to specialized vascular centres with advanced experience and high caseload.