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

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

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

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

Cette étude a pour objectifs d'analyser l'incidence de l'hyperpression abdominale (HPA) et du syndrome du compartiment abdominal (SCA) chez les brûlés graves. Il s'agit d'une étude monocentrique prospective conduite auprès des 64 patients admis avec une brûlure >20% SCT entre août 2015 et janvier 2018. La préssion intraabdominale (PIA) était régulièrement mesurée pendant la première semaine. L'âge médian des patients était de 39 ans (IQR 28-53) et les 2/3 d'entre eux étaient des hommes. La SCT médiane était de 30% (IQR 20-46). Vingt huit (56%) patients avaient des critères d'HPA et 7 (14%) ont présenté des signes de SCA. Le score ABSI et la créatininémie étaient plus élevés chez les patients avec HPA, qui avaient aussi un bilan entrées-sorties positif. Les patients avec un SCA avaient plus de défaillances rénale et respiratoire. Les défaillances les plus fréquemment observées chez les patients avec HPA/SCA étaient rénales, cardio-vasculaires et respiratoires. La mortalité était de 56%. En conclusion, l'incidence de HPA est élevée chez les patients gravement brûlés. La survenue de SCA est une cause de défaillances rénale, cardio-vasculaire et respiratoire. Les facteurs prédicitifs de HPA étaient l'âge, la surface brûlée, l'inhalation de fumées et le recours à la ventilation mécanique.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis.

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors' own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric-rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

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.

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.

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

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 6.37kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65L/min/m2 (IQR 3.12-4.03), 3.38L/min/m2 (IQR 3.04-3.73), 3.16L/min/m2 (IQR 2.70-3.53), 2.89L/min/m2 (IQR 2.38-3.22), and 2.42L/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.

Intra-abdominal hypertension secondary to chronic diaphragmatic rupture in a dog / Hipertensão intra-abdominal secundária à ruptura diafragmática crônica em um cão

ABSTRACT: Intra-abdominal hypertension (IAH) is the persistent increase of intra-abdominal pressure (IAP) that could be caused by several pathologies. It is capable of promoting organ dysfunction, thereby increasing the mortality rate of human patients. As for cats and dogs, there are still few reports on how this pressure can be monitored and treated as a routine for admitted and hospitalized animals and on its relationship with the mortality of the patients. Therefore, the objective of this paper was to report a case of IAH secondary to chronic diaphragmatic rupture in a dog, which was treated with a temporary abdominal closure (TAC). A bitch was admitted to the veterinary hospital to undergo an elective ovariohysterectomy when it was diagnosed with a diaphragmatic rupture and displacement of the liver and intestinal loops in the chest. After repositioning these structures in the abdominal cavity, tension was observed in the abdomen. A temporary abdominal closure was then performed with a Bogota bag. Immediately after the surgery, the IAP was measured, presenting a value of 15 mmHg, indicating that there was an increase in intra-abdominal pressure. The animal was hospitalized, and IAP was monitored. After 24 hours, IAP was 5.8 mmHg when the Bogota bag was removed, and definitive celiorraphy was performed. The patient showed satisfactory clinical progress and was discharged 72 hours after the surgical procedure. The treatment used for IAH proved to be effective and contributed to the quick and satisfactory recovery of the patient.

RESUMO: A hipertensão intra-abdominal (HIA) é o aumento persistente da pressão intra-abdominal (PIA), podendo ser causada por diversas afecções e caraterizada por promover disfunções orgânicas, aumentando a taxa de mortalidade no homem. Em cães e gatos, ainda há poucos relatos da monitoração dessa pressão e do seu tratamento na rotina dos animais admitidos e internados, e sua relação com a mortalidade dos pacientes. Assim, objetivou-se relatar um caso de HIA secundária à ruptura diafragmática crônica em cão, a qual foi tratada com o fechamento abdominal temporário (FAT). Uma cadela foi admitida no hospital veterinário para realização de uma cirurgia de ovário-histerectomia eletiva, quando foi diagnosticada com ruptura diafragmática com fígado e alças intestinais deslocadas para o interior do tórax. Após reposicionamento dessas estruturas na cavidade abdominal, observou-se tensão no abdômen. Realizou-se então o fechamento abdominal temporário com bolsa de Bogotá. Imediatamente após o término da cirurgia, a PIA foi aferida e seu valor era de 15 mmHg, indicando aumento da mesma. O animal foi mantido internado e sua PIA monitorada. Após 24 horas seu valor era de 5,8 mmHg, quando a bolsa de Bogotá foi removida e realizada a celiorrafia definitiva. O paciente teve evolução clínica satisfatória e 72h após a cirurgia recebeu alta hospitalar. O tratamento utilizado para a HIA se mostrou eficaz, contribuindo para a rápida e satisfatória recuperação da paciente.

Intra-abdominal hypertension secondary to chronic diaphragmatic rupture in a dog / Hipertensão intra-abdominal secundária à ruptura diafragmática crônica em um cão

Intra-abdominal hypertension (IAH) is the persistent increase of intra-abdominal pressure (IAP) that could be caused by several pathologies. It is capable of promoting organ dysfunction, thereby increasing the mortality rate of human patients. As for cats and dogs, there are still few reports on how this pressure can be monitored and treated as a routine for admitted and hospitalized animals and on its relationship with the mortality of the patients. Therefore, the objective of this paper was to report a case of IAH secondary to chronic diaphragmatic rupture in a dog, which was treated with a temporary abdominal closure (TAC). A bitch was admitted to the veterinary hospital to undergo an elective ovariohysterectomy when it was diagnosed with a diaphragmatic rupture and displacement of the liver and intestinal loops in the chest. After repositioning these structures in the abdominal cavity, tension was observed in the abdomen. A temporary abdominal closure was then performed with a Bogota bag. Immediately after the surgery, the IAP was measured, presenting a value of 15 mmHg, indicating that there was an increase in intra-abdominal pressure. The animal was hospitalized, and IAP was monitored. After 24 hours, IAP was 5.8 mmHg when the Bogota bag was removed, and definitive celiorraphy was performed. The patient showed satisfactory clinical progress and was discharged 72 hours after the surgical procedure. The treatment used for IAH proved to be effective and contributed to the quick and satisfactory recovery of the patient.

A hipertensão intra-abdominal (HIA) é o aumento persistente da pressão intra-abdominal (PIA), podendo ser causada por diversas afecções e caraterizada por promover disfunções orgânicas, aumentando a taxa de mortalidade no homem. Em cães e gatos, ainda há poucos relatos da monitoração dessa pressão e do seu tratamento na rotina dos animais admitidos e internados, e sua relação com a mortalidade dos pacientes. Assim, objetivou-se relatar um caso de HIA secundária à ruptura diafragmática crônica em cão, a qual foi tratada com o fechamento abdominal temporário (FAT). Uma cadela foi admitida no hospital veterinário para realização de uma cirurgia de ovário-histerectomia eletiva, quando foi diagnosticada com ruptura diafragmática com fígado e alças intestinais deslocadas para o interior do tórax. Após reposicionamento dessas estruturas na cavidade abdominal, observou-se tensão no abdômen. Realizou-se então o fechamento abdominal temporário com bolsa de Bogotá. Imediatamente após o término da cirurgia, a PIA foi aferida e seu valor era de 15 mmHg, indicando aumento da mesma. O animal foi mantido internado e sua PIA monitorada. Após 24 horas seu valor era de 5,8 mmHg, quando a bolsa de Bogotá foi removida e realizada a celiorrafia definitiva. O paciente teve evolução clínica satisfatória e 72h após a cirurgia recebeu alta hospitalar. O tratamento utilizado para a HIA se mostrou eficaz, contribuindo para a rápida e satisfatória recuperação da paciente.

Intra-abdominal hypertension secondary to chronic diaphragmatic rupture in a dog / Hipertensão intra-abdominal secundária à ruptura diafragmática crônica em um cão

Intra-abdominal hypertension (IAH) is the persistent increase of intra-abdominal pressure (IAP) that could be caused by several pathologies. It is capable of promoting organ dysfunction, thereby increasing the mortality rate of human patients. As for cats and dogs, there are still few reports on how this pressure can be monitored and treated as a routine for admitted and hospitalized animals and on its relationship with the mortality of the patients. Therefore, the objective of this paper was to report a case of IAH secondary to chronic diaphragmatic rupture in a dog, which was treated with a temporary abdominal closure (TAC). A bitch was admitted to the veterinary hospital to undergo an elective ovariohysterectomy when it was diagnosed with a diaphragmatic rupture and displacement of the liver and intestinal loops in the chest. After repositioning these structures in the abdominal cavity, tension was observed in the abdomen. A temporary abdominal closure was then performed with a Bogota bag. Immediately after the surgery, the IAP was measured, presenting a value of 15 mmHg, indicating that there was an increase in intra-abdominal pressure. The animal was hospitalized, and IAP was monitored. After 24 hours, IAP was 5.8 mmHg when the Bogota bag was removed, and definitive celiorraphy was performed. The patient showed satisfactory clinical progress and was discharged 72 hours after the surgical procedure. The treatment used for IAH proved to be effective and contributed to the quick and satisfactory recovery of the patient.(AU)

A hipertensão intra-abdominal (HIA) é o aumento persistente da pressão intra-abdominal (PIA), podendo ser causada por diversas afecções e caraterizada por promover disfunções orgânicas, aumentando a taxa de mortalidade no homem. Em cães e gatos, ainda há poucos relatos da monitoração dessa pressão e do seu tratamento na rotina dos animais admitidos e internados, e sua relação com a mortalidade dos pacientes. Assim, objetivou-se relatar um caso de HIA secundária à ruptura diafragmática crônica em cão, a qual foi tratada com o fechamento abdominal temporário (FAT). Uma cadela foi admitida no hospital veterinário para realização de uma cirurgia de ovário-histerectomia eletiva, quando foi diagnosticada com ruptura diafragmática com fígado e alças intestinais deslocadas para o interior do tórax. Após reposicionamento dessas estruturas na cavidade abdominal, observou-se tensão no abdômen. Realizou-se então o fechamento abdominal temporário com bolsa de Bogotá. Imediatamente após o término da cirurgia, a PIA foi aferida e seu valor era de 15 mmHg, indicando aumento da mesma. O animal foi mantido internado e sua PIA monitorada. Após 24 horas seu valor era de 5,8 mmHg, quando a bolsa de Bogotá foi removida e realizada a celiorrafia definitiva. O paciente teve evolução clínica satisfatória e 72h após a cirurgia recebeu alta hospitalar. O tratamento utilizado para a HIA se mostrou eficaz, contribuindo para a rápida e satisfatória recuperação da paciente.(AU)

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.

Abdominal compartment syndrome: Current concepts and management. / Síndrome compartimental abdominal: conceptos actuales y manejo.

Abdominal compartment syndrome occurs when 2 or more anatomic compartments have a sustained intra-abdominal pressure >20mmHg, associated with organ failure. Incidence is 2% and prevalence varies from 0% to 36.4%. A literature search was conducted utilizing different databases. Articles published from 1970 to 2018 were included, in English or Spanish, to provide the concepts, classifications, and comprehensive management in the approach to abdominal compartment syndrome, for its treatment and the prevention of severe complications associated with the entity. Intravesical pressure measurement is the standard diagnostic method. Treatment is based on evacuation of the intraluminal content, identification and treatment of intra-abdominal lesions, improvement of abdominal wall compliance, and optimum administration of fluids and tissue perfusion. Laparotomy is generally followed by temporary abdominal wall closure 5 to 7 days after surgery. Reconstruction is performed 6 to 12 months after the last operation. Abdominal compartment syndrome should be diagnosed and operated on before organic damage from the illness occurs. Kidney injury can frequently progress and is a parameter for considering abdominal decompression. Having a biomarker for early damage would be ideal. Surgical treatment is successful in the majority of cases. A multidisciplinary focus is necessary for the intensive care and reconstructive needs of the patient. Thus, efforts must be made to define and implement strategies for patient quality of life optimization.

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.

Clinical warning signs for intra-abdominal hypertension in septic shock patients.

BACKGROUND: The latest World Society of the Abdominal Compartment (WSACS) guideline published in 2013 states that risk factors are the most reliable predictors for the diagnosis of intra-abdominal hypertension (IAH) and the bottom line to guide propaedeutic and clinical practice. The objective of this study is to search for clinical, laboratory, and ventilator-associated factors in order to warn medical staff for prompt IAH diagnosis in septic shock patients beyond risk factors simply. METHODS: This is a prospective, observational study, involving all admitted intensive care unit septic shock patients of a single teaching hospital between April and October 2016. All enrolled patients met Sepsis III and Surviving Sepsis Campaign diagnostic criteria. Patients with primary abdominal conditions were excluded, in order to avoid possible bias. Intra-abdominal pressure (IAP) was measured every 6 hours in accordance with WSACS guidelines. RESULTS: 25 sequential patients were included and followed for 10 days after admission. Median age was 51.13 ± 16.52 years old, 64% male. Pulmonary infection was the most frequent etiology of sepsis, representing 76% of the cases. Elevated IAP correlated with higher central venous pressure (CVP) (P = 0.0421); positive end-expiratory pressure (PEEP) (P = 0.0056); elevated airway pressure (P = 0.0015); accumulated fluid balance (P = 0.0273), and elevated SOFA (P = 0.0393) in all septic patients. Reduction of acidosis (P = 0.0096) and increase of serum bicarbonate (P = 0.0247) correlated with lower IAP values. CONCLUSIONS: Elevated CVP, PEEP, SOFA, airway pressure and accumulated fluid balance are correlated with elevated IAP in septic shock patients. Acidosis correction appears to decrease the risk for IAH. Multicentric randomized studies are needed to confirm this hypothesis in a large population.

Pancreatitis aguda: fisiopatología y manejo inicial / Acute pancreatitis: pathophysiology and initial management

Resumen La pancreatitis aguda es un trastorno intracelular del calcio en las células pancreáticas, el cual constituye la vía final común de múltiples estímulos etiopatogénicos y puede desencadenar cambios necroinflamatorios locales, efectos multisistémicos y compromiso en órganos distantes. Todo esto lleva a los pacientes a múltiples complicaciones por disfunción orgánica e infección. El diagnóstico adecuado y oportuno, el abordaje según severidad y la optimización de la terapia nutricional, así como una adecuada analgésica, reanimación hídroelectrolítica, detección de disfunción orgánica y de complicaciones locales e infecciosas, determinan el desenlace clínico de dicha patología. Se realizó una revisión narrativa incluyendo estudios clínicos, guías de manejo, protocolos y revisiones pertinentes, y se aporta un enfoque desde el punto de vista de medicina crítica para el abordaje inicial de esta patología.

Abstract Acute pancreatitis is an intracellular calcium disorder in pancreatic cells, which constitutes the final common pathway of multiple etiopathogenic stimuli and can trigger local necroinflammatory changes, multisystemic effects and compromise distant organs. All of this leads to multiple complications due to organ dysfunction and infection in patients. The adequate and opportune diagnosis, the approach according to severity and the optimization of the nutritional therapy; as well as an adequate analgesic, hydroelectrolytic resuscitation, the detection of organic dysfunction and of local and infectious complications, determine the clinical outcome of this pathology. A narrative review was carried out including clinical studies, management guidelines, protocols and reviews. An initial approach for this pathology, from the critical medicine point of view, is provided.

Tension pneumoperitoneum: Case report of a rare form of acute abdominal compartment syndrome.

INTRODUCTION: Tension pneumoperitoneum is a severe and rare form of pneumoperitoneum with concomitant hemodynamic instability and respiratory failure. It is a variant of abdominal compartment syndrome (ACS) causing an abrupt increase in intra-abdominal pressure. PRESENTATION OF CASE: We present a case of pneumoperitoneum, after an endoscopic mucosal resection with the development of ACS. The patient was successfully treated with percutaneous decompression. DISCUSSION: Decompressive laparotomy is the first treatment option for both most forms of pneumoperitoneum and ACS; nevertheless, this issue is controversial. Recent reports have shown that some patients may be candidates for a minimally invasive catheter decompression avoiding major decompressive surgery. Identifying these patients is vital to avoiding unnecessary surgeries. CONCLUSIONS: Tension pneumoperitoneum is a life-threatening event, early detection and intervention is critical in order to provide prompt and optimal treatment approaches.

Effect of abdominal negative-pressure wound therapy on the measurement of intra-abdominal pressure.

BACKGROUND: In critically ill surgical patients undergoing abdominal negative-pressure wound therapy (NPWT), it remains uncertain whether or not intra-abdominal pressure (IAP) measurements should be obtained when NPWT is activated. We aimed to determine agreement between IAP measured with and without NPWT. METHODS: In this analytic cross-sectional study, critically ill surgical adults (≥18 y) requiring abdominal NPWT for temporary abdominal closure after a damage control laparotomy were selected. Patients with urinary tract injuries or with pelvic packing were excluded. Paired IAP measures were performed in the same patient, with and without NPWT; two different operators performed the measures unaware of the other's result. Bland-Altman methods assessed the agreement between the two measures. Subgroup analyses (trauma and nontrauma) were performed. RESULTS: There were 198 IAP measures (99 pairs) in 38 patients. Mean IAP with and without NPWT were 8.33 (standard deviation 4.01) and 8.65 (standard deviation 4.04), respectively. Mean IAP difference was -0.323 (95% confidence interval -0.748 to 0.101), and reference range for difference was -4.579 to 3.932 (P = 0.864). From 112 IAP measures (56 pairs) in 21 trauma patients, mean IAP difference was -0.268 (95% confidence interval -0.867 to 0.331), and reference range for the difference was -4.740 to 4.204 (P = 0.427). CONCLUSIONS: There was no statistically significant disagreement in IAP measures. IAP could be measured with or without NPWT. In critically ill surgical patients with abdominal NPWT for temporary abdominal closure, monitoring and management of IAP either with or without NPWT is recommended.

The role of point-of-care ultrasound in intra-abdominal hypertension management.

BACKGROUND: Intra-abdominal hypertension is a common complication in critically ill patients. Recently the Abdominal Compartment Society (WSACS) developed a medical management algorithm with a stepwise approach according to the evolution of the intra-abdominal pressure and aiming to keep IAP ≤ 15 mm Hg. With the increased use of ultrasound as a bedside modality in both emergency and critical care patients, we hypothesized that ultrasound could be used as an adjuvant point-of-care tool during IAH management. This may be particularly relevant to the first and second basic stages of the algorithm. The objective of this paper is to test the use of POCUS as an adjuvant tool in the management of patients with IAH/ACS. METHODS: Seventy-three consecutive adult critically ill patients admitted to the surgical intensive care unit (ICU) of a single urban institution with risk factor for IAH/ACS were enrolled. Those who met the inclusion criteria were allocated to undergo POCUS as an adjuvant tool in their IAH/ACS management. RESULTS: A total of 50 patients met the inclusion criteria and were included in the study. The mean age of study participants was 55 ± 22.6 years, 58% were men, and the most frequent admission diagnosis was post-operative care following abdominal intervention. All admitted patients presented with a degree of IAH during their ICU stay. Following step 1 of the WSACS IAH medical management algorithm, ultrasound was used for NGT placement, confirmation of correct positioning, and evaluation of stomach contents. Ultrasound was comparable to abdominal X-ray, but shown to be superior in determining the gastric content (fluid vs. solid). Furthermore, POCUS allowed faster determination of correct NGT positioning in the stomach (antrum), avoiding bedside radiation exposure. Ultrasound also proved useful in: 1) evaluation of bowel activity; 2) identification of large bowel contents; 3) identification of patients that would benefit from bowel evacuation (enema) as an adjuvant to lower IAP; 4) and in the diagnosis of moderate to large amounts of free intra-abdominal fluid. CONCLUSION: POCUS is a powerful systematic ultrasound technique that can be used as an adjuvant in intra-abdominal hypertension management. It has the potential to be used in both diagnosis and treatment during the course of IAH.

Open abdomen in gastrointestinal surgery: Which technique is the best for temporary closure during damage control?

AIM: To compare the 3 main techniques of temporary closure of the abdominal cavity, vacuum assisted closure (vacuum-assisted closure therapy - VAC), Bogota bag and Barker technique, in damage control surgery. METHODS: After systematic review of the literature, 33 articles were selected to compare the efficiency of the three procedures. Criteria such as cost, infections, capacity of reconstruction of the abdominal wall, diseases associated with the technique, among others were analyzed. RESULTS: The Bogota bag and Barker techniques present as advantage the availability of material and low cost, what is not observed in the VAC procedure. The VAC technique is the most efficient, not only because it reduces the tension on the boarders of the lesion, but also removes stagnant fluids and debris and acts at cellular level increasing cell proliferation and division. Bogota bag presents the higher rates of skin laceration and evisceration, greater need for a stent for draining fluids and wash-ups, higher rates of intestinal adhesion to the abdominal wall. The Barker technique presents lack of efficiency in closing the abdominal wall and difficulty on maintaining pressure on the dressing. The VAC dressing can generate irritation and dermatitis when the drape is applied, in addition to pain, infection and bleeding, as well as toxic shock syndrome, anaerobic sepsis and thrombosis. CONCLUSION: The VAC technique, showed to be superior allowing a better control of liquid on the third space, avoiding complications such as fistula with small mortality, low infection rate, and easier capability on primary closure of the abdominal cavity.