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      Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

      research-article
      , , , , , , , , , , , , , , , , , , , , , , The Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome
      Intensive Care Medicine
      Springer-Verlag
      Intra-abdominal hypertension, Abdominal compartment syndrome, Critical care, Grading of Recommendations, Assessment, Development, and Evaluation, Evidence-based medicine, World Society of the Abdominal Compartment Syndrome

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          Abstract

          Purpose

          To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).

          Methods

          We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear).

          Results

          In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation.

          Conclusion

          Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00134-013-2906-z) contains supplementary material, which is available to authorized users.

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          Most cited references65

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          Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations.

          Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.
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            Different techniques to measure intra-abdominal pressure (IAP): time for a critical re-appraisal.

            The diagnosis of intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS) is heavily dependent on the reproducibility of the intra-abdominal pressure (IAP) measurement technique. Recent studies have shown that a clinical estimation of IAP by abdominal girth or by examiner's feel of the tenseness of the abdomen is far from accurate, with a sensitivity of around 40%. Consequently, the IAP needs to be measured with a more accurate, reproducible and reliable tool. The role of the intra-vesical pressure (IVP) as the gold standard for IAP has become a matter of debate. This review will focus on the previously described indirect IAP measurement techniques and will suggest new revised methods of IVP measurement less prone to error. Cost-effective manometry screening techniques will be discussed, as well as some options for the future with microchip transducers.
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              Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients.

              To determine whether implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival. DCR aims at preventing coagulopathy through permissive hypotension, limiting crystalloids and delivering higher ratios of plasma and platelets. Previous work has focused only on the impact of delivering higher ratios (1:1:1). A retrospective cohort study was performed on all DCL patients admitted between January 2004 and August 2010. Patients were divided into pre-DCR implementation and DCR groups and were excluded if they died before completion of the initial laparotomy. The lethal triad was defined as immediate postoperative temperature less than 95°F, international normalized ratio more than 1.5, or a pH less than 7.30. A total of 390 patients underwent DCL. Of these, 282 were pre-DCR and 108 were DCR. Groups were similar in demographics, injury severity, admission vitals, and laboratory values. DCR patients received less crystalloids (median: 14 L vs 5 L), red blood cells (13 U vs 7 U), plasma (11 U vs 8 U), and platelets (6 U vs 0 U) in 24 hours, all P < 0.05. DCR patients had less evidence of the lethal triad upon intensive care unit arrival (80% vs 46%, P < 0.001). 24-hour and 30-day survival was higher with DCR (88% vs 97%, P = 0.006 and 76% vs 86%, P = 0.03). Multivariate analysis controlling for age, injury severity, and emergency department variables, demonstrated DCR was associated with a significant increase in 30-day survival (OR: 2.5, 95% CI: 1.10-5.58, P = 0.028). In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration. More importantly, DCR is associated with an improvement in 30-day survival.
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                Author and article information

                Contributors
                +1-403-9442888 , +1-403-9448799 , Andrew.kirkpatrick@albertahealthservices.ca
                Derek.Roberts01@gmail.com
                jan.dewaele@UGent.be
                jaeschke@mcmaster.ca
                manu.malbrain@skynet.be
                bdekeul@hotmail.com
                jduchesn@tulane.edu
                martin@bjorck.pp.se
                ari.leppaniemi@hus.fi
                jejike@llu.edu
                acstrauma@hotmail.com
                Michael.cheatham@orlandohealth.com
                rivatury@mcvh-vcu.edu
                ball.chad@gmail.com
                annika.reintam.blaser@ut.ee
                Adrian.regli@gmail.com
                Zsolt.balogh@hne.health.nsw.gov.au
                Scott.Damours@swsahs.nsw.gov.au
                dieter.debergh@UGent.be
                kaplanm@einstein.edu
                Edward.kimball@hsc.utah.edu
                claudia_olvera@me.com
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer-Verlag (Berlin/Heidelberg )
                0342-4642
                1432-1238
                15 May 2013
                15 May 2013
                July 2013
                : 39
                : 7
                : 1190-1206
                Affiliations
                [ ]The Departments of Surgery and Critical Care Medicine and Regional Trauma Services Foothills Medical Centre, Calgary, Alberta T2N 2T9 Canada
                [ ]Departments of Surgery and Community Health Sciences, University of Calgary, Calgary, AB T2N 5A1 Canada
                [ ]Department of Critical Care Medicine, Ghent University Hospital and Ghent Medical School, Ghent, Belgium
                [ ]Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON L8P 3B6 Canada
                [ ]Intensive Care Unit and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen 6, Belgium
                [ ]Intensive Care Unit, Fremantle Hospital, Alma Street, PO Box 480, Fremantle, WA 6959 Australia
                [ ]Section of Trauma and Critical Care Surgery, Division of Surgery, Anesthesia and Emergency Medicine, Tulane Surgical Intensive Care Unit, 1430 Tulane Ave., SL-22, New Orleans, LA 70112-2699 USA
                [ ]Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
                [ ]Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, PO Box 340, 00029 Helsinki, Finland
                [ ]Loma Linda University Children’s Hospital, 11175 Campus Street, Ste A1117, Loma Linda, CA USA
                [ ]Letterkenny Hospital and the Donegal Clinical Research Academy, Donegal Ireland, and the University College Hospital, Galway, Ireland
                [ ]Department of Surgical Education, Orlando Regional Medical Center, 86 West Underwood St, Suite 201, Orlando, FL 32806 USA
                [ ]Medical College of Virginia, 417 11 St, Richmond, VA USA
                [ ]Regional Trauma Services, EG 23 Foothills Medical Centre, Calgary, AB T2N 2T9 Canada
                [ ]Clinic of Anaesthesiology and Intensive Care, University of Tartu, Puusepa 8, 51014 Tartu, Estonia
                [ ]School of Medicine and Pharmacology, The University of Western Australia, Crawley, WA 6009 Australia
                [ ]School of Medicine, The University of Notre Dame, Fremantle, WA 6959 Australia
                [ ]John Hunter Hospital, University of Newcastle, Newcastle, NSW 2310 Australia
                [ ]Trauma Department, Liverpool Hospital, Locked Bag 1871, Liverpool, NSW BC 2170 Australia
                [ ]Department of Intensive Care, Ghent University Hospital, 9000 Ghent, Belgium
                [ ]Albert Einstein Medical Center, Philadelphia, PA 19141 USA
                [ ]Department of Surgery, University of Utah, 50 N Medical Drive, Salt Lake City, UT USA
                [ ]The American British Cowdray Medical Center, Universidad Anahuac, Mexico City, Mexico
                Article
                2906
                10.1007/s00134-013-2906-z
                3680657
                23673399
                f1ef51e7-6e90-4014-8b2c-44d97a2c73d8
                © The Author(s) 2013

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

                History
                : 10 February 2013
                : 18 March 2013
                Categories
                Conference Reports and Expert Panel
                Custom metadata
                © Springer-Verlag Berlin Heidelberg and ESICM 2013

                Emergency medicine & Trauma
                intra-abdominal hypertension,abdominal compartment syndrome,critical care,grading of recommendations, assessment, development, and evaluation,evidence-based medicine,world society of the abdominal compartment syndrome

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