Abstract
Intra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. In this narrative review, we aim to provide a comprehensive overview of current insights into intra-abdominal pressure monitoring, intra-abdominal hypertension, and abdominal compartment syndrome. The focus of this review is on the pathophysiology, risk factors and outcome of intra-abdominal hypertension and abdominal compartment syndrome, and on therapeutic strategies, such as non-operative management, surgical decompression, and management of the open abdomen. Finally, future steps are discussed, including propositions of what a future guideline should focus on. Pathological intra-abdominal pressure is a continuum ranging from mild intra-abdominal pressure elevation without clinically significant adverse effects to substantial increase in intra-abdominal pressure with serious consequences to all organ systems. Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension. Although continuous intra-abdominal pressure monitoring is feasible, this is currently not standard practice. There are a number of effective non-operative medical interventions that may be performed early in the patient's course to reduce intra-abdominal pressure and decrease the need for surgical decompression. Abdominal decompression can be life-saving when abdominal compartment syndrome is refractory to non-operative treatment and should be performed expeditiously. The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time. There is still a lot to learn and change. The 2013 World Society of Abdominal Compartment Syndrome guidelines should be updated and multicentre studies should evaluate the effect of intra-abdominal hypertension treatment on patient outcome.
Highlights
Background and objectiveIntra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality
In clinical practice, pathological intra-abdominal pressure (IAP) is a continuum ranging from mild IAP elevations without clinically significant adverse effects to substantial increases in IAP with multi-organ failure.[3]
There is still no consensus on indications for decompression, both in terms of IAP values and of timing,[46] but abdominal decompression can be life-saving when abdominal compartment syndrome (ACS) is refractory to non-operative treatment and should be performed expeditiously.[41]
Summary
Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are conditions that result from increased intra-abdominal pressure (IAP). Negative pressure wound therapy (NPWT) or vacuum therapy is the procedure currently recommended in the treatment of the open abdomen.[53] Roberts et al performed a systematic review to determine the comparative efficacy and safety of NPWT versus alternate temporary abdominal closure techniques in critically ill adults with open abdominal wounds.[54] In this study of 1018 adults, two randomized controlled trials and nine cohort studies (three prospective and six retrospective) were included. A multi-center study which randomizes between early decompression surgery with open abdomen management and bundles of non-operative treatment in ACS patients might answer some of the many remaining important clinical questions. We recommend that this study is performed in a homogeneous patient population with a relatively high prevalence of IAH, for example, in patients with SAP
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