Intra-abdominal Pressure Measurement Research Articles

The \u2018AbdoMAN\u2019: an artificial abdominal wall simulator for biomechanical studies on laparotomy closure techniques

PurposeIncisional hernia remains a frequent complication after abdominal surgery associated with significant morbidity and high costs. Animal and clinical studies have exhibited some limitations. The purpose of this study was to develop an artificial human abdominal wall (AW) simulator in order to enable investigations on closure modalities. We hypothesized that a physical model of the human AW would give new insight into commonly used suture techniques representing a substantial complement or alternative to clinical and animal studies.MethodsThe ‘AbdoMAN’ was developed to simulate human AW biomechanics. The ‘AbdoMAN’ capacities include measurement and regulation of intra-abdominal pressure (IAP), generation of IAP peaks as a result of muscle contraction and measurements of AW strain patterns analyzed with 3D image stereo correlation software. Intact synthetic samples were used to test repeatability. A laparotomy closure was then performed on five samples to analyze strain patterns.ResultsThe ‘AbdoMAN’ was capable of simulating physiological conditions. AbdoMAN lateral muscles contract at 660 N, leading the IAP to increase up to 74.9 mmHg (range 65.3–88.3). Two strain criteria were used to assess test repeatability. A test with laparotomy closure demonstrated closure testing repeatability.ConclusionsThe ‘AbdoMAN’ reveals as a promising enabling tool for investigating AW surgery-related biomechanics and could become an alternative to animal and clinical studies. 3D image correlation analysis should bring new insights on laparotomy closure research. The next step will consist in evaluating different closure modalities on synthetic, porcine and human AW.

The value of intra-abdominal pressure monitoring through transvesical route in the choice and outcome of management of congenital abdominal wall defects

Introduction Gastroschisis and omphalocele are most common congenital abdominal wall defects (AWDs). Surgical management aims to reduce the evisceration safely, close the defect with a cosmetically acceptable outcome under guidance of intraoperative monitoring of intra-abdominal pressure (IAP). Intravesical pressure monitoring technique recommended by (WSACS) is the most reliable technique for IAP measurement in neonates. Aim The aim of this study is to assess the value of IAP monitoring via vesical pressure measurement in the choice and outcome of management of congenital AWDs. Patients and methods This is a prospective study of 25 cases that suffered congenital anterior AWDs (gastroschisis and omphalocele) admitted to Mansoura University Children Hospital during the period from October 2013 to October 2015. They were all operated upon guided by IVP monitoring during and after repair. Results In our study, 14 (56%) cases presented with gastroschisis and 11 (44%) presented with exomphalos with a median age of 24 h. Males (56%) were slightly more than females (44%). Congenital anomalies were reported in 16 cases (64%). Primary fascial closure was successful in 15 (60%) cases, whereas Silo repair was done in six (24%) cases and skin closure in only four (16%) cases. During the attempts of closure the mean abdominal perfusion pressure was 40.24 ± 5.59, the mean peak inspiratory pressure was 24 ±6.11 and the mean IAP was 22.60± 6.89. Two cases developed intra-abdominal hypertension after abdominal closure (8%) and only one of them needed decompressive laparotomy (4%). Postoperative complications were reported in 15 (60%) cases and mortality occurred in eight (32%) cases. Conclusion Increased IAP secondary to forceful closure of the abdominal defect is associated with the occurrence of complications. IVP monitoring is feasible during closure of AWDs and a threshold of 20cm H2O is appropriate to decide between primary and staged approach. Keywords : congenital abdominal wall defect, intravesical pressure, intra-abdominal hypertension

Long-term prognosis of idiopathic chronic adult hydrocephalus: I. The University Hospital Marqués de Valdecilla diagnostic and therapeutic protocol

IntroductionDespite the existence of published guidelines for more than a decade, there is still a substantial variation in the management of idiopathic normal pressure hydrocephalus due to its diagnostic and therapeutic complexity. DevelopmentThe diagnostic and therapeutic protocol for the management of idiopathic normal pressure hydrocephalus in use at the Department of Neurosurgery of the University Hospital Marqués de Valdecilla is presented. The diagnostic process includes neuropsychological testing, phase contrast cine MRI, urodynamic evaluation, continuous intracranial pressure monitoring, cerebrospinal fluid hydrodynamics by means of lumbar infusion testing, and intra-abdominal pressure measurement. A patient is considered a surgical candidate if any of the following criteria is met: mean intracranial pressure >15mmHg, or B-waves present in >10% of overnight recording; pressure–volume index <15ml, or resistance to cerebrospinal fluid outflow (ROUT) >4.5mmHg/ml/min in bolus infusion test; ROUT >12mmHg/ml/min, intracranial pressure >22mmHg, or high amplitude B-waves in the steady-state of the continuous rate infusion test; or a clinical response to high-volume cerebrospinal fluid withdrawal. ConclusionsThe implementation of a diagnostic and therapeutic protocol for idiopathic normal pressure hydrocephalus management could improve various aspects of patient care. It could reduce variability in clinical practice, optimise the use of health resources, and help in identifying scientific uncertainty areas, in order to direct research efforts in a more appropriate way.

腹腔内圧測定を行いTAPP法で修復した巨大鼠径ヘルニアの1例

腹腔内圧測定を行いTAPP法で修復した巨大鼠径ヘルニアの1例

The role of routine measurement of intra-abdominal pressure in preventing abdominal compartment syndrome

Introduction:Abdomen, a closed compartment, is prone to raised intra-abdominal pressure (IAP) in the postoperative period. After a critical value of ≥ 15 cm of water, IAP produces abdominal compartment syndrome (ACS). ACS leads to reduced venous return, reduced cardiac output, and domino effect of organ dysfunction, leading to death. Hence, it is the need of hour to monitor IAP to pick up intra-abdominal hypertension (IAH) and ACS. This routine facilitates early institution of treatment measures.Aims and Objectives:To study IAP in abdominal operations in neonates, infants, and older children and to promote concept of routine measurement of IAP as standard care.Materials and Methods:Intravesical route was used to measure IAP in this prospective observational study. Seventy-nine pediatric abdominal surgeries met with criteria of availability of complete data for analysis and formed the cohort of the study. All major, infective, traumatic, tumor-related abdominal surgeries were included in the study. Outcome, C-reactive protein (CRP), procalcitonin, platelet counts, Simplified Sequential Organ Failure Assessment Score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were the parameters analyzed. The World Society of ACS grading was adopted in the study with subdivision of normal into low-normal and high-normal subgroups.Results:Extended Mantel–Haenszel Chi-square statistical tool when applied for linear relationship showed a linear relationship with outcome (P < 0.05), CRP (P < 0.05), procalcitonin (P < 0.05), Simplified Sequential organ failure Assessment Score, and APACHE II. Platelet counts (P > 0.05) were not significantly correlated. Decision for laparotomy was delayed in cases of ACS.Conclusion:Routine measure of IAP facilitates early recognition of IAH. This facilitates therapeutic measures to be initiated to reduce IAP. Early decision to decompress by laparotomy/laparostomy saves lives. Hence, routine IAP measurement should be a part of standard care in pediatric abdominal surgery.

Can femoral venous pressure be used as an estimate for standard vesical intra-abdominal pressure measurement?

Intra-abdominal hypertension (IAH) is highly prevalent in critically ill patients admitted to the intensive care unit and is associated with an increased morbidity and mortality. The present study investigated whether femoral venous pressure (FVP) can be used as a surrogate parameter for intra-abdominal pressure (IAP) measured via the bladder in IAH grade II (IAP <20 mmHg) or grade III (IAP ≥20 mmHg). This was a single-centre prospective study carried out in a tertiary adult intensive care unit. IAP was measured via the bladder with a urinary catheter with simultaneous recording of the FVP via a femoral central line. If the IAP was <20 mmHg external weight to a maximum of 10 kg was applied to the abdomen with subsequent measurements of IAP and FVP. Eleven patients were enrolled into the study. IAH (IAP >12 mmHg) was identified in five patients (42%) and abdominal compartment syndrome (ACS, IAP >20 mmHg with new onset organ failure) in two (18%) with all-cause study mortality of 18%. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 21 ± 5, Simplified Acute Physiology (SAPS 2) score 49 ± 8, and Sequential Organ Failure Assessment (SOFA) score 9 ± 3. At baseline the bias between IAP and FVP was 3.2 with a precision of 3.63 mmHg (limits of agreement [LA] -4.1, 10.4). At 5 kg and 10 kg, the bias was 2.5 with a precision of 3.92 mmHg (LA -5.4, 10.3) and 2.26 mmHg (LA -2.1, 7.0) respectively. A receiver operating characteristic analysis for FVP to predict IAH showed an area under the curve of 0.87 (95% confidence interval 0.74-0.94, P=0.0001). FVP cannot be recommended as a surrogate measure for IAP even at IAP values above 20 mmHg. However, an elevated FVP was a good predictor of IAH.

Outcomes in pediatric patients with abdominal compartment syndrome following urgent exploratory laparotomy

Background/purposeAbdominal compartment syndrome (ACS) is a serious condition with high mortality in critically ill children. Our objectives were to characterize the incidence of ACS in pediatric patients who underwent urgent exploratory laparotomy and to compare outcomes of patients with and without ACS. MethodsThis retrospective review examined pediatric patients (0–18years) who underwent urgent exploratory laparotomy over a 2-year period. Primary outcome was mortality; secondary outcomes were achievement of primary fascial closure and necessity of bowel resection. ResultsOne hundred nineteen patients were included, of which 33 (28%) had ACS, with 27 (23%) being primary ACS and 6 (5%) secondary ACS. Twenty-eight-day mortality was higher in the ACS versus non-ACS group (52% versus 0%, p<0.001) and overall hospitalization (64% versus 2%, p<0.001). Primary fascial closure was achieved less often in ACS compared to non-ACS patients (46% versus 98%, p<0.001). Bowel resection was more frequent in ACS versus non-ACS patients, approaching statistical significance (49% versus 30%, p 0.056). ConclusionDuring the study period, almost one third of children who underwent urgent exploratory laparotomy had ACS and 64% died. Children undergoing evaluation for acute surgical abdomen may benefit from routine intraabdominal pressure measurement. Level of evidenceLevel III retrospective comparative study

Abstract PR086

Background & Objectives: To investigate the influence of paravertebral analgesia on renal function in patients with intra-abdominal hypertension after various emergency surgery. Materials & Methods: The work is based on a study of treatment outcomes in 52 patients with generalized peritonitis (mean age 43,2 ± 3,84 years). All the patients were divided into 2 groups. The first (control) group included 24 patients who received postoperative conventional (antibiotics, analgesics, infusion-transfusion therapy, stimulate bowel, etc.) therapy. The second group involved 28 patients whom paravertebral analgesia was included in the complex of intensive therapy at Th-9–10 (1% - 50 mg lidocaine bilaterally (1.2-1.4mg/kg) every 4 hours). The glomerular filtration rate (GFR), filtration gradient (FG), urea and creatinine of blood,hourly urine output, and a verbal pain scale were studied in both groups. Measurement of intra-abdominal pressure (IAP) was performed by the method I. Kron (1984) through the bladder. Results: The analysis showed that both groups against the background of intensive therapy tend to decrease of IAP and improvement in renal function. However, the most prominent and persistent changes were observed in patients 2nd group. In this group, the baseline IAP of 15,7 ± 0,4 mm Hg, after 24 hours, dropped to 8,1 ± 0,4 mm Hg (P <0.05). In day 1 the IAP of first-group patients actually remained unchanged, and only since day 2 the decline had been significant (p <0.05). Glomerular filtration rate in patients with usage of paravertebral analgesia after a day has increased from 76,7 ± 6,4 ml / min to 83,0 ± 4,5 ml / min, reaching 100,5 ± 8,8 ml / min to the end of day 3. Filtration gradient also had a similar picture. At the same time the indications significantly differ from group 1 at all stages of the research. Indicators of blood urea in group 2 patients significantly decreased only on day 3 of the study compared with baseline (6,8 ± 0,7 mmol / l). A similar pattern was observed with serum creatinine levels. No significant changes were observed in patients of group 1. Conclusion: Our studies show that blockade of the sympathetic innervation due to the administering of lidocaine in the paravertebral space leads to a decrease of pain impulses and reduce stress of the abdominal wall and results of reduction intra-abdominal pressure. Moreover renal hyperemia is improved, which obviously leads to an increase in glomerular filtration rate and urine output. Apparently this is due to improvement of renal blood flow, glomerular vazodilatation and reduction tubular reabsorption. However, in order to decrease in blood urea and creatinine more time is needed. Disclosure of Interest: None declared

The effect of different reference transducer positions measurement on intra-abdominal pressure in ICU patients

Objective To investigate the effect of different reference transducer positions measurement on intra-abdominal pressure (IAP) in ICU patients. Methods 31 cases of patients in ICU in need of measuring IAP were studied from January 2015 to July 2015 in this study. In each patient, transvesical and the direct methods were both used to measure IAP. Three sets of IAP measurements were obtained in the supine position, using the different reference levels and kept as IAPpubis, IAPmidax, IAPphlebostatic. The results were compared using Spearman rank correlation, paired t test and Bland - Altman statistics. Results When symphysis pubis was uesd, the result of direct method was (9.82±4.01) mmHg, the result of indirect method was (8.77 ± 4.48) mmHg (P <0.05), the correction between two methods was 0.967, P < 0.05. When midaxillary level was uesd to measure, the result of direct method was (11.74±4.71) mmHg, the result of indirect method was (11.65±4.63) mmHg, the correction between two methods was 0.972, P=0.10. When phlebostatic was uesd, the result of direct method was (10.98±4.65) mmHg, the result of indirect method was (10.38±4.75) mmHg, the correction between two methods was 0.970, P <0.05. The calculated bias between IAPmidax and IAPpubis was 2.9 mmHg, 95% agreement of limits was (- 0.8- 6.5) mmHg, and the maximum difference value was 11 mmHg. The calculated bias between IAPmidax and IAPphlebostatic was1.3 mmHg, 95% agreement of limits was -1.4-4.0 mmHg, and the maximum difference value was 4.2 mmHg. Conclusion In supine position, the value obtained via the bladder can reflect the true IAP, and the symphysis pubis or phlebostatic axis reference lines are not interchangeable with the midaxillary level. Key words: Intra- abdominal pressure; Abdominal compartment syndrome; Intra- abdominal hypertension; Reference

Preperitoneal Blockade in the Treatment of Patients with Perforated Gastroduodenal Ulcers and Peritonitis

The objective of this study was to improve the results of surgical treatment for patients with perforated gastroduodenal ulcers and peritonitis (PGDU-P) by applying the preperitoneal blockade. Materials and Methods: The study included 102 patients with perforated gastroduodenal ulcers (PGDU) complicated by peritonitis. Patients between 18 and 30 years were predominant. Pain was measured using the Visual Analog Scale (VAS) for Pain. The measurements of intra-abdominal pressure (IAP) by indirect infravesical tensometry were performed daily from the first day after the operation. Surgical interventions (laparotomy, laparoscopic suturing of PGDU, sanitation and drainage of the abdominal cavity) was performed under endotracheal anesthesia in all patients. Patients were divided into two groups depending on the method of postoperative analgesia. Patients of Group 1 (n=62) were subjected only to systemic opioid analgesia (an intramuscular injection of 1% solution of Promedol 1ml 4 times a day). Patients of Group 2 were subjected to systemic opioid analgesia and catheterization of the preperitoneal space for infusion of 0.5% solution of Novocaine in the postoperative period. Results: Postoperative analgesia using preperitoneal blockade after laparotomy and suturing of perforated gastroduodenal ulcers reduced the pain intensity by 2 times in comparison with conventional analgesia. The preperitoneal blockade after laparotomy in PGDU-P patients promotes the effective reduction of intra-abdominal hypertension (IAH) for 2 days. The comparative evaluation of the incidence of the early postoperative complications showed that using preperitoneal blockade contributed to significantly reducing the complications in Group 2. Postoperative mortality was 1.6% in Group 1 and 0 in Group 2. The average length of stay was reduced by approximately 3 days in Group 2 compared to traditional anesthesia. (Int J Biomed. 2016;6(2):114-118.).

Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients: Pilot study and review of the literature.

Burn patients are at high risk for secondary intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) due to capillary leak and large volume fluid resuscitation. Our objective was to examine the incidence the incidence of IAH and ACS and their relation to outcome in mechanically ventilated (MV) burn patients. This observational study included all MV burn patients admitted between April 2007 and December 2009. Various physiological parameters, intra-abdominal pressure (IAP) measurements and severity scoring indices were recorded on admission and/or each day in ICU. Transpulmonary thermodilution parameters were also obtained in 23 patients. The mean and maximum IAP during admission was calculated. The primary endpoint was ICU (burn unit) mortality. Fifty-six patients were included. The average Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores were 43.4 (± 15.1) and 6.4 (± 3.4), respectively. The average total body surface area (TBSA) affected by burns was 24.9% (± 24.9), with 33 patients suffering inhalational injuries. Forty-four (78.6%) patients developed IAH and 16 (28.6%) suffered ACS. Patients with ACS had higher TBSAs burned (35.8 ± 30 vs. 20.6 ± 21.4%, P = 0.04) and higher cumulative fluid balances after 48 hours (13.6 ± 16L vs. 7.6 ± 4.1 L, P = 0.03). The TBSA burned correlated well with the mean IAP (R = 0.34, P = 0.01). Mortality was notably high (26.8%) and significantly higher in patients with IAH (34.1%, P = 0.014) and ACS (62.5%, P < 0.0001). Most patients received more fluids than calculated by the Parkland Consensus Formula while, interestingly, non-survivors received less. However, when patients with pure inhalation injury were excluded there were no differences. Non-surgical interventions (n = 24) were successful in removing body fluids and were related to a significant decrease in IAP, central venous pressure (CVP) and an improvement in oxygenation and urine output. Non-resolution of IAH was associated with a significantly worse outcome (P < 0.0001). Based on our preliminary results we conclude that IAH and ACS have a relatively high incidence in MV burn patients compared to other groups of critically ill patients. The percentage of TBSA burned correlates with the mean IAP. The combination of high CLI, positive (daily and cumulative) fluid balance, high IAP, high EVLWI and low APP suggest a poor outcome. Non-surgical interventions appear to improve end-organ function. Non-resolution of IAH is related to a worse outcome.

Intra-abdominal Pressure Monitoring in Open Abdomen Management with Dynamic Abdominal Closure.

The importance of elevated intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) have been recognized in critical care for its potential damaging effects. But, quantification of IAP values may be useful as a clinical tool for determining efficacy of coughing and straining for functional recovery of OA patients. We would like to evaluate IAP generated in an OA patient and the effect of negative pressure therapy (NPT) and dynamic abdominal closure systems (ABRA) on the IAP values at rest and during coughing and straining and compare those with IAP measurements of closed abdomen after standard open elective colorectal surgery (non-OA). Eight OA and eight non-OA patients were included in this study. OA patient with NPT and ABRA (OA + NA), OA patient without NPT and ABRA completely unbraced (OA-NA) (NA stands for NPT and ABRA), and non-OA patients underwent IAP measurements at rest, during coughing, and during straining via transurethral catheter. There was no difference in the mean of IAP measurement at rest in OA-NA (6.1mmHg), OA + NA (6.5mmHg), and non-OA (6.0mmHg) patients. During coughing, IAP of OA-NA, OA + NA, and non-OA patients were 11.5, 19.1, and 22.0mmHg and during straining, IAP of OA-NA, OA + NA, and non-OA patients were 11.5, 17.5, and 23.5mmHg, respectively. Application of NPT in conjunction with ABRA did not increase IAP at rest but provided significant IAP increase in OA + NA patients, when compared to OA-NA patients during coughing and straining. NPT in conjunction with ABRA offers the advantage of increase of IAP during coughing and straining.

Study of the occurrence of intra-abdominal hypertension and abdominal compartment syndrome in patients of blunt abdominal trauma and its correlation with the clinical outcome in the above patients.

BackgroundIntra-abdominal pressure (IAP) measurements have been identified as essential for diagnosis and management of both intra-abdominal hypertension (IAH) and Abdominal compartment syndrome (ACS). It has gained prominent status in ICUs worldwide. We aimed to evaluate the utility of measurement of rise in bladder pressure to assess IAP levels in blunt abdominal trauma (BAT) patients.Patients and methodsThirty patients of BAT with solid organ injuries were included in this study. Intra-abdominal pressure was measured through a Foleys bladder catheter throughout their stay. Bladder pressure was compared with clinical parameters like mean arterial pressures(MAP), respiratory rate(RR), serum creatinine(SC) and abdominal girth(AG) and also with outcome in terms of intervention whether operative(OI) or non-operative(NOI).ResultsBladder pressure showed significant correlation with MAP (R = −0.418; P = 0.022), AG (R = 0.755; P = 0.000), SC (R = 0.689; P = 0.000) and RR (R = 0.537; P = 0.002). Bladder pressure (R = 0.851; P = 0.000), SC (R = 0.625; P = 0.000), MAP (R = −0.350; P = 0.058) and maximum AG difference (R = 0.634; P = 0.000) showed significant correlation with intervention. In total, 17 patients (56 %) required intervention, 9 patients (30 %) underwent NOI (pigtailing or aspiration) while 8 (27 %) needed OI. More than 3 derailed parameters were associated with 100 % intervention (Mean 3.47, SD-1.23). High APACHE III score on admission (>40) was associated with increased intervention (p = 0.001). Intervention correlates well with Grade of injury (p = 0.000) and not with number of organs injured (p = 0.061). Blood transfusion of 2 or more units of blood was associated with increased intervention (p = 0.000).ConclusionIncreased bladder pressure and other clinical parameters (MAP, SC, RR and change in AG) correlates well with intervention. Elevated bladder pressure correlates well with other clinical parameters in patients with BAT. Bladder pressure, SC, MAP, RR and AG difference can be used to determine the group of patients that can be managed conservatively and those that would benefit with minimal intervention or exploration. During Non-operative management (NOM) of patients with BAT and multiple solid organ injuries, IAP monitoring may be a simple and objective guideline to suggest further intervention whether NOI or OI. Although routine bladder pressure measurements will result in unnecessary monitoring of large number of patients it is hoped that patients with IAH can be detected early and subsequent ACS with morbid abdominal exploration can be prevented. However the criterion for non-operative failure and the point of decompression needs further refinement to prevent an increase of nontherapeutic operations.

The patient with intra-abdominal hypertension

An intra-abdominal hypertension (IAH) defined as a pathological increase in intra-abdominal pressure (IAP) is commonly found on ICU admission or during the ICU stay. Several studies confirmed that an IAH is an independent predictor for mortality of critically ill patients. The abdominal compartment syndrome (ACS) which is defined as a sustained IAP>20 mmHg (with or without an abdominal perfusion pressure [APP]<60mmHg) that is associated with new organ dysfunction or failure has a mortality of up to 60%. In general, an IAH may be induced by several intra-abdominal as well as extra-abdominal conditions. Reduced abdominal wall compliance, intra-abdominal pathologies (either of the peritoneal space or parenchymateous organs) may lead to an IAH. Most commonly, intra-abdominal infections and/or sepsis and severe trauma or burns are predisposing for an IAH. An early sign may be a decrease in urinary output. The effects of an increased IAP on cardiovascular function are well recognized and include negative effects on preload, afterload and contractility. However, all other compartments of the body may be affected by an IAH. Thus, by an increase of the respective compartment pressure, e.g. intracranial pressure, a poly-compartment syndrome may result. Adequate prevention, a forward-looking strategy, and objective techniques for measurement of IAP are required to avoid or early detect an IAH or ACS. Finally, an immediate and consequent interdisciplinary management using conservative, interventional and operative options are necessary to solve an IAH or ACS.

Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis.

IntroductionSevere acute pancreatitis may be complicated by intra-abdominal hypertension (IAH), abdominal compartment syndrome (ACS), and intestinal ischemia. The aim of this retrospective study is to describe the incidence, treatment, and outcome of patients with severe acute pancreatitis and ACS, in particular the occurrence of intestinal ischemia.MethodsThe medical records of all patients admitted with severe acute pancreatitis admitted to the ICU of a tertiary referral center were reviewed. The criteria proposed by the World Society of the Abdominal Compartment Syndrome (WSACS) were used to determine whether patients had IAH or ACS.ResultsFifty-nine patients with severe acute pancreatitis were identified. Intra-abdominal pressure (IAP) measurements were performed in 29 patients (49.2 %). IAH was present in all patients (29/29). ACS developed in 13/29 (44.8 %) patients. Ten patients with ACS underwent decompressive laparotomy. A large proportion of patients with ACS had intra-abdominal ischemia upon laparotomy: 8/13 (61.5 %). Mortality was high in both the ACS group and the IAH group.ConclusionThis study confirms that ACS is common in severe acute pancreatitis. Intra-abdominal ischemia occurs in a large proportion of patients with ACS. Swift surgical intervention may be indicated when conservative measures fail in patients with ACS. National and international guidelines need to be updated so that routine IAP measurements become standard of care for patients with severe acute pancreatitis in the ICU.

Intra-abdominal pressure: an integrative review.

ABSTRACTThere is a growing request for measuring intra-abdominal pressure in critically ill patients with acute abdominal pain to be clarified. Summarizing the research results on measurement of vesical intra-abdominal pressure and analyzing the level of evidence were the purposes of this integrative literature review, carried out based on the databases LILACS, MEDLINE and PubMed, from 2005 to July 2012. Twenty articles were identified, in that, 12 literature reviews, 4 descriptive and exploratory studies, 2 expert opinions, one prospective cohort study and one was an experience report. The vesical intra-abdominal pressure measurement was considered gold standard. There are variations in the technique however, but some common points were identified: complete supine position, in absence of abdominal contracture, in the end of expiration and expressed in mmHg. Most research results indicate keeping the transducer zeroed at the level of the mid-axillary line at the iliac crest level, and instill 25mL of sterile saline. Strong evidence must be developed.

Evolving Techniques in Pancreatic Surgery.

Evolving Techniques in Pancreatic Surgery.

Biophysical Validation of Intra- Abdominal Pressure and Transurethral Method

Biophysical Validation of Intra- Abdominal Pressure and Transurethral Method Objective: The increase in intra-abdominal pressure (IAP) is a well-documented phenomenon, directly associated with pathophysiological changes in all organic systems, increasing morbidity and mortality. The gold standard for its determination is the transurethral method (TM), which still today is surrounded by controversy. The purpose of the study is to, through physical principles, demonstrate IAP, validate TM and explain the variables that influence IAP. Materials and Methods: Development of a biophysical formulation, based on mechanics of fluids, to explain IAP, TM and its variables. Validation of the principles formulated in a non-living animal model, where all components that generate the IAP were determined. Determination of: IAP by TM, intragastric and direct method; gastric, bladder and abdominal areas and volumes; weight of all abdominal structures. Results: IAP values obtained by the several methods are within the limits described for the species with average values between 2.31 and 7.14 mmHg. Determination of the areas and strength of all anatomical structures allowed the replacement of values in the biophysical formulation and calculation of IAP. The mathematically calculation of IAP confirms the theoretical definition of IAP. This value when compared with the direct readings per sensor showed no statistical differences (P<0.05). IAP determination by direct method also showed no differences in the five body positions (P=0.765). Indirect methods revealed statistically significant differences from the direct method only in the Trendelenburg and reverse Trendelenburg. Breathing, muscle contraction, body position and water manometer position influence IAP measurement by indirect methods. Using digital treatment of images and using pixels analysis algorithms, it is also possible to determine bladder and gastric surface area, in average 6.17*10-3 ± 5.05*103 m2 and 3.55*10-2 ± 1.65*10-2 m2 respectively. Conclusion: This study improves the knowledge of the application of the direct and indirect methods to accesses IAP. The biophysical principles explain the formation of IAP and prove the accuracy of TM, explaining the variables which affect it.

Methodological background and strategy for the 2012-2013 updated consensus definitions and clinical practice guidelines from the abdominal compartment society.

The Abdominal Compartment Society (www.wsacs.org) previously created highly cited Consensus Definitions/Management Guidelines related to intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Implicit in this previous work, was a commitment to regularly reassess and update in relation to evolving research. Two years preceding the Fifth World Congress on Abdominal Compartment Syndrome, an International Guidelines committee began preparation. An oversight/steering committee formulated key clinical questions regarding IAH/ /ACS based on polling of the Executive to redundancy, structured according to the Patient, Intervention, Comparator, and Outcome (PICO) format. Scientific consultations were obtained from Methodological GRADE experts and a series of educational teleconferences were conducted to educate scientific review teams from among the wscacs. org membership. Each team conducted systematic or structured reviews to identify relevant studies and prepared evidence summaries and draft Grades of Recommendation Assessment, Development and Evaluation (GRADE) recommendations. The evidence and draft recommendations were presented and debated in person over four days. Updated consensus definitions and management statements were derived using a modified Delphi method. A writingcommittee subsequently compiled the results utilizing frequent Internet discussion and Delphi voting methods to compile a robust online Master Report and a concise peer-reviewed summarizing publication. A dedicated Paediatric Guidelines Subcommittee reviewed all recommendations and either accepted or revised them for appropriateness in children. Of the original 12 IAH/ACS definitions proposed in 2006, three (25%) were accepted unanimously, with four (33%) accepted by &gt; 80%, and four (33%) accepted by &gt; 50%, but required discussion to produce revised definitions. One (8%) was rejected by &gt; 50%. In addition to previous 2006 definitions, the panel also defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, abdominal compliance, and suggested a refined open abdomen classification system. Recommendations were possible regarding intra-abdominal pressure (IAP) measurement, approach to sustained IAH, philosophy of protocolized IAP management and same-hospital-stay fascial closure, use of decompressive laparotomy, and negative pressure wound therapy. Consensus suggestions included use of non-invasive therapies for treating IAH/ACS, considering body position and IAP, damage control resuscitation, prophylactic open abdomen usage, and prudence in early biological mesh usage. No recommendations were made for the use of diuretics, albumin, renal replacement therapies, and utilizing abdominal perfusion pressure as a resuscitation-endpoint. Collaborating Methodological Guideline Development and Clinical Experts produced Consensus Definitions/Clinical Management statements encompassing the most contemporary evidence. Data summaries now exist for clinically relevant IAH/ACS questions, which will facilitate future scientific reanalysis.

How to deal with an open abdomen?

Appropriate open abdomen treatment is one of the key elements in the management of patients who require decompressive laparotomy or in whom the abdomen is left open prophylactically. Apart from fluid control and protection from external injury, fluid evacuation and facilitation of early closure are now the goals of open abdomen treatment. Abdominal negative pressure therapy has emerged as the most appropriate method to reach these goals. Especially when combined with strategies that allow progressive approximation of the fascial edges, high closure rates can be obtained. Intra-abdominal pressure measurement can be used to guide the surgical strategy and continued attention to intra-abdominal hypertension is necessary. This paper reviews recent advances as well as identifying the remaining challenges in patients requiring open abdomen treatment. The new classification system of the open abdomen is an important tool to use when comparing the efficacy of different strategies, as well as different systems of temporary abdominal closure.