Reduction In Intra-abdominal Pressure Research Articles

Abdominal vacuum therapy is a component of DAMAGE CONTROL SURGERY tactics for combat trauma to the abdomen

The goal of the study was to improve the outcomes of surgical care and treatment for patients with combat-related abdominal injuries at different levels of medical support during combat operations by using abdominal vacuum therapy as a component of Damage Control Surgery tactics. At the II level of combat medical support within the Damage Control Surgery tactics, abdominal vacuum therapy was applied to 75 wounded male combatants with a combat abdominal injury, aged 37.4±8.3 years (main group). The comparison group consisted of 87 wounded patients aged 37.5±10.2 years, operated on using Damage Control Surgery tactics with drainage of the abdominal cavity and suturing of the skin only. 40.0% of the wounded in the main group and 46.0% of the comparison group were admitted with signs of traumatic shock of various degrees. According to the AdTS scale, 78.7% of the wounded in the main group were admitted in a serious condition, 21.3% – in an extremely serious condition; in the comparison group, 74.7% were in severe condition, 25.3% were in extremely severe condition. In 57.3% of the wounded of the main group, abdominal vacuum therapy was carried out in the irrigation-flow mode. 24.0% used standard bandages for abdominal vacuum therapy, 76.0% used partially improvised ones. The level of negative pressure was set in the range of 40-125 mm Hg in constant mode. Intra-abdominal pressure was measured by a standard method (through the bladder) at admission and after surgery. The assessment of the state of the abdominal cavity in the I and III phases of Damage Control Surgery was carried out according to the Abdominal Cavity Index scale – an integral assessment expressed in points based on factors that can be assessed visually during surgery. The volume of surgical interventions in the 1st phase of the Damage Control Surgery tactic depended on the nature of the damage to the abdominal organs and the condition of the wounded. After the completion of Phase I of Damage Control Surgery tactics, all wounded were evacuated by road medical transport and medical helicopters to the next level of medical support, with abdominal vacuum therapy during evacuation in the main group and Damage Control Resuscitation measures. Under the effect of abdominal vacuum therapy, the reduction of intra-abdominal pressure in the main group was pronounced (Δ=9.2; p<0.01) than in the comparison group (Δ=6.1; p<0.01). Abdominal vacuum therapy during the II phase of the Damage Control Surgery tactic made it possible to clean the abdominal cavity better (p<0.0001) than in the comparison group and provided better preparation for the implementation of the III phase of this tactic. As a result, reliable protection from external factors, active prevention of intra-abdominal pressure and rehabilitation of the abdominal cavity during the application of abdominal vacuum therapy during the II phase of Damage Control Surgery tactics in the main group of wounded after obstructive resections of the small intestine in the I phase made it possible to completely abandon terminal stomas in the III phase (in the comparison group – 5) in favor of the formation of small bowel intestinal anastomoses, and during obstructive colon resections, the number of terminal colostomas in the main group was reduced to 50.0% (in the comparison group -90.9%, р=0.004), also in favor of the formation anastomoses, which significantly improved the functional results of providing assistance to the wounded with a combat abdominal injury. The use of abdominal vacuum therapy during phases I-II of the Damage Control Surgery (DCS) tactics allows for the optimization of the scope of surgical interventions in phase III of Damage Control Surgery and significantly improves the functional outcomes of surgical care and treatment for patients with combat abdominal injuries at various levels of medical support during combat operations.

Effect of Different Methods of Abdominal Decompression on the Dynamics of Intra-Abdominal Pressure in the Early Postoperative Period in Patients with Secondary Diffuse Peritonitis: Observational Study

Background. Intra-abdominal hypertension complicates the course of secondary diffuse peritonitis in at least 60–70% of cases. Abdominal decompression is an essential component in the complex of therapeutic measures in patients with secondary diffuse peritonitis. However, no clear criteria for choosing the method and timing of abdominal decompression have been developed so far. The effectiveness of its use in various forms of peritonitis remains controversial.Objectives — to study the dynamics of intra-abdominal pressure in the early postoperative period when using various methods of abdominal decompression in patients with secondary diffuse peritonitis.Methods. The work was performed on the basis of an observational clinical study under the auspices of Regional Clinical Emergency Hospital over a period from January 2021 to December 2022. The authors studied intra-abdominal pressure in 74 patients with secondary diffuse peritonitis in the early postoperative period. In 39 (52.7%) patients (group 1), decompression was carried out in the form of prolonged nasogastric intubation. 15 (20.3%) patients (group 2) underwent nasointestinal intubation. Group 3 was represented by 10 patients (13.5%) which were affected by open abdomen technology and vacuum assisted closure (VAC). Group 4 included patients with vacuum-assisted laparostoma who underwent nasointestinal intubation. The severity of peritonitis was assessed using WSES cIAIs Score and Mannheim Peritonitis Index. The dynamics of intra-abdominal pressure was determined through the urinary catheter using the Uno Meter Abdo Pressure® Kit (Unomedical, Russia) before surgery and within 5 days of the postoperative period. Statistical analysis was based on non-parametric Wilcoxon test for comparing the values of the same group at different periods of observation. Mann-Whitney U-test was used to compare absolute values in different groups.Results. Nasogastric tube did not provide an acceptable reduction in intra-abdominal pressure, especially in patients with severe forms of peritonitis. Prolonged nasointestinal intubation contributed to a steady decrease in intra-abdominal pressure throughout the postoperative period, while simultaneous intubation resulted in an increase in intra-abdominal hypertension after a decline in values one day after surgery. The best results of intra-abdominal pressure dynamics were observed in case of vacuum-assisted laparostomy and its combination with nasointestinal intubation. Throughout the postoperative period, the intra-abdominal pressure did not exceed 15–17 mmHg. This method can be used only in treatment of the most severe forms of peritonitis, with indications for sanitation relaparotomy and in case of threatened abdominal compression syndrome.Conclusion. The data obtained enable the process of choosing surgical tactics and method of abdominal decompression to be optimized with respect to the severity of peritonitis and intra-abdominal hypertension.

Assessing the Usefulness of Severity Markers in Women with Ovarian Hyperstimulation Syndrome.

The present study aims to assess the usefulness of severity markers in women with ovarian hyperstimulation syndrome (OHSS). An observational study was designed including 76 women with varying degrees of severity of OHSS. Clinical history, physical examination, laboratory tests, and ultrasound measurement of the ovarian size and ascites index were carried out in all patients. Intra-abdominal pressure (IAP) was measured using an intravesical Foley Manometer catheter. Ascites index and ovarian volume increased progressively being highest in the most severe stage of OHSS. The median IAP in mild OHSS was found to be lower than that in the moderate and severe OHSS (4.0mm, 12mm, and 16.0mm, respectively). Critical cases of OHSS presented the highest IAP (25.0mm). IAP did not reach the level of intra-abdominal hypertension in mild OHSS, whereas moderate and severe OHSS was associated with intra-abdominal hypertension grade I and grade II-III, respectively. Values of IAP in critical OHSS were found similar to those observed in abdominal compartment syndrome patients. The IAP showed a strong positive correlation with ovarian volume and ascites index. The reduction of IAP after paracentesis was greater among critical OHSS patients. The ovarian volume and the level of intra-abdominal hypertension are related to the severity of OHSS and are of particular importance in the initialization of the syndrome. Ascites index is simple and convenient and can serve as an indirect marker of the abdominal reserve volume. In conjunction with clinical and laboratory data, ascites index and IAP values might be indicators for paracentesis.

Acute Cardiorenal Syndrome in Heart Failure: from Dogmas to Advances.

This review aims to summarize our current understanding and management strategies of acute cardiorenal syndrome (CRS). The definition of acute CRS remains debated, in part due to the lack of reliable insights into salt and water handling of the kidneys beyond impairment in glomerular filtration. Protocolized use of loop diuretics to ensure adequate delivery to their target of action, as well as segmental tubular blockade with adjunctive use of thiazide diuretics, acetazolamide, amiloride, or sodium-glucose transporter 2 (SGLT2) inhibitors, may result in more effective natriuresis in patients with acute CRS who exhibit diuretic resistance. Other strategies, such as modulating renal sodium avidity with the use of hypertonic saline, reduction of intra-abdominal pressure, or device-based salt and volume removal, are promising and warrant further investigation. Acute CRS remains a significant contributor of morbidity and mortality for the acute heart failure population. New strategies have challenged current dogmas in our understanding of its pathophysiology, which may lead to potential new treatment approaches.

The effect of low- versus normal-pressure pneumoperitoneum during laparoscopic colorectal surgery on the early quality of recovery with perioperative care according to the enhanced recovery principles (RECOVER): study protocol for a randomized controlled study

BackgroundThere is increasing evidence for the use of lower insufflation pressures during laparoscopic surgery. Deep neuromuscular blockade allows for a safe reduction in intra-abdominal pressure without compromising the quality of the surgical field. While there is considerable evidence to support superior surgical conditions during deep neuromuscular blockade, there is only a limited amount of studies investigating patient outcomes. Moreover, results are not always consistent between studies and vary between different types of laparoscopic surgery. This study will investigate the effect of low-pressure pneumoperitoneum facilitated by deep NMB on quality of recovery after laparoscopic colorectal surgery.MethodsThe RECOVER study is a multicenter double-blinded randomized controlled trial consisting of 204 patients who will be randomized in a 1:1 fashion to group A, low-pressure pneumoperitoneum (8 mmHg) facilitated by deep neuromuscular blockade (post tetanic count of 1–2), or group B, normal-pressure pneumoperitoneum (12 mmHg) with moderate neuromuscular blockade (train-of-four response of 1–2). The primary outcome is quality of recovery on postoperative day 1, quantified by the Quality of Recovery-40 questionnaire.DiscussionFew studies have investigated the effect of lower insufflation pressures facilitated by deep neuromuscular blockade on patient outcomes after laparoscopic colorectal procedures. This study will identify whether low pressure pneumoperitoneum and deep neuromuscular blockade will enhance recovery after colorectal laparoscopic surgery and, moreover, if this could be a valuable addition to the Enhanced Recovery After Surgery guidelines.Trial registrationEudraCT 2018-001485-42. Registered on April 9, 2018. Clinicaltrials.govNCT03608436. Registered on July 30, 2018.

Reduction of intra-abdominal pressure after percutaneous catheter drainage of pancreatic fluid collection predicts survival

ObjectiveIntra-abdominal hypertension (IAH) can adversely affect the outcome in patients of acute pancreatitis (AP). Effect of percutaneous drainage (PCD) on IAH has not been studied. We studied the effect of PCD on IAH in patients with acute fluid collections. Material and methodsConsecutive patients of AP undergoing PCD between Jan 2016 and May 2018 were evaluated for severity markers, clinical course, hospital and ICU stay, and mortality. Patients were divided into two groups: with IAH and with no IAH (NIAH). The two groups were compared for severity scores, organ failure, hospital and ICU stay, reduction in IAP and mortality. ResultsOf the 105 patients, IAH was present in 48 (45.7%) patients. Patients with IAH had more often severe disease, BISAP ≥2, higher APACHE II scores and computed tomography severity index (CTSI). IAH group had more often OF (87.5% vs. 70.2%, p = 0.033), prolonged ICU stay (12.5 vs. 6.75 days, p = 0.007) and higher mortality (52.1% vs. 15.8%, p < 0.001). After PCD, IAP decreased significantly more in the IAH group (21.85 ± 4.53 mmHg to 12.5 ± 4.42 mmHg) than in the NIAH group (12.68 ± 2.72 mmHg to 8.32 ± 3.18 mmHg), p = <0.001. Reduction of IAP in patients with IAH by >40% at 48 h after PCD was associated with better survival (63.3% vs. 36.7%, p = 0.006). ConclusionWe observed that patients with IAH have poor outcome. PCD decreases IAP and a fall in IAP >40% of baseline value predicts a better outcome after PCD in patients with acute fluid collections.

Ascites in acute pancreatitis: not a silent bystander

Background & aimAscites in patients with acute pancreatitis (AP) is understudied although recent literature hints at its evident role in the final outcome. This study was planned to study the characteristics of ascites in patients of AP and its effect on the disease course and outcome. MethodsConsecutive patients of AP were studied and patients with or without ascites were evaluated for the baseline parameters and severity assessment. Ascites was quantified and fluid analyzed for its characteristics. Intraabdominal pressure (IAP) was monitored. The various outcome parameters were compared between the two groups of patients with and without ascites. ResultsOf the cohort of 213 patients, 82 (38.5%) developed ascites. Ascites group had significantly higher rates of organ failure (p = 0.001), necrosis (p=<0.001) and higher severity assessment scores. The ascites group had significantly longer hospital and ICU stay and higher ventilator days compared to the non-ascites group. Mortality was also higher in the ascites group (34.1% vs 8.45; p = 0.001). Majority of patients with ascites had moderate to gross ascites (75.6%), low serum ascites albumin gradient (87.8%) with low amylase levels (71.9%). Sub-group analysis in ascites group showed that patients with fatal outcome had higher rates of moderate to gross ascites, higher baseline IAP and lower reduction in IAP after 48 h. Moderate to gross ascites and grades of intra-abdominal hypertension (IAH) were significant predictors of mortality (AUC – 0.76). ConclusionAP patients with ascites have a more severe disease with poorer outcome. Higher degrees of ascites and IAH grades are significant predictors of mortality.

Early Paracentesis-Induced Thrombocytopenia (EPIT): A Retrospective Study With Novel Insights Regarding Splenic Hemodynamics

Introduction: Thrombocytopenia is commonly observed in patients with advanced liver disease. The occurrence of a temporary reduction in platelet count after paracentesis has not been described in the literature. An acute drop in platelet count after paracentesis often leads to unnecessary tests to search for causes such as heparin-induced thrombocytopenia (HIT). The primary purpose of this study is to document this phenomenon occurring in the early post-paracentesis period and test the hypothesis that this is related to a temporary reduction in intra-abdominal pressure and increase in splenic arterial flow leading to splenic congestion and increased splenic sequestration of platelets. Methods: A retrospective review of patients who underwent inpatient paracentesis was performed. The primary outcome was an acute reduction in platelet count post-paracentesis. The secondary outcome was a concomitant drop in WBC and RBC counts. Using multiple regressions, we examined variables including etiology of the liver disease, amount of ascitic fluid removed, presence of infection, splenomegaly, use of antibiotics, intravenous fluids (IVF), steroid use, and venous thromboembolism prophylaxis that may independently predict changes in platelet, WBC and RBC counts after paracentesis. Results: Out of 220 patients who underwent inpatient paracentesis, 190 (86.4%) patients had a reduction in platelet count (p < .001). Reductions in Platelet, WBC and RBC after paracentesis were 14.5% (p < .001), 14.2% (p < .001) and 5.9%, respectively (p < .001). Among multiple predictors of a drop in platelet count in the early post-paracentesis period, only the amount of fluid removed was a significant predictor (p < .001). Conclusion: We coined this phenomenon of acute drop in platelet count after paracentesis - Early paracentesis induced thrombocytopenia (EPIT) - that represents an absolutely new mechanism of thrombocytopenia in patients with advanced liver disease. This phenomenon is related temporary mechanical alteration in splenic hemodynamics due to reduction in intra-abdominal pressure (IAP) post-paracentesis and increase in cardiac output with subsequent increase in splenic congestion and platelet sequestration. Physicians and other practitioners caring for patients with chronic liver disease need to be aware of this condition and pathophysiological phenomenon to reduce unnecessary testing, patient aggravation, and reduce healthcare costs.915_A Figure 1. Platelet counts pre- and post-paracentesis.915_B Figure 2. Patient Characteristics:915_C Figure 3. Variable affecting change in Platelet count.

Effect of Body Mass on Oxygenation and Intra-Abdominal Pressure When Using a Jackson Surgical Table in the Prone Position During Lumbar Surgery.

Prospective observational study. To test the hypothesis that different types of surgical frame and the patient's body mass index (BMI) can affect pulmonary compliance, intra-abdominal pressure (IAP), and oxygenation. The oxygenation index (PaO2/FiO2) and IAP are known to be associated with BMI when patients are in the supine position. However, there are few reports on the correlation between BMI, the oxygenation index, and IAP in the prone position, especially when a Jackson surgical table is used. Thirty-seven adult patients were divided into two groups according to BMI: normal-weight patients (n = 19, BMI: 18.5-24.9 kg m) and overweight patients (n = 18, BMI ≥ 25 kg m). After the induction of general anesthesia, patients were turned to the prone position onto either a Jackson surgical table (Mizuho OSI) or a general surgical table (MAQUET; foam pad, China). The patient's IAP, peak airway pressure, pulmonary dynamic compliance (Cdyn), and oxygenation index were recorded. In overweight patients, there was a greater increase in peak airway pressure and a greater decrease in Cdyn observed when a general surgical table was used compared with the Jackson surgical table. When the Jackson surgical table was used, there was a greater increase in the oxygenation index and a greater decrease in IAP. There was a significant negative correlation between the oxygenation index and BMI and a significant positive correlation between IAP and BMI in the prone position. Turning patients from the supine to the prone position during anesthesia results in an increase in the oxygenation index and a decrease in IAP. Both of these factors are dependent upon the type of surgical frame used and the patient's BMI. The reduction in IAP was particularly significant when a Jackson surgical table was used for overweight patients. 4.

Successful peritoneal dialysis using a percutaneous tube for peritoneal drainage in an extremely low birth weight infant: a case report

BackgroundPeritoneal dialysis (PD) for acute kidney injury (AKI) of newborns has been performed safely. AKI occurs in 8 to 24% of extremely low birth weight (ELBW) infants. Although PD has only been used occasionally in ELBW infants, prognosis is poor for ELBW infants with AKI. Several reports have described successful PD in these infants, but no guideline-based evidence concerning indications for renal replacement therapy in ELBW infants are currently available. Here, we report on our experience with PD in an ELBW infant with AKI resulting from septic shock.Case presentationA male was born at 24 weeks and 3 days gestation weighing 264 g by emergency cesarean section due to complications of pregnancy in a patient with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. On day of life (DOL) 15, the inability to ventilate, along with cardiovascular dysfunction, acute kidney injury, and ascites under tension led to the tentative diagnosis of abdominal compartment syndrome (ACS). On DOL 17, placement of a percutaneous drainage tube immediately released compression of the tense abdomen. Although intra-abdominal pressure reduction with percutaneous drainage temporarily improved respiratory status, circulatory impairment persisted and infections were not well controlled. Finally, the patient developed anuria. On DOL 21, peritoneal dialysis (PD) was started by initially inserting a drainage tube. Although the patient had catheter-associated peritonitis, urine output improved by DOL 44 and PD was discontinued on DOL 53. On DOL 75, extubation was conducted without circulatory dysfunction. The patient was discharged on DOL 224.ConclusionsWe emphasize that starting PD treatment before the onset of anuria is important in ELBW infants with AKI. Although the catheter used in our case was initially inserted for drainage of ascites, this type of catheter is sufficiently useful for PD in ELBW infants, and PD using a drainage tube may represent a safe, effective, and minimally invasive treatment for ELBW infants. To our knowledge, this is the first report to describe the use of a percutaneous tube to conduct successful PD for peritoneal drainage in an ELBW infant. This is the lowest-weight ELBW infant with successful PD reported to date.

Sa1365 - Reduction in Intra-Abdominal Pressure After Percutaneous Catheter Drainage Predicts Outcome in Patients of Severe Acute Pancreatitis

Sa1365 - Reduction in Intra-Abdominal Pressure After Percutaneous Catheter Drainage Predicts Outcome in Patients of Severe Acute Pancreatitis

A prospective double-blinded randomized controlled trial comparing systemic stress response in Laparoascopic cholecystectomy between low-pressure and standard-pressure pneumoperitoneum

IntroductionLaparoscopic cholecystectomy (LC) has become the gold-standard treatment for gallstone diseases. However, despite huge reduction in operative injury, systemic stress response remains high. This randomized controlled trial (RCT) aimed to compare systemic stress response between 2 different techniques of CO2 pneumoperitoneum. MethodsTrough a prospective, double-blinded RCT, serum levels of cortisol, adrenaline, glucose, and C-reactive protein (CRP) were compared between the two groups consisted of 50 patients undergoing LC under low-pressure and standard-pressure CO2 pneimoperitoneum. ResultsA total of fifty patients undergoing LC were equally assigned to 2 groups of twenty five patients. Average age was 48 ± 13.8 years (range, 19–74 years). Operative time was similar between standard-pressure group (47.8 ± 16.8 min) and low-pressure group (53.6 ± 25.1). Moreover, intra-operative IV volume administration and urine output did not differ significantly between the 2 groups (p > 0.05). Although the average heart rate and mean arterial pressure were slightly higher in a standard-pressure group compared with a low-pressure group, serial measurements of these parameters were statistically similar between the 2 groups. Serial changes of serum levels of cortisol, glucose, adrenaline, and CRP were compared between surgery day, postoperative 6-h and 1st postoperative day, which did not differ significantly between the standard-pressure and the low-pressure groups (p > 0.05). ConclusionOur study did not reveal any alteration in systemic stress response with reduction in intra-abdominal pressure of pneumoperitoneum in LC. RCT Registrationirct.ir ID: IRCT201110072982N5.

Treatment of Intestinal Paralysis Using Revised Major Purgative Decoction Combined with Nasointestinal Decompression: Experience with 31 Patients.

To investigate the feasibility of using a revised major purgative decoction in combination with nasointestinal decompression for the treatment of intestinal paralysis. 31 patients with intestinal paralysis underwent gastrointestinal decompression. A fluoroscopic guided tri-lumen nasointestinal decompression tube was placed, and the patients were randomly divided into two groups: patients in the study group (n=16) received 100ml of a revised major purgative decoction infused through the decompression tube, three times daily; and patients in the control group (n=15) were given neostigmine 0.5mg by muscle injection, twice daily. The clinical presentations and imaging findings both before and after the treatment were recorded and compared. A significant increase in decompression volumes and a rapid reduction in intra-abdominal pressure (IAP) were observed in all patients undergoing nasointestinal decompression (p<0.05). Patients in the study group achieved significantly earlier restoration of intestinal function by presenting with earlier restoration of bowel sound, earlier passage of flatus and stools (p<0.05). The deployment of gastrointestinal decompression using a long tri-lumen nasointestinal decompression tube is effective in reducing IAP and relieve abdominal distension, whereas revised major purgative decoction can enhance the recovery of intestinal function. The joint application of these two strategies is effective and safe in the management of intestinal paralysis and is worthy of adoption in clinical settings.

Diagnosis and treatment of abdominal compartment syndrome secondary to fulminant acute pancreatitis

Objective To study the treatment of abdominal compartment syndrome(ACS) secondary to fulminant acute pancreatitis (FAP).Method A retrospective study was conducted from Jan.2009 to Dec.2011 to analyze the therapeutic results of 18 patients with ACS secondary to FAP.Results Three out of 7 patients who received non-operative therapy died (mortality rate 42.9％).Three out of 11 patients treated with early surgery died (mortality rate 27.3％),which was significantly better than those patients treated conservatively.Conclusion A reduction in intra-abdominal pressure improved the function of the viscera in the treatment of ACS secondary to FAP.The decompressive effects of early surgery was efficacious,and it reduced the mortality rate. Key words: Pancreatitis, acute necrotizing; Abdominal compartment syndrome

Bradycardia during laparoscopic surgery due to high flow rate of CO2insufflation

Bradycardia during laparoscopic surgery due to high flow rate of CO₂insufflation

L23. Short and long term neurological consequences of (pre) eclampsia

Pre-eclampsia remains a leading cause of maternal and fetal morbidity and mortality. Despite extensive research, the mechanisms that cause pre-eclampsia are unknown and it has been considered to be the ‘disease of theories’. Hippocrates wrote in one of his Aphorisms that ‘convulsions take place from either repletion or depletion’. Since then, obstetricians have been divided on the question of which factor accounted for the convulsions observed during childbirth. Some considered that a sudden reduction in intra-abdominal pressure at delivery led to a pooling of blood diverted from the brain, causing collapse of the cerebral blood vessels and convulsions. Others postulated that cerebral congestion, secondary to compression of the abdominal organs by the large uterus, diverted blood to the brain, causing eclamptic convulsions. It is the purpose of this review to examine those theories about the cause of pre-eclampsia for which modern evidence is available. At present, it is believed that the pathological chain of events leading to pre-eclampsia is scheduled in two steps: an absolute or relative placental ischaemia is followed by a diffuse endothelial cell activation, which causes the clinical features of the disease.

Haemodynamic response to abdominal decompression in acute Budd–Chiari syndrome

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome commonly occur in patients with liver disease. We compared haemodynamic variables pre- and post-abdominal decompression in patients with acute Budd-Chiari syndrome (BCS) and patients with chronic liver disease (CLD), ascites and IAH. Patients with IAH admitted to the Liver ICU, King's College Hospital were studied. Transpulmonary thermodilution cardiac output (CO) monitoring was performed with the PiCCO(®) system. Ten patients with decompensated BCS (median age 39 years, 20-52) and eight patients with CLD (59 years, 33-65) and tense ascites requiring paracentesis were studied. Intra-abdominal pressure (IAP) was raised in both groups pre-intervention (BSC 23 mmHg, 17-40; CLD 26, 20-40). Intrathoracic blood volume (ITBVI) was persistently low in the BCS group (632 ml/m(2) , 453-924) despite volume resuscitation. Post-intervention, reduction in IAP was noted in both groups (BCS P<0.001, CLD P<0.0001). The ITBVI increased (P=0.001) in the BCS group only. An increase in cardiac index (CI) and stroke volume index (SVI) was noted in both groups (BCS: CI P=0.003, SVI: P=0.007; CLD: CI P=0.005, SVI P=0.02). The central venous pressure did not change in either group and did not correlate with markers of flow (CI, SVI) or IAP. Both groups demonstrated an inverse relationship between IAP, CI and SVI. Patients with BCS and IAH have evidence of central hypovolaemia. In addition to raised IAP, hepatic venous obstruction and caudate lobe hypertrophy limit venous return in patients with BCS. Reduction in IAP and re-establishment of caval flow restores preload with improvement in CO.

Renal resistive index and renal function before and after paracentesis in patients with hepatorenal syndrome and tense ascites

To assess the effect of reducing intra-abdominal pressure (IAP) by paracentesis on renal resistive index (RI), hemodynamics and renal function. Uncontrolled trial in a university gastroenterological intensive care unit. Twelve spontaneously breathing cirrhotic patients with hepatorenal syndrome, tense ascites and a clinical indication for paracentesis. Paracentesis and substitution of albumin. Hemodynamic variables were assessed by transpulmonary thermodilution, RI was determined by Doppler ultrasound of renal interlobar arteries. After paracentesis and albumin substitution, there was a significant decrease of IAP (20 mmHg (19-22) to 12 mmHg (10-13), systemic vascular resistance index (from 1,243 dyn s/cm(5)/m(2) (1,095-1,745) to 939 dyn s/cm(5)/m(2) (812-1,365); p = 0.005) and RI (from 0.848 (0.810-0.884) to 0.810 (0.780-0.826); p = 0.003). Arterial compliance increased from 1.33 mL/mmHg (0.89-1.74) to 1.71 mL/mmHg (1.21-2.12), pulse pressure index remained unchanged. Creatinine clearance (ClCreat) increased significantly from 5 mL/min (0-28) to 9 mL/min (0-36) (p = 0.018) and urinary output from 12 mL/h (0-49) to 16 mL/h (0-64) (p = 0.043). In patients with cirrhosis, HRS and tense ascites, IAP may contribute to renal dysfunction. Reduction of IAP following paracentesis and albumin substitution may improve ClCreat, probably by improving renal blood flow as reflected by decreasing RI in Doppler ultrasound.

Closure of a contained open abdomen using a bipedicled myofascial oblique rectus abdominis flap technique

A contained open abdomen is commonly used during damage control laparotomy and consists of the temporary coverage of the abdomen for protection of the viscera and reduction of intra-abdominal pressure. Definitive closure of a contained open abdomen is technically difficult due to the inability to obtain primary fascial suture. The insertion of a prosthetic mesh can be complicated with enterocutaneous fistula, and other definitive closure techniques need several surgical procedures. We describe a low cost technique that allows definitive closure of large abdominal wall defects avoiding the risk of intestinal fistula.

Prompt reduction in Intra-Abdominal Pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated Heart Failure

Prompt reduction in Intra-Abdominal Pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated Heart Failure