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294
Abdominal Compartment Syndrome
Commentary
Rao R. Ivatury
The most definitive management, prophylactic or therapeutic, of IAH and ACS is surgical
treatment and temporary abdominal closure (TAC) and non-suture of abdominal fascia. The
preceding chapters of this book have substantiated the superiority of this “open-abdomen”
approach in reducing multiple organ failure and the resulting mortality in this high-risk group
of patients. Dampening the enthusiasm for this strategy is the complex management of the
open abdomen in the critically ill patient. The need for extensive nursing care, the adverse
effects of exposed bowel in terms of serositis and secondary hemorrhage, fluid losses from
dessication, the theoretical possibility of “tertiary peritonitis”, aesthetic unpalatability and the
most dreaded complication of fistulization of bowel in the open abdomen, the so-called
“entero-atmospheric” fistula have been just some of the deterrents to this approach. As “damage-control” operations in the trauma scenario became ever more frequent, trauma surgeons
have become comfortable with the open-abdomen and are now the champions of the concept
of IAH and ACS . Converts in other specialities of surgery have been scarce for many reasons,
not the least of which is the need to deal with the open abdomen. They cite the convenient
excuse of loss of fascial closure until a subsequent readmission for complex prosthetic and
plastic hernia repairs.
The last decade has seen remarkable improvements in our ability to deal with the open
abdomen in the ICU . Better prosthetic meshes have become available for hernia closure. Even
more important, new concepts in vacuum-assisted closure have helped us achieve abdominal
closure in a very high percentage of these patients. The complication of bowel fistulas has been
reduced to less than five percent.
This chapter on surgical treatment is a distillation of this experience and is comprised of
three sections. Kaplan builds a succinct summary of the problems and solutions in dealing with
the open abdomen on a scientific basis of our understanding of IAH and ACS. Goettler, Rotondo
and Schwab take the reader by hand step-by-step from the decision to do”damage-control” and
the conduct of the stages of this approach. They provide valuable insights in the management
of stomas and tubes in the open abdomen and the methods of temporary closure. Zsolt, Balogh
and Moore, leaders in vacuum-assisted closure, give a succinct account, rich in pearls, of their
current practice. The reader will excuse the repetition in these three sections. The editors have
consciously and deliberately included all of them to underscore the surgical approach. It is
fervently hoped that these sections, packed with practical pointers form pioneers in the field ,
will enable more clinicians to embrace the concept of the open abdomen and reap the benefits
of temporary abdominal closure in the management of the critically ill or injured patient.
References
1. Asensio JA, McDuffie L, Petrone P et al. Reliable variables in the exsanguinated patient which
indicate damage control and predict outcome. Am J Surg 2001; 182:743-751.
2. Shapiro MB, Jenkins DH, Schwab CW et al. Damage control: Collective review. J Trauma 2000;
49:969-978.
3. Raeburn CD, Moore EE, Biffl WL et al. The abdominal compartment syndrome is a morbid
complication of postinjury damage control surgery. Am J Surgery 2001; 182:542-546.
4. Nicholas JM, Rix EP, Easley A et al. Changing patterns in the management of penetrating abdominal trauma: The more things change, the more they stay the same. J Trauma 2003;
55:1095-1110.
5. Cheatham ML, Safcsak K, Lierena LE et al. Long-term physical, mental, and functional consequences of abdominal decompression. J Trauma 2004; 56(2):237-242.
6. Mayberry JC. Bedside open abdominal surgery. Critical Care Clinics 2000; 16(1):151-172.
7. Sugrue M, Jones F, Janjua K et al. Temporary abdominal closure: A prospective evaluation of its
effects on Renal and Respiratory Physiology. J Trauma1998; 45(5):914-921.
8. Losanoff JE, Richman BW, JonesJW et al. Temporary abdominal coverage and reclosure of the
open abdomen: Frequently asked questions. Journal of American College of Surgeons 2002(1);
195:105-115.
295Surgical Management of Abdominal Compartment Syndrome
9. Hirshberg A, Stein M, Adar R et al. Damage control surgery. Reoperation planned and unplanned.
Surgical Clinics of North America 1997; 77(4):897-907.
10. Marshall JC, Innes M, Dellinger RP et al. Concise definitive review. Intensive care unit management of intra-abdominal infection. Critical Care Medicine 2003; 31(8):2228-2237.
11. Mayberry JC, Welker KJ, Goldman RK et al. Mechanism of acute ascites formation after trauma
resuscitation. Arch Surg 2003; 138:773-776.
12. Schein M, Wittmann DH, Holzheimer R et al. Hypothesis: Compartmentalization of cytokines in
intraabdominal infection. Surgery 1996; 119(6):694-700.
13. Adams JM, Hauser CJ, Livingston DH et al. The immunomodulatory effects of damage control
abdominal packing on local and systemic neutrophil activity. J Trauma 2001; 50:792-800.
14. Rezende-Neto JB, Moore EE, Melo de Andrade MV et al. Systemic inflammatory response secondary to abdominal compartment syndrome. Stage for multiple organ failure. J Trauma 2002;
53:1121-1128.
15. Martin RR, Byrne M. Damage control surgery. Post operative care and compications of damage
control surgery. Surgical Clinics of North America 1997; 77(4):929-942.
16. Ivatury RR, Porter JM, Simon RJ et al. Intra-abdominal hypertension after life threatening penetrating abdominal trauma. Prophylaxis, incidence, and clinical relevance to gastric mucosal pH
and abdominal compartment syndrome. J Trauma 1998; 44(6):1016-1023.
17. Chavarria-Aguilar M, Cockerham WT, Barker DE et al. Management of destructive bowel injury
in the open abdomen. J Trauma 2004; 56(3):560-564.
18. Fabian TC, Croce MA, Pritchard FE et al. Planned ventral hernia. Staged management for acute
abdominal wall defects. Ann of Surg 1994; 219(6):643-653.
19. Ivatury RR, Diebel L, Porter JM et al. Damage control surgery: Intra-abdominal hypertension and
the abdominal compartment syndrome. Surgical Clinics of North America 1997; 77(4):783-800.
20. Moore EE. Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J
Surg 1996; 172(5):405-410.
21. Mayberry JC, Goldman RK, Mullins RJ et al. Surveyed opinion of American trauma surgeons on
the prevention of the abdominal compartment syndrome. J Trauma 1999; 47(3):509-514.
22. Mayberry JC, Mullins RJ, Crass RA et al. Prevention of abdominal compartment syndrome by
absorbable mesh prosthesis closure. Arch Surg 1997; 132:957-962.
23. Offner PJ, Laurence de Souza A, Moore EE et al. Avoidance of abdominal compartment syndrome
in damage-control laparotomy after trauma. Arch Surg 2001; 136:676-681.
24. Gracias VH, Braslow B, Johnson J et al. Abdominal compartment syndrome in the open abdomen.
Arch Surg 2002; 137(11):1298-300.
25. McNeilis J, Marini CP, Jurkiewicz A et al. Predictive factors associated with the development of
abdominal compartment syndrome in the surgical intensive care unit. Arch Surg 2002; 137:133-136.
26. Balogh Z, McKinley BA, Holcomb JB et al. Both primary and secondary abdominal compartment
syndrome can be predicted early and are harbinger of multiple organ failure. J Trauma 2003;
54(5):848-861.
27. Meldrum DR, Moore FA, Moore E et al. Prospective characterization and selective management of
the abdominal compartment syndrome. Am J Surg 1997; 174(6):667-673.
28. Ertel W, Oberholzer A, Platz A et al. Incidence and clinical pattern of the abdominal compartment syndrome after “damage-control” laparotomy in 311 patients with severe abdominal and/or
pelvic trauma. Crit Care Med 2000; 28(6):1747-1753.
29. Saggi BH, Sugerman HJ, Ivatury RR et al. Abdominal compartment syndrome. J Trauma 1998;
45:595-609.
30. Tremblay LN, Feliciano DV, Schmidt J et al. Skin only or silo closure in the critically ill patient
with an open abdomen. Am J Surg 2001; 182(6):670-675.
31. Smith PC, Tweddell JS, Bessey PQ et al. Alternative approaches to abdominal wound closure in
severely injured patients with massive visceral edema. J Trauma 1992; 32(1):16-20.
32. Ferrada R, Birolini D. Trauma care in the new millennium. New concepts in the management of
patients with penetrating abdominal wounds. Surg Clinics of North America 1999; 79(6):1331-1356.
33. Fernandez L, Norwood S, Roettger R et al. Temporary intravenous bag silo closure in severe abdominal trauma. J Trauma 1996; 40(2):258-260.
34. Nagy KK, Fildes JJ, Mahr C et al. Experience with three prosthetic materials in temporary abdominal wall closure. Am Surg 1996; 62(5):331-335.
35. Fansler RF, Taheri P, Cullinane C et al. Polypropylene mesh closure of the complicated abdominal
wound. Am J Surg 1995; 170:15-18.
36. Greene MA, Mullins R, Malangoni MA et al. Laparotomy wound closure with absorbable
polyglycolic acid mesh. SGO 1993; 176:213-218.
37. Buck JR, Fath JJ, Chung SK et al. Use of absorbable mesh as an aid in abdominal wall closure in
the emergent setting. Am Surg 1995; 61:655-658.
296
38. Aprahamian C, Wittmann D, Bergstein J et al. Temporary abdominal closure (TAC) for planned
relaparotomy (Etappenlavage) in trauma. J Trauma 1990; 30(6):719-723.
39. Barker DE, Kaufman HJ, Smith LA et al. Vacuum pack technique of temporary abdominal closure: A 7-year experience with 112 patients. J Trauma 2000; 48(2):201-207.
40. Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new method for wound control and treatment: Clinical experience. Ann of Plastic Surg 1997; 38(6):563-576.
41. Garner B, Ware DN, Cocanour CS et al. Vacuum-assisted wound closure provides early fascial
reapproximation in trauma patients with open abdomens. Am J of Surg 2001; 182(6):630-638.
42. Suliburk JW, Ware DN, Balogh Z et al. Vacuun-assisted wound closure achieves early fascial closure of open abdomens after severe trauma. J Trauma 2003; 55(6):1155-1160.
43. Miller PR, Thompson JT, Faler B et al. Late fascial closure in lieu of ventral hernias: The next
step in open abdomen management. J Trauma 2003; 53(5):843-849.
44. Kaplan M. Managing the open abdomen: Acknowledging the risks, utilizing the technology. Ostomy/Wound Management 2004; 50(1A suppl):C2-8.
Abdominal Compartment Syndrome
297Epilogue
CHAPTER 23
Epilogue:
Options and Challenges for the Future
Michael L. Cheatham,* Rao R. Ivatury, Manu L. N. G. Malbrain
and Michael Sugrue
ntra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are
widely believed to be relatively new disease processes that occur in direct response to
exuberant crystalloid over-resuscitation.
I
ACS are largely iatrogenic in origin and would not occur were more conservative resuscitation
strategies employed. If we study the past, however, we learn that elevated intra-abdominal
pressure (IAP) and its detrimental impact on end-organ function was first identified almost
150 years ago in a number of pioneering studies (Fig. 1). The existence of IAH in the critically
ill, therefore, clearly predates by well over a century any concept of supraphysiologic resuscitation. We must also humbly recognize that the pathophysiology of injury and reperfusion-induced
increases in IAP secondary to visceral edema was largely forgotten until its “rediscovery” as
IAH and ACS just over a decade ago. Perhaps in consolation, the incidence of IAH and ACS
have most likely become clinically significant only within the past several decades as advancements in surgical practice and intensive care unit (ICU) management have allowed patients to
survive the first 24 hours of critical illness to develop subsequent elevations in IAP. IAH and
ACS, therefore, along with sepsis and multiple system organ failure, likely represent a consequence of the improved survival from shock and critical illness afforded by modern goal-directed
ICU management and not necessarily a by-product thereof.
As the preceding chapters illustrate, our understanding and management of IAH and ACS
as potentially life-threatening concerns in the critically ill have evolved tremendously since
their rediscovery. Significant strides have been made in a relatively brief period of time in both
our knowledge of the pathophysiology involved and the interventions necessary to improve
patient outcome. We now recognize that the etiology of IAH and ACS is commonly
multi-factorial, that there are several different forms of both IAH and ACS, and that early
detection and management significantly improves survival.
To imply that clinicians now understand IAH and ACS, however, would be naïve. The
complex relationship between IAP and organ dysfunction, the prevalence of IAH and ACS in
various patient populations, the true progression of IAH to ACS following systemic injury, and
the optimal management strategy for this multifaceted pathophysiologic process have yet to be
fully elucidated and tested. We are clearly far from the end of the process in understanding
IAH and ACS, but rather very much at the beginning. This chapter will deal with the options
and challenges for the future, focusing on educating and informing clinicians, standardizing
definitions and concepts, developing appropriate research programs, inventing the necessary
new technologies, and finally reflecting on the need and potential for the World Society on
1
The conventional wisdom dictates that IAH and
*Corresponding Author: Michael L. Cheatham—Department of Surgical Education, Orlando
Regional Medical Center, 86 West Underwood Street, Mailpoint #100, Orlando, Florida,
32806 U.S.A. Email: michael.cheatham@orhs.org
Abdominal Compartment Syndrome, edited by Rao R. Ivatury, Michael L. Cheatham,
Manu L. N. G. Malbrain and Michael Sugrue. ©2006 Landes Bioscience.
298
Figure 1. Intra-abdominal hypertension / abdominal compartment syndrome timeline. IAP: intra-abdominal
pressure; IAH: intra-abdominal hypertension; ACS: abdominal compartment syndrome.
Abdominal Compartment Syndrome
Abdominal Compartment Syndrome (WSACS) (Table 1). Through each of these options and
challenges, we possess the potential to define and invent the future of IAH and ACS.
Education
In looking to the future, we must begin by recognizing that IAH and ACS may occur in
virtually all patient populations, irrespective of age, illness, or injury. Although most commonly recognized in the traumatically-injured patient, we need to abandon the widely held
belief that IAH and ACS afflict only the surgical patient and acknowledge their presence in the
medical and pediatric patient populations as well.
with educating clinicians of all disciplines as to the widespread presence, morbidity, and associated mortality of elevated IAP, IAH, and ACS within their patient populations. These efforts
should focus upon three key areas: incidence, detection, and management.
A recent prospective, multi-center epidemiologic trial identified that among a mixed medical and surgical intensive care unit (ICU) patient population, IAH was present upon ICU
admission in 32.1% and ACS in 4.2% of patients.
ICU stay was found to be an independent predictor of mortality (relative risk 1.85; 95% CI
1.12-3.06; p = 0.01). The clinical importance of these findings cannot be overemphasized. The
incidence and associated mortality of IAH and ACS are quite similar to those associated with
sepsis, a disease process that has recently received significant worldwide attention among the
international medical community. Widespread educational and research efforts are currently
being mounted to reduce sepsis-associated morbidity and mortality by 25% over the next five
4
years.
Although sepsis-induced organ failure is a frequent cause of IAH/ACS, and IAH/ACS
may well contribute to the subsequent development of sepsis, this association is infrequently recognized by many clinicians. In the absence of future educational efforts, the relative
2,3
The future of IAH and ACS must begin
3
Further, the occurrence of IAH during the
Table 1. The future of intra-abdominal hypertension/abdominal compartment
syndrome
• Education of physicians, nurses, and other healthcare providers
• Standardisation of definitions and concepts
• Research
• Technology Development
• World Society on Abdominal Compartment Syndrome (WSACS)
299Epilogue
anonymity of IAH and ACS as important disease processes in the critically ill places them at
risk of being forgotten yet again.
A recent survey of intensivists (those most likely to encounter IAH and ACS based upon the
incidences described above) identified that 34% of medical and 32% of pediatric intensivists
believed that they had “never” encountered a patient with ACS.
5
This study, among others,
demonstrates that a significant lack of knowledge exists among physicians worldwide as to the
presence of IAH and ACS among the critically ill. IAH and ACS are either not being recognized or are being misdiagnosed as acute respiratory distress syndrome (ARDS), mesenteric
ischemia, or multiple system organ failure (MSOF) among others. If the significant morbidity
and mortality of these disease processes is to be changed in the near future, the education of
physicians, nurses, respiratory therapists, and others must be given considerable emphasis, much
as is being done in the Surviving Sepsis Campaign.
In the novel, “The House of God” by Samuel Shem, MD, the tenth law governing the care
of all patients is “If you don’t take a temperature, you can’t find a fever”.
6
As restated by Dr.
Malbrain in Chapter 3, “If you don’t measure IAP you cannot make a diagnosis of IAH or
ACS”. In the above cited survey of intensivists, 24% of respondents were “unaware” that IAP
could be measured clinically and utilized to guide therapy.
poor in identifying the presence of IAH.
7
The safety, simplicity, cost-effectiveness, and impor-
tance of IAP monitoring in the patient at risk for IAH and ACS cannot be over-emphasized.
5
Clinical examination is notoriously
8,9
IAP monitoring does not require specialized equipment, but rather can be performed using
materials that are readily available in any hospital. Educational efforts must encourage the
application of liberal IAP monitoring to detect the presence of IAH and serial calculations of
abdominal perfusion pressure (APP) to assess the adequacy of end-organ perfusion and resusci-
10
Institution of routine IAP monitoring in patients at risk for IAH would likely have an
tation.
immediate and dramatic impact upon the detection of IAH and ACS with significant reductions in IAP-associated morbidity and mortality. Such monitoring should be implemented as a
standard practice in all intensive care units.
Whereas educating clinicians on the incidence and detection of IAH and ACS will likely be
relatively easy, educating them as to the appropriate management will be more difficult. IAH
and ACS, like sepsis, may present in a variety of forms depending upon the patient population,
the inciting cause of illness, and the resuscitative strategy required. IAH and ACS in a surgical
/ trauma patient must be recognized as frequently requiring a different management strategy
from that of a medical or pediatric patient. The efficacy of nonsurgical treatment options in
reducing elevated IAP, the relative risks and benefits of open abdominal decompression versus
percutaneous paracentesis, and the merits of prophylactic decompression on patient survival
and end-organ dysfunction must all be considered and carefully weighed. In the intensivist
survey, 20% of medical, 33% of pediatric, and 4% of surgical intensivists stated that they
would “never” consider decompressive laparotomy for the treatment of ACS.
5
This emphatic
stance further emphasizes the common lack of knowledge on the part of many clinicians as to
the appropriate management options for the patient with IAH and/or ACS. No therapeutic
option should ever be excluded from potential consideration. The current variety of management options for the treatment of IAH and ACS will only increase in diversity in the coming
years. Education on the management of IAH and ACS will no doubt require an ongoing
discussion and debate among clinicians based upon the current best evidence at that point in
time. Just as our understanding of IAH and ACS are evolving, so must our education efforts.
Consensus Definitions
IAH and ACS are now recognized as being dynamic, rather than static, processes characterised
by a constantly changing continuum of physiological events. IAH and ACS do not appear
suddenly, but rather develop over time in response to cellular ischemia and reperfusion injury.
As our understanding of this continuum has evolved, so have our definitions of IAH and ACS.
The “critical IAP” that was considered to mandate intervention in years past has been steadily
revised downward as the detrimental effect of IAH on end-organ perfusion and patient survival
300
Abdominal Compartment Syndrome
has been documented. The current standard of care would now suggest the need for intervention at an IAP of 20-25 mm Hg rather than the 35-40 mm Hg that was commonly accepted a
decade ago. Further, we now appreciate that absolute intra-abdominal pressures possess limited
diagnostic sensitivity and are of less clinical importance than the calculated perfusion pressure
across the compartment.
10,11
As a result of our changing understanding of IAH and ACS physiology and the numerous
discoveries that have been made with regard to improving patient outcome, a variety of definitions for IAH and ACS have been utilized over the years in both scientific trials and clinical
reviews. This diversity has made comparison of one trial with another difficult and has, at
times, led to confusion over what constitutes IAH and ACS, how IAP should be measured,
when intervention is necessary, and which management strategies are associated with the lowest morbidity and mortality.
To facilitate communication regarding IAH and ACS and to allow meaningful comparison
of clinical trials, it is imperative that a common terminology and data set be adopted for future
discussions and research. The International ACS Consensus Definitions Conference, sponsored by the World Society on Abdominal Compartment Syndrome (WSACS), has proposed
a series of definitions for IAH and ACS which will hopefully serve as an initial foundation
upon which future investigations and trials will be developed. These consensus definitions,
based upon the current best evidence and discussed in detail in Chapter 2, emphasize the
clinical value of IAP monitoring in the detection of IAH and ACS, the importance of perfusion pressure calculations, the varying presentation of IAH and ACS by patient population,
and the need for a standardized statistical approach to analyzing new monitoring techniques.
These definitions should be carefully considered during the design of any future IAH / ACS
research and will serve as a valuable tool in any educational effort. These consensus definitions
will no doubt require periodic review and reassessment with changes being made as necessary
based upon our understanding and interpretation of the available literature and research at that
time. Only through the application of such consensus definitions will effective, clinically meaningful comparisons between future trials and investigations be possible.
Research
The past decade has witnessed an explosion of scientific investigation into the organ-specific
physiology and clinical treatment of IAH and ACS. As a result, significant progress has been
made in defining what constitutes IAH and ACS and which interventions are currently most
effective in improving patient outcome. The majority of the research performed so far, however, has been either retrospective or observational in nature, or based upon animal or laboratory investigations.
formed. In addition, the majority of investigations have been published in surgery or critical
care journals with a paucity of reports in the medicine literature. As a result, surgeons tend to
be more cognizant of the existence of IAH and ACS than do their medical and pediatric colleagues simply due to the increased exposure in the surgical literature.
The scarcity of Level I and Level II scientific evidence is no doubt due, in part, to the
emerging nature of these disease processes. Future research must be focused on performing
rigorous, prospective, multi-center, human trials to answer the numerous questions that remain. Additionally, there is a need for more widespread publishing of articles on IAH and ACS
throughout the scientific literature in order to more effectively educate all clinicians who may
encounter these disease processes.
To promote future rigorous scientific trials in this area, the WSACS has formed a “Clinical
Trials Working Group” to facilitate performance of prospective, multi-center, clinical trials
using the proposed consensus definitions. Areas for future investigation include defining the
true incidence and causative factors associated with IAH and ACS among various patient populations, evaluating the impact of early goal-directed therapy strategies in the resuscitation of
patients with IAH and ACS, comparing the efficacy of various abdominal wall closure methods, and evaluating new organ-specific monitoring techniques.
12
Very few prospective, randomized trials on IAH or ACS have been per-
301Epilogue
Technology Development
As a result of the frequently insidious nature of IAH and the poor clinical sensitivity of
physical examination in its detection, bedside monitoring techniques are crucial to the detection and management of the patient with IAH and/or ACS. The importance of IAP monitoring and APP calculations has previously been emphasized. There remains significant debate
over the optimal technique for measuring IAP. Dr. Malbrain has eloquently discussed the advantages and disadvantages of each methodology in Chapter 3. Most of the current methods
for IAP measurement, while effective, are cobbled together from pieces of stray pressure tubing
and plastic connectors, or use devices that are intended for unrelated purposes. New techniques for IAP measurement that overcome the pitfalls of the current methods must be developed. Specifically, there is currently a great need for adoption of a standardized technique and
infusion volume (for intravesicular pressure monitoring) to ensure reproducibility and accuracy of the measurements obtained. Proactive development of such monitoring techniques by
bedside physicians, in collaboration with industry, will be essential.
The trend in monitoring in recent years has been a move towards continuous rather than
intermittent monitoring techniques. Such is no less the case in the management of IAH and
ACS. Methods for measuring IAP and APP continuously and using this real-time information
to guide patient resuscitation have recently been reported.
adopted for hemodynamic monitoring, continuous assessment of IAP and APP with early
goal-directed resuscitation based upon these parameters will no doubt become the standard of
care over the next decade.
Monitoring of IAP and APP, while state-of-the-art at this point in the evolution of IAH and
ACS resuscitation, will not be sufficient for the future. Each organ system possesses a differential sensitivity and response to elevations in IAP. The kidneys and liver demonstrate significant
reductions in regional perfusion at an IAP of 10-15 mm Hg while the lungs and heart appear
to retain sufficient reserve to maintain adequate perfusion at higher levels. Development of
organ specific monitoring techniques should be aggressively pursued to allow accurate assessment of regional as opposed to global perfusion adequacy. For some organ systems, simple
markers of regional resuscitation adequacy already exist. Intracranial pressure (ICP) monitoring for the brain, intramucosal pH (pHi) and gastric luminal carbon dioxide tension (PrCO
for the stomach, and indocyanine green (ICG) clearance for the liver have all been proposed as
useful markers of regional perfusion adequacy in the management of the patient with IAH and
ACS. Clearly, additional regional markers are needed and should be a primary focus of future
research in IAH and ACS.
9,13
As is currently being widely
)
2
World Society on Abdominal Compartment Syndrome (WSACS)
Unlike many commonly encountered disease processes which remain within the purview of
a given discipline, IAH and ACS readily cross the usual barriers and may occur in any patient
population regardless of age, illness, or injury. As a result, no one scientific society or association can represent the wide variety of physicians, nurses, respiratory therapists, and other allied
healthcare personnel who might encounter patients with IAH and/or ACS in their daily practice. To fill this void, the World Society on Abdominal Compartment Syndrome (WSACS) has
been founded to serve as a peer-reviewed forum and educational resource for all healthcare
providers as well as industry who have an interest in IAH and ACS. Launched at the Inaugural
World Congress on Abdominal Compartment Syndrome in December 2004, the mission of
the WSACS is to foster education, promote research, and thereby improve the survival of
patients with IAH and ACS by bringing together physicians, nurses, and others from throughout the world and from a variety of clinical disciplines.
Effective communication and discussion between clinicians and researchers worldwide will
be essential to accomplish these goals. The widespread availability, speed, and visual nature of
Internet-based education and communication will significantly increase the rapidity and
efficiency with which these objectives are achieved. The WSACS website (www.wsacs.org) is
302
Abdominal Compartment Syndrome
intended to serve as the definitive resource on IAH and ACS. Multimedia educational modules, lectures, case discussions, and other resources and links will be utilized to promote IAH /
ACS education worldwide. Further, an electronic mail discussion list will facilitate discussion
of patient problems, questions, and ideas among experienced clinicians, researchers, and others
in near real-time fashion.
The WSACS Clinical Trials Working Group (CTWG) will promote prospective, multi-center
scientific trials to study pertinent research questions and hypotheses based upon the foundation of the proposed consensus definitions. The CTWG, in collaboration with other scientific
organizations worldwide, will set the standard and lead the effort towards performing the prospective, multi-center clinical trials that are necessary to more fully define the nature and appropriate management of IAH and ACS.
Modeled on the highly successful Inaugural World Congress meeting, biannual international scientific symposia will be organized to promote face-to-face discussion of research findings and the current state-of-the-art in IAH and ACS treatment and management. During
these sessions, the consensus definitions will be reassessed and revised as necessary. In addition,
joint collaborative educational opportunities will be pursued with other scientific organizations worldwide.
Conclusions
IAH and ACS are significant causes of organ failure, increased resource utilization, decreased economic productivity, and increased mortality among a wide variety of patient populations. Considerable progress has been made in the field of IAH and ACS over the past decade, but there is significant work yet to be done. We must study and learn from the past and,
at the same time, proactively “invent” the future. As aptly described by Dr. Ivatury, IAH / ACS
is “…a clinical entity that had been ignored for far too long”.
in our hands. It is time to pay attention.
14
The future of IAH and ACS is
References
1. Lyons WS. Uncontrolled resuscitation and “sepsis”. J Trauma 2002; 52:412.
2. Balogh Z, Moore FA. Intra-abdominal hypertension: Not just a surgical critical care curiosity. Crit
Care Med 2005; 33:447-449.
3. Malbrain MLNG, Chiumello D, Pelosi P et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: A multiple-center epidemiological study.
Crit Care Med 2005; 33:315-322.
4. Dellinger RP, Carlet JM, Masur H et al. Surviving sepsis campaign guidelines for management of
severe sepsis and septic shock. Crit Care Med 2004; 32:858-873.
5. Kimball EJ, Mone MC, Barton RG et al. Survey of ICU physicians on the recognition and management of abdominal compartment syndrome. Presented at the 2004 World Congress on Abdominal Compartment Syndrome. Noosa, Queensland, Australia: 2004.
6. Shem S. The House of God. Dell Publishing. ISBN: 0-440-13368-8.
7. Sugrue M, Bauman A, Jones F et al. Clinical examination is an inaccurate predictor of
intraabdominal pressure. World J Surg 2002; 26:1428-1431.
8. Cheatham ML, Safcsak K. Intraabdominal pressure: A revised method for measurement. J Am Coll
Surg 1998; 186:594-595.
9. Malbrain ML. Different techniques to measure intra-abdominal pressure (IAP): Time for critical
reappraisal. Intensive Care Med 2004; 30:357-371.
10. Cheatham ML, White MW, Sagraves SG et al. Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma 2000; 49:621-627.
11. Malbrain MLNG. Abdominal perfusion pressure as prognostic marker in intra-abdominal hypertension. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine. Berlin, Heidelberg, New York: Springer, 2002:792-814.
12. Andrews K, Lynch J, Sugrue M. A scientific evaluation of the level of evidence of publications
relating to abdominal compartment syndrome. Presented at the 2004 World Congress on Abdominal Compartment Syndrome. Noosa, Queensland, Australia: 2004.
13. Balogh Z, Jones F, D’Amours S et al. Continuous intra-abdominal pressure measurement technique. Am J Surg 2004; 188:679-684.
14. Ivatury RR, Sugerman HJ. Abdominal compartment syndrome: A century later, isn’t it time to pay
attention? Crit Care Med 2000; 28:2137-2138.
Index
A
Abbreviated injury scale (AIS) 171, 224
Abdominal aortic aneurysm (AAA) 5, 14, 179,
197, 210-215, 224, 226-229
Abdominal blow-out 3, 105
Abdominal girth 19, 21, 25, 189, 290
Abdominal pelvic trauma score (APTS) 224,
228
Abdominal perfusion pressure (APP) 10, 35,
49, 51, 52, 62, 65, 68-70, 72-79, 101,
114, 119, 122, 135, 215, 233, 236, 299,
301
Abdominal trauma index (ATI) 171, 224
Abdominal wall repair 280
AbViser™ 35, 38, 59, 64
ACE inhibitors 122, 126
Acute lung injury (ALI) 10, 95, 96, 107, 108,
237
Acute pancreatitis 1, 14, 16, 197-202, 215,
233, 235
Acute Physiology and Chronic Health
Evaluation (APACHE) 83, 85, 120, 223
Acute renal failure (ARF) 76, 77, 120, 122,
140, 141, 160
Acute respiratory distress syndrome (ARDS)
29, 107-109, 114, 140, 160, 186, 226,
237, 253, 259, 260, 299
Aldosterone 122, 123, 191, 193
Alveolar dead space 71, 106, 113
Analgesia 106, 254, 255, 257, 262
Anesthetic management 254, 261, 262
Aortoiliac surgery 210, 212, 213
APACHE II 83, 85, 120
Ascites 2-4, 8, 21, 64, 72, 78, 127, 138, 140,
158, 175, 197, 199, 200, 215, 218, 223,
224, 233, 235, 252, 284
Assist/control ventilation (ACV) 112
B
Baby-lungs 114
Bacterial translocation 71, 107, 108, 113,
132, 133, 139, 163, 166, 167, 260
Bi-level positive airway pressure (BiPAP) 113
BIS 255
Bladder PV curve 61, 63, 64
Bloody vicious cycle 157, 158, 286
Body mass index (BMI) 9, 20, 23, 27,
189-191, 193, 194, 241, 247
Bogotá bag 200, 214, 226, 267, 272, 268,
269, 288, 294, 295
Bronchoalveolar lavage (BAL) 108, 134, 135,
161
Burn 14, 16, 82-84, 87, 138, 158, 167, 175,
178-181, 183-187, 220, 223-225, 229,
233, 235, 252, 272
Bursting pressure 130, 131
C
Cardiopulmonary resuscitation (CPR) 226
Catecholamine 122, 259
Central obesity 189-191
Cerebral perfusion pressure (CPP) 49, 70, 72,
140, 144-149, 153-155, 192, 236, 245,
254
Chest wall elastance 246, 249-252
Chronic ambulatory peritoneal dialysis
(CAPD) 27, 52
CIAH study 76
Classic Intermittent Technique 39, 44
Clinical indicator 174
Clinical Trials Working Group (CTWG) 302
Closed System Single Measurement Technique
30
CO
-gap 74, 75
2
Coefficient of variation (COVA) 60-62, 82,
83
Color power Doppler (CPD) 205, 207, 215
Common iliac venous pressure (CIVP) 55
Continuous cardiac output (CCO) 97, 98,
101, 245
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