Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians

Abstract

This survey was designed to clarify the current understanding and clinical management of intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) among intensive care physicians in tertiary Chinese hospitals. A postal twenty-question questionnaire was sent to 141 physicians in different intensive care units (ICUs). A total of 108 (76.6%) questionnaires were returned. Among these, three quarters worked in combined medical-surgical ICUs and nearly 80% had primary training in internal or emergency medicine. Average ICU beds, annual admission, ICU length of stay, acute physiology and chronic health evaluation (APACHE) II score, and mortality were 18.2 beds, 764.5 cases, 8.3 d, 19.4, and 21.1%, respectively. Of the respondents, 30.6% never measured intra-abdominal pressure (IAP). Although the vast majority of the ICUs adopted the exclusively transvesicular method, the overwhelming majority (88.0%) only measured IAP when there was a clinical suspicion of IAH/ACS and only 29.3% measured either often or routinely. Moreover, 84.0% used the wrong priming saline volume while 88.0% zeroed at reference points which were not in consistence with the standard method for IAP monitoring recommended by the World Society of Abdominal Compartment Syndrome. ACS was suspected mainly when there was a distended abdomen (92%), worsening oliguria (80%), and increased ventilatory support requirement (68%). Common causes for IAH/ACS were "third-spacing from massive volume resuscitation in different settings" (88%), "intra-abdominal bleeding", and "liver failure with ascites" (52% for both). Though 60% respondents would recommend surgical decompression when the IAP exceeded 25 mmHg, accompanied by signs of organ dysfunction, nearly three quarters of respondents preferred diuresis and dialysis. A total of 68% of respondents would recommend paracentesis in the treatment for ACS. In conclusion, urgent systematic education is absolutely necessary for most intensive care physicians in China to help to establish clear diagnostic criteria and appropriate management for these common, but life-threatening, diseases.

Intra-abdominal pressure: an integrative review

“…(5,16) A second study revealed significantly higher mortality indices in critically ill patients presenting with increased IAP compared to unaffected patients (37.9% and 19.1% respectively). (8,16) These data suggest increased IAP is common among critically ill patients, and may increase morbidity and mortality risks.…”

“…(8,10,13,16,18,25,26) A prospective study involving 13 intensive care unit (ICUs) in Belgium, Austria, Israel, Brazil and Australia reported IAH and ACS prevalence of 32.1% and 4.2%, respectively, upon patient admission. (5,16) A second study revealed significantly higher mortality indices in critically ill patients presenting with increased IAP compared to unaffected patients (37.9% and 19.1% respectively). (8,16) These data suggest increased IAP is common among critically ill patients, and may increase morbidity and mortality risks.…”

“…The major indications comprise patients presenting with two or more risk factors, patient screening upon ICU admission or presence of progressive or new organ failure. (5,12,16) In such cases, IAP should be monitored at 4-to-6-hour intervals, with hourly IAP monitoring restricted to patients suffering from severe organ dysfunction. (5,8,12,17) In actual fact, in many cases IAP measurement is restricted to suspected cases of IAH; (15) hence, implementation of routine IAP monitoring is paramount for IAH/ACS recognition and effective treatment.…”

“…(16,26,27) Clinical presentation generally includes a tense, distended abdomen, hypotension, high airway pressure, hypercapnia and oliguria. (25) …”

“…Three algorithms (assessment, management and medical management) can be found at the World Society of the Abdominal Compartment Syndrome (WSACS) website at www.wsacs.org. (16,27) …”