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

Abstract

Background: 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. Methods: 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. Results: 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 ± 4.1L, 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). Conclusion: 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.

Fluid Stewardship During Critical Illness: A Call to Action

“…18 Large volume resuscitation and CFB have been identified as risk factors for development of AKI secondary to abdominal compartment syndrome. 11,19 While the potential for FO as a consequence of oliguria may be expected, the association between FO and mortality in patients with AKI is independent of urine output. 20 Furthermore, FO and AKI may independently necessitate RRT or other fluid-related interventions including thoracentesis and diuretics.…”

Abdominal Compartment Syndrome—When Is Surgical Decompression Needed?

“…Among the complications that develop in patients with burns >15% total body surface area (TBSA), ACS occurs with a prevalence of 4.1–16.6%, and is most often associated with burns on >70% TBSA [ 47 ]. There are no clinical trials to indicate the optimal treatment for patients with ACS secondary to severe burns, and studies to date include a small number of patients [ 48 , 49 , 50 , 51 , 52 , 53 , 54 ] ( Table 3 ). The groups of patients who underwent DL usually include both pediatric and adult patients, most with burns >50% TBSA and a mean IAP pre-decompression >40, in whom conservative treatment instituted for at least 24 h failed ( Table 3 ).…”

“…The groups of patients who underwent DL usually include both pediatric and adult patients, most with burns >50% TBSA and a mean IAP pre-decompression >40, in whom conservative treatment instituted for at least 24 h failed ( Table 3 ). The post-laparotomy survival of decompression reported by the studies identified so far varies between 0% and 66% [ 48 , 49 , 50 , 51 , 52 , 53 , 54 ].…”

Abdominal Compartment Syndrome in Burn Patients

“…The use of mechanical ventilation is also associated with an increased incidence of IAH and to a worse prognosis in untreated cases [19]. This risk factor is proportional to the severity of respiratory symptoms and the mechanical ventilation requirement.…”