Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Abstract

PurposeTo update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).MethodsWe conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear).ResultsIn addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation.ConclusionAlthough IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-013-2906-z) contains supplementary material, which is available to authorized users.

Decompressive laparotomy for abdominal compartment syndrome

“…Although the pathophysiology of IAH is well understood12, 13, 14, the treatment of ACS remains challenging. Few non‐surgical options are available.…”

Relationship between intra-abdominal hypertension, outcome and the revised Atlanta and determinant-based classifications in acute pancreatitis

“…Unlike earlier studies where rates of decompressive laparotomy were high (74–77 per cent)18, 21, only 8·7 per cent of the present cohort diagnosed with ACS were treated in this way. Some patients in the present series were treated with effective medical decompressive methods (nasogastric and rectal tubes, percutaneous drainage of abdominal collections, negative fluid balance with diuretics and renal support), as recommended elsewhere1, 2, 3. As the treatment of ACS was not specified by protocol in the study design, participating centres may not have considered that existing data from decompressive laparotomy justified this procedure.…”

“…The following definitions were used: AP diagnosed by at least two of the following three criteria – upper abdominal pain, amylase or lipase levels raised at least threefold with respect to laboratory upper limits of normal, appropriate imaging findings; organ failure – RAC and DBC definitions, adapted to intensive care, using SEMICYUC consensus conference criteria3; shock – systolic arterial pressure below 90 mmHg or a reduction of 40 mmHg in basal systolic arterial pressure, with tissue hypoperfusion signs where lactate concentration was greater than 3 mmol/l and central venous oxygen saturation was less than 70 per cent19; respiratory failure – either basal arterial partial pressure of oxygen ( P a o 2 ) below 60 mmHg, or P a o 2 or fraction of inspired oxygen ( F i o 2 ) of less than 300 mmHg with supplementary oxygen; acute renal failure – increase in serum creatinine to more than twice the upper limit of normal and/or less than 0·5 ml per kg per h for more than 12 h according to urinary output criteria for the Acute Kidney Injury Network (AKIN) classification; IAH – a repeated pathological IAP increase of 12 mmHg or above; and ACS – when IAP was above 20 mmHg with or without an abdominal perfusion pressure below 60 mmHg and associated with an organ failure that was cardiovascular, respiratory or renal1, 20.…”

“…IAP was measured via the urinary bladder at end expiration in the completely supine position after ensuring that abdominal muscle contractions were absent and with the transducer zeroed at the level of the mid‐axillary line, according to the updated consensus definition from the World Society of the Abdominal Compartment Syndrome1, 20. IAP was measured every 6 h daily, and maximum IAP value obtained during the ICU stay was the one analysed.…”

“…When IAP is above 20 mmHg (with or without an abdominal perfusion pressure below 60 mmHg) and associated with organ failure (mainly cardiovascular, respiratory or renal dysfunction), it is called abdominal compartment syndrome (ACS). According to its severity, IAH is classified in four categories1, 2, 3 ( Fig . 1).…”