Intra-abdominal hypertension and abdominal compartment syndrome in burns, obesity, pregnancy, and general medicine

Abstract

Intra-abdominal hypertension (IAH) is an important contributor to early organ dysfunction in trauma and sepsis. However, relatively little is known about the impact of intra-abdominal pressure (IAP) in general internal medicine, pregnant patients, and those with obesity or burns. The aim of this paper is to review the pathophysiologic implications and treatment options for IAH in these specific situations. A MEDLINE and PubMed search was performed and the resulting body-of-evidence included in the current review on the basis of relevance and scientific merit. There is increasing awareness of the role of IAH in different clinical situations. Specifically, IAH will develop in most (if not all) severely burned patients, and may contribute to early mortality. One should avoid over-resuscitation of these patients with large volumes of fluids, especially crystalloids. Acute elevations in IAP have similar effects in obese patients compared to non-obese patients, but the threshold IAP associated with organ dysfunction may be higher. Chronic elevations in IAP may, in part, be responsible for the pathogenesis of obesity-related co-morbid conditions such as hypertension, pseudotumor cerebri, pulmonary dysfunction, gastroesophageal reflux disease, and abdominal wall hernias. At the bedside, measuring IAP and considering IAH in all critical maternal conditions is essential, especially in preeclampsia/eclampsia where some have hypothesized that IAH may have an additional role. IAH in pregnancy must take into account the precautions for aorto-caval compression and has been associated with ovarian hyperstimulation syndrome. Recently, IAP has been associated with the cardiorenal dilemma and hepatorenal syndrome, and this has led to the recognition of the polycompartment syndrome. In conclusion, IAH and ACS have been associated with several patient populations beyond the classical ICU, surgical, and trauma patients. In all at risk conditions the focus should be on the early recognition of IAH and prevention of ACS. Patients at risk for IAH should be identified early through measurements of IAP. Appropriate actions should be taken when IAP increases above 15 mm Hg, especially if pressures reach above 20 mm Hg with new onset organ failure. Although non-operative measures come first, surgical decompression must not be delayed if these fail. Percutaneous drainage of ascites is a simple and potentially effective tool to reduce IAP if organ dysfunction develops, especially in burn patients. Escharotomy may also dramatically reduce IAP in the case of abdominal burns.

An overview on fluid resuscitation and resuscitation endpoints in burns: Past, present and future. Part 2 — avoiding complications by using the right endpoints with a new personalized protocolized approach

“…This holds also true in burn patients with increased IAP and artificially increased CVP or PAOP [6,33,43].…”

“…This usually develops within 48 hours after the burn injury during the acute resuscitation phase, occurring again later on as fluid accumulates in the interstitium and peritoneal cavities, made worse by an ileus [19]. ACS is a life-threatening complication with mortality rate of 50−80%, even in treated patients [6,20,21]. Patients who reach the "flow phase" have a lower risk of IAH/ACS.…”

“…Functional hemodynamics in combination with volumetric indices acquired by transpulmonary thermodilution may also be useful as a resuscitation endpoint [30−32]. It is recommended that the clinician should routinely monitor IAP every 4 to 6 hours throughout the resuscitation of patients with a TBSA of more than 20% [6]. The clinical diagnosis of ACS is a very late finding and the presence of IAH should be detected before the development of this potentially lethal complication.…”

“…IAH/ACS requires specific strategies to prevent, monitor, diagnose and manage such conditions [6]. IAH is defined as a sustained or repeated pathological elevation in IAP ≥ 12 mm Hg, and ACS as a sustained IAP > 20 mm Hg that is associated with new organ dysfunction [5].…”

Mesenteric ischemia, intra-abdominal hypertension,and the abdominal compartment syndrome

“…Judiciousness is essential, because modern burn resuscitation frequently grossly exceeds volumes predicted by the Parkland formula (12,13), and other formulas. Thus, it may not be surprising that it remains accepted -if not expectedthat nearly all patients with large burns (>60% to 70% body surface area), especially with smoke inhalation, will develop severe IAH/ACS (12,14,15). Given this expected risk, we believe it is mandatory, not elective, to measure IAP in all severe burns, regardless of the physical examination of the abdomen, because clinical examination has proven inaccurate (16,17).…”