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					   Results from the International Conference of
Experts on Intra-Abdominal Hypertension (IAH) and
    Abdominal Compartment Syndrome (ACS)



         RECOMMENDATIONS

         Intensive Care Medicine 2007; 33(6): 951-962




 World Society of the Abdominal Compartment Syndrome    www.wsacs.org
INTRODUCTION TO THE RECOMMENDATIONS


• Intra-abdominal hypertension (IAH) and abdominal compartment
  syndrome (ACS) are causes of significant morbidity and mortality
  in the critically ill
• Intra-abdominal pressure (IAP) measurements are essential to the
  diagnosis of both IAH and ACS
• The World Society of the Abdominal Compartment Syndrome
  (WSACS) has created evidence-based medicine
  recommendations for the management of patients with IAH/ACS




   World Society of the Abdominal Compartment Syndrome   www.wsacs.org
GRADES OF EVIDENCE

• Evidence-based guidelines are now commonplace in medicine
• The WSACS has adopted a modification of the approach
  developed by the international GRADE group
   – Recommendations are classified as either strong
     recommendations (Grade 1) or weak suggestions (Grade 2)
   – Quality of evidence is ranked as high (grade A), moderate
     (grade B), or low (grade C)
• While difficult to perform given the acuity of IAH/ACS, these
  recommendations emphasize the need for rigorous clinical trials
  to be performed in the future




   World Society of the Abdominal Compartment Syndrome   www.wsacs.org
OVERVIEW

• Given the wide variety of patients that may develop IAH/ACS, no
  one management strategy can be uniformly applied to all patients
• While surgical decompression is commonly considered the only
  treatment, non-operative medical management strategies play a
  vital role in the prevention and treatment of IAH-induced organ
  dysfunction and failure
• Appropriate IAH/ACS management is based upon four principles:
   – Serial monitoring of IAP
   – Optimization of systemic perfusion and organ function
   – Institution of specific medical interventions to reduce IAP
   – Prompt surgical decompression for refractory IAH




   World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
RISK FACTORS & SURVEILLANCE FOR IAH/ACS

Patients should be screened for IAH / ACS risk factors upon ICU
   admission and in the presence of new or progressive organ
                        failure (Grade 1B)

• Independent risk factors for IAH / ACS include:
    – Large volume fluid resuscitation (> 3.5 L / 24 hrs)
    – Acidosis
    – Hypothermia
    – Coagulopathy / polytransfusion
    – Pulmonary, renal, hepatic dysfunction
    – Ileus
    – Abdominal surgery / primary fascial closure



   World Society of the Abdominal Compartment Syndrome      www.wsacs.org
RECOMMENDATIONS:
IAP MEASUREMENT

 If two or more risk factors for IAH / ACS are present, a baseline
          IAP measurement should be obtained (Grade 1B)
 If IAH is present, serial IAP measurements should be performed
           throughout the patient’s critical illness (Grade1C)


• Physical examination is insensitive in detecting IAH
• IAP monitoring is a cost-effective, safe, and accurate tool for
  identifying the presence of IAH and guiding resuscitative
  therapy for ACS
• Serial IAP measurements are necessary to guide resuscitation
  of patients with IAH / ACS



   World Society of the Abdominal Compartment Syndrome    www.wsacs.org
RECOMMENDATIONS:
IAP MEASUREMENT TECHNIQUE

 Studies should adopt the standardized IAP measurement method
  recommended by the consensus definitions OR provide sufficient
   detail of the technique utilized to allow accurate interpretation of
                    the IAP data presented (Grade 2C)

• IAP should be measured:
    – In mmHg (1 mmHg = 1.36 cm H 2O)
    – In the supine position at end-expiration with the transducer
      zeroed at the mid-axillary line
    – Using an instillation volume of no greater than 25 mL (1 mL/kg
      for children up to 20 kg) for the bladder technique
    – 30-60 seconds after instillation of priming fluid to allow
      bladder detrusor muscle relaxation
    – In the absence of active abdominal muscle contractions

   World Society of the Abdominal Compartment Syndrome    www.wsacs.org
IAH ASSESSMENT
   ALGORITHM

www.wsacs.org
RECOMMENDATIONS:
ABDOMINAL PERFUSION PRESSURE

   APP should be maintained above 50–60 mmHg in patients with
                       IAH/ACS (Grade 1C)

• The critical IAP that leads to organ failure varies by patient
• A single threshold IAP cannot be applied to all patients
• APP assesses not only the severity of IAP, but also the relative
  adequacy of abdominal blood flow
• APP is superior to IAP, arterial pH, base deficit, and arterial
  lactate in predicting organ failure and patient outcome
• Failure to maintain APP > 50-60 mmHg in patients with IAH
  predicts survival



   World Society of the Abdominal Compartment Syndrome     www.wsacs.org
RECOMMENDATIONS:
SEDATION AND ANALGESIA

          No recommendations can be made at this time

• Pain, agitation, ventilator dyssynchrony, and accessory muscle
  use during breathing may all lead to increased abdominal
  muscle tone
• This increased muscle activity can increase IAP
• Sedation and analgesia can reduce muscle tone and decrease
  IAP to less detrimental levels
• While such therapy would appear prudent, no prospective trials
  have been performed evaluating the benefits and risks of
  sedation and analgesia in IAH/ACS



  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
NEUROMUSCULAR BLOCKADE

A brief trial of neuromuscular blockade (NMB) may be considered
     in selected patients with mild to moderate IAH while other
        interventions are performed to reduce IAP (Grade 2C)

• Diminished abdominal wall compliance due to pain, tight
  abdominal closures, and third-space fluid can increase IAP to
  detrimental levels
• The potential beneficial effects of NMB in reducing abdominal
  muscle tone must be balanced against the risks of prolonged
  paralysis
• NMB is unlikely to be an effective therapy for patients with
  severe IAH or the patient who has already progressed to ACS



  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
BODY POSITIONING

   The potential contribution of body position in elevating IAP
  should be considered in patients with moderate to severe IAH
                        or ACS (Grade 2C)

• Head of bed elevation can significantly increase IAP compared
  to supine positioning, especially at higher levels of IAH
• Such increases in IAP become clinically significant (increase >
  2 mmHg) when the patient’s head of bed exceeds 20 degrees
  elevation
• Supine IAP measurements may underestimate the true IAP if
  the patient’s head of bed is elevated between measurements




  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS: GASTRIC/RECTAL
SUCTIONING, PROKINETIC AGENTS

          No recommendations can be made at this time

• Both air and fluid within the hollow viscera can raise IAP and
  lead to IAH / ACS
• Nasogastric and/or rectal drainage, enemas, and even
  endoscopic decompression can reduce IAP
• Prokinetic motility agents such as erythromycin,
  metoclopromide, or neostigmine can aid in evacuating the
  intraluminal contents and decreasing the size of the viscera
• Insufficient evidence is currently available to confirm the
  benefit of such therapies in IAH/ACS



  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
FLUID RESUSCITATION

Fluid resuscitation volume should be carefully monitored to avoid
    over-resuscitation in patients at risk for IAH/ACS (Grade 1B)

 Hypertonic crystalloid and colloid-based resuscitation should be
  considered in patients with IAH to decrease the progression to
                     secondary ACS (Grade 1C)

• Fluid resuscitation and “early goal-directed therapy” are
  cornerstones of critical care management
• Excessive fluid resuscitation is an independent predictor of
  IAH/ACS and should be avoided
• The use of goal-directed hemodynamic monitoring should be
  considered to achieve appropriate fluid resuscitation


  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
DIURETICS & CONTINUOUS HEMOFILTRATION

          No recommendations can be made at this time

• Diuretic therapy, in combination with colloid, may be considered
  to mobilize third-space edema following initial resuscitation and
  once the patient is hemodynamically stable
• Continuous hemofiltration / ultrafiltration may be an appropriate
  intervention rather than continuing to volume load and increase
  the likelihood of secondary ACS
• These therapies have yet to be subjected to prospective clinical
  study in IAH/ACS patients




  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
PERCUTANEOUS CATHETER DECOMPRESSION

 Percutaneous catheter decompression should be considered in
     patients with intraperitoneal fluid, abscess, or blood who
         demonstrate symptomatic IAH or ACS (Grade 2C)

• Paracentesis represents a less invasive method for treating
  IAH/ACS due to free fluid, ascites, air, abscess, or blood
• Percutaneous catheter insertion under ultrasound guidance
  allows ongoing drainage of intraperitoneal fluid and may help
  avoid the need for open abdominal decompression in selected
  patients with secondary ACS




  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
ABDOMINAL DECOMPRESSION

   Surgical decompression should be performed in patients with
    ACS that is refractory to other treatment options (Grade 1B)
 Presumptive decompression should be considered at the time of
  laparotomy in patients who demonstrate multiple risk factors for
                        IAH/ACS (Grade 1C)

• Surgical abdominal decompression has long been the standard
  treatment for the patient who develops ACS
• It represents a life-saving intervention when a patient’s IAH has
  become refractory to medical treatment options and organ
  dysfunction and/or failure is evident



  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
RECOMMENDATIONS:
DEFINITIVE ABDOMINAL CLOSURE

          No recommendations can be made at this time

• Most patients will tolerate primary fascial closure within 5–7
  days if decompressed before significant organ failure develops
• Management options for the “open abdomen” include split-
  thickness skin grafting, cutaneous advancement flap (“skin
  only”) closure, and vacuum-assisted closure techniques
• Prospective trials to identify the optimal management technique
  have yet to be performed




  World Society of the Abdominal Compartment Syndrome   www.wsacs.org
  IAH/ACS
MANAGEMENT
 ALGORITHM

www.wsacs.org
RECOMMENDATIONS:
FUTURE RESEARCH
 Incidence and prevalence estimates of IAH/ACS should be based
            upon the consensus definitions (Grade 1C)
 To facilitate communication of the severity of IAH in future trials,
  we suggest that mean, median, and maximal IAP values should
     be provided both on admission and during the study period
                            (Grade 2C)
• Previous research has been complicated by the lack of
  consensus definitions
• Use of the definitions and recommendations presented should
  facilitate the interpretation and comparison of future studies
• There is a significant need for well-designed, prospective
  clinical trials to clarify the many questions and issues that
  remain unanswered with respect to IAH/ACS

  World Society of the Abdominal Compartment Syndrome    www.wsacs.org
CONCLUSIONS


• The WSACS hopes that these evidence-based consensus
  definitions, recommendations, and algorithms will aid in
  interpreting past research, improving current patient care, and
  planning future clinical and basic science research
• The WSACS anticipates that these definitions and
  recommendations will be dynamic and will change as new
  research becomes available




   World Society of the Abdominal Compartment Syndrome   www.wsacs.org
WORLD SOCIETY OF THE ABDOMINAL
COMPARTMENT SYNDROME (WSACS)


• The WSACS was founded to
  promote education and research on
  IAH and ACS
• Its membership includes
  physicians, surgeons, anesthetists,
  intensivists, nurses, respiratory
  therapists, and others
• For further details, go to:
  www.wsacs.org




    World Society of the Abdominal Compartment Syndrome   www.wsacs.org

				
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posted:11/15/2011
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