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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> INTRODUCTION</span></p><p class="elsevierStylePara">Intra-abdominal hypertension &#40;IAH&#41; and abdominal compartment syndrome &#40;ACS&#41; have been shown to occur frequently in Intensive Care Units &#40;ICU&#41; patients and have been independently associated with mortality<span class="elsevierStyleSup">1&#44;2</span>&#46; Unlike many commonly encountered disease processes which remain within the purview of a given discipline&#44; IAH and the ACS readily cross the usual barriers and may occur in any patient population regardless of age&#44; illness&#44; or injury&#46; As a result&#44; no one specific speciality can represent the wide variety of health care workers who might encounter patients with IAH and&#47;or ACS in their daily practice&#46; For this reason&#44; a multidisciplinary&#44; international organisation&#44; the World Society of the Abdominal Compartment Syndrome &#40;WSACS &#173; www&#46;wsacs&#46;org&#41; was founded in 2004 with the aim to foster education&#44; to facilitate research and to improve outcome for these patients&#46; As an introduction to the Third World Congress on Abdominal Compartment Syndrome &#40;www&#46;wcacs&#46;org&#41;&#44; organised by the WSACS&#44; which will be held in March 2007 in Antwerp&#44; Belgium&#44; this review will try to give a concise overview of the epidemiologic data&#44; etiology&#44; diagnosis&#44; IAP measurement&#44; organ dysfunction&#44; prevention and treatment options related to ACS&#44; focusing on recent developments and possibilities for the future&#46; It reflects the most important evolutions in literature as well as well as the personal experience of the authors&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ETIOLOGY AND EPIDEMIOLOGY</span></p><p class="elsevierStylePara">The ACS is diagnosed when there is increased intra-abdominal pressure &#40;IAP&#41; along with evidence of end-organ dysfunction<span class="elsevierStyleSup">3</span>&#46; IAH is diagnosed when IAP is moderately increased&#44; but there is no evidence of organ dysfunction yet&#44; although subtle forms of organ dysfunction may be present at levels of IAP previously deemed to be safe<span class="elsevierStyleSup">4</span>&#46; There may even be a &#171;dose-dependent&#187; association between IAP and organ dysfunction&#46; Where etiology is concerned&#44; there are two major factors to discuss&#58; first&#44; the origin of the increased IAP itself and secondly&#44; the etiology of organ dysfunction in the presence of IAH&#46;</p><p class="elsevierStylePara">Why and when does the pressure within the abdominal cavity rise&#63; In analogy to the situation in the brain&#44; there are essentially two parts in the abdominal pressure-volume curve&#46; At low intra-abdominal volumes &#40;and pressures&#41; the abdominal wall is very compliant and relatively large increases in volume will lead to minor changes in IAP only<span class="elsevierStyleSup">5</span>&#46; However&#44; at higher volumes the abdominal wall compliance reaches its compensatory limits and small volume changes can lead to large changes in IAP&#44; which means that a small increase in intra-abdominal volume can lead to clinically important IAH&#46; This abdominal pressure-volume curve is shifted to the left in situations where the abdominal wall compliance is decreased due to haematoma&#44; voluntary muscle activity&#44; edema or other factors&#46; Therefore&#44; IAH is usually associated with a situation that leads to increased abdominal volume&#44; decreased abdominal compliance or a combination of both&#46; The WSACS published a list of risk factors associated with these situations<span class="elsevierStyleSup">4</span>&#46; They are summarized in table 1&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab01.gif"></img></p><p class="elsevierStylePara">The mechanisms that link IAH with organ dysfunction are not yet completely understood&#46; There is certainly a direct mechanical effect of the increased IAP on the blood supply of the intra-abdominal organs&#44; which is most convincingly seen in the kidney<span class="elsevierStyleSup">6&#44;7</span>&#46; Some of the deleterious effects may be associated with direct compression of the organ involved and hormonal changes have been implicated as well&#46; However&#44; IAH also has an impact on distant organ function&#46; Ischemia-reperfusion injury may be involved in this complex pathophysiology as a &#171;second-hit&#187; phenomenon after shock resuscitation<span class="elsevierStyleSup">8&#44;9</span>&#46; The mechanisms involved will be clarified when discussing the effect of IAH on the different organ systems&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DEFINITIONS AND DIAGNOSIS OF IAH AND ACS</span></p><p class="elsevierStylePara">The first consensus paper by the WSACS&#44; published in 2006&#44; contains a list of definitions related to IAH and ACS<span class="elsevierStyleSup">4</span>&#46; The definitions are listed in table 2 and the recommendations in table 3&#46; These definitions are based on the best available scientific data today&#44; but they are likely to undergo some minor changes in the future&#46; The different methods used for diagnosis of ACS will be discussed here&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab02.gif"></img></p><p class="elsevierStylePara"><img src="64v31n02-13101465tab03.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical examination and medical imaging</span></p><p class="elsevierStylePara">Several surveys among clinicians show that many of them use clinical examination for the diagnosis of ACS&#46; This has been shown to be unreliable with a sensitivity and positive predictive value of around 40-60&#37;<span class="elsevierStyleSup">10&#44;11</span>&#46; The use of abdominal perimeter is equally inaccurate&#46; Radiologic investigation with plain radiography of the chest or abdomen&#44; abdominal ultrasound or CT-scan are also insensitive to the presence of increased IAP&#46; However&#44; they can be indicated to illustrate the cause of IAH &#40;bleeding&#44; hematoma&#44; ascites&#44; abscess&#46;&#46;&#46;&#41; and may offer clues for management &#40;paracenthesis&#44; drainage of collections&#46;&#46;&#46;&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IAP measurement</span></p><p class="elsevierStylePara">The most important prerequisite for the diagnosis and treatment of ACS is IAP measurement&#46; Since the abdominal contents are primarily non compressive in nature and predominantly fluid-based&#44; they can be assumed to behave according to Pascal&#39;s law&#46; Therefore&#44; the IAP measured at one point can be assumed to be the pressure throughout the abdominal cavity&#46;</p><p class="elsevierStylePara">The IAP can be measured directly or indirectly&#44; either intermittently or continuously<span class="elsevierStyleSup">6</span>&#46; The gold standard is direct intraperitoneal measurement&#44; but this is rarely available in clinical situations&#46; Today&#44; it is mostly used for animal research or in clinical studies during laparoscopy where IAP can be measured directly through a Verres needle or a laparoscopy port&#46; The most frequently used routes for indirect IAP measurement are the bladder and the stomach&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Transvesical IAP measurement</span></p><p class="elsevierStylePara">The previously mentioned surveys indicate that the transvesical technique is the most frequently used method for IAP measurement today&#44; due to simplicity and minimal cost<span class="elsevierStyleSup">5</span>&#46; It was also put forward as the gold standard in the WSACS consensus paper by Malbrain et al<span class="elsevierStyleSup">4</span>&#46; There is still some debate about the optimal amount of instillation volume for measurement&#46; Initially&#44; up to 200 mL of instillation volume was used&#44; but this has been shown to lead to overestimation of IAP<span class="elsevierStyleSup">12</span> and thus to false classification and possibly treatment of IAH&#46; There is a trend towards using smaller instillation volumes<span class="elsevierStyleSup">12-14</span>&#46; The WSACS consensus paper mentions an instillation volume of &#171;no more than 25 mL&#187;&#46; It is possible that even lower instillation volumes may be advocated in the future&#46; Several commercially available tools have been developed for transvesical IAP measurement e&#46;g&#46; the FoleyManometer &#40;Holtech Medical&#44; Kopenhagen&#44; Denmark &#173; www&#46;holtech-medical&#46;com&#41; or the AbViser valve &#40;Wolfe Tory&#44; Salt Lake City&#44; Utah&#44; USA &#173; www&#46;wolfetory&#46;com&#41;&#46; A transvesical technique for continuous measurement has been described&#44; but this technique is not widely used today<span class="elsevierStyleSup">15</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Transgastric measurement</span></p><p class="elsevierStylePara">Measurement through the stomach has some advantages&#58; it avoids the problems associated with creating a hydrostatic fluid column in the bladder and it is easier to use for continuous measurement&#46; Several balloon tipped catheters have been developed for IAP measurement&#46; The Spiegelberg monitor &#40;Spiegelberg&#44; Hamburg&#44; Germany &#173; www&#46;spiegelberg&#46;de&#41; was developed for intracranial pressure measurement but can be used also for continuous IAP measurement<span class="elsevierStyleSup">16&#44;17</span>&#46; Pulsion &#40;Pulsion Medical Systems&#44; Munich&#44; Germany &#173; www&#46;pulsion&#46;com&#41; developed a balloon tipped catheter for continuous measurement&#46; The CiMON monitor attached to it will offer continuous IAP and abdominal perfusion pressure &#40;APP&#41; measurement&#44; along with respiratory variations in IAP&#46; This monitor is yet to be clinically validated&#44; but it may offer more possibilities for real-time dynamic evaluation of IAH in the future&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">APP measurement</span></p><p class="elsevierStylePara">Analogous to the widely accepted and clinically utilized concept of cerebral perfusion pressure&#44; calculated as mean arterial pressure &#40;MAP&#41; minus intracranial pressure &#40;ICP&#41;&#44; APP&#44; calculated as MAP minus IAP&#44; has been proposed as a more accurate predictor of visceral perfusion and a potential endpoint for resuscitation<span class="elsevierStyleSup">18-21</span>&#46; APP&#44; by considering both arterial inflow &#40;MAP&#41; and restrictions to venous outflow &#40;IAP&#41;&#44; has been demonstrated to be statistically superior to either parameter alone in predicting patient survival from IAH and ACS<span class="elsevierStyleSup">21</span>&#46; A target APP of at least 60 mmHg has been demonstrated to correlate with improved survival from IAH and ACS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE EFFECT OF IAH ON ORGAN FUNCTION</span></p><p class="elsevierStylePara">It is beyond the scope of this text to give a complete overview of all pathophysiologic mechanisms involved&#46; We have focused on those pathologic observations that have direct implications on the clinical management of critically ill patients</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Effect on the cardiovascular system</span></p><p class="elsevierStylePara">IAH is associated with a number of effects on the cardiovascular system that are caused by multiple factors<span class="elsevierStyleSup">22</span>&#46; A very important concept is the abdominothoracic transmission&#44; which means that the intrathoracic pressure increases during IAH due to the cephalad movement of the diaphragm&#46; Animal and human experiments have shown that 20-80&#37; of the IAP is transmitted to the thorax&#46; This phenomenon accounts for most of the cardiovascular as well as the pulmonary and neurologic consequences of IAH&#46; Figure 1 illustrates the cardiovascular effects of IAH&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab04.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Figura 1&#46; The cardiovascular effects of IAH&#46; APP&#58; abdominal perfusion pressure&#59; CO&#58; cardiac output&#59; CVP&#58; central venous pressure&#58; DVT&#58; deep vein thrombosis&#59; EDV&#58; end diastolic volume&#59; IAP&#58; intra-abdominal pressure&#59; MAP&#58; mean arterial pressure&#59; PAOP&#58; pulmonary artery occlusion pressure&#59; PE&#58; pulmonary embolism&#59; PPV&#58; pulse pressure variation&#46; P™&#58; transmural pressure&#59; SVV&#58; stroke volume variation&#46;</span></p><p class="elsevierStylePara">A very important issue in the management of patients with IAH is the interpretation of haemodynamic monitoring parameters&#46; Due to the abdominothoracic transmission of pressure&#44; traditional filling pressures &#40;central venous pressure &#91;CVP&#93;&#44; and pulmonary artery occlusion pressure &#91;PAOP&#93;&#41; are &#171;falsely&#187; elevated in the presence of IAH&#44; and do not reflect true cardiac filling&#46; Therefore&#44; it may be more useful to use volumetric monitoring parameters such as right ventricular end diastolic volume index &#40;RVEDVI&#41; or global end diastolic volume index &#40;GEDVI&#41;<span class="elsevierStyleSup">23-27</span>&#46; Preload responsiveness can best be evaluated using dynamic parameters such as pulse pressure variation &#40;PPV&#41; or stroke volume variation &#40;SVV&#41;<span class="elsevierStyleSup">28&#44;29</span>&#44; provided that patients have a regular sinus rhythm&#44; are completely sedated and do not exhibit spontaneous breathing movements&#46; If these volumetric or dynamic parameters are not available and filling pressures have to be used for haemodynamic monitoring&#44; they should be corrected for intrathoracic pressure&#46; This means that transmural CVP &#40;CVPTM&#41; is equal to CVP minus intrathoracic pressure &#40;ITP&#41; and PAOPTM &#61; PAOP &#173; ITP&#46; Since the abdominothoracic transmission amounts to 20-80&#37;&#44; ITP can be assumed to be IAP&#47;2 and transmural filling pressures can be estimated as&#58;</p><p class="elsevierStylePara">CVP<span class="elsevierStyleSup">TM</span> &#61; CVP &#173; IAP&#47;2</p><p class="elsevierStylePara"> PAOP<span class="elsevierStyleSup">TM</span> &#61; PAOP &#173; IAP&#47;2</p><p class="elsevierStylePara">The surviving sepsis campaign guidelines targeting initial and ongoing resuscitation towards a CVP of 8 to 12 mmHg<span class="elsevierStyleSup">30</span> and other studies targeting a MAP of 65 mmHg<span class="elsevierStyleSup">31</span> should be interpreted and adjusted according to these findings&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Effects of IAH on the respiratory system</span></p><p class="elsevierStylePara">The transmission of IAP to the thorax also has an impact on the respiratory system&#46; The major problem lies in the reduction of the functional residual capacity &#40;FRC&#41;&#46; Together with the alterations caused by secondary adult respiratory distress syndrome &#40;ARDS&#41; this will lead to the so-called &#171;baby-lungs&#187;&#46; The chest wall compliance is reduced during IAH while lung compliance remains virtually unchanged&#44; which leads to decreased overall compliance of the respiratory system<span class="elsevierStyleSup">32&#44;33</span>&#46; Some recommendations can be made in terms of ventilation strategy for patients with IAH&#58;</p><p class="elsevierStylePara">1&#41; Best PEEP should be set to counteract IAP whilst in the same time avoiding over-inflation of already well-aerated lung regions&#46;</p><p class="elsevierStylePara">Best PEEP &#61; IAP</p><p class="elsevierStylePara">2&#41; In analogy to the cardiovascular system&#44; ARDS consensus definitions and recommendations should be adapted to take into account the influence of IAP on intrathoracic pressure&#46; During lung protective ventilation&#44; the plateau pressures should be limited to transmural plateau pressures below 35 cmH<span class="elsevierStyleInf">2</span>O</p><p class="elsevierStylePara">Pplat™ &#61; Pplat &#173; IAP&#47;2</p><p class="elsevierStylePara">3&#41; Monitoring of extravascular lung water index &#40;EVLWI&#41; seems warranted in risk patients since IAH is associated with increased risk of lung edema<span class="elsevierStyleSup">34</span>&#46; Capillary leak syndrome and IAH have a synergistic effect on the generation of lung edema&#46;</p><p class="elsevierStylePara">4&#41; The presence of IAH will lead to pulmonary hypertension via increased ITP with direct compression on lung parenchyma and vessels and via the diminished left and right ventricular compliance&#46; In this case the administration of inhaled NO or ilomedine &#40;prostacyclin&#41; may be justified&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on the central nervous system</span></p><p class="elsevierStylePara">A direct relationship between IAP and ICP has been observed in both animal and human studies<span class="elsevierStyleSup">20&#44;35-38</span>&#46; Several authors hypothesized that the increase in ICP secondary to IAH was caused by increased ITP&#44; leading to increased CVP and decreased venous return from the brain and thus&#44; venous congestion and brain edema&#46; This hypothesis gained acceptance when Bloomfield et al demonstrated that the association between IAP and ICP could be abolished by performing a sternotomy and bilateral pleuropericardotomy in pigs<span class="elsevierStyleSup">37</span>&#46; The reduced systemic blood pressure associated with decreased cardiac preload and the increase in ICP also leads to a decrease in cerebral perfusion pressure &#40;CPP&#41;&#46; Some authors have demonstrated successful treatment of refractory intracranial hypertension with abdominal decompression or neuromuscular blockers<span class="elsevierStyleSup">20&#44;35</span>&#46;</p><p class="elsevierStylePara">Some recommendations&#58;</p><p class="elsevierStylePara">1&#41; IAP monitoring is essential for all traumatic or nontraumatic patients at risk for intracranial hypertension &#40;ICH&#41; or IAH &#40;according to the risk factors published by the WSACS&#41;&#46;</p><p class="elsevierStylePara">2&#41; In all patients with ICH&#44; preventive measures should be undertaken to avoid increase in IAP&#44; and conversely&#44; in all patients with IAH&#44; a possible association with ICH should be considered and preventive measures should be taken &#40;head of bed elevation&#44; avoid hypervolemia&#44; hypernatriemia and hyperthermia&#46;&#46;&#46;&#41;&#46;</p><p class="elsevierStylePara">3&#41; Avoid hypervolemia in patients with IAH to prevent further increase in ICP&#46;</p><p class="elsevierStylePara">4&#41; Consider using APP &#40;abdominal perfusion pressure&#59; APP &#61; MAP-IAP&#41; as a resuscitation target in patients where ICP is not available and CPP can not be used as a target&#46;</p><p class="elsevierStylePara">5&#41; Avoid laparoscopy in patients at risk for ICH&#46; The pneumoperitoneum used for laparoscopy creates a situation analogous to experimental settings of IAH and ICH in which detrimental effects on ICP have been observed&#46; This is especially important in trauma patients with associated brain and abdominal injuries&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on renal function</span></p><p class="elsevierStylePara">Renal dysfunction is one of the most consistently described organ dysfunctions associated with IAH&#46; The etiology is multifactorial and offers a unique insight into the deleterious and sometimes cumulative effects of IAH on organ function&#46;</p><p class="elsevierStylePara">The most important effect of IAH on the kidney is related to renal blood flow&#46; IAH has been shown to lead to renal venous compression and increased renal venous pressure<span class="elsevierStyleSup">39&#44;40</span>&#46; Also&#44; renal arterial blood flow and microcirculatory flow in the renal cortex are decreased&#46;&#46; Direct compression of the renal cortex may be a contributing factor<span class="elsevierStyleSup">39&#44;41</span>&#46; The changes in renal blood flow lead to activation of the renin-angiotensin-aldosteron pathway and also&#44; ADH secretion is increased in IAH<span class="elsevierStyleSup">42&#44;43</span>&#46; The clinical importance of these changes is still unclear&#46;</p><p class="elsevierStylePara">Biancofiore and Sugrue showed that renal dysfunction is rather common in IAH<span class="elsevierStyleSup">6&#44;7&#44;44-46</span>&#46; Ulyatt suggested that filtration gradient &#40;FG&#41; is an important factor in explaining renal failure associated with IAH<span class="elsevierStyleSup">47</span>&#46; The FG is the mechanical force across the glomerulus and is equal to the difference between glomerular filtration pressure and the proximal tubular pressure&#46; Glomerular filtration pressure is equal to RPF and thus to MAP &#173; IAP&#46; In the presence of IAH&#44; proximal tubular pressure can be equated with IAP&#46; The FG can therefore be calculated as FG &#61; MAP &#173; &#40;2x IAP&#41;&#46; This explains why the kidney seems to be more vulnerable to IAH than other surrounding organs and is probably one of the key factors in the development of IAH-induced renal failure<span class="elsevierStyleSup">7&#44;21</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on other organ functions</span></p><p class="elsevierStylePara">Animal and human studies have shown decreased hepatic arterial flow as well as decreased portal flow and increased portacollateral flow&#46; Furthermore&#44; even moderate levels of IAP have been associated with impaired hepatocellular function<span class="elsevierStyleSup">48&#44;49</span>&#46; IAH is inversely correlated with indocyanine green clearance<span class="elsevierStyleSup">50</span>&#46; Biancofiore et al demonstrated that liver disease and especially liver surgery and transplantation are often associated with IAH and ACS<span class="elsevierStyleSup">51</span>&#46; Cytochrome P450 function and other liver functions may be impaired in IAH&#46; Therefore&#44; it seems wise to avoid hepatotoxic medications&#44; increase the attention towards therapeutic interactions&#44; treat IAH aggressively and maximize supportive treatment for patients with IAH and liver dysfunction&#46;</p><p class="elsevierStylePara">Where the digestive tract is concerned&#44; intra-abdominal hypertension causes diminished perfusion and mucosal acidosis and sets the stage for multiple organ failure<span class="elsevierStyleSup">52</span>&#46; The ischemia and reperfusion injury to the gut serves as a second insult in a two hit model of MOF where the lymph flow conducts gut-derived pro-inflammatory cytokines to remote organs<span class="elsevierStyleSup">9&#44;52</span>&#46; These complex mechanisms are not yet completely understood&#44; but they will undoubtedly be the subject of further study in the next few years&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">TREATMENT OF IAH</span></p><p class="elsevierStylePara">In analogy to other compartment syndromes in the human body&#44; decompressive laparotomy &#40;DL&#41; seems the most logical treatment option&#46; It is also the most widely used and best described treatment modality today&#46; However&#44; DL leaves the patient with an open abdomen which can lead to extensive fluid losses&#44; infection&#44; enterocutaneous fistulae&#44; ventral hernia and cosmetic dysfunction&#46; Therefore&#44; DL is mostly used today as a rescue therapy for patients with overt ACS&#44; who have not responded to medical treatment&#46; Indications and results for different treatment modalities will be discussed here&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Decompressive laparotomy</span></p><p class="elsevierStylePara">A recent systematic review on decompressive laparotomy&#44; based on 18 studies&#44; was published by De Waele et al<span class="elsevierStyleSup">53</span>&#46; This review illustrated that DL is successful in lowering IAP in all studies&#46; Concerning the results on organ function&#44; results are variable&#46; Regarding the cardiovascular function&#44; heart rate en MAP remained unchanged in most studies&#46; CVP and PAOP decreased significantly&#44; which is to be expected in view of the abdominothoracic transmission&#46; This probably does not reflect a true improvement in cardiac function&#46; However&#44; cardiac index was also improved&#46; In analogy&#44; peak inspiratory pressures decreased after decompression&#44; but also PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> improved&#46; The effect on renal function is less clear&#46; In most studies&#44; urine output was significantly improved after DL&#44; but interestingly&#44; in the two largest series<span class="elsevierStyleSup">54&#44;55</span> urine output was not affected&#46; Sugrue suggests that acute tubular necrosis might be involved which takes longer to recuperate and does not appear in short-term outcome analyses&#46; In general&#44; DL seems to have a beneficial effect on organ function&#46; Overall mortality remains high &#40;49&#46;2&#37;&#41;&#46; Although most authors agree that DL should be performed in patients with IAP &#62; 20 mmHg and new or progressive organ failure&#44; there is some reluctance to perform DL because of the practical consequences in terms of fluid loss through the open abdomen&#44; difficult wound dressings&#44; risk of infection or fistula&#44; re-interventions&#44; cost and longer hospital stay&#46; However&#44; a well performed study by Cheatham et al<span class="elsevierStyleSup">56</span> demonstrated that physical&#44; social and mental health after DL is restored to the level of the general population after abdominal wall reconstruction and DL does not lead to permanent disability or unemployment&#46;</p><p class="elsevierStylePara">Since the goal of DL is to decompress and thereby increase intra-abdominal volume it is usually not possible to close the abdomen primarily&#44; which means that some form of temporary abdominal closure &#40;TAC&#41; has to be performed to protect the abdominal contents and to allow healing&#44; followed by an abdominal wall reconstruction which is usually planned after several months&#46; The most widely used techniques for TAC are a Bogota bag &#40;a plastic sheet cut from a sterile bag of infusion fluids sewn to the fascia or skin edges&#41;&#44; resorbable surgical mesh with or without split thickness skin grafting&#44; towel clip closure &#40;in situations where other TAC methods are not available or too time consuming&#41;&#44; commercially available devices such as zippers or Wittman patches or vacuum assisted closure &#40;VAC&#41;&#46; The detailed description of these techniques&#44; their indications and results are beyond the scope of this text&#46; There is certainly a vast body of scientific data on this subject&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Minimally invasive surgical decompression</span></p><p class="elsevierStylePara">Because of the complications associated with full DL&#44; surgeons have been searching for less invasive techniques to decompress the abdomen&#46; Endoscopic techniques based on the components separation concept described by Ramirez&#44; Voss and others<span class="elsevierStyleSup">57&#44;58</span>&#44; like the subcutaneous anterior abdominal fasciotomy<span class="elsevierStyleSup">59</span> are being developed and might replace DL in selected cases in the future&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Non surgical management</span></p><p class="elsevierStylePara">Most non-surgical treatment strategies are aimed at either decreasing abdominal volume or increasing wall compliance&#46; An overview of possible treatment strategies is given in table 4&#46; Some of these will be highlighted here in detail&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Evacuation of intraluminal contents</span></p><p class="elsevierStylePara">Non-invasive removal of intraluminal contents by gastric tube placement and suctioning&#44; rectal tube placement&#44; enemas and&#44; if indicated&#44; endoscopic decompression should be attempted<span class="elsevierStyleSup">60-62</span>&#46;</p><p class="elsevierStylePara">Also&#44; gastroprokinetics &#40;such as metoclopramide or erythromycin&#41; and&#47;or colonoprokinetics &#40;neostygmine or prostygmine&#41; can be used<span class="elsevierStyleSup">63-67</span>&#46; In patients with gross dilatation of the stomach or the colon&#44; this alone may be sufficient to lower IAP to harmless levels&#44; but in most general ICU patients&#44; other measures will have to be considered&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Evacuation of extraluminal contents</span></p><p class="elsevierStylePara">Drainage of tense ascites may result in a decrease in IAP<span class="elsevierStyleSup">68-72</span>&#46; Paracenthesis is the treatment of choice in burn patients with secondary ACS<span class="elsevierStyleSup">73-75</span> or any other patients who develop ascites after massive &#40;usually crystalloid&#41; fluid resuscitation&#46; If intra-abdominal abscesses&#44; hematomas or fluid collections are present&#44; they should be drained also&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Use of sedation and neuromuscular blockers</span></p><p class="elsevierStylePara">Increased muscle tone in the rectus abdominal wall muscles due to voluntary muscle contraction&#44; pain or agitation&#44; causes decreased abdominal wall compliance and thus IAH&#46; Therefore&#44; it is important to titrate analgesia and sedation to allow for maximal relaxation of the abdominal wall muscles&#46; However&#44; in critically ill patients with capillary leak and abdominal wall edema&#44; control of pain and agitation are often not sufficient and the use of neuromuscular blockers has to be considered&#46; In a single case report&#44; single dose administraton of cisatracurium&#44; followed later by continuous infusion of cisatracurium&#44; was successful in lowering IAP to safe levels and was also associated with an increase in urine output<span class="elsevierStyleSup">76</span>&#46; Other authors have confirmed these findings<span class="elsevierStyleSup">20&#44;77</span>&#46; However&#44; neuromuscular blockers have been associated with increased incidence of ventilator-associated pneumonia and ICU muscular weakness and their use has been restricted in the last few years to avoid these and other complications&#46; The possible benefit of reducing IAP has to be balanced against the risk of complications at the individual patient level&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Correction of capillary leak and positive fluid balance</span></p><p class="elsevierStylePara">Most patients with IAH&#44; due to the nature of their illness or trauma&#44; present with capillary leak syndrome&#46; In the early stages of their illness it is important to resuscitate these patients towards euvolemia and adequate intravascular fluid status&#44; both in terms of their general condition and in terms of their IAH&#44; since hypovolemia in patients with IAH can lead to splanchnic hypoperfusion and aggravation of the organ dysfunction<span class="elsevierStyleSup">78&#44;79</span>&#46; Dobutamine may help to counteract this splanchnic hypoperfusion<span class="elsevierStyleSup">80</span>&#46;</p><p class="elsevierStylePara">However&#44; fluid resuscitation will lead also to increased edema formation&#44; third spacing and possibly to a vicious cycle of ongoing IAH&#46; After hemodynamic stabilisation&#44; correction of the fluid balance and decreasing edema formation becomes important&#46; If renal function is only minimally to mildly compromised and the patient is hemodynamically stable&#44; mobilisation of edema by administration of colloids e&#46;g&#46; albumin &#40;to increase colloid osmotic pressure&#41; and diuretics can be attempted&#46; However&#44; as renal function deteriorates further&#44; patients often do not respond to diuretic therapy&#46; Fluid removal by means of ultrafiltration has been demonstrated to have a beneficial effect on IAP and possibly on organ function<span class="elsevierStyleSup">81&#44;82</span>&#46; The institution of renal replacement therapy with fluid removal&#44; if hemodynamically tolerated&#44; should not be delayed&#46; In patients with borderline hemodynamic status&#44; continuous forms of RRT may be preferred over intermittent RRT to avoid hemodynamic instability&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> Octreotide</span></p><p class="elsevierStylePara">Kacmaz et al found evidence of ischemia-reperfusion injury in animals after decompressive laparotomy<span class="elsevierStyleSup">83</span>&#46; They hypothesize that the organ dysfunction associated with IAH is caused by ischemic damage&#44; and decompressive laparotomy leads to reperfusion injury causing a second-hit phenomenon&#46; This reperfusion injury seems to be counteracted by the administration of octreotide&#44; a long acting somatostatin analogue&#44; before decompression&#46; Further research in humans is necessary to confirm these findings&#46;</p><p class="elsevierStylePara">The most difficult issue is to decide what to do to whom and when&#46; Few scientific data are available at this moment to guide treatment&#46; A possible treatment algorithm is shown in figure 2&#46; Large interventional studies will have to be conducted to further elucidate this complex issue&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab06.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Figura 2&#46; Possible treatment algorithm&#46; Adapted from Cheatham ML&#44; et al<span class="elsevierStyleSup">86</span>&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> CONCLUSION</span></p><p class="elsevierStylePara">Intra-abdominal hypertension and abdominal compartment syndrome occur frequently in ICU patients and are independently associated with mortality&#46; Since diagnosis relies entirely on the knowledge of IAP&#44; the different techniques for accurate IAP measurement are mentioned in this paper&#46; The effect of IAH on different organ systems is described&#44; along with recommendations to compensate for these effects&#46; The ultimate goal of treatment is not only to decrease IAP&#44; but also to improve organ function and to decrease mortality&#46; Decompressive laparotomy is the only treatment option that has been shown to reach most of these goals today&#46; However&#44; some less invasive techniques and some medical treatment strategies have shown promise in achieving IAP reduction as well as organ function improvement&#46; Indications for these techniques and implementation of a treatment algorithm will require additional clinical research&#44; which is likely to be fostered by the WSACS&#46; &#171;It is time to pay attention&#33;&#187;&#44; this was the title of a recent review 4 and the slogan of the 3rd World Congress on Abdominal Compartment Syndrome &#40;WCACS2007&#41; held in Antwerp&#44; Belgium in 2007&#44; march 22-24 &#40;www&#46; wcacs&#46;org&#41;&#46;</p><hr></hr><p class="elsevierStylePara"> Correspondence&#58;</p><p class="elsevierStylePara">Dr&#46; M&#46; Malbrain&#46;  <br></br> e-mail&#58; <a href="mailto&#58;manu&#46;malbrain&#64;skynet&#46;be" class="elsevierStyleCrossRefs"> manu&#46;malbrain&#64;skynet&#46;be</a></p><p class="elsevierStylePara">Manuscrito aceptado el 30-I-2007&#46;</p>"
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        "resumen" => "Existe s&#237;ndrome compartimental cuando el aumento de presi&#243;n en un espacio cerrado amenaza la viabilidad del tejido dentro del compartimento&#46; Cuando esto ocurre en la cavidad abdominal&#44; no s&#243;lo amenaza la funci&#243;n de los &#243;rganos intra-abominales&#44; sino que tambi&#233;n puede tener un efecto devastador en los &#243;rganos distantes&#46; Datos de estudios recientes en animales y humanos sugieren que los efectos adversos de la presi&#243;n elevada pueden ocurrir a niveles m&#225;s bajos de lo que se hab&#237;a pensado y hasta antes de que el s&#237;ndrome compartimental abdominal sea cl&#237;nicamente evidente&#46; El s&#237;ndrome compartimental abdominal no es una enfermedad&#44; sino que es un verdadero s&#237;ndrome&#59; es decir&#44; consiste en un espectro de s&#237;ntomas y signos que pueden tener m&#250;ltiples causas&#46; Hace poco tiempo que esta condici&#243;n recibe atenci&#243;n y empieza a conocerse ampliamente&#46; Este art&#237;culo revisa el estado actual del conocimiento de la hipertensi&#243;n intra-abdominal en cuanto a su etiolog&#237;a&#44; epidemiolog&#237;a&#44; diagn&#243;stico&#44; medici&#243;n de presi&#243;n intra-abdominal&#44; disfunci&#243;n de &#243;rganos&#44; prevenci&#243;n y tratamiento&#46;"
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Current insights in intra-abdominal hypertension and abdominal compartment syndrome
Current insights in intra-abdominal hypertension and abdominal compartment syndrome
IE. de Laeta, M. Malbrainb
a General surgeon-Intensivist, Intensive Care Unit.
b Internist-Intensivist, ICU director, Founding president World Society on Abdominal Compartment Syndrome (WSACS), Intensive Care Unit. ZiekenhuisNetwerk Antwerpen Campus Stuivenberg. Belgium.
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold"> INTRODUCTION</span></p><p class="elsevierStylePara">Intra-abdominal hypertension &#40;IAH&#41; and abdominal compartment syndrome &#40;ACS&#41; have been shown to occur frequently in Intensive Care Units &#40;ICU&#41; patients and have been independently associated with mortality<span class="elsevierStyleSup">1&#44;2</span>&#46; Unlike many commonly encountered disease processes which remain within the purview of a given discipline&#44; IAH and the ACS readily cross the usual barriers and may occur in any patient population regardless of age&#44; illness&#44; or injury&#46; As a result&#44; no one specific speciality can represent the wide variety of health care workers who might encounter patients with IAH and&#47;or ACS in their daily practice&#46; For this reason&#44; a multidisciplinary&#44; international organisation&#44; the World Society of the Abdominal Compartment Syndrome &#40;WSACS &#173; www&#46;wsacs&#46;org&#41; was founded in 2004 with the aim to foster education&#44; to facilitate research and to improve outcome for these patients&#46; As an introduction to the Third World Congress on Abdominal Compartment Syndrome &#40;www&#46;wcacs&#46;org&#41;&#44; organised by the WSACS&#44; which will be held in March 2007 in Antwerp&#44; Belgium&#44; this review will try to give a concise overview of the epidemiologic data&#44; etiology&#44; diagnosis&#44; IAP measurement&#44; organ dysfunction&#44; prevention and treatment options related to ACS&#44; focusing on recent developments and possibilities for the future&#46; It reflects the most important evolutions in literature as well as well as the personal experience of the authors&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ETIOLOGY AND EPIDEMIOLOGY</span></p><p class="elsevierStylePara">The ACS is diagnosed when there is increased intra-abdominal pressure &#40;IAP&#41; along with evidence of end-organ dysfunction<span class="elsevierStyleSup">3</span>&#46; IAH is diagnosed when IAP is moderately increased&#44; but there is no evidence of organ dysfunction yet&#44; although subtle forms of organ dysfunction may be present at levels of IAP previously deemed to be safe<span class="elsevierStyleSup">4</span>&#46; There may even be a &#171;dose-dependent&#187; association between IAP and organ dysfunction&#46; Where etiology is concerned&#44; there are two major factors to discuss&#58; first&#44; the origin of the increased IAP itself and secondly&#44; the etiology of organ dysfunction in the presence of IAH&#46;</p><p class="elsevierStylePara">Why and when does the pressure within the abdominal cavity rise&#63; In analogy to the situation in the brain&#44; there are essentially two parts in the abdominal pressure-volume curve&#46; At low intra-abdominal volumes &#40;and pressures&#41; the abdominal wall is very compliant and relatively large increases in volume will lead to minor changes in IAP only<span class="elsevierStyleSup">5</span>&#46; However&#44; at higher volumes the abdominal wall compliance reaches its compensatory limits and small volume changes can lead to large changes in IAP&#44; which means that a small increase in intra-abdominal volume can lead to clinically important IAH&#46; This abdominal pressure-volume curve is shifted to the left in situations where the abdominal wall compliance is decreased due to haematoma&#44; voluntary muscle activity&#44; edema or other factors&#46; Therefore&#44; IAH is usually associated with a situation that leads to increased abdominal volume&#44; decreased abdominal compliance or a combination of both&#46; The WSACS published a list of risk factors associated with these situations<span class="elsevierStyleSup">4</span>&#46; They are summarized in table 1&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab01.gif"></img></p><p class="elsevierStylePara">The mechanisms that link IAH with organ dysfunction are not yet completely understood&#46; There is certainly a direct mechanical effect of the increased IAP on the blood supply of the intra-abdominal organs&#44; which is most convincingly seen in the kidney<span class="elsevierStyleSup">6&#44;7</span>&#46; Some of the deleterious effects may be associated with direct compression of the organ involved and hormonal changes have been implicated as well&#46; However&#44; IAH also has an impact on distant organ function&#46; Ischemia-reperfusion injury may be involved in this complex pathophysiology as a &#171;second-hit&#187; phenomenon after shock resuscitation<span class="elsevierStyleSup">8&#44;9</span>&#46; The mechanisms involved will be clarified when discussing the effect of IAH on the different organ systems&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DEFINITIONS AND DIAGNOSIS OF IAH AND ACS</span></p><p class="elsevierStylePara">The first consensus paper by the WSACS&#44; published in 2006&#44; contains a list of definitions related to IAH and ACS<span class="elsevierStyleSup">4</span>&#46; The definitions are listed in table 2 and the recommendations in table 3&#46; These definitions are based on the best available scientific data today&#44; but they are likely to undergo some minor changes in the future&#46; The different methods used for diagnosis of ACS will be discussed here&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab02.gif"></img></p><p class="elsevierStylePara"><img src="64v31n02-13101465tab03.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical examination and medical imaging</span></p><p class="elsevierStylePara">Several surveys among clinicians show that many of them use clinical examination for the diagnosis of ACS&#46; This has been shown to be unreliable with a sensitivity and positive predictive value of around 40-60&#37;<span class="elsevierStyleSup">10&#44;11</span>&#46; The use of abdominal perimeter is equally inaccurate&#46; Radiologic investigation with plain radiography of the chest or abdomen&#44; abdominal ultrasound or CT-scan are also insensitive to the presence of increased IAP&#46; However&#44; they can be indicated to illustrate the cause of IAH &#40;bleeding&#44; hematoma&#44; ascites&#44; abscess&#46;&#46;&#46;&#41; and may offer clues for management &#40;paracenthesis&#44; drainage of collections&#46;&#46;&#46;&#41;&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">IAP measurement</span></p><p class="elsevierStylePara">The most important prerequisite for the diagnosis and treatment of ACS is IAP measurement&#46; Since the abdominal contents are primarily non compressive in nature and predominantly fluid-based&#44; they can be assumed to behave according to Pascal&#39;s law&#46; Therefore&#44; the IAP measured at one point can be assumed to be the pressure throughout the abdominal cavity&#46;</p><p class="elsevierStylePara">The IAP can be measured directly or indirectly&#44; either intermittently or continuously<span class="elsevierStyleSup">6</span>&#46; The gold standard is direct intraperitoneal measurement&#44; but this is rarely available in clinical situations&#46; Today&#44; it is mostly used for animal research or in clinical studies during laparoscopy where IAP can be measured directly through a Verres needle or a laparoscopy port&#46; The most frequently used routes for indirect IAP measurement are the bladder and the stomach&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Transvesical IAP measurement</span></p><p class="elsevierStylePara">The previously mentioned surveys indicate that the transvesical technique is the most frequently used method for IAP measurement today&#44; due to simplicity and minimal cost<span class="elsevierStyleSup">5</span>&#46; It was also put forward as the gold standard in the WSACS consensus paper by Malbrain et al<span class="elsevierStyleSup">4</span>&#46; There is still some debate about the optimal amount of instillation volume for measurement&#46; Initially&#44; up to 200 mL of instillation volume was used&#44; but this has been shown to lead to overestimation of IAP<span class="elsevierStyleSup">12</span> and thus to false classification and possibly treatment of IAH&#46; There is a trend towards using smaller instillation volumes<span class="elsevierStyleSup">12-14</span>&#46; The WSACS consensus paper mentions an instillation volume of &#171;no more than 25 mL&#187;&#46; It is possible that even lower instillation volumes may be advocated in the future&#46; Several commercially available tools have been developed for transvesical IAP measurement e&#46;g&#46; the FoleyManometer &#40;Holtech Medical&#44; Kopenhagen&#44; Denmark &#173; www&#46;holtech-medical&#46;com&#41; or the AbViser valve &#40;Wolfe Tory&#44; Salt Lake City&#44; Utah&#44; USA &#173; www&#46;wolfetory&#46;com&#41;&#46; A transvesical technique for continuous measurement has been described&#44; but this technique is not widely used today<span class="elsevierStyleSup">15</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Transgastric measurement</span></p><p class="elsevierStylePara">Measurement through the stomach has some advantages&#58; it avoids the problems associated with creating a hydrostatic fluid column in the bladder and it is easier to use for continuous measurement&#46; Several balloon tipped catheters have been developed for IAP measurement&#46; The Spiegelberg monitor &#40;Spiegelberg&#44; Hamburg&#44; Germany &#173; www&#46;spiegelberg&#46;de&#41; was developed for intracranial pressure measurement but can be used also for continuous IAP measurement<span class="elsevierStyleSup">16&#44;17</span>&#46; Pulsion &#40;Pulsion Medical Systems&#44; Munich&#44; Germany &#173; www&#46;pulsion&#46;com&#41; developed a balloon tipped catheter for continuous measurement&#46; The CiMON monitor attached to it will offer continuous IAP and abdominal perfusion pressure &#40;APP&#41; measurement&#44; along with respiratory variations in IAP&#46; This monitor is yet to be clinically validated&#44; but it may offer more possibilities for real-time dynamic evaluation of IAH in the future&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">APP measurement</span></p><p class="elsevierStylePara">Analogous to the widely accepted and clinically utilized concept of cerebral perfusion pressure&#44; calculated as mean arterial pressure &#40;MAP&#41; minus intracranial pressure &#40;ICP&#41;&#44; APP&#44; calculated as MAP minus IAP&#44; has been proposed as a more accurate predictor of visceral perfusion and a potential endpoint for resuscitation<span class="elsevierStyleSup">18-21</span>&#46; APP&#44; by considering both arterial inflow &#40;MAP&#41; and restrictions to venous outflow &#40;IAP&#41;&#44; has been demonstrated to be statistically superior to either parameter alone in predicting patient survival from IAH and ACS<span class="elsevierStyleSup">21</span>&#46; A target APP of at least 60 mmHg has been demonstrated to correlate with improved survival from IAH and ACS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">THE EFFECT OF IAH ON ORGAN FUNCTION</span></p><p class="elsevierStylePara">It is beyond the scope of this text to give a complete overview of all pathophysiologic mechanisms involved&#46; We have focused on those pathologic observations that have direct implications on the clinical management of critically ill patients</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Effect on the cardiovascular system</span></p><p class="elsevierStylePara">IAH is associated with a number of effects on the cardiovascular system that are caused by multiple factors<span class="elsevierStyleSup">22</span>&#46; A very important concept is the abdominothoracic transmission&#44; which means that the intrathoracic pressure increases during IAH due to the cephalad movement of the diaphragm&#46; Animal and human experiments have shown that 20-80&#37; of the IAP is transmitted to the thorax&#46; This phenomenon accounts for most of the cardiovascular as well as the pulmonary and neurologic consequences of IAH&#46; Figure 1 illustrates the cardiovascular effects of IAH&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab04.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Figura 1&#46; The cardiovascular effects of IAH&#46; APP&#58; abdominal perfusion pressure&#59; CO&#58; cardiac output&#59; CVP&#58; central venous pressure&#58; DVT&#58; deep vein thrombosis&#59; EDV&#58; end diastolic volume&#59; IAP&#58; intra-abdominal pressure&#59; MAP&#58; mean arterial pressure&#59; PAOP&#58; pulmonary artery occlusion pressure&#59; PE&#58; pulmonary embolism&#59; PPV&#58; pulse pressure variation&#46; P™&#58; transmural pressure&#59; SVV&#58; stroke volume variation&#46;</span></p><p class="elsevierStylePara">A very important issue in the management of patients with IAH is the interpretation of haemodynamic monitoring parameters&#46; Due to the abdominothoracic transmission of pressure&#44; traditional filling pressures &#40;central venous pressure &#91;CVP&#93;&#44; and pulmonary artery occlusion pressure &#91;PAOP&#93;&#41; are &#171;falsely&#187; elevated in the presence of IAH&#44; and do not reflect true cardiac filling&#46; Therefore&#44; it may be more useful to use volumetric monitoring parameters such as right ventricular end diastolic volume index &#40;RVEDVI&#41; or global end diastolic volume index &#40;GEDVI&#41;<span class="elsevierStyleSup">23-27</span>&#46; Preload responsiveness can best be evaluated using dynamic parameters such as pulse pressure variation &#40;PPV&#41; or stroke volume variation &#40;SVV&#41;<span class="elsevierStyleSup">28&#44;29</span>&#44; provided that patients have a regular sinus rhythm&#44; are completely sedated and do not exhibit spontaneous breathing movements&#46; If these volumetric or dynamic parameters are not available and filling pressures have to be used for haemodynamic monitoring&#44; they should be corrected for intrathoracic pressure&#46; This means that transmural CVP &#40;CVPTM&#41; is equal to CVP minus intrathoracic pressure &#40;ITP&#41; and PAOPTM &#61; PAOP &#173; ITP&#46; Since the abdominothoracic transmission amounts to 20-80&#37;&#44; ITP can be assumed to be IAP&#47;2 and transmural filling pressures can be estimated as&#58;</p><p class="elsevierStylePara">CVP<span class="elsevierStyleSup">TM</span> &#61; CVP &#173; IAP&#47;2</p><p class="elsevierStylePara"> PAOP<span class="elsevierStyleSup">TM</span> &#61; PAOP &#173; IAP&#47;2</p><p class="elsevierStylePara">The surviving sepsis campaign guidelines targeting initial and ongoing resuscitation towards a CVP of 8 to 12 mmHg<span class="elsevierStyleSup">30</span> and other studies targeting a MAP of 65 mmHg<span class="elsevierStyleSup">31</span> should be interpreted and adjusted according to these findings&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Effects of IAH on the respiratory system</span></p><p class="elsevierStylePara">The transmission of IAP to the thorax also has an impact on the respiratory system&#46; The major problem lies in the reduction of the functional residual capacity &#40;FRC&#41;&#46; Together with the alterations caused by secondary adult respiratory distress syndrome &#40;ARDS&#41; this will lead to the so-called &#171;baby-lungs&#187;&#46; The chest wall compliance is reduced during IAH while lung compliance remains virtually unchanged&#44; which leads to decreased overall compliance of the respiratory system<span class="elsevierStyleSup">32&#44;33</span>&#46; Some recommendations can be made in terms of ventilation strategy for patients with IAH&#58;</p><p class="elsevierStylePara">1&#41; Best PEEP should be set to counteract IAP whilst in the same time avoiding over-inflation of already well-aerated lung regions&#46;</p><p class="elsevierStylePara">Best PEEP &#61; IAP</p><p class="elsevierStylePara">2&#41; In analogy to the cardiovascular system&#44; ARDS consensus definitions and recommendations should be adapted to take into account the influence of IAP on intrathoracic pressure&#46; During lung protective ventilation&#44; the plateau pressures should be limited to transmural plateau pressures below 35 cmH<span class="elsevierStyleInf">2</span>O</p><p class="elsevierStylePara">Pplat™ &#61; Pplat &#173; IAP&#47;2</p><p class="elsevierStylePara">3&#41; Monitoring of extravascular lung water index &#40;EVLWI&#41; seems warranted in risk patients since IAH is associated with increased risk of lung edema<span class="elsevierStyleSup">34</span>&#46; Capillary leak syndrome and IAH have a synergistic effect on the generation of lung edema&#46;</p><p class="elsevierStylePara">4&#41; The presence of IAH will lead to pulmonary hypertension via increased ITP with direct compression on lung parenchyma and vessels and via the diminished left and right ventricular compliance&#46; In this case the administration of inhaled NO or ilomedine &#40;prostacyclin&#41; may be justified&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on the central nervous system</span></p><p class="elsevierStylePara">A direct relationship between IAP and ICP has been observed in both animal and human studies<span class="elsevierStyleSup">20&#44;35-38</span>&#46; Several authors hypothesized that the increase in ICP secondary to IAH was caused by increased ITP&#44; leading to increased CVP and decreased venous return from the brain and thus&#44; venous congestion and brain edema&#46; This hypothesis gained acceptance when Bloomfield et al demonstrated that the association between IAP and ICP could be abolished by performing a sternotomy and bilateral pleuropericardotomy in pigs<span class="elsevierStyleSup">37</span>&#46; The reduced systemic blood pressure associated with decreased cardiac preload and the increase in ICP also leads to a decrease in cerebral perfusion pressure &#40;CPP&#41;&#46; Some authors have demonstrated successful treatment of refractory intracranial hypertension with abdominal decompression or neuromuscular blockers<span class="elsevierStyleSup">20&#44;35</span>&#46;</p><p class="elsevierStylePara">Some recommendations&#58;</p><p class="elsevierStylePara">1&#41; IAP monitoring is essential for all traumatic or nontraumatic patients at risk for intracranial hypertension &#40;ICH&#41; or IAH &#40;according to the risk factors published by the WSACS&#41;&#46;</p><p class="elsevierStylePara">2&#41; In all patients with ICH&#44; preventive measures should be undertaken to avoid increase in IAP&#44; and conversely&#44; in all patients with IAH&#44; a possible association with ICH should be considered and preventive measures should be taken &#40;head of bed elevation&#44; avoid hypervolemia&#44; hypernatriemia and hyperthermia&#46;&#46;&#46;&#41;&#46;</p><p class="elsevierStylePara">3&#41; Avoid hypervolemia in patients with IAH to prevent further increase in ICP&#46;</p><p class="elsevierStylePara">4&#41; Consider using APP &#40;abdominal perfusion pressure&#59; APP &#61; MAP-IAP&#41; as a resuscitation target in patients where ICP is not available and CPP can not be used as a target&#46;</p><p class="elsevierStylePara">5&#41; Avoid laparoscopy in patients at risk for ICH&#46; The pneumoperitoneum used for laparoscopy creates a situation analogous to experimental settings of IAH and ICH in which detrimental effects on ICP have been observed&#46; This is especially important in trauma patients with associated brain and abdominal injuries&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on renal function</span></p><p class="elsevierStylePara">Renal dysfunction is one of the most consistently described organ dysfunctions associated with IAH&#46; The etiology is multifactorial and offers a unique insight into the deleterious and sometimes cumulative effects of IAH on organ function&#46;</p><p class="elsevierStylePara">The most important effect of IAH on the kidney is related to renal blood flow&#46; IAH has been shown to lead to renal venous compression and increased renal venous pressure<span class="elsevierStyleSup">39&#44;40</span>&#46; Also&#44; renal arterial blood flow and microcirculatory flow in the renal cortex are decreased&#46;&#46; Direct compression of the renal cortex may be a contributing factor<span class="elsevierStyleSup">39&#44;41</span>&#46; The changes in renal blood flow lead to activation of the renin-angiotensin-aldosteron pathway and also&#44; ADH secretion is increased in IAH<span class="elsevierStyleSup">42&#44;43</span>&#46; The clinical importance of these changes is still unclear&#46;</p><p class="elsevierStylePara">Biancofiore and Sugrue showed that renal dysfunction is rather common in IAH<span class="elsevierStyleSup">6&#44;7&#44;44-46</span>&#46; Ulyatt suggested that filtration gradient &#40;FG&#41; is an important factor in explaining renal failure associated with IAH<span class="elsevierStyleSup">47</span>&#46; The FG is the mechanical force across the glomerulus and is equal to the difference between glomerular filtration pressure and the proximal tubular pressure&#46; Glomerular filtration pressure is equal to RPF and thus to MAP &#173; IAP&#46; In the presence of IAH&#44; proximal tubular pressure can be equated with IAP&#46; The FG can therefore be calculated as FG &#61; MAP &#173; &#40;2x IAP&#41;&#46; This explains why the kidney seems to be more vulnerable to IAH than other surrounding organs and is probably one of the key factors in the development of IAH-induced renal failure<span class="elsevierStyleSup">7&#44;21</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">The effect of IAH on other organ functions</span></p><p class="elsevierStylePara">Animal and human studies have shown decreased hepatic arterial flow as well as decreased portal flow and increased portacollateral flow&#46; Furthermore&#44; even moderate levels of IAP have been associated with impaired hepatocellular function<span class="elsevierStyleSup">48&#44;49</span>&#46; IAH is inversely correlated with indocyanine green clearance<span class="elsevierStyleSup">50</span>&#46; Biancofiore et al demonstrated that liver disease and especially liver surgery and transplantation are often associated with IAH and ACS<span class="elsevierStyleSup">51</span>&#46; Cytochrome P450 function and other liver functions may be impaired in IAH&#46; Therefore&#44; it seems wise to avoid hepatotoxic medications&#44; increase the attention towards therapeutic interactions&#44; treat IAH aggressively and maximize supportive treatment for patients with IAH and liver dysfunction&#46;</p><p class="elsevierStylePara">Where the digestive tract is concerned&#44; intra-abdominal hypertension causes diminished perfusion and mucosal acidosis and sets the stage for multiple organ failure<span class="elsevierStyleSup">52</span>&#46; The ischemia and reperfusion injury to the gut serves as a second insult in a two hit model of MOF where the lymph flow conducts gut-derived pro-inflammatory cytokines to remote organs<span class="elsevierStyleSup">9&#44;52</span>&#46; These complex mechanisms are not yet completely understood&#44; but they will undoubtedly be the subject of further study in the next few years&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">TREATMENT OF IAH</span></p><p class="elsevierStylePara">In analogy to other compartment syndromes in the human body&#44; decompressive laparotomy &#40;DL&#41; seems the most logical treatment option&#46; It is also the most widely used and best described treatment modality today&#46; However&#44; DL leaves the patient with an open abdomen which can lead to extensive fluid losses&#44; infection&#44; enterocutaneous fistulae&#44; ventral hernia and cosmetic dysfunction&#46; Therefore&#44; DL is mostly used today as a rescue therapy for patients with overt ACS&#44; who have not responded to medical treatment&#46; Indications and results for different treatment modalities will be discussed here&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Decompressive laparotomy</span></p><p class="elsevierStylePara">A recent systematic review on decompressive laparotomy&#44; based on 18 studies&#44; was published by De Waele et al<span class="elsevierStyleSup">53</span>&#46; This review illustrated that DL is successful in lowering IAP in all studies&#46; Concerning the results on organ function&#44; results are variable&#46; Regarding the cardiovascular function&#44; heart rate en MAP remained unchanged in most studies&#46; CVP and PAOP decreased significantly&#44; which is to be expected in view of the abdominothoracic transmission&#46; This probably does not reflect a true improvement in cardiac function&#46; However&#44; cardiac index was also improved&#46; In analogy&#44; peak inspiratory pressures decreased after decompression&#44; but also PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> improved&#46; The effect on renal function is less clear&#46; In most studies&#44; urine output was significantly improved after DL&#44; but interestingly&#44; in the two largest series<span class="elsevierStyleSup">54&#44;55</span> urine output was not affected&#46; Sugrue suggests that acute tubular necrosis might be involved which takes longer to recuperate and does not appear in short-term outcome analyses&#46; In general&#44; DL seems to have a beneficial effect on organ function&#46; Overall mortality remains high &#40;49&#46;2&#37;&#41;&#46; Although most authors agree that DL should be performed in patients with IAP &#62; 20 mmHg and new or progressive organ failure&#44; there is some reluctance to perform DL because of the practical consequences in terms of fluid loss through the open abdomen&#44; difficult wound dressings&#44; risk of infection or fistula&#44; re-interventions&#44; cost and longer hospital stay&#46; However&#44; a well performed study by Cheatham et al<span class="elsevierStyleSup">56</span> demonstrated that physical&#44; social and mental health after DL is restored to the level of the general population after abdominal wall reconstruction and DL does not lead to permanent disability or unemployment&#46;</p><p class="elsevierStylePara">Since the goal of DL is to decompress and thereby increase intra-abdominal volume it is usually not possible to close the abdomen primarily&#44; which means that some form of temporary abdominal closure &#40;TAC&#41; has to be performed to protect the abdominal contents and to allow healing&#44; followed by an abdominal wall reconstruction which is usually planned after several months&#46; The most widely used techniques for TAC are a Bogota bag &#40;a plastic sheet cut from a sterile bag of infusion fluids sewn to the fascia or skin edges&#41;&#44; resorbable surgical mesh with or without split thickness skin grafting&#44; towel clip closure &#40;in situations where other TAC methods are not available or too time consuming&#41;&#44; commercially available devices such as zippers or Wittman patches or vacuum assisted closure &#40;VAC&#41;&#46; The detailed description of these techniques&#44; their indications and results are beyond the scope of this text&#46; There is certainly a vast body of scientific data on this subject&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Minimally invasive surgical decompression</span></p><p class="elsevierStylePara">Because of the complications associated with full DL&#44; surgeons have been searching for less invasive techniques to decompress the abdomen&#46; Endoscopic techniques based on the components separation concept described by Ramirez&#44; Voss and others<span class="elsevierStyleSup">57&#44;58</span>&#44; like the subcutaneous anterior abdominal fasciotomy<span class="elsevierStyleSup">59</span> are being developed and might replace DL in selected cases in the future&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Non surgical management</span></p><p class="elsevierStylePara">Most non-surgical treatment strategies are aimed at either decreasing abdominal volume or increasing wall compliance&#46; An overview of possible treatment strategies is given in table 4&#46; Some of these will be highlighted here in detail&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Evacuation of intraluminal contents</span></p><p class="elsevierStylePara">Non-invasive removal of intraluminal contents by gastric tube placement and suctioning&#44; rectal tube placement&#44; enemas and&#44; if indicated&#44; endoscopic decompression should be attempted<span class="elsevierStyleSup">60-62</span>&#46;</p><p class="elsevierStylePara">Also&#44; gastroprokinetics &#40;such as metoclopramide or erythromycin&#41; and&#47;or colonoprokinetics &#40;neostygmine or prostygmine&#41; can be used<span class="elsevierStyleSup">63-67</span>&#46; In patients with gross dilatation of the stomach or the colon&#44; this alone may be sufficient to lower IAP to harmless levels&#44; but in most general ICU patients&#44; other measures will have to be considered&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Evacuation of extraluminal contents</span></p><p class="elsevierStylePara">Drainage of tense ascites may result in a decrease in IAP<span class="elsevierStyleSup">68-72</span>&#46; Paracenthesis is the treatment of choice in burn patients with secondary ACS<span class="elsevierStyleSup">73-75</span> or any other patients who develop ascites after massive &#40;usually crystalloid&#41; fluid resuscitation&#46; If intra-abdominal abscesses&#44; hematomas or fluid collections are present&#44; they should be drained also&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Use of sedation and neuromuscular blockers</span></p><p class="elsevierStylePara">Increased muscle tone in the rectus abdominal wall muscles due to voluntary muscle contraction&#44; pain or agitation&#44; causes decreased abdominal wall compliance and thus IAH&#46; Therefore&#44; it is important to titrate analgesia and sedation to allow for maximal relaxation of the abdominal wall muscles&#46; However&#44; in critically ill patients with capillary leak and abdominal wall edema&#44; control of pain and agitation are often not sufficient and the use of neuromuscular blockers has to be considered&#46; In a single case report&#44; single dose administraton of cisatracurium&#44; followed later by continuous infusion of cisatracurium&#44; was successful in lowering IAP to safe levels and was also associated with an increase in urine output<span class="elsevierStyleSup">76</span>&#46; Other authors have confirmed these findings<span class="elsevierStyleSup">20&#44;77</span>&#46; However&#44; neuromuscular blockers have been associated with increased incidence of ventilator-associated pneumonia and ICU muscular weakness and their use has been restricted in the last few years to avoid these and other complications&#46; The possible benefit of reducing IAP has to be balanced against the risk of complications at the individual patient level&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Correction of capillary leak and positive fluid balance</span></p><p class="elsevierStylePara">Most patients with IAH&#44; due to the nature of their illness or trauma&#44; present with capillary leak syndrome&#46; In the early stages of their illness it is important to resuscitate these patients towards euvolemia and adequate intravascular fluid status&#44; both in terms of their general condition and in terms of their IAH&#44; since hypovolemia in patients with IAH can lead to splanchnic hypoperfusion and aggravation of the organ dysfunction<span class="elsevierStyleSup">78&#44;79</span>&#46; Dobutamine may help to counteract this splanchnic hypoperfusion<span class="elsevierStyleSup">80</span>&#46;</p><p class="elsevierStylePara">However&#44; fluid resuscitation will lead also to increased edema formation&#44; third spacing and possibly to a vicious cycle of ongoing IAH&#46; After hemodynamic stabilisation&#44; correction of the fluid balance and decreasing edema formation becomes important&#46; If renal function is only minimally to mildly compromised and the patient is hemodynamically stable&#44; mobilisation of edema by administration of colloids e&#46;g&#46; albumin &#40;to increase colloid osmotic pressure&#41; and diuretics can be attempted&#46; However&#44; as renal function deteriorates further&#44; patients often do not respond to diuretic therapy&#46; Fluid removal by means of ultrafiltration has been demonstrated to have a beneficial effect on IAP and possibly on organ function<span class="elsevierStyleSup">81&#44;82</span>&#46; The institution of renal replacement therapy with fluid removal&#44; if hemodynamically tolerated&#44; should not be delayed&#46; In patients with borderline hemodynamic status&#44; continuous forms of RRT may be preferred over intermittent RRT to avoid hemodynamic instability&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> Octreotide</span></p><p class="elsevierStylePara">Kacmaz et al found evidence of ischemia-reperfusion injury in animals after decompressive laparotomy<span class="elsevierStyleSup">83</span>&#46; They hypothesize that the organ dysfunction associated with IAH is caused by ischemic damage&#44; and decompressive laparotomy leads to reperfusion injury causing a second-hit phenomenon&#46; This reperfusion injury seems to be counteracted by the administration of octreotide&#44; a long acting somatostatin analogue&#44; before decompression&#46; Further research in humans is necessary to confirm these findings&#46;</p><p class="elsevierStylePara">The most difficult issue is to decide what to do to whom and when&#46; Few scientific data are available at this moment to guide treatment&#46; A possible treatment algorithm is shown in figure 2&#46; Large interventional studies will have to be conducted to further elucidate this complex issue&#46;</p><p class="elsevierStylePara"><img src="64v31n02-13101465tab06.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Figura 2&#46; Possible treatment algorithm&#46; Adapted from Cheatham ML&#44; et al<span class="elsevierStyleSup">86</span>&#46;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> CONCLUSION</span></p><p class="elsevierStylePara">Intra-abdominal hypertension and abdominal compartment syndrome occur frequently in ICU patients and are independently associated with mortality&#46; Since diagnosis relies entirely on the knowledge of IAP&#44; the different techniques for accurate IAP measurement are mentioned in this paper&#46; The effect of IAH on different organ systems is described&#44; along with recommendations to compensate for these effects&#46; The ultimate goal of treatment is not only to decrease IAP&#44; but also to improve organ function and to decrease mortality&#46; Decompressive laparotomy is the only treatment option that has been shown to reach most of these goals today&#46; However&#44; some less invasive techniques and some medical treatment strategies have shown promise in achieving IAP reduction as well as organ function improvement&#46; Indications for these techniques and implementation of a treatment algorithm will require additional clinical research&#44; which is likely to be fostered by the WSACS&#46; &#171;It is time to pay attention&#33;&#187;&#44; this was the title of a recent review 4 and the slogan of the 3rd World Congress on Abdominal Compartment Syndrome &#40;WCACS2007&#41; held in Antwerp&#44; Belgium in 2007&#44; march 22-24 &#40;www&#46; wcacs&#46;org&#41;&#46;</p><hr></hr><p class="elsevierStylePara"> Correspondence&#58;</p><p class="elsevierStylePara">Dr&#46; M&#46; Malbrain&#46;  <br></br> e-mail&#58; <a href="mailto&#58;manu&#46;malbrain&#64;skynet&#46;be" class="elsevierStyleCrossRefs"> manu&#46;malbrain&#64;skynet&#46;be</a></p><p class="elsevierStylePara">Manuscrito aceptado el 30-I-2007&#46;</p>"
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        "resumen" => "Existe s&#237;ndrome compartimental cuando el aumento de presi&#243;n en un espacio cerrado amenaza la viabilidad del tejido dentro del compartimento&#46; Cuando esto ocurre en la cavidad abdominal&#44; no s&#243;lo amenaza la funci&#243;n de los &#243;rganos intra-abominales&#44; sino que tambi&#233;n puede tener un efecto devastador en los &#243;rganos distantes&#46; Datos de estudios recientes en animales y humanos sugieren que los efectos adversos de la presi&#243;n elevada pueden ocurrir a niveles m&#225;s bajos de lo que se hab&#237;a pensado y hasta antes de que el s&#237;ndrome compartimental abdominal sea cl&#237;nicamente evidente&#46; El s&#237;ndrome compartimental abdominal no es una enfermedad&#44; sino que es un verdadero s&#237;ndrome&#59; es decir&#44; consiste en un espectro de s&#237;ntomas y signos que pueden tener m&#250;ltiples causas&#46; Hace poco tiempo que esta condici&#243;n recibe atenci&#243;n y empieza a conocerse ampliamente&#46; Este art&#237;culo revisa el estado actual del conocimiento de la hipertensi&#243;n intra-abdominal en cuanto a su etiolog&#237;a&#44; epidemiolog&#237;a&#44; diagn&#243;stico&#44; medici&#243;n de presi&#243;n intra-abdominal&#44; disfunci&#243;n de &#243;rganos&#44; prevenci&#243;n y tratamiento&#46;"
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