Le syndrome compartimental abdominal

A rapid and uncontrolled increase in the volume of intra-abdominal organs can induce an intra-abdominal hypertension which leads to organ dysfunctions: renal, gastro-intestinal, hemodynamic, respiratory and neurologic. The association of these organ dysfunctions to an increased abdominal pressure level over 15–20 mmHg has been known as the abdominal compartment syndrome. Along with surgical and traumatic patients, the syndrome has been described in medical critically ill patients. Suggestive systemic symptoms are mainly decreased cardiac output with metabolic acidosis, oliguria, hypoxia and increased airway pulmonary pressure. Finally, it can result in multiple organ failure. The confirmation of abdominal compartment syndrome is simply performed by the measurement of bladder pressure. The syndrome might lead to an increased mortality rate in critically ill patients. The specific treatment remains not determined: early surgical decompression might improve the outcome but different medical treatments (neuromuscular blockade, gastric suctioning, hemofiltration) remain to be evaluated. A greater awareness of abdominal compartment syndrome might improve the management of multiple organ failure syndrome especially in medical critically ill patients.     

Abdominal compartment syndrome

PURPOSE OF REVIEW: This review will set forth the new consensus definitions for intra-abdominal pressure, intra-abdominal hypertension, and the abdominal compartment syndrome from the World Congress on the Abdominal Compartment Syndrome in December 2004. The review will explore the challenges in diagnosis, pathophysiology, and recent concepts in the treatment of abdominal compartment syndrome. RECENT FINDINGS: Intra-abdominal pressure greater than 12 mm Hg may exert adverse physiologic sequelae, progressing to intra-abdominal hypertension and full-blown abdominal compartment syndrome as intra-abdominal pressure increases. The first challenge is to recognize that abdominal compartment syndrome may be a potential problem in critically ill patients. Intra-abdominal pressure monitoring is essential for this. Continuous monitoring of intra-abdominal pressure and abdominal perfusion pressure adds real-time measurements and can be performed by way of the stomach or bladder. Intra-abdominal hypertension occurs in approximately 35% of patients in the intensive care unit, and abdominal compartment syndrome in approximately 5%. SUMMARY: Massive resuscitation is increasingly recognized as a major contributor to abdominal compartment syndrome. Prophylactic decompression and temporary abdominal closure have important roles in preventing tertiary or recurrent abdominal compartment syndrome. Failure to recognize and treat intra-abdominal hypertension will result in increased risk of renal impairment, visceral and intestinal ischemia, respiratory failure and death.     

Abdominal compartment syndrome in the intensive care unit

The abdominal compartment syndrome is an increasingly recognized complication of both medical and surgical patients in the ICU setting. This syndrome has been described in a wide variety of clinical scenarios and results from a persistent elevation in intra-abdominal pressure characterized by graded organ system dysfunction. Manifestations of abdominal compartment syndrome include cardiovascular, pulmonary, renal, splanchnic, and neurologic impairment. The diagnosis of abdominal compartment syndrome requires a high level of clinical suspicion combined with an increased intra-abdominal pressure, usually obtained via urinary bladder pressure measurement. Patients at risk for abdominal compartment syndrome warrant close monitoring and we recommend prompt abdominal decompression following documentation of increased intra-abdominal pressure in the setting of physiologic compromise. Abdominal compartment syndrome can significantly contribute to the morbidity and mortality of both medical and surgical patients alike in the ICU. The signs and symptoms of abdominal compartment syndrome should become familiar to all critical care practitioners.     

腹腔间隔室综合征手术减压的进展

腹腔室隔综合征是指各种病理状态下的腹腔压力升高所引起的致死性器官功能衰竭。腹腔减压、释放腹腔内的压力和延迟关腹是挽救病人生命的有效方法。有关腹腔减压治疗腹腔室隔综合征报道有明显增多,现就减压的指征、方法和切口延迟关腹的进展作一综述。     

急性重症胰腺炎合并腹腔间室综合征临床分析

目的探讨急性重症胰腺炎（SAP）合并腹腔间室综合征（ACS）的诊断及治疗.方法回顾性分析160例SAP合并腹腔高压（IAH）患者的临床资料,从发病原因、腹压增高程度、治疗、预后等方面量化指标结合病理生理特点进行探讨、总结.结果160例SAP合并IAH患者中诊断为ACS17例（17/160,14.16%）.高脂血症性急性胰腺炎13例（13/17,76.5%）.原发型ACS 12例（12/17,70.6%）、迟发型ACS 5例（5/17,29.4%）.迟发型ACS全部行开腹减压手术,无死亡病例;原发型ACS开腹减压手术治疗6例（6/12,50.0%）,死亡5例（5/6,83.3%）,保守治疗6例（6/12,50.0%）,死亡2例（2/6,33.3%）.结论重症胰腺炎合并腹腔间室综合征病情严重,微创腹腔穿刺减压疗效显著,原发性ACS选择开腹减压手术应谨慎,迟发型ACS开腹减压手术效果良好.     

Group a streptococcal toxic shock syndrome with severe necrotizing fasciitis following hysterectomy — a case report

In the last 10 years an increasing number of cases of group A streptococcal toxic shock syndrome have appeared in various clinical settings. The manifestation of this syndrome includes rapidly progressive multiorgan failure and soft-tissue necrosis. This report presents a case of streptococcal toxic shock syndrome caused by Streptococcus pyogenes with severe necrotizing fasciitis of the abdominal wall following hysterectomy. Aggressive surgical intervention with debridement of all necrotic tissue necessitated resection of the complete abdominal wall (skin, subcutaneous tissue, muscle and peritoneum). The abdominal wall defect was covered with free myocutaneous flaps and split-skin grafts. Optimal treatment, including adequate antibiotic therapy and radical surgical intervention, is an indispensable prerequisite of successful outcome. Received: 18 July 1997 Accepted: 11 November 1997     

腹间隔综合征13例临床分析

目的：分析总结腹间隔综合征(ACS)早期诊断与治疗。方法：回顾性分析13例经临床特征诊断的腹间隔综合征患者,诊断病例早期行胃肠腔内减压引流术、非手术治疗和开腹减压术。结果：3例死于多器官功能不全(MODS),1例死于感染性休克,1例死于呼吸衰竭,死亡率为39％(5／13),8例治愈出院。结论：重视原发病因及诱发因素,密切观察患者腹部体征及全身变化是早期发现并诊断ACS的关键所在,及早手术及腹腔减压治疗可望改善预后。     

Abdominal compartment syndrome: clinical aspects and monitoring

Markedly elevated intra-abdominal pressures will result in predictable hemodynamic consequences related to compromised venous return. When the hemodynamic abnormalities are associated with organ dysfunction of failure, patients suffer from the abdominal compartment syndrome. At-risk patients should be routinely monitored for intra-abdominal hypertension, and a multidisciplinary care paradigm should be established. Vigorous resuscitation of both surgical and medical patients highly correlates with IAH and ACS risk. Vigilance, prompt diagnosis, and intervention for abdominal compartment syndrome will reduce the morbidity and mortality in critically ill. Future challenges include altering resuscitation strategies to reduce ascites formation, earlier diagnosis of organ dysfunction, and intra-organ monitoring techniques.     

超声引导下经皮穿刺置管引流术的应用时机对中度重症急性胰腺炎的疗效

  目的  评估经皮穿刺置管引流在中度重症急性胰腺炎（MSAP）治疗中应用时机的选择对患者结局和并发症方面的影响。  方法  纳入2017年7月~2021年4月在广东省第二人民医院住院的113例MSAP患者,根据其是否行超声引导下经皮穿刺置管引流术（PCD）分为早期PCD组、晚期PCD组以及对照组,记录患者基本资料（年龄、性别、BMI、病因）,比较3组临床结局（转为重症急性胰腺炎（SAP）患者人数、转外科手术患者人数、死亡患者人数）、实验室检查指标（白细胞计数、血清淀粉酶、C反应蛋白、血钙）、临床疗效时间指标（全身炎症反应时间、腹痛时间、肠鸣音恢复时间、饮食恢复时间和总住院时间）、不良事件（腹腔感染、腹腔内出血、导管堵塞）及并发症（胰腺假性囊肿、胰腺脓肿、腹腔间室综合征及多器官组织衰竭）。  结果  早期PCD组及晚期PCD组治疗成功率高于对照组,而死亡率、转为SAP患者率、外科手术率低于对照组,且早期PCD组治疗成功率高于晚期PCD组（P < 0.05）;PCD组的全身炎症反应时间、肠鸣音恢复时间和住院时间少于对照组,且早期PCD组的全身炎症反应时间及住院时间明显少于晚期PCD组（P < 0.05）;PCD组白细胞计数、血清淀粉酶、C反应蛋白和血钙的改善均优于对照组,且早期PCD组的血清淀粉酶及C反应蛋白的改善优于晚期PCD组（P < 0.05）;PCD组并发症胰腺假性囊肿、胰腺脓肿、腹腔间室综合征及多器官组织衰竭明显低于对照组（P < 0.05）,且早期PCD组的腹腔间室综合征及多器官组织衰竭明显低于晚期PCD组,3组腹腔感染及出血差异无统计学意义。  结论  对MSAP患者来说,晚期等待积聚物形成包裹后再进行PCD并不会产生任何额外的好处。早期PCD治疗可有效提高MSAP患者治疗成功率,减少住院时间及并发症。      

Prophylactic open abdomen in patients with postoperative intra-abdominal hypertension

Postoperative intra-abdominal hypertension (IAH) is a frequent occurrence in critically ill patients operated on for severe abdominal trauma, secondary peritonitis or ruptured abdominal aortic aneurysm. IAH may progress to abdominal compartment syndrome (ACS) with new-onset organ dysfunction. Early recognition of IAH and interventions that prevent the development of ACS may preserve vital organ functions and increase the probability of survival. The best method to prevent postoperative ACS is to leave the abdomen open during the operation. The decision to leave the abdomen open is usually based on the surgeon's judgment without intra-abdominal pressure (IAP) measurements during the operation. Because significant morbidity and mortality are associated with the open abdomen, the measurement of IAP immediately after the fascial closure, when feasible, could offer an objective method for determining the optimal IAP threshold for leaving the abdomen open. The management of the open abdomen requires a temporary abdominal closure (TAC) system that would ideally prevent the development of ACS and facilitate later primary fascia closure. Among several TAC systems, the most promising are those that provide negative pressure to the wound or continuous fascial traction or both.     

'Progression towards the minimum': the importance of standardizing the priming volume during the indirect measurement of intra-abdominal pressures

The abdominal compartment syndrome is a state of serious organ dysfunction. The syndrome results from sustained intra-abdominal hypertension, which is indirectly identified by measuring intra-bladder pressures (IBPs) using various priming volumes. This technique is poorly standardized across published data. Malbrain and Deeren have identified the risk of falsely elevated IBPs with instillation priming volumes greater than 50 ml. This overestimation appears to increase with larger priming aliquots. As a result, erroneous IBP measurements may incorrectly label a patient with the abdominal compartment syndrome, and therefore subject them to the potential complications of surgical and/or medical decompression techniques. The utility and benefit of using continuous IBP monitoring is discussed. These data require confirmation in other patient subgroups with younger ages, altered body mass indices and varied diagnoses.     

Survey of intensive care physicians on the recognition and management of intra-abdominal hypertension and abdominal compartment syndrome

OBJECTIVE: To assess current understanding and clinical management of intra-abdominal hypertension and abdominal compartment syndrome among critical care physicians. DESIGN: A ten-question, written survey. SETTING: University health sciences center. SUBJECTS: Physician members of the Society of Critical Care Medicine (SCCM). INTERVENTIONS: The survey was sent to 4,538 SCCM members with a response rate of 35.7% (1622). MEASUREMENTS AND MAIN RESULTS: Primary training, intensive care unit type, and methods for management of abdominal compartment syndrome were assessed. Surgically trained intensivists managed the highest number of abdominal compartment syndrome cases (47% managed 4-10 cases, 16% managed >10 cases). No cases were seen by 25% of medically trained and pediatric trained intensivists. Respondents agreed that bladder pressures and clinical variables were needed to diagnose abdominal compartment syndrome (70%) vs. bladder pressure (7%) or clinical variables (20%) alone. Two percent of surgical intensivists were unaware of a bladder pressure measurement procedure compared with 24% (p < .0001) of pediatric and 23% (p < .0001) of medical intensivists. Forty-two percent of respondents believed bladder pressures of 20-27 mm Hg may cause physiologic compromise. However, 25-27% of pediatric, medicine, or anesthesia trained intensivists believed that compromise occurs between 12 and 19 mm Hg compared with 18% of surgeons. No respondent believed that physiologic compromise occurred at <8 mm Hg. Thirty-eight percent of pediatric intensivists believed that physiologic compromise was patient dependent vs. 7-17% from other specialties (p < .0001; all comparisons). In managing intra-abdominal hypertension, 33% of pediatric intensivists and 19.6% of medical intensivists would never use decompression laparotomy to treat abdominal compartment syndrome compared with 3.6% of intensivists with surgical training (p < .0001; both comparisons). CONCLUSIONS: Significant variation across medical training exists in the management of intra-abdominal hypertension and abdominal compartment syndrome. A significant percentage of intensivists may be unaware of current approaches to abdominal compartment syndrome management including monitoring bladder pressures and decompression laparotomy. Future research and education are necessary to establish clear diagnostic criteria and standards for treatment of this relatively common life-threatening disease process.     

Abdominal compartment syndrome: an emergency department perspective

Compartment syndromes can occur in many body regions. Abdominal compartment syndrome, initially described many years ago, has become increasingly recognised in critical care patients. The key points regarding its definition, pathophysiology, aetiology and treatment are described and discussed. Abdominal compartment syndrome is defined as an intra-abdominal pressure >20 mm Hg with evidence of organ dysfunction. At risk patients should be identified in the emergency department and early monitoring of intra-abdominal pressure instituted. Interventions in the emergency department potentially contribute to the development of abdominal compartment syndrome during subsequent phases of care. The need to ensure an early multidisciplinary approach in the management of this complex condition is essential for the best possible patient outcome.     

Prevalence and risk factors of organ failure in patients with severe acute pancreatitis

BACKGROUND:

This study was undertaken to determine the prevalence of organ failure and its risk factors in patients with severe acute pancreatitis (SAP).

METHODS:

A retrospective analysis was made of 186 patients with SAP who were had been hospitalized in the intensive care unit of Jinzhong First People’s Hospital between March 2000 and October 2009. The patients met the diagnostic criteria of SAP set by the Surgical Society of the Chinese Medical Association in 2006. The variables collected included age, gender, etiology of SAP, the number of comorbidit, APACHEII score, contrast-enhanced CT (CECT) pancreatic necrosis, CT severity index (CTSI) , abdominal compartment syndrome (ACS) , the number of organ failure, and the number of death. The prevalence and mortality of organ failure were calculated. The variables were analyzed by unconditional multivariate logistic regression to determine the independent risk factors for organ failure in SAP.

RESULTS:

Of 186 patients, 96 had organ failure. In the 96 patients, 47 died. There was a significant association among the prevalence of organ failure and age, the number of comorbidity, APACHEII score, CECT pancreatic necrosis, CTSI, and ACS. An increase in age, the number of comorbidity, APACHEII score, CECT pancreatic necrosis were correlated with increased number of organ failure. Age, the number of comorbidity, APACHEII score, CECT pancreatic necrosis, CTSI and ACS were assessed by unconditional multivariate logistic regression.

CONCLUSIONS:

Organ failure occurred in 51.6% of the 186 patients with SAP. The mortality of SAP with organ failure was 49.0%. Age, the number of comorbidity, APACHEII score, CECT pancreatic necrosis, CTSI and ACS are independent risk factors of organ failure.KEY WORDS: Severe acute pancreatitis, Organ failure, Prevalence, Risk factor, Age, Comorbidity, APACHE, Pancreatic necrosis, Abdominal compartment syndrome     

Abdominal compartment syndrome: A case review

Compartment syndrome is classically considered a complication of a musculoskeletal injury. Recent research has confirmed the abdomen as a potential compartment with the capability to cause life-threatening local and systemic manifestations. Abdominal compartment syndrome (ACS) is precipitated by an acute increase in abdominal contents volume with resulting intraabdominal hypertension. Presenting signs of ACS include a firm tense abdomen, increased peak inspiratory pressures, and oliguria, all of which improve after abdominal decompression. Patients at risk for ACS include trauma (blunt or open), retroperitoneal hemorrhage, massive fluid resuscitation, pancreatitis, pneumoperitoneum, and neoplasm. Surgical decompression is the treatment of choice. The perianesthesia nurse plays a critical role in the team managing a patient at risk for abdominal compartment syndrome through intraabdominal pressure monitoring, wound care, and end organ perfusion support.     

Intra-abdominal hypertension and abdominal compartment syndrome: a comprehensive overview

Intra-abdominal hypertension has a prevalence of at least 50% in the critically ill population and has been identified as an independent risk factor for death. Yet, many of the members of the critical care team do not assess for intra-abdominal hypertension and are unaware of the consequences of untreated intra-abdominal hypertension. These consequences can be abdominal compartment syndrome, multisystem organ failure, and death. This article provides an overview of the pathophysiology of intra-abdominal hypertension and abdominal compartment syndrome. In addition, the evidence-based definitions, guidelines, and recommendations of the World Society of the Abdominal Compartment Syndrome are presented.     

Défaillance multiviscérale précoce associée à la pancréatite aiguë : stratégie thérapeutique chirurgicale ou conservatrice ?

The mortality of severe acute pancreatitis still ranges between 10% and 20%. Nowadays, infected pancreatic necrosis is the leading cause of death. Despite advances in intensive care therapy, however, early and worsening multi-system organ failure remains a source of substantial morbidity and still accounts for 20–50% of the deaths.News and hotspots.– The three interrelated pathophysiological mechanisms underlying glandular necrosis include the premature intra-acinar activation of pancreatic pro-enzymes, an early pancreatic microcirculatory impairment, and the excessive stimulation of immune effector cells. In recent years, the systemic inflammatory response syndrome and the relevant cascades of inflammatory mediators have been implicated as the key factor in the emergence of remote tissue damage. Early multi-system organ failure that supervenes in the first week is typically associated with a sterile necrotizing process. The correlation between pathomorphological and clinical severity and the similarity between their respective pathophysiological mechanisms are not straightforward, however. There are no pathophysiological, clinical or economical data to support the practice of debridement of sterile necrosis to prevent or to control early multi-system organ failure. This issue has never been addressed in a controlled study. Besides intensive care support, non-surgical therapeutic modalities including urgent endoscopic sphincterotomy for impacted stones, antibiotic prophylaxis for the prevention of pancreatic infection and early jejunal nutrition have been specifically developed hopefully to attenuate multiple organ failure, to obviate the need of surgical drainage and to improve survival. Fine needle aspiration of necrotic areas must be incorporated in any conservative therapeutic strategy in order not to jeopardize those with infected necrosis that remains an absolute indication for drainage.Perspectives.– There is ample experimental and pathophysiological evidence in favour of immunomodulatory therapy in severe acute pancreatitis. The administration of one or several antagonists of inflammatory mediators possibly combined with a protease inhibitor may at last provide the opportunity to interfere with the two major determinants of prognosis: the severity of multiple organ failure and the extent of necrotic areas that creates the culture medium for bacterial superinfection. These benefits remain to be substantiated in a controlled study, however.     

重症胰腺炎并发腹腔高压的影像学研究进展

腹腔高压(intra-abdominal hypertension,IAH)是重症胰腺炎(severe acute pancreatitis,SAP)的常见并发症之一,按照腹内压等级和伴/不伴器官功能不全可分为腹腔高压或腹腔间隔室综合征(abdominal compartment syndrome,ACS)。IAH/ACS时引起的病理生理改变可导致多器官功能障碍(multiple organ dysfunction syndrome,MODS),是影响SAP病情演进及患者预后的要素。影像学检查是诊断SAP不可或缺的方法,但对其合并IAH/ACS的研究有限。本研究就目前IAH/ACS的发病机制、影像学研究进展及展望进行综述,旨在更准确地评估患者病情及为临床医生制订个体化治疗方案提供更多信息。     

腹腔室隔综合征的早期急诊处理

目的 总结腹腔室隔综合征(ACS)的诊断和早期急救治疗经验。方法 11例均以间接腹腔测压和临床特征得出诊断,行早期剖腹腹腔和胃肠腔内减压引流术和非手术治疗 结果 1例死于术后呼吸功能衰竭,1例死于伤口全层裂开腹腔内感染性休克,2例死于MODS,死亡率为36.3％,7例治愈出院 结论 动态监测腹腔内压和全身变化是发现ACS的关键,并有助于手术指征和时机的确定,一旦确诊,尤其是中、重度ACS应早期开腹充分减压引流,才可望改善预后