Effects of escharotomy as abdominal decompression on cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients

BACKGROUND: Abdominal compartment syndrome (ACS) can become fatal; however, it has rarely been described as a complication of burn injury. This study clarified the physiologic results of abdominal decompression (AD) for ACS in patients with burn injury in detail. METHODS: Extensively burned patients admitted to our burn unit between January 2003 and February 2004 were prospectively monitored by pulmonary artery catheter. Physiologic parameters from the catheter, blood gas analysis, intrabladder pressure as a parameter of intra-abdominal pressure (IAP), peak inspiratory pressure, and urine output (UO) were compared before and after escharotomy as AD in patients with ACS. RESULTS: Eight of 36 patients who had sustained more than 30% total body surface area burn developed ACS requiring AD in 18.3 +/- 4.9 hours. AD significantly decreased IAP (52 +/- 9 cm H2O vs. 26 +/- 7 cm H2O), peak inspiratory pressure (53 +/- 13 cm H2O vs. 35 +/- 6 cm H2O), heart rate, and Paco2, and increased cardiac index (1.6 +/- 0.7 L/min/m2 vs. 2.5 +/- 0.9 L/min/m2), abdominal perfusion pressure (50 +/- 11 mm Hg vs. 72 +/- 17 mm Hg), UO (0.45 +/- 0.46 mL/h/kg vs. 2.0 +/- 2.1 mL/h/kg), and oxygen delivery index (290 +/- 195 mL/m2/min vs. 455 +/- 218 mL/m2/min). Impaired oxygen consumption index increased (86 +/- 43 mL/m2/min vs. 153 +/- 58 mL/m2/min) after AD. CONCLUSION: In patients with severe burn injury, elevated IAP makes pulmonary artery wedge pressure and UO unreliable indices of preload or intravascular volume, and decreases abdominal perfusion in the resuscitation period. AD in these patients significantly improves the ventilation, hemodynamic parameters, and oxygen metabolism.     

Intra-abdominal hypertension and abdominal compartment syndrome in burn patients

BACKGROUND: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are known to occur in patients after major abdominal surgery. The incidence of IAH and ACS in the burn population is not known. METHODS: We prospectively recorded the intra-abdominal pressures of major burn patients admitted to our burn center from February 1999 to September 1999. A bladder pressure greater than 25 mm Hg was diagnosed as IAH. ACS was diagnosed when pulmonary compliance decreased in association with persistent IAH and was treated with abdominal decompression. RESULTS: Ten patients were placed on the protocol; of these, seven developed IAH. Five responded to conservative treatment. Two patients with 80% body surface area burns developed ACS and required decompression. CONCLUSIONS: IAH occurs commonly in major burn patients, and ACS is seen regularly in patients with more than 70% body surface area burns. We recommend bladder pressure measurements after infusion of more than 0.25 L/kg during the acute resuscitation phase and for peak inspiratory pressures greater than 40 cm H2O. Whereas ACS warrants surgical decompression of the abdominal cavity, IAH usually responds to conservative therapy.     

Futility of resuscitation criteria for the "young" old and the "old" old trauma patient: a national trauma data bank analysis

BACKGROUND: Increasing geriatric trauma is producing disproportionate use of resources. In burn victims, age and burn extent correlate with mortality, yielding the establishment of criteria for futile resuscitation. Such criteria would be useful to trauma patients and their families in making withdrawal-of-care decisions while reducing resource use. Our objective, therefore, was to identify injury and physiologic parameters that would indicate a high probability of futile resuscitation among geriatric trauma patients. METHODS: Data pertaining to patients greater than or equal to 65 years of age within the National Trauma Databank from 1994 to 2001 were analyzed. Multivariate logistic regression-with mortality as the outcome variable and head, chest, and/or abdominal injury; base deficit; gender; comorbidities; and admission systolic blood pressure (SBP) as covariates-was performed to develop a stratification scheme providing criteria indicative of a high probability of futile resuscitation. RESULTS: There were 76,304 patients with a mean age of 79.4 years. Head, thoracic, and abdominal injury; age; gender; comorbidities; admission SBP; and base deficit were associated with mortality. Patients with severe chest and/or abdominal injury, moderate to severe head injury, admission SBP less than 90 mm Hg, and significant base deficit had mortalities approaching 100%. Older patients with modest shock and mild to moderate head injury admitted with severe chest and/or abdominal injury had a less than 5% chance of survival. CONCLUSION: Geriatric trauma patients with severe chest and/or abdominal trauma with moderate shock and mild to moderate head injury have an exceedingly low probability of survival. These data support early withdrawal of care in these individuals.     

Intraabdominal Hypertension and the Abdominal Compartment Syndrome in Burn Patients

Severe burns represent a devastating injury that induces profound systemic inflammation requiring large volumes of resuscitative fluids. The consequent massive swelling and peritoneal ascites raises intraabdominal pressures (IAP) to supraphysiologic levels commensurate with intraabdominal hypertension (IAH) and with the abdominal compartment syndrome (ACS) if consistently associated with IAP >20 mmHg and associated with new organ failure. Severe burn injuries are an example of the secondary ACS (2° ACS), wherein there has been no primary inciting intraperitoneal injury, yet severe IAH/ACS develops, setting the stage for progressive multiorgan dysfunction. These definitions along with practice management guidelines have recently been promulgated by the World Society of the Abdominal Compartment Syndrome (WSACS) in an effort to standardize terminology and communication regarding IAH/ACS in critical care. It is currently unknown whether these syndromes are iatrogenic consequences of excessive or poorly managed fluid resuscitation or unavoidable sequelae of the primary injury. It occurs frequently with burns of >60% body surface area, especially with associated inhalational injury, delayed resuscitation, and abdominal wall injuries. IAH/ACS is often a hyperacute phenomenon that occurs within the first hours of admission and thereafter with any complication requiring aggressive fluid resuscitation. Despite a number of noninvasive management strategies, interventions such as percutaneous peritoneal drainage and, ultimately, decompressive laparotomy are often required once the ACS is established. Whether novel resuscitation strategies can avoid or minimize IAH/ACS is unproven at present and requires further study. Truly understanding postburn ACS may require further insights into the basic mechanisms of injury and resuscitation.     

Secondary abdominal compartment syndrome: an underappreciated manifestation of severe hemorrhagic shock

OBJECTIVE: Abdominal compartment syndrome (ACS) has multiple well-described etiologies, but almost no attention has focused on ACS in the absence of abdominal injury. This study describes a secondary ACS that occurs after severe hemorrhagic shock with no evidence of abdominal injury. METHODS: The trauma registry at a Level I trauma center was reviewed for a 13-month period beginning July 1, 1997. RESULTS: During the study period, there were 46 of 1,216 intensive care unit admissions (4%) who required laparotomy and mesh closure of the abdominal wall because of visceral edema. In that subgroup, six patients (13% of mesh closures, 0.5% intensive care unit admissions) had hemorrhagic shock (5/1, blunt/penetrating trauma) but no evidence of intra-abdominal injury. Associated extremity compartment syndrome developed in two of six (33%). Overall mortality was four of six (67%), secondary to sepsis (n = 3), and head injury (n = 1). Time from admission to decompression averaged 3 hours in survivors and 25 hours in nonsurvivors (overall average = 18+/-9 hours). Resuscitation volume before abdominal decompression averaged 19+/-5 liters of crystalloid and 29+/-10 units of packed red blood cells. Bladder pressure averaged 33+/- 3 mm Hg. Decompression significantly improved peak inspiratory pressure (p < 0.003) and base deficit (p < 0.003). CONCLUSION: ACS can occur with no abdominal injury; The incidence of secondary ACS was 0.5% in this cohort trauma intensive care unit patients, so it probably occurs more frequently than is currently appreciated. Because survivors were decompressed 20 hours before nonsurvivors, early recognition might improve outcomes. On the basis of these observations, we recommend that bladder pressures should be routinely checked and acted on appropriately when resuscitation volumes approach 10 liters of crystalloid or 10 units of packed red cells.     

危重烧伤合并腹腔间隙综合征的临床诊治特点分析

目的总结危重烧伤合并腹腔间隙综合征(ACS)的临床诊治特点。方法2001年1月—2005年4月笔者单位收治12例特重度烧伤合并ACS的患者,其中3例予以非手术治疗(胃肠减压、肛管排气),4例行腹壁减张,5例开腹减压。统计、分析本组患者的治疗结果。予以腹壁减张或开腹减压术者,监测其术后24 h尿量、膀胱内压、中心静脉压、动脉收缩压、动脉血氧分压(PaO2),并与术前比较。结果本组患者病死率为41．7％,9例手术患者死亡3例。多数患者术前24 h尿量偏少,膀胱内压、中心静脉压、动脉收缩压和PaO2表现异常,手术患者术后各项指标较术前明显好转(P<0．01)。结论危重烧伤合并ACS的患者及时给予腹壁减张和开腹减压是治疗的关键。     

Resuscitation fluid volume and abdominal compartment syndrome in patients with major burns

Abdominal compartment syndrome (ACS) is rarely reported as a complication of severe burn. This study clarified the risk of burned patients with and without ACS, especially regarding the resuscitation fluid volume. Extensively burned patients admitted to our burn unit from January 2003, through to June 2004, were examined. Vital signs, blood gas analysis, bladder pressure to estimate intra-abdominal pressure (IAP), peak inspiratory pressure (PIP), resuscitation fluid volume, and urine output (UO) were analyzed. Intra-abdominal hypertension (IAH) was defined as an IAP of more than 30 cm of H2O. Eight of 48 patients suffering from a more than 30% total burn surface area developed ACS in 18.3+/-4.9 h. In these patients, IAP (49+/-12 cmH2O), PIP (50+/-16 cmH2O), heart rate (115+/-8/min), and PaCO2 (54.6+/-10.1 mmHg) were higher than normal, and their resuscitation volume was 0.40+/-0.11 L/kg. Also, a significant correlation between the IBP, PIP and resuscitation volume was observed. Most patients with severe burns required more than 300 mL/kg of resuscitation fluid for the first 24 h after injury that led to ACS and had higher HR, IBP, PIP and PaCO2 despite arterial pressure showing no significant difference.     

Abdominal compartment syndrome in children: experience with three cases

BACKGROUND/PURPOSE: Abdominal compartment syndrome (ACS) is defined as cardiopulmonary or renal dysfunction caused by an acute increase in intraabdominal pressure. Although the condition is well described in adults, particularly trauma patients, little is known about ACS in children. METHODS: Three girls, ages 4, 5, and 5 years, were treated for ACS by silo decompression. Each child presented in profound shock, required massive fluid resuscitation, and had tremendous abdominal distension. The first child sustained a thoracoabdominal crush injury, underwent immediate celiotomy for splenic avulsion and a liver laceration, and required decompression 5 hours postoperatively. The second underwent ligation of her bluntly transected inferior vena cava; because of massive edema, her abdominal wall could not be closed, and prophylactic decompression had to be performed. The third presented with shock of unknown etiology, and ACS developed acutely with a bladder pressure of 26 mm Hg. RESULTS: Respiratory, renal, and hemodynamic function improved immediately in all 3 patients after decompression. Subsequently, each child underwent abdominal wall reconstruction and recovered uneventfully. CONCLUSIONS: ACS is a potentially lethal complication of severe trauma and shock in children. To prevent the development of renal or cardiopulmonary failure in these patients, decompression should be considered for acute, tense abdominal distension.     

Abdominal compartmental syndrome in non-injured patients

Abdominal compartment syndrome (ACS) is characterized by increased intraabdominal pressure and a set of secondary pathophysiological changes in the abdominal. ACS has reappeared in the literature recently in relation to the surgical concept to damage control, applied particularity in contexts of severe abdominal injury polytraumatized patients. We report two cases of ACS that appeared after scheduled abdominal surgery: one after repair of a large eventration and the other in the context of septic shock due to fecaloid peritonitis. Both patients died of multisystem organ failure in spite of surgical decompression. We wish to emphasize that ACS can appear in contexts other than surgery for damage control, and we stress the need to measure intravesical pressure as a reflection of intraabdominal pressure, particularly in certain high risk patients in the postoperative recovery ward. Finally, we review the pathophysiology of ACS and its management, which is based on early treatment to prevent multisystem organ failure with an associated high risk of death.     

The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn

BACKGROUND: Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem. METHODS: From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound. RESULTS: Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up. CONCLUSION: In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.     

The abdominal compartment syndrome

The abdominal compartment syndrome (ACS) causes dysfunctions of various organs through a progressive unphysiologic increase of the intraabdominal pressure. While the primary ACS is a result of the underlying disease/injury, secondary ACS is caused by surgical interventions. In the severely injured patient intra- and/or retroperitoneal bleeding, edema of viscera due to systemic ischemia reperfusion injury following hemorrhagic shock, abdominal/pelvic packing, and laparotomy closure under tension lead to ACS. The clinical signs of ACS are a tense abdomen with a decreased abdominal wall compliance. Early signs of ACS are a rise in inspiratory pressure and oliguria. Manifest ACS results in anuria, respiratory failure, reduced intestinal perfusion, and low cardiac output syndrome. If untreated, patients die due to left ventricular failure. Diagnosis of ACS is made using the patient's history including the injury pattern, the symptoms, the time period between injury and the occurrence of organ dysfunctions, and the physiologic response to decompression. Frequent determinations of the bladder pressure represent the "golden standard" for early recognition of ACS. Decompressive laparotomy should be performed with a bladder pressure > or = 20 mmHg and rapidly restores impaired organ functions. In the case of a multiple injured patients in shock or with associated severe head injury decompressive laparotomy may even be carried out at a lower bladder pressure. The abdomen is left open. In most patients staged laparotomy is necessary. The final closure of the abdominal wall is carried out after the edema have resolved between day 6 and 8 after primary laparotomy.     

Hypertonic lactated saline resuscitation reduces the risk of abdominal compartment syndrome in severely burned patients

BACKGROUND: Secondary abdominal compartment syndrome is a lethal complication after resuscitation from burn shock. Hypertonic lactated saline (HLS) infusion reduces early fluid requirements in burn shock, but the effects of HLS on intraabdominal pressure have not been clarified. METHODS: Patients admitted to our burn unit between 2002 and 2004 with burns > or =40% of the total body surface area without severe inhalation injury were entered into a fluid resuscitation protocol using HLS (n = 14) or lactated Ringer's solution (n = 22). Urine output was monitored hourly with a goal of 0.5 to 1.0 mL/kg per hour. Hemodynamic parameters, blood gas analysis, intrabladder pressure as an indicator of intraabdominal pressure (IAP), and the peak inspiratory pressure were recorded. Pulmonary compliance and the abdominal perfusion pressure were also calculated. RESULTS: In the HLS group, the amount of intravenous fluid volume needed to maintain adequate urine output was less at 3.1 +/- 0.9 versus 5.2 +/- 1.2 mL/24 h per kg per percentage of total body surface area, and the peak IAP and peak inspiratory pressure at 24 hours after injury were significantly lower than those in the lactated Ringer's group. Two of 14 patients (14%) in the HLS group and 11 of 22 patients (50%) developed IAH within 20.8 +/- 7.2 hours after injury. CONCLUSION: In patients with severe burn injury, a large intravenous fluid volume decreases abdominal perfusion during the resuscitative period because of increased IAP. Our data suggest that HLS resuscitation could reduce the risk of secondary abdominal compartment syndrome with lower fluid load in burn shock patients.     

Clinical diagnosis and treatment of abdominal visceral injury complicated by craniocerebral injury

Objective : To improve the cure rate of patients with abdominal visceral injury complicated by craniocerebral injury. Methods: Clinical data of 176 cases of abdominal visceral injury complicated by craniocerebral injury were retrospectively analyzed. Results: In this series, 44 cases died and the mortality was 25.0%. The main cause of death is abdominal visceral injury combined with shock and severe craniocerebral injury. Conclusions: It is essential to improve the cure rate by accurate diagnosis at early stage. Abdominal paracentesis and CT should be performed promptly and dynamically. Priority should be given to the treatment of life-threatening injuries.     

Current insights in intra-abdominal hypertension and abdominal compartment syndrome: open the abdomen and keep it open!

Background and aims  The abdominal compartment syndrome (ACS) is associated with organ dysfunction and mortality in critically ill patients. Furthermore, the deleterious effects of increased IAP have been shown to occur at levels of intra-abdominal pressure (IAP) previously deemed to be safe. The aim of this article is to provide an overview of all aspects of this underrecognized pathological syndrome for surgeons. Methods and contents  This review article will focus primarily on the recent literature on ACS as well as the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased IAP will be listed, followed by a brief but comprehensive overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP will be discussed, as well as recommendations for organ function support in patients with IAH. Finally, surgical treatment and management of the open abdomen are briefly discussed, as well as some minimally invasive techniques to decrease IAP. Conclusions  The ACS was first described in surgical patients with abdominal trauma, bleeding, or infection, but in recent years ACS has also been described in patients with other pathologies such as burn injury and sepsis. Some of these so-called nonsurgical patients will require surgery to treat their ACS. This review article is intended to provide surgeons with a clear insight into the current state of knowledge regarding IAH, ACS, and the impact of IAP on the critically ill patient.     

Secondary abdominal compartment syndrome: risk factors and outcomes

Secondary abdominal compartment syndrome (ACS), defined as intra-abdominal hypertension with associated pulmonary, renal, or hemodynamic compromise in the absence of preceding abdominal operation or injury, can markedly increase surgical morbidity and mortality. We performed a retrospective chart review of the physiologic parameters and outcomes of 10 patients with secondary ACS. Ten patients developed secondary ACS after aggressive resuscitation, at an average of 20.2 hours. Four of the patients sustained burns greater than 40 per cent, three of the patients had penetrating extremity trauma, one patient had blunt abdominal trauma, one patient was struck by lightning, and one patient developed a retroperitoneal bleed while on heparin. The average bladder pressure was 40.6. The average volume given in the first 24 hours was 33,001 cc (range, 12,400 to 69,000). The average base deficit at admission was -12 (range, +1 to -25). Seven of the 10 patients had decreased urine output. Nine of the 10 patients had decreased tidal volumes on pressure control ventilation. All 10 patients were hypotensive, with 7 of the 10 requiring vasopressors. Overall mortality was 60 per cent, with 43 per cent mortality for those decompressed. Prompt recognition and treatment are mandatory for survival of ACS. We recommend routine bladder pressure monitoring for patients with ongoing resuscitation greater than 500 cc/hr.     

Ischemic bowel as a late sequela of abdominal compartment syndrome secondary to severe burn injury

Abdominal compartment syndrome (ACS) is a known complication of the large-volume resuscitation that burn patients receive. Bowel ischemia has been theorized to occur in ACS but has yet to be described in the literature. The authors report an occurrence of late bowel obstruction related to ACS-associated bowel ischemia in a burn patient.A four-year-old previously well girl sustained 70% total body surface area burns with inhalation injury. The areas injured were the anterior neck, circumferential torso from neck to waist, left arm, left thigh and two-thirds of her right thigh. Fluid resuscitation was initially administered using the modified Parkland formula. Her transfer to the regional burn unit from a local hospital was complicated by early septic shock from a line infection, which increased her resuscitation fluid requirements. Infection ultimately led to multiple instances of ACS. Intervention with percutaneous drainage led to immediate improvement; however, the episodes of ACS resulted in a late small bowel obstruction secondary to stricture, requiring a laparotomy and bowel resection.     

Acute chest syndrome after abdominal surgery in children with sickle cell disease: Is a laparoscopic approach better?

BACKGROUND/PURPOSE: Acute chest syndrome (ACS) is the leading cause of hospitalization and death among patients with sickle cell disease (SCD). Surgery is a risk factor for the development of ACS. It has been suggested that laparoscopic surgery could diminish the risk of sickle-related complications; therefore, more procedures may be encouraged in asymptomatic patients. The goal of the authors was to determine the incidence of postoperative ACS and assess for predisposing factors in all sickle cell patients undergoing abdominal surgery. METHODS: A retrospective analysis of all sickle cell patients receiving abdominal surgery (open and laparoscopic) between 1994 and 1998 was conducted. Data pertaining to demographics, perioperative clinical status, postoperative care, and outcome were collected and analyzed using Student's t test or chi(2) where appropriate. RESULTS: Fifty-four children underwent 62 procedures (35 abdominal and 27 extracavitary). All abdominal cases were either cholecystectomy or splenectomy (22 laparoscopic and 13 open). ACS occurred in 7 of 62 (11.3%) overall, and all were in abdominal cases 7 of 35 (20%). ACS occurred in 5 of 22 (22.7%) laparoscopic cases and 2 of 13 (15.4%) open cases. Operating time was significantly longer in the laparoscopic group compared with open cases (P <.05). A higher percentage of patients who had ACS had at least 1 previous episode (71.4% v 39.3%; P value not significant) and a smaller percentage of ACS patients received a preoperative blood transfusion (14.3% v 32.1%; P value not significant). Postoperative hospitalization was prolonged if ACS occurred (9 +/- 2 v 3 +/- 2 days; P <.05). CONCLUSIONS: Abdominal surgery carries a significantly high risk (20%) of ACS. Laparoscopy does not decrease the incidence of ACS compared with open approach. Predisposing factors were not significant in predicting postoperative ACS. There is considerable morbidity and potential cost implications in patients with ACS.     

Intra-abdominal hypertension and the abdominal compartment syndrome

BACKGROUND: Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure is abnormally high in association with organ dysfunction. It tends to have a poor outcome, even when treated promptly by abdominal decompression. METHODS: A search of the Medline database was performed to identify articles related to intra-abdominal hypertension and ACS. RESULTS: Currently there is no agreed definition or management of ACS. However, it is suggested that intra-abdominal pressure should be measured in patients at risk, with values above 20 mmHg being considered abnormal in most. Abdominal decompression should be considered in patients with rising pressure and organ dysfunction, indicated by increased airway pressure, reduced cardiac output and oliguria. Organ dysfunction often occurs at an intra-abdominal pressure greater than 35 mmHg and may start to develop between 26 and 35 mmHg. The mean survival rate of patients affected by compartment syndrome is 53 per cent. CONCLUSION: The optimal time for intervention is not known, but outcome is often poor, even after decompression. Most of the available information relates to victims of trauma rather than general surgical patients.     

Systemic inflammatory response secondary to abdominal compartment syndrome: stage for multiple organ failure

BACKGROUND: The abdominal compartment syndrome (ACS) has been implicated in the pathogenesis of postinjury multiple organ failure. The ACS is defined as intra-abdominal hypertension causing adverse physiologic response. This study was designed to determine the effects of IAH on the production of interleukin-1b (IL-1beta), interleukin-6 (IL-6), tumor necrosis factor (TNF-alpha), and the effects on remote organ injury. METHODS: IAH was induced in Sprague-Dawley rats which were divided into 5 groups, 10 animals each. Intra-abdominal pressure (IAP) was increased to 20 mm Hg for 60 and 90 minutes in two different groups. In a third group following IAP of 20 mm Hg the abdomen was decompressed for 30 minutes before samples were collected. The other animals were used as controls. Hemodynamic response was monitored throughout the procedure. Cytokine levels were assessed in the plasma. Remote organ injury was assessed by histopathology and myeloperoxidase activity. RESULTS: IAH caused a significant decrease in MAP. After abdominal decompression MAP returned to baseline levels. A significant decrease in arterial pH was also noted. Increase in the levels of TNF-alpha and IL-6 was noted 30 minutes after abdominal decompression. Plasma concentration of IL-1b was elevated after 60 minutes of IAH. Abdominal decompression, however, did not cause a significant increase in the levels of this cytokine. Lung neutrophil accumulation was significantly elevated only after abdominal decompression. Histopathological findings showed intense pulmonary inflammatory infiltration including atelectasis and alveolar edema. CONCLUSIONS: IAH provokes the release of pro-inflammatory cytokines which may serve as a second insult for the induction of MOF.     

Abdominal compartment syndrome following damage-control surgery: pathophysiology and decompression of intraabdominal pressure

In Stone's milestone article on damage-control surgery (DCS) (Ann Surg 1983; 197:532-535), detailed clinical observations of abdominal compartment syndrome (ACS) were presented although the concept of ACS had not yet been established at that time. Since then the concept of ACS has been developed concomitantly with the widespread application of DCS for severe trauma victims. Intraabdominal pressure (IAP) is the most important factor for determining the severity of pathophysiological consequences in patients with ACS. Increased IAP pushes the diaphragm upward, which may cause deterioration of pulmonary function. Increased IAP decreases the glomerular filtration rate and urinary secretion. Patients with severe torso injury may have intraabdominal and/or retroperitoneal hematomaor edema formation in the mesentery, and all those can be factors that elevate IAP. About one-third of patients who undergo DCS develop ACS. Decompression of IAP clearly ameliorates physiological parameters in those patients, although the, mortality rate may not be improve despite adequate control of IAP. This suggest that in addition to elevated IAP other factors such as increased cytokine production might be important in ACS. Inserting a plastic infusion bag between intraabdominal organs and the abdominal wall rather than suturing a plastic bag to the edge of the opened abdominal wall may be preferable for further reconstruction of the wall.