Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.

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Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations.

ObjectiveIntra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. The variety of definitions proposed has led to confusion and difficulty in comparing one study to another.DesignAn international consensus group of critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to standardize definitions for IAH and ACS based upon the current understanding of the pathophysiology surrounding these two syndromes.MethodsPrior to the conference the authors developed a blueprint for the various definitions, which was further refined both during and after the conference. The present article serves as the final report of the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of Abdominal Compartment Syndrome (WSACS).ResultsIAH is redefined as an intra-abdominal pressure (IAP) at or above 12 mmHg. ACS is redefined as an IAP above 20 mmHg with evidence of organ dysfunction/failure. ACS is further classified as either primary, secondary, or recurrent based upon the duration and cause of the IAH-induced organ failure. Standards for IAP monitoring are set forth to facilitate accuracy of IAP measurements from patient to patient.ConclusionsState-of-the-art definitions for IAH and ACS are proposed based upon current medical evidence as well as expert opinion. The WSACS recommends that these definitions be used for future clinical and basic science research. Specific guidelines and recommendations for clinical management of patients with IAH/ACS are published in a separate review.

Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome

Immediate and early trauma deaths are determined by primary brain injuries, or significant blood loss (haemorrhagic shock), while late mortality is caused by secondary brain injuries and host defence failure. First hits (hypoxia, hypotension, organ and soft tissue injuries, fractures), as well as second hits (e.g. ischaemia/reperfusion injuries, compartment syndromes, operative interventions, infections), induce a host defence response. This is characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators: it is defined as systemic inflammatory response syndrome (SIRS), according to clinical parameters. However, in parallel, anti-inflammatory mediators are produced (compensatory anti-inflammatory response syndrome (CARS). An imbalance of these dual immune responses seems to be responsible for organ dysfunction and increased susceptibility to infections. Endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulation (DIC) and microcirculatory disturbances lead finally to apoptosis and necrosis of parenchymal cells, with the development of multiple organ dysfunction syndrome (MODS), or multiple organ failure (MOF). Whereas most clinical trials with anti-inflammatory, anti-coagulant, or antioxidant strategies failed, the implementation of pre- and in-hospital trauma protocols and the principle of damage control procedures have reduced post-traumatic complications. However, the development of immunomonitoring will help in the selection of patients at risk of post-traumatic complications and, thereby, the choice of the most appropriate treatment protocols for severely injured patients.

Pathophysiology of polytrauma.

Background The aging population of the United States results in increasing numbers of surgical operations on elderly patients. This study observed aging related to morbidity, mortality, and their risk factors in patients undergoing major operations. Study design We reviewed our institution's American College of Surgeons National Surgical Quality Improvement Program database from February 24, 2002, through June 30, 2005, including standardized preoperative, intraoperative, and 30-day postoperative data points. This required review and analysis of the prospectively collected data. We examined patient demographics, preoperative risk factors, intraoperative risk factors, and 30-day outcomes with a focus on those aged 80 years and older. Results A total of 7,696 surgical procedures incurred a 28% morbidity rate and 2.3% mortality rate, although those older than 80 years of age had a morbidity of 51% and mortality of 7%. Hypertension and dyspnea were the most frequent risk factors in those aged 80 years and older. Preoperative transfusion, emergency operation, and weight loss best predicted morbidity for those 80 years of age and older. Operative duration predicted "other" postoperative occurrences and emergent case status predicted respiratory occurrences across all age groups. Preoperative impairment of activities of daily living, emergency operation, and increased American Society of Anesthesiology classification predicted mortality across all age groups. A 30-minute increment of operative duration increased the odds of mortality by 17% in patients older than 80 years. Postoperative morbidity and mortality increased progressively with increasing age. Age was statistically significantly associated with morbidity (wound, p=0.021; renal, p=0.001; cardiovascular, p=0.0004; respiratory, p Conclusions Although several risk factors for postoperative morbidity and mortality increase with age, increasing age itself remains an important risk factor for postoperative morbidity and mortality.

Surgical risk factors, morbidity, and mortality in elderly patients.

ContextPrevious studies have reported that the number and distribution of trauma
centers are uneven across states, suggesting large differences in access to
trauma center care.ObjectiveTo estimate the proportion of US residents having access to trauma centers
within 45 and 60 minutes.Design and SettingCross-sectional study using data from 2 national databases as part of
the Trauma Resource Allocation Model for Ambulances and Hospitals (TRAMAH)
project. Trauma centers, base helipads, and block group population were counted
for all 50 states and the District of Columbia as of January 2005.Main Outcome MeasuresPercentages of national, regional, and state populations having access
to all 703 level I, II, and III trauma centers in the United States by either
ground ambulance or helicopter within 45 and 60 minutes.ResultsAn estimated 69.2% and 84.1% of all US residents had access to a level
I or II trauma center within 45 and 60 minutes, respectively. The 46.7 million
Americans who had no access within an hour lived mostly in rural areas, whereas
the 42.8 million Americans who had access to 20 or more level I or II trauma
centers within an hour lived mostly in urban areas. Within 45 and 60 minutes,
respectively, 26.7% and 27.7% of US residents had access to level I or II
trauma centers by helicopter only and 1.9% and 3.1% of US residents had access
to level I or II centers only from trauma centers or base helipads outside
their home states.ConclusionSelecting trauma centers based on geographic need, appropriately locating
medical helicopter bases, and establishing formal agreements for sharing trauma
care resources across states should be considered to improve access to trauma
care in the United States.

https://www.lifeflightmaine.org/Documents/EMS-and-Hospitals/Research/Access-to-Care/Access-to-Trauma-Centers-06_2005.aspx

Access to trauma centers in the United States.

A meta-analysis of prehospital care times for trauma.

Objective:
To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model.

http://osp.mans.edu.eg/tmahdy/Surgeons/eBooks/Books/An%20Acute%20Care%20Surgery%20Model%20Improves%20Outcomes.pdf

An acute care surgery model improves outcomes in patients with appendicitis.

Background Multiple methods exist to manage in the intensive care unit the patient with an open abdomen. An increasingly common method is the vacuum packed technique. This method accommodates considerable expansion of intra-abdominal contents and should obviate the potential development of the abdominal compartment syndrome (ACS). Despite this, some patients with these temporary abdominal dressings will go on to develop ACS. For the purpose of this study we have defined this clinical entity as the open abdomen ACS. Hypothesis Patients with an open abdomen who develop ACS have a poor prognosis. Fluid requirements and resuscitative indices may predict which of these patients will develop open abdomen ACS. Methods A retrospective review was performed of patients with trauma who had an open abdomen treated with vacuum packed dressings at our urban level I trauma center. Over 1 year (July 1, 1999-June 30, 2000), 5 patients managed with an open abdomen developed ACS. These patients were compared with 15 consecutive patients with an open abdomen who did not develop clinical ACS during that same period. Fluid resuscitation, base deficit, pH, lactate level, systolic blood pressure, prothrombin time, temperature, peak inspiratory pressure, and PCO 2 were abstracted. The Fisher exact test was used for statistical analysis. Results In patients managed with an open abdomen, ACS developed between 1.5 and 12 hours (mean [SD], 7.5 [3.9] hours) after placement of the vacuum packed dressing. The base deficit, pH, peak inspiratory pressure, PCO 2, and lactate level were more abnormal and the crystalloid requirements were significantly higher in the ACS group. The systolic blood pressure, temperature, and prothrombin time did not differ between groups. Three patients with ACS developed a second episode of ACS. Mortality in the ACS group was 3 (60%) of 5 patients vs 1 (7%) of 15 patients in the control group. Conclusions Management of the open abdomen with the temporary abdominal closure does not prevent the development of ACS. Mortality is high when ACS occurs in this scenario. Severe physiologic derangement and high crystalloid requirements may predict which patients will develop ACS.

https://jamanetwork.com/journals/jamasurgery/articlepdf/213101/soa2077.pdf

Abdominal compartment syndrome in the open abdomen.

Background: An anteroposterior pelvic radiograph (PXR) continues to be recommended by Advanced Trauma Life Support protocol as an early diagnostic adjunct in the resuscitation of blunt trauma patients. At the same time, computed tomographic (CT) scanning has become a practice standard for diagnosis of most abdominal and pelvic injury. The objective of this study was to determine the necessity of obtaining an early PXR in stable trauma patients who will undergo CT scanning during the initial resuscitation. Methods: A retrospective review of all blunt trauma patients undergoing immediate abdomen and pelvic CT scanning was performed from July 2000 until June 2001 at an urban Level I trauma center. These patients were divided into two groups depending on whether they also received a PXR (group I) or not (group II). At the time of the study, there was no formal protocol to determine which patients underwent pelvic radiography. Radiology reports of all PXRs and CT scans were reviewed. Patient demographics and Injury Severity Scores (ISSs) were abstracted from our trauma registry. The data were analyzed using Student's t test. Results: A total of 686 patients with blunt trauma underwent CT scanning of the abdomen and pelvis. Group I consisted of 311 (45%) patients with an average ISS of 12.3 ± 0.7. In group 1, 56 (10%) patients were found to have at least one pelvic fracture on CT scan, 38 of which were also identified on the PXR. Defining CT scanning as the definitive test, the sensitivity and specificity of the PXR in group I was 68% and 98%, respectively. The false-negative rate for pelvic radiography was 32%. In all patients with a positive PXR, the majority (55%) had either additional fractures or an increase in the Young and Burgess grade of fracture diagnosed on CT scan. Group II consisted of 375 patients, with 16 fractures noted in 13 (3%) patients, none of which required treatment. The mean ISS of group II was 8.0 ± 0.5. Conclusion: The PXR has limited sensitivity for detecting pelvic fractures compared with CT scanning. Selected hemodynamically stable patients who undergo CT scanning during their immediate resuscitation do not need a routine PXR. The PXR may continue to be beneficial in unstable patients, those with positive physical findings, or those who cannot undergo CT scanning because of other clinical priorities.

Pelvic radiography in blunt trauma resuscitation: a diminishing role.

Background: Cervical spinal cord injury (SCI) has a well-established association with a high risk of respiratory complications. We sought to determine whether high-thoracic (HT) SCI was associated with a similar increased risk of respiratory complications and death. Methods: This was a retrospective cohort study of all adult patients with thoracolumbar injuries entered into the Pennsylvania Trauma System Foundation registry between January 1993 and December 2002. Records were reviewed for the documentation of respiratory complications (intubation, tracheostomy, bronchoscopy, pneumonia) and mortality. The data were then evaluated controlling for age, sex, Glasgow Coma Scale, and Injury Severity Score. Results: In all, 11,080 patients met inclusion criteria: 4,258 patients had thoracic spine fractures and 6,226 patients had lumbar spine fractures, all without SCI; and 596 patients had thoracic SCI (T1 to T6, 231; T7 to T12, 365). Respiratory complications occurred in 51.1% of patients with Tl to T6 SCI (versus 34.5% in T7 to T12 SCI and 27.5% in thoracic fractures). The need for intubation, the risk of pneumonia, and risk of death were significantly greater for patients with T1-to T6-level spinal cord injuries. Among patients with an Injury Severity Score less than 17 (n = 6427), the relative mortality risk was 26.7 times higher among those who developed respiratory complications (9.9% versus 0.4%). Conclusion: Compared with patients with low thoracic SCI or thoracolumbar fractures, patients with HT-SCI have an increased risk of pneumonia and death. Respiratory complications significantly increase the mortality risk in less severely injured patients. The current findings suggest that HT-SCI patients warrant intensive monitoring and aggressive pulmonary care and attention, similar to that given for patients with cervical SCI.

John P. Pryor

Papers

A meta-analysis of prehospital care times for trauma.

An acute care surgery model improves outcomes in patients with appendicitis.

Abdominal compartment syndrome in the open abdomen.

Pelvic radiography in blunt trauma resuscitation: a diminishing role.

Respiratory complications and mortality risk associated with thoracic spine injury.