Introduction
Methods
Evaluation of existing 2006 consensus definitions and risk factors
Development of consensus management statements
Grading of evidence and development of management statements
Results
Existing consensus definitions and risk factors
No. | Definition |
---|---|
1. | IAP is the steady-state pressure concealed within the abdominal cavity |
2. | The reference standard for intermittent IAP measurements is via the bladder with a maximal instillation volume of 25 mL of sterile saline |
3. | IAP should be expressed in mmHg and measured at end-expiration in the supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line |
4. | IAP is approximately 5–7 mmHg in critically ill adults |
5. | IAH is defined by a sustained or repeated pathological elevation in IAP ≥ 12 mmHg |
6. | ACS is defined as a sustained IAP > 20 mmHg (with or without an APP < 60 mmHg) that is associated with new organ dysfunction/failure |
7. | IAH is graded as follows |
Grade I, IAP 12–15 mmHg | |
Grade II, IAP 16–20 mmHg | |
Grade III, IAP 21–25 mmHg | |
Grade IV, IAP > 25 mmHg | |
8. | Primary IAH or ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention |
9. | Secondary IAH or ACS refers to conditions that do not originate from the abdominopelvic region |
10. | Recurrent IAH or ACS refers to the condition in which IAH or ACS redevelops following previous surgical or medical treatment of primary or secondary IAH or ACS |
11. | APP = MAP − IAP |
New definitions accepted by the 2013 consensus panel
| |
12. | A polycompartment syndrome is a condition where two or more anatomical compartments have elevated compartmental pressures |
13. | Abdominal compliance is a measure of the ease of abdominal expansion, which is determined by the elasticity of the abdominal wall and diaphragm. It should be expressed as the change in intra-abdominal volume per change in IAP |
14. | The open abdomen is one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy |
15. | Lateralization of the abdominal wall is the phenomenon where the musculature and fascia of the abdominal wall, most exemplified by the rectus abdominus muscles and their enveloping fascia, move laterally away from the midline with time |
Risk factor |
---|
Diminished abdominal wall compliance
|
Major burns |
Increased intra-luminal contents
|
Gastroparesis/gastric distention/ileus [35] |
Ileus |
Colonic pseudo-obstruction |
Volvulus |
Increased intra-abdominal contents
|
Acute pancreatitis [28] |
Distended abdomen |
Hemoperitoneum/pneumoperitoneum or intra-peritoneal fluid collections [36] |
Intra-abdominal infection/abscess [37] |
Intra-abdominal or retroperitoneal tumors |
Laparoscopy with excessive insufflation pressures |
Liver dysfunction/cirrhosis with ascites [28] |
Peritoneal dialysis |
Capillary leak/fluid resuscitation
|
Damage control laparotomy |
Hypothermia [30] |
Polytransfusion [30] |
Others/miscellaneous
|
Age [29] |
Bacteremia |
Coagulopathy |
Massive incisional hernia repair |
Mechanical ventilation [35] |
PEEP > 10 [28] |
Peritonitis |
Pneumonia |
Classification of the open abdomen
1 No fixation
| |
1A: | Clean, no fixation |
1B: | Contaminated, no fixation |
1C: | Enteric leak, no fixation |
2 Developing fixation
| |
2A: | Clean, developing fixation |
2B: | Contaminated, developing fixation |
2C: | Enteric leak, developing fixation |
3 Frozen abdomen
| |
3A: | Clean, frozen abdomen |
3B: | Contaminated, frozen abdomen |
4 Established enteroatmospheric fistula, frozen abdomen
|
Pediatric Guidelines Sub-Committee: definitions
No. | Definition |
---|---|
Definitions accepted without change from the adult guidelines
| |
1. | IAP is the steady-state pressure concealed within the abdominal cavity |
2. | APP = MAP − IAP |
3. | Primary IAH or ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention |
4. | Secondary IAH or ACS refers to conditions that do not originate from the abdominopelvic region |
5. | IAP should be expressed in mmHg and measured at end-expiration in the supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line |
6. | Recurrent IAH or ACS refers to the condition in which IAH or ACS redevelops following previous surgical or medical treatment of primary or secondary IAH or ACS |
7. | A polycompartment syndrome is a condition where two or more anatomical compartments have elevated compartmental pressures |
8. | The open abdomen is one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy |
9. | Pathophysiological classification of the open abdomen |
1A: clean, no fixation | |
1B: contaminated, no fixation | |
1C: enteric leak, no fixation | |
2A: clean, developing fixation | |
2B: contaminated, developing fixation | |
2C: enteric leak, developing fixation | |
3A: clean, frozen abdomen | |
3B: contaminated, frozen abdomen | |
4: established enteroatmospheric fistula, frozen abdomen | |
10. | Abdominal compliance is a measure of the ease of abdominal expansion, which is determined by the elasticity of the abdominal wall and diaphragm. It should be expressed as the change in intra-abdominal volume per change in intra-abdominal pressure |
Proposed pediatric specific definitions
| |
11. | ACS in children is defined as a sustained elevation in IAP of greater than 10 mmHg associated with new or worsening organ dysfunction that can be attributed to elevated IAP |
12. | The reference standard for intermittent IAP measurement in children is via the bladder using 1 mL/kg as an instillation volume, with a minimal instillation volume of 3 mL and a maximum installation volume of 25 mL of sterile saline |
13. | IAP in critically ill children is approximately 4–10 mmHg |
14. | IAH in children is defined by a sustained or repeated pathological elevation in IAP > 10 mmHg |
Structured clinical questions and consensus management statements
Recommendations
| |
1. | We recommend measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or injured patient [GRADE 1C] |
2. | Studies should adopt the trans-bladder technique as the standard IAP measurement technique [not GRADED] |
3. | We recommend use of protocolized monitoring and management of IAP versus not [GRADE 1C] |
4. | We recommend efforts and/or protocols to avoid sustained IAH as compared to inattention to IAP among critically ill or injured patients [GRADE 1C] |
5. | We recommend decompressive laparotomy in cases of overt ACS compared to strategies that do not use decompressive laparotomy in critically ill adults with ACS [GRADE 1D] |
6. | We recommend that among ICU patients with open abdominal wounds, conscious and/or protocolized efforts be made to obtain an early or at least same-hospital-stay abdominal fascial closure [GRADE 1D] |
7. | We recommend that among critically ill/injured patients with open abdominal wounds, strategies utilizing negative pressure wound therapy should be used versus not [GRADE 1C] |
Suggestions
| |
1. | We suggest that clinicians ensure that critically ill or injured patients receive optimal pain and anxiety relief [GRADE 2D] |
2. | We suggest brief trials of neuromuscular blockade as a temporizing measure in the treatment of IAH/ACS [GRADE 2D] |
3. | We suggest that the potential contribution of body position to elevated IAP be considered among patients with, or at risk of, IAH or ACS [GRADE 2D] |
4. | We suggest liberal use of enteral decompression with nasogastric or rectal tubes when the stomach or colon are dilated in the presence of IAH/ACS [GRADE 1D] |
5. | We suggest that neostigmine be used for the treatment of established colonic ileus not responding to other simple measures and associated with IAH [GRADE 2D] |
6. | We suggest using a protocol to try and avoid a positive cumulative fluid balance in the critically ill or injured patient with, or at risk of, IAH/ACS after the acute resuscitation has been completed and the inciting issues have been addressed [GRADE 2C] |
7. | We suggest use of an enhanced ratio of plasma/packed red blood cells for resuscitation of massive hemorrhage versus low or no attention to plasma/packed red blood cell ratios [GRADE 2D] |
8. | We suggest use of PCD to remove fluid (in the setting of obvious intraperitoneal fluid) in those with IAH/ACS when this is technically possible compared to doing nothing [GRADE 2C]. We also suggest using PCD to remove fluid (in the setting of obvious intraperitoneal fluid) in those with IAH/ACS when this is technically possible compared to immediate decompressive laparotomy as this may alleviate the need for decompressive laparotomy [GRADE 2D] |
9. | We suggest that patients undergoing laparotomy for trauma suffering from physiologic exhaustion be treated with the prophylactic use of the open abdomen versus intraoperative abdominal fascial closure and expectant IAP management [GRADE 2D] |
10. | We suggest not to routinely utilize the open abdomen for patients with severe intraperitoneal contamination undergoing emergency laparotomy for intra-abdominal sepsis unless IAH is a specific concern [GRADE 2B] |
11. | We suggest that bioprosthetic meshes should not be routinely used in the early closure of the open abdomen compared to alternative strategies [GRADE 2D] |
No recommendations
| |
1. | We could make no recommendation regarding use of abdominal perfusion pressure in the resuscitation or management of the critically ill or injured |
2. | We could make no recommendation regarding use of diuretics to mobilize fluids in hemodynamically stable patients with IAH after the acute resuscitation has been completed and the inciting issues have been addressed |
3. | We could make no recommendation regarding the use of renal replacement therapies to mobilize fluid in hemodynamically stable patients with IAH after the acute resuscitation has been completed and the inciting issues have been addressed |
4. | We could make no recommendation regarding the administration of albumin versus not, to mobilize fluid in hemodynamically stable patients with IAH after acute resuscitation has been completed and the inciting issues have been addressed |
5. | We could make no recommendation regarding the prophylactic use of the open abdomen in non-trauma acute care surgery patients with physiologic exhaustion versus intraoperative abdominal fascial closure and expectant IAP management |
6. | We could make no recommendation regarding use of an acute component separation technique versus not to facilitate earlier abdominal fascial closure |
Should we measure IAP? Should we measure it via the bladder? Should we use an IAP measurement protocol? (Supplement 8; see ESM)
Statement
Should we use abdominal perfusion pressure (APP) as a resuscitation endpoint? (Supplement 9; see ESM)
Statement
Should we treat or prevent IAH? (Supplement 10; see ESM)
Statement
How should we manage IAH/ACS?
Non-invasive options: sedation and analgesia (Supplement 11; see ESM)
Statement
Neuromuscular blockade (Supplement 12; see ESM)
Statement
Body positioning (Supplement 13; see ESM)
Statement
Nasogastric/colonic decompression (Supplement 14; see ESM)
Statement
Promotility agents (Supplement 15; see ESM)
Statement
Should we keep fluid balance neutral or even negative among ICU patients? (Supplement 16; see ESM)
Statement
Diuretics (Supplement 17; see ESM)
Statement
Renal replacement therapies (Supplement 18; see ESM)
Statement
Albumin (Supplement 19; see ESM)
Statement
Should we use damage control resuscitation? (Supplement 20; see ESM)
Statement
Minimally-invasive options
Should we use PCD? (Supplement 21; see ESM)
Statement
Invasive options: should we use decompressive laparotomy for IAH or ACS? (Supplement 22; see ESM)
Statement
Use of the open abdomen after trauma damage control laparotomy (Supplement 23; see ESM)
Statement
Damage control laparotomy for non-trauma acute care surgery patients (Supplement 24; see ESM)
Statement
Damage control surgery for patients with intra-abdominal sepsis (Supplement 25; see ESM)
Statement
Definitive abdominal closure
Should we attempt to achieve same-hospital-stay closure of the open abdomen? (Supplement 26; see ESM)
Statement
Should we preferentially use negative pressure wound therapy (NPWT) for temporary abdominal closure after damage control laparotomy? (Supplement 27; see ESM)
Statement
Should we use component separation to facilitate early fascial closure of the open abdomen? (Supplement 28; see ESM)
Statement
Should we use bioprosthethic mesh closures to achieve closure of the open abdomen? (Supplement 29; see ESM)
Statement
Pediatric IAH and ACS management
Statements accepted as appropriate
| |
1. | Measure IAP when any known risk factor is present in a critically ill or injured patient |
2. | Protocolized monitoring and management of IAP should be utilized when caring for the critically ill or injured |
3. | Use percutaneous catheter drainage to remove fluid in those with IAH/ACS when this is technically possible, whether an alternative is doing nothing or decompressive laparotomy |
4. | Use decompressive laparotomy in cases of overt ACS |
5. | Negative pressure wound therapy should be utilized to facilitate earlier abdominal fascial closure among those with open abdominal wounds |
6. | Use a protocol to try to avoid a positive cumulative fluid balance in the critically ill with, or at risk of, IAH |
Statements not accepted as appropriate for pediatric care that were not supported for adult care
| |
1. | No recommendation was made regarding the use of the abdominal perfusion pressure as a resuscitation endpoint |
2. | No recommendation was made regarding the use of decompressive laparotomy for patients with severe IAH without formal ACS |
3. | Biological meshes should not be routinely utilized to facilitate early acute fascial closure |
4. | No recommendation could be made to utilize the component separation technique to facilitate earlier acute fascial closure among patients with open abdominal wounds |
5. | Use of enhanced ratios of plasma to packed red blood cells during resuscitation from massive hemorrhage |
6. | Efforts and/or protocols to obtain early or at least same-hospital-stay fascial closure |