wsacs recommendations

World Society of the Abdominal Compartment Syndrome www.wsacs.orgWorld Society of the Abdominal Compartment Syndrome www.wsacs.org

Results from the International Conference of Results from the International Conference of Experts on Intra-Abdominal Hypertension (IAH) and Experts on Intra-Abdominal Hypertension (IAH) and

Abdominal Compartment Syndrome (ACS)Abdominal Compartment Syndrome (ACS)

RECOMMENDATIONSRECOMMENDATIONS

Intensive Care Medicine Intensive Care Medicine 2007; 33(6): 951-9622007; 33(6): 951-962


INTRODUCTION TO THE RECOMMENDATIONSINTRODUCTION TO THE RECOMMENDATIONS

• Intra-abdominal hypertension (IAH) and abdominal compartment Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are causes of significant morbidity and mortality syndrome (ACS) are causes of significant morbidity and mortality in the critically illin the critically ill

• Intra-abdominal pressure (IAP) measurements are essential to the Intra-abdominal pressure (IAP) measurements are essential to the diagnosis of both IAH and ACSdiagnosis of both IAH and ACS

• The World Society of the Abdominal Compartment Syndrome The World Society of the Abdominal Compartment Syndrome (WSACS) has created evidence-based medicine (WSACS) has created evidence-based medicine recommendations for the management of patients with IAH/ACSrecommendations for the management of patients with IAH/ACS


GRADES OF EVIDENCEGRADES OF EVIDENCE

• Evidence-based guidelines are now commonplace in medicine Evidence-based guidelines are now commonplace in medicine

• The WSACS has adopted a modification of the approach The WSACS has adopted a modification of the approach developed by the international GRADE groupdeveloped by the international GRADE group

– Recommendations are classified as either strong Recommendations are classified as either strong recommendations (Grade 1) or weak suggestions (Grade 2)recommendations (Grade 1) or weak suggestions (Grade 2)

– Quality of evidence is ranked as high (grade A), moderate Quality of evidence is ranked as high (grade A), moderate (grade B), or low (grade C)(grade B), or low (grade C)

• While difficult to perform given the acuity of IAH/ACS, these While difficult to perform given the acuity of IAH/ACS, these recommendations emphasize the need for rigorous clinical trials recommendations emphasize the need for rigorous clinical trials to be performed in the futureto be performed in the future


OVERVIEWOVERVIEW

• Given the wide variety of patients that may develop IAH/ACS, no Given the wide variety of patients that may develop IAH/ACS, no one management strategy can be uniformly applied to all patientsone management strategy can be uniformly applied to all patients

• While surgical decompression is commonly considered the only While surgical decompression is commonly considered the only treatment, non-operative medical management strategies play a treatment, non-operative medical management strategies play a vital role in the prevention and treatment of IAH-induced organ vital role in the prevention and treatment of IAH-induced organ dysfunction and failure dysfunction and failure

• Appropriate IAH/ACS management is based upon four principles: Appropriate IAH/ACS management is based upon four principles: – Serial monitoring of IAPSerial monitoring of IAP– Optimization of systemic perfusion and organ function Optimization of systemic perfusion and organ function – Institution of specific medical interventions to reduce IAP Institution of specific medical interventions to reduce IAP – Prompt surgical decompression for refractory IAHPrompt surgical decompression for refractory IAH


RECOMMENDATIONS:RECOMMENDATIONS:RISK FACTORS & SURVEILLANCE FOR IAH/ACSRISK FACTORS & SURVEILLANCE FOR IAH/ACS

Patients should be screened for IAH / ACS risk factors upon ICU Patients should be screened for IAH / ACS risk factors upon ICU admission and in the presence of new or progressive organ admission and in the presence of new or progressive organ

failure (Grade 1B)failure (Grade 1B)

• Independent risk factors for IAH / ACS include:Independent risk factors for IAH / ACS include:– Large volume fluid resuscitation (> 3.5 L / 24 hrs)Large volume fluid resuscitation (> 3.5 L / 24 hrs)– AcidosisAcidosis– HypothermiaHypothermia– Coagulopathy / polytransfusionCoagulopathy / polytransfusion– Pulmonary, renal, hepatic dysfunctionPulmonary, renal, hepatic dysfunction– IleusIleus– Abdominal surgery / primary fascial closureAbdominal surgery / primary fascial closure


RECOMMENDATIONS:RECOMMENDATIONS:IAP MEASUREMENTIAP MEASUREMENT

If two or more risk factors for IAH / ACS are present, a baseline If two or more risk factors for IAH / ACS are present, a baseline IAP measurement should be obtained (Grade 1B)IAP measurement should be obtained (Grade 1B)

If IAH is present, serial IAP measurements should be performed If IAH is present, serial IAP measurements should be performed throughout the patient’s critical illness (Grade1C)throughout the patient’s critical illness (Grade1C)

• Physical examination is insensitive in detecting IAHPhysical examination is insensitive in detecting IAH

• IAP monitoring is a cost-effective, safe, and accurate tool for IAP monitoring is a cost-effective, safe, and accurate tool for identifying the presence of IAH and guiding resuscitative identifying the presence of IAH and guiding resuscitative therapy for ACStherapy for ACS

• Serial IAP measurements are necessary to guide resuscitation Serial IAP measurements are necessary to guide resuscitation of patients with IAH / ACSof patients with IAH / ACS


RECOMMENDATIONS:RECOMMENDATIONS:IAP MEASUREMENT TECHNIQUEIAP MEASUREMENT TECHNIQUE

Studies should adopt the standardized IAP measurement method recommended by the consensus definitions OR provide sufficient detail of the technique utilized to allow accurate interpretation of

the IAP data presented (Grade 2C)

• IAP should be measured:IAP should be measured:

– In mmHg (1 mmHg = 1.36 cm HIn mmHg (1 mmHg = 1.36 cm H22O) O)

– In the supine position at end-expiration with the transducer In the supine position at end-expiration with the transducer zeroed at the mid-axillary linezeroed at the mid-axillary line

– Using an instillation volume of no greater than 25 mL (1 mL/kg Using an instillation volume of no greater than 25 mL (1 mL/kg for children up to 20 kg) for the bladder techniquefor children up to 20 kg) for the bladder technique

– 30-60 seconds after instillation of priming fluid to allow 30-60 seconds after instillation of priming fluid to allow bladder detrusor muscle relaxationbladder detrusor muscle relaxation

– In the absence of active abdominal muscle contractionsIn the absence of active abdominal muscle contractions

IAH ASSESSMENT IAH ASSESSMENT ALGORITHMALGORITHM

www.wsacs.orgwww.wsacs.org


RECOMMENDATIONS:RECOMMENDATIONS:ABDOMINAL PERFUSION PRESSUREABDOMINAL PERFUSION PRESSURE

APP should be maintained above 50–60 mmHg in patients with IAH/ACS (Grade 1C)

• The critical IAP that leads to organ failure varies by patientThe critical IAP that leads to organ failure varies by patient

• A single threshold IAP cannot be applied to all patientsA single threshold IAP cannot be applied to all patients

• APP assesses not only the severity of IAP, but also the relative APP assesses not only the severity of IAP, but also the relative adequacy of abdominal blood flowadequacy of abdominal blood flow

• APP is superior to IAP, arterial pH, base deficit, and arterial APP is superior to IAP, arterial pH, base deficit, and arterial lactate in predicting organ failure and patient outcomelactate in predicting organ failure and patient outcome

• Failure to maintain APP > 50-60 mmHg in patients with IAH Failure to maintain APP > 50-60 mmHg in patients with IAH predicts survivalpredicts survival


RECOMMENDATIONS:RECOMMENDATIONS:SEDATION AND ANALGESIASEDATION AND ANALGESIA

No recommendations can be made at this timeNo recommendations can be made at this time

• Pain, agitation, ventilator dyssynchrony, and accessory muscle Pain, agitation, ventilator dyssynchrony, and accessory muscle use during breathing may all lead to increased abdominal use during breathing may all lead to increased abdominal muscle tonemuscle tone

• This increased muscle activity can increase IAPThis increased muscle activity can increase IAP

• Sedation and analgesia can reduce muscle tone and decrease Sedation and analgesia can reduce muscle tone and decrease IAP to less detrimental levelsIAP to less detrimental levels

• While such therapy would appear prudent, no prospective trials While such therapy would appear prudent, no prospective trials have been performed evaluating the benefits and risks of have been performed evaluating the benefits and risks of sedation and analgesia in IAH/ACSsedation and analgesia in IAH/ACS


RECOMMENDATIONS:RECOMMENDATIONS:NEUROMUSCULAR BLOCKADENEUROMUSCULAR BLOCKADE

A brief trial of neuromuscular blockade (NMB) may be considered A brief trial of neuromuscular blockade (NMB) may be considered in selected patients with in selected patients with mild to moderate IAHmild to moderate IAH while other while other

interventions are performed to reduce IAP (Grade 2C)interventions are performed to reduce IAP (Grade 2C)

• Diminished abdominal wall compliance due to pain, tight Diminished abdominal wall compliance due to pain, tight abdominal closures, and third-space fluid can increase IAP to abdominal closures, and third-space fluid can increase IAP to detrimental levels detrimental levels

• The potential beneficial effects of NMB in reducing abdominal The potential beneficial effects of NMB in reducing abdominal muscle tone must be balanced against the risks of prolonged muscle tone must be balanced against the risks of prolonged paralysisparalysis

• NMB is unlikely to be an effective therapy for patients with NMB is unlikely to be an effective therapy for patients with severe IAHsevere IAH or the patient who has already progressed to ACS or the patient who has already progressed to ACS


RECOMMENDATIONS:RECOMMENDATIONS:BODY POSITIONINGBODY POSITIONING

The potential contribution of body position in elevating IAP The potential contribution of body position in elevating IAP should be considered in patients with moderate to severe IAH should be considered in patients with moderate to severe IAH

or ACS (Grade 2Cor ACS (Grade 2C))

• Head of bed elevation can significantly increase IAP compared Head of bed elevation can significantly increase IAP compared to supine positioning, especially at higher levels of IAHto supine positioning, especially at higher levels of IAH

• Such increases in IAP become clinically significant (increase > Such increases in IAP become clinically significant (increase > 2 mmHg) when the patient’s head of bed exceeds 20 degrees 2 mmHg) when the patient’s head of bed exceeds 20 degrees elevationelevation

• Supine IAP measurements may underestimate the true IAP if Supine IAP measurements may underestimate the true IAP if the patient’s head of bed is elevated between measurementsthe patient’s head of bed is elevated between measurements


RECOMMENDATIONS: GASTRIC/RECTAL RECOMMENDATIONS: GASTRIC/RECTAL SUCTIONING, PROKINETIC AGENTSSUCTIONING, PROKINETIC AGENTS


• Both air and fluid within the hollow viscera can raise IAP and Both air and fluid within the hollow viscera can raise IAP and lead to IAH / ACSlead to IAH / ACS

• Nasogastric and/or rectal drainage, enemas, and even Nasogastric and/or rectal drainage, enemas, and even endoscopic decompression can reduce IAPendoscopic decompression can reduce IAP

• Prokinetic motility agents such as erythromycin, Prokinetic motility agents such as erythromycin, metoclopromide, or neostigmine can aid in evacuating the metoclopromide, or neostigmine can aid in evacuating the intraluminal contents and decreasing the size of the visceraintraluminal contents and decreasing the size of the viscera

• Insufficient evidence is currently available to confirm the Insufficient evidence is currently available to confirm the benefit of such therapies in IAH/ACSbenefit of such therapies in IAH/ACS


RECOMMENDATIONS: RECOMMENDATIONS: FLUID RESUSCITATIONFLUID RESUSCITATION

FFluid resuscitation volume should be carefully monitored to avoid luid resuscitation volume should be carefully monitored to avoid over-resuscitation in patients at risk for IAH/ACS (Grade 1B)over-resuscitation in patients at risk for IAH/ACS (Grade 1B)

Hypertonic crystalloid and colloid-based resuscitation should be Hypertonic crystalloid and colloid-based resuscitation should be considered in patients with IAH to decrease the progression to considered in patients with IAH to decrease the progression to

secondary ACS (Grade 1C)secondary ACS (Grade 1C)

• Fluid resuscitation and “early goal-directed therapy” are Fluid resuscitation and “early goal-directed therapy” are cornerstones of critical care managementcornerstones of critical care management

• Excessive fluid resuscitation is an independent predictor of Excessive fluid resuscitation is an independent predictor of IAH/ACS and should be avoided IAH/ACS and should be avoided

• The use of goal-directed hemodynamic monitoring should be The use of goal-directed hemodynamic monitoring should be considered to achieve appropriate fluid resuscitationconsidered to achieve appropriate fluid resuscitation


RECOMMENDATIONS: RECOMMENDATIONS: DIURETICS & CONTINUOUS HEMOFILTRATIONDIURETICS & CONTINUOUS HEMOFILTRATION


• Diuretic therapy, in combination with colloid, may be considered Diuretic therapy, in combination with colloid, may be considered to mobilize third-space edema following initial resuscitation and to mobilize third-space edema following initial resuscitation and once the patient is hemodynamically stableonce the patient is hemodynamically stable

• Continuous hemofiltration / ultrafiltration may be an appropriate Continuous hemofiltration / ultrafiltration may be an appropriate intervention rather than continuing to volume load and increase intervention rather than continuing to volume load and increase the likelihood of secondary ACSthe likelihood of secondary ACS

• These therapies have yet to be subjected to prospective clinical These therapies have yet to be subjected to prospective clinical study in IAH/ACS patientsstudy in IAH/ACS patients


RECOMMENDATIONS: RECOMMENDATIONS: PERCUTANEOUS CATHETER DECOMPRESSIONPERCUTANEOUS CATHETER DECOMPRESSION

Percutaneous catheter decompression should be considered in Percutaneous catheter decompression should be considered in patients with intraperitoneal fluid, abscess, or blood who patients with intraperitoneal fluid, abscess, or blood who

demonstrate symptomatic IAH or ACS (Grade 2C)demonstrate symptomatic IAH or ACS (Grade 2C)

• Paracentesis represents a less invasive method for treating Paracentesis represents a less invasive method for treating IAH/ACS due to free fluid, ascites, air, abscess, or bloodIAH/ACS due to free fluid, ascites, air, abscess, or blood

• Percutaneous catheter insertion under ultrasound guidance Percutaneous catheter insertion under ultrasound guidance allows ongoing drainage of intraperitoneal fluid and may help allows ongoing drainage of intraperitoneal fluid and may help avoid the need for open abdominal decompression in selected avoid the need for open abdominal decompression in selected patients with secondary ACS patients with secondary ACS


RECOMMENDATIONS: RECOMMENDATIONS: ABDOMINAL DECOMPRESSIONABDOMINAL DECOMPRESSION

Surgical decompression should be performed in patients with Surgical decompression should be performed in patients with ACS that is refractory to other treatment options (Grade 1B)ACS that is refractory to other treatment options (Grade 1B)

Presumptive decompression should be considered at the time of Presumptive decompression should be considered at the time of laparotomy in patients who demonstrate multiple risk factors for laparotomy in patients who demonstrate multiple risk factors for

IAH/ACS (Grade 1C)IAH/ACS (Grade 1C)

• Surgical abdominal decompression has long been the standard Surgical abdominal decompression has long been the standard treatment for the patient who develops ACStreatment for the patient who develops ACS

• It represents a life-saving intervention when a patient’s IAH has It represents a life-saving intervention when a patient’s IAH has become refractory to medical treatment options and organ become refractory to medical treatment options and organ dysfunction and/or failure is evidentdysfunction and/or failure is evident


RECOMMENDATIONS: RECOMMENDATIONS: DEFINITIVE ABDOMINAL CLOSUREDEFINITIVE ABDOMINAL CLOSURE


• Most patients will tolerate primary fascial closure within 5–7 Most patients will tolerate primary fascial closure within 5–7 days if decompressed before significant organ failure developsdays if decompressed before significant organ failure develops

• Management options for the “open abdomen” include split-Management options for the “open abdomen” include split-thickness skin grafting, cutaneous advancement flap (“skin thickness skin grafting, cutaneous advancement flap (“skin only”) closure, and vacuum-assisted closure techniquesonly”) closure, and vacuum-assisted closure techniques

• Prospective trials to identify the optimal management technique Prospective trials to identify the optimal management technique have yet to be performedhave yet to be performed

IAH/ACS IAH/ACS MANAGEMENT MANAGEMENT

ALGORITHMALGORITHM

www.wsacs.orgwww.wsacs.org


RECOMMENDATIONS: RECOMMENDATIONS: FUTURE RESEARCHFUTURE RESEARCH

Incidence and prevalence estimates of IAH/ACS should be based Incidence and prevalence estimates of IAH/ACS should be based upon the consensus definitions (Grade 1C)upon the consensus definitions (Grade 1C)

To facilitate communication of the severity of IAH in future trials, To facilitate communication of the severity of IAH in future trials, we suggest that mean, median, and maximal IAP values should we suggest that mean, median, and maximal IAP values should

be provided both on admission and during the study period be provided both on admission and during the study period (Grade 2C)(Grade 2C)

• Previous research has been complicated by the lack of Previous research has been complicated by the lack of consensus definitionsconsensus definitions

• Use of the definitions and recommendations presented should Use of the definitions and recommendations presented should facilitate the interpretation and comparison of future studiesfacilitate the interpretation and comparison of future studies

• There is a significant need for well-designed, prospective There is a significant need for well-designed, prospective clinical trials to clarify the many questions and issues that clinical trials to clarify the many questions and issues that remain unanswered with respect to IAH/ACSremain unanswered with respect to IAH/ACS


CONCLUSIONSCONCLUSIONS

• The WSACS hopes that these evidence-based consensus The WSACS hopes that these evidence-based consensus definitions, recommendations, and algorithms will aid in definitions, recommendations, and algorithms will aid in interpreting past research, improving current patient care, and interpreting past research, improving current patient care, and planning future clinical and basic science researchplanning future clinical and basic science research

• The WSACS anticipates that these definitions and The WSACS anticipates that these definitions and recommendations will be dynamic and will change as new recommendations will be dynamic and will change as new research becomes availableresearch becomes available


WORLD SOCIETY OF THE ABDOMINAL WORLD SOCIETY OF THE ABDOMINAL COMPARTMENT SYNDROME (WSACS)COMPARTMENT SYNDROME (WSACS)

• The WSACS was founded to The WSACS was founded to promote education and research on promote education and research on IAH and ACSIAH and ACS

• Its membership includes Its membership includes physicians, surgeons, anesthetists, physicians, surgeons, anesthetists, intensivists, nurses, respiratory intensivists, nurses, respiratory therapists, and otherstherapists, and others

• For further details, go to: For further details, go to: www.wsacs.orgwww.wsacs.org

wsacs recommendations

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