Recognition and management of abdominal compartment syndrome among German pediatric intensivists: results of a national survey

Abstract

Introduction: Several decades ago, the beneficial effects of goal-directed therapy, which include decompressive laparotomy (DL) and open abdomen procedures in cases of intra-abdominal hypertension (IAH) in children, were proven in the context of closures of abdominal wall defects and large-for-size organ transplantations. Different neonatologic and pediatric disease patterns are also known to be capable of increasing intra-abdominal pressure (IAP). Nevertheless, a considerable knowledge transfer regarding such risk factors has hardly taken place. When left undetected and untreated, IAH threatens to evolve into abdominal compartment syndrome (ACS), which is accompanied by a mortality rate of up to 60% in children. Therefore, the present study looks at the recognition and knowledge of IAH/ACS among German pediatric intensivists.

Methods: In June 2010, a questionnaire was mailed to the heads of pediatric intensive care units of 205 German pediatric hospitals.

Results: The response rate was 62%. At least one case of IAH was reported by 36% of respondents; at least one case of ACS, by 25%. Compared with adolescents, younger critically ill children appeared to develop IAH/ACS more often. Routine measurements of IAP were said to be performed by 20% of respondents. Bladder pressure was used most frequently (96%) to assess IAP. Some respondents (17%) only measured IAP in cases of organ dysfunction and failure. In 2009, the year preceding this study, 21% of respondents claimed to have performed a DL. Surgical decompression was indicated if signs of organ dysfunction were present. This was also done in cases of at least grade III IAH (IAP > 15 mmHg) without organ impairment.

Conclusions: Although awareness among pediatricians appears to have been increasing over the last decade, definitions and guidelines regarding the diagnosis and management of IAH/ACS are not applied uniformly. This variability could express an ever present lack of awareness and solid prospective data.

Figure 1

Risk factors for IAH/ACS among children dependent on the age group. Respondents were asked to mention disease patterns which, to their experiences, most often cause IAH/ACS in children of different age classes (n = 32 to 63; percentage of given answers). 'Abdominal wall defects' consist of gastroschisis, omphalocele, and diaphragmatic hernia. 'Organ dysfunction' subsumes cardiac insufficiency as well as hepatic and renal dysfunction or failure. 'Postoperative' includes abdominal, cardiac, and thoracic surgery. CLS, capillary leak syndrome; CPAP, continuous positive airway pressure; SIRS, systemic inflammatory response syndrome. ^aThe different disease patterns which are summarized with 'acute abdomen' are more detailed in Figure 2.

Figure 2

Risk factors for IAH-/ACS-inducing acute abdomen among children. Respondents were asked to mention disease patterns which, to their experiences, most often cause IAH/ACS in children (Figure 1). Dependent on the age class, different 'acute abdominal risk factors' were mentioned (n = 32 to 63; percentage of given answers). Dependent on the age causes might be divided into two clusters (neonatal vs. pediatric). FIP, focal intestinal perforation; NEC, necrotizing enterocolitis.

Figure 3

Critical IAP threshold used for surgical decompression dependent on the age of patient. Respondents were asked to mention at which IAP level surgical decompression would be taken into consideration if children of different age classes would be affected (n = 31 to 35; percentage of given answers).

Figure 4

Critical IAP threshold used for surgical decompression dependent on organ (dys)function. Respondents were asked to mention at which IAP level surgical decompression would be taken into consideration depending on the absence or presence of organ dysfunction (n = 42 to 52; percentage of given answers).