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Intensive Care Med (2006) 32:906–909
DOI 10.1007/s00134-006-0106-9
BRIEF REPORT
Alok Tiwari
Fiona Myint
George Hamilton
Recognition and management of abdominal
compartment syndrome in the United Kingdom
Receiv ed: 2 October 2005
Accepted: 9 February 2006
Published online: 7 April 2006
© Springer-Verlag 2006
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Presented in part as an oral presentation
at the World Congress on Abdominal
Compartment Syndrome in December
2004 at Noosa, Australia, and as a poster
at the Intensive Care Society, December
2004, London, UK, and at the Association
of Surgeons of Great Britain and Ireland
meeting in April 2005.
A. Tiwari · F. Myint · G. Hamilton (u)
Royal Free and University College Medical
School, Department of Vascular Surgery,
Royal Free Hospital,
Pond Street, NW3 2QG London, UK
e-mail: g.hamilton@medsch.ucl.ac.uk
Tel.: +44-207-7940500
Fax: +44-207-4726278
Abstract Objective: Abdominal
compartment syndrome(ACS) is
a condition associated with high mor-
tality if undiagnosed and untreated.
ACS is seen in patients managed
in intensive care units. Very little
is known on the causes, diagnosis
and treatment of this condition in
the United Kingdom. Design:
Questionnaire study. Settings: 222
intensive care units in the UK dealing
with acute abdominal condition.
Results: 127 (57.2%) questionnaires
were returned (32 from teaching
hospitals and 95 from district general
hospitals. Among these, 96.9% of
teaching hospitals and 72.6% of
district general hospitals had seen
cases of ACS. The conditions most
frequently associated with ACS
were small and large bowel surgery
(67%), vascular surgery (62%) and
trauma (60%). ACS was suspected
mainly when there was a distended
abdomen (98.6%), oliguria (94.5%)
and increased ventilatory support
(72.2%). The diagnosis was
confirmed either clinically (68.4%)
or by measuring intra-abdominal
pressure (83.7%). The commonest
method for measuring intra-
abdominal pressure was the intra-
vesical route. The pressure threshold
for diagnosing the condition was
variable, with a range of
11–50 mmHg. There was a large
variation in the number of patients
who were decompressed. Conclu-
sion: Fewer patients are diagnosed
with ACS in district general hos-
pitals compared with teaching
hospitals. The threshold for the
diagnosis of ACS is variable in the
UK, as were the numbers of patients
who were decompressed, suggesting
that many doctors are still reluctant
to accept this condition. This study
would suggest that there is a need
for standardisation of diagnostic
threshold and protocols regarding
decompression in ACS.
Keywords Abdominal compart-
ment syndrome · Decompression ·
Intensive care unit · Intra-abdominal
pressure · Questionnaire
Introduction
Abdominal compartment syndrome (ACS) is defined as
the presence of both an intra-abdominal pressure (IAP) of
more than 20 mmHg, with or without an abdominal per-
fusion pressure (APP) of less than 50 mmHg recorded by
a minimum of three standardised measurements conducted
1–6 h apart; and single or multiple organ system failure
which was not previously present [1]. This condition has
significant morbidity and mortality if unrecognised or un-
treated [2]. It is diagnosed in intensive care units because it
is seen in patients who have major intra-abdominal pathol-
ogy or who have needed major surgery, are unstable and
need close monitoring. Not all doctors universally accept
ACS, and this may be due to a reluctance to accept the
condition or lack of knowledge, resulting in inadequate
treatment [3]. Very little is known about the diagnosis and
management of ACS in the United Kingdom. The aim of
907
our questionnaire study was therefore to test the general
knowledge of ACS, causes, current methods for diagnosis
and its subsequent treatment.
Materials and method
A postal questionnaire was sent to clinical directors of
all the intensive care units in the UK in 2004 who would
be expected to treat patients susceptible to abdominal
compartment syndrome, i.e., general hospitals and not
specialised units (Appendix A). A total of 222 question-
naires were sent out and a prepaid addressed envelope
included. A reminder was sent to units that had not replied
within a few weeks. The total survey period was 12 weeks.
All statistical analysis was done using GraphPad Prism
version 3.00 for Windows, GraphPad Software, San
Diego, CA, USA.
Results
One hundred twenty-seven (127, 57.2%) questionnaires
were returned (32 from teaching hospitals and 95 from
district general hospitals) [4, 5]. Thirty-one (96.9%) of
the teaching hospital intensive care units had seen ACS
compared with 69 (72.6%) of intensive care units in
district general hospitals (p = 0.0037, chi-squared test).
Causes of ACS
These are summarised in Table 1. It is interesting to
note the other types of conditions associated with ACS
that were seen in our survey, including pancreatitis, liver
failure, intra-abdominal sepsis, ascites and patients on
extra-corporeal membrane oxygenator (ECMO). The
main difference between district general hospitals and
teaching hospitals was that district general hospitals rarely
saw cases of ACS after hepatobiliary surgery, reflecting
the centralisation of this type of operation to specialised
units in teaching hospitals (p < 0.0001, chi-squared test).
Teaching hospitals District general hospitals p (chi-squared test)
n =31 n =69
Gynaecological surgery 2 (6.70) 5 (7.2) 0.89
Hepatobiliary surgery 9 (30.0) 1 (1.4) < 0.0001
Small/large bowel obstruction 8 (26.7) 29 (42.0) 0.06
Small/large bowel surgery 17 (54.8) 50 (72.5) 0.08
T rauma 16 (53.3) 44 (63.8) 0.25
Urological surgery 2 (13.3) 6 (8.7) 0.70
Vascular surgery 21 (70.0) 41 (59.4) 0.43
Other 6 (19.4)
∗
15 (21.7)
∗∗
0.79
∗
Includes pancreatitis, liver failure and patients on extra-corporeal membrane oxygenator
∗∗
Includes pancreatitis, ascites, intra-abdominal sepsis and pseudo-obstruction
Table 1 Differing conditions
associated with abdominal
compartment syndrome (ACS)in
intensive care units that had seen
cases of ACS (% are given in
parentheses)
The commonest cause of ACS in teaching hospitals was
vascular surgery, whilst in the district general hospitals
this was small/large bowel surgery.
Recognition and diagnosis of ACS
ACS was suspected in teaching hospitals, compared with
district general hospitals, when there was a distended
abdomen (100% vs. 97.1%), oliguria (90.3% vs. 98.6%),
increased ventilatory support requirement (67.7% vs.
76.8%), hypotension (54.8% vs. 63.8%) and other (26.7%
vs. 24.6%). The others in this survey refer to persistent
acidosis, increased lactate, feeding difficulties, persistent
ileus, hepatic dysfunction and palpitations.
Diagnosis was confirmed in teaching hospitals, com-
pared with district general hospitals, by measuring IAP
(93.5% vs. 73.9%), clinically (60% vs. 76.8%), with
a computed tomography scan (3% vs. 11.6%) or by pH
manometry (3% vs. 0%). If IAP was measured, this was
done by measuring the intra-vesical pressure (89.7% in
teaching hospitals and 96.1% in district general hospi-
tals) o r by using an intra-abdominal catheter (10.3% in
teaching hospitals and 3.9% in district general hospitals).
The pressure thresholds for diagnosing ACS were very
variable. In the teaching hospitals, the pressure threshold
for diagnosing was 11–30 mmHg, and in the district
general hospitals this was 11–50 mmHg.
Treatment of ACS
The number of patients in the units who were decom-
pressed following a diagnosis of ACS is summarised in
Table 2 . This shows that, in the majority of the units, less
than 50% of the patients were decompressed.
Discussion
ACS is increasingly being recognised as a significant cause
of morbidity and mortality worldwide. It is frequently seen
908
Percentage of patients decompressed Teaching hospitals (%) District general hospitals (%)
< 10 32.1 25.8
10–25 14.3 14.5
25–50 14.3 21.0
50–75 10.7 17.7
75–100 28.6 21.0
Table 2 Percentage of patients
decompressed following
diagnosis of abdominal
compartment syndrome in the
intensive care units. There was
no statistical difference
(chi-squared test)
in patients in the intensive care units but not always recog-
nised, as shown by a recent multicentre prevalence study.
In this study by Malbrain et al., 8.2% of patients in in-
tensive care units had ACS, which, based on clinical and
biochemical factors alone, would not have been evident,
demonstrating the need for a high index of suspicion [6].
Therefore, we conducted this survey to find out how many
patients were being diagnosed, and then treated, for ACS
in the UK. A questionnaire study on ACS in the intensive
care unit has also recently been published by Ravishankar
and Hunter [7]. In their study they looked at when IAP
was measured, the pressure threshold for diagnosing ACS
and when they would recommend decompression. They
showed that 75.9% of units had measured IAP, which was
similar to our study (78.7% of units). However, we have
also shown that the recognition of this condition in teach-
ing hospitals was good, whilst this was relatively poor in
district general hospitals, with 27.4% of the units not see-
ing this condition. Our study, which was more comprehen-
sive than that of Ravishankar and Hunter, also showed the
differing causes for ACS, the pressure thresholds for diag-
nosing ACS and the reasons for measuring IAP.
In terms of causal factors, our survey showed results
similar to those previously published, mainly vascular,
trauma and following large and small bowel surgery [8,
9, 10]. The other common causal factors for ACS were
pancreatitis and ascites. Pancreatitis as a causal factor is
probably under-recognised by doctors who manage this
condition in the UK [11].
The diagnosis was confirmed by most of the units by
a combination of clinical parameters and IAP measure-
ment. However, district general hospitals were more likely
to diagnose ACS based only on clinical examination,
though there is no evidence to support this, and diagnosis
should only be made after measuring IAP. The most
important part in the diagnosis of ACS is to have a high
index of suspicion for the condition [6, 8].
Measuring the intra-abdominal pressure is the gold
standard for confirming this condition, though other
methods have been described. These include gastric pH
manometry and computed tomography scans, but in our
survey these were rarely used and reflect the limited
data on using these modalities [12, 13]. Computed to-
mography may show compression of the inferior vena
cava and the round belly sign (increased ratio of the
anteroposterior to transverse abdominal greater then
0.80) [13].
Intra-abdominal pressure can be measured directly by
using an intra-abdominal catheter or indirectly using intra-
vesical or intra-gastric pressure. The current method used
in most published series has been the intra-vesical mea-
surement, as popularised by Kron et al., and was previ-
ously considered the gold standard [14]. This was reflected
in our survey. However, recent work has shown that the in-
termittent method of Kron is not reliable and reproducible,
and, therefore, it is recommended that continuous intra-
vesical monitoring should be used [15, 16, 17].
The pressure threshold for diagnosing ACS has var-
ied in published studies, and this was reflected in our sur-
vey. However, a consensus on this was recently reached at
the World Society of the Abdominal Compartment Syn-
drome (WSACS) meeting (www.wsacs.org), which is that
ACS will be diagnosed if IAP is more than 20 mmHg. This
definition should help in the diagnosis and management
of these patients. In the future, intra-abdominal pressure
alone may be less important, with the APP thought to be
more sensitive [12].
The treatment of ACS is decompression of the ab-
domen, failure of which results in a high mortality.
However, even with decompression, mortality remains
high, because these patients are very unwell, with high
APACHE (acute physiology and chronic health evalua-
tion) and ISS (injury severity score) scores [2]. In our
survey, many units, even after diagnosing this condition,
had a limited number of patients who were actually de-
compressed. This shows that there is reluctance amongst
surgeons to operate on these ill patients, and, again, this
could be because of lack of awareness or reluctance to
accept this condition. We also found that many units had
no proper data on the overall mortality and morbidity of
patients with ACS.
In this study, we have shown that recognition of ACS
is relatively poor in district general hospitals. The pres-
sure threshold for diagnosing this condition is variable, and
rates of decompression of patients with ACS are low. The
founding of the WSACS and adoption of the definition for
ACS should result in standardisation and improvement in
the management of this condition.
Conclusion
ACS is a condition with a high morbidity and mortality if
unrecognised and treated. In this survey, we have shown
909
that this condition is not always recognised and, even if di-
agnosed, is not treated. Wider education is needed for all
doctors who deal with conditions leading to ACS.
Acknowledgements. The authors w ould like to thank the directors
of the intensive care units who sent in their replies, and Sarah Louth
for her help in the sending and collating of the questionnaires.
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