Recognition and management of abdominal compartment syndrome among German anesthetists and surgeons: a national survey

  • Torsten Kaussen1Email author,

    Affiliated with

    • Jens Otto2,

      Affiliated with

      • Gerd Steinau2,

        Affiliated with

        • Jörg Höer3,

          Affiliated with

          • Pramod Kadaba Srinivasan4 and

            Affiliated with

            • Alexander Schachtrupp2

              Affiliated with

              Contributed equally
              Annals of Intensive Care20122(Suppl 1):S7

              DOI: 10.1186/2110-5820-2-S1-S7

              Published: 5 July 2012

              Abstract

              Background

              Abdominal compartment syndrome (ACS) is a life threatening condition that may affect any critically ill patient. Little is known about the recognition and management of ACS in Germany.

              Methods

              A questionnaire was mailed to departments of surgery and anesthesia from German hospitals with more than 450 beds.

              Results

              Replies (113) were received from 222 eligible hospitals (51%). Most respondents (95%) indicated that ACS plays a role in their clinical practice. Intra-abdominal pressure (IAP) is not measured at all by 26%, while it is routinely done by 30%. IAP is mostly (94%) assessed via the intra-vesical route. Of the respondents, 41% only measure IAP in patients expected to develop ACS; 64% states that a simpler, more standardized application of IAP measurement would lead to increased use in daily clinical practice.

              Conclusions

              German anesthesiologists and surgeons are familiar with ACS. However, approximately one fourth never measures IAP, and there is considerable uncertainty regarding which patients are at risk as well as how often IAP should be measured in them.

              Keywords

              abdominal compartment syndrome intra-abdominal pressure intra-abdominal hypertension intensive care unit survey questionnaire bladder pressure intra-vesical pressure measurement.

              Introduction

              Abdominal compartment syndrome (ACS) is defined as a persistent intra-abdominal pressure (IAP) of more than 20 mmHg accompanied by new organ dysfunction or failure. Left untreated, this condition has a high mortality rate [16]. Intra-abdominal hypertension (IAH) is defined by a sustained or repeated pathological elevation of IAP to more than 12 mmHg and is considered a precursor of ACS [1]. Both IAH and ACS may occur in any patient population requiring intensive care [7, 8].

              According to surveys in Canada, Great Britain, Australasia, Belgium, China and the USA, detection and management of IAH and ACS are inconsistent [2, 4, 916]. Familiarity with the devastating consequences of increased IAP is abundant; however, the relevance of ACS in routine care varies. There is no agreement regarding the indication for IAP measurement and its timing [4]. Moreover, the threshold for decompression is still a matter of debate, as prospective randomized trials are missing [1, 10].

              Whether a similar level of uncertainty concerning the recognition and management of ACS exists in Germany, and whether this may be related to the techniques available in clinical routine is unknown. We also speculate that a simple, more standardized technique might help improve monitoring of IAP. As comparable studies have yet to be published, we performed this one using a questionnaire.

              Methods

              In 2006, a questionnaire (see Additional file 1) was sent to the head physicians of departments of surgery and anesthesia in hospitals with more than 450 beds in Germany. This 450-bed threshold was chosen because hospitals of this size are frequently teaching hospitals and serve as referral centers for smaller hospitals with elective or out-patient surgery.

              According to these criteria, the hospitals were selected via an internet-based hospital registry http://​www.​krankenhaus.​net. A total of 222 questionnaires were sent out. Recipients were asked to reply by fax within 2.5 months. No reminder was sent.

              Statistical analysis was calculated using Statistical Package for Social Sciences 12.0.1 for Windows (SPSS Inc., Chicago, IL, USA). Some questions could have more than one answer; in these cases, results were analyzed for multiple responses. The answers were analyzed with respect to training completed by unpaired non-parametric testing (Mann-Whitney U).

              Results

              A total of 113 questionnaires were returned, four were incomplete or unreadable. Excluding these, 109 questionnaires were analyzed (49%). Participants stated they had completed training either in anesthesiology (49%) or surgery (51%). Their indicated years of clinical practice averaged 21.8 (range 7 to 40).

              The majority (65%) stated ACS rarely plays a role in their clinical practice; 24% are concerned regularly; 6% often. Not more than 5% do not encounter this complication. Responding to 'Do you measure IAP?', 28 (26%) stated 'no'. Of those 81 respondents (73%) who measured IAP, 48 (59%) do so 'Only when clinically indicated'. Failure to establish an IAP measurement technique, cited by 22 respondents (28%, see Figure 1a, b), was the most common reason for not measuring it. The method indicated as most often used for IAP assessment was the measurement of intra-vesical pressure (bladder pressure measurement; 94%, multiple answers possible). In the other cases, a trans-gastric technique was reported. Multiple answers were possible for the question 'In which patients do you measure IAP?'. Respondents most often (41%) answered that measurement is only performed in patients thought likely to develop ACS (Figure 2).
              http://static-content.springer.com/image/art%3A10.1186%2F2110-5820-2-S1-S7/MediaObjects/13613_2012_Article_70_Fig1_HTML.jpg
              Figure 1

              Reasons for not measuring IAP and frequency of IAP measurements. (a) Stated reasons for not measuring IAP. Out of 109 respondents, 28 denied regularly measuring IAP due to the reasons presented (% of respondents, multiple answers; question 2). (b) Frequency of IAP measurements among those who stated to measure IAP. Of the 109 respondents, 81 elaborated on when to measure IAP (% of respondents, multiple answers; question 2).

              http://static-content.springer.com/image/art%3A10.1186%2F2110-5820-2-S1-S7/MediaObjects/13613_2012_Article_70_Fig2_HTML.jpg
              Figure 2

              Patient groups which are regularly IAP monitored. Eighty-one stated their criteria regarding in which kind of patients IAP should be measured (% of respondents, multiple answers; question 4).

              The majority (86%) of respondents stated that the decision to surgically decompress is rather a matter of beginning organ dysfunction than of exceeding pressure thresholds (Figure 3). A simpler, more standardized application would lead to an increased use in 70 of 104 respondents (67%). Of the 26 participants not measuring IAP, even 77% think a simplified technique would improve acceptance.
              http://static-content.springer.com/image/art%3A10.1186%2F2110-5820-2-S1-S7/MediaObjects/13613_2012_Article_70_Fig3_HTML.jpg
              Figure 3

              Critical IAH threshold calling for surgical decompression dependent on organ function and dysfunction. Ninety-four respondents stated their criteria concerning when performing decompressive laparotomy dependend on IAP and organ dysfunction (% of respondents, multiple answers; question 5)

              Discussion

              Consensus definitions concerning ACS have been published in order to provide a basis for current treatment [1, 3, 8]. Prospective randomized trials are missing which is probably due to the variable incidence (1% to 15%), rapid progression and the disease pattern [1719]. This situation leaves some questions open. Furthermore, the overall purpose of this survey was to study the current status in Germany.

              Awareness of ACS and performance of IAP measurements

              According to our results, ACS plays a role in 95% of participants' clinical practice. About one third encounter ACS regularly or often. This is comparable to other countries where familiarity with ACS reportedly ranges from 73% to 99% of respondents (Table 1). More than one third of respondents from all over the world diagnose at least five cases of ACS each year. Although knowledge regarding ACS seems abundant, about one fourth of respondents claim they never measure IAP. In other surveys, the non-measuring rate was mostly comparable (range 2% to 80%; Table 1). How those participants (who do not measure IAP) establish the diagnosis of ACS remains unclear. Clinical examination of the abdomen has a sensitivity of only 50% to 60% which is similar to a coin toss [2022]. Malbrain et al. demonstrated that also the abdominal perimeter is an inaccurate way for assessing increasing IAP [23].
              Table 1

              Comparison between results of current surveys related to IAH and ACS

              Authors

              Reference

              Awareness of ACS

              Yearly frequency of AS at ICUs

              Performance of IAP measurements

              Basis of IAH/ACS diagnosis

              Measure method

              Frequency of measurements

              Threshold IAH

              Threshold ACS

              Experience with/opinion about DL and OA

              Mayberry et al.

              [9]

              85%

              14%: No cases

              69% to 95%

              66% IAP measure

              IVP

              59% If suspected

              15 mmHg (11%)

               

              86%: DL if IAH + OD (= ACS)

                 

              52%: One to five cases

               

              34% Clinical

               

              6% Regularly

              18 mmHg (22%)

               

              14%: DL if IAH alone

                 

              33%: Five cases

                  

              22 mmHg (31%)

               

              If OA: Bag > absorb. Mesh > non-absorb. Mesh

                      

              25 mmHg (12%)

                

              Kirkpatrick et al.

              [10]

              100%

               

              52%

              43% IAP measure

              97% IVP

                

              25 mmHg + OD

              8%: DL if IAH alone

                    

              3% IGP

                

              34 mmHg - OD

              90% OA after trauma surgery

                        

              If OA: Bag > VAC > non-absorb. > absorb. Mesh

              Ravishankar and Hunter

              [4]

              99%

               

              76%

              76% IAP measure

              IVP

              93% If suspected

               

              20 mmHg (29%)

              2%: DL if IAP > 20 mmHg alone (= IAH III)

                   

              24% Clinical

               

              4% After EL

               

              25 mmHg (71%)

              27%: DL if IAP > 20 mmHg + OD (= ACS)

                     

              3% After EL + HVR

                

              7%: DL if IAP > 25 mmHg alone (= IAH IV)

                     

              15%: Zero to four hourly

                

              64%: DL if IAP > 25 mmHg + OD (= ACS)

                     

              27%: Four to eight hourly

                 
                     

              11%: 12 hourly

                 
                     

              3%: 24 hourly

                 

              Nagappan et al.

              [14]

              92%

              'Depending on used thresholds'; ICU-dependent

              48% to 93%

              8% Clinical

              89% IVP

              8% Never

              12 mmHg (11%)

              IAH + OD (69%)

              92%: ACS = decompression (ever)

                    

              39% Direct

              53% Rarely

              20 mmHg (64%)

              ≥30 mmHg - OD (33%)

              64%: 'ACS should be treated regardless of IAH'

                    

              6% IGP

              19% Regularly

                 
                    

              6% IRP

              25% Often

                 

              Tiwari et al.

              [2]

              73% to 97%

                

              74% to 94% IAP measure

              90% to 96% IVP

                

              11 to 30 mmHg (teaching hospit.)

              42% Performed DL in 0% to 25% of ACS patients

                   

              60% to 77% Clinical

              4% to 10% Direct

                

              11 to 50 mmHg (district hospital)

              19% Performed DL in 25% to 50% of ACS patients

                   

              3% to 12% CT scan

                  

              16% Performed DL in 50% to 75% of ACS patients

                   

              3% pH manometry

                  

              23% Performed DL in 75% to 100% of ACS patients

              Kimball et al.

              [15]

              75% to 98%

              17%: No cases

              76% to 98%

              70% IAP + clinical

              IVP

              47% Seldom

              'Patient dependent'

              20 to 27 mmHg (42%)

              'Useful invasive therapy options':

                 

              39%: One to three cases

               

              20% Clinical

               

              23% Often

               

              12 to 19 mmHg (18% to 25%)

              -Decompressive laparotomy

                 

              27%: Four to seven cases

               

              7% IAP measure

               

              8% Routinely

               

              12 to 19 mmHg (18% to 25%)

              -Paracentesis/drains

                 

              10%: Eight to 10 cases

               

              3% Others

               

              1% Other

                

              -Escharatomy/fasciotomy

                 

              8%: > Ten cases

                    

              -Peritoneal dialysis (catheter)

              De Laet et al.

              [12]

              80%

               

              41%

              51% IAP measure

              'Majority' IVP

              59% Never

              15 mmHg (IQR 12 to 15)

              20 mmHg (IQR 20 to 20)

              75% Performed at least one DL

                   

              49% Clinical

               

              28% If suspected

                

              60% Performed at least one OA

                     

              12% Continuously

                

              If OA: Bag > abs. > VAC > gauze > non-absorb.

              Ejike et al.

              [13]

                

              76%

              76% IAP measure

              68% IVP

              27% Never

                 
                   

              24% Clinical

              13% Direct

                  
                    

              +/- Doppler

                  
                    

              +/- IGP

                  

              Zhou et al.

              [16]

               

              0%: No cases

              69%

              31% Clinical

              100% IVP

              88% If suspected

               

              25 mmHg

              68%: First-line therapy paracentesis

                 

              44%: One to three cases

                

              7% CVP

              71% Seldom

                

              56%: DL if IAP > 25 mmHg + OD (= ACS)

                 

              16%: Four to seven cases

                 

              29% Regularly

                 
                 

              8%: Eight to ten cases

                 

              8% After EL

                 
                 

              32%: > Ten cases

                 

              4% After HVR

                 

              Kaussen et ala

               

              95%

              6%: Never

              75%

              26% Clinical

              94% IVP

              40% If suspected

               

              20 mmHg (43%)

              4%: DL if IAP > 20 mmHg alone (= IAH III)

                 

              64%: Seldom

                

              6% IGP

              4%: Zero to four hourly

               

              25 mmHg (57%)

              39%: DL if IAP > 20 mmHg + OD (= ACS)

                 

              24%: Regularly

                 

              22%: Four to eight hourly

                

              10%: DL if IAP > 25 mmHg alone (= IAH IV)

                 

              6%: Often

                 

              7%: 12 hourly

                

              46%: DL if IAP > 25 mmHg + OD (= ACS)

                     

              2%: 24 hourly

                 

              Malbrain et al.

              [11]

              99%

              0.3%: No cases

              86%

              69% IAP + clinical

              92% IVP

              42% If suspected

              5 mmHg (< 1%)

              20 mmHg (27%)

              74%: DL if IAH + OD

                     

              4% Continuously

                 
                 

              62%: One to five cases

               

              24% IAP measure

              4% Direct

              32% Four hourly

              10 mmHg (6%)

              25 mmHg (12%)

              9%: DL if severe OD (even without IAH)

                 

              20%: Six to ten cases

               

              13% CT scan

              3% IGP

              26% Six to eight hourly

              12 mmHg (18%)

              > 25 mmHg (58%)

              6%: DL dependent on cause of ACS

                 

              6%: 11 to 15 Cases

               

              10% Abdom. perimeter

               

              6% 12 hourly

              15 mmHg (25%)

               

              If OA: VAC (39%) > Bag (24%) > mesh (21%)

                 

              5%: 16 to 20 cases

               

              8% Abdom. ultrasound

               

              2% 24 hourly

              20 mmHg (29%)

                
                 

              6%: > 25 Cases

                  

              25 mmHg (5%)

                
                      

              > 25 mHg (15%)

                
                      

              Others (2%)

                

              Newcombe et al.

              [38]

              88%

               

              92%

              83% IAP measure

              93% IVP

              21% Regularly

               

              ≤15 mmHg (11%)

               
                   

              8% IAP + clinical

              7% Direct

              54% Sometimes

               

              ≤25 mmHg (59%)

               
                   

              7% Clinical

              0% IGP

              19% Never

               

              > 25 mmHg (30%)

               

              absorb., absorbable (mesh); abdom., abdominal; ACS, abdominal compartment syndrome; AustAsia, Australia and Asia (Australasia); Bag, 'bowel bag' such as 'Bogota bag'; CVP, central venous pressure measurement; direct, intra-abdominal pressure measurement via intra-abdominal placed probes; DL, decompressive laparotomy; EL, emergeny laparotomy; hospit., hospital; HVR, high-volume resuscitation; IAH, intra-abdominal hypertension; IAP, intra-abdominal pressure; ICU, intensive care unit; IGP, intra-gastric pressure measurement; IQR, inter-quartile range; IRP, intra-rectal pressure measurement; IVP, intra-vesical (bladder) pressure measurement; non-absorb., non-absorbable (mesh); OA, open abdomen management; OD, organ dysfunction/failure; VAC, vacuum-assisted. aUnpublished work.

              Among participants measuring IAP, the majority (59%) stated they perform measurements only if clinically indicated; in contrast, 30% advocate a routine measurement one to six times per day (Figure 1b). This appears to correlate with respondents tending to perform measurements mostly in patients expected to develop ACS (40%).

              IAP measurement methods

              In accordance with all formerly published surveys, IAP measurement via the bladder is the most frequently used technique also in Germany (Table 1). Of the respondents, 70% stated that a simpler, more standardized technique would be used more often to assess IAP. This impression is supported by the finding that some respondents refuse bladder pressure measurement because the technique may 'not be established' or appears 'too complex in technical regards'. Both points of criticism appear unjustified. Several studies in humans as well as in animals proved replicability and reliability of the method [24, 25]. Further, the measurement techniques have become increasingly simple and user-friendly over the last years, making it no longer possible to speak of an overly complicated IAP measurement technique. For example, the manometer technique, published by Harrahill in 1998 [26] and perfected by Lee [27], offers a maximum simplification of the bladder pressure test and requires no additional instruments other than a ruler and trans-urethral catheter. Using this principle, even commercially available measurement systems have been developed (for example Foleymanometer, Holtech® medical, Charlottenlund, Denmark). Nevertheless, a minimum amount of training for personnel is required to avoid certain pitfalls. This includes, for example, ruling out a neurogenic or organic bladder dysfunction, ensuring sufficient relaxation of the local abdominal muscles, and the correct steady positioning of the patient with a continuous transparent reference point for the measurement of pressure equivalents.

              Other indirect methods such as intra-gastric and intra-rectal pressure measurements rather constitute an exception than the rule and were stated to be performed by no more than 6% of respondents (Table 1). This is noteworthy in so far as different commercially available measurement systems, meanwhile, have been developed which allow to continuously monitor IAP levels via the stomach (for example CiMON®, Pulsion® Medical Systems, Munich, Germany or 'IAP catheter', Spiegelberg®, Hamburg, Germany). Continuous measurement systems are able to minimize health care providers' workload as well as ensure non-stop observation of especially at risk patients. Pressure transducers, which are directly inserted into the abdomen, even more precisely reflect the IAP. Further information with respect to direct and indirect IAP measurement methods, as well as to continuous and intermittent techniques can be found on excellent reviews which have been published by Malbrain [28] and De Keulenaer [29].

              If various measurement procedures are available, the illness and the dynamic of possibly increasing abdominal pressure should be considered. The higher the IAP, and respectively, the more quickly it is increasing, the sooner continuous pressure monitoring should be considered in order to begin the necessary therapeutic procedures, including invasive ones, in time. Apparently, it is of utmost importance that IAP be quantified when, as recommended by the World Society on the Abdominal Compartment Syndrome (WSACS), certain risk factors are present (Figure 2; Table 2). Using appropriate therapy algorithms, it should thereby become possible to react earlier and assertively enough to IAH that an ACS case does not even arise.
              Table 2

              Risk factors for IAH/ACS as proposed by the WSACS (adapted from [24])

              Category

              Risk factors

              1. Diminished abdominal wall compliance

              Mechanical ventilation, especially fighting with the ventilator and use of accessory respiratory muscles

               

              Use of positive end expiratory pressure (PEEP) or the presence of auto-PEEP

               

              Basal pleuropneumonia

               

              High body mass index

               

              Pneumoperitoneum

               

              Abdominal (vascular) surgery, especially with tight abdominal closures

               

              Pneumatic anti-shock garments

               

              Prone and other body positioning

               

              Abdominal wall bleeding or rectus sheath hematomas

               

              Correction of large hernias, gastroschisis or omphalocele

               

              Burns with abdominal eschars

              2. Increased intra-luminal contents

              Gastroparesis/gastric distension/ileus/colonic pseudo-obstruction

               

              Abdominal tumor

               

              Retroperitoneal/abdominal wall hematoma

              3. Increased intra-abdominal contents

              Liver dysfunction with ascites

               

              Abdominal infection (pancreatitis, peritonitis, abscess, etc.)

               

              Hemoperitoneum/pneumoperitoneum

               

              Acidosis (pH below 7.2)

              4. Capillary leak

              Hypothermia (core temperature below 33°C)

               

              Polytransfusion/trauma (> 10 units of packed red cells/24 h

               

              Coagulopathy (platelet count below 5,000/mm3, an activated partial thromboplastin time (aPTT) more than 2 times normal, a prothrombin time (PTT) below 50%, or an international standardized ration (INR) more than 1.5)

               

              Sepsis (as defined by the American-European Consensus Conference definitions)

               

              Bacteremia

               

              Massive fluid resuscitation (> 5 l of colloid or crystalloid/24 h with capillary leak and positive fluid balance)

               

              Major burns

              IAP thresholds

              Although the WSACS published definitions more than 5 years ago [3], there is still a remarkable lack of knowledge concerning the recommended threshold values in relation to IAH and ACS (Table 1). On the one hand, this might be caused by a lack of awareness of current literature; on the other, this might be influenced by personal experience, which might differ from published results and consensus. While the values gathered in the course of the surveys were partially over the WSACS limits for adults, the majority of pediatricians reported much lower values. This reflects the clinical impression that IAH and ACS can appear at much lower levels of abdominal pressure in children. In the framework of the 5th WSACS World Congress 2011 and using the data available at that time, Ejike et al. correctly demanded the establishment of pediatric limits (IAH: IAP > 10 mmHg, ACS: IAH + new organ dysfunction) (KT et al., unpublished work) [30].

              Surgical therapy options

              Most of our respondents decide to decompress the abdomen based on the presence of organ dysfunction or failure in combination with IAH (Figure 3). The attitude towards the critical threshold (> 20 mmHg or > 25 mmHg) divides respondents into two groups of similar size (39% vs 46%). This is comparable to the surveys done by Ravishankar and Mayberry ([4, 9], Table 1). One reason may be the lack of evidence as prospective outcome studies are missing and the mortality rate of ACS has remained high despite decompression [18, 31]. Tiwari describes a reluctance among surgeons to operate patients with ACS [2]. They probably try to avoid complications associated with decompression and the management of an open abdomen as described by Kirkpatrick et al. in their survey of Canadian surgeons [10]. This restraint might arise from reports about sudden deaths following surgical decompression in patients suffering from IAH and ACS [3234]. Fatal outcome in these patients might be related to fatal pulmonary embolism caused by venous stasis in the splanchnic venous capacitance pool during IAH/ACS. It has also been stated that lethal acute circulatory collapses and asystolia after decompression might be caused by the release of anaerobic metabolic products and inflammatory mediators from prior less perfused tissues (ischemia-reperfusion syndrome [35, 36]). This pathogenesis, however, is not generally accepted.

              Cheatham and Safcsak have demonstrated that routinely monitoring adult patients at risk and a stage-by-stage-guided therapy algorithm comprising medical as well as surgical options may considerably reduce patient mortality by up to 50% [37]. This also supports not delaying decompression when necessary. Respondents as well as participants in other surveys are familiar with decompressive laparotomy and more or less perform this escalated therapy option partly in combination with open-abdomen management often (Table 1). In this connection, it should be noted that, in all studies, the majority of physicians interviewed work in tertiary care hospitals and high-level ICUs. To a lesser degree, these results reflect circumstances found in basic and regular care hospitals where recognition and standardized therapy of IAH and ACS seem to lead a miserable existence.

              Limitations

              Surveys are known to have limitations as results represent personal assessment rather than objective data. A limitation might be that the survey was only sent to the heads of departments and not to section members. It can be argued that the majority of head physicians carry out more administrative than clinical-curative tasks; meaning, they may not be sufficiently informed about current developments in the treatment of IAH and ACS which could have had a negative impact on the validity of the survey results. On the other hand, it appears less likely that establishment of IAP measurements nor therapeutic procedures, including decompressive laparotomies, are carried out in a department without the decision of the head of the department to do so. As a result, head physicians, even if less involved in everyday clinical work, are considered to be sufficiently knowledgeable to answer the questions posed.

              A further limitation is that participants might have simply used their gut feeling instead of clinical databanks to answer the questions. Since doing so would cause more work, it must be assumed that the response rate would have been worse (range of response rates of published IAP surveys: 6% to 90%; Table 3). Therefore, it was decided not to perform a databank survey. The results, which are, to a great extent, identical to the available literature, appear not to express an undue bias (Table 1).
              Table 3

              Overview and structural description of current surveys related to IAH and ACS

              Authors

              Reference

              Country

              Year a

              Questionnaires (returned/sent)

              Response rate

              Communication channel

              Specialty of participitants

              Level of medical care

              Mayberry et al.

              [9]

              USA

              1999/1997

              292/473

              62%

              Mail

              Trauma surgeons

              85% Teaching hospitals

              Kirkpatrick et al.

              [10]

              Canada

              2005/2005

              86/102

              84%

              Mail and email

              Trauma surgeons

               

              Ravishankar and Hunter

              [4]

              UK

              2005/NA

              137/207

              66%

              Mail

              Intensivists

               

              Nagappan et al.

              [14]

              Australasia

              2005/2004

              36/40

              90%

              Hand-out at workshop

              ICU registrars

              72% High-level ICU

                      

              10% Medium-level ICU

                      

              3% Low-level ICU

              Tiwari et al.

              [2]

              UK

              2006/2004

              127/222

              57%

              Mail

              Intensivists

              25% Teaching hospitals

                      

              75% District hospitals

              Kimball et al.

              [15]

              USA

              2006/2001

              1622/4538

              36%

              Mail

              35% Surgeons

               
                     

              32% Internists

               
                     

              18% Pediatricians

               
                     

              10% Anesthetics

               
                     

              1% Emergency doctors

               

              De Laet et al.

              [12]

              Belgium

              2007/2005

              41/689

              6%

              Email

              Surgeons

              73% Teaching hospitals

                      

              27% District hospitals

              Ejike et al.

              [13]

              60% America

              2010/2006

              517/1107

              47%

              Hand-out at pediatric congresses

              60% Pediatric nurses

              81% Tertiary care hospitals

                

              26% Europe

                  

              30% Pediatric intensivists

              14% Community hospitals

                

              12% Australasia

                  

              4% General pediatricians

              2% Private practise

                     

              6% Other pediatric health care providers

              1% Clinics

                      

              2% Others

              Zhou et al.

              [16]

              China

              2011/2010

              108/141

              77%

              Mail

              39% Emergency doctor

              100% Tertiary care hospitals

                     

              36% Internists

               
                     

              19% Surgeons

               
                     

              6% Anesthetics

               

              Kaussen et al.

               

              Germany

              2012b/2006

              113/222

              51%

              Mail

              52% Surgeons

              Larger hospitals with > 450 patient beds

                     

              48% Anesthetics

               

              Malbrain et al.

              [11]

              58% America

              2012/2007

              2244/8081

              28%

              Contacting via email/online-questionnaire

              37% ICU physicians

               
                

              32% Europe

                  

              23% Surgeons

               
                

              9% Australasia

                  

              21% Anesthetics

               
                

              1% Africa

                  

              8% Internists

               
                     

              6% Pediatricians

               
                     

              2% Emergency physicians

               
                     

              1% Cardiologists

               
                     

              2% Others

               

              Newcombe et al.

              [38]

              97% USA

              2012/2010

              433/691

               

              Hand-out at pediatric congress

              Pediatric nurses

              > 60% Tertiary care hospitals

                      

              < 30% Community hospitals

                      

              < 10% Others

              Australasia, Australia and Asia; ICU, intensive care unit. aContains 2 annual details: 1st, year of publication; 2nd, year of conduction of underlying study/survey. bUnpublished work.

              It was decided to send questionnaires to intensive care units of surgical and anesthesiological departments. Due to the current structure in Germany, patients with IAH/ACS are predominantly placed in departments of surgery and anesthesiology and by far less often present in internal departments.

              However, the data display an attitude towards the management of ACS in Germany, thereby, demonstrating a lack of consensus and certainty. This might help guide future studies with a multi-center prospective randomized approach.

              Conclusion

              ACS is known among German anesthesiologists and surgeons, and both groups do not differ in their attitude towards this complication. Measurement of bladder pressure appears to be the current standard to assess IAP. However, about one fourth of responding physicians in Germany never measure IAP, and there is considerable uncertainty about which patients are at risk of developing ACS and how often IAP should be measured. Regarding the IAP threshold for decompression (20 or 25 mmHg), respondents remain undecided. These findings lead to the overall impression that recognition and management of IAH or ACS need to be further established in Germany.

              Abbreviations

              ACS: 

              abdominal compartment syndrome

              IAH: 

              intra-abdominal hypertension

              IAP: 

              intra-abdominal pressure

              WSACS: 

              World Society on the Abdominal Compartment Syndrome.

              Declarations

              Acknowledgements

              The authors would like to thank the directors of the departments of surgery and anesthesia who sent in their replies. We would also like to thank Dawn Nichols for linguistic advice. The charges on the publication of this article were taken on by meas of the promotion programme "Open access publishing" by the German research council (Deutsche Forshungsgemeinschaft).

              This article has been published as part of Annals of Intensive Care Volume 2 Supplement 1, 2012: Diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome. The full contents of the supplement are available online at http://​www.​annalsofintensiv​ecare.​com/​supplements/​2/​S1

              Authors’ Affiliations

              (1)
              Department of Pediatric Cardiology and Intensive Care, University Children's Hospital, Hannover Medical School (MHH)
              (2)
              Department of Surgery, RWTH Aachen University Hospital
              (3)
              Department of Surgery, Hochtaunus-Kliniken Bad Homburg
              (4)
              Institute of Experimental Animal Science, RWTH Aachen University Hospital

              References

              1. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, De Waele J, Ivatury R: Abdominal compartment syndrome: it's time to pay attention! Intensive Care Med 2006, 32: 1912–1914. 10.1007/s00134-006-0303-6PubMedView Article
              2. Tiwari A, Myint F, Hamilton G: Recognition and management of abdominal compartment syndrome in the United Kingdom. Intensive Care Med 2006, 32: 906–909. 10.1007/s00134-006-0106-9PubMedView Article
              3. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A: Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med 2006, 32: 1722–1732. 10.1007/s00134-006-0349-5PubMedView Article
              4. Ravishankar N, Hunter J: Measurement of intra-abdominal pressure in intensive care units in the United Kingdom: a national postal questionnaire study. Br J Anaesth 2005, 94: 763–766. 10.1093/bja/aei117PubMedView Article
              5. Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, De Keulenaer BL, Daelemans R, Jacquet L, Laterre PF, Frank G, de Souza P, Cesana B, Gattinoni L: Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005, 33: 315–322. 10.1097/01.CCM.0000153408.09806.1BPubMedView Article
              6. Malbrain ML, Chiumello D, Pelosi P, Wilmer A, Brienza N, Malcangi V, Bihari D, Innes R, Cohen J, Singer P, Japiassu A, Kurtop E, De Keulenaer BL, Daelemans R, del Turco M, Cosimini P, Ranieri M, Jacquet L, Laterre PF, Gattinoni L: Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med 2004, 30: 822–829. 10.1007/s00134-004-2169-9PubMedView Article
              7. Ivatury RR: Abdominal compartment syndrome: a century later, isn't it time to accept and promulgate? Crit Care Med 2006, 34: 2494–2495. 10.1097/01.CCM.0000235680.83667.EEPubMedView Article
              8. Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Wilmer A: Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. II. Recommendations. Intensive Care Med 2007, 33: 951–962. 10.1007/s00134-007-0592-4PubMedView Article
              9. Mayberry JC, Goldman RK, Mullins RJ, Brand DM, Crass RA, Trunkey DD: Surveyed opinion of American trauma surgeons on the prevention of the abdominal compartment syndrome. J Trauma 1999, 47: 509–513. 10.1097/00005373-199909000-00012PubMedView Article
              10. Kirkpatrick AW, Laupland KB, Karmali S, Bergeron E, Stewart TC, Findlay C, Parry N, Khetarpal S, Evans D: Spill your guts! Perceptions of Trauma Association of Canada member surgeons regarding the open abdomen and the abdominal compartment syndrome. J Trauma 2006, 60: 279–286. 10.1097/01.ta.0000205638.26798.dcPubMedView Article
              11. Kimball EJ, Kim W, Cheatham ML, Malbrain ML: Clinical awareness of intra-abdominal hypertension and abdominal compartment syndrome in 2007. Acta Clin Belg Suppl 2007, 1: 66–73.PubMedView Article
              12. De Laet IE, Hoste EA, De Waele JJ: Survey on the perception and management of the abdominal compartment syndrome among Belgian surgeons. Acta Chir Belg 2007, 107: 648–652.PubMed
              13. Ejike JC, Newcombe J, Baerg J, Bahjri K, Mathur M: Understanding of abdominal compartment syndrome among pediatric healthcare providers. Crit Care Res Pract 2010. Epub 876013
              14. Nagappan R, Ernest D, Whitfield A: Recognition and management of intra-abdominal hypertension and abdominal compartment syndrome. Crit Care Resusc 2005, 7: 298–302.PubMed
              15. Kimball EJ, Rollins MD, Mone MC, Hansen HJ, Baraghoshi GK, Johnston C, Day ES, Jackson PR, Payne M, Barton RG: Survey of intensive care physicians on the recognition and management of intra-abdominal hypertension and abdominal compartment syndrome. Crit Care Med 2006, 34: 2340–2348. 10.1097/01.CCM.0000233874.88032.1CPubMedView Article
              16. Zhou JC, Zhao HC, Pan KH, Xu QP: Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians. J Zhejiang Univ Sci B 2011, 12: 156–162. 10.1631/jzus.B1000185PubMed CentralPubMedView Article
              17. Balogh Z, Jones F, D'Amours S, Parr M, Sugrue M: Continuous intra-abdominal pressure measurement technique. Am J Surg 2004, 188: 679–684. 10.1016/j.amjsurg.2004.08.052PubMedView Article
              18. De Waele JJ, Hoste EA, Malbrain ML: Decompressive laparotomy for abdominal compartment syndrome--a critical analysis. Crit Care 2006, 10: R51. 10.1186/cc4870PubMed CentralPubMedView Article
              19. Hong JJ, Cohn SM, Perez JM, Dolich MO, Brown M, McKenney MG: Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg 2002, 89: 591–596. 10.1046/j.1365-2168.2002.02072.xPubMedView Article
              20. Schachtrupp A, Jansen M, Bertram P, Kuhlen R, Schumpelick V: Abdominal compartment syndrome: significance, diagnosis and treatment. Anaesthesist 2006, 55: 660–667. 10.1007/s00101-006-1019-2PubMedView Article
              21. Kirkpatrick AW, Brenneman FD, McLean RF, Rapanos T, Boulanger BR: Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients? Can J Surg 2000, 43: 207–211.PubMed CentralPubMed
              22. Sugrue M, Bauman A, Jones F, Bishop G, Flabouris A, Parr M, Stewart A, Hillman K, Deane SA: Clinical examination is an inaccurate predictor of intraabdominal pressure. World J Surg 2002, 26: 1428–1431. 10.1007/s00268-002-6411-8PubMedView Article
              23. Malbrain ML, De Laet I, Van RN, Schoonheydt K, Dits H: Can the abdominal perimeter be used as an accurate estimation of intra-abdominal pressure? Crit Care Med 2009, 37: 316–319. 10.1097/CCM.0b013e318192678ePubMedView Article
              24. De Waele JJ, De Laet I, Malbrain ML: Rational intraabdominal pressure monitoring: how to do it? Acta Clin Belg Suppl 2007, 1: 16–25.PubMedView Article
              25. Balogh Z, De Waele JJ, Malbrain ML: Continuous intra-abdominal pressure monitoring. Acta Clin Belg Suppl 2007, 1: 26–32.PubMedView Article
              26. Harrahill M: Intra-abdominal pressure monitoring. J Emerg Nurs 1998, 24: 465–466. 10.1016/S0099-1767(98)70019-4PubMedView Article
              27. Lee SL, Anderson JT, Kraut EJ, Wisner DH, Wolfe BM: A simplified approach to the diagnosis of elevated intra-abdominal pressure. J Trauma 2002, 52: 1169–1172. 10.1097/00005373-200206000-00024PubMedView Article
              28. Malbrain ML: Different techniques to measure intra-abdominal pressure (IAP): time for a critical re-appraisal. Intensive Care Med 2004, 30: 357–371. 10.1007/s00134-003-2107-2PubMedView Article
              29. De Keulenaer BL, Regli A, Malbrain ML: Intra-abdominal measurement techniques: is there anything new? Am Surg 2011,77(Suppl 1):S17–22.PubMed
              30. Ejike JC, Mathur M, Moores DC: Abdominal compartment syndrome: focus on the children. Am Surg 2011, 77: 72–77.
              31. De Waele JJ, Pletinckx P, Blot S, Hoste E: Saline volume in transvesical intra-abdominal pressure measurement: enough is enough. Intensive Care Med 2006, 32: 455–459. 10.1007/s00134-005-0062-9PubMedView Article
              32. Morris JA Jr, Eddy VA, Blinman TA, Rutherford EJ, Sharp KW: The staged celiotomy for trauma. Issues in unpacking and reconstruction. Ann Surg 1993, 217: 576–584. 10.1097/00000658-199305010-00019PubMed CentralPubMedView Article
              33. Schein M, Wittmann DH, Aprahamian CC, Condon RE: The abdominal compartment syndrome: the physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 1995, 180: 745–753.PubMed
              34. Shelly MP, Robinson AA, Hesford JW, Park GR: Haemodynamic effects following surgical release of increased intra-abdominal pressure. Br J Anaesth 1987, 59: 800–805. 10.1093/bja/59.6.800PubMedView Article
              35. Bathe OF, Chow AW, Phang PT: Splanchnic origin of cytokines in a porcine model of mesenteric ischemia-reperfusion. Surgery 1998, 123: 79–88. 10.1016/S0039-6060(98)70232-6PubMedView Article
              36. Cullen DJ, Coyle JP, Teplick R, Long MC: Cardiovascular, pulmonary, and renal effects of massively increased intra-abdominal pressure in critically ill patients. Crit Care Med 1989, 17: 118–121. 10.1097/00003246-198902000-00002PubMedView Article
              37. Cheatham ML, Safcsak K: Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival? Crit Care Med 2010, 38: 402–407. 10.1097/CCM.0b013e3181b9e9b1PubMedView Article
              38. Newcombe J, Mathur M, Bahjiri K, Ejike JC: Pediatric critical care nurses' experience with abdominal compartment syndrome. Annals of Intensive Care, in press.

              Copyright

              © Kaussen et al.; licensee Springer 2012

              This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.