Volume 2 Supplement 1
Recognition and management of abdominal compartment syndrome among German anesthetists and surgeons: a national survey
- Torsten Kaussen†1Email author,
- Jens Otto†2,
- Gerd Steinau2,
- Jörg Höer3,
- Pramod Kadaba Srinivasan4 and
- Alexander Schachtrupp2
© Kaussen et al.; licensee Springer 2012
Published: 5 July 2012
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.
A questionnaire was mailed to departments of surgery and anesthesia from German hospitals with more than 450 beds.
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.
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.
Keywordsabdominal compartment syndrome intra-abdominal pressure intra-abdominal hypertension intensive care unit survey questionnaire bladder pressure intra-vesical pressure measurement.
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 [1–6]. 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 . 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, 9–16]. 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 . 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.
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).
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).
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 [17–19]. 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
Comparison between results of current surveys related to IAH and ACS
Awareness of ACS
Yearly frequency of AS at ICUs
Performance of IAP measurements
Basis of IAH/ACS diagnosis
Frequency of measurements
Experience with/opinion about DL and OA
Mayberry et al.
14%: No cases
69% to 95%
66% IAP measure
59% If suspected
15 mmHg (11%)
86%: DL if IAH + OD (= ACS)
52%: One to five cases
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.
43% IAP measure
25 mmHg + OD
8%: DL if IAH alone
34 mmHg - OD
90% OA after trauma surgery
If OA: Bag > VAC > non-absorb. > absorb. Mesh
Ravishankar and Hunter
76% IAP measure
93% If suspected
20 mmHg (29%)
2%: DL if IAP > 20 mmHg alone (= IAH III)
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.
'Depending on used thresholds'; ICU-dependent
48% to 93%
12 mmHg (11%)
IAH + OD (69%)
92%: ACS = decompression (ever)
20 mmHg (64%)
≥30 mmHg - OD (33%)
64%: 'ACS should be treated regardless of IAH'
Tiwari et al.
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.
75% to 98%
17%: No cases
76% to 98%
70% IAP + clinical
20 to 27 mmHg (42%)
'Useful invasive therapy options':
39%: One to three cases
12 to 19 mmHg (18% to 25%)
27%: Four to seven cases
7% IAP measure
12 to 19 mmHg (18% to 25%)
10%: Eight to 10 cases
8%: > Ten cases
-Peritoneal dialysis (catheter)
De Laet et al.
51% IAP measure
15 mmHg (IQR 12 to 15)
20 mmHg (IQR 20 to 20)
75% Performed at least one DL
28% If suspected
60% Performed at least one OA
If OA: Bag > abs. > VAC > gauze > non-absorb.
Ejike et al.
76% IAP measure
Zhou et al.
0%: No cases
88% If suspected
68%: First-line therapy paracentesis
44%: One to three cases
56%: DL if IAP > 25 mmHg + OD (= ACS)
16%: Four to seven cases
8%: Eight to ten cases
8% After EL
32%: > Ten cases
4% After HVR
Kaussen et ala
40% If suspected
20 mmHg (43%)
4%: DL if IAP > 20 mmHg alone (= IAH III)
4%: Zero to four hourly
25 mmHg (57%)
39%: DL if IAP > 20 mmHg + OD (= ACS)
22%: Four to eight hourly
10%: DL if IAP > 25 mmHg alone (= IAH IV)
7%: 12 hourly
46%: DL if IAP > 25 mmHg + OD (= ACS)
2%: 24 hourly
Malbrain et al.
0.3%: No cases
69% IAP + clinical
42% If suspected
5 mmHg (< 1%)
20 mmHg (27%)
74%: DL if IAH + OD
62%: One to five cases
24% IAP measure
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
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%)
Newcombe et al.
83% IAP measure
≤15 mmHg (11%)
8% IAP + clinical
≤25 mmHg (59%)
> 25 mmHg (30%)
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  and perfected by Lee , 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  and De Keulenaer .
Risk factors for IAH/ACS as proposed by the WSACS (adapted from )
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
High body mass index
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
Retroperitoneal/abdominal wall hematoma
3. Increased intra-abdominal contents
Liver dysfunction with ascites
Abdominal infection (pancreatitis, peritonitis, abscess, etc.)
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)
Massive fluid resuscitation (> 5 l of colloid or crystalloid/24 h with capillary leak and positive fluid balance)
Although the WSACS published definitions more than 5 years ago , 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) .
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 . 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 . This restraint might arise from reports about sudden deaths following surgical decompression in patients suffering from IAH and ACS [32–34]. 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% . 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.
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.
Overview and structural description of current surveys related to IAH and ACS
Specialty of participitants
Level of medical care
Mayberry et al.
85% Teaching hospitals
Kirkpatrick et al.
Mail and email
Ravishankar and Hunter
Nagappan et al.
Hand-out at workshop
72% High-level ICU
10% Medium-level ICU
3% Low-level ICU
Tiwari et al.
25% Teaching hospitals
75% District hospitals
Kimball et al.
1% Emergency doctors
De Laet et al.
73% Teaching hospitals
27% District hospitals
Ejike et al.
Hand-out at pediatric congresses
60% Pediatric nurses
81% Tertiary care hospitals
30% Pediatric intensivists
14% Community hospitals
4% General pediatricians
2% Private practise
6% Other pediatric health care providers
Zhou et al.
39% Emergency doctor
100% Tertiary care hospitals
Kaussen et al.
Larger hospitals with > 450 patient beds
Malbrain et al.
Contacting via email/online-questionnaire
37% ICU physicians
2% Emergency physicians
Newcombe et al.
Hand-out at pediatric congress
> 60% Tertiary care hospitals
< 30% Community hospitals
< 10% Others
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.
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.
abdominal compartment syndrome
World Society on the Abdominal Compartment Syndrome.
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.annalsofintensivecare.com/supplements/2/S1
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