The World Society of the Abdominal Compartment Syndrome (WSACS) has developed definitions for intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) and outlined standardized techniques for intraabdominal pressure (IAP) monitoring to facilitate research and improve patient care [
ACS has a clinically significant direct adverse effect on organ function and mortality despite its apparently low incidence of 0.9% to 12% [
It is important that pediatric healthcare providers (HCP) understand how to recognize, manage, and most importantly prevent ACS in those at risk to minimize the morbidity and mortality associated with it. Publications in children related to this field have greatly lagged behind those involving the adult population (Figure
Trends of publications in Pubmed related to abdominal compartment syndrome (1990–2008).
The objective of this study was to assess the awareness of ACS as an entity, the understanding of the definition of ACS among pediatric HCP, and IAP measurement techniques currently being used.
The Institutional Review Board of Loma Linda University approved this study. A pilot study was first conducted to validate the questionnaire used. The questionnaire validity was checked by the correlation between items addressing the same objectives. In addition, factor analysis was used to assess the construct validity of the questionnaire. The internal consistency of ACS awareness achieved significance (
Descriptive statistics of the categorical variables were described as count and percent. Multivariable logistic regression was performed to assess the determinants of ACS awareness, measurement of IAP and knowledge of the ACS definition. Univariable logistic regression was used to identify the univariate effect of the potential determinants of the outcome. Significant variables were then put in a multivariable analysis to assess the significant variables after adjusting for all the other variables in the model. All statistical analyses were performed using SPSS statistical software version 17.0 (SPSS Institute Inc). Statistical significance was set at
Of 1107 questionnaires distributed, 517 (46.7%) were completed and returned.
Participants included General Pediatricians, Pediatric Registered Nurses (RN), Pediatric Intensivists (PCCM), and other providers (Pediatric Surgeons, Neonatologists, Pediatric Cardiologists, Pediatric Pulmonologists, Anesthesiologists, and Physician Assistants). More than half of the participants (57.1%) practiced in the USA/Canada compared to 26.1% in Europe and 16.8% in other places (Table
Descriptive statistics of responder demographics.
Profession | Percentage | |
General Pediatrician | 20 | 3.9 |
Pediatric Registered Nurse | 307 | 59.8 |
Pediatric Intensivist | 155 | 30.2 |
Others | 31 | 6.1 |
Type of Practice | Percentage | |
Tertiary/Teaching Institution | 407 | 80.8 |
Community Hospital | 72 | 14.3 |
Private Practice | 10 | 2.0 |
Clinics | 4 | 0.8 |
Others | 11 | 2.2 |
Place of Practice | Percentage | |
USA/Canada | 293 | 57.1 |
Europe | 134 | 26.1 |
Others | 86 | 16.8 |
Years in Practice | Percentage | |
0 to 5 years | 149 | 29.1 |
| 121 | 23.6 |
Greater than 10 years | 242 | 47.3 |
Of all the HCP that participated in the study 77.8% (399/513) indicated that they had heard of ACS. The place, type and length of practice did not influence the awareness of ACS (Table
Univariable analysis of factors affecting ACS awareness, IAP measurement, and knowledge of ACS definition.
ACS Awareness | IAP Measurement | ACS Definition | |
Determinants | OR (95% CI) | OR (95% CI) | OR (95% CI) |
Institution Type | |||
Tertiary versus others | |||
Community versus others | |||
ICU | |||
Yes versus No | |||
Profession | |||
Nurses versus PCCM | |||
Others versus PCCM | |||
Length of Practice | |||
6–10 yrs versus | |||
| |||
Place of Practice | |||
Europe vesus USA | |||
Others vesus USA |
ACS: Abdominal compartment syndrome, IAP: Intraabdominal pressure, OR: Odds ration, CI: Confidence interval, ICU: Intensive care unit, PCCM: Pediatric Intensivist.
Multivariable analysis of factors affecting ACS awareness, IAP measurement, and knowledge of ACS definition.
ACS Awareness | IAP Measurement | ACS Definition | |
Determinants | OR (95% CI) | OR (95% CI) | OR (95% CI) |
ICU | |||
Yes versus No | — | ||
Profession | |||
Nurses versus PCCM | |||
Others versus PCCM | |||
Place of Practice | |||
Europe versus USA | — | ||
Others versus USA | — |
ACS: Abdominal compartment syndrome, IAP: Intraabdominal pressure, OR: Odds ratio, CI: Confidence interval, ICU: Intensive care unit, PCCM: Pediatric Intensivist.
Pediatric intensivists demonstrated the greatest awareness of ACS among the professionals that participated in the survey. Ninety-seven percent of 153 pediatric intensivist respondents had heard of ACS. They showed more awareness than pediatric nurses and other specialties 95.0% and 89.9% of the time, respectively, as demonstrated by the odds ratios presented in Table
Of the HCP that were aware of ACS, 24.2% (83/343) indicated that they had never measured IAP. Pediatric intensivists were more likely to measure IAP 44.9% of the time than nurses and 64.9% more often than other subspecialties (Table
When IAP was measured, the method used most commonly was the intravesical technique, 210/311 (67.5%). Clinical exams alone were used by 20.3% (63/311) to detect IAP elevation. Other methods used less frequently included the direct method, the intraesophageal technique, and renal perfusion Doppler.
The definition of ACS was characterized as an elevation of IAP by a specific number (threshold) in 53.2% (157/295) of respondents without indicating a need for evidence of new organ dysfunction as well. Only 46.8% understood that ACS is an elevation in IAP along with new multiorgan dysfunction. Pediatric intensivists understood the current definition of ACS more often than pediatric nurses by 55.8% but there was no significant statistical difference in understanding the definition when compared to other pediatric specialists (Table
This is the first survey targeting pediatric HCP directly and assessing their awareness and understanding of ACS.
Our study demonstrates a lower awareness (77.8%) among pediatric HCP overall compared to adult ICU and surgical counterparts where awareness ranges of 80%–98.5% have been reported [
HCP working in ICUs are more likely to encounter patients at risk for developing ACS and showed more awareness of this entity than those that worked outside of the ICU.
Of all the questions in the survey, the question related to knowledge of the definition of ACS had the least participation (only 57% of participants). Most pediatric HCP in our survey incorrectly defined ACS as an elevation in IAP using a specific number alone. Only 46.8% understood that the development of new organ dysfunction/failure in addition to an elevation in IAP constituted the definition of ACS [
It is important to understand that ACS is the end of the spectrum of IAH [
In fact, prior to the emergence of the consensus definitions, there was great variability in thresholds for defining ACS, ranging from 11–40 mmHg within and between different specialties [
To our knowledge, there are no studies examining the APP threshold in children associated with organ dysfunction or ACS. Critical APP associated with new organ dysfunction may be of greater significance for defining ACS in the pediatric population than an actual IAP value due to the wide range of MAPs seen in children. It may be more practical to define ACS as a rising or sustained elevation of IAP above normal along with the development of new organ dysfunction [
Measuring and monitoring IAP is fundamental to recognizing, diagnosing, and managing IAH/ACS appropriately. IAH occurs more frequently than ACS and has been identified as an independent predictor of morbidity and mortality among the critically ill [
Early intervention should be directed at lowering elevated IAP before organ damage occurs [
Among the study participants that did measure IAP, the intravesical method was most often used. This was also the preferred technique described in other surveys done amongst adult HCP [
Of the participants that were aware of ACS, 33.3% (132/396) had never managed a child with ACS. A survey amongst trauma surgeons found that busier trauma surgeons, regardless of age or academic appointment, and those who measure IAP were more likely to have recent experience with ACS. An overwhelming majority of those who indicated they never or rarely measure IAP stated they had not diagnosed ACS in the previous year [
The low response rate in our survey is a limitation and may suggest that the findings may not be accurately reflective of the study population. Persons directly interested in the subject or those with strong opinions regarding the subject may have responded, introducing a selection bias. Other eligible participants not knowledgeable or not interested in the subject might not have participated at all. Some others who participated provided incomplete responses, reducing the strength of our conclusions. For instance, there was a 100% response rate to questions that asked about personal factual information such as profession, place of practice, and type of practice and even regarding whether or not they had heard about ACS or had managed a child with ACS. However the questions addressing personal clinical practice patterns or specific knowledge regarding the subject generated a response rate that varied from 74 to 86%. These questions might have been perceived as having a “right or wrong answer” making the respondents who were not sure of the “expected” answer unwilling to respond. The reduced response rates to certain questions may be interpreted as a lack of knowledge or comfort with the subject or “survey fatigue” even though the survey consisted of only 10 questions. Another limitation was that the survey was conducted soon after the emergence of the consensus definitions, probably before the new definitions could be adequately disseminated. Nonetheless our study highlights that further education regarding ACS is necessary to improve the existing knowledge among pediatric HCP.
The majority of pediatric HCP surveyed were aware of ACS, with pediatric intensivists having the greatest awareness. Definitions of ACS specific to children are needed. Further dissemination of knowledge related to the importance of objective monitoring of IAP is necessary for diagnosis and early recognition of ACS among pediatric HCP.
The authors would like to thank WolfeTory Medical Inc. for supplying the Abviser kits for intraabdominal pressure measurement and partial grant support of this study.