Abdominal compartment syndrome (ACS) increases the risk for mortality in critically ill children. It occurs in association with a wide variety of medical and surgical diagnoses. Management of ACS involves recognizing the development of intra-abdominal hypertension (IAH) by intra-abdominal pressure (IAP) monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP. When ACS is already present, supporting dysfunctional organs and decreasing IAP to prevent new organ involvement become an additional focus of therapy. Medical management strategies to achieve these goals should be employed but when medical management fails, timely abdominal decompression is essential to reduce the risk of mortality. A literature review was performed to understand the role and outcomes of abdominal decompression among children with ACS. Abdominal decompression appears to have a positive effect on patient survival. However, prospective randomized studies are needed to fully understand the indications and impact of these therapies on survival in children.
Abdominal compartment syndrome (ACS) increases the risk of mortality in critically ill children [
The National Library of Medicine (PUBMED) was queried for “decompressive laparotomy and children”; “decompressive laparotomy and pediatrics”; “decompression laparotomy and children”; “decompression laparotomy and pediatrics”, “percutaneous drainage and abdominal compartment.” These searches yielded a total of 67 articles. Eight articles were excluded for language other than English, and 37 were not selected because they were irrelevant or exclusively related to adults. Hence, 22 articles pertinent to the role of abdominal decompression in children were included for review.
There is a relative paucity of literature on ACS in children compared to adults. Publications related to abdominal decompression in children are lacking in their scope and generalizability of findings. ACS definitions differed among the studies which could influence outcomes by unintentionally selecting patients with ACS at varying stages of progression. The majority of publications are case reports or case series, and amongst the outcome studies reviewed, none included randomization of assigned treatment. Outcomes including mortality and postoperative complications vary widely between studies and cannot be directly compared because of small numbers, varied reporting criteria, and differences in study design. The differences seen may be due to a number of contributing factors such as the populations studied; the underlying diagnoses that led to ACS; pre-existing comorbidities such as congenital malformations or genetic syndromes; timing and type of decompression; the type of temporary abdominal closure used and the grade of IAH that the patient presented with. The reported clinical experience of abdominal decompression in children is presented in Table
Reported clinical experience with abdominal decompression in children.
Study (Year) | Study type | Population | ACS definition used | ACS incidence (%) | Mortality (%) | Decompression type | 1° closure fascial (%) | Days to closure | Complications of decompression | |
---|---|---|---|---|---|---|---|---|---|---|
Akhobadze et al. (2011) [ | R | Neonates with IAP monitoring | 32 | IAP > 20 mmHg + 3 specified SOD | 34 | Grade I and II —17 Grade III —37.5 Grade IV —100 | PD | NA | NA | None |
Steinau et al. (2011) [ | R | Neonates and children with ACS | 28 | IAP > 12 mmHg + 1 specified SOD | NA | 21.4 | DL | 64.2 | 53 (10–63) | ECF-21.4%, hernia needing repair-27.3% |
Pearson et al. (2010) [ | R | Children with exploratory laparotomy | 264 | IAP > 12 mmHg + new SOD | 9.8 | 58 | DL | 100.0 | 8.6 (1–61) | ECF, Renal failure |
Ejike et al. (2007) [ | P | Critically ill children with mechanical ventilation | 75 | IAP > 12 mmHg with new SOD | 4.7 | ACS –50 non-ACS –8.1 | PD, DL | NR | NR | ECF |
Hershberger et al. (2007) [ | R | Burn patients (adults and children); 7 children (ages 6 months to 8 years) | 25 of 5195 | IAP > 12 mmHg + specified SOD | NR | 88 | DL ( | 16.0 | NR | NR |
Diaz et al. (2006) [ | P | Critically ill children | 1052 | IAP > 10 mmHg + SOD | 0.9 | 40 | DL ( | NR | NR | NR |
Latenser et al. (2002) [ | P | Burn patients (adults and children) with >40% TBSA burns | 9 | ≥30 mm Hg + pulmonary or renal dysfunction | 0.7 | No IAH —50, IAH with PD—40, DL—100 | PD, DL with chest/abdominal escharotomy | NR | NR | NR |
Beck et al. (2001) [ | P | PICU patients | 1762 | abdominal distention + IAP > 15 mmHg + at least 2 SOD | 0.6 (0.7% of trauma pts) | 60 | DL with Dacron Mesh or Bogota bag | NR | NR | Recurrent ACS |
Neville et al. (2000) [ | R | Patch abdominoplasty for ACS | 23 | Elevated PIP, O2 req., or worsening renal or cardiac function | NR | 34.7 | DL with patch abdominoplasty | 47.8% | 6 (2–11) | Intra-abdominal abscess and ECF |
IAH, intra-abdominal hypertension; ACS, abdominal compartment syndrome; IAP, intra-abdominal pressure;
Adult studies that included pediatric patients.
Definitions related to IAH and ACS in children are derived from the consensus statements put forward by the WSACS (World Society of Abdominal compartment Syndrome;
The WSACS consensus definitions and suggested pediatric definitions.
WSACS consensus definitions [ | Suggested pediatric definitions | |
---|---|---|
IAP | The pressure concealed within the abdominal cavity (It should be expressed in mmHg and measured at end expiration) | |
Normal IAP | Approximately 5–7 mmHg in critically ill adults | 7 ± 3 mmHg in critically ill children [ |
APP | The difference between MAP and IAP | |
IAH | Defined by a sustained or repeated pathological elevation in IAP ≥ 12 mmHg. | Defined by a sustained or repeated pathological elevation in IAP ≥ 10 mmHg [ |
IAH grade I | IAP 12–15 mmHg | IAP 10–12 mmHg |
IAH grade II | IAP 16–20 mmHg | IAP 13–15 mmHg |
IAH grade III | IAP 21–25 mmHg | IAP 16–19 mmHg |
IAH grade IV | IAP | IAP ≥ 20 mmHg |
ACS | Sustained IAP | A sustained IAP of greater than 10 mmHg associated with new organ dysfunction/failure |
Primary ACS | A condition associated with injury or disease in the abdomino-pelvic region that frequently requires early surgical or interventional radiological intervention | |
Secondary ACS | Refers to conditions that do not originate from the abdomino-pelvic region | |
Recurrent ACS | Refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS |
WSACS, World Society of Abdominal Compartment Syndrome; IAP, intra-abdominal pressure; IAH, intra-abdominal hypertension; APP, abdominal perfusion pressure; MAP, mean arterial pressure; ACS, abdominal compartment syndrome.
The true incidence of ACS in children is difficult to determine because of the wide variety of illnesses it is associated with, the relative lack of consensus on the threshold IAP used to define ACS in children, and the paucity of publications. Studies have reported occurrence rates between 0.6 and 9.8% in single-center studies involving critically ill children [
Risk factors that predispose patients to IAH and ACS can be grouped into four major categories based on the pathophysiology of elevated IAP.
Some conditions reported to be associated with ACS in children are listed in Table
Reported conditions associated with ACS in children.
Primary ACS | |
---|---|
Gastroschisis [ | |
Cantrell Syndrome [ | |
Small intestine intussusception [ | |
Ileus [ | |
Hirschprung's disease [ | |
Intra-abdominal trauma (edematous viscera) [ | |
Intestinal transplantation [ | |
Intra-abdominal bleeding/retroperitoneal bleeding [ | |
GI bleeding | |
Extracorporeal life support [ | |
Nonpancreatic pseudocyst [ | |
Wilm's Tumor [ | |
Neuroblastoma [ | |
Burkitt's Lymphoma [ | |
Pyonephrosis/obstructive megaureter [ | |
Pancreatitis [ | |
Tension pneumoperitoneum/intestinal perforation [ | |
Peritonitis/intra-abdominal infection [ | |
Infectious enterocolitis [ | |
Post surgical complication (abdominal surgery) [ | |
Bowel obstruction or perforation [ | |
Secondary ACS | |
Sepsis/Septic shock [ | |
Toxic shock syndrome [ | |
Dengue shock syndrome [ | |
Trauma shock [ | |
Cardiogenic shock/cardiac arrest [ | |
Burns [ |
ACS, abdominal compartment syndrome.
There may be an increased risk for the development of ACS among children with congenital malformations and genetic disorders. In Steinau’s series, 12 out of 26 children who developed ACS had at least one underlying congenital malformation or genetic disorder [
The WSACS recommends that IAP measurement be obtained if two or more risk factors for IAH/ACS are present. If IAH is detected, serial IAP measurements should be performed [
Techniques used to measure IAP can be divided into two groups, the direct and the indirect method. The direct method entails placing a needle or catheter directly into the peritoneal space and transducing the pressure in the abdomen. In clinical practice, its use solely for IAP measurement is limited by the potential for complications such as bowel perforation and peritoneal contamination [
The main goals in management of IAH include recognizing its presence by objective IAP monitoring, treating the underlying cause, and preventing progression to ACS by lowering IAP.
Medical management strategies to lower IAP and improve organ perfusion can be guided by the following principles [ Evacuate intraluminal contents via nasogastric or rectal tubes; avoiding or minimizing enteral feeds; administering enemas or prokinetic agents; colonoscopic decompression. Improve abdominal wall compliance by ensuring adequate sedation, analgesia, and neuromuscular blockade; removal of constrictive dressings and placing in the reverse Trendelenberg position. Optimize fluid administration by avoiding excessive fluid resuscitation (especially with crystalloids, consider using hypertonic fluids and colloids early); aiming for a net negative or zero fluid balance by the third day from initial resuscitation and begin fluid removal through judicious diuresis, ultrafiltration, or dialysis once stable. Optimize systemic and regional perfusion by goal directed fluid resuscitation, hemodynamic monitoring to guide resuscitation, and use of vasoactive medications to maintain adequate abdominal perfusion pressures. Evacuate free intraperitoneal fluid or air, by paracentesis or percutaneous catheter drainage.
Identification and specific treatment of the underlying cause of IAH must be addressed concomitantly. Abdominal ultrasound or Computerized Tomography can be useful in diagnosing the underlying cause and directing management. If the underlying cause of IAH or ACS is surgical, medical management strategies should be used to stabilize the patient without delaying definitive surgery. When medical management is failing and ACS is already present, surgical DL should be performed promptly.
Decompressive laparotomy (DL) is essential and potentially lifesaving in treating IAH-induced organ failure [
DL is the treatment of choice for most patients with IAH or ACS that is refractory to nonoperative medical management strategies and it is associated with significantly improved patient survival [
DL involves making an incision to open all layers of skin, subcutaneous tissue, fascia, and peritoneum [
DL is often supported by open abdomen (OA) management to avoid recurrence of ACS. OA management is achieved by leaving the fascia and the skin open, and temporarily covering the viscera. An OA with temporary abdominal closure (TAC) may also be necessary following operations in which edematous viscera preclude easy fascial closure, management of abdominal wall defects or in which an adult size organ has been transplanted into a small child [
Temporary abdominal closure (TAC) techniques have recently been characterized into three generations reflecting the historical evolution of the devices, from simple coverings, to contain the viscera, to closure devices to cover and aid in the gradual approximation of the abdominal edges [
Temporary abdominal closure techniques reported in children.
Study | TAC | Primary fascial closure (%) | Complications | Conclusion | |
---|---|---|---|---|---|
Keene et al. (2011) [ | 2 | Prolene mesh (Pt 1); Extracellular matrix mesh and vacuum therapy (Pt 2) | 0.0 | Patient 1-sepsis and ECF; Patient 2-skin dehiscence, infected extracellular mesh. Both patients healed by secondary intention | Using extracellular matrix mesh and vacuum therapy for fascial and skin closure, respectively, is superior to Prolene mesh |
Biebl et al. (2010) [ | 5 | Neuropatches (3), Polytetrafluoroethylene (1), Silastic sheet (1) | 80.0 | Subileus in one pt at 18 months post closure | Recommend early operation for ACS using patch abdominoplasty |
Pentlow et al. (2008) [ | 5 | Porcine dermal collagen implants | 100.0 | Incisional hernia, skin dehiscence over implant | Porcine dermal collagen implant is a helpful adjunct to abdominal wall closure following organ transplantation |
Fenton et al. (2007) [ | 7 | Temporary abdominal vacuum packing | 100.0 | None | Vac-Pac closure in infants is a safe and effective method of TAC |
Barker et al. (2007) [ | 258* | Temporary vacuum pack | 68.1 | Fistulae (5%), abscesses (3.5%), bowel obstr (1.2%), ACS (1.2%), evisceration (0.4%) | Method demonstrates ease of mastery, effectiveness in patient care and comfort, low cost, and complication rates |
Howdieshell et al. (2004) [ | 88* | Silicone sheeting TAC | 81.0 (of survivors) | Revision of sheeting due to recurrent ACS or fascial-sheeting dehiscence | Provides a safe and reliable TAC allowing for later definitive reconstruction |
Wu et al. (2003) [ | 15 | Primary Silastic spring-loaded silo | 100.0 | Temporary dislodgement of silo (13.3%) | Permits safe, gentle, and gradual reduction of the exposed viscera |
Markley et al. (2002) [ | 6 | Pediatric vacuum packing wound closure and corset-like lacing | 80.0 | none | The Vac-Pac wound closure technique and its corset modification are important additions to the armamentarium of the general and pediatric surgeon for the management of the ACS |
Tremblay et al. (2001) [ | 181* | Skin only closure, Silo, Polygalactin mesh or packing | 52 | ACS (13%), ECF (14%), evisceration/dehiscence (5%), hernias (48%) | No definite conclusions. Recommended prospective trials to determine the optimal technique for abdominal closure |
Barker et al. (2000) [ | 112* | Temporary vacuum pack | 55.4 | ECF (4.5%), abscesses (4.5%), required re-exploration after closure (2.7%) | The technique is simple and easily mastered and primary closure is achieved in the majority with a low complication rate |
Neville et al. (2000) [ | 23 | Patch abdominoplasty | 43.4 | 21.7%-ECF, abscesses | Patch abdominoplasty effectively decreases airway pressures and oxygen requirements associated with ACS |
de Ville de Goyet et al. (1998) [ | 329* | Temporary Silastic prosthetic closure with skin closure | 76.5 (36 of 47) | None related to TAC | Very useful variation of TAC that is free of related complications and esthetically preferable to others |
Sherck et al. (1998) [ | 50* | Sutureless coverage (clear plastic sheet + sump drains + iodophore impregnated adhesive plastic drape) | 87.5 | No recurrent ACS, evisceration, wound infection, fasciitis nor bowel obstruction; ECF (2), pelvic/abdominal abscess (3), pancreatic fistula (1) | Rapid, safe, easily available means of managing the OA |
Smith et al. (1997) [ | 93* | Vacuum pack | 73.9 (of survivors) | ECF (4.3%), abcesses (4.3%) | Good patient outcomes can be achieved with its use and careful subsequent management |
Ong et al. (1996) [ | 21 | Temporary Silastic patch closure | 100.0 | 23.8 wound complications (dehiscence = 1, infection = 3, incisional hernia = 1) | In patients with difficult abdominal closure after liver transplant recommended as treatment of choice at that time |
Seaman et al. (1996) [ | 17 | Polytetrafluoroethylene patch + abdominal drains with suction | 100.0 (skin closure by secondary intention) | None | Suggests that PTFE can be used safely for temporary wound closure in liver transplant recipients. The majority of patches can be removed during the first postoperative week |
Brock et al. (1995) [ | 28* | Vacuum pack | 50.0 | ECF (4), wound dehiscence (2) | Inexpensive, readily available and valuable |
Shun et al. (1992) [ | 2 | Expanded Polytetrafluoroethylene | 100.0 | Technique allows greater flexibility in use of donor livers for pediatric patients | |
Schnaufer and Everett (1975) [ | 2 | Silastic patch | 50.0 | Sepsis | Can be useful in pts with stage IV neuroblastoma. |
TAC, temporary abdominal closure; ACS, abdominal compartment syndrome; ECF, enterocutaneous fistula; obstr, obstruction; PTFE, polytetrafluoroethylene; OA, open abdomen.
Abdominal decompression by catheter decompression is gaining favor because of its less invasive quality and decreased morbidity associated with its use. Abdominal decompression has been achieved by percutaneous catheter decompression in situations in which intra-abdominal fluid plays a significant role in the underlying diagnosis [
Percutaneous drainage (PD) of peritoneal fluid can prevent the progression of IAH to ACS altogether or may allow time to stabilize the patient for DL [
Paracentesis using angiocatheters, peritoneal dialysis catheters, and hemodialysis catheters have been reported [
Complications with catheter decompression have not been well reported in the literature. Latenser et al.’s study reported peritoneal contamination that did not progress to peritonitis in one patient [
DL was widely considered the only therapeutic option for abdominal decompression in the recent past but less invasive methods of abdominal decompression like catheter decompression are gaining favor because of the decreased morbidities they may offer compared to DL with OA management. Only patients with moderate amounts of free intraperitoneal fluid and no surgical intra-abdominal pathology may benefit from this procedure. Patients with no surgical intra-abdominal pathology and insignificant amounts of intraperitoneal fluid will need other means of decompression. Minimally invasive subcutaneous fasciotomy has been described in adults but its use has not been reported in pediatrics. It entails subcutaneous division of the linea alba between cutaneous incisions or subcutaneous anterior medial rectus abdominis fasciotomy through small skin incisions (with drainage of intra-abdominal fluid) [
Reported complications with OA management include intra-abdominal abscesses, enteroatmospheric fistulae, and herniae when primary fascial closure cannot be achieved. It is difficult to tease out morbidity or mortality associated with DL or OA management from morbidity and mortality related to the underlying cause and the progression of ACS itself. However, arguments for its benefits can be made based on the improvements in physiologic parameters and when death from ACS is imminent, in its absence [
An adult study looking at the long-term impact of DL on physical and mental health, quality of life, and subsequent employment showed that DL initially decreased physical, but not mental health perception compared with that of the United States general population, and that abdominal wall reconstruction restores physical and mental health to normal levels [
ACS is a potentially lethal condition associated with a wide variety of conditions some of which are seemingly innocent at presentation. Clinicians should screen children in the intensive care unit at risk for developing ACS on an ongoing basis. ACS must be recognized early. Clear consensus definitions specific to pediatric patients based on organized studies are still necessary and will help in ACS recognition. Appropriate treatment options supporting organ function and timely assessment for catheter or surgical decompression should be employed. Current therapies being utilized for abdominal decompression appear to have a positive impact on patient survival. However, prospective randomized studies are needed, to fully understand the indications and impact of therapies directed at IAH and ACS management on survival in children. A number of children who would have died without intervention may survive after management of ACS by abdominal decompression, but may acquire varying physiological and psychological complications. Long-term studies to understand the impact of abdominal decompression techniques need to be conducted in children.