Judul

Journal Reading Anesthesia Department

Andreas Nicolaus Ola

NIM
Introduction
• Intra-abdominal hypertension (IAH) and abdominal
compartment syndrome (ACS) are common and associated
with morbidity and mortality among critically ill adults
• These conditions have been linked with
– acute and chronic renal failure,
– multi-organ dysfunction syndrome (MODS),
– increased lengths of intensive care unit (ICU) and hospital stay
– and elevated mortality
• Unfortunately, it remains unknown if prevention or
treatment of IAH/ACS among these patients improves
patient outcomes.
• Identifying critically ill patients at risk for IAH/ACS is
therefore important in order to guide identification of the
source population for future treatment trials and to stratify
patients into risk groups based on prognosis
Introduction

• The World Society of the Abdominal

Compartment Syndrome (WSACS) recommends
measuring IAP via the bladder when one or more
risk factors for IAH or ACS are present
• However, as the risk factors proposed in the
latest WSACS guideline were reported to be
largely opinion- or pathophysiology-based and
occur among nearly all of the patients admitted
to the ICU
• Identifying evidence-based risk factors may
better inform IAP screening practices
Materials and methods

• Methods for inclusion of articles and analysis

and reporting of their results using:
– preferred reporting items for systematic reviews
and meta-analyses (PRISMA)
– meta-analysis of observational studies in
epidemiology (MOOSE)
Search Strategy
We searched
• Ovid MEDLINE and EMBASE
• PubMed
• Cochrane Central Register of Controlled Trials (CENTRAL)
• Cochrane Database of Systematic Reviews
• from their first available date until January 21, 2013 without
restrictions

Adding additional thesaurus/ indexing search terms Medical

Subject Heading (MeSH)/Emtree terms and keywords

We constructed search filters covering the themes IAH/ACS, risk

factors, and critical care

Identify additional citations, using

• PubMed ‘related articles’ feature
• contacted content experts (including members of the WSACS)
• manually searched relevant articles

Wrote to the first or corresponding author of nine articles in order

to clarify study procedures or obtain additional study
Study Selection

• Inclusion criteria:
1. study participants were adult (≥16 years old) ICU
patients
2. study reported patient-level characteristics considered
candidate risk factors for IAH or ACS
3. IAH was reported to be diagnosed using trans-bladder
pressure measurements
4. odds ratios (ORs) or relative risks (RRs) (either adjusted
or unadjusted for potential confounding factors) relating
the candidate risk factor with the development of IAH or
ACS were provided or could be calculated
5. the study design was observational
Study Selection

• WSACS definition:
– primary ACS was considered to be ACS associated
with injury or disease in the abdomino-pelvic
region
– secondary ACS included that not originating from
the abdomino-pelvic region
Data Extraction

Design and setting, including ICU type Indications used for IAP measurement

whether the method of trans-bladder IAP

measurement followed the
Study participant characteristics recommendations of the WSACS*
• age
• primary patient diagnosis
• severity of illness (for whether the patient was mechanically
example acute physiology ventilated or breathing unassisted
and chronic health
evaluation II (APACHE-II)
• sequential organ failure reported candidate risk factors for IAH or ACS
assessment (SOFA) and their exact definitions
• injury severity score (ISS)
definition of IAH and ACS
(*that is measurement via the bladder at end-expiration in the completely supine position with a
maximal instillation volume of 25 mL and the transducer zeroed at the mid-axillary line)
Risk of Bias Assessment

 Logistic regression equation

 Identify selected variables for inclusion
 Study temporality (prospective vs retrospective)
 Patient enrollment (consecutive vs non-
consecutive)
 Definition of IAH and ACS
 Method of bladder pressure measurement
 Abdominal muscular contraction during IAP
measurement
Analysis

• Clustering the identified candidate risk factors

as themes and subthemes
• Vote counting
• Summarize:
– Risk factor (OR point estimate and CI>1)
– Exposure that was neither hazardous nor
protective (CI included 1)
– Exposure that was protective (OR and CI<1)
Result: Study Selection and
Characteristics

• Data: 14 studies with 2.500 critically ill adults

• Characteristic:
11 cohort 2 Mechanically
2 case control ventilated
1 cross-sectional patients

7 mixed ICU patients

1 surgical ICU
2 severe acute pancreatitis
4 trauma
Result: Risk of Bias Assessment

• 8 studies failed to provide clearly operational

definitions of their reported candidate risk factors
• Only 2 studies specifically reported which
covariateswere included in the regression model
• 8 studies select variables for inclusion using
stepwise selection procedure
• None mentioned whether investigators assessed
for effect measure modification
• Only 3 reported using a goodness-of-fit test for
model validation
Result: Risk factors of IAH and ACS

• From 14 studies:
– 9 report candidate risk factor for IA
– 6 report risk factor for ACS
• Most common risk factors:
– Large-volume crystalloid resuscitation
– Respiratory status of the patient
– Shock/ hypotension
Result: Risk Factors for IAH
Result: Risk Factors for IAH
Result: Risk Factors for IAH

• Mixed patients
– Obesity (OR 5.10)
– Sepsis/ infection (OR 2.38)
– Abdominal surgery (OR 1.93)
– Acidosis (OR 1.93)
– Hypotension (OR 2.12)
– Mechanical ventilation/ ARDS (OR 6.78)
– Large Crystalloid and non crystalloid resuscitation (OR
2.17)
• Trauma and Severe Acute Pancreatitis Patients
Result: Risk Factors for IAH

• Mixed patients
• Trauma patients
– Abdominal surgery (OR 5.72)
– Increase plasma base deficit (OR 1.15)
– Pre-ICU crystalloid resuscitation (OR 1.40)
• Severe Acute Pancreatitis Patients
– Age
– Gender
– Disease severity (OR 1.652)
– Large volume crystalloid resuscitation
Result: Risk Factors for ACS

• Pre-ICU
– Prehospital crystalloid administration >3L
– Surgical intervention within 75 minutes of ER
admission
• ICU
– Disease severity score
– Markers of metabolic derangement/ organ failure
– Shock/hypotension
– Large volume crystalloid and non-crystalloid
resuscitation
Discussion
• Clinical practice guidelines: IAP be
measured via bladder in all ICU
patients with risk factors for IAH Need to define
and ACS
• Intra-vesicular pressure patient group at
measurement is time consuming, increased risk
• May not be required in many ICU
patients  Crystalloid
• Instillation of saline into bladder resuscitation prior to
may increase risk of UTI
ICU admission
 Metabolic
derangement/ organ
failure
 Shock/ hypotension
 Disease severity
Discussion

• Study limitations
– Heterogeneous risk factor definitions + inclusion
of varying patient population  impossible to
estimate OR
– Many risk factors cannot be readily applied in
practice
– Several studies cannot be assessed in more detail
due to methodological limitations
– Need to be consider: patient-level variable such as
head of bed elevation, prone vs supine position
Key Messages
• This systematic review and meta-analysis identified 25
unique evidence-informed risk factors for IAH and 16 for
ACS
• Although several of these risk factors appeared to
transcend across patients populations (for example large-
volume crystalloid resuscitation, and the presence of
shock/ hypotension), many were specific to the type of
patient population under study
• Among mixed ICU patients, there specific presenting or
ICU admission diagnosis, the presence of shock or
metabolic derangement, and the volume of crystalloids
used in their initial resuscitation appear to be important
considerations in determining risk of IAH and ACS
Key Messages

• Risk factors for IAH with pooled evidence supporting an

increased risk among mixed ICU patients included
obesity, sepsis, abdominal surgery, ileus development,
and fluid resuscitation
• As our findings were partially limited by clinical
heterogeniety and the quality of statistical analyses
conducted in the included studies, the risk factors
reported in this study should be considered candidate
evidence-based risk factors until formally evaluated in
prospective multi-centre observational study
 Judul

Thank you