Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Intensive Care Medicine, Jul 2013

Purpose To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS). Methods We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear). Results In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation. Conclusion Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.

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Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Andrew W. Kirkpatrick Derek J. Roberts Jan De Waele Roman Jaeschke Manu L. N. G. Malbrain Bart De Keulenaer Juan Duchesne Martin Bjorck Ari Leppaniemi Janeth C. Ejike Michael Sugrue Michael Cheatham Rao Ivatury Chad G. Ball Annika Reintam Blaser Adrian Regli Zsolt J. Balogh Scott D'Amours Dieter Debergh Mark Kaplan Edward Kimball Claudia Olvera The Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome 0 1 2 3 4 5 6 0 J. De Waele Department of Critical Care Medicine, Ghent University Hospital and Ghent Medical School , Ghent, Belgium 1 D. J. Roberts Departments of Surgery and Community Health Sciences, University of Calgary , Calgary, AB T2N 5A1, Canada 2 A. Leppaniemi Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki , Haartmaninkatu 4, PO Box 340, 00029 Helsinki, Finland 3 M. Bjorck Department of Surgical Sciences, Vascular Surgery, Uppsala University , Uppsala, Sweden 4 J. Duchesne Section of Trauma and Critical Care Surgery, Division of Surgery, Anesthesia and Emergency Medicine, Tulane Surgical Intensive Care Unit , 1430 Tulane Ave., SL-22, New Orleans, LA 70112-2699, USA 5 B. De Keulenaer A. Regli Intensive Care Unit, Fremantle Hospital , Alma Street, PO Box 480, Fremantle, WA 6959, Australia 6 R. Jaeschke Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University , Hamilton, ON L8P 3B6, Canada - J. C. Ejike D. Debergh system. RECOMMENDATIONS Loma Linda University Childrens Hospital, Department of Intensive Care, Ghent included intra-abdominal pressure 11175 Campus Street, Ste A1117, Loma University Hospital, 9000 Ghent, Belgium (IAP) measurement, avoidance of eL-imndaail,:CjeAji,kUe@S Allu.edu e-mail: sustained IAH, protocolized IAP M. Kaplan monitoring and management, deM. Sugrue Albert Einstein Medical Center, compressive laparotomy for overt Letterkenny Hospital and the Donegal Philadelphia, PA 19141, USA ACS, and negative pressure wound Clinical Research Academy, Donegal e-mail: therapy and efforts to achieve sameIreland, and the University College hospital-stay fascial closure among Hospital, Galway, Ireland E. Kimball patients with an open abdomen. e-mail: 5D0epNarMtmeednitcaolf DSruirvgee,ryS,alUt nLiavkeersiCtyityo,f UUTta,h, SUGGESTIONS included use of M. Cheatham USA medical therapies and percutaneous Department of Surgical Education, Orlando e-mail: catheter drainage for treatment of Regional Medical Center, 86 West IAH/ACS, considering the associaUnderwood St, Suite 201, Orlando, FL C. Olvera tion between body position and IAP, 32806, USA The American British Cowdray Medical attempts to avoid a positive fluid e-mail: Michael.cheatham@ Center, Universidad Anahuac, Mexico City, balance after initial patient resuscitaorlandohealth.com eM- mexaiiclo: tion, use of enhanced ratios of plasma R. Ivatury to red blood cells and prophylactic Medical College of Virginia, 417 11 St, open abdominal strategies, and Richmond, VA, USA Abstract Purpose: To update the avoidance of routine early biologic e-mail: World Society of the Abdominal mesh use among patients with open Compartment Syndrome (WSACS) abdominal wounds. NO RECOMC. G. Ball consensus definitions and manage- MENDATIONS were possible RMeegdiiocnaallCTernaturme,aCSaelgrvaircye,sA,EBGT223NF2oTo9th,ills ment statements relating to intra- regarding monitoring of abdominal Canada abdominal hypertension (IAH) and perfusion pressure or the use of e-mail: the abdominal compartment syn- diuretics, renal replacement therapies, drome (ACS). Methods: We albumin, or acute component-parts A. Reintam Blaser conducted systematic or structured separation. Conclusion: Although Clinic of Anaesthesiology and Intensive reviews to identify relevant studies IAH and ACS are common and freCare, University of Tartu, Puusepa 8, 51014 relating to IAH or ACS. Updated quently associated with poor eT-amrtaui,l: consensus definitions and manage- outcomes, the overall quality of eviment statements were then derived dence available to guide development A. Regli using a modified Delphi method and of RECOMMENDATIONS was School of Medicine and Pharmacology, The the Grading of Recommendations, generally low. Appropriately University of Western Australia, Crawley, Assessment, Development, and Eval- designed intervention trials are WA 6009, Australia uation (GRADE) guidelines, urgently needed for patients with IAH e-mail: respectively. Quality of evidence was and ACS. A. Regli graded from high (A) to very low School of Medicine, The University of (D) and management statements from Keywords Intra-abdominal Notre Dame, Fremantle, WA 6959, strong RECOMMENDATIONS hypertension Abdominal Australia (desirable effects clearly outweigh compartment syndrome potential undesirable ones) to weaker Critical care Grading of Z. J. Balogh SUGGESTIONS (potential risks and Recommendations, Assessment, John Hunter Hospital, University of benefits of the intervention are less Development, and Evaluation NAeuwstrcaalsitale, Newcastle, NSW 2310, clear). Results: In addition to Evidence-based medicine e-mail: Zsolt.balogh@ reviewing the consensus definitions World Society of the Abdominal hne.health.nsw.gov.au proposed in 2006, the WSACS Compartment Syndrome defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification Development of consensus management statements In concordance with the levels of agreement appropriate for consensus [19], all 2006 expert consensus definitions for which more than 80 % of the members voted to Results accept as is were retained, while all those with less than 50 % acceptance were rejected. Definitions with Existing consensus definitions and risk factors only 5080 % agreement were revised through ongoing discussion until complete consensus was obtained. The 2013 WSACS consensus definitions are presented in Where extensive discussion among subspecialists or Table 1. Changes from the previously published 2006 other experts was required, special sub-committees were definitions, and the pertinent rationale for such, are outcreated, including a dedicated Pediatric Guidelines Sub- lined in Supplement 5 (see ESM). Risk Factors for IAH Committee who reviewed the adult guidelines to deter- and ACS are shown in Table 2 [2, 4, 7, 2742]. mine their generalizability to pediatrics. We also searched the literature to determine which IAH or ACS risk factors proposed in 2006 are now supported by Classification of the open abdomen evidence and developed a consensus open abdomen classification system. Further details are presented in Critical complications which should be considered in manSupplement 2 (see ESM). aging the open abdomen include [43]: (1) fixation of the Table 1 Final 2013 consensus definitions of the World Society of Table 2 Risk factors for intra-abdominal hypertension and the Abdominal Compartment Syndrome abdominal compartment syndrome Retained definitions from the original 2006 consensus statements [13] 1. IAP is the steady-state pressure concealed within the abdominal cavity 2. The reference standard for intermittent IAP measurements is via the bladder with a maximal instillation volume of 25 mL of sterile saline 3. IAP should be expressed in mmHg and measured at end expiration in the supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line 4. IAP is approximately 57 mmHg in critically ill adults 5. IAH is defined by a sustained or repeated pathological elevation in IAP C 12 mmHg 6. ACS is defined as a sustained IAP [ 20 mmHg (with or without an APP \ 60 mmHg) that is associated with new organ dysfunction/failure 7. IAH is graded as follows Grade I, IAP 1215 mmHg Grade II, IAP 1620 mmHg Grade III, IAP 2125 mmHg Grade IV, IAP [ 25 mmHg 8. Primary IAH or ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention 9. Secondary IAH or ACS refers to conditions that do not originate from the abdominopelvic region 10. Recurrent IAH or ACS refers to the condition in which IAH or ACS redevelops following previous surgical or medical treatment of primary or secondary IAH or ACS 11. APP = MAP - IAP New definitions accepted by the 2013 consensus panel 12. A polycompartment syndrome is a condition where two or more anatomical compartments have elevated compartmental pressures 13. Abdominal compliance is a measure of the ease of abdominal expansion, which is determined by the elasticity of the abdominal wall and diaphragm. It should be expressed as the change in intra-abdominal volume per change in IAP 14. The open abdomen is one that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy 15. Lateralization of the abdominal wall is the phenomenon where the musculature and fascia of the abdominal wall, most exemplified by the rectus abdominus muscles and their enveloping fascia, move laterally away from the midline with time Diminished abdominal wall compliance Abdominal surgery [2729] Major trauma [27, 30, 31] Major burns Prone positioning [3234] Increased intra-luminal contents Increased intra-abdominal contents 1 No fixation 1A: 1B: 1C: Definitions accepted without change from the adult guidelines Clean, no fixation Contaminated, no fixation Enteric leak, no fixation 1. IAP is the steady-state pressure concealed within the abdominal cavity 2. APP = MAP - IAP 2 Developing fixation 3. Primary IAH or ACS is a condition associated with injury or 4. Secondary IAH or ACS refers to conditions that do not 3 Frozen abdomen originate from the abdominopelvic region 5. IAP should be expressed in mmHg and measured at end 4 Established enteroatmospheric fistula, frozen abdomen transducer zeroed at the level of the midaxillary line 6. Recurrent IAH or ACS refers to the condition in which IAH or 9. Pathophysiological classification of the open abdomen 1A: clean, no fixation Pediatric Guidelines Sub-Committee: definitions 1B: contaminated, no fixation Structured clinical questions and consensus management statements Consensus management statements are summarized in Table 5. Each of these statements are denoted below to indicate whether they were unchanged from previous guidelines, a new guideline, or revised from previous guidelines [5]. An associated summary of overall management and medical management algorithms are presented in Figs. 1 and 2, respectively. The summary of findings and rationale for each of the following management statements is described in the supporting Supplements (see ESM). expansion, which is determined by the elasticity of the abdominal wall and diaphragm. It should be expressed as the change in intra-abdominal volume per change in intraabdominal pressure Proposed pediatric specific definitions 11. ACS in children is defined as a sustained elevation in IAP of greater than 10 mmHg associated with new or worsening organ dysfunction that can be attributed to elevated IAP 12. The reference standard for intermittent IAP measurement in children is via the bladder using 1 mL/kg as an instillation volume, with a minimal instillation volume of 3 mL and a maximum installation volume of 25 mL of sterile saline 13. IAP in critically ill children is approximately 410 mmHg 14. IAH in children is defined by a sustained or repeated pathological elevation in IAP [ 10 mmHg ACS abdominal compartment syndrome, APP abdominal perfusion pressure, IAH intra-abdominal hypertension, IAP intra-abdominal pressure, MAP mean arterial pressure Should we measure IAP? Should we measure it via the bladder? Should we use an IAP measurement protocol? (Supplement 8; see ESM) Table 5 Final 2013 WSACS consensus management statements We recommend measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or injured patient [GRADE 1C] Studies should adopt the trans-bladder technique as the standard IAP measurement technique [not GRADED] We recommend use of protocolized monitoring and management of IAP versus not [GRADE 1C] We recommend efforts and/or protocols to avoid sustained IAH as compared to inattention to IAP among critically ill or injured patients [GRADE 1C] We recommend decompressive laparotomy in cases of overt ACS compared to strategies that do not use decompressive laparotomy in critically ill adults with ACS [GRADE 1D] We recommend that among ICU patients with open abdominal wounds, conscious and/or protocolized efforts be made to obtain an early or at least same-hospital-stay abdominal fascial closure [GRADE 1D] We recommend that among critically ill/injured patients with open abdominal wounds, strategies utilizing negative pressure wound therapy should be used versus not [GRADE 1C] 1. We suggest that clinicians ensure that critically ill or injured patients receive optimal pain and anxiety relief [GRADE 2D] 2. We suggest brief trials of neuromuscular blockade as a temporizing measure in the treatment of IAH/ACS [GRADE 2D] 3. We suggest that the potential contribution of body position to elevated IAP be considered among patients with, or at risk of, IAH or ACS [GRADE 2D] 4. We suggest liberal use of enteral decompression with nasogastric or rectal tubes when the stomach or colon are dilated in the presence of IAH/ACS [GRADE 1D] 5. We suggest that neostigmine be used for the treatment of established colonic ileus not responding to other simple measures and associated with IAH [GRADE 2D] 6. We suggest using a protocol to try and avoid a positive cumulative fluid balance in the critically ill or injured patient with, or at risk of, IAH/ACS after the acute resuscitation has been completed and the inciting issues have been addressed [GRADE 2C] 7. We suggest use of an enhanced ratio of plasma/packed red blood cells for resuscitation of massive hemorrhage versus low or no attention to plasma/packed red blood cell ratios [GRADE 2D] 8. We suggest use of PCD to remove fluid (in the setting of obvious intraperitoneal fluid) in those with IAH/ACS when this is technically possible compared to doing nothing [GRADE 2C]. We also suggest using PCD to remove fluid (in the setting of obvious intraperitoneal fluid) in those with IAH/ACS when this is technically possible compared to immediate decompressive laparotomy as this may alleviate the need for decompressive laparotomy [GRADE 2D] 9. We suggest that patients undergoing laparotomy for trauma suffering from physiologic exhaustion be treated with the prophylactic use of the open abdomen versus intraoperative abdominal fascial closure and expectant IAP management [GRADE 2D] 10. We suggest not to routinely utilize the open abdomen for patients with severe intraperitoneal contamination undergoing emergency laparotomy for intra-abdominal sepsis unless IAH is a specific concern [GRADE 2B] 11. We suggest that bioprosthetic meshes should not be routinely used in the early closure of the open abdomen compared to alternative strategies [GRADE 2D] We could make no recommendation regarding use of abdominal perfusion pressure in the resuscitation or management of the critically ill or injured We could make no recommendation regarding use of diuretics to mobilize fluids in hemodynamically stable patients with IAH after the acute resuscitation has been completed and the inciting issues have been addressed We could make no recommendation regarding the use of renal replacement therapies to mobilize fluid in hemodynamically stable patients with IAH after the acute resuscitation has been completed and the inciting issues have been addressed We could make no recommendation regarding the administration of albumin versus not, to mobilize fluid in hemodynamically stable patients with IAH after acute resuscitation has been completed and the inciting issues have been addressed We could make no recommendation regarding the prophylactic use of the open abdomen in non-trauma acute care surgery patients with physiologic exhaustion versus intraoperative abdominal fascial closure and expectant IAP management We could make no recommendation regarding use of an acute component separation technique versus not to facilitate earlier abdominal fascial closure ACS abdominal compartment syndrome, IAP intra-abdominal pressure, IAH intra-abdominal hypertension, PCD percutaneous catheter drainage Fig. 1 Updated intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) management algorithm. IAP intraabdominal pressure Should we use abdominal perfusion pressure (APP) as a resuscitation endpoint? (Supplement 9; see ESM) This measure has previously been suggested as a more accurate predictor of visceral perfusion and a better endpoint for resuscitation than IAP or mean arterial Abdominal perfusion pressure (APP) may be thought of pressure (MAP) alone [3, 46]. as the abdominal analogue to cerebral perfusion pressure. Fig. 2 Updated intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) medical management algorithm. IAP intraabdominal pressure We could make NO RECOMMENDATION regarding use of APP in the resuscitation or management of the Intra-abdominal hypertension (IAH) has consistently been critically ill or injured. associated with morbidity and mortality in observational studies. However, it remains uncertain as to whether treating Body positioning (Supplement 13; see ESM) or preventing this condition improves patient outcomes. We RECOMMEND efforts and/or protocols to avoid sustained IAH as compared to inattention to IAP among Statement critically ill or injured patients (New Management Recommendation 4 [GRADE 1C]). Body positioning may change IAP by altering the zero reference for IAP measurement and/or the external forces on the abdominal cavity [32, 4042, 51]. We SUGGEST that the potential contribution of body position to elevated IAP be considered among patients with, or at risk of, IAH or ACS (Unchanged Management Suggestion 3 [GRADE 2D]). How should we manage IAH/ACS? In addition to decompressive laparotomy for ACS, numerous medical and minimally invasive therapies have Nasogastric/colonic decompression (Supplement 14; been proposed or studied that may be beneficial for see ESM) patients with IAH or ACS [4749]. Approaches or techniques of potential utility include sedation and analgesia, While the routine use of enteric tubes post-operatively has neuromuscular blockade, body positioning, nasogastric/ not been associated with benefit after uncomplicated colonic decompression, promotility agents, diuretics and surgery [52, 53], there are anecdotal reports that gastric continuous renal replacement therapies, fluid resuscitation and colonic distension can induce marked IAH comstrategies, percutaneous catheter drainage (PCD), and mensurate with ACS [5256]. different temporary abdominal closure (TAC) techniques among those requiring an open abdomen [5]. Statement Non-invasive options: sedation and analgesia (Supplement 11; see ESM) While sedation and analgesia have been incorporated into previous IAH/ACS management algorithms, it remains unclear if they alter outcomes among those with IAH/ACS. Promotility agents (Supplement 15; see ESM) We SUGGEST liberal use of enteral decompression with nasogastric or rectal tubes when the stomach or colon are dilated in the presence of IAH/ACS (New Management Suggestion 4 [GRADE 1D]). We SUGGEST brief trials of neuromuscular blockade as a temporizing measure in the treatment of IAH (Unchanged Management Suggestion 2 [GRADE 2D]). Should we keep fluid balance neutral or even negative among ICU patients? (Supplement 16; see ESM) An increased or positive fluid balance has been associated with third space fluid accumulation and organ dysfunction We SUGGEST using a protocol to try to avoid a positive cumulative fluid balance in the critically ill or injured with, or at risk of, IAH/ACS after the acute resuscitation Should we use damage control resuscitation? has been completed and the inciting issues have been (Supplement 20; see ESM) addressed (New Management Suggestion 6 [GRADE 2C]). Diuretics (Supplement 17; see ESM) We could make NO RECOMMENDATION regarding the use of diuretics to mobilize fluids in hemodynamically stable patients with IAH after acute resuscitation has been completed and the inciting issues have been addressed. Damage control resuscitation is increasingly being used among critically injured patients [7, 8, 10, 61]. This type of resuscitation is characterized by permissive hypotension, limitation of crystalloid intravenous fluids, and delivering higher ratios of plasma and platelets to red blood cells [8]. We SUGGEST use of an enhanced ratio of plasma/packed red blood cells for resuscitation of massive hemorrhage versus low or no attention to plasma/packed red blood cell ratios (New Management Suggestion 7 [GRADE 2D]). If the medical management approaches suggested above do not alleviate IAH, then clinicians will need to consider Renal replacement therapies (Supplement 18; see ESM) whether invasive treatments may be necessary. Renal replacement therapies are increasingly being used to modify fluid balance among the critically ill. Should we use PCD? (Supplement 21; see ESM) the setting of obvious intraperitoneal fluid) in those with Damage control laparotomy for non-trauma acute IAH/ACS when this is technically possible compared to care surgery patients (Supplement 24; see ESM) immediate decompressive laparotomy, as this may alleviate the need for decompressive laparotomy (Revised Management Suggestion 8 [GRADE 2D]). While damage control techniques are being used among non-trauma acute care surgery patients (which largely includes emergency general surgery) [70, 71], very little evidence exists to support their use, or to support prophylactic open abdominal management afterwards. Invasive options: should we use decompressive laparotomy for IAH or ACS? (Supplement 22; see ESM) Decompressive laparotomy historically constituted the standard method to treat severe IAH/ACS and to protect We could make NO RECOMMENDATION regarding the against their development in high risk situations (e.g., fol- prophylactic use of the open abdomen in non-trauma acute lowing damage control laparotomy for significant intra- care surgery patients with physiological exhaustion versus peritoneal injury) [63, 64]. It has been reported to result in an intra-operative abdominal fascial closure and expectant IAP immediate decrease in IAP and in improvements in organ management. function [65, 66]. However, decompressive laparotomy is associated with multiple complications and overall reported patient mortality is considerable (up to 50 %), even after Damage control surgery for patients with intradecompression [66]. abdominal sepsis (Supplement 25; see ESM) We RECOMMEND decompressive laparotomy in cases of overt ACS compared to strategies that do not use decompressive laparotomy in critically ill adults with ACS (Unchanged Management Recommendation 5 [GRADE 1D]). Use of the open abdomen after trauma damage control laparotomy (Supplement 23; see ESM) Intra-abdominal sepsis is a particularly devastating and common form of sepsis, which is commonly associated with development of IAH/ACS [7274]. We SUGGEST NOT to routinely utilize the open abdomen approach for patients with severe intra-peritoneal contamination undergoing emergency laparotomy for intra-abdominal sepsis unless IAH is a specific concern (New Management Suggestion 10 [GRADE 2B]). We SUGGEST that patients undergoing laparotomy for Should we attempt to achieve same-hospital-stay closure trauma suffering from physiologic exhaustion be treated of the open abdomen? (Supplement 26; see ESM) with the prophylactic use of the open abdomen versus closure and expectant IAP management (New Manage- As the inability to achieve primary fascial closure after ment Suggestion 9 [GRADE 2D]). damage control laparotomy has been associated with increased morbidity and reduced quality of life among crit- Statement ically ill adults, efforts to close the abdominal fascia before discharge could potentially lead to improved outcomes. We could make NO RECOMMENDATION regarding use of an acute component separation technique versus not to facilitate early abdominal fascial closure. We RECOMMEND that among ICU patients with open abdominal wounds, conscious and/or protocolized efforts Should we use bioprosthethic mesh closures be made to obtain an early or at least same-hospital-stay to achieve closure of the open abdomen? abdominal fascial closure (New Management Recom- (Supplement 29; see ESM) mendation 6 [GRADE 1D]). Advances in tissue recovery and engineering have driven production of a large range of bioprosethic mesh prostheses that provide new options for abdominal wall reconstruction [8688]. It has been suggested that these meshes can be used to achieve earlier abdominal fascia closure among those with an open abdomen as they may allow for an increased intra-peritoneal domain without enteric fistula formation [89, 90]. Should we preferentially use negative pressure wound therapy (NPWT) for temporary abdominal closure after damage control laparotomy? (Supplement 27; see ESM) We RECOMMEND that among critically ill or injured patients with open abdominal wounds, strategies utilizing negative pressure wound therapy should be used versus not Discussion (New Management Recommendation 7 [GRADE 1C]). Table 6 Opinions of the Pediatric Guidelines Sub-Committee reflected in the quality of evidence assessment. With this regarding the suitability of the WSACS management recommendations for the care of children 1. Measure IAP when any known risk factor is present in a nized fashion. However, these guidelines should not be 2. Protocolized monitoring and management of IAP should be used as performance measures or quality assurance criteria 3. Use percutaneous catheter drainage to remove fluid in those In utilizing these guidelines, clinicians should be aware 4. Use decompressive laparotomy in cases of overt ACS edge. The panelists made great efforts to review the 5. Negative pressure wound therapy should be utilized to facilitate literature broadly, and to be aware of ongoing research that 6. Use a protocol to try to avoid a positive cumulative fluid available in the public domain. Although some studies 1. No recommendation was made regarding the use of the probable that new knowledge will require future revision 2. No recommendation was made regarding the use of 3. Biological meshes should not be routinely utilized to facilitate their patients, acting at the bedside, and considering new 4. No recommendation could be made to utilize the component 5. Use of enhanced ratios of plasma to packed red blood cells vatesHealth Solutions Clinician Fellowship Award and funding 6. Efforts and/or protocols to obtain early or at least same-hospital- gary. We thank Gordon Guyatt, MD, MSc, Department of estimates of effect size [96]. The combined, collective Annika Reintam Blaser has consulted for Nestle Health Science. Additional group authorship: the Pediatric Guidelines Hospital, Loma Linda, CANo conflicts of interest. Pediatrics, Loma Linda University Childrens Hospital, Francisco J. Diaz Sotomayor, MD, Assistant Profes Members Rebecka Meyers, MD, Professor of Surgery, Univer Michael Sasse, MD, Hanover Medical School, Depart- AmericaNo conflicts of interest.


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Andrew W. Kirkpatrick, Derek J. Roberts, Jan De Waele, Roman Jaeschke, Manu L. N. G. Malbrain, Bart De Keulenaer, Juan Duchesne, Martin Bjorck, Ari Leppaniemi, Janeth C. Ejike, Michael Sugrue, Michael Cheatham, Rao Ivatury, Chad G. Ball, Annika Reintam Blaser, Adrian Regli, Zsolt J. Balogh, Scott D’Amours, Dieter Debergh, Mark Kaplan, Edward Kimball, Claudia Olvera, The Pediatric Guidelines Sub-Committee for the World Society of the Abdominal Compartment Syndrome. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome, Intensive Care Medicine, 2013, 1190-1206, DOI: 10.1007/s00134-013-2906-z