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Towards new consensus 2022 definitions on IAH and ACS

PURPOSE:
The first WSACS consensus definitions date back from 2006 with a 2013 update of 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). After 8 years it is time for a new update, to be released in 2022, which is 20 years after the initial meeting in Sydney.

There is still a lack of clinical awareness and many colleagues do not feel the need for monitoring intra-abdominal pressure (IAP). Furthermore there are still a lot of misconceptions, like IAP is not trustworthy in head-of-bed (HOB) elevation or in patients that are awake, on non-invasive ventilation (NIV) or during spontaneous breathing. Also some believe that during vacuum assisted closure (VAC) or negative pressure wound therapy (NPWT) treatment the IAP can be negative and during open abdomen you cannot develop IAH/ACS so monitoring of IAP is unnecessary, etc...

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* 1. What is your education?

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* 2. Are you an intensivist?

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* 3. What is your basic training/speciality (when relevant)?

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* 4. How many years of experience do you have (please enter number or enter 0 when still in training)?

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* 5. The abdominal cavity/compartment is considered as being primarily fluid in character following Pascal's law

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* 6. IAP (intra-abdominal pressure) is the steady-state pressure concealed within the abdominal cavity.

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* 7. Clinical assessment and estimation of IAP is inaccurate.

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* 8. The reference standard for intermittent IAP measurement is via the bladder with a maximal instillation volume of 20-25 mL of sterile saline.

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* 9. The gastric route can be used as alternative for intermittent IAP measurement with a maximal instillation volume of 50-75 mL of water or nutritional fluid.

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* 10. 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 (The conversion factor from mmHg to cmH2O is 1.36 and conversely, from cmH2O to mmHg it is 0.74).

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* 11. After IAP measurement in the supine position, IAP should also be measured in the "resting" position of the patient, eg the normal HOB (head of bed) 30-45° position or prone position

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* 12. IAP measurement can also be performed in awake or spontaneously breathing patients

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* 13. Normal IAP is approximately 5-7 mmHg in critically ill adults. => suggestion to modify as follows: IAP is approximately 5-7 mmHg in healthy adults.

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* 14. Normal IAP is approximately 10 mmHg in critically ill adults.

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* 15. The normal IAP differs regarding the patient population and anthropometry and can be non-pathologically increased 10-15 mmHg in obese patients, pregnancy,...

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* 16. IAH (intra-abdominal hypertension) is defined by a sustained or repeated pathological elevation in IAP > 12 mmHg.

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* 17. ACS (abdominal compartment syndrome) is an all or nothing phenomenon and defined as a sustained IAP>20mmHg (with or without an APP, abdominal perfusion pressure < 60mmHg) that is associated with new organ dysfunction/failure.

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* 18. Organ dysfunction/failure is assessed by (a daily) SOFA (sequential organ failure assessment) or equivalent scoring system (qSOFA); organ failure is defined as a SOFA organ system subscore of >2)

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* 19. Sustained increase in IAP is defined as a pathological value during a minimum of three standardized measurements that are performed 1-2 hours apart for ACS and 4-6 hours apart for IAH

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* 20. IAH is a continuum and graded as follows: Grade I, IAP 12-15 mmHg, Grade II, IAP 16-20 mmHg, Grade III, IAP 21-25 mmHg, Grade IV, IAP > 25 mmHg

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* 21. 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.

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* 22. Secondary IAH or ACS refers to conditions that do not originate from the abdominopelvic region.

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* 23. Recurrent IAH or ACS refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS.

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* 24. For further fine-tuning and classification of IAH/ACS four questions need to be answered. 1. What is the duration of IAH/ACS? 2. Is an intra-abdominal problem responsible for the IAH/ACS? 3. What is the etiology of the IAH/ACS? 4. Is there a local compartment syndrome?

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* 25. IAH duration can be chronic, acute, subacute or hyperacute

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* 26. Chronic IAH is defined as IAH that lasts for months or years (eg ovarian tumour, ascites, pregnancy)

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* 27. acute IAH is defined as IAH that develops within hours (eg ruptured AAA)

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* 28. subacute IAH is defined as IAH that develops within days (eg fluid overload an capillary leak)

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* 29. hyperacute IAH is defined as IAH that only lasts for second or minutes (eg coughing, sneezing)

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* 30. APP (abdominal perfusion pressure) = MAP – IAP and should be kept above 60 mmHg.

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* 31. The FG (filtration gradient) is the mechanical force across the glomerulus and equals the difference between the glomerular filtration pressure (GFP) and the proximal tubular pressure (PTP). FG = GFP – PTP, with GFP = MAP - RVP (renal venous pressure).

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* 32. In the presence of IAH, PTP may be assumed to equal RVP and IAP, and thus GFP can be estimated as MAP - IAP. The FG can then be calculated by the formula: FG = MAP - 2*IAP

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* 33. A poly-compartment syndrome is a condition where two or more anatomical compartments have elevated compartmental pressures.

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* 34. There are 4 major body compartments (head, chest, abdomen, and extremities).

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* 35. Abdominal compliance (Cab) 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 intra-abdominal pressure.

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* 36. RAV (respiratory abdominal variation) is an indirect measure of abdominal compliance (Cab) and can be caluclated as IAPei - IAPee (delta IAP)

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* 37. RAVT (respiratory abdominal variation test) is a nonivasive test assessing RAV during gradual increase in tidal volume (in mechanically ventilated patients) and provides indirect measure of Cab

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* 38. PAVT (positional abdominal variation test) is a nonivasive test assessing RAV during gradual changes in HOB (also in spontaneous breathing) and provides indirect measure of Cab

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* 39. APV (abdominal pressure variation) is an indirect measure of Cab and can be calculated as (IAPei - IAPee)/IAPmean

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* 40. Continuous IAP can be used to keep track of changes in IAP during treatment.

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* 41. Different techniques exist to perform continuous IAP monitoring (eg gastric, bladder, direct). A gold standard yet needs to be identified.

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* 42. The open abdomen is one that requires a temporary abdominal closure (TAC) due to the skin and fascia not being closed after laparotomy.

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* 43. 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 lateraly away from the midine with time.

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* 44. When left open with a temporary abdominal closure (TAC), the open abdomen should be closed as soon as possible (best within 1 week)

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* 45. Medical management is defined as a nonsurgical intervention with the purpose to lower increased IAP and consists of 5 treatment options: improvement of Cab, decrease of intra-abdominal volume (IAV), decrease of Intra-luminal Volume, fluid management, organ support.

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* 46. The four distinct IAH categories are defined as medical, surgical, trauma or burns

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* 47. Localised IAH and ACS is defined as a local increase in IAP that does not lead to a systemic elevation (eg pelvic trauma, liver or spleen trauma)

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* 48. Have you heard before from WSACS?

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* 49. Are you a member of the WSACS?

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* 50. Are you aware of the previous WSACS consensus definitions from 2013?

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* 51. Were you involved in previous WSACS consensus definitions development?

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* 52. Are you aware of the WSACS treatment guidelines and recommendations?

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* 53. Have you implemented the WSACS consensus definitions, guidelines and treatment recommendations in clinical practice?

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* 54. What do you think is the future of the Abdominal compartment society (WSACS)?

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* 55. In what country do you live?

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* 56. Would you like to become more actively involved in future WSACS projects?

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* 57. Please leave your contact details if you want to be more actively involved (mandatory for future feedback - information will be dealt with GDPR proof)

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