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BACKGROUND: Abdominal compartment syndrome (ACS) sometimes occurs in critically ill patients following damage control surgery. The purpose of the present study was to develop a model of ACS and to evaluate its pathologic impact on liver, kidney, and lung morphology. METHODS: Twenty Wistar rats (mass 300–350 g) were randomly divided into four groups: 1) intra-abdominal hypertension (IAH): a laparotomy was performed and the abdomen packed with cotton until an intra-abdominal pressure (IAP) of 15 mm Hg was reached; 2) hypovolemia (HYPO): blood was withdrawn until a mean arterial pressure ~60 mm Hg was reached; 3) IAH + HYPO (to resemble clinical ACS); and 4) sham surgery. After 3 hours of protective mechanical ventilation, the animals were euthanized and the liver, kidney and lungs removed to examine the degree of tissue damage. RESULTS: IAH resulted in the following: oedema and neutrophil infiltration in the kidney; necrosis, congestion, and microsteatosis in the liver; and alveolar collapse, haemorrhage, interstitial oedema, and neutrophil infiltration in the lungs. Furthermore, IAH was associated with greater cell apoptosis in the kidney, liver and lungs compared to sham surgery. HYPO led to oedema and neutrophil infiltration in the kidney. The combination of IAH and HYPO resulted in all the aforementioned changes in lung, kidney and liver tissue, as well as exacerbation of the inflammatory process in the kidney and liver and kidney cell necrosis and apoptosis. CONCLUSIONS: Intra-abdominal hypertension by itself is associated with kidney, liver and lung damage; when combined with hypovolemia, it leads to further impairment and organ damage.

Evaluating the degree of organ dysfunction is a cornerstone in distinguishing patients with critical illness from those without. However, evaluation of the gastrointestinal function in critically ill patients is not unified, and is still largely based on subjective clinical evaluation. Although intra-abdominal pressure has been proposed as a parameter to facilitate monitoring of abdominal compartment in critical illness, the interactions between intra-abdominal pressure and gastrointestinal function are poorly clarified. The aim of this current review is to describe interactions and associations between gastrointestinal dysfunction and intra-abdominal pressure from a pathophysiological and clinical point of view.

Background.: Daily and globally, millions of adult hospitalized patients are exposed to maintenance i.v. fluid solutions supported by limited scientific evidence. In particular, it remains unclear whether fluid tonicity contributes to the recently established detrimental effects of fluid, sodium, and chloride overload. Methods.: This crossover study consisted of two 48 h study periods, during which 12 fasting healthy adults were treated with a frequently prescribed solution (NaCl 0.9% in glucose 5% supplemented by 40 mmol litre -1 of potassium chloride) and a premixed hypotonic fluid (NaCl 0.32% in glucose 5% containing 26 mmol litre -1 of potassium) at a daily rate of 25 ml kg -1 of body weight. The primary end point was cumulative urine volume; fluid balance was thus calculated. We also explored the physiological mechanisms behind our findings and assessed electrolyte concentrations. Results.: After 48 h, 595 ml (95% CI: 454-735) less urine was voided with isotonic fluids than hypotonic fluids ( P

Purpose: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. Methods: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. Results: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. Conclusions: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access., SCOPUS: re.j, info:eu-repo/semantics/published

International audience; Over the past decades, ultrasound (US) has gained its place in the armamentarium of monitoring tools in the intensive care unit (ICU). Critical care ultrasonography (CCUS) is the combination of general CCUS (lung and pleural, abdominal, vascular) and CC echocardiography, allowing prompt assessment and diagnosis in combination with vascular access and therapeutic intervention. This review summarises the findings, challenges lessons from the 3rd Course on Acute Care Ultrasound (CACU) held in November 2015, Antwerp, Belgium. It covers the different modalities of CCUS; touching on the various aspects of training, clinical benefits and potential benefits. Despite the benefits of CCUS, numerous challenges remain, including the delivery of CCUS training to future intensivists. Some of these are discussed along with potential solutions from a number of national European professional societies. There is a need for an international agreed consensus on what modalities are necessary and how best to deliver training in CCUS.

The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18–19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: “Acute Renal Failure in the ICU: from injury to recovery.” The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools, (c) old and new treatments, (d) renal replacement therapy and management, (e) acute renal failure witness of other conditions, (f) prognosis and recovery, (g) extracorporeal epuration beyond the kidney, (h) the use of biomarkers in clinical practice http://www.srlf.org/5th-paris-international-conference-jeudi-18-et-vendredi-19-juin-2015/ .

Over the last few decades, increasing attention has been paid to understanding the pathophysiology, aetiology, prognosis, and treatment of elevated intra-abdominal pressure (IAP) in trauma, surgical, and medical patients. However, there is presently a relatively poor understanding of intra-abdominal volume (IAV) and the relationship between IAV and IAP (i.e. abdominal compliance). Consensus definitions on Cab were discussed during the 5th World Congress on Abdominal Compartment Syndrome and a writing committee was formed to develop this article. During the writing process, a systematic and structured Medline and PubMed search was conducted to identify relevant studies relating to the topic. According to the recently updated consensus definitions of the World Society on Abdominal Compartment Syndrome (WSACS), abdominal compliance (Cab) is defined as 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 IAV per change in IAP (mL [mm Hg]⁻¹). Importantly, Cab is measured differently than IAP and the abdominal wall (and its compliance) is only a part of the total abdominal pressure-volume (PV) relationship. During an increase in IAV, different phases are encountered: the reshaping, stretching, and pressurisation phases. The first part of this review article starts with a comprehensive list of the different definitions related to IAP (at baseline, during respiratory variations, at maximal IAV), IAV (at baseline, additional volume, abdominal workspace, maximal and unadapted volume), and abdominal compliance and elastance (i.e. the relationship between IAV and IAP). An historical background on the pathophysiology related to IAP, IAV and Cab follows this. Measurement of Cab is difficult at the bedside and can only be done in a case of change (removal or addition) in IAV. The Cab is one of the most neglected parameters in critically ill patients, although it plays a key role in understanding the deleterious effects of unadapted IAV on IAP and end-organ perfusion. The definitions presented herein will help to understand the key mechanisms in relation to Cab and clinical conditions and should be used for future clinical and basic science research. Specific measurement methods, guidelines and recommendations for clinical management of patients with low Cab are published in a separate review.

Background: Sepsis is associated with generalised endothelial injury and capillary leak and has traditionally been treated with large volume fluid resuscitation. Some patients with sepsis will accumulate bodily fluids. The aim of this study was to systematically review the association between a positive fluid balance/fluid overload and outcomes in critically ill adults, and to determine whether interventions aimed at reducing fluid balance may be linked with improved outcomes. Methods: We searched MEDLINE, PubMed, EMBASE, Web of Science, The Cochrane Database, clinical trials registries, and bibliographies of included articles. Two authors independently reviewed citations and selected studies examining the association between fluid balance and outcomes or where the intervention was any strategy or protocol that attempted to obtain a negative or neutral cumulative fluid balance after the third day of intensive care compared to usual care. The primary outcomes of interest were the incidence of IAH and mortality. Results: Among all identified citations, one individual patient meta-analysis, 11 randomised controlled clinical trials, seven interventional studies, 24 observational studies, and four case series met the inclusion criteria. Altogether, 19,902 critically ill patients were studied. The cumulative fluid balance after one week of ICU stay was 4.4 L more positive in non-survivors compared to survivors. A restrictive fluid management strategy resulted in a less positive cumulative fluid balance of 5.6 L compared to controls after one week of ICU stay. A restrictive fluid management was associated with a lower mortality compared to patients treated with a more liberal fluid management strategy (24.7% vs 33.2%; OR, 0.42; 95% CI 0.32−0.55; P < 0.0001). Patients with intra-abdominal hypertension (IAH) had a more positive cumulative fluid balance of 3.4 L after one week of ICU stay. Interventions to decrease fluid balance resulted in a decrease in intra-abdominal pressure (IAP): an average total body fluid removal of 4.9 L resulted in a drop in IAP from 19.3 ± 9.1 mm Hg to 11.5 ± 3.9 mm Hg. Conclusions: A positive cumulative fluid balance is associated with IAH and worse outcomes. Interventions to limit the development of a positive cumulative fluid balance are associated with improved outcomes. In patients not transgressing spontaneously from the Ebb to Flow phases of shock, late conservative fluid management and late goal directed fluid removal (de-resuscitation) should be considered.

A compartment syndrome is defined as an increase in the compartmental pressure to such an extent that the viability of the tissues and organs within the compartment are threatened. The term describes a syndrome and not a disease, and as such there are many diseases and underlying pathophysiological processes that may lead to such a scenario. The aim of this review is to give a state-of-the-art overview on the current knowledge on different compartment syndromes and how they may interact. Suggested definitions are included. There are four major compartments in the human body: the head, chest, abdomen, and the extremities. Initially, the term multicompartment syndrome was suggested when more than one compartment was affected. But this led to confusion as the term multi- or multiple compartment syndromes is mostly used in relation to multiple limb trauma leading to compartment syndrome requiring fasciotomy. Only recently was the term 'polycompartment syndrome' coined to describe a condition where two or more anatomical compartments have elevated pressures. When more than one compartment is affected, an exponential detrimental effect on end-organ function to both immediate and distant organs can occur. Within each compartment, the disease leading towards a compartment syndrome can be primary or secondary. The compliance of each compartment is the key to determining the transmission of a given compartmental pressure from one compartment to another. The intra-abdominal pressure helps to explain the severe pathophysiological condition occurring in patients with cardiorenal, hepatopulmonary and hepatorenal syndromes. Initial treatment of a compartment syndrome should be focused on the primary compartment and is based on three principles: lowering of compartmental pressure, supporting organ perfusion, and optimisation and prevention of specific adverse events. Clinicians need to be aware of the existence of the polycompartment syndrome and the interactions of increased compartmental pressures between compartments.

In a non-obstetric population, the optimization of cardiac output (CO) had been shown to improve survival and to reduce postoperative complications, organ failure and the length of stay1. CO monitoring might be very useful in the obstetric population as well, as physiologic changes of CO during pregnancy are mandatory for a normal outcome. An uncomplicated pregnancy is associated with a 50% increase in maternal CO, which is mediated by plasma volume expansion and a decrease in peripheral resistance2. An aberrant change of this maternal CO might influence pregnancy outcome: pregnancies complicated with foetal growth restriction and/or preeclampsia are characterized by increased total vascular resistance and reduced systolic function (i.e. lower CO and stroke volume (SV))3–5.

Background: Gastric residual volume (GRV) can be measured in a variety of ways in critically ill patients, most often, the nasogastric tube is disconnected and the GRV is aspirated via a 60 mL syringe. Bladder pressure (IBP) measurement is the gold standard for intra-abdominal pressure (IAP) estimation. This study will look at the validation of a novel method combining measurement of GRV and estimation of IAP via intra-gastric pressure (IGP). Methods: In total 135 paired IAP and 146 paired GRV measurements were performed in 37 mechanically ventilated ICU patients. The IAP was estimated via the bladder (i.e. IBP) using the FoleyManometer and via the stomach (i.e. IGP) with the new device. The GRV was measured with the new device (GRV prototype ) and via the classic method (GRV classic ). The devices were provided by Holtech Medical (Charlottenlund, Denmark) and data were retrospectively analysed. Results: The number of paired measurements in each patient was 4 ± 1. The mean IBP was 10.7 ± 4.1 and mean IGP was 11.6 ± 4.1 mm Hg. Correlation between the IBP and IGP was significant, however moderate (R 2 = 0.51). Analysis according to Bland and Altman showed a bias and precision of 0.8 and 2.7 mm Hg respectively, however the limits of agreement (LA) were large and ranged from −4.5 to 6.1 mm Hg. Changes in IGP correlated well with changes in IBP. The median GRV prototype was 80 mL (0–1050) and equal to the median GRV classic of 80 mL (0−1250). Correlation between the 2 methods was excellent (R 2 = 0.89). Analysis according to Bland and Altman showed a bias and precision of -0.8 and 52.3 mL respectively and the LA ranged from –103 to 102 mL. Changes in GRV classic correlated well with changes in GRV prototype . Conclusions: The results of this multicentre pilot study show that GRV can be measured with the new device. Furthermore this allows simultaneous screening for intra-abdominal hypertension with IAP estimation via IGP.

Background: Little is known about serum galactomannan (GM) testing in (mostly non-neutropenic) mixed intensive care unit (ICU) patients. The aim of this study was to look for the incidence of invasive aspergillosis (IA) in critically ill patients, to validate previously reported GM thresholds, and to evaluate the prognostic value of GM. Methods: This was a retrospective study of 474 GM samples in 160 patients from the start of January 2003 until the start of February 2004. GM tests were ordered because of a clinical suspicion of IA or on a regular basis in immune compromised patients. The number of samples per patient was 3 ± 2.6. We used the criteria of the European Organisation for Research and Treatment of Cancer (EORTC) to define proven IA, probable IA, and possible IA. The number of positive samples, with GM optical density (OD) > 0.5 was 230 (48.5%). Results: In our study population, five (3%) patients had proven IA, 11 (7%) had probable, 27 (17.5%) had possible, and 116 (72.5%) had no IA. We could not identify a GM threshold for IA with analysis of receiver operating characteristics (ROC) curves: with a sensitivity of (56.3%, 50%, 50%, 37.5%), specificity (38.2%, 67.5%, 68.8%, 72.9%), NPV (88.7%, 91.8%, 92.5%, 91.3%) and PPV (9.2%, 12.9%, 15.1%, 13.3%) for a cut-off of OD > 0.5, > 0.8, > 1.1 and > 1.5 respectively. IA was associated with high mortality of 87.5% and 100% in patients with probable and proven IA respectively. Patients with IA had a significant increase of GM during their stay (GM delta 0.7 ± 1.5 vs –0.2 ± 1.5, P = 0.027). The overall ICU mortality was 41.9% and the hospital mortality was 58.1%. Patients who died in the ICU and in the hospital had higher APACHE-II, SAPS-II and SOFA scores (P < 0.0001) and also a significant increase in GM during their stay with 0.27 ± 1.26 (ICU non-survivors) and 0.11 ± 1.55 (hospital non-survivors) compared to a decrease in GM –0.43 ± 1.7 (P = 0.004) and –0.48 ± 1.51 (P = 0.017) in ICU and hospital survivors respectively. Non-survivors also had higher mean GM values but this was not statistically significant. There was a trend towards higher GM values in patients treated with piperacillin/ta zobactam (n = 34), but this did not reach statistical significance. Neutropenic patients (n = 31) showed an increase in GM during their stay 0.32 ± 1.3 vs a decrease with –0.43 ± 1.7 in non-neutropenic patients (P = 0.07). Patients on total parenteral nutrition (n = 125) had higher maximal GM levels (1.55 ± 1.94 vs 0.88 ± 1.25, P = 0.058). Patients who were mechanically ventilated had significantly higher mean ( P = 0.038) and maximal (P = 0.007) GM levels. Conclusions: We found a high incidence of proven and probable IA in a group of mixed ICU patients (10%) and the presence of IA was associated with a high mortality. The serum GM antigen detection test may not be useful in the diagnosis of IA in mixed ICU patients, according to the results of the ROC analysis. We could not define a useful threshold.

Background Intra-abdominal hypertension (IAH) impairs cardiovascular function, however an effect of IAH on cardiac electrophysiology has been poorly documented. The aim of this study was to evaluate the effect of IAH following pneumoperitoneum on vectorcardiographic variables reflecting cardiac repolarisation and depolarisation. Methods Otherwise healthy women undergoing elective gynaecological laparoscopy were studied. Intra-abdominal pressure (IAP), spatial QRS-T angle and ST-segment J-point (STJ) were observed during surgery and the early postoperative period. Results Forty women, ages 22 to 43 were examined. Induction of IAH to 15 mmHg significantly widened the spatial QRS-T angle, whereas the Trendelenburg position subsequently reduced this widening. IAH also increased STJ voltage in leads III, aVF, V2 and V3 during surgery, with increased STJ voltage persisting in several leads through the morning of postoperative day 1. Conclusion Induction of IAH impacts the relationship between cardiac depolarisation and repolarisation and increases spatial QRS-T angle and STJ voltage.

The deleterious effects of raised intra-abdominal pressure (IAP) on organ function and mortality have been known for decades, even centuries. Interest in this phenomenon has revived since the 1980s and, recently, the World Society for the Abdominal Compartment Syndrome has published new consensus definitions and guidelines. This chapter will focus on the new definitions for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), identify risk factors for the development of IAH/ACS, provide guidelines for IAP monitoring (including when to start, how to measure, and when to stop), and discuss both surgical and medical treatment options for both IAH and ACS. The effect of increased IAP on different organ systems is explained and suggestions on how to adjust ICU management of the patient with IAH are offered.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Critically ill patients are often hemodynamically unstable (or at risk of becoming unstable) owing to hypovolemia, cardiac dysfunction, or alterations of vasomotor function, leading to organ dysfunction, deterioration into multi-organ failure, and eventually death. With hemodynamic monitoring, we aim to guide our medical management so as to prevent or treat organ failure and improve the outcomes of our patients. Therapeutic measures may include fluid resuscitation, vasopressors, or inotropic agents. Both resuscitation and de-resuscitation phases can be guided using hemodynamic monitoring. This monitoring itself includes several different techniques, each with its own advantages and disadvantages, and may range from invasive to less- and even non-invasive techniques, calibrated or non-calibrated. This article will discuss the indications and basics of monitoring, further elaborating on the different techniques of monitoring.

Background The effect of decompressive laparotomy on outcomes in patients with abdominal compartment syndrome has been poorly investigated. The aim of this prospective cohort study was to describe the effect of decompressive laparotomy for abdominal compartment syndrome on organ function and outcomes. Methods This was a prospective cohort study in adult patients who underwent decompressive laparotomy for abdominal compartment syndrome. The primary endpoints were 28-day and 1-year all-cause mortality. Changes in intra-abdominal pressure (IAP) and organ function, and laparotomy-related morbidity were secondary endpoints. Results Thirty-three patients were included in the study (20 men). Twenty-seven patients were surgical admissions treated for abdominal conditions. The median (i.q.r.) Acute Physiology And Chronic Health Evaluation (APACHE) II score was 26 (20–32). Median IAP was 23 (21–27) mmHg before decompressive laparotomy, decreasing to 12 (9–15), 13 (8–17), 12 (9–15) and 12 (9–14) mmHg after 2, 6, 24 and 72 h. Decompressive laparotomy significantly improved oxygenation and urinary output. Survivors showed improvement in organ function scores, but non-survivors did not. Fourteen complications related to the procedure developed in eight of the 33 patients. The abdomen could be closed primarily in 18 patients. The overall 28-day mortality rate was 36 per cent (12 of 33), which increased to 55 per cent (18 patients) at 1 year. Non-survivors were no different from survivors, except that they tended to be older and on mechanical ventilation. Conclusion Decompressive laparotomy reduced IAP and had an immediate effect on organ function. It should be considered in patients with abdominal compartment syndrome.

Introduction Mechanical intestinal obstruction is a disorder associated with intra-abdominal hypertension and abdominal compartment syndrome. As the large intestine intraluminal and intra-abdominal pressures are increased, so the patient’s risk for intestinal ischaemia. Previous studies have focused on hypoperfusion and bacterial translocation without considering the concomitant effect of intra-abdominal hypertension. The objective of this study was to design and evaluate a mechanical intestinal obstruction model in pigs similar to the human pathophysiology. Materials and Methods Fifteen pigs were divided into three groups: a control group (n = 5) and two groups of 5 pigs with intra-abdominal hypertension induced by mechanical intestinal obstruction. The intra-abdominal pressures of 20 mmHg were maintained for 2 and 5 hours respectively. Hemodynamic, respiratory and gastric intramucosal pH values, as well as blood tests were recorded every 30 min. Results Significant differences between the control and mechanical intestinal obstruction groups were noted. The mean arterial pressure, cardiac index, dynamic pulmonary compliance and abdominal perfusion pressure decreased. The systemic vascular resistance index, central venous pressure, pulse pressure variation, airway resistance and lactate increased within 2 hours from starting intra-abdominal hypertension (p

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are commonly encountered in surgical intensive care units. While IAH is a graded phenomenon, ACS is an all-or-none condition that causes dysfunction of cardiovascular, respiratory, renal, hepatic, and neurological systems. This chapter provides a detailed and evidence-informed overview of the historical background, definitions/classification, pathogenesis/pathophysiology, epidemiology, and clinical presentation/diagnosis of IAH/ACS. We also review medical, minimally invasive, and surgical management strategies for these conditions in light of existing evidence and clinical practice guideline statements. Finally, we provide an overview of temporary abdominal closure (TAC) and open abdominal management after decompressive laparotomy.

In critically ill patients, many decisions depend on accurate assessment of the hemodynamic status. We evaluated the accuracy of physicians' conventional hemodynamic assessment and the impact that additional advanced monitoring had on therapeutic decisions. Physicians from seven European countries filled in a questionnaire in patients in whom advanced hemodynamic monitoring using transpulmonary thermodilution (PiCCO system; Pulsion Medical Systems SE, Feldkirchen, Germany) was going to be initialized as part of routine care. The collected information included the currently proposed therapeutic intervention(s) and a prediction of the expected transpulmonary thermodilution-derived variables. After transpulmonary thermodilution measurements, physicians recorded any changes that were eventually made in the original therapeutic plan. A total of 315 questionnaires pertaining to 206 patients were completed. The mean difference (±standard deviation; 95 % limits of agreement) between estimated and measured hemodynamic variables was -1.54 (±2.16; -5.77 to 2.69) L/min for the cardiac output (CO), -74 (±235; -536 to 387) mL/m(2) for the global end-diastolic volume index (GEDVI), and -0.5 (±5.2; -10.6 to 9.7) mL/kg for the extravascular lung water index (EVLWI). The percentage error for the CO, GEDVI, and EVLWI was 66, 64, and 95 %, respectively. In 54 % of cases physicians underestimated the actual CO by more than 20 %. The information provided by the additional advanced monitoring led 33, 22, 22, and 13 % of physicians to change their decisions about fluids, inotropes, vasoconstrictors, and diuretics, respectively. The limited clinical ability of physicians to correctly assess the hemodynamic status, and the significant impact that more physiological information has on major therapeutic decisions, support the use of advanced hemodynamic monitoring in critically ill patients.

A compartment syndrome (CS) exists when increased pressure in a closed anatomic space threatens the viability of enclosed tissue. Within the body there are four types of compartments, the head, the chest, the abdomen, and the extremities, but when a compartment syndrome occurs in the abdominal cavity the impact on end-organ function both within and outside of the cavity can be devastating (Table 1). Intra-abdominal hypertension (IAH) is a graded phenomenon and can evolve to the end-stage abdominal compartment syndrome (ACS), which is an all or nothing phenomenon. The ACS is not a disease and as such it can have many causes and it can develop within many disease processes. The development of IAH is of extreme importance in the care of critically ill patients, because of the impact of increased intraabdominal pressure (IAP) on end-organ function. Recent animal and human data suggest that the adverse effects of elevated IAP can occur at much lower levels than previously thought and even before the development of clinically overt ACS. This review gives a concise overview of the definitions, epidemiology, pathophysiology, and management of IAH and ACS.

PURPOSE: To investigate if femoral venous pressure (FVP) measurement can be used as a surrogate measure for intra-abdominal pressure (IAP) via the bladder. METHODS: This was a prospective, multicenter observational study. IAP and FVP were simultaneously measured in 149 patients. The effect of BMI on IAP was investigated. RESULTS: The incidences of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) were 58 and 7% respectively. The mean APACHE II score was 22 ± 10, SAPS 2 score 42 ± 20, and SOFA score 9 ± 4. The mean IAP was 11.2 ± 4.5 mmHg versus 12.7 ± 4.7 mmHg for FVP. The bias and precision for all measurements were -1.5 and 3.6 mmHg respectively with the lower and upper limits of agreement being -8.6 and 5.7. When IAP was above 20 mmHg, the bias between IAP and FVP was 0.7 with a precision of 2.0 mmHg (lower and upper limits of agreement -3 and 4.6 respectively). Excluding those with ACS, according to the receiver operating curve analysis FVP = 11.5 mmHg predicted IAH with a sensitivity and specificity of 84.8 and 67.0% (AUC of 0.83 (95% CI 0.81-0.86) with P < 0.001). FVP = 14.5 mmHg predicted IAP above 20 mmHg with a sensitivity of 91.3% and specificity of 68.1% (AUC 0.85 (95% CI 0.79-0.91), P < 0.001). Finally, at study entry, the mean IAP in patients with a BMI less then 30 kg/m(2) was 10.6 ± 4.0 mmHg versus 13.8 ± 3.8 mmHg in patients with a BMI ≥ 30 kg/m(2) (P < 0.001). CONCLUSIONS: FVP cannot be used as a surrogate measure of IAP unless IAP is above 20 mmHg.

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 ± 17, four (80%) male with an Injury Severity Score of 27 ± 9. Pre- and post-LAF, IAP was 20.6 ± 4.7 and 10.6 ± 2.7 ( P < 0.0001), APP 55.2 ± 5.5 and 77.6 ± 7.1 ( P < 0.0001), RVEDVI 86.4 ± 9.3 and 123.6 ± 11.9 ( P < 0.0001), and EF 27.6 ± 4.2 and 40.8 ± 5 ( P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.

PURPOSE: To describe what is defined as normal intra-abdominal pressure (IAP) and how body positioning, body mass index (BMI) and positive end-expiratory pressure (PEEP) affect IAP monitoring. METHODS: A review of different databases was made (Pubmed, MEDLINE (January 1966-June 2007) and EMBASE.com (January 1966-June 2007)) using the search terms of "IAP", "intra-abdominal hypertension" (IAH), "abdominal compartment syndrome" (ACS), "body positioning", "prone positioning", "PEEP" and "acute respiratory distress syndrome" (ARDS). Prior to 1966, we selected older articles by looking at the reference lists displayed in the more recent papers. RESULTS: This review focuses on the concept that the abdomen truly behaves as a hydraulic system. The definitions of a normal IAP in the general patient population and morbidly obese patients are reviewed. Subsequently, factors that affect the accuracy of IAP monitoring, i.e., body position (head of bed elevation, lateral decubitus and prone position) and PEEP, are explored. CONCLUSION: The abdomen behaves as a hydraulic system with a normal IAP of about 5-7 mmHg, and with higher baseline levels in morbidly obese patients of about 9-14 mmHg. Measuring IAP via the bladder in the supine position is still the accepted standard method, but in patients in the semi-recumbent position (head of the bed elevated to 30 degrees and 45 degrees ), the IAP on average is 4 and 9 mmHg, respectively, higher. Future research should be focused on developing and validating predictive equations to correct for supine IAP towards the semi-recumbent position. Small increases in IAP in stable patients without IAH, turned prone, have no detrimental effects. The role of prone positioning in the unstable patient with or without IAH still needs to be established.

OBJECTIVE: To investigate the effect of different reference transducer positions on intra-abdominal pressure (IAP) measurement. Three reference levels were studied: the symphysis pubis; the phlebostatic axis; and the midaxillary line at the level of the iliac crest. DESIGN: Prospective cohort study. SETTING: The intensive care units of participating hospitals PATIENTS AND PARTICIPANTS: One hundred thirty-two critically ill patients at risk for intra-abdominal hypertension (IAH). INTERVENTIONS: In each patient, three sets of IAP measurements were obtained in the supine position, using the different reference levels. The IAP measurements obtained at the different reference levels were compared using a paired t-test and Bland-Altman statistics were calculated. MEASUREMENTS AND RESULTS: IAP(phlebostatic) (9.9 +/- 4.67 mmHg) and IAP(pubis) (8.4 +/- 4.60 mmHg) were significantly lower that IAP(midax) (12.2 +/- 4.66 mmHg; p < 0.0001 for both comparisons). The bias between the IAP(midax) and IAP(pubis) was 3.8 mmHg (95% CI 3.5-4.1) and 2.3 mmHg (95% CI 1.9-2.6) between the IAP(midax) and the IAP(phlebostatic). The precision was 3.03 and 3.40, respectively. CONCLUSIONS: In the supine position, IAP(midax) is higher than both IAP(phlebostatic) and IAP(pubis), differences found to be clinically significant; therefore, the symphysis pubis or phlebostatic axis reference lines are not interchangeable with the midaxillary level.

OBJECTIVE: Intra-abdominal pressure (IAP) measurement is important in daily clinical practice. Most measurement techniques vary in automaticity and reproducibility. This study tested a new fully automated continuous technique for IAP measurement, the CiMON. METHODS: Three IAP measurement catheters (a Foley manometer and two balloon-tipped catheters) contained in a 50-ml infusion bag were placed on the bottom of a half open 3-l container. To simulate IAH the container was filled with water using 5 cmH2O increments (0-30 cmH2O). Pressure was estimated by observers using the Foley manometer (IAP(FM)) and simultaneously recorded using two IAP monitors: IAP(spie) with Spiegelberg and IAP(CiM) with CiMON. Observers were blinded to the reference levels. Fifteen observers (three intensivists, four residents, two medical students, and six nurses) conducted three pressure readings at each of the seven pressure levels with the FM technique, giving 315 readings. These were paired with the automated IAP(spie) and IAP(CiM) readings and the height of the H2O column. RESULTS: The intra- and interobserver coefficients of variation (COVA) were low for all methods. There was no difference in the results between specialists, physicians in training, andnurses. Spearman's correlation coefficient (R2) values for all paired measurements were greater than 0.9, and Bland-Altman analysis comparing the reference H2O column, IAP(FM), and IAP(spie) to IAP(CiM) showed a very good agreement at all pressure levels (bias -0.1+/-0.6 cmH2O, 95%CI -0.2 to 0). There was a consistent, low underestimation of the reference H2O pressure by the Spiegelberg technique and a low overestimation at pressures below 20 cmH2O by both other techniques. CONCLUSIONS: All three measurement techniques, IAP(FM), IAP(spie), and IAP(CiM) have good agreement with the applied hydrostatic pressure in this in vitro model of IAP measurement.

OBJECTIVE: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade. In the absence of consensus definitions and treatment guidelines the diagnosis and management of IAH and ACS remains variable from institution to institution. DESIGN: An international consensus group of multidisciplinary critical care specialists convened at the second World Congress on Abdominal Compartment Syndrome to develop practice guidelines for the diagnosis, management, and prevention of IAH and ACS. METHODS: Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. The present article is the second installment of the final report from the 2004 International ACS Consensus Definitions Conference and is endorsed by the World Society of the Abdominal Compartment Syndrome. RESULTS: The prevalence and etiological factors for IAH and ACS are reviewed. Evidence-based medicine treatment guidelines are presented to facilitate the diagnosis and management of IAH and ACS. Recommendations to guide future studies are proposed. CONCLUSIONS: These definitions, guidelines, and recommendations, based upon current best evidence and expert opinion are proposed to assist clinicians in the management of IAH and ACS as well as serve as a reference for future clinical and basic science research.

Background: Burn patients are at high risk for secondary intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) due to capillary leak and large volume fluid resuscitation. Our objective was to examine the incidence the incidence of IAH and ACS and their relation to outcome in mechanically ventilated (MV) burn patients. Methods: This observational study included all MV burn patients admitted between April 2007 and December 2009. Various physiological parameters, intra-abdominal pressure (IAP) measurements and severity scoring indices were recorded on admission and/or each day in ICU. Transpulmonary thermodilution parameters were also obtained in 23 patients. The mean and maximum IAP during admission was calculated. The primary endpoint was ICU (burn unit) mortality. Results: Fifty-six patients were included. The average Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores were 43.4 (± 15.1) and 6.4 (± 3.4), respectively. The average total body surface area (TBSA) affected by burns was 24.9% (± 24.9), with 33 patients suffering inhalational injuries. Forty-four (78.6%) patients developed IAH and 16 (28.6%) suffered ACS. Patients with ACS had higher TBSAs burned (35.8 ± 30 vs. 20.6 ± 21.4%, P = 0.04) and higher cumulative fluid balances after 48 hours (13.6 ± 16L vs. 7.6 ± 4.1 L, P = 0.03). The TBSA burned correlated well with the mean IAP (R = 0.34, P = 0.01). Mortality was notably high (26.8%) and significantly higher in patients with IAH (34.1%, P = 0.014) and ACS (62.5%, P < 0.0001). Most patients received more fluids than calculated by the Parkland Consensus Formula while, interestingly, non-survivors received less. However, when patients with pure inhalation injury were excluded there were no differences. Non-surgical interventions (n = 24) were successful in removing body fluids and were related to a significant decrease in IAP, central venous pressure (CVP) and an improvement in oxygenation and urine output. Non-resolution of IAH was associated with a significantly worse outcome ( P < 0.0001). Conclusion: Based on our preliminary results we conclude that IAH and ACS have a relatively high incidence in MV burn patients compared to other groups of critically ill patients. The percentage of TBSA burned correlates with the mean IAP. The combination of high CLI, positive (daily and cumulative) fluid balance, high IAP, high EVLWI and low APP suggest a poor outcome. Non-surgical interventions appear to improve end-organ function. Non-resolution of IAH is related to a worse outcome.

"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered and supra-physiologic in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental effect on renal function associated with hyperchloremia. Despite efforts for its identification, the ideal balanced solution, with minimal effects on acid-base status, low chloride content, and adequate tonicity, is not yet available. After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solution on renal function in critically-ill patients (SPLIT trial, the 0.9% Saline vs Plasma-Lyte 148 for Intensive Cate Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions, secondly, by summarizing their potential pathophysiologic effects, and lastly, by presenting the clinical evidence available to support, at the moment, their use.

The use of ultrasound has gained its place in critical care as part of our day-to-day monitoring tools. A better understanding of ultrasound techniques and recent publications including protocols for the lungs, the abdomen and the blood vessels has introduced ultrasound to the bedside of our ICU patients. However, we will prove in this paper that early machines, dating back more than 25 years, were perfectly able to do the job as compared to modern laptop machines with more features but few additional advantages. Ultrasound is not only a diagnostic tool, but should also be seen as an extension of the traditional physical examination. This paper will focus on the use of the SESAME-protocol in cardiac arrest. The SESAME-protocol suggests starting with a lung scan to rule out possible causes leading to cardiac arrest. Firstly, pneumothorax needs to be ruled out. Secondly, a partial diagnosis of pulmonary embolism is done following the BLUE-protocol. Thirdly, fluid therapy can be guided, following the FALLS-protocol. The SESAME-protocol continues by scanning the lower femoral veins to check for signs of deep venous thrombosis, followed by (or before, in case of trauma) the abdomen to detect massive bleeding. Next comes the pericardium, to exclude pericardial tamponade. Finally, a transthoracic cardiac ultrasound is performed to check for other (cardiac) causes leading to cardiac arrest. The emphasis is on a holistic approach, where ultrasound can be seen as the modern stethoscope needed by clinicians to complete the full physiological examination of their critically ill unstable patients.

The Abdominal Compartment Society (www.wsacs.org) previously created highly cited Consensus Definitions/Management Guidelines related to intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Implicit in this previous work, was a commitment to regularly reassess and update in relation to evolving research. Two years preceding the Fifth World Congress on Abdominal Compartment Syndrome, an International Guidelines committee began preparation. An oversight/steering committee formulated key clinical questions regarding IAH//ACS based on polling of the Executive to redundancy, structured according to the Patient, Intervention, Comparator, and Outcome (PICO) format. Scientific consultations were obtained from Methodological GRADE experts and a series of educational teleconferences were conducted to educate scientific review teams from among the wscacs. org membership. Each team conducted systematic or structured reviews to identify relevant studies and prepared evidence summaries and draft Grades of Recommendation Assessment, Development and Evaluation (GRADE) recommendations. The evidence and draft recommendations were presented and debated in person over four days. Updated consensus definitions and management statements were derived using a modified Delphi method. A writing committee subsequently compiled the results utilizing frequent Internet discussion and Delphi voting methods to compile a robust online Master Report and a concise peer-reviewed summarizing publication. A dedicated Paediatric Guidelines Subcommittee reviewed all recommendations and either accepted or revised them for appropriateness in children. Of the original 12 IAH/ACS definitions proposed in 2006, three (25%) were accepted unanimously, with four (33%) accepted by >80%, and four (33%) accepted by >50%, but required discussion to produce revised definitions. One (8%) was rejected by >50%. In addition to previous 2006 definitions, the panel also defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, abdominal compliance, and suggested a refined open abdomen classification system. Recommendations were possible regarding intra-abdominal pressure (IAP) measurement, approach to sustained IAH, philosophy of protocolized IAP management and same-hospital-stay fascial closure, use of decompressive laparotomy, and negative pressure wound therapy. Consensus suggestions included use of non-invasive therapies for treating IAH/ACS, considering body position and IAP, damage control resuscitation, prophylactic open abdomen usage, and prudence in early biological mesh usage. No recommendations were made for the use of diuretics, albumin, renal replacement therapies, and utilizing abdominal perfusion pressure as a resuscitation-endpoint. Collaborating Methodological Guideline Development and Clinical Experts produced Consensus Definitions/Clinical Management statements encompassing the most contemporary evidence. Data summaries now exist for clinically relevant IAH/ACS questions, which will facilitate future scientific reanalysis.

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An improved understanding of burn shock pathophysiology and subsequent development of fluid resuscitation strategies has led to dramatic outcome improvements in burn care during the 20th century. While organ hypoperfusion caused by inadequate resuscitation has become rare in clinical practice, there is growing concern that increased morbidity and mortality related to over-resuscitation is occurring more frequently in burn care. In order to reduce complications related to this concept of "fluid creep", such as respiratory failure and compartment syndromes, efforts should be made to resuscitate with the least amount of fluid in order to provide adequate organ perfusion. In this first part of a concise review, historic and current evidence regarding the available fluids is discussed, as well as some adjunctive treatments modulating the inflammatory response. In the second part, special reference will be made to the role of abdominal hypertension in burn care and the endpoints used to guide fluid resuscitation will be discussed. Finally, as urine output has been recognized as a poor resuscitation target, a resuscitation protocol is suggested in part two which includes new targets and endpoints that can be obtained with modern, less invasive hemodynamic monitoring devices.

Background: In critically ill patients, multi-trauma and intensive therapy can influence the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics with time-dependent bacterial killing. Consequently, PK/PD targets (%fT >MIC ) — crucial for antimicrobial effects -may not be attained. Methods: Two patients admitted to the surgical ICU of the University Hospital in Hradec Kralove for multiple-trauma were given piperacillin/tazobactam by 1-hour IV infusion 4/0.5 g every 8h. PK variables: total and renal clearance (CL tot , CL R ), volume of distribution (V d ), and elimination half-life (T 1/2 ) were calculated, followed by glomerular filtration rate (MDRD) and cumulative fluid balance (CFB-total fluid volume based on 24-h registered fluid intake minus output). The PK/PD target attainment (100% f T >MIC ) was defined as free ( f ) piperacillin plasma concentrations that remain, during the entire dosing interval (T), above the minimum inhibitory concentration (100% f T >MIC ) within days 4-8 (when CFB culminates and disappears). Piperacillin concentrations were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS) and corrected for unbound fraction (22%). Results: CFB culminated over days 2−5 reaching 15−30 L and was associated with a large V d (29−42 L). While MDRD in patient 1 was low (0.3−0.4 mL s -1 1.7 m -2 ), that of patient 2 was increasing (> 3.1 mL s -1 1.7 m -2 ), which was associated with augmented CLR. In patient 2, the f T reached only 62, 52, and 44% on days 4, 6, and 8, respectively. In patient 1, the % f T was much higher, attaining values four to fivefold greater than that targeted. Conclusions: Critically ill patients are at risk of drug under- or overdosing without dose up-titration with regard to covariate effects and individual drug pharmacokinetics.

Intra-abdominal hypertension (IAH) is an important contributor to early organ dysfunction in trauma and sepsis. However, relatively little is known about the impact of intra-abdominal pressure (IAP) in general internal medicine, pregnant patients, and those with obesity or burns. The aim of this paper is to review the pathophysiologic implications and treatment options for IAH in these specific situations. A MEDLINE and PubMed search was performed and the resulting body-of-evidence included in the current review on the basis of relevance and scientific merit. There is increasing awareness of the role of IAH in different clinical situations. Specifically, IAH will develop in most (if not all) severely burned patients, and may contribute to early mortality. One should avoid over-resuscitation of these patients with large volumes of fluids, especially crystalloids. Acute elevations in IAP have similar effects in obese patients compared to non-obese patients, but the threshold IAP associated with organ dysfunction may be higher. Chronic elevations in IAP may, in part, be responsible for the pathogenesis of obesity-related co-morbid conditions such as hypertension, pseudotumor cerebri, pulmonary dysfunction, gastroesophageal reflux disease, and abdominal wall hernias. At the bedside, measuring IAP and considering IAH in all critical maternal conditions is essential, especially in preeclampsia/eclampsia where some have hypothesized that IAH may have an additional role. IAH in pregnancy must take into account the precautions for aorto-caval compression and has been associated with ovarian hyperstimulation syndrome. Recently, IAP has been associated with the cardiorenal dilemma and hepatorenal syndrome, and this has led to the recognition of the polycompartment syndrome. In conclusion, IAH and ACS have been associated with several patient populations beyond the classical ICU, surgical, and trauma patients. In all at risk conditions the focus should be on the early recognition of IAH and prevention of ACS. Patients at risk for IAH should be identified early through measurements of IAP. Appropriate actions should be taken when IAP increases above 15 mm Hg, especially if pressures reach above 20 mm Hg with new onset organ failure. Although non-operative measures come first, surgical decompression must not be delayed if these fail. Percutaneous drainage of ascites is a simple and potentially effective tool to reduce IAP if organ dysfunction develops, especially in burn patients. Escharotomy may also dramatically reduce IAP in the case of abdominal burns.

The practice of critical care nephrology demands an intimate understanding of the interactions and “crosstalk” that occurs between the kidney and multiple organ systems, in particular the heart, lung, gut, and brain. Accumulating evidence suggests that acute injury and dysfunction to the kidney can incite and propagate cardiac, pulmonary, gastrointestinal, and neurologic injury and dysfunction through a host of mechanisms.

The intra-abdominal pressure (IAP) measurement is a key to diagnosing and managing critically ill medical and surgical patients. There are an increasing number of techniques that allow us to measure the IAP at the bedside. This paper reviews these techniques. IAP should be measured at end-expiration, with the patient in the supine position and ensuring that there is no abdominal muscle activity. The intravesicular IAP measurement is convenient and considered the gold standard. The level where the mid-axillary line crosses the iliac crest is the recommended zero reference for the transvesicular IAP measurement; moreover, marking this level on the patient increases reproducibility. Protocols for IAP measurement should be developed for each ICU based on the locally available tools and equipment. IAP measurement techniques are safe, reproducible and accurate and do not increase the risk of urinary tract infection. Continuous IAP measurement may offer benefits in specific situations in the future. In conclusion, the IAP measurement is a reliable and essential adjunct to the management of patients at risk of intra-abdominal hypertension.

In the future, medical management may play an increasingly important role in the prevention and management of intra-abdominal hypertension (IAH). A review of different databases was used (PubMed, MEDLINE and EMBASE) with the search terms 'Intra-abdominal Pressure' (IAP), 'IAH', ' Abdominal Compartment Syndrome' (ACS), 'medical management' and 'non-surgical management'. We also reviewed all papers with the search terms 'IAH', 'IAP' and 'ACS' over the last three years, only extracting those papers which showed a novel approach in the non-surgical management of IAH and ACS.IAH and ACS are associated with increased morbidity and mortality. Non-surgical management is an important treatment option in critically ill patients with raised IAP. There are five medical treatment options to be considered to reduce IAP: 1) improvement of abdominal wall compliance; 2) evacuation of intra-luminal contents; 3) evacuation of abdominal fluid collections; 4) optimisation of fluid administration; and 5) optimisation of systemic and regional perfusion. This paper will review the first three treatment arms of the WSACS algorithm: abdominal wall compliance; evacuation of intra-luminal contents and evacuation of abdominal fluid collections. Emerging medical treatments will be analysed and finally some alternative specific treatments will be assessed. Other treatment options with regard to optimising fluid administration and systemic and regional perfusion will be described elsewhere, and are beyond the scope of this review. Medical management of critically ill patients with raised IAP should be instigated early to prevent further organ dysfunction and to avoid progression to ACS. Many treatment options are available and are often part of routine daily management in the ICU (nasogastric, rectal tube, prokinetics, enema, sedation, body position). Some of the newer treatments are very promising options in specific patient populations with raised IAP. Future studies are warranted to confirm some of these findings.