Abdominal Compartment Syndrome:

Pocus on the Children

J. CHIAKA EJIKE, M.D.,* MUDIT MATHUR, M.D.,* DONALD C, MOORES, M.D.t

From the Department of Pediatrics, *Division of Pédiatrie Critical Care and the f Division of Pédiatrie
Surgery, Loma Linda University School of Medicine, Loma Linda, California

This article is a concise summary of intra-abdominal hypertension (IAH) and abdominal com-
partment syndrome (ACS) with an emphasis on factors relevant to their occurrence in children. It
discusses the limitations in the direct application of the current World Society of Abdominal
Compartment Syndrome consensus definitions and extrapolation of management practices derived
from studying adult patients to the pédiatrie age group. Techniques that may be used for measuring
intra-abdominal pressure (IAP) in children, normal IAP ranges, risk factors for developing ACS as
well as current medical and surgical management options in children are discussed.

end point or predictor of mortality in patients with IAH.

A BDOMINAL COMPARTMENT syndrome (ACS) refers to
organ dysfuncdon that occurs as a result of increased
intra-abdominal pressure (IAP). It is an increasingly
recognized complication in cridcally ill children with
both medical and surgical diagnoses and is associated
with a high mortality rate.
Definitions
A number of authors have promulgated a wide variety
of sometimes subtly different definitions and classifica-
tions.' The World Society of Abdominal Compartment
Syndrome (WSACS) met in 2004 to produce a consensus
statement related to the definidon, diagnosis, and treat-
ment of ACS.^ These consensus guidelines were primarily
directed at diagnosis and management of ACS in adults.
The current definitions of intra-abdominal hyperten-
sion (IAH) and ACS serve as guides for pédiatrie pa-
tients but cannot be applied directly to some children.-'
Cridcal IAP varies from padent to patient and even
within the same padent depending on severity of illness.
The concept of abdominal perfusion pressure (APP)
defined as the difference between the mean arterial
pressure (MAP) and IAP best explains why a single
threshold value of IAP cannot be globally applied to
all cridcally ill padents.'^ Clinicians can think of APP in
the same way that cerebral perfusion pressure (CPP) is
used when discussing brain perfusion in the face of
intracranial hypertension. Cheatham et al. demonstrated
that IAP measurements alone do not have sufficient
sensitivity and specificity to be useful as a resuscitation
Address correspondence and reprint requests to J. Chiaka Ejike,
M.D., 11175 Campus Street, Suite A1117, Loma Linda, CA 92354.
E-mail: jejike@llu.edu.
APP seems to be the best predictor of padent outcome
when compared with MAP, IAP, or other traditional
resuscitation end points such as arterial pH, base deficit,
arterial lactate, and hourly urinary output.'^
Children have a wide range of normal MAP depend-
ing on their age, making the designadon of a single ap-
propriate IAP or APP value impractical. The current
proposed working definidon for ACS in children is an
elevated IAP 10 mmHg or greater with development of
new or worsening multiorgan failure.^ These criteria are
based on elevadon of the IAP higher than the established
normal IAP of 7 ± 3 mmHg with the occurrence of organ
dysfuncdon serving as a surrogate for inadequate APP.
Pédiatrie studies to determine critical APP associated
with organ dysfuncdon may be useful in defining ACS in
children.
Normal Intra-abdominal Pressure and Current
Techniques Used for Measuring
Intra-abdominal Pressure
The WSACS defines normal IAP as approximately 5
to 7 mmHg in cridcally ill adults (Table 1). In cridcally
ill children on mechanical ventilation, it was found to be
7 ± 3 mmHg.^ The two common methods of IAP mea-
surements reported in children include the direct method,
which is achieved by measuring IAP direcdy though
a needle or catheter placed in the peritoneal space, or the
indirect intravesical method by transducing the patient's
urinary catheter. This method involves recording the
steady-state pressure after instilling an appropriate
amount of sterile saline into the bladder to establish
a continuous fluid column with the transducer. Other
methods of IAP measurements such as intragastric, in-
trarectal, intrauterine, and venocaval have also been

S72
No. 7 ACS: FOCUS ON CHILDREN Ejike et al. S73

TABLE 1. The WSACS Consensus Definitions and Suggested Pédiatrie Definitions

WSACS Consensus Definitions Suggested Pédiatrie Definitions
*IAP The pressure concealed within the abdominal Same
cavity; it should be expressed in mmHg and
measured at end-expiration
Normal IAP Approximately 5-7 mmHg in 7 ± 3 mmHg in critically
critically ill adults ill children^
APP MAP - IAP Same
flAH IAH is defined by a sustained or IAH is defined by a sustained
repeated pathological elevation in or repeated pathological
IAP 12 mmHg or greater elevation in IAP 10 mmHg
or greater*
IAH Grade I IAP 12 to 15 mmHg IAP 10 to 15 mmHg
IAH Grade II IAP 16 to 20 mmHg IAP 16 to 20 mmHg
IAH Grade III IAP 21 to 25 mmHg IAP 21 to 25 mmHg
IAH Grade IV IAP greater than 25 mmHg IAP greater than 25 mmHg
ACS A sustained IAP greater than 20 mmHg (with A sustained IAP of
or without an APP less than 60 mmHg) that greater than 10 mrnHg
is associated with new organ dysfunction/failure associated with new organ
dysfunction/failure
Primary ACS A condition associated with injury or disease Same
in the abdominopelvic region that frequently
requires early surgical or interventional
radiological intervention
Secondary ACS A condition that does not originate from the Same
abdominopelvic region
Recurrent ACS A condition in which ACS redevelops after previous Same
surgical or medical treatment of primary or
secondary ACS
* The reference standard for intermittent IAP measurement is via the bladder with a maximal instillation volume of 25 mL
sterile saline.
t IAH should be expressed in mmHg and measured at end-expiration in the complete supine position after ensuring that
abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line.
WSACS, World Society of Abdominal Compartment Syndrome; IAP, intra-abdominal pressure; APP, abdominal perfusion
pressure; MAP, mean arterial pressure; IAH, intra-abdominal hypertension; ACS, abdominal compartment syndrome.

reported in adult studies. The bladder method is the
recommended method for IAP measurements in chil-
dren because it is simple, reliable, and minimally inva-
sive. The bladder insdllation volumes reported to give
accurate IAP in children are a minimum instillation
volume of 3 mL or 1 mL/kg up to a maximum instil-
lation volume of 25 mL of sterile normal saline.^' ^
IAP should be expressed in mmHg and measured at
end-expiration in the complete supine position after
ensuring that abdominal muscle contractions are ab-
sent and with the transducer zeroed at the level of the
midaxillary line. Healthcare professionals measuring
IAP should be familiar with factors that affect accurate
measurements, which include: 1) body posidon: sem-
irecumbent and reverse Trendelenburg positions are
associated with higher pressures^; 2) voluntary abdo-
minal muscle contraction: causes elevadons in IAP^;
3) large insdllation volumes: may exaggerate IAP.^- '';
4) transducer position: the transducer should be zeroed
and kept at the level of the midaxillary line in the su-
pine patient for accurate measurements'"; and 5) body
mass index (BMI): higher BMI results in higher IAP
readings in adults but was not found to be a significant
factor affecting IAP measurement in children.^' ' '
Epidemiology of Intra-abdominal Hypertension and
Abdominal Compartment Syndrome in Children
The occurrence of IAH is variable ranging from 18 to
81 per cent depending on the IAP threshold used to de-
fine it and on the patient populadon studied, differing in
trauma, surgical, or medical padents.'^ No studies report
the prevalence of IAH in children.
The occurrence of ACS in children has been reported
to range from 0.6 to 4.7 per cent in single-center mixed
pédiatrie intensive care unit (PICU) populations.^' '^' "*
ACS is infrequendy reported, rapidly progressive, and
often a lethal condition underappreciated in the pédi-
atrie population.^ Eailure to recognize ACS can result in
a cridcal delay in its diagnosis and medical or surgical
intervendon, which contributes to the resulting mor-
bidity and mortality.'^ ACS-related mortality has been
reported to be 40 to 60 per cent in various studies fo-
cusing on children admitted to the PICU (Table 2).
Risk Factors for Developing Abdominal Compartment
Syndrome: Which Patients Should Be Monitored?
According to the WSACS, risk factors that predispose
patients to IAH and ACS can be categorized into four
S74 THE AMERICAN SURGEON
TABLE 2. Pédiatrie ACS Occurrence and Mortality
Pédiatrie ACS Occurrence and Mortality
Number
Study Population Screened
Pearson (2010) Abdominal surgical patients 264
Ejike (2007) Medical/surgical ICU 294
Diaz (2006) Medical/surgical ICU 1052
Beck (2001) Medical/surgical ICU 1762
* Cutoff refers to the IAP threshold used to define ACS.
ACS, abdominal compartment syndrome; IAP, intra-abdominal pressure; ICU, intensive care unit; R, retrospective study; P,
prospective study.
major conditions associated with certain clinical char-
acteristics. Some examples of conditions more specific
to pédiatrie patients include: 1) diminished abdominal
wall compliance, e.g., gastroschisis, omphalocele,
third-degree circumferential abdominal wall bums and
abdominal surgery with tight closure; 2) increased in-
traluminal contents, e.g., fecal impaction, Hirschsprung
disease, toxic megacolon; 3) increased abdominal con-
tents, e.g., splenomegaly, hepatomegaly, intra-abdominal
tumors (Wilm tumor), ascites, and intraperitoneal or
retroperitoneal bleeding. Intra-abdominal catastrophes
resulting from necrotizing enterocolitis, intussusception,
midgut volvulus, and perforated viscus associated with
significant fluid shifts into the abdomen also fall under
this category; and 4) capillary leak/fluid resuscitation, e.g.,
systemic inflammatory response syndrome, sepsis, and
patients receiving extracorporeal membrane oxygénation.'^
The WSACS recommends that if two or more risk
factors for IAH/ACS are present, an IAP measurement
should be obtained. If IAH is detected, serial IAP
measurements should be performed. IAP monitoring has
been useful in the management of critically ill children
for the detection of the onset of IAH or ACS. It can also
be useful intraoperatively as a guide to closure of the
abdomen in circumstances such as repair of abdominal
wall defects and transplantation of large organs.^ It is
important to note that clinical examination is an in-
accurate predictor of IAP and should not be substituted
for IAP measurement.'"'
Pathophysiology of Abdominal
Compartment Syndrome
The main clinical features of ACS include abdominal
distention associated with elevated IAP, reduced per-
fusion to intra-abdominal organs leading to ischemia
and refractory metabolic acidosis as well as interference
with cardiopulmonary interactions.'^
Progressive elevation of IAP leading to ACS results
in increasing compromise of multiple intra- and extra-
abdominal organ systems. Blood flow to intra-abdominal
organs and APP (governed by the relationship APP =
July Supplement 2011 Vol. 77
IAP Cutoff Occurrence Mortality
Type Used* (mm Hg) (%) (%)
R 12 9.8 58
P 12 4.7 50
P 10 0.9 40
P 15 0.6 60
MAP - IAP) decreases as IAP rises resulting in di-
minishing portal venous flow; hepatic and mesenteric
arterial flow; renal plasma flow, and glomerular filtra-
tion rate.'^-^^
Consequently, gastric mucosal saturation and pH
were demonstrated to be lower in patients undergoing
laparoscopy.^' Glucose metabolism, lactate clearance,
cytochrome p450 activity, and mitochondrial function
are all affected. As a result of ischémie mucosal injury,
capillary leak and bacterial translocation across in-
testinal mucosa occurs.^^
The effects of IAH are not limited to abdominal or-
gans. Elevation of the diaphragm causes atelectasis in the
lower lobes of the lung. Decreasing functional residual
capacity results in worsening ventilation-perfusion mis-
match. Respiratory compliance decreases linearly with
elevated IAP. Beyond an IAP of 12 mmHg, there is a 50
per cent increase in elastance and flattening and right-
ward shift of the pressure-volume curve.^^ In addition,
lung neutrophils are activated and extravascular lung
water increases, further worsening oxygénation.^^ In
children undergoing laparoscopy, effects on cardiore-
spiratory function may be seen at IAP as low as 6 mmHg
in neonates and 12 mmHg in older children.^'* This again
suggests that IAP thresholds that are clinically relevant in
infants and children may be lower than current recom-
mended thresholds.
Cardiovascular effects from IAH include decreased
venous retum resulting from direct inferior vena cava
compression and elevated intrathoracic pressures. In-
creased systemic vascular resistance (SVR) and pul-
monary vascular resistance results in an initial increase
and subsequent decline in MAP as left ventricular
compliance and regional wall motion become affected
and then cardiac output decreases. Preload assessment is
difficult because central venous pressure and pulmonary
capillary wedge pressure seem higher, although these
patients require higher filling pressures to maintain their
cardiac output. Increased lactate production resulting fi-om
impaired oxygen delivery and decreased lactate clearance
by the liver worsen the metabolic acidosis, which may
further compromise cardiac function.
No. 7 ACS: FOCUS ON CHILDREN Ejike et al. S75

. IAH leads to itnmediate increases in both intracranial A spring-loaded Silasdc"^" silo is frequently used in
pressure (ICP) and internal jugular venous pressure. Be- the management of gastroschisis but can also be used
cause MAP increases initially as a result of increased in small children who require a DL.-'^ The spring-
SVR, CPP may be maintained briefiy, although condn- loaded orifice of the silo is easily inserted under the
ued IAP elevadon results in loss of this compensadon and fascial edge and does not require sutures. Additionally,
diminished cerebral perfusion. Relief of ICP may then the Silastic™ silo is clear and permits visual inspection
require decompressive craniectomy and/or decompressive of the bowel but does not easily allow evacuation of
laparotomy (DL).^^ As a result of far-reaching effects on any fiuid that may accumulate in the silo.
both intra- and extra-abdominal organs, untreated ACS Another option is the vacuum pack, in which the
can result in multisystem organ failure, progressive shock, bowel is covered with an adhesion-preventing barrier
metabolic acidosis, and, eventually, the padent's death. followed by a gauze layer or surgical towel. One or two
drains are laid on the gauze and the abdomen is then
covered with an Ioban'''" dressing (3M, St. Paul, MN).
Medical Management
The drains are then placed to sucdon. This has been
IAH in the critically ill is an independent predictor of very effective in some series, but one must be aware
mortality; therefore, serial IAP monitoring is paramount that ACS can redevelop with the dressing in place.^''- 3'
in its identificadon in high-risk padents.^- '^ Failure The Wittmann Patch® (Novomedicus, Nokomis, FL)
to recognize and treat IAH may result in increased risk is a hook and loop system sewn to opposing fascial
of renal impairment, visceral and intestinal ischemia, edges, permitting frequent adjustment of wound tension
cardiorespiratory failure, and death. Nonsurgical op- while gradually closing the fascial gap.^^ Placement of
tions should be tried initially in an attempt to control an adhesion-prevendng barrier between the fascia and
IAH with progression to DL if medical measures are the viscera has been advised with its use. An occlusive
inadequate. vacuum pack dressing as described previously is then
As recommended by the WSACS, the overall goals applied over the patch. Débridement of the fascial edges
of management should include the following along at the time of closure may be necessary.
with provision of organ-specific support when indi- Vacuum-assisted closure (V.A.C.®) using the ABThera'''"
cated^: 1) evacuation of intraluminal contents of the Open Abdomen Negative Pressure Therapy System
intestines by gastric suctioning, use of rectal tubes or (Kinedc Concepts Incorporated, San Antonio, TX) in-
enemas, and gastro- and coloprokinedcs; 2) evacuation volves a proprietary dressing that covers the viscera
of intra-abdominal space-occupying lesions such as as- with a thin sponge sandwiched between two layers of
cites, hemo- or pneumoperitoneum, which may require permeable adhesion-prevendng film. A second sponge
paracentesis; 3) opdmizadon of fiuid administration by shaped to the size of the wound is laid into the gap
goal-directed therapies and controlling capillary leak between the wound edges and an adhesive film applied.
syndrome. Diuredcs, condnuous renal replacement ther- This is connected to a suction device that evacuates any
apy, or dialysis may be helpful in reducing fiuid overload fiuid that may accumulate, reduces edema, and provides
with resultant dssue, organ, and abdominal wall edema medial tension to limit fascial retraction and loss of
contribudng to IAH; and 4) abdominal wall compliance domain.
can be improved with adequate analgesia, sedadon, and The use of prosthetic material to bridge the gap when
neuromuscuiar blockade. the fascial edges cannot be approximated has also been
described. Polyglycolic mesh, polytetrafiuoroethylene,
and, more recendy, biologic materials such as porcine
Surgical Management
dermal tissue or small intesdnal submucosa have been
If IAH persists or progresses with ongoing organ used for fascial closure.^^- ^^- ^^ Sometimes primary skin
dysfunction despite nonoperative therapy, the man- closure over the fascia is possible, but in other cases, the
agement of ACS then becomes surgical. When ACS is biological material has been supplemented with negative
the result of the accumuladon of intraperitoneal fiuid pressure therapy to promote granulation tissue and
evacuation of the fiuid by paracentesis, a peritoneal epithelializadon or topically managed with wet-to-dry
catheter or Penrose drain may relieve the pressure and dressings until enough granuladon tissue develops to
restore perfusion. '^' ^^ Most cases, however, will require permit split-thickness skin grafting.^'*- ^^
a DL and some form of temporary abdominal wall The V.A.C.® and Wittmann Patch® have been shown
closure (TAC) while awaidng resol udon of IAH.'^' '^' ^^ to have the highest success rate for primary fascial clo-
An open abdomen with TAC may also be necessary sure and the lowest mortality rates.-^^
after operations in which edematous viscera preclude Complicadons associated with TAC management oc-
easy fascial closure or in which an adult-sized organ has cur with varying frequency depending on the type of
been transplanted into a small child.^^- •^^ TAC. They include wound dehiscence, enteroatmospheric
S76 THE AMERICAN SURGEON
or enterocutaneous fistulae development, and intendonal
incisional hemia when fascial closure cannot be achieved,
eventually requidng abdominal reconstruction.
Outcomes
IAH by itself has been increasingly recognized as
a cause of significant morbidity and mortality in cdd-
cally ill patients."' The dsk of organ dysfuncdon is re-
lated to the magnitude of the IAP and the APP: the
higher the IAP and the lower the APP, the higher the dsk
for organ failure.'^ The level of IAP has been shown to
be an independent cause of renal impairment.^^ In liver
transplant recipients, renal impairment has been found
to be independently correlated with IAH. The most
sensitive and specific IAP value predictive of acute renal
failure was 25 mmHg demonstrated in Dalfino's study.^"^
The occurrence of IAH dudng an intensive care unit stay
is an independent predictor of mortality.-'' '^ Progression
of IAH to ACS clearly worsens patient outcome even
further and cardes 40 to 60 per cent mortality in affected
infants and children^- '3-i5 (Table 2).
Conclusion
Although challenges with establishing appropriate
APP thresholds and defining ACS in children exist,
ACS occurs in children and carries a high mortality
rate. Routine IAP monitoring is vital in the manage-
ment of at-risk critically ill children for the detecdon of
the onset of IAH or ACS. IAP can be easily measured
in cridcally ill children at the bedside by the indirect
intravesical method, and normal IAP range is 7 ± 3 mm
Hg in this populadon. IAP monitodng can be used
intraoperatively as a guide to the dming of the closure of
the abdomen in circumstances such as repair of ab-
dominal wall defects and transplantadon of large organs.
Goals of medical management of IAH include vadous
measures to decrease IAP and support of failing organs.
If conservadve management fails, DL with consider-
ation of open abdomen management may be useful in
improving outcomes related to ACS in children.
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