Original Research

Journal of Intensive Care Medicine

2016, Vol. 31(6) 403-408
Incidence, Risk Factors, and Prognosis ª The Author(s) 2015
Reprints and permission:
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of Intra-Abdominal Hypertension in DOI: 10.1177/0885066615583645
jic.sagepub.com
Critically Ill Children: A Prospective
Epidemiological Study

Farah Chedly Thabet, MD1, Iheb Mohamed Bougmiza, MD2,

May Said Chehab, MD1, Hind Ali Bafaqih, MD1,
Sulaiman Abdulkareem AlMohaimeed, MD1,
and Manu L.N.G. Malbrain, MD, PhD3

Abstract
Purpose: To assess the incidence, risk factors, and outcomes of intra-abdominal hypertension (IAH) in a pediatric intensive care
unit (PICU). Methods: Prospective cohort study from January 2011 to January 2013. All children consecutively admitted to the
PICU, staying more than 24 hours and requiring bladder catheterization, were included in the study. On admission, demographic
data and risk factors for IAH were studied. The intra-abdominal pressure was measured every 6 hours through a bladder catheter
until discharge, death, or removal of the catheter. Results: Of the 175 patients, 22 (12.6%) had IAH and 7 (4%) had abdominal
compartment syndrome during the intensive care unit (ICU) stay. The independent risk factors associated with IAH were the
presence of abdominal distension (odds ratio [OR] 7.1; 95% confidence interval [CI], 2.6-19.9; P < .0001) and a plateau pressure of
more than 30 cm H2O (OR 6.42; 95% CI, 2.13-19.36; P ¼ .01). The presence of IAH was associated with higher mortality (40.9% vs
15.6%; P ¼ .01) and prolonged ICU stay (19.5 [3-97] vs 8 [1-104] days, OR 1.02; 95% CI, 1.00-1.04; P ¼ .02). Thirty-three (18.8%)
patients died in the ICU, and IAH was an independent risk factor for mortality (OR 6.98; 95% CI, 1.75-27.86; P ¼ .006).
Conclusion: Intra-abdominal hypertension does occur in about 13% of the critically ill children, albeit less frequently than adult
patients, probably related to a better compliance of the abdominal wall. The presence of abdominal distension and a plateau
pressure of more than 30 cm H2O was found to be independent predictors of IAH. Children with IAH had higher mortality rate
and more prolonged ICU stay.

Keywords
abdominal pressure, abdominal hypertension, abdominal compartment syndrome, risk factors, outcome, children

Introduction
The World Society of Abdominal Compartment Syndrome
(WSACS, www.wsacs.org) has previously published a consen-
sus definitions and guidelines statement including definitions
and recommendations for the screening and management of
intra-abdominal hypertension (IAH) and abdominal compart-
ment syndrome (ACS) in critically ill adult patients,1,2 with
some specific considerations for pediatric patients in the last
updated guidelines.3 Following this consensus, more studies
have been performed to define the incidence, risk factors, and
outcomes of patients with IAH,4-7 but the pediatric data are still
scarce and focus mainly on ACS.8-11
Previous study has reported that clinical presentation is sim-
ilar to adults, but children may develop organ damage at lower
intra-abdominal pressure (IAP) level.10 This implies that in
children, ACS occurs probably at lower IAP level than adults.
The aim of this study was to assess the incidence of IAH in
an exclusive population of critically ill pediatric patients. We
also wanted to identify possible risk factors associated with this
1
Division of Pediatric Intensive Care, Department of Pediatrics, Prince Sultan
Military Medical City, Riyadh, Saudi Arabia
2
Department of Family and Community Medicine, Faculty of Medicine of
Sousse, Sousse, Tunisia
3
Intensive Care Unit and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen,
ZNA Stuivenberg, Antwerpen, Belgium
Received September 30, 2014. Received revised February 11, 2015.
Accepted February 11, 2015.
Corresponding Author:
Farah Chedly Thabet, Division of Pediatric Intensive Care, Department of
Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
Email: thabetfarah@yahoo.fr
404
condition and the impact on prognosis and outcome during
the intensive care unit (ICU) stay.
Methods
Patient Selection and Ethics
This study was conducted in our tertiary pediatric ICU (PICU)
in Prince Sultan Military Medical City at Riyadh, Saudi Arabia.
It is an 18-bed multidisciplinary unit, admitting around 500 to
550 patients per year.
All consecutive children admitted to our PICU from January
2011 to January 2013 and expected to stay more than 24 hours
were prospectively enrolled, provided they needed an indwel-
ling bladder catheter any time during their admission. Exclu-
sion criteria were ICU stay of less than 24 hours, age less than
1 month, contraindication for intravesical pressure measure-
ment (pelvic fracture, hematuria, or neurogenic bladder), and
bladder surgery. All data were collected prospectively. There
were no interventions and patients received standard care. The
study protocol was approved by the local ethics committee
and the institutional review board (10/2010). Since there was
no deviation from standard of care, the need for obtaining
informed consent was waived.
Data Collection
On admission, the following information was obtained: age,
gender, main diagnosis, and pediatric risk score for mortality
(PRISM II). In all patients, the duration of mechanical ventila-
tion and the length of stay in the ICU were calculated. Primary
end point was ICU mortality. In addition, all patients were
assessed for the following risk factors for IAH/ACS suggested
by the WSACS guidelines: abdominal surgery, abdominal infec-
tion, liver failure, mechanical ventilation with positive end-
expiratory pressure (PEEP), alveolar plateau pressure, presence
of acidosis and lactate levels, fluid resuscitation, hypotension,
multiple transfusion, pneumonia, sepsis, or acute respiratory dis-
tress syndrome (ARDS).
Intra-Abdominal Pressure Monitoring
The IAP was measured according to WSACS guidelines1
through a Foley bladder catheter, according to the modified
Kron technique described by Cheatham and Safcsak.12 The
aspiration port was attached to a short 18-gauge catheter with
3 stopcocks connected to an intravenous infusion set, a syringe
for flushing and draining the tubing system, and a pressure
transducer. The pressure transducer was zeroed at the level
where the midaxillary line crosses the iliac crest. With the
patient in the supine position and the urine drainage tubing
leading to the urine collection bag being clamped, 1 mL/kg
of sterile saline (maximum of 25 mL) was injected into the
bladder under a sterile technique, and the maximum IAP was
measured at end expiration ensuring the absence of abdominal
muscle contractions. Measurements of IAP were recorded
every 6 hours until discharge, death, or removal of the Foley
Journal of Intensive Care Medicine 31(6)
catheter, whichever came first. The decision of the removal of
Foley catheter was left to the discretion of the treating physician.
Definitions
Intra-abdominal hypertension was defined as a sustained (at
least two consecutive values separated by 6 h) elevation in IAP
>10 mm Hg. Abdominal compartment syndrome was defined
as a sustained elevation in IAP >10 mm Hg with new organ
dysfunction that can be attributed to elevated IAP. These defi-
nitions were based on the study by Ejike et al13 and Beck
et al,10 respectively, and they were adopted recently as specific
definition of IAH and ACS for pediatric patients in the updated
consensus definitions.3 Abdominal distension was defined as a
sagittal abdominal diameter (approximately at the level of the
umbilicus) higher than the virtual line between xiphoid and
symphysis pubis. We defined sepsis according to the criteria
of the Society of Critical Care Medicine,14 we defined ARDS
according to the criteria of the American–European Consensus
Conference,15 and we defined the following risk factors:
1. Abdominal surgery as any surgery that required incision
of the abdominal wall.
2. Abdominal infection defined by either radiological evi-
dence suggestive of infection (intra-abdominal collec-
tion with evidence of systemic inflammation) and/or
microbiological evidence of infection of the peritoneal
cavity (positive culture from peritoneal fluid).
3. Acidosis as an arterial pH below 7.2.
4. Liver dysfunction as cirrhosis or other liver failure with
ascites.
5. Coagulopathy (platelets <55 000/mm3 or prothrombin
time < 15 seconds or partial thromboplastin time >2
times normal or international standardized ratio >1.5).
6. Fluid resuscitation was considered as risk factor if more
than 40 mL/kg of colloids or crystalloids.
7. Use of mechanical ventilation as invasive positive pres-
sure ventilation through an endotracheal tube or a tra-
cheostomy tube with or without PEEP.
Statistical Analysis
Results are expressed as mean + standard deviation in case of
normal distribution. Variables between patients with and
without IAH were compared using univariate analysis with
student t test. Nonnormally distributed continuous variables
were expressed as the median with range and compared using
the nonparametric Mann-Whitney U test. Categorical vari-
ables were expressed as numbers and percentages and com-
pared using the chi-square or Fisher exact test. To assess the
independent predictors of IAH, all the variables that differed
significantly in patients with and without IAH in the univari-
ate analysis were entered in a backward logistic regression
model with the results expressed as an odds ratio (OR) and
95% confidence interval (CI). A P value of less than .05 was
considered statistically significant. Statistical analyses were
Thabet et al 405

Table 1. Patients’ Demographics.a

Total (n ¼ 175) IAH (n ¼ 22) No IAH (n ¼ 153) P Value OR Crude 95% CI

Age, months 36 [12-72] 24 [9.5-72] 36 [12-72] .6 1 0.98-1.01

Sex Male 98 8 (36.3%) 90 (58.8%) .047 2.5 0.99-6.31
Female 77 14 (63.6%) 63 (41.1%)
Type of admission Medical 108 17 (77.2%) 91 (59.4%) NS
Burn 8 1 (4.5%) 7 (4.5%) NS
Surgical 59 4 (18.1%) 55 (35.9%) NS
PRISM 13.9 + 8.4 17.6 + 9.1 13.4 + 8.1 0.031 1.055 1.005-1.108
Length of ICU stay, days 9 [1-104] 19.5 [3-97] 8 [1-104] 0.02 1.02 1.003-1.044
Length of mechanical ventilation, days 6.5 [1-100] 13 [1-51] 6 [1-100] 0.06 1.03 1.0-1.06
Death 33 9 (40.9%) 24 (15.6%) 0.011 3.72 1.43-9.67
Abbreviations: CI, confidence interval; IAH, intra-abdominal hypertension; ICU, intensive care unit; max, maximum; min, minimum; OR, odds ratio; PRISM, pedia-
tric risk of mortality score; SD, standard deviation.
a
Results are expressed as mean + SD or median with range [min-max].

Table 2. Univariate and Multivariate Analysis (Only Significant) of Risk Factors Associated With IAH.

Univariate Analysis Multivariate Analysis

Total IAH (n ¼ 22), No IAH Crude P Adjusted P

(n ¼ 175) n (%) (n ¼ 153), n (%) OR 95% CI Value OR 95% CI Value

Abdominal surgery 31 4 (18.1) 27 (11.7) 1.03 0.3-3.3 .99

Fluid resuscitation 80 14 (63.6) 66 (43.1) 2.3 0.9-5.8 .07
Abdominal distension 34 12 (54.5) 22 (14.3) 7.1 2.7-18.5 <.001 7.1 2.4-21.2 <.001
Abdominal infection 5 2 (9) 3 (1.9) 5 0.7-31.7 .11
Inotropes 66 10 (45.5) 56 (36.6) 1.44 0.5-3.5 .42
Acidosis 28 2 (9) 26 (16.9) 0.48 0.1-2.2 .52
Lactate level 1.2 [0.1-27] 1.25 [0.6-13.7] 1.05 [0.1-27] 1.05 0.9-1.2 .2
Hypothermia 14 1 (4.5) 15 (9.8) 0.51 0.06-4.1 .99
Coagulopathy 59 14 (63.6) 45 (29.4) 4.2 1.6-10.7 .001
Sepsis 47 9 (40.9) 38 (24.8) 2.09 0.8-5.28 .11
Liver dysfunction 39 11 (50) 28 (18.3) 4.46 1.7-11.3 .002
Mechanical ventilation 142 20 (90.9) 122 (79.7) 2.54 0.5-11.4 .33
Pneumonia 43 6 (27.2) 37 (24.1) 1.17 0.4-3.2 .75
ARDS 29 10 (45.4) 19 (12.4) 5.8 2.2-15.4 <.001
Plateau pressure >30 cm H2O 24 9 (40.9) 15 (9.8) 5.8 2.07-16.4 .001 5.9 1.91-18.6 .002
PEEP >5 cm H2O 101 17 (77.2) 84 (54.9) 2.6 0.7-9.27 .14
Abbreviations: ARDS, acute respiratory distress syndrome; CI, confidence interval; IAH, intra-abdominal hypertension; OR, odds ratio; PEEP, positive end expira-
tory pressure.

performed using SPSS version 12.0 (SPSS, Inc, Chicago,
Illinois).
Results
Patient Demographics
During the study period, 1055 patients were admitted to PICU
with an overall mortality rate of 32%. Of the patients admitted
to PICU, 175 fulfilled the inclusion criteria for IAP measure-
ment. Twenty-two (12.6%) patients had IAH: 7 (4%) patients
had IAH on admission and 15 (8.5%) developed IAH during
the first week of ICU stay.
Table 1 compares the characteristics of patients with and
without IAH. The median age of the patient with IAH was
24 months [9-72]. There were more female patients in the IAH
group and they were also sicker as demonstrated by a signifi-
cantly higher PRISM score (17.6 + 9.1 vs 13.4 + 8.1, OR
1.05; 95% CI, 1.00-1.10, P ¼ .03). Patients with IAH had signif-
icantly more ARDS and plateau pressures above 30 cm H2O.
Patients with IAH were also more likely to have liver dysfunc-
tion, abnormal coagulation profile on admission, and abdominal
distention. We performed multivariable logistic regression anal-
ysis to assess independent clinical and demographic factors asso-
ciated with development of IAH. We found that abdominal
distension as well as a plateau pressure of more than 30 cm H2O
were the independent risk factors for the development of IAH
in critically ill children (OR 7.1; 95% CI, 2.6-19.9; P < .001
and OR 6.42; 95% CI, 2.13-19.36; P ¼ .01, respectively). Results
of univariate and multivariate analyses are shown in Table 2.
406 Journal of Intensive Care Medicine 31(6)

Table 3. Univariate and Multivariate Analysis (Only Significant) of Risk Factors Associated With Mortality.

Univariate analysis Multivariate analysis

Total (n ¼ 175) Death n (%) Crude OR 95% CI P value Adjusted OR 95% CI P value

IAH 22 9 (40.9) 3.72 1.43-9.67 .01 6.98 1.75-27.86 0.006

Abdominal surgery 31 1 (3.2) 0.11 0.01-0.88 .01
Fluid resuscitation 80 24 (30%) 4.09 1.7-9.4 .07
Abdominal distension 34 12 (35.3) 3.1 1.3-7.2 .006
Abdominal infection 5 2 (40) 2.9 0.4-18.6 .23
Inotrope 66 28 (42.4) 15.3 5.5-42.5 <.001
Acidosis 28 9 (32.1) 2.42 0.9-6 .05
Lactate level 1.2 [0.1-27] 2 [0.6-27] 1.84 1.32-2.57 <.001 1.65 1.225-2.18 <.001
Hypothermia 14 11 (78.6) 23.1 5.9-89.6 <.001 55.51 10.41-295.9 <.001
coagulopathy 59 20 (33.9) 4.06 1.8-8.9 <.001
Sepsis 47 21 (44.7) 7.8 3.4-17.8 <.001 10.2 3.09-33.64 <.001
Liver dysfunction 39 11 (28.2) 2.03 0.88-4.6 .09
Mechanical ventilation 142 33 (23.1) 1.3 1.1-1.42 .002
Pneumonia 43 8 (18.6) 0.97 0.4-2.3 .96
ARDS 29 13 (44.8) 5.1 2.1-12.2 <.001
Plateau pressure >30 cm H2O 24 10 (41.7) 2.9 1.16-7.4 .01
PEEP >5 cm H2O 101 26 (25.7) 1.68 0.66-4.25 .26
Abbreviations: ARDS, acute respiratory distress syndrome; CI, confidence interval; IAH, intra-abdominal hypertension; OR, odds ratio; PEEP, positive end expira-
tory pressure.

Abdominal Compartment Syndrome 12.6% during ICU stay. Second, ARDS, a plateau pressure of
more than 30 cm H2O, liver dysfunction, abnormal coagulation
Seven (4%) patients developed ACS that was primary in all
profile, and abdominal distention were the risk factors signifi-
cases. This group of patients was sicker as demonstrated by the
cantly associated with the development of IAH, but these fac-
high mean PRISM score (23.7 + 8.4). Only 1 patient survived
tors did not remain statistically significant when placed in the
giving a mortality of 85.7%. All received the usual medical
multivariate analysis. Only a plateau pressure of more than
treatment as suggested by the WSACS: nasogastric aspiration,
30 cm H2O and the presence of abdominal distension were
rectal decompression, diuretics, deep sedation, and neuromus-
found to be independent risk factors of IAH. Third, IAH was
cular blockade. An abdominal drain was inserted in 5 cases,
associated with higher mortality rate and more prolonged ICU
and 1 patient underwent decompressive laparotomy.
stay. Finally IAH was an independent risk factor for mortality.

Primary Outcome
In this study, the IAH was associated with significant increase
in mortality rate (40.9% vs 15.6%, OR 3.72; 95% CI, 1.43-9.67;
P ¼ .01). Multivariate analysis of risk factors for death
showed that IAH was an independent risk factor for ICU mor-
tality (Table 3). The ICU length of stay was also longer in
patients with IAH (19.5 [3-97] vs 8 [1-104]; OR 1.023; 95%
CI, 1.003-1.044; P ¼ .02). The duration of mechanical venti-
lation was not significantly different between patient with
or without IAH (13 [1-51] vs 6 [1-100]; OR 1.03; 95% CI,
1.0-1.06; P ¼ .06).
Discussion
Major Findings
This is one of the largest prospective observational studies per-
formed in a population of critically ill pediatric patients follow-
ing the WSACS guidelines for the assessment of IAH risk
factors, IAP measurement, definitions, and recommendations.
Our study revealed several interesting findings. First, we found
an incidence of IAH in our pediatric critically ill population of
Incidence of IAH/ACS
The incidence of IAH in the adult literature varies from 18% to
81%.16,17 Only few studies reported the incidence of IAH in
children. We found an incidence of 12.6% of IAH in critically
ill children admitted to PICU. This is much less than what is
reported in the adult literature, and this finding could be
partially explained by the better compliance of the abdominal
wall in children compensating for increases in intra-abdominal
volume, hence resulting in lower IAP. Occurrence of ACS in
pediatric patients has been previously reported ranging between
0.6% and 9.8%, depending on the IAP threshold (10, 12, and
15 mm Hg) used to define it and on the patient population stud-
ied, differing in surgical or medical patients.8-11,17 The incidence
of ACS in our study was 4% which is closer to the results of
Ejike et al (4.7%).8 Our patient population was similar, as
we included the most critically ill children in need of Foley
catheter only, whereas in Ejike et al study mechanically ven-
tilated patients in need of Foley catheter were included. The
cutoff point used to define IAH was slightly different in the
2 studies (IAP > 10 mm Hg vs > 12 mm Hg, respectively).
Thabet et al
These similarities in patient population and results suggest
that the incidence rate of ACS of around 4% can be expected
in similar critically ill children admitted to the PICU.
Risk Factors for IAH
The WSACS suggested a wide range of risk factors that predis-
pose patients to IAH and ACS. Some examples of conditions
that are considered more specific to pediatric patients include
(1) diminished abdominal wall compliance, for example, gas-
troschisis, omphalocele, and abdominal surgery with tight clo-
sure; (2) increased intraluminal contents, for example, fecal
impaction and Hirschsprung disease; (3) increased abdominal
contents, for example, splenomegaly, hepatomegaly, intra-
abdominal tumors, and ascites; and (4) capillary leak and fluid
resuscitation, for example, systemic inflammatory response
syndrome and sepsis. These conditions are extrapolated from
the adult studies or from the neonatal cases of abdominal wall
defect. To our knowledge, our study is the first in the English
literature which evaluates the different risk factors for IAH in
critically ill children. Many of the conditions we examined
were significantly correlated with increased IAP (ARDS, a pla-
teau pressure of more than 30 cm H2O, liver dysfunction,
abnormal coagulation profile, and abdominal distention).
Abdominal distension and a plateau pressure >30 cm H2O for
ventilated patients were found to be independently associated
with IAH.
Clinical examination and the use of the abdominal perimeter
(AP) have previously been reported to have a poor correlation
with IAP,18,19 suggesting that the AP cannot be used as a sur-
rogate marker for IAP. We found that abdominal distension is
an accurate predictor of IAH. This can probably be explained
by the better abdominal wall compliance in children compared
to adults, as such children can distend their abdomen in
response to increases in intra-abdominal volume, hence result-
ing in lower IAP. Although it should not replace IAP measure-
ment, the presence of abdominal distension as defined by a
sagittal abdominal diameter (at the level of the umbilicus)
higher than the virtual line between xiphoid and symphysis
pubis in critically ill children should be a warning sign for the
pediatric intensivist to obtain a baseline IAH value.
In our study, setting a plateau pressure of more than 30 cm
H2O was found to be an independent predictor of IAH. As was
demonstrated previously in an experimental study, there is a
linear correlation between IAP and alveolar plateau pres-
sures.20,21 The use of a plateau pressure <30 cm H2O may lead
to underventilation and respiratory acidosis in patients with
IAH. Of course, the plateau pressure has nothing to do with the
development of IAH, as it is a mere sign of the extent of the
impact of IAH on other body compartments.22 On average
about 50% of the increased IAP is transmitted to the thoracic
compartment. This results in increased intrathoracic pressure
and thus also alveolar peak and plateau pressure.23 Our results
suggest performing IAP monitoring whenever there is a need to
exceed a plateau pressure of 30 cm H2O in order to achieve
acceptable ventilation and oxygenation.
407
Outcome Predictors
Development of IAH has been described in several studies in
adults as an independent predictor of ICU mortality in mixed
populations16,24; this result was confirmed by a recent systema-
tic review and meta-analysis.17 In our study, IAH was associ-
ated with significant higher mortality, and multiple logistic
regression analysis confirmed IAH to be an independent pre-
dictor of ICU mortality.
Limitation of the Study
The present study has several limitations. First, the main weak-
ness is the single-center design. Differences depending on other
study populations with different case mix can be expected and
as such the present results cannot be generalized or extrapo-
lated to other PICUs. However, our PICU has all the character-
istics of most general PICU’s in developed countries. Second,
studying only patients staying in ICU for at least 24 hours
excludes not only patients discharged early but also the more
severe cases dying within the first 24 hours. In most of the
patients dying within the first few hours in the ICU, measure-
ment of IAP is not the main priority, and therefore, we did not
include them due to expected insufficient data. Third, we stud-
ied only 175 patients, and this may have limited our power to
detect further independent associations. And fourth, studying
only patients having a Foley catheter may overestimate the inci-
dence of IAH and ACS, as these patients are usually sicker and
more at risk for IAH. Finally, this study was purely observational
and as such no final conclusion can be drawn regarding risk fac-
tors, causes, and effect or whether medical management could
decrease IAP and improve outcomes.
Regardless of these limitations, the present study is a good
representation of the IAH epidemiology in most PICUs. This
information can be used by pediatrician working in a similar
environment to estimate the incidence, severity, and clinical
importance of IAH in their patients.
Conclusion
This is the first study looking at the epidemiology, risk fac-
tors, and outcomes associated with increased IAP in a PICU
population using the revised WSACS guidelines. We found
that IAH was not uncommon and that the presence of IAH
is an independent risk factor for mortality. Abdominal disten-
sion and a plateau pressure of more than 30 mm Hg are inde-
pendent predictors of IAH. These warning signs should help
the pediatric intensivist to be more vigilant in such cases and
to monitor IAP more closely in order to treat possible compli-
cations in timely manner according to the WSACS guidelines.
A multicenter study is needed in the pediatric population.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
408
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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