Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival?

Objective: The diagnosis and management of intra-abdominal hypertension and abdominal compartment syndrome have changed significantly over the past decade with improved understanding of the pathophysiology and appropriate treatment of these disease processes. Serial intra-abdominal pressure measurements, nonoperative pressure-reducing interventions, and early abdominal decompression for refractory intra-abdominal hypertension or abdominal compartment syndrome are all key elements of this evolving strategy. Design: Prospective, observational study. Setting: Tertiary referral/level I trauma center. Patients: Four hundred seventy-eight consecutive patients requiring an open abdomen for the management of intra-abdominal hypertension or abdominal compartment syndrome. Interventions: Patients were managed by a defined group of surgical intensivists using established definitions and an evidence-based management algorithm. Both univariate and multi-variate analyses were performed to identify patient and management factors associated with improved survival. Measurements and Main Results: Whereas patient demographics and severity of illness remained unchanged over the 6-yr study period, the use of a continually revised intra-abdominal hypertension/abdominal compartment syndrome management algorithm significantly increased patient survival to hospital discharge from 50% to 72% (p = .015). Clinically significant decreases in resource utilization and an increase in same-admission primary fascial closure from 59% to 81% were recognized. Development of abdominal compartment syndrome, prophylactic use of an open abdomen to prevent development of intra-abdominal hypertension/abdominal compartment syndrome, and use of a multi-modality surgical/medical management algorithm were identified as independent predictors of survival. Conclusions: A comprehensive evidence-based management strategy that includes early use of an open abdomen in patients at risk significantly improves survival from intra-abdominal hypertension/abdominal compartment syndrome. This improvement is not achieved at the cost of increased resource utilization and is associated with an increased rate of primary fascial closure. (Crit Care Med 2010; 38:402-407)