Decompressive laparotomy for abdominal compartment syndrome – a critical analysis

INTRODUCTION: Abdominal compartment syndrome (ACS) is increasingly recognized in critically ill patients, and the deleterious effects of increased intraabdominal pressure (IAP) are well documented. Surgical decompression through a midline laparotomy or decompressive laparotomy remains the sole definite therapy for ACS, but the effect of decompressive laparotomy has not been studied in large patient series. METHODS: We reviewed English literature from 1972 to 2004 for studies reporting the effects of decompressive laparotomy in patients with ACS. The effect of decompressive laparotomy on IAP, patient outcome and physiology were analysed. RESULTS: Eighteen studies including 250 patients who underwent decompressive laparotomy could be included in the analysis. IAP was significantly lower after decompression (15.5 mmHg versus 34.6 mmHg before, p < 0.001), but intraabdominal hypertension persisted in the majority of the patients. Mortality in the whole group was 49.2% (123/250). The effect of decompressive laparotomy on organ function was not uniform, and in some studies no effect on organ function was found. Increased PaO(2)/FIO(2 )ratio (PaO(2 )= partial pressure of oxygen in arterial blood, FiO(2 )= fraction of inspired oxygen) and urinary output were the most pronounced effects of decompressive laparotomy. CONCLUSION: The effects of decompressive laparotomy have been poorly investigated, and only a small number of studies report its effect on parameters of organ function. Although IAP is consistently lower after decompression, mortality remains considerable. Recuperation of organ dysfunction after decompressive laparotomy for ACS is variable

RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis

INTRODUCTION: The lack of a standard definition for acute kidney injury has resulted in a large variation in the reported incidence and associated mortality. RIFLE, a newly developed international consensus classification for acute kidney injury, defines three grades of severity – risk (class R), injury (class I) and failure (class F) – but has not yet been evaluated in a clinical series. METHODS: We performed a retrospective cohort study, in seven intensive care units in a single tertiary care academic center, on 5,383 patients admitted during a one year period (1 July 2000–30 June 2001). RESULTS: Acute kidney injury occurred in 67% of intensive care unit admissions, with maximum RIFLE class R, class I and class F in 12%, 27% and 28%, respectively. Of the 1,510 patients (28%) that reached a level of risk, 840 (56%) progressed. Patients with maximum RIFLE class R, class I and class F had hospital mortality rates of 8.8%, 11.4% and 26.3%, respectively, compared with 5.5% for patients without acute kidney injury. Additionally, acute kidney injury (hazard ratio, 1.7; 95% confidence interval, 1.28–2.13; P < 0.001) and maximum RIFLE class I (hazard ratio, 1.4; 95% confidence interval, 1.02–1.88; P = 0.037) and class F (hazard ratio, 2.7; 95% confidence interval, 2.03–3.55; P < 0.001) were associated with hospital mortality after adjusting for multiple covariates. CONCLUSION: In this general intensive care unit population, acute kidney 'risk, injury, failure', as defined by the newly developed RIFLE classification, is associated with increased hospital mortality and resource use. Patients with RIFLE class R are indeed at high risk of progression to class I or class F. Patients with RIFLE class I or class F incur a significantly increased length of stay and an increased risk of inhospital mortality compared with those who do not progress past class R or those who never develop acute kidney injury, even after adjusting for baseline severity of illness, case mix, race, gender and age

Acute kidney disease and renal recovery : consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup

Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of > 90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD

Additional file 2: Figure S1. of Urinary chitinase 3-like protein 1 for early diagnosis of acute kidney injury: a prospective cohort study in adult critically ill patients

Area under the receiver-operating characteristics curve (AUC-ROC) with 95 % confidence interval (CI) of urinary chitinase 3-like protein 1 (UCHI3L1) (a) and urinary neutrophil gelatinase-associated lipocalin (UNGAL) (b) at enrollment for predicting acute kidney injury (AKI) stage ≥2 based on the Kidney Disease | Improving Global Outcomes (KDIGO) serum creatinine (SCr) or urine output (UO) criteria (AKI SCr/UO ) within 12 h in different subgroups of patients. (TIF 434 kb

Additional file 4: Figure S3. of Urinary chitinase 3-like protein 1 for early diagnosis of acute kidney injury: a prospective cohort study in adult critically ill patients

Distribution of urinary chitinase 3-like protein 1 (UCHI3L1) (a) and urinary neutrophil gelatinase-associated lipocalin (UNGAL) (b) at enrollment in the eight selected subgroups of patients who did not develop acute kidney injury (AKI) based on the Kidney Disease | Improving Global Outcomes serum creatinine (SCr) or urine output (UO) criteria (No AKI SCr/UO ) within 7 days after enrollment, compared to the distribution in all patients with no AKISCr/UO within 12 h after enrollment, and in all those maximally reaching AKISCr/UO stages 1, 2, or 3 within 12 h after enrollment. (TIF 715 kb

Additional file 5: Figure S4. of Urinary chitinase 3-like protein 1 for early diagnosis of acute kidney injury: a prospective cohort study in adult critically ill patients

Distribution of urinary chitinase 3-like protein 1 (UCHI3L1) (a) and urinary neutrophil gelatinase-associated lipocalin (UNGAL) (b) at enrollment in the eight selected subgroups of patients who did not develop acute kidney injury (AKI) based on the Kidney Disease | Improving Global Outcomes serum creatinine (SCr) criteria (No AKI SCr ) within 7 days after enrollment, compared to the distribution in all patients with no AKISCr within 24 h after enrollment, and in all those maximally reaching AKISCr stages 1, 2, or 3 within 24 h after enrollment. (TIF 716 kb