IAH and ACS are underrecognized in critically ill children despite being associated with high morbidity and mortality. Studies show that up to half of pediatric healthcare providers are unaware of or unable to correctly define ACS. Measurement of IAP is also not routinely performed. The normal IAP range in children is 4-10 mmHg. IAH is defined as IAP above 10 mmHg and ACS is IAP above 10 mmHg with new organ dysfunction. Risk factors for IAH/ACS in children include diminished abdominal wall compliance, increased intra-abdominal contents, and fluid resuscitation. Treatment involves medical management through optimization of fluids and improving abdominal wall compliance. Surgical decompression through decompressive laparotomy may

2. Intra Abdominal Hypertension
and Abdominal Compartment Syndrome in
Children
Farah Thabet.MD
Consultant Pediatric intensivist PSMMC Riyadh, Saudi Arabia
Assistant professor Pediatrics, Farhat Hached hospital, Sousse Tunisia
IT IS TIME TO PAY ATTENTION

3. IAH and ACS in children
• It is not rare in critically ill children
• IAH and ACS are associated with high risk of morbidity and mortality
• Still under recognized
Why we have to pay attention

4. Ejike JC et al. Understanding of Abdominal Compartment Syndrome among Pediatric Healthcare Providers.
Crit Care Res Pract. 2010

5. • A written survey distributed at 2 PCC conferences.
• To assess awareness of ACS among pediatric HCP
• 520 questionnaires were completed.
• Participants : pediatric intensivists, pediatric nurses, and others.
• 23% of surveyed HCP were unaware of ACS.
• 46.8% defined ACS correctly.
• The threshold IAP value used to define ACS was variable among participants.
• 24% had never measured IAP.

6. • A questionnaire was mailed to the heads of PICU of 205 German pediatric hospitals.
• The response rate was 62%.
• Routine measurements of IAP were said to be performed by 20%.
• Bladder pressure was used most frequently (96%) to assess IAP.
• (17%) only measured IAP in cases of organ dysfunction.
• In 2009, 21% of respondents claimed to have performed a DL.
• DL was indicated if signs of organ dysfunction were present and in cases of at least
grade III IAH without organ impairment.

7. WHAT’S THE NORMAL IAP IN CHILDREN
Ejike JC et al. What is the normal intra-abdominal pressure in critically ill children and how should we
measure it? Crit Care Med 2008
IAP: The steady-state pressure concealed within the abdominal cavity .

8. What’s IAH and ACS

10. DEFINITIONS
• Normal IAP: 4 -10mmHg in critically ill children
• APP: The difference between MAP and IAP
• IAH: A sustained or repeated pathological elevation in IAP >10 mmHg
- IAH grade I : IAP 10- 12mmHg
- IAH grade II : IAP 13- 15mmHg
- IAH grade III: IAP 16- 19mmHg
- IAH grade IV: IAP ≥ 20mmHg
• ACS: A sustained elevation in IAP >10 mmHg associated with new or worsening
organ dysfunction that can be attributed to elevated IAP.

11. • Evidence of organ dysfunction has been reported to occur at IAPs as low as
12-15 mmHg in critically ill children.
Beck R et al. Pediatr Crit Care Med 2001;2:51–6.
Thabet F et al. J Intensive Care Med 2015;31(6): 403–8.
• Children have lower MAP than adults; therefore MOF may occur in children at
lower IAP thresholds than those defined for adults.

12. How to measure the IAP in children
• Gold standard: intra-peritoneal catheter
• Intra-vesical pressure closely correlate with IAP in children.
Suominen PK. J Pediatr Surg 2006; 41(8): 1381-5
Davis PJ. Intensive care Med 2005; 31:471-5

13. Instillation volume: 1 mL/ kg ( min 3ml, max 25mL)

14. Specific considerations in children
• Continuous bladder pressure monitoring, is difficult to apply in children due to
the lack of small 3-way urethral catheters .
• Factors that affect accurate IAP readings are similar to those in adults.
No correlation between BMI percentiles or actual BMI have been reported in
children .
• Infants are abdominal breathers and breathe more rapidly than adults: the
acquisition of measurements at end-expiration challenging.
• Abdominal breathing in a child with respiratory distress may overestimate IAP
readings.
Ejike JC et al. Intensive Care Med 2010; 36: 329−35

15. How common is IAH in children?
UNDERESTIMATED
“The eye cannot see what the mind does not know ”
Definitions

16. • To assess the incidence, risk factors, and outcomes of IAH in the PICU.
• Prospective cohort study from January 2011 to January 2013.
• Inclusion criteria's: All children admitted to the PICU, staying > 24 hours and
requiring bladder catheterization.
• The IAP was measured every 6 hours through a bladder catheter until discharge,
death, or removal of the catheter.
• 175 patients: 22 (12.6%) had IAH and 7 (4%) had ACS during the ICU stay.

18. RISK FACTORS OF IAH IN CHILDREN

19. Intra-abdominal hypertension
and the abdominal
compartment syndrome:
updated consensus definitions
and clinical practice guidelines
from the World Society of the
Abdominal Compartment
Syndrome . Intensive Care Med
(2013) 39: 1190–1206

20. Risk Factors in Pediatrics
• Diminished abdominal wall compliance:
Congenital abdominal wall defects , abdominal circumferential burn, and abdominal
surgery with tight closure…
• Increased intra-luminal contents:
Fecal impaction or accumulation of gas, stool or fluid in the intestines (Hirschsprung
disease or toxic megacolon)…
• Increased abdominal contents:
Ascites, splenomegaly, hepatomegaly, intra-abdominal tumors, post kidney
transplant from an adult donor, post liver transplant …
• Capillary leak, and fluid resuscitation:
Cause of secondary ACS , especially in trauma, sepsis and burn resuscitation

24. Holodinsky et al. Critical Care 2013, 17:R249 F.C. Thabet, J.C. Ejike. Journal of Critical Care 2017

25. Prognosis of IAH and ACS

26. Thabet F et al. J Intensive Care Med 2015;31(6): 403–8.

28. How to treat IAH and ACS
•

29. • The goal of IAH management is to prevent further organ dysfunction and avoid
progression to ACS.
• Medical/ Surgical
• The WSACS medical management algorithm is based on 4 treatment options:
1- evacuation of intraluminal contents
2- evacuation of intra-abdominal space occupying lesions
3- improvement of abdominal wall compliance
4- optimization of fluid administration

30. • Optimize fluid administration:
- Careful daily assessment of the fluid balance,
- Use of restrictive fluid therapy in shock and recovering critically ill patients,
- Diuretics and CRRT
→ Reduce FO, organ and abdominal wall edema contributing to IAH.
• Improve abdominal wall compliance:
- Pain increase the IAP
→ Using adequate analgesia and sedation.
- Head of bed elevation and the prone position significantly increase IAP
→ having a patient lie supine can contribute to decrease IAP.
Ejike et al. Semi-recumbent position and body mass percentiles: effects on intra-abdominal pressure measurements in critically ill
children. Intensive care med 2010

31. • Evacuation of intra-luminal content:
- Insertion of NGT, OGT and/or rectal tubes
- Use of prokinetic agents
- Enemas, or colonic decompression
→ reduce GI contents and Intra-abdominal volume → reduction in IAP in patients
with gastric or colonic distention.
• Evacuation of extra-luminal content:
when IAH is related to the presence of intra-peritoneal fluid, Percutaneous catheter
decompression is an effective way to treat IAH.
- PCD can prevent the progression of IAH to ACS.
- It may allow time to stabilize the patient for DL.
- It is a useful treatment option in patients for whom DL is less desirable because of a
high surgical risk.

32. • Retrospective study : included children diagnosed
with ACS with massive ascites admitted to the PICU
from April 2011 to June 2013.
• To investigate the effectiveness and safety of PCD in
children with ACS.

33. Surgical management
Decompressive Laparotomy + post-OP open-abdomen management
• Open-abdomen management is achieved by leaving the fascia and the skin open, and
temporarily covering the viscera (negative pressure dressing, prosthetic mesh or Wittmann
patch).
• The open-abdomen management with TAC releases the IAP by creating a larger abdominal
compartment.
• Spring loaded silastic silos are used in the management of gastroschisis, and biological
membranes are popular for coverage of exposed viscera of ruptured omphalocoeles.

34. • DL has been shown to be associated with improvement in physiologic parameters
associated with ACS and in mortality.
• This is further demonstrated if the surgical decompression is performed before
irreversible organ dysfunction occurs.
• Optimization of conservative therapies and early decompression guided by use of
a therapeutic algorithm likely contribute to improved outcomes.

35. • A prospective study : December 2009 and October 2010
IAH : IAP ≥ 12 mmHg without a new organ Failure
ACS : IAP ≥ 15 mmHg with a new organ dysfunction/ failure.
• After recognition of IAH or ACS, patients underwent prompt decompressive interventions
as medical or surgical procedures.
• 150 patients were enrolled to the study.
• The incidences of IAH and ACS were 9% and 4%.
• High risk disorders were trauma, ileus, necrotizing enterocolitis, abdominal wall defects,
diaphragmatic hernia and septic shock with massive fluid resuscitation.
Divarci E, et al, Incidence and prognosis of intraabdominal hypertension and abdominal compartment
syndrome in children, J Pediatr Surg (2014)

36. Lower mortality rates can be achieved by early
recognition and timely intervention in children.

37. • Surgical intervention was performed more frequently in patients
with primary ACS (80%) vs secondary ACS (11%).
Ejike et al. OUTCOMES OF CHILDREN WITH ABDOMINAL COMPARTMENT SYNDROME, Acta Clinica Belgica, 2007; 62: sup1, 141-8.

38. • In all 28 children ACS decompression of the abdominal cavity was carried out by performing
a transverse laparotomy and creating a laparostoma by implantation of an absorbable mesh.
• In 18 children direct closure was carried out,
• In 10 wounds healed by secondary intention.
• The median time until closure of the abdominal cavity was 53 days (10–63).
• In 6 children repeated Vicryl mesh reduction was needed prior to the final surgical closure.
• The most frequent complication (6/28) was formation of an enterocutaneous fistula (21.4%).

39. • Median follow-up time was 6.8 years ( 2.2–10 years).
• Further surgical interventions during follow-up :
- Incisional hernia repair 6 cases (27.3%)
- Closure of a stoma (1 case)
- Relaparotomy for ileus due to adhesions (1 case)
• A questionnaire was sent to the parents of 22 surviving children with a response rate of
72.7% (16/22).
• The scar area keeps discomforting 10 of 16 (62%) children physiologically or psychologically.

40. CONCLUSIONS
• IAH and ACS are important problems in critically ill children, and are regularly
observed in PICUs.
• They are associated with high morbidity and mortality rates.
• Active IAP surveillance for at-risk patients is essential in the early detection and
management of IAH and ACS.
• DON’T FORGET KIDS DEVELOP ACS AT LOWER IAP than adults
• The pediatric intensivists' knowledge of IAH and ACS, and an awareness of patients at
risk for IAH are of paramount importance

41. Thank you