We read with interest the recent case note by Vikrama and colleagues1 describing the percutaneous management of a patient with purported primary abdominal compartment syndrome (ACS). We congratulate the authors on their successful application of a less invasive technique for the management of this potentially life-threatening injury. However, the Executive Committee of the World Society of the Abdominal Compartment Syndrome (WSACS) would like to clarify several incorrect and potentially misleading statements in this case note.
The author’s definition of abdominal compartment syndrome (ACS) is incorrect. According to the International Conference of Experts on Intra-Abdominal Hypertension and Abdominal Compartment Syndrome, intra-abdominal hypertension (IAH) is defined as the sustained or repeated pathologic elevation of intra-abdominal pressure (IAP) greater than or equal to 12 mm Hg.2,3 Abdominal compartment syndrome is defined as a sustained IAP greater than 20 mm Hg that is associated with the development of new organ dysfunction or failure. The authors’ description of their patient is consistent with IAH (IAP 26 mm Hg), but they fail to define the new organ dysfunction or failure that would qualify their patient for a diagnosis of ACS. In addition, such a diagnosis should not be based upon a single IAP measurement but rather a sustained increase as IAP can be transiently elevated due to coughing, agitation or ventilator dyssynchrony. Further, whereas ACS is classically considered a disease of the traumatically injured patient, as illustrated by the authors, IAH / ACS may also be encountered in medical and pediatric patient-populations. The presence of elevated IAP among critically ill patients is grossly underappreciated and represents a clinically important cause of potentially preventable morbidity and mortality.3
The authors state that the diagnosis of IAH / ACS is “difficult” and imply that radiologic testing should be used to identify the presence of elevated IAP. These statements are also inaccurate; IAH / ACS can be easily and accurately diagnosed with the use of inexpensive bedside IAP measurements such as those used by the authors. The medical literature is replete with studies demonstrating the efficacy and diagnostic accuracy of IAP measurements.3–5 Such measurements can be used to diagnose IAH / ACS and to direct ongoing therapeutic interventions. Radiologic tests are unnecessary, expensive and time-consuming, and they have poor diagnostic sensitivity and specificity for IAH / ACS. Their routine application as a diagnostic tool only serves to delay and confuse the appropriate management of patients with IAH / ACS.
The WSACS has described a graded approach to the diagnosis and management of IAH / ACS (www.wsacs.org) that can be used to avoid the need for surgical decompression in many patients.2,3 In this algorithm, percutaneous drainage is considered as a potential therapeutic option before proceeding with surgical decompression. If percutaneous drainage is unsuccessful in reducing IAP and restoring adequate visceral perfusion in the setting of ACS, surgical decompression should be immediately performed. The clinical situation in which “surgical decompression is not feasible” and percutaneous treatment would be an effective rescue therapy, as suggested by the authors, is exceedingly rare and unlikely.
Footnotes
Competing interests: None declared.