Risk factors for intra-abdominal hypertension and abdominal compartment syndrome among adult intensive care unit patients: a systematic review and meta-analysis

Jessalyn K Holodinsky, Derek J Roberts, Chad G Ball, Annika Reintam Blaser, Joel Starkopf, David A Zygun, Henry Thomas Stelfox, Manu L Malbrain, Roman C Jaeschke, Andrew W Kirkpatrick, Jessalyn K Holodinsky, Derek J Roberts, Chad G Ball, Annika Reintam Blaser, Joel Starkopf, David A Zygun, Henry Thomas Stelfox, Manu L Malbrain, Roman C Jaeschke, Andrew W Kirkpatrick

Abstract

Introduction: Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis.

Methods: We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis.

Results: Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients.

Conclusions: Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.

Figures

Figure 1
Figure 1
Flow chart of steps in systematic review.
Figure 2
Figure 2
Vote counting descriptive analysis of candidate risk factors for IAH/ACS. Vote counting is a descriptive tool that can be used to identify patterns across heterogeneous data. All candidate risk factors from the included studies were first grouped into a subtheme (which is reported along the vertical axis of each of the displayed graphs) and then categorized as to whether they were a: (1) risk factor (odds ratio (OR) point estimate and confidence interval (CI) >1), (2) an exposure that was neither hazardous nor protective (CI included 1), or (3) an exposure that was protective (OR and CI <1) by arbitrarily assigning each of these three categories a representative color (shown in the legend). Subsequently, studies reporting candidate risk factors were assigned a value of one within each of the above-named categories and then summed in order to display the stacked horizontal bar charts shown in each of the vote-counting summary plots. IAH/ACS, intra-abdominal hypertension/abdominal compartment syndrome.

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