resuscitation | The Journal of Critical Care Medicine

Intraabdominal hypertension is less common than it used to be: A pilot step wedge trial

Shane Smith¹^,²^,³, Fran Priestap³, Neil Parry¹^,²^,³, Robert Arntfield⁴, Patrick Murphy⁵, Kelly Vogt²^,³, Ian Ball¹^,³^,⁴

1 Office of Academic Military Medicine, Western University, London, Ontario, Canada
2 Department of Surgery, Western University, London, Ontario, Canada
3 London Health Sciences Centre Trauma Program, London, Ontario, Canada
4 Department of Medicine, Western University, London, Ontario, Canada
5 Department of Surgery, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WI, USA

DOI: 10.2478/jccm-2025-0002

Objective: This is a pilot study to determine the feasibility of a multicentre stepped wedge cluster randomized trial of implementing the 2013 World Society of the Intraabdominal Compartment Syndrome (WSACS) guidelines as an intervention to treat intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in critically ill patients.
Design: Single-centre before-and-after trial, with an observation / baseline period of 3 months followed by a 9-month intervention period.
Setting: A 35 bed medical-surgical-trauma intensive care unit in a tertiary level, Canadian hospital.
Patients: Recruitment from consecutively admitted adult intensive care unit patients.
Intervention: In the intervention period, treatment teams were prompted to implement WSACS interventions in all patients diagnosed with IAH.
Measurements and Main Results: 129 patients were recruited, 59 during the observation period and 70 during the intervention period. Only 17.0% and 12.9%, respectively, met diagnostic criteria for IAH. Many recruited patients did not have intraabdominal pressures measured regularly per study protocol. There was no difference in ICU mortality for patients in either cohort or between those with and without IAH.
Conclusions: The incidence of IAH in our patient population has decreased significantly since 2015. This is likely due to a significant change in routine care of critically ill patients, especially with respect to judicious goal-directed fluid resuscitation. Patient recruitment and protocol adherence in this study were low, exacerbated by other staffing and logistical pressures during the study period. We conclude that a larger multicentre trial is unlikely to yield evidence of a detectable treatment effect.

Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis

Varsha M. Asrani^1,2, Annabelle Brown³, Ian Bissett^1,4, John A. Windsor^1,4

1 Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
2 Department of Nutrition and Dietetics, Auckland City Hospital, Auckland, New Zealand
3 Discipline of Nutrition and Dietetics, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
4 Department of General Surgery, Auckland City Hospital, Auckland, New Zealand

DOI: 10.2478/jccm-2020-0009

Introduction: Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF.
Aim: To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice.
Methods: Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity.
Results: Restricted/goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally-fed patients experience increased episodes of vomiting (p = <0.01) but are less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group.
Conclusions: There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.