Supplement 8. The Opinion of the Pediatric Guidelines Sub-Committee
Akin to the adult situation, IAH and ACS are being more commonly reported in children [[1]]. While the original, and now updated, WSACS guidelines may serve as guides for these conditions, they cannot be applied directly to children [[1-3]].
The Sub-Committee accepted 10 of the adult definitions as appropriate for Pediatric use, but rejected 4 as inappropriate. Further, they were unable to make a decision regarding the external validity of the defined threshold levels used to define the four grades of IAH. A summary of the final accepted Pediatric Definitions is presented in Table 4. For the four definitions rejected, new definitions, specific for pediatric use, were proposed.
Although the data are limited in quality, it is well known that all physiologic pressures are generally lower in children than in adults, including IAP, even during critical illness.[3] Thus, as the threshold cut-off of 20 mmHg for IAH may be too high, the Pediatric Sub-Committee of the WSACS DEFINED ACS in children as a sustained elevation in IAP of greater than 10mmHg associated with new or worsening organ dysfunction that can be attributed to elevated IAP.
Second, although several adult studies have demonstrated that over-distending the bladder with a priming volume of fluid may lead to erroneous readings [[4-7]], the appropriate priming volume for use in children likely differs from adults. In a prospective study involving 96 pediatric patients in whom IAP-bladder volume curves were generated, the minimum optimal volumes for bladder instillations in children were 3 mL. In this study, IAP in critically ill children was 7±3 mmHg on average [[3]]. Thus, the Pediatric Sub-Committee of the WSACS DEFINED the reference standard for intermittent IAP measurement in children as being via the bladder using 1 ml/kg with a minimal instillation volume of 3ml and a maximum instillation volume of 25ml of sterile saline. The Pediatric Sub-Committee of the WSACS further DEFINED IAP in critically ill children as being approximately 4 – 10 mmHg and DEFINED IAH in children as being a sustained or repeated pathological elevation in IAP > 10mmHg.
Membership of the Pediatric Guidelines Sub-Committee
Chair: Janeth Chiaka Ejike, Loma Linda, California
Members: Francisco Diaz, MD,
Torsten Kaussen, MD,
Mudit Mathur, MD,
Rebecka Meyers, MD,
Donald Moores, MD
Michael Sasse, MD
References
1. Ejike JC, Mathur M, Moores DC, (2011) Abdominal compartment syndrome: focus on the children. The American surgeon 77 Suppl 1: S72-77
2. Ejike JC, Humbert S, Bahjri K, Mathur M, (2007) Outcomes of children with abdominal compartment syndrome. Acta clinica Belgica Supplementum: 141-148
3. Ejike JC, Bahjri K, Mathur M, (2008) What is the normal intra-abdominal pressure in critically ill children and how should we measure it? Critical care medicine 36: 2157-2162
4. Ball CG, Kirkpatrick AW, (2006) 'Progression towards the minimum': the importance of standardizing the priming volume during the indirect measurement of intra-abdominal pressures. Crit Care 10: 153
5. Malbrain ML, Deeren DH, (2006) Effect of bladder volume on measured intravesical pressure: a prospective cohort study. Crit Care 10: R98
6. De Waele J, Pletinckx P, Blot S, Hoste E, (2006) Saline volume in transvesical intra-abdominal pressure measurement: enough is enough. Intensive Care Med 32: 455-459
7. De laet I, Hoste E, De Waele JJ, (2008) Transvesical intra-abdominal pressure measurement using minimal instillation volumes: how low can we go? Intensive Care Med 34: 746-750