E. Grobock. Chaminade University of Honolulu, Hawaii.
It can be used to determine whether a blood donor is currently or has recently been infected with the spirochete 130mg malegra dxt overnight delivery. Other Concerns Hepatitis Viruses In recent years generic malegra dxt 130mg with mastercard, numerous infectious agents found worldwide have been identiﬁed as potential threats to the blood supply and among these are several newly discov- ered hepatitis viruses that present unique challenges in assessing possible risks purchase malegra dxt 130mg mastercard. Even if the hepatitis virus test is negative for all known A–E hepatitis agents buy malegra dxt 130 mg lowest price, there 28 Molecular Techniques for Blood and Blood Product Screening 527 are some unidentiﬁed hepatitis viruses, called non A–E hepatitis viruses that can still be transmitted by blood transfusion. It also remains a major pathogen for solid-organ transplant recipi- ents causing febrile syndromes, hepatitis, pneumonitis, retinitis and colitis. Hu Malaria Sensitive screening tests for malaria are neither commercially available nor ofﬁcially approved yet. The most effective way of screening donors is to take a proper history of malaria or of fever that could be due to malaria. Donor selection criteria should be designed to exclude potentially infectious individuals from donating red blood cells for transfusion. Because there are no practical laboratory tests available to test donor blood, donors traveling to high risk malaria areas are excluded from donating blood for 6 months. However, there is a need to develop suitable screening tests, especially for use in an endemic area. These subtypes are different strains of dengue virus that have 60–80 % homology between each other. With more than one-third of the world’s population living in areas at risk for transmission, dengue infection is a leading 28 Molecular Techniques for Blood and Blood Product Screening 529 cause of illness and death in the tropics and subtropics. There have been healthcare-related transmissions, including transmission by blood products . Dengue infection has a viremic phase that lasts 4–8 days, and blood collected during this phase may be infective when transfused into susceptible hosts [ 40]. Babesia Species Babesia is a protozoan parasite of the blood that causes a hemolytic disease known as Babesiosis. Babesiosis is a malaria-like parasitic disease, and there are over 100 species of Babesia identiﬁed. In the United States, Babesia microti is the agent most commonly reported to cause human infection. Clinical confusion between human babesiosis and malaria is often reported in literature . In fact, there have been many cases of transfusion- induced babesiosis documented . Risk of developing this clinical infection is increased for elderly, asplenic, or immunosuppressed patients. Diagnosis depends upon ﬁnding parasites on blood ﬁlm examination which can be detected 2–4 weeks after a tick bite. Chagas’ Disease Chagas disease is named after the Brazilian physician Carlos Chagas, who discovered the disease in 1909. Chagas disease is spread mainly by blood-sucking insects infected with Trypanosoma cruzi. Chagas disease can also be spread through blood transfusion, organ transplants, and from a mother to an unborn child. It is still possible that unexplained cases of posttransfusion hepatitis may be caused by a new, undiscovered pathogen. In recent years, numerous new infectious agents found worldwide have been identiﬁed through time-consuming procedures. There is an urgent need to develop methods for rapid identiﬁcation and characterization of previously unknown pathogenic viruses. The new unrecognized and uncharacterized viral agents can be rapid identiﬁed by some of the new molecular approaches, e. The high safety level of the blood supply is the result of continued improvements in blood donor screening and testing. It will be achieved by intro- ducing more updated nucleic acid tests to the ﬁeld of blood safety. This improved sensitivity should enable us to signiﬁcantly decrease the infection window period, allowing for earlier detection of the infection and diminishing the chances for transmission of the agent via transfusion. We are to protect the blood supply from not only known pathogens but also the emergence of new and unrecognized and uncharacterized infectious agents. Food & Drug Administration (2004) Testing requirements for communicable disease agents. J Clin Virol 17:1–3 28 Molecular Techniques for Blood and Blood Product Screening 533 33. Das K, Kar P, Gupta R, Das B (2004) Role of transfusion-transmitted virus in acute viral hepa- titis and fulminant hepatic failure of unknown etiology. Ano H, Makimura S, Harasawa R (2001) Detection of Babesia species from infected dog blood by polymerase chain reaction. Lo and Kai Man Kam Introduction Molecular techniques for identifying and detecting microorganisms have been proven readily adaptable for use in the clinical diagnostic laboratory. Nearly half of the cases occur in individuals between the ages of 15 and 24 years. Since then, numerous molecular detection techniques have been designed to detect speciﬁc nucleic acids without relying on the ability to culture or directly observe intact organisms. Kam (*) Public Health Laboratory Services Branch, Department of Health, Centre for Health Protection , Kowloon , Hong Kong Public Health Laboratory Centre , 382 Nam Cheong Street, Room 731 , Kowloon , Hong Kong e-mail: kmkam@dh. More sensitive detec- tion techniques are often required for detecting asymptomatic individuals with low microbial load. Currently available molecular techniques using nucleic acid ampliﬁcation and hybridization can now offer high sensitivity in screening for these infections and disrupt the transmission chains within the community leading to decrease in case burden and ultimately eliminate the reservoir of infections. In the United States, gonorrhea is the second most commonly reported notiﬁable disease leading to serious outcomes in women, such as tubal infertility, ectopic pregnancy, and chronic pelvic pain. Nucleic Acid Hybridization Nucleic acid hybridization is a molecular technique based on annealing of complemen- tary nucleic acid strands on a stable double-strand nucleic acid without ampliﬁcation. The opa and porA pseudogene have been validated as suitable conﬁrmatory test for positive nucleic acid ampliﬁcation tests [28, 29 ]. This target region has two highly conserved sequence variations and is repeated three times on the genome. The sensitivity and speciﬁcity of this assay on urine and swab samples were ranged from 92. The assay contains two sets of primers targeting a 122 bp conserved sequence in the C. There are four approaches to additional molecular conﬁrmatory tests: (1) testing a second specimen with a different test using different target; (2) testing the original specimen with a different test that uses a different target or format; (3) repeating the original test on the original specimen with a blocking antibody or competitive probe; and (4) repeating the original test on the original specimen . Therefore, these three assays can be used as conﬁrmatory tests for each other assay [47, 48]. Owing to the slow generation time and the inability to survive and multiply outside the mammalian body, despite repeated attempts over the years, T. Dark-ﬁeld microscopic examination in lesion exudate or tissue and serology are the deﬁnitive methods for diagnosing early syphilis. However, these tests may be problem- atic in the early stages of primary syphilis, as both serological tests and microscopic examinations are limited by low degrees of sensitivity and speciﬁcity [51 ]. The assays provide a robust, sensitive, and speciﬁc assay to directly detect the presence of T. Several studies have shown that the accuracy of clinical diagnosis for chancroid ranged from 33 to 80% [68, 69]. The optimal sensitivity of culture can only be 50–90% even in experienced and well-equipped laboratories, while the sensitivity can be less than 50% in inexperienced laboratories [70, 71]. The “gold standards” for the diagnosis of chancroid were clinical diagnosis and laboratory culture of H. Mycoplasma hominis, Mycoplasma genitalium, Ureaplasma parvum, and Ureaplasma urealyticum are important etiological agents of postpar- tum fever, infertility, and pelvic inﬂammatory diseases [82, 83]. No commercial diagnostic system is available for the detection of mycoplasmas and ureaplasmas. Introduction of molecular detection techniques provides a new horizon in the identiﬁcation and detection of Mycoplasma and Ureaplasma species.
Te infow and outfow cannula are shortened and a reduced size of the fow probe on the out- fow tract is used 130mg malegra dxt free shipping. A very aggressive anti- tion in a 2 years old child coagulation was necessary to prevent pump 364 M best 130mg malegra dxt. Te authors Ruygrok and coworkers published their experi- reported their experience of 28 pediatric patients ence with the VentrAssist in three patients (10– (11–18 years generic malegra dxt 130 mg without prescription, 50–132 safe 130 mg malegra dxt. One patient was success- of the patients underwent transplantation, four fully transplanted, one died on support, and one patients died on support, and the others were still showed signs of recovery, and the pump was ongoing at the end of follow-up. Te device is no longer available reported four patients with favorable outcome on the market. Te pump is in the setting of single ventricles and Fontan 365 36 Continuous-Flow Pumps in Pediatric Population. Successful anatomically lef ventricle deteriorates [16, 26] implantations have been reported in young adults (. While there is no debate for the need of anti- Explantation coagulation, there are no standardized protocols. To evaluate cardiac Most of the protocols used propose a two- or recovery under continuous axial fow pumps, a three-drug regimen involving oral anticoagula- “three-step” approach (regularly echocardiography, tion with additional antiplatelet therapy (i. To achieve a balance between reports of successful device explantation published minimizing thromboembolic events and bleeding . Strueber M et al (2011) Multicenter evaluation of an lation) and temporary catheter blocking of the out- intrapericardial left ventricular assist system. Huebler M et al (2012) Mechanical circulatory support of systemic ventricle in adults with transposition of invasive hemodynamics and echocardiographic great arteries. Semin Thorac Cardiovasc Surg Pediatr Card Cardiovasc Surg Pediatr Card Surg Annu 99–108 Surg Annu 109–114 3. Wei X et al (2013) Pre-clinical evaluation of the infant ventricular assist device. Jeewa A et al (2010) Outcomes with ventricular assist Lung Transplant 32(1):112–119 device versus extracorporeal membrane oxygenation 22. Schweiger M et al (2013) Paediatric ventricular assist as a bridge to pediatric heart transplantation. Schweiger M et al (2015) Biventricular failure in dextro- 32(11):1107–1113 transposition of the great arteries corrected with the 8. Schweiger M et al (2015) Outpatient management of congenital heart disease listed for heart transplant: intra-corporeal left ventricular assist device system in impact of ventricular assist devices. Fan Y et al (2011) Outcomes of ventricular assist device port with two miniaturized implantable assist devices. Reinhartz O et al (2005) Thoratec ventricular assist assistance with the Jarvik FlowMaker: a case report. Reinhartz O et al (2001) Multicenter experience with dual Jarvik 2000 biventricular assist device. Interact the thoratec ventricular assist device in children and Cardiovasc Thorac Surg 19(6):1083–1084 adolescents. J Heart Lung Transplant 30(4):467–470 J 61(5):569–573 369 36 Continuous-Flow Pumps in Pediatric Population 32. J Heart Lung Transplant Assist Device as Bridge to Transplant in Children and 32(6):615–620 Adolescents. Morales Heart transplantation is the fnal therapeutic In spite of these logistical issues, the device was option in children with end-stage heart failure due implanted 100 times between June 2000 and May to cardiomyopathy or congenital heart disease. Tis review will summarize these congenital heart disease were less encouraging. Te most common teria and who received the device under compas- serious adverse events were major bleeding sionate use protocols further explored risk factors (46%), infection (56%), and stroke (29%). Children in the com- in the study was neurologic insult (n = 17, 33%), passionate use cohort were less likely to reach with thromboembolic strokes signifcantly out- numbering hemorrhagic stroke. Neurologic Berlin database demonstrates there is consider- dysfunction was also a frequent cause of morbid- able variation (tenfold) in the incidence of stroke ity (29% of patients sufered a neurologic insult)  and the risk was not explained by center vol- among patients who survived to transplant in ume. Given the importance of this topic, outcomes through shared learning and establish- Jordan et al. Of the 204 children included in the study, 59 (29%) experienced at least one neurologic event 37. Tere was no a history of pump change due to thrombus were diference in serious adverse events or total days the sole risk factors for neurologic insult identi- on support. Single centers have demon- there was no patient subgroup (based on pre- strated improvement in stroke-related outcomes implant characteristics) that showed improved with increased institutional experience . Tis last point is sig- Centers have also explored alternate management nifcant and should be underscored. Hypoplastic left heart syndrome 15 (58) Unbalanced atrioventricular canal 2 (8) 37. Te ventricle presence of congenital heart disease was not iden- Tricuspid atresia 1 (4) tifed as a risk factor in the fnal multivariable Pulmonary atresia with intact 1 (4) model; however, a specifc analysis examining the septum outcomes of patients with a univentricular heart was not performed, but was rather the focus of a Palliative stage subsequent study by Weinstein et al. Only one of nine stage I patients and none of the neonatal Norwood patients survived. In particu- showed that there was no diference in midterm lar, the rate of neurologic dysfunction and mixed post-transplant outcomes. Circulation 113:2313–2319 the incidence of stroke in children supported with the 4. J Heart Lung Transplant M, Prodhan P (2015) Steroid therapy attenuates acute 24:331–337 phase reactant response among children on ventricular 5. Ann Reinhartz O (2015) Refning of the pump exchange Thorac Surg 66:1498–1506 procedure in children supported with the Berlin heart 6. N Engl J Med 367:532–541 plantation with berlin heart ventricular assist device in a 10. Artif Organs Humpl T (2015) Delineating survival outcomes in chil- 36:555–559 dren <10 kg bridged to transplant or recovery with the 23. Eur J Cardiothorac Surg 48:910–916 ; discus- device as a bridge to cardiac transplantation. The infow cannula is anatomical and hemodynamic variables with two inserted in the apex of the single right ventricle and the outfow cannula at the level of the Damus-Kaye-Stansel diferent approaches [1, 2]. Te correct landmark of apical as site for infow cannulation in case of inadequate cannulation must be carefully identifed, as previ- drainage with the apical cannula. Te outfow can- ous surgical adhesions and coronary abnormalities nula placement results are likewise challenging due can distort the anatomy. Right orientation of the to the previous surgically reconstructed aorta via infow cannula to the septum and accurate resec- Norwood patch and Damus-Kaye-Stansel anasto- tion of right single ventricle inner trabeculation are mosis, so that an extension with prosthetic graf can also mandatory for an optimal drainage of the be used to obtain a better alignment and orienta- heart. Te single systemic atrium can also be used tion avoiding compression by the sternum. Complications related to excessive bleeding are likely to be encoun- tered in these patients and are due to a combination of multiple previous operations and coagulation abnormalities related to multisystem failure. A higher fow is required to cope in the apex of the single right ventricle and the outfow with the increased load of the systemic single ven- cannula at the level of the Damus-Kaye-Stansel anastomo- sis. Te fundamental require- the early stages of the palliation, the small size of ment is to create a systemic venous reservoir by the patients (most likely less than 15 kg) limits the 384 F. In the acute phase, continuous fow is pref- undergoing successful transplantation in these erable as it can also allow a better unloading of the cohorts were lucky to have received a donor organ systemic ventricle, can occur throughout the in a relatively short period of time, with none of entire cardiac cycle, and can consequently pro- the survivors mechanically assisted for longer than vide higher fow than pulsatile pumps at the same 21 days. Fontan-failing As general presumption, the identifcation of patients are commonly bigger size children, ado- predominant etiology of failure may direct the lescents, and young adults, allowing the option to 38 most suitable approach to mechanically support use adult-designed implantable devices in pediat- the circulation (. Device implantation can be performed on a beating heart or inducing ventricular fbrillation, with cardioplegic arrest established when a concomitant systemic atrio-. Right sketch shows the implantation of the arterial cannula Te implantation of ventricular assist device in the proximal stump of the extracardiac conduit, the is facilitated by the loss of tripartite confgura- capacity chamber created with an enlarging patch, and the tion of systemic right ventricle. However, there connection of the superior vena cava in the capacity chamber could be difculties related to the presence of with enlargement patch. Both cannulas are brought percutaneously trabeculae in the body of morphological right and connected to a paracorporeal ventricle ventricle.
Recent studies and editorials suggest that we do not yet fully understand the etiologic mechanisms of positioning issues cheap malegra dxt 130mg online. Surprisingly buy malegra dxt 130mg lowest price, the majority of these patients had widespread microvasculitic neuropathies discount 130 mg malegra dxt amex, and many were responsive to immunologic modulation with high doses of corticosteroids safe malegra dxt 130 mg. The inflammatory response may be dramatically altered in the perioperative period, and microvasculitic neuropathy appears to be a previously unrecognized cause of peripheral neuropathy. For example, anesthetic drugs and transfusion of blood products are known to promote systemic inflammation. In the meantime, these reports serve as evidence that a number of perioperative neuropathies may, in fact, have no relationship to intraoperative positioning or management of physiologic factors. As noted earlier, immunosuppression is present in a fairly significant proportion of patients undergoing major surgical procedures. This immunosuppression may provide opportunities for existing viruses or newly introduced viruses to activate, particularly in neural tissues. For example, the onset of shingles may be more frequent in surgical compared to general populations. Stretch of neural tissue may be an important factor in the development of peripheral and central neuropathies. Stretch of many mammalian nerves to 5% greater than their normal resting length has been shown repeatedly to lead to ischemia by reducing both arteriole and venule blood flow. The kinking of the arterioles and venules associated with neuronal stretch leads to ischemia. The impact of stretch on other soft tissues is less well documented and would be highly dependent on the type of tissue and amount of stretch. Cerebral circulation is slightly above heart level if the head is on a small pillow. B: Head-down tilt aids blood return from lower extremities but encourages reflex vasodilation, congests vessels in the poorly ventilated lung apices, and increases intracranial blood volume. C: Elevation of the head shifts abdominal viscera away from the diaphragm and improves ventilation of the lung bases. According to the gradient above the heart, pressure in arteries of the head and neck decreases; pressure in 2008 accompanying veins may become subatmospheric. There are many ways to reduce point pressure, but the most commonly used involve padding. Although there may be distinct differences in mechanical properties of various padding materials (e. The basic principle is to use any of these materials to protect nerves and soft tissues from point pressure. Supine Positions Variations of Supine Positions Horizontal In the traditional supine position, the patient lies on his or her back with a small pillow beneath the head (Fig. The arms are either comfortably padded and restrained alongside the trunk or abducted on well-padded arm boards. Either arm (or both) may be extended ventrally and the flexed forearm secured to an elevated frame in such a way that perfusion of the hand is not compromised, no skin-to-metal contact exists to cause electrical burns if cautery is used, and the brachial neurovascular bundle is neither stretched nor compressed at the axilla. The lumbar spine may need padded support to prevent a postoperative backache (see “Complications of Supine Positions”). Fortunately, most modern surgical tables have mattress pads that are sufficiently buoyant and thick to allow dispersion of point pressure. Although the horizontal supine posture has a long history of widespread use, it does not place hip and knee joints in neutral positions and is poorly tolerated for prolonged periods by an immobilized, awake patient. It is established by arranging the surface of the operating table so that the trunk–thigh hinge is angulated approximately 15 degrees and the thigh–knee hinge is angulated a similar amount in the opposite direction. Alternatively, a rolled towel, pillow, or blanket can be placed beneath the patient’s knees to keep them flexed. The patient of average height then lies comfortably with hips and knees flexed gently. A significant degree of perfusion can be restored if the compressive mass is rolled toward the left hemiabdomen by leftward tilt of the tabletop or by a wedge under the right hip. Each lower extremity is flexed at the hip and knee, and both limbs are simultaneously elevated and separated so that the perineum becomes accessible to the surgeon. For many gynecologic and urologic procedures, the patient’s thighs are flexed approximately 90 degrees on the trunk and the knees are bent sufficiently to maintain the lower legs nearly parallel to the floor. More acute flexion of the knees or hips can threaten to angulate and compress major vessels at either joint. In addition, hip flexion to greater than 90 degrees on the trunk has been shown to increase stretch of the inguinal ligaments. Branches of the lateral femoral cutaneous nerves8 often pass directly through these ligaments and can be impinged and become ischemic within the stretched ligament. Numerous devices are available to hold legs that are elevated during obstetric delivery or perineal operations. Care should be taken to ensure that angulations or edges of the padded holder do not compress the popliteal space or the upper dorsal thigh. Compartment syndromes of one or both lower extremities have resulted from prolonged use of the lithotomy position with various types of support devices. Thighs are flexed approximately 90 degrees on the abdomen; knees are flexed enough to bring the lower legs grossly parallel to the torso section of the tabletop. Arms are retained on the boards, crossed on the abdomen, or snugged at the sides of patient. Low For most urologic procedures and for many procedures that require simultaneous access to the abdomen and perineum, the degree of thigh elevation in the lithotomy position is only approximately 30 to 45 degrees (Fig. This reduces perfusion gradients to and from the lower extremities and improves access to a perineal surgical site for members of the 2011 operating team who may need to stand at the lateral aspect of either leg. Figure 29-4 Low lithotomy position for perineal access, transurethral instrumentation, or combined abdominoperineal procedures. High Some surgeons prefer to improve access to the perineum by suspending the patient’s feet from high poles. The effect is to have the patient’s legs almost fully extended on the thighs (Fig. The posture produces a significant uphill gradient for arterial perfusion into the feet, requiring careful avoidance of systemic hypotension. There is considerable variation in lower extremity perfusion pressure in volunteers placed in high lithotomy positions; they all tend to have low perfusion pressures, however. Exaggerated Transperineal access to the retropubic area requires that the patient’s pelvis be flexed ventrally on the spine, the thighs almost forcibly flexed on the trunk, and the lower legs aimed skyward so they are out of the way (Fig. The result places the long axis of the symphysis pubis almost parallel to the floor. This exaggerated lithotomy position stresses the lumbar spine, produces a significant uphill gradient for perfusion of the feet, and may restrict ventilation because of abdominal compression by bulky thighs. If pre- existing painful lumbar spine disease is present, an alternative surgical position may need to be chosen beforehand to avoid severely accentuating the lumbar distress after surgery. This position has been associated with a very high frequency of lower extremity compartment syndrome. Note potential for angulation and compression/obstruction of contents of femoral canal (A, inset) or stretch of sciatic nerve (B). Complications of Supine Positions Brachial Plexus Neuropathy Root Injuries Shoulder braces placed tight against the base of the neck can compress and injure the roots of the brachial plexus when steep head-down positions are used. Braces, if needed at all, are considered less harmful when placed more laterally over the acromioclavicular joint. The same is true of straps or tape criss-crossed from above the shoulders to keep patients from sliding cephalad. Supine positions do not usually threaten structures in the patient’s neck unless considerable lateral displacement of the head occurs or if steep head- down tilt is added. When lateral displacement of the head occurs, the roots of 2013 the brachial plexus on the side of the obtuse head–shoulder angle can be stretched and damaged. Similarly, exaggerated rotation of the head away from an extended arm may be associated with a brachial plexus injury. If used, it should be placed over the acromioclavicular area to minimize compression of the brachial plexus and adjacent vessels. Sternal Retraction Frequently, the patient undergoing a median sternotomy has both arms padded and secured alongside the torso.
As a result buy cheap malegra dxt 130mg online, such patients are at risk of acute respiratory failure and the need for prolonged mechanical ventilatory support order malegra dxt 130 mg overnight delivery. The majority of such patients are appropriately managed using traditional volume-based modes of ventilation malegra dxt 130 mg overnight delivery. Patients are optimally ventilated using 6–8 mL/kg ideal body weight (not actual body weight) discount 130mg malegra dxt with visa. Patients who require abdominal decompression and maintenance of a temporary open abdomen commonly require mechanical ventilation postoperatively. Traditionally, such patients have been left intubated throughout the duration of their open abdomen. Recent evidence, however, demonstrates that such patients can be successfully extubated prior to defnitive abdominal closure (Sujka et al. Predictors of successful extuba- tion include higher Glasgow Coma Scores and lower Injury Severity Scores (espe- cially the Chest Abbreviated Injury Score component) suggesting that patients who are more alert, able to participate in post-extubation pulmonary rehabilitation, and less severely injured are good candidates for early extubation despite an open abdomen. Early enteral nutrition, once the patient’s acute shock state has been corrected and adequate visceral perfusion is present, helps to prevent the development of ileus and bacterial translocation and improves wound healing. Parenteral nutrition, due to its infectious complications and increased cost, should be reserved for those patients who develop a high-volume enterocutaneous fstula or intestinal malabsorption. In fact, enteral nutrition helps to reduce intestinal edema and can speed the process of defnitive abdominal closure. Nutritional support should begin with a caloric goal of 30 kcal/kg/day and protein goal of 1. It is important to account for addi- tional protein losses from the open abdomen, if present, by replacing each liter of peritoneal fuid lost with 12. This therapy should be implemented only after ensuring adequate intravascular volume administration to avoid causing unnecessary 13 Intensive Care Unit Management of the Adult Open Abdomen 161 vasoconstriction and worsening visceral ischemia. It can be lifesaving when a patient’s organ dysfunction and/or failure are refractory to medical treatment. Emergent decompression may be performed either in the operating room or at the patient’s bedside in the intensive care unit if cardiopulmonary instability precludes safe transport. This procedure is appropriate given that early decompression signifcantly improves survival and the patient’s open abdomen can generally be closed within the frst week without 162 M. Active communication between intensivist and surgeon is vital in the successful manage- ment of these patients. Incidence and prognosis of intraabdominal hyper- tension in a mixed population of critically ill patients: a multiple-center epidemiological study. A survey of critical care nurses’ knowledge of intra-abdominal hypertension and abdominal compartment syndrome. Intra-abdominal hypertension and abdominal compartment syndrome in the medical patient. Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. The duration of intra-abdominal hypertension strongly predicts outcomes for the critically ill surgical patient: a prospective observational study. Long-term physical, mental, and functional consequences of abdominal decompression. Long-term implications of intra-abdominal hyper- tension and abdominal compartment syndrome: physical, mental, and fnancial. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus defnitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intra-abdominal pressure measurements in lateral decubitus versus supine position. Percutaneous catheter decompression in the treatment of elevated intra-abdominal pressure. Prospective study examining clinical out- comes associated with a negative pressure wound therapy system and Barker’s vacuum pack- ing technique. Further methods are used—albeit much less often—in everyday clinical practice [9–14]. Kaussen Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Street 1, 30625 Hannover, Germany e-mail: torsten. This rate decreases as the patients age, lying at ~4% in adolescents [17, 21, 22]. According to a retrospective investigation in adults, a decompressive laparotomy occurs on average 18 h following diagnosis Table 14. Generally speaking, the indication for invasive methods in pediatrics is clearly more conserva- tive. Experiences as well as developments in and around the care of congenital abdominal wall and diaphragmatic hernias have helped pave the way to the different laparostomata used in today’s pediatric surgery. Given the discrepancy between the abdominal space available and volume required for the transfer of prolapsed organs in neonatal patients, therapeutic procedures enabling successful abdominal wall closures and the survival of most children affected were not possible until the 1940s . This was after the development of the “Schuster procedure” and compa- rable ways of expanding the abdominal wall . Besides modern cardiocirculatory and respiratory intensive management, the availability of parenteral nutrition [48, 49] and calcula- ble anti-infective strategies can be viewed as evolutionary breakthroughs . In the second half of the twentieth century, laparostoma therapy began to be applied for other indications. Even with the advent of split-liver Txs in 1988 and living organ donations in 1989 (which increased the availability of smaller transplants), as well as the ability to approxi- mate the supply needed for infants , the volume of small split-liver transplants frequently exceeds the capacity of children’s abdomens (large-for-size Tx) and requires temporary expansion of the abdominal wall followed by an incremental closure over a period of days or weeks [17, 53–55]. During this time the abdominal wall and cavity’s capacity can expand and be adjusted where necessary. As patient age, level of physical activity, and personal mobility increase, the spectrum becomes more similar to that of adults, thus necessi- tating therapeutic laparostomata (e. The differentiation between a “prophylactic” and “therapeutic” laparotomy directly affects how intensive medicine is provided and correlates with Bjork et al. Anti-infection therapy must take the accompanying risk into consideration and be properly adjusted to the bacteria and resistance spectrum as quickly as possible. During this process the prophylactic or therapeutic broad- spectrum antibiosis should be supplemented with a systemic antimycotic (triazole or echinocandin) if the abdomen is expected to be open longer than 3 days. Beyond coding the degree of contamination, the Bjork classifcation describes the extent of peritoneal adhesion (1°, no adhesion; 2°, incipient adhesion; 3°, enterocutaneous fstula formation; 4°, frozen abdomen). Unlike in the treatment of adults, the latter two only occur as exceptions in pediatric and youth medicine . If diagnosed too late and/or treated inad- equately, it can lead to multiorgan failure as well as death. Metabolized products, infammation mediators, and radicals are released due to local compression, lym- phatic and venous stasis, and arterial perfusion defcits with ischemia and possibly reperfusion. However, against the backdrop of failing specifcity, a therapeu- tic consequence in the sense of a clinically useful biomarker was not able to be determined. Special pathogenic meaning is given to (1) the synthesis of infammation mediators, which are additionally facilitated by ischemia and reperfusion, and (2) the para- as well as endocrinal, resp. It is via the axis of these organs that a self-perpetuating activation of and damage to tissue (lung, liver, and gastrointestinal 170 T. Kaussen tract) can take place before the other organs and tissue are affected by the resulting cytokine storm [30–32]. Pressure, stasis, ischemia–reperfusion, and activation via mediators can accelerate infammation and the damage to mucosal barrier function of the respiratory and gastrointestinal so much enough that a hematogenic and/or lymphogenic translocation [67–69] of bacteria and fungi occurs [70–78]. This, in turn, leads to sepsis, which can further boost the circulus vitiosus of the systemic hyper-infammation. Therefore, the gastrointestinal tract is unfairly seen as the “motor of organ failure” [79–81] and should rather be considered part of the “axis of organ failure. Therefore, after abdominal decompression, intensive care physicians’ main tasks are to do the following as quickly as possible: 1. Aside from nursing aspects, there are no major dif- ferences for the intensive care physician in terms of management. In most cases the protective flm is changed aseptically, and/or revision assessments are made two to seven times a week.