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News on intra-abdominal hypertension – focus on fluids and hemodynamics

News on intra-abdominal hypertension – focus on fluids and hemodynamics. Conflicts of interest. World Society of the Abdominal Compartment Syndrome Secretary – Inneke De laet President – Jan De Waele. Fluids and intra-abdominal pressure (IAP): what’s new?. Inneke De laet ZNA Stuivenberg.

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News on intra-abdominal hypertension – focus on fluids and hemodynamics

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  1. News on intra-abdominal hypertension – focus on fluids and hemodynamics

  2. Conflicts of interest • World Society of the Abdominal Compartment Syndrome • Secretary – Inneke De laet • President – Jan De Waele

  3. Fluids and intra-abdominal pressure (IAP): what’s new? Inneke De laet ZNA Stuivenberg

  4. What is IAP? Definitions

  5. Effect on organ function CNS: ICP CPP Pulmonary: intrathoracic pressure  PIP  Paw  Cdyn  paO2  paCO2  Qs/Qt  Vd/Vt  Cardiac: CVP PCWP SVR COvenous return HR= MAP= IAH Hepatic: portal blood flow  lactate clearance  mitochondrial function  Renal: diuresis  renal blood flow  RVR  GFR  Visceral: Feeding intolerance  SMA blood flow  mucosal blood flow  pHi  Abdominal Wall: compliance  rectus sheath blood flow 

  6. IAP is associated with mortality Reintam A et al., Intensive Care Med 2008, 34: 1624-31. Prospective observational study in mechanically ventilated mixed ICU patients

  7. Relationship fluids and IAP Conclusions: Among mixed ICU patients, … and the volume of crystalloids used in their initial resuscitation appear to be important considerations in determining risk of IAH/ACS Risk factors for IAH … among mixed ICU patients included obesity, sepsis, abdominal surgery, ileus development and fluid resuscitation.

  8. WSACS medical management algorithm www.wsacs.org

  9. Evacuatingintraluminal contents Evacuating extraluminal contents Improvingabdominal compliance Controlling fluidbalance Optimizing systemic /regionalperfusion Determinewhichmechanism(s) is/are most likelyto benefit the patient Patientdevelops IAH (IAP>12mmHg)

  10. Evacuatingintraluminal contents Evacuating extraluminal contents Improvingabdominal compliance Controlling fluidbalance Optimizing systemic /regionalperfusion Determinewhichmechanism(s) is/are most likelyto benefit the patient Patientdevelops IAH (IAP>12mmHg)

  11. How to deal with IAP and fluids

  12. Limiting crystalloid resuscitation

  13. Colloidstoreduce fluid requirement? • Some data in patients with SAP, e.g. • Retrospective analysis of 47 patients with SAP • 3 groups: • Low ratio group: crystalloid colloid ratio of <1,5 • Middle ratio group: crystalloid colloid ratio of 1,5-3 • High ratio group: crystalloid colloid ratio of >3 Chang YS et al. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013 Jan: 25(1): 48-51

  14. Choice of fluids: colloids *: statistically significant Chang YS et al. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013 Jan: 25(1): 48-51

  15. Choice of fluids: colloids *: statistically significant Chang YS et al. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013 Jan: 25(1): 48-51

  16. Colloidstoreduce fluid requirement? Too many data about adverse outcomeswithsyntheticcolloids Adverse effects of excessivecrystalloidresuscitation are well documtented Thereseemstobe a needfor a solution withcolloidproperties without the complications So, back to the naturalcolloids (plasma, albumin)?

  17. Plasma: the “new” colloid? O'Mara MS et al, J Trauma 2005, 58(5):1011-1018.

  18. Choice of fluids: plasma? • RCT in patients with SAP comparing 3 fluid regimens: • Control group: Ringer’s lactate + HES (2:1), routine resuscitation • EGDT 1 group: Ringer’s lactate + HES, EGDT (CVP, MAP, diuresis, ScvO2 or SvO2) • EGDT 2 group: Ringer’s lactate, HES, 2 units of FFP daily for 3 days, EGDT • n=200 • Results: Wang MD et al. Chin Med J (Engl) 2013 May: 126(10): 1987-8

  19. Choice of fluids: plasma? Wang MD et al. Chin Med J (Engl) 2013 May: 126(10): 1987-8

  20. Choice of fluids: plasma? • Secondary outcomes: • Ventilation days: control > EGDT 1 > EGDT 2 • ICU length of stay: control > EGDT 1 > EGDT 2 • Fluid resuscitation: control = EGDT 1 > EGDT 2 • Cumulative fluid balance: control = EGDT 1 > EGDT 2 • Negative fluid balance on day 3 was achieved only in the EGDT 2 group

  21. Use of plasma as a colloid • Pro: • Should avoid complications associated with synthetic molecules • May be biologically active • Con: • Expensive • Limited availability • May be biologically active (possibility of immunologic complications, inflammatory complications, TRALI, TEE…)

  22. Use of albuminto limit crystalloids • Only 1 retrospective study on PAL treatment • No prospective data in resuscitation settings incorporating IAP • Surviving Sepsis Campaign Guidelines 2013: “we suggest the use of albumin in the resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids.” • Controversy remains about methodology of studies supporting these recommendations

  23. Removing excess fluid

  24. Conservative fluid strategiesseemto impact outcome Murphy et al, Chest 2009: 136B(1): 102-109

  25. Can diuretics be used? • Pro: • Can achieve fluid removal • Questions: • Renal function? • Will injured kidney(s) respond? • Haemodynamic tolerance?

  26. Works in ADHF Mullens et al, J Am Coll Card 2008; 51 (3): 300-306

  27. PAL treatment • Hypothesis: • Combined therapy with PEEP, albumin and frusemide • Should mobilize interstitial fluid to the vascular compartment and evacuate fluids through diuresis • Retrospective matched control case series (n=114)

  28. PAL treatment and outcome Cordemans C et al. Ann Intens Care 2012, 2(Suppl 1): S15

  29. BUMIAP study • Retrospective study on all patients receiving loop diuretics while monitoring IAP (Ghent University Hospital)

  30. In patients with IAH and negative fluid balance, IAP was significantly decreased after 24h of bumetanide (difference -1.32mmHg ± 0.50, p<0.001)

  31. Alternative: ultrafiltration • Pro: • Can be applied in patients with AKI • Can achieve fluid removal • Con: • Hemodynamic consequences? • Adverse effect on renal function or renal recovery? • Riisk of catheter related and RRT related complications

  32. If the diuretics don’t work Mullens et al. J Card Fail 2008; 14 (6): 508-514

  33. CRRT: some small reports Kula et al.Intens Care Med 2004; 30: 2138-2139

  34. Conclusions Crystalloid fluid resuscitation is the most important risk factor for secondary IAH/ACS Secondary IAH/ACS carries a high morbidityandmortality We needbetter fluid strategiesto limit the amount of crystalloidresuscitation We needprospective studies on albumin (and plasma?) used as add-onresuscitationforpatientswithdistributive shock requiring large amounts of crystalloids

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