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Intra-Abdominal Hypertension (IAH). &. Abdominal Compartment Syndrome (ACS). By: Tim Wolfe, MD Email: twolfe@wolfetory.com. What was their intra-abdominal pressure?. Have you ever seen a critically ill patient become progressively more swollen and edematous after fluid resuscitation?

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intra abdominal hypertension iah

Intra-Abdominal Hypertension (IAH)

&

Abdominal CompartmentSyndrome (ACS)

By: Tim Wolfe, MD

Email: twolfe@wolfetory.com

what was their intra abdominal pressure
What was their intra-abdominal pressure?
  • Have you ever seen a critically ill patient become progressively more swollen and edematous after fluid resuscitation?
  • Have any of your ICU patients developed renal failure requiring dialysis?
  • Have you ever seen a patient develop multiple organ failure and die?
case septic child
Case: Septic child

5 y.o. female presenting with septic syndrome

  • Treatment: Fluids, antibiotics, vasopressors
  • 24 hours into therapy develops worsening hypotension, oliguria, hypoxemia, hypercarbia. PIP rises from 20 to 40 cm
  • IAP = 26 mm Hg decompressive laparotomy
  • Immediate resolution of renal, pulmonary and hemodynamic compromise
  • 7 days later abdomen closed. Alive and well now.

DeCou, J Ped Surg 2000

case dyspnea in er
Case: Dyspnea in ER

67 y.o. female presenting to ER with pleurisy, dyspnea

  • Hypotensive, agitated, H&P suggest liver dz
  • IVF resuscitation, intubation, sedation
  • Worsened over next 4-6 hours - Difficult to ventilate, hypoxic/hypercarbic, hypotension, no UOP.
  • IAP = 45 mm Hg, abdominal ultrasound showed tense ascites paracentesis of 4500 cc fluid (IAP = 14)
  • Immediate resolution of renal, pulmonary and hemodynamic compromise.
  • Pathology shows malignant effusion – pancreatic CA.
  • Care withdrawn at later time and allowed to expire.

Etzion, Am J EM 2004

case aspiration patient
Case: Aspiration patient

77 y.o. male aspirated on general medicine floor. Transferred to MICU & intubated; hypotensive.

  • 10 liters IVF overnight, Levophed 40 mcg/min.
  • Anuric (35 ml urine in 8 hours).
  • IAP = 31 mm Hg. KUB – massively distended small and large bowel. U/S shows no free ascitic fluid.
  • Surgeon consulted for possible decompressive surgery
  • Rx: NGT, Rectal Tube, oral cathartics
  • 1 hour later: IAP 12 mm Hg, UOP 210 ml, norepinephrine discontinued.

Cheatham, WSACS 2006

case points
Case Points
  • Trauma is not required for ACS to develop:
    • Intra-abdominal hypertension and ACS occur in many settings (PICU, MICU, SICU, CVICU, NCC, OR, ER).
  • IAP measurements are clinically useful: Help to determine if IAH is contributing to organ dysfunction (i.e. useful if normal or abnormal)
  • “Spot” IAP check results in delayed diagnosis:
    • Waiting for clinically obvious ACS to develop before checking IAP changes urgent problem to emergent one.
  • IAP monitoring will allow early detection and early intervention for IAH before ACS develops.
d efinitions wcacs antwerp belgium 2007
DefinitionsWCACS, Antwerp Belgium 2007
  • Intra-abdominal Pressure (IAP): Intrinsic pressure within the abdominal cavity
  • Intra-abdominal Hypertension (IAH): An IAP > 12 mm Hg (often causing occult ischemia) without obvious organ failure
  • Abdominal Compartment Syndrome (ACS): IAH with at least one overt organ failing
types of iah acs wcacs antwerp belgium 2007
Types of IAH /ACSWCACS, Antwerp Belgium 2007
  • Primary – Injury/disease of abdomino-pelvic region, “surgical”
  • Secondary – Sepsis, capillary leak, burns, “medical”
  • Recurrent – ACS develops despite surgical intervention
iap interpretation
IAP Interpretation

Pressure (mm Hg) Interpretation

0-5 Normal

5-10 Common in most ICU patients

> 12 (Grade I) Intra-abdominal hypertension

16-20 (Grade II) Dangerous IAH - begin non-

invasive interventions

>21-25 (Grade III) Impending abdominal compartment

syndrome - strongly consider

decompressive laparotomy

physiologic insult critical illness
Physiologic Insult/Critical Illness

Inflammatory response

Ischemia

Fluid resuscitation

Capillary leak

Tissue Edema

(Including bowel wall and mesentery)

Intra-abdominal hypertension

causes of intra abdominal pressure iap elevation
Causes of Intra-abdominal Pressure (IAP) Elevation
  • Major abdominal / retroperitoneal problem
  • Ischemic insult / SIRS requiring fluid resuscitation with a positive fluid balance of 5 or more liters within 24 hours – (10 lb weight gain)

Where does all that fluid go?

physiologic sequelae
Physiologic Sequelae

Cardiac:

  • Increased intra-abdominal pressures cause:
    • Compression of vena cava with reduced venous return
    • Elevated intra-thoracic pressure with multiple negative cardiac effects
  • Result:
    • Decreased cardiac output, increased SVR
    • Increased cardiac workload
    • Decreased tissue perfusion
    • Misleading elevations of CVP and PAWP
    • Cardiac insufficiency; cardiac arrest
physiologic sequelae1
Physiologic Sequelae

Pulmonary:

  • Increased intra-abdominal pressures causes:
    • Elevated diaphragm, reduced lung volumes & alveolar inflation, stiff thoracic cage,, increased interstitial fluid

Result:

    • Elevated intrathoracic pressure (which further reduces venous return to heart, exacerbating cardiac problems)
    • Increased peak pressures, reduced tidal volumes
    • Barotrauma - atelectasis, hypoxia, hypercarbia
    • ARDS (indirect - extrapulmonary)
physiologic sequelae2
Physiologic Sequelae

Gastrointestinal:

  • Increased intra-abdominal pressures causes:
    • Compression / Congestion of mesenteric veins and capillaries
    • Reduced cardiac output to the gut

The result:

    • Decreased gut perfusion, increased gut edema and leak
    • Ischemia, necrosis
    • Bacterial translocation
    • Development and perpetuation of SIRS
    • Further increases in intra-abdominal pressure
physiologic sequelae3
Physiologic Sequelae

Renal:

  • Elevated intra-abdominal pressure causes:
    • Compression of renal veins, parenchyma
    • Reduced cardiac output to kidneys

The Result:

    • Reduced blood flow to kidney
    • Renal congestion and edema
    • Decreased glomerular filtration rate (GFR)
    • Renal failure, oliguria/anuria
      • Mortality of renal failure in ICU is over 50% - DO NOT WAIT for this to occur!
physiologic sequelae4
Physiologic Sequelae

Neuro:

  • Elevated intra-abdominal pressure causes:
    • Increases in intrathoracic pressure
    • Increases in superior vena cava (SVC) pressure with reduction in drainage of SVC into the thorax

The Result:

    • Increased central venous pressure and IJ pressure
    • Increased intracranial pressure
    • Decreased cerebral perfusion pressure
    • Cerebral edema, brain anoxia, brain injury
slide18

Circling the Drain

Intra-abdominal Pressure

Mucosal

Breakdown

(Multi-System Organ Failure)

Bacterial translocation

Acidosis

Decreased O2 delivery

Anaerobic metabolism

Capillary leak

Free radical formation

MSOF

iah acs affects outcome
IAH / ACS affects outcome

Points:

  • IAH and ACS are common entities in the critical care environment (including your own).
  • IAH and ACS increase morbidity, mortality and ICU length of stay…………

However:

  • Clinical signs of IAH are unreliable and only show up late in the clinical course …..SO
  • Early monitoring (TRENDING) & detection of IAH with early intervention is needed to reduce these complications.
abdominal perfusion pressure app
Abdominal Perfusion Pressure (APP)

APP = MAP – IAP

  • Abdominal perfusion pressure reflects actual gut perfusion better than IAP alone
  • Optimizing APP to > 60 mm Hg should probably be primary endpoint
decompressive laparotomy
Decompressive Laparotomy
  • Delay in abdominal decompression may lead to intestinal ischemia
  • Decompress early!
intra abdominal pressure monitoring1
Intra-Abdominal Pressure Monitoring

Bladder pressure monitoring through the Foley catheter is:

  • The current standard for monitoring abdominal pressures(Consensus, World Congress ACS Dec 2004)
  • Comparable to direct intraperitoneal pressure measurements, but is non-invasive(Fusco 2001, Davis 2005, Risin 2006, Schachtrupp 2006)
  • More reliable and reproducible than clinical judgment(Kirkpatrick, CJS 2000; Sugrue World J Surg 2002)
home made pressure transducer technique
“Home Made” Pressure Transducer Technique

Home-made assembly:

  • Transducer
  • 2 stopcocks
  • 1 60 ml syringe,
  • 1 tubing with saline bag spike / luer connector
  • 1 tubing with luer both ends
  • 1 needle / angiocath
  • Clamp for Foley

Assembled sterilely in proper fashion

home made pressure transducer technique1
“Home Made” Pressure Transducer Technique

PROBLEMS:

  • Home-made:
    • No standardization
    • Sterility issues
  • Time consuming – therefore it is used infrequently due to the hassle factor (i.e. not monitoring - waiting for ACS)
  • Data reproducibility errors - what are the costs / morbidity of inaccurate or delayed information?
  • Other: Needle stick, recurrent penetration of sterile system, leaks, re-zeroing problems, failure to trend
bladder pressure monitoring how to do it
Bladder Pressure Monitoring: How to do it

Commercially available devices :

  • Foley Manometer – (Bladder manometer)
  • CiMon (Gastric)
  • Spiegelberg (Gastric)
  • AbViser – (Bladder transduction)

Advantages – Simple, standardized, reproducible, time-efficient, sterile

abviser intra abdominal pressure monitoring kit
AbViser Intra-Abdominal Pressure Monitoring Kit

Closed system in-line with the Foley catheter

  • Once attached it is left in place during entire time IAP is measured.
  • 30 seconds to measure IAP
  • Standardized measurement
  • No reproducibility errors
intra abdominal pressure monitoring2
Intra-Abdominal Pressure Monitoring
  • How much fluid should be infused into the bladder?
    • The minimal amount of fluid required to obtain a reliable IAP measurement.
    • Too much fluid leads to bladder over distention and bladder wall compliance issues
    • Currently it appears that one never needs more than 25 ml in an adult, less (10-20 ml) is probably adequate
final thoughts
Final Thoughts

Do NOT wait for signs of ACS to check IAP

    • By then the patient has one foot in the grave!
    • You have lost your opportunity for medical therapy

Monitor ALL high risk patients early and often:

    • TREND IAP like a vital sign
  • 30-50+% of all ICU patients have some IAH and are at risk for ACS
  • 1 in 11 suffer full blown abdominal compartment syndrome
for more information
For More Information

IAH and ACS Educational Web sites:

www.abdominal-compartment-syndrome.org

http://www.wolfetory.com/education.html

Video to review concepts of monitor set-up:

http://www.wolfetory.com/abviser_autovalve.html

My email:

twolfe@wolfetory.com