Hemodynamic optimization in intra-abdominal hypertension

1. Hemodynamic optimization in intra-abdominal hypertension Jan J. De Waele MD PhD Surgical ICU Ghent University Hospital Ghent, Belgium.

2. Introduction • Hemodynamics? • Blood pressure • Cardiac function • Macro-circulation • Micro-circulation and end-organ function may still be affected despite “normal hemodynamics”

3. IAH affects the cardiovascular system

4. IAP  Vascularcompression Thoracicpressure Organcompression Venous return  Cardiaccompression Renin Aldosteron Preload Contractility Afterload  Cardiac output 

5. Preload evaluation in IAH is different

6. How does IAH affect preload • Cheatham ML et al., Acta Clin Belg Suppl 2007, 98-112.

7. IAH and preload monitoring • 1. Intrathoracic pressure increase • Diaphragm elevation • Affected: • Central venous pressure • PAOP • Pleural pressure • SVV, PPV ITP ↑ IAP ↑

8. IAH and preload monitoring • 2. Inferior vena cava flow decrease • Direct pressure on IVC • Affected: • Passive leg raising (PLR)

9. IAH and preload monitoring • 3. Cardiac volumes decrease • Diaphragm elevation – cardiac compression • Affected: • GEDV, ITBV • LVEDA

10. Preload evaluation in IAH • CVP/PAOP • After Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145

11. Preload evaluation in IAH • SVV and PPV • Duperret S, Intensive Care Med 2007 33: 163-171. Hypovolemia Normovolemia

12. Preload evaluation in IAH • SVV and PPV • Jacques D, Crit Care 2011 15: R33. Hypovolemia Normovolemia

13. Preload evaluation in IAH • GEDV

14. Prediction of fluid responsiveness

16. Preload evaluation in IAH • Passive leg raising • Malbrain ML, Crit Care Med 2010 38: 1912-5.

17. Preload evaluation in IAH • Passive leg raising • 31 fluid responsive patients • 48% false negative • IAP >16mmHg ideal cutoff • Mahjoub Y, Crit Care Med 2010 38: 1824-9.

18. Preload evaluation in IAH • LVEDA • Vivier E et al. Br J Anaesth 2006; 96: 701–7

19. Preload and IAH: conclusion • Application of IAH • Volumetric parameters decrease • Barometric parameters increase • Dynamic indices suggest fluid responsiveness but may be false negative (PLR)

20. Optimizing preload in IAH

21. Preload optimization in IAH • Fluid responsiveness = fluid depletion? • Signs of hypoperfusion? • Avoid treating numbers

22. Practical implications for IAH patients • IAH mimicks • Fluid overload • Fluid requirement • Fluid responsiveness • → SVV and PPV • Accept higher tresholds • Avoid fluid overload – vicious cycle!

23. Practical implications for IAH patients • IAH mimicks • Fluid overload • Fluid requirement • Fluid responsiveness • → CVP/PAOP • Use transmural pressure?

24. Practical implications for IAH patients • → Use transmural filling pressures! • CVPTM = CVP - IAP/2 • PAOPTM = PAOP - IAP/2 CVP  PAOP  ITP 

25. Practical implications for IAH patients • IAH mimicks • Fluid overload • Fluid requirement • Fluid responsiveness • → Passive leg raising • Beware of false negative results • Not to be used at all?

26. The most effective method for hemodynamic optimization is reducing the intra-abdominal pressure

27. Targets for medical management

28. www.wsacs.org

29. PCD as an alternative for laparotomy • Cheatham ML, Chest 2011 140: 1428-35. • 31 patients • 54y, 65% male • APACHE II 24 • SOFA 8 • Indication for PCD • ACS 71% • IAH 23% • Hemoperitoneum 6% • Matched to open decompression patients

30. PCD as an alternative for laparotomy • Cheatham ML, Chest 2011 140: 1428-35.

31. Laparotomy remains effective • Chiara O, Minerva Anestesiol 2011 77: 457-62.

32. Before I came here I was confused about this subject. Having listened to your lecture I am still confused. But on a higher level. • Enrico Fermi

33. Take home messages • IAH affects the cardiovascular system • All methods of preload evaluation are influenced by IAH • Fluid administration not to used lightly • Lowering IAP is the best method for hemodynamic optimization

34. Thank you for your attention Email: Jan.DeWaele@UGent.be Twitter: @CriticCareDoc