Abdominal Hypertension No Photos

8/11/2019 Abdominal Hypertension No Photos

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What was their intra-abdominal pressure?

Have you ever seen a critically ill patient become

progressively more swollen and edematous afterfluid resuscitation?

Have any of your ICU patients developed renalfailure requiring dialysis?

Have you ever seen a patient develop multiple

organ failure and die?


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Case: Septic child5 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 andhemodynamic compromise 7 days later abdomen closed. Alive and well

now.DeCou, J Ped Surg 2000


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Case: Dyspnea in ER67 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 Care withdrawn at later time and allowed to expire.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


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Case: Aspiration patient77 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 distendedsmall and large bowel. U/S shows no free asciticfluid.

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


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Case Points Trauma is not required for ACS to develop:

Intra-abdominal hypertension and ACS occur inmany settings (PICU, MICU, SICU, CVICU, NCC,OR, ER).

IAP measurements are clinically useful: Help to

determine if IAH is contributing to organdysfunction (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 emergentone. IAP monitoring will allow early detection and

early intervention for IAH before ACS develops.


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DefinitionsWCACS, Antwerp Belgium 2007

Intra-abdominal Pressure (IAP): Intrinsicpressure within the abdominal cavity

Intra-abdominal Hypertension (IAH): AnIAP > 12 mm Hg (often causing occultischemia) without obvious organ failure

Abdominal Compartment Syndrome(ACS): IAH with at least one overt organfailing


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Types of IAH /ACS WCACS, Antwerp Belgium 2007

Primary Injury/disease of abdomino-pelvic region, surgical

Secondary Sepsis, capillary leak, burns,medical

Recurrent ACS develops despitesurgical intervention


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IAP Interpretation

Pressure (mm Hg) Interpretation0-5 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 compartmentsyndrome - strongly considerdecompressive laparotomy


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Causes of Intra-abdominalPressure (IAP) Elevation

Major abdominal / retroperitoneal problem

Ischemic insult / SIRS requiring fluidresuscitation with a positive fluid balance of 5 ormore liters within 24 hours (10 lb weight gain)

Where does all that fluid go?


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Intra-abdominal Hypertension&

Abdominal CompartmentSyndrome

Physiologic Sequelae


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Cardiac: Increased intra-abdominal pressures cause:

Compression of vena cava with reduced venous

return Elevated intra-thoracic pressure with multiplenegative cardiac effects

Result:

Decreased cardiac output, increased SVR Increased cardiac workload Decreased tissue perfusion Misleading elevations of CVP and PAWP

Cardiac insufficiency; cardiac arrest


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Pulmonary: Increased intra-abdominal pressures causes:

Elevated diaphragm, reduced lung volumes &

alveolar inflation, stiff thoracic cage,, increasedinterstitial fluidResult:

Elevated intrathoracic pressure (which furtherreduces venous return to heart, exacerbating

cardiac problems) Increased peak pressures, reduced tidal volumes Barotrauma - atelectasis, hypoxia, hypercarbia ARDS (indirect - extrapulmonary)


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Gastrointestinal: Increased intra-abdominal pressures causes:

Compression / Congestion of mesenteric veins andcapillaries

Reduced cardiac output to the gutThe result:

Decreased gut perfusion, increased gut edema andleak

Ischemia, necrosis Bacterial translocation Development and perpetuation of SIRS Further increases in intra-abdominal pressure


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Renal: Elevated intra-abdominal pressure causes:

Compression of renal veins, parenchyma Reduced cardiac output to kidneysThe 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 WAITfor this to occur!


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Neuro: Elevated intra-abdominal pressure causes:

Increases in intrathoracic pressure

Increases in superior vena cava (SVC) pressurewith 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


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Circling the Drain

Intra-abdominal Pressure

MucosalBreakdown

(Multi-System Organ Failure)

Bacterial translocation

Acidosis

Decreased O2 delivery

Anaerobic metabolism

Capillary leak

Free radical formation


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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 thesecomplications.


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Management of IAH and ACS


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Abdominal Perfusion Pressure (APP)

APP = MAP IAP

Abdominal perfusion pressure reflectsactual gut perfusion better than IAPalone

Optimizing APP to > 60 mm Hg shouldprobably be primary endpoint


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IAH/ACS Management:

Decompressive Laparotomy


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Decompressive Laparotomy

Delay in abdominal decompressionmay lead to intestinal ischemia

Decompress early!


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Intra-Abdominal Pressure

Monitoring


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Intra-Abdominal PressureMonitoring

Bladder pressure monitoring through theFoley catheter is: The current standard for monitoring

abdominal pressures (Consensus, World Congress ACS Dec 2004)

Comparable to direct intraperitoneal pressuremeasurements, 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 Surg2002)


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Home Made Pressure TransducerTechnique

Home-made assembly: Transducer 2 stopcocks 1 60 ml syringe, 1 tubing with saline

bag spike / luerconnector

1 tubing with luer both

ends 1 needle / angiocath Clamp for Foley Assembled sterilely in

proper fashion


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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


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AbViser Intra-Abdominal PressureMonitoring Kit

Closed system in-line with the Foleycatheter

Once attached it is left in place duringentire time IAP is measured.

30 seconds to measure IAP

Standardized measurement

No reproducibility errors


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Intra-Abdominal PressureMonitoring

How much fluid should be infused intothe 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) isprobably adequate


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WSACSGuidelines

Cheatham, ICM 2006


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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:[email protected]
http://www.abdominal-compartment-syndrome.org/http://www.wolfetory.com/education.htmlhttp://www.wolfetory.com/abviser_autovalve.htmlmailto:[email protected]:[email protected]://www.wolfetory.com/abviser_autovalve.htmlhttp://www.wolfetory.com/education.htmlhttp://www.abdominal-compartment-syndrome.org/http://www.abdominal-compartment-syndrome.org/http://www.abdominal-compartment-syndrome.org/http://www.abdominal-compartment-syndrome.org/http://www.abdominal-compartment-syndrome.org/

Abdominal Hypertension No Photos

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