HOLTECH MEDICAL Intra-abdominal Pressure Monitoring Clinical Background 15. marts 2018 www. holtech-medical. com 1
www. WSACS. org Definitions • • Normal range: IAP<10 -12 mm. Hg Intra-abdominal Hypertension = IAH = IAP > 12 mm. Hg ACS = IAP > 20 mm. Hg+1 new organ failure • APP (abdominal perfusion pressure) = MAP – IAP (same concept as CPP) 15. marts 2018 www. holtech-medical. com 2
Why monitor IAP? • IAH occurs in more than 50% of all surgical and medical • • ICU patients (ref. 1) IAH adversely affects venous return and microcirculation IAH is associated with significantly increased morbidity and mortality (ref. 2) IAH adversely affects all organs and promotes MOF (ref. 3) IAH causes a covert elevation of CVP, PAOP, ICP (ref. 4) Ref. 1: Manu Malbrain et al: Prevalence of intra-abdominal hypertension in critically ill patients: A multicentre epidemiological study. ICM 2004, 30: 822 -9. Ref. 2: Manu LNG Malbrain et al: Incidence and prognosis of Intraabdominal hypertension in a mixed population of critically ill patients: A multicentre epidemiological study. CCM 2005 Vol. 33, No. 2. Ref. 3: Manu LNG Malbrain: Is it wise not to think about intraabdominal hypertension in the ICU? Curr Opin Crit Care 2004; 10: 132 -145. Ref. 4: Cheatham ML et al: Preload assessment in patients with an open abdomen. J Trauma 1999; 46: 16 -22. 15. marts 2018 www. holtech-medical. com 3
Pathophysiology CARDIOVASCULAR SYSTEM CENTRAL NERVOUS SYSTEM Intracranial pressure Cerebral perfusion pressure Idiopathic intracranial hypertension (obesity) RESPIRATORY SYSTEM Intrathoracic pressure Difficult preload assessment Pleural pressure Wedge pressure Functional residual capacity Central venous pressure All lung volumes Intra thoracic blood volume index = (~restrictive disease) Extra vascular lung water = Auto-PEEP ? Right ventricular end-diastolic volume index Peak airway pressure = Plateau pressures Cardiac output Dynamic compliance Venous return Static compliance Systemic vascular resistance RENAL SYSTEM Chest wall compliance Venous thrombosis Hypercarbia Renal blood flow Pulmonary embolism Pa. O 2 Diuresis Heart rate = Pa. O 2/Fi. O 2 Tubular dysfunction Mean arterial pressure GASTRO-INTESTINAL = Glomerular filtration rate Dead-space ventilation SYSTEM HEPATICPulmonary artery pressure SYSTEM Renal vascular resistance Intrapulmonary shunt Celiac blood flow Hepatic arterial flow Renal vein compression Lower inflection point Superior mesenteric artery blood flow Portal venous blood flow Compression ureters Upper inflection point Blood flow to intra-abdominal organs Portocollateral flow Anti-diuretic hormone Prolonged ventilation ? Mucosal blood flow Lactate clearance Difficult weaning ? Adrenal blood flow = Mesenteric vein compression Glucose metabolism Intramucosal p. H Mitochondrial function ABDOMINAL WALL Regional CO 2 Cytochrome p 450 function Compliance CO 2 -gap Rectus sheath blood flow Success enteral feeding ? Wound complications Intestinal permeability Incisional hernia Bacterial translocation ? 15. marts 2018 www. holtech-medical. com 4 Multiple organ failure ? Malbrain. Current Opinion Crit Care 2004; 10(2): 132 -145 Gastro-intestinal (re)bleeding
IAP affects blood pressure • IAP affects all blood pressures • CVP increases by 3 -6 mm. Hg when IAP increases by 10 mm. Hg. An example: • IAP=10 mm. Hg, CVP=10 mm. Hg. A sudden increase of IAP to 20 mm. Hg changes CVP to 15 mm. Hg. Now, what’s the correct CVP? • PAOP, ICP, and lung pressures are also • affected by IAP. Correct interpretation of pressures is supported by IAP monitoring 15. marts 2018 www. holtech-medical. com 5
IAH prevalence in 13 EU ICUs Cut-Off Total (n=97) Medical (n=57) Surgery (n=40) IAPmax>= 12 mm. Hg 57(58. 8%) 31(54. 4%) 26(65%) IAPmax>= 15 mm. Hg 28(28. 9%) 17(29. 8%) 11(27. 5%) IAPmax>=20 mm. Hg 8(8. 2%) 6(10. 5%) 2(5%) IAPmean>=12 mm. Hg 23(23. 7%) 14(24. 6%) 9(22. 5%) IAPmean>=15 mm. Hg 9(9. 3%) 7(12. 3%) 2(5%) IAPmean>=20 mm. Hg 4(4. 1%) 2(3. 5%) 2(5%) Malbrain. Intensive Care Med. 2004 DOI 10. 1007/s 00134004 -2169 -9 (online first) 15. marts 2018 www. holtech-medical. com 6
265 pts in 14 ICUs in EU 28 -day Mortality: 23% 38% 15. marts 2018 www. holtech-medical. com 7
Indications for IAP monitoring • • Postoperative (abdom. Surgery) pts Pts with abdominal trauma Ventilated pts with other Organ Failure Pts with signs of ACS: • Oliguria, hypoxia, hypotension, acidosis, mesenteric ischemia, ileus, elevated ICP. • Pts with high cumulative fluid balance • Pts with abdominal packing 15. marts 2018 www. holtech-medical. com 8
Which IAP measurement interval? • IAH may develop rapidly • Monitor the trend: rising IAP or sustained IAH poor prognosis • Recommendation: Measure IAP at each Urine Output determination 15. marts 2018 www. holtech-medical. com 9
IAH treatment options WSACS recommendations • Non-surgical treatment options: • • • Paracenthesis Gastric suctioning, enemas Gastro/colon prokinetics Furosemide, with or without albumin CVVH with aggressive ultrafiltration Sedation or curarisation • Surgical: Decompression 15. marts 2018 www. holtech-medical. com 10
WSACS’ protocol 15. marts 2018 www. holtech-medical. com 11
University of Utah: IAP monitoring algorithm • Entry criteria defined in table • Nurse is empowered to enter any patient fulfilling these criteria 15. marts 2018 www. holtech-medical. com 12
University of Utah: IAP Monitoring Protocol IAP monitoring Q 1 -2 hours for first 12 hours IAP consistently <12 mm Hg IAP 12 to 15 mm Hg IAP 15 -20 mm Hg with no evidence of organ dysfunction/ ischemia (ACS) IAP >20 mm Hg OR APP< 50 -60 mm Hg? Plus evidence of organ dysfunction/ ischemia (ACS) Optimize Abdominal perfusion pressure • Careful fluid management • Pressors Reduce IAP measurements Consider Medical Management to Q 4 -6 hours • Sedation/Neuromuscular blockade for 24 hours • Paracentesis of free fluid • Other options Surgical -Gastric suction, cathartics Decompression “Second Hit” pt. IAP remains -Rectal tube/enemas develops new <12 mm Hg -Continuous filtration indication for IAP discontinue -Colloids monitoring 15. marts 2018 www. holtech-medical. com 13
Why monitor IAP rather than ACS • Monitoring IAP and normalizing IAH may prevent ACS from happening. It´s like having a SMOKE DETECTOR in your home: It gives you time to locate the smoke (IAH) and cure the problem before the house catches fire (ACS) 15. marts 2018 www. holtech-medical. com 14
How to measure IAP? • Patient position: Supine • Bladder must be empty • Always use same 0 mm. Hg reference = symph. pubis, or mid-axillary line. 15. marts 2018 www. holtech-medical. com 15
The easy way: 40 mm. Hg 1. Urine drainage: The urine fills the Foley. Manometer and flows on to the urine collection device Pves Mid-ax line = 0 mm. Hg 2. Measure intra-vesical pressure: The urine in the vertical manometer tube returns to the bladder when the vent clamp is opened. Hold the “ 0 mm. Hg” mark of the manometer at the midaxillary line/iliac crest, and read Pvesical at the position of the meniscus 15. marts 2018 www. holtech-medical. com 16
Find more information • World Society on ACS www. wsacs. org • • Complete reference list • Consensus definitions • IAP discussion list • Links www. holtech-medical. com • Product information • Clinical issues • Key references 15. marts 2018 www. holtech-medical. com 17
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