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Intra-abdominal Hypertension

39

 

Rajesh Chawla and Sananta K. Dash

 

A 53-year-old female patient was admitted to the ICU postoperatively after cholecystectomy for a failed endoscopic retrograde cholangiopancreatography for retrieval of common bile duct stones. She had recent history of gallstoneinduced pancreatitis. On the fifth postoperative day, she suddenly became tachypneic and complained of abdominal tightness. She continued to have respiratory distress and later on was intubated in view of severe respiratory distress and hypoxemia. While on the ventilator, her peak airway pressure and the plateau pressure were very high.

Raised intra-abdominal pressure and abdominal compartment syndrome are commonly noticed in critically ill patients. In the recent past, their presence in a variety of medical and surgical conditions other than trauma has been emphasized. Early detection, prevention, and treatment reduce the morbidity and mortality in these critically ill patients.

Understand definitions

IAP (intra-abdominal pressure): It is the pressure concealed within the abdominal cavity. Normal IAP is approximately 5–7 mmHg in critically ill adults. Physiological changes occur when the IAP rises up to 15 mmHg.

APP (abdominal perfusion pressure) (MAP-IAP): It is a better reflection of gut perfusion.

R. Chawla, M.D., F.C.C.M. (*)

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: drchawla@hotmail.com

S.K. Dash, M.D.

Department of Respiratory & Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,

311

DOI 10.1007/978-81-322-0535-7_39, © Springer India 2012

 

312

R. Chawla and S.K. Dash

 

 

IAH (intra-abdominal hypertension): A sustained or repeated pathologic elevation of IAP more than or equal to 12 mmHg and is divided into four grades:

Grade I, IAP 12–15 mmHg

Grade II, IAP 16–20 mmHg

Grade III, IAP 21–25 mmHg

Grade IV, IAP >25 mmHg

ACS (abdominal compartment syndrome): A sustained IAP of more than 20 mmHg (with or without an APP <60 mmHg) that is associated with new organ dysfunction/failure.

Primary goal is an APP more than or equal to 60 mmHg.

Primary ACS: A condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or radiological intervention.

Secondary ACS: ACS due to conditions that do not originate from the abdominopelvic region.

Recurrent ACS: The condition in which ACS redevelops following previous surgical or medical treatment of the primary or secondary ACS.

Approach to a patient with IAH

Step 1: Initial resuscitation

Initiate resuscitation as mentioned in Chap. 78.

The elevated IAP has a direct effect on pulmonary and cardiac functions.

Pulmonary compliance suffers with resultant progressive reduction in total lung capacity, functional residual capacity, and residual volume and is manifested by hypoxia, hypercapnia, and increasing ventilatory pressure.

Elevated IAP above 20 mmHg consistently correlates with reduction in cardiac output.

IAP above 20 mmHg produces elevations in measured hemodynamic parameters including central venous pressure and pulmonary artery wedge pressure. Half of IAP should be subtracted from these measures of vascular pressures to arrive at an approximately true pressure.

Step 2: Assess the possible risk factors for IAH/ACS

IAH or ACS can be the result of abnormality in any of the four constituents that determine the IAP (Fig. 39.1):

I. Abdominal wall compliance

II. Intraluminal contents

III. Abdominal contents

IV. Capillary leak/fluid resuscitation

Step 3: Take focused clinical history and do physical examination

The mode of presentation and associated conditions many a times gives a clue to the possible cause of IAH and ACS in a patient. History should be taken on the basis of the background condition. Do detailed general and abdominal examination (Fig. 39.2).

39 Intra-abdominal Hypertension

313

 

 

I. Decreased abdominal wall compliance

Acute respiratory failure (increased intrathoracic pressure)

Abdominal surgery with primary fascial or tight closure

Major trauma/burns

Prone positing, head of bed more than 30°

II. Increased intra-luminal contents

Gastroparesis

Ileus

Colonic pseudo-obstruction

III. Increased abdominal contents

Hemoperitoneum/pneumoper itoneum

Ascites/liver dysfunction

Fig. 39.1 Risk factors for IAH/ACS

I

A

H

or

A

C

S

IV. Increased capillary leak/fluid resuscitation

Acidosis (pH <7.2)

Hypotension

Hypothermia (core temperature <33°C)

Polytransfusion (>10 units of blood/24 hours)

Coagulopathy (platelets

<55,000/mm, PT >15 seconds or PTT>2 times normal, or INR >1.5)

Massive fluid resuscitation (>5 L/24 hours)

Pancreatitis

Oliguria

Sepsis

Major trauma/burns

Damage control laparotomy

IAP >12 mmHg

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there any

 

 

 

H/O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is it spontaneous?

 

 

 

 

Is the patient

 

 

 

 

Laparoscopy, abdominal

 

 

 

 

postoperative?

 

 

history of trauma?

 

packing, abdominal closure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

under tension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

Peritonitis

1.

Peritonitis

 

1.

Retroperitoneal

 

 

Think of surgery

 

 

 

bleeding

 

 

2.

Intra-abdominal abscess

2.

Abscess

 

 

 

 

 

related Iatrogenic

 

2.

Postresuscitation

 

 

3.

Intestinal obstructions

3.

Ileus

 

 

 

causes

 

 

 

visceral oedema

 

 

4.

Ruptured abdominal

4.

Intraperitoneal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Hemoperitoneum

 

 

 

 

 

aorticaneurysm

 

 

hemorrhage

 

 

 

 

 

 

 

 

 

4.

Vascular injury,

 

 

 

 

5.

Tension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

splenic rupture

 

 

 

 

 

pneumoperitoneum,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.Acute pancreatitis

7.Acute mesenteric ischemia

Fig. 39.2 General and abdominal examination

314

R. Chawla and S.K. Dash

 

 

Step 4: Measure IAP

IAP can be measured either directly (through needle puncture of the abdomen during laparoscopy or peritoneal dialysis treatment) or indirectly (using intravesicular pressure or gastric pressure through a balloon catheter as a surrogate of IAP). The transvesicular IAP measurement techniques are based on the same principle; namely, that a fluid column in the bladder catheter and tubing to the collecting bag serve as a pressure-transducing medium.

Method 1

An assembly is made, as shown in Fig. 39.3.

An 18-gauge needle or an angiocath (A) with tubing is inserted into the urinary catheter port, as shown in the figure.

Clamp the urinary catheter distal to angiocath insertion site.

The tubing (B) is then attached to a pressure transducer (C).

Fill the syringe with saline and infuse 20–30 ml of saline in to the bladder.

Keep the second stop cork (D) opened to air and closed to patient. Calibrate the transducer to zero at the level of iliac crest.

IAP is measured 30–60 s after instillation to allow for bladder detrusor muscle relaxation (for bladder technique), and it is ensured that there are no active abdominal muscle contractions.

The pressure is measured at end-expiration in the supine position, with iliac crest in the midaxillary line taken as the zero level.

If available, Foley’s catheter with a third sample collection port is preferable in place of needle or angiocath for IAP measurement as it avoids puncturing of the Foley’s tube with needle.

Method 2

The drainage tubing is first marked with a silk tape/permanent marker along its length.

The drainage tube is marked as “0” which serves as the zero reference point when it is at the level of symphysis pubis.

The drainage tubing is marked at an increment of 1 cm (up to 30–40 cm).

A three way (E) is placed in the drainage tube past the marking. One hundred milliliters of sterile saline is introduced into the bladder.

The drainage tubing is raised vertically keeping the zero point at the pubic symphysis and the three way open to patient’s bladder side and atmosphere.

The sterile saline is allowed to rise vertically. The distance of saline meniscus

above the zero reference point is the IAP in cm of H2O. 1 mm of Hg = 1.36 cm of H2O.

This is an effective and easy monitoring method of IAP and can be done hourly.

This method is not advisable in ICU setting as it leads to risk of retrograde urinary infection.

39 Intra-abdominal Hypertension

315

 

 

20 mL Syringe

500 mL NS

Pressure

Transducer

Standard

IV Tubing

Measure intra-vesical pressure

Open vent. clamp

Manometer

“0”mmHg

A

B

18 G

Angiocath

D

C

Urinary Catheter

Symphisispubis

Foleys catheter

Fig. 39.3 (a) Intra-abdominal pressure monitoring (Method - 1) (b) Intrabdominal pressure monitoring (Method - 2)

316

R. Chawla and S.K. Dash

 

 

Step 5: Start management

IAH/ACS evaluation and medical management is summarized in flow diagrams 4 and 5.

Once a patient is detected to be having a raised IAP and possible ACS, the approach to treat the underlying condition should be aggressive.

A prompt response by a physician at the impending ACS can be lifesaving for his patient.

Many a times early detection and management prevents need for any surgical means of decompression, and a satisfactory result can be achieved by medical treatment only.

Keys to success are the high level of suspicion and anticipation when managing patients who are prone to IAH and subsequent ACS.

Medical interventions are aimed at decreasing IAP, targeting the four important contributors to IAH (as described in Step 2). Figure 39.4 and 39.5 analyzes each step of approach and specific medical management for each of the four contributing factors.

When using medical management options to decrease IAP, it is important to always consider individualized pathophysiologic mechanisms leading to IAH because these may differ considerably from one patient to another, and the management depends on this (Fig. 39.4).

Critically, in patients with IAH, small changes in intra-abdominal volume may have a pronounced effect on IAP.

Step 6: Surgical management

In spite of early detection and adequate medical therapy, few patients may progress from a raised IAP state to ACS, and the ACS may be unresponsive to medical therapy.

This state of no response to adequate medical therapy needs to be picked up early, and ACS refractory to medical therapy should be treated with timely surgical approach.

IAH/ACS surgical management.

While doing surgical management of IAH/ACS, certain precautions should be taken:

Prevent heat loss from the viscera (by plastic sheet).

Protect the swollen viscera.

Allow free drainage of fluid that may accumulate within the cavity with continued resuscitation.

Do not damage the fascia and skin so that closure will be easier at a later period.

Method

Midline laparotomy.

Abdomen is left open and fascia is not closed.

39 Intra-abdominal Hypertension

317

 

 

SUSPECT

MEASURE

Clinical suspicion, If-

1)Decrease U/O, Worsening Acidosis,

2)Hypoperfusion changes (cold, pale, cyanosed lower limbs)

3)Raised peak airway and platue pressure (if intubated and Ventilated)

4)Raised CVP, Raised JVP, Hypotension in a normal base line cardiac status

5)Worsening sensorium, increasing ascites

 

Measure IAP

 

 

 

 

 

 

See for

 

 

 

 

 

1. hypokalemia,

 

 

 

 

 

 

 

 

 

 

2. hypomagnesemia,

 

 

 

 

 

3. hypophosphatemia

Monitor IAP

 

4. hypercalcemia

at least every 4hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IAH-If >12 mm Hg

ACS-If >20 mm Hg +

Organ dysfunction-

Goal

GOAL APP> 60 mm Hg (APP=MAP-IAP)

Evaluate the cause EVALUATE by assessing the

possible risk factors (I,II,III,IV)

Fig. 39.4 IAH/ACS evaluation

A large plastic sheet is laid over the bowel and tucked deep in the paracolic gutters in both sides, over the stomach/spleen and liver superiorly, and deep into the pelvis inferiorly. It protects viscera, prevents heat loss, and prevents adhesion formation between the bowel surface and the abdominal wall.

Small perforations are made in this sheet to allow fluid drainage.

Moistened gauze bandage is placed on top of this plastic sheet, and drains made up of red rubber with multiple holes are placed within the bandage and are connected, through collecting buckets, to wall suction at about 100 mmHg.

A Steri-Drape large enough to cover the bandage and adhere to the surrounding skin is placed over the bandage.

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