- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Intra-abdominal Hypertension |
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Rajesh Chawla and Sananta K. Dash |
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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, |
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DOI 10.1007/978-81-322-0535-7_39, © Springer India 2012 |
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R. Chawla and S.K. Dash |
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•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 |
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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
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Is there any |
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H/O |
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Is it spontaneous? |
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Is the patient |
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Laparoscopy, abdominal |
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postoperative? |
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history of trauma? |
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packing, abdominal closure |
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under tension |
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1. |
Peritonitis |
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Peritonitis |
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Retroperitoneal |
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bleeding |
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Intra-abdominal abscess |
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Abscess |
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Intestinal obstructions |
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Ileus |
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Ruptured abdominal |
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3. |
Hemoperitoneum |
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aorticaneurysm |
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hemorrhage |
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Vascular injury, |
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Tension |
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splenic rupture |
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pneumoperitoneum, |
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6.Acute pancreatitis
7.Acute mesenteric ischemia
Fig. 39.2 General and abdominal examination
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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 |
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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)
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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 |
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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
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Measure IAP |
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See for |
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1. hypokalemia, |
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2. hypomagnesemia, |
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3. hypophosphatemia |
Monitor IAP |
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4. hypercalcemia |
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at least every 4hours |
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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.