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HOLTECH MEDICAL

HOLTECH MEDICAL. Intra-abdominal Pressure Monitoring Clinical Background. Publications on IAP and ACS 2001-09. www.WSACS.org Definitions. Normal range: IAP<10-12 mmHg Intra-abdominal Hypertension = IAH IAH = IAP > 12 mmHg ACS = IAP > 20 mmHg+1 new organ failure

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HOLTECH MEDICAL

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  1. HOLTECH MEDICAL Intra-abdominal Pressure Monitoring Clinical Background www.holtech-medical.com

  2. Publications on IAP and ACS 2001-09 www.holtech-medical.com

  3. www.WSACS.org Definitions • Normal range: IAP<10-12 mmHg • Intra-abdominal Hypertension = IAH • IAH = IAP > 12 mmHg • ACS = IAP > 20 mmHg+1 new organ failure • APP (abdominal perfusion pressure) = MAP – IAP (same concept as CPP) www.holtech-medical.com

  4. 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. www.holtech-medical.com

  5. Pathophysiology CENTRAL NERVOUS SYSTEM Intracranial pressure  Cerebral perfusion pressure Idiopathic intracranial hypertension (obesity) CARDIOVASCULAR SYSTEM Difficult preload assessment Wedge pressure  Central venous pressure  Intra thoracic blood volume index = Extra vascular lung water = Right ventricular end-diastolic volume index = Cardiac output  Venous return  Systemic vascular resistance  Venous thrombosis  Pulmonary embolism  Heart rate  = Mean arterial pressure  = Pulmonary artery pressure  RESPIRATORY SYSTEM Intrathoracic pressure  Pleural pressure  Functional residual capacity  All lung volumes  (~restrictive disease) Auto-PEEP  ? Peak airway pressure  Plateau pressures  Dynamic compliance  Static compliance  Chest wall compliance  Hypercarbia  PaO2  PaO2/FiO2  Dead-space ventilation  Intrapulmonary shunt  Lower inflection point  Upper inflection point  Prolonged ventilation ? Difficult weaning ? RENAL SYSTEM Renal blood flow  Diuresis  Tubular dysfunction  Glomerular filtration rate  Renal vascular resistance  Renal vein compression  Compression ureters  Anti-diuretic hormone  Adrenal blood flow = GASTRO-INTESTINAL SYSTEM Celiac blood flow  Superior mesenteric artery blood flow  Blood flow to intra-abdominal organs  Mucosal blood flow  Mesenteric vein compression  Intramucosal pH  Regional CO2  CO2-gap  Success enteral feeding  ? Intestinal permeability  Bacterial translocation  ? Multiple organ failure  ? Gastro-intestinal (re)bleeding  HEPATIC SYSTEM Hepatic arterial flow  Portal venous blood flow  Portocollateral flow  Lactate clearance  Glucose metabolism  Mitochondrial function  Cytochrome p450 function  ABDOMINAL WALL Compliance  Rectus sheath blood flow  Wound complications  Incisional hernia  www.holtech-medical.com Malbrain. Current Opinion Crit Care 2004; 10(2): 132-145

  6. IAP affects blood pressure • IAP affects all blood pressures • CVP increases by 3-6mmHg when IAP increases by 10mmHg. An example: • IAP=10mmHg, CVP=10mmHg. A sudden increase of IAP to 20mmHg changes CVP to 15mmHg. 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 www.holtech-medical.com

  7. IAH prevalence in 13 EU ICUs Malbrain. Intensive Care Med. 2004 DOI 10.1007/s00134004-2169-9 (online first) www.holtech-medical.com

  8. 265 pts in 14 ICUs in EU 28-day Mortality: 23% 38% www.holtech-medical.com

  9. 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 www.holtech-medical.com

  10. 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 www.holtech-medical.com

  11. 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 www.holtech-medical.com

  12. WSACS’ protocol www.holtech-medical.com

  13. University of Utah: IAP monitoring algorithm • Entry criteria defined in table • Nurse is empowered to enter any patient fulfilling these criteria www.holtech-medical.com

  14. University of Utah: IAP Monitoring Protocol IAP monitoring Q1-2 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 to Q4-6 hours for 24 hours • Consider Medical Management • Sedation/Neuromuscular blockade • Paracentesis of free fluid • Other options • Gastric suction, cathartics • Rectal tube/enemas • Continuous filtration • Colloids Surgical Decompression “Second Hit” pt. develops new indication for IAP monitoring IAP remains <12 mm Hg discontinue monitoring www.holtech-medical.com

  15. 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) www.holtech-medical.com

  16. How to measure IAP? • Patient position: Supine • Bladder must be empty • Always use same 0 mmHg reference = symph. pubis, or mid-axillary line. www.holtech-medical.com

  17. The easy way: 40 mmHg 1. Urine drainage: The urine fills the FoleyManometer and flows on to the urine collection device Pves Symph. Pubis=0 mmHg 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 mmHg” mark of the manometer tube at the symph. pubis level and read Pvesical at the position of the meniscus www.holtech-medical.com

  18. 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 www.holtech-medical.com

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