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ABDOMINAL PERFUSION PRESSURE Michael L. Cheatham, MD, FACS, FCCM

APP = 50 mmHg. IAP = 25 mmHg. IAP = 15 mmHg. ABDOMINAL PERFUSION PRESSURE Michael L. Cheatham, MD, FACS, FCCM Director, Surgical Intensive Care Units Orlando Regional Medical Center Orlando, Florida, USA. CRITICAL IAP. Even small elevations in IAP can impact survival

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ABDOMINAL PERFUSION PRESSURE Michael L. Cheatham, MD, FACS, FCCM

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  1. APP = 50 mmHg IAP = 25 mmHg IAP = 15 mmHg ABDOMINAL PERFUSION PRESSURE Michael L. Cheatham, MD, FACS, FCCM Director, Surgical Intensive Care Units Orlando Regional Medical Center Orlando, Florida, USA

  2. CRITICAL IAP • Even small elevations in IAP can impact survival • The critical IAP that mandates intervention has been revised downward • The IAP that defines IAH / ACS varies from patient to patient and even within the same patient • A single threshold value of IAP cannot be universally applied to all critically ill patients • IAP is a specific, but non-sensitive predictor of illness and resuscitation adequacy

  3. MAKING IAP BETTER Question: Why do some patients tolerate high IAPs while others do not?

  4. MAKING IAP BETTER Question: Why do some patients tolerate high IAPs while others do not? Answer:Their perfusion pressure remains adequate despite the elevated IAP

  5. PERFUSION PRESSURE • The pressure difference across an organ or anatomic compartment • Dependent upon three factors: 1) Arterial inflow pressure 2) Venous outflow pressure 3) Compliance of the compartment Perfusion pressure = Pressureinflow – Pressureoutflow

  6. CORONARY PERFUSION PRESSURE • A primary goal in any resuscitation • Calculated as the perfusion pressure (PP) across the coronary artery during maximal blood flow (diastole) • DBP = coronary artery inflow • PAOP = coronary artery outflow during diastole Coronary PP = DBP - PAOP • Goal: To maintain coronary PP above 50 mmHg

  7. CEREBRAL PERFUSION PRESSURE • An essential parameter in the head-injured patient with elevated ICP • Maintenance of an adequate cerebral PP is associated with improved long-term outcome • Calculated as the perfusion pressure across the brain • MAP = cerebral inflow • ICP = cerebral outflow Cerebral PP = MAP - ICP • Goal: To maintain cerebral PP above 70 mmHg

  8. ABDOMINAL PERFUSION PRESSURE • Calculated as the perfusion pressure across the abdomen • MAP = abdominal inflow • IAP = abdominal outflow Abdominal PP or APP = MAP - IAP • Goal: To maintain APP above 50-60 mmHg

  9. CLINICAL EVIDENCE • Retrospective study • 144 surgical patients with IAH (IAP  15 mmHg) • IAP and APP were calculated every 4 hours • Liberal abdominal decompression was performed for symptomatic IAH and ACS • Multivariate logistic regression analysis was utilized to identify resuscitation endpoints significantly associated with survival Cheatham et al. J Trauma 2000; 49:621-627

  10. PREDICTORS OF SURVIVAL IN IAH / ACS Cheatham et al. J Trauma 2000; 49:621-627

  11. PREDICTORS OF SURVIVAL IN IAH / ACS APP IAP Cheatham et al. J Trauma 2000; 49:621-627

  12. APP = 60 mmHg APP = 50 mmHg APP = 40 mmHg IAP = 25 mmHg IAP = 20 mmHg IAP = 15 mmHg ROC CURVES

  13. IAH / ACS IN THE GENERAL ICU • Prospective 12 month evaluation of IAH in the ICU • 405 mixed medical / surgical patients • IAP and APP were routinely measured Non- SurvivorsSurvivorsSignificance Lowest APP (mmHg) 76  23 61  23 <0.0001 Lowest MAP (mmHg) 83  22 72  22 <0.0001 Highest IAP (mmHg) 7  4 11  4 <0.0001 Malbrain et al. Yearbook Intensive Care (2002: 792-814)

  14. IAH / ACS IN THE GENERAL ICU Malbrain et al. Yearbook Intensive Care (2002: 792-814)

  15. CIAH STUDY • Critically Ill and Abdominal Hypertension Study • Prospective, multi-center screening trial • 257 mixed ICU patients (145 with IAH) • IAH (IAP  12 mmHg) screening twice daily Non- SurvivorsSurvivorsSignificance Lowest APP (mmHg) 65  23 52  14 <0.001 Highest IAP (mmHg) 17  5 17  4 ns Malbrain et al. Yearbook Intensive Care (2002: 792-814)

  16. CIAH STUDY Malbrain et al. Yearbook Intensive Care (2002: 792-814)

  17. CIRFAH STUDY • Critically Ill Renal Failure and Abdominal Hypertension Study • Prospective, multicenter, epidemiological study of acute renal failure • 60 mixed medical / surgical ICU patients • IAP / APP evaluated as predictors of outcome • The presence of IAH and a low APP by day 3 was able to discriminate between survivors and nonsurvivors

  18. CIRFAH STUDY

  19. RESUSCITATION ALGORITHM • Maintain a low threshold for measuring IAP • Serial IAP measurements are essential • Decompress immediately for ACS

  20. RESUSCITATION ALGORITHM • Maintain APP > 60 mmHg • Decompress if unable to maintain adequate APP • Attempts to close patient’s abdomen should be guided by their IAP and APP

  21. CONCLUSIONS • Critical IAP varies from patient to patient • No single threshold IAP can be universally applied to all critically ill patients • Calculation of APP assesses not only IAP severity, but also MAP adequacy • APP is superior to IAP, arterial pH, base deficit, and arterial lactate in predicting organ failure and patient outcome • APP is useful for guiding resuscitation and management of the patient with IAH / ACS

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