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HOLTECH MEDICAL

Learn about the clinical background of intra-abdominal pressure monitoring, its impact on organ function, indications for monitoring, and non-surgical and surgical treatment options. This information is provided by HOLTECH.MEDICAL and WSACS.org.

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HOLTECH MEDICAL

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

  2. 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

  3. 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

  4. 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

  5. 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

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

  7. 265 pts in 14 ICUs in EU 28-day Mortality: 23% 38% www.holtech-medical.com

  8. 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

  9. 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

  10. 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

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

  12. 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

  13. 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

  14. 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

  15. 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

  16. The easy way: 40 mmHg 1. Urine drainage: The urine fills the FoleyManometer and flows on to the urine collection device Pves Mid-ax line = 0mmHg 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 at the midaxillary line/iliac crest, and read Pvesical at the position of the meniscus www.holtech-medical.com

  17. 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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