WRAP IT UP Manu Malbrain, MD

1. 08-Dec-04 WRAP IT UP Manu Malbrain, MD Director Intensive Care Unit Ziekenhuis Netwerk Antwerpen Campus Stuivenberg B-2060 Antwerp BELGIUM manu.malbrain@skynet.be

2. Isn’t it time to pay attention? Ivatury RR. Sugerman HJ. Abdominal compartment syndrome: A century later, isn't it time to pay attention? Crit Care Med 2000; 28:2137-2138. Sugrue M. Intra-abdominal pressure: time for clinical practice guidelines? Intensive Care Med 2002; 28(4):389-391.

3. It is time to pay attention! Malbrain MLNG. Intraabdominal hypertension in the critically ill: it is time to pay attention. Current Opinion Crit Care 2005; 11(2) (Ed. Julia Wendon)

4. Why didn’t you pay attention! Malbrain MLNG. Intraabdominal hypertension in the critically ill: why didn’t you pay attention. Current Opinion Crit Care 2006; 12(2) (Ed. Julia Wendon)

5. Evolution of baro- and volo-indicators

6. IAP Assessment

7. ACS Publications 80 70 60 50 40 30 20 10 1990 1995 2000

8. CENTRAL NERVOUS SYSTEM Intracranial pressure  Cerebral perfusion pressure Idiopathic intracranial hypertension (obesity) Pathophysiology 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 

9. CENTRAL NERVOUS SYSTEM Intracranial pressure  Cerebral perfusion pressure Idiopathic intracranial hypertension (obesity) Pathophysiology 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  IAP-HYPE? 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 = MASS-HYSTERIA? FASHION? 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 

10. CENTRAL NERVOUS SYSTEM Intracranial pressure  Cerebral perfusion pressure Idiopathic intracranial hypertension (obesity) Pathophysiology 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 = NO it is real! 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 

11. Dilemma: “dry lungs are happy lungs” “keep them dry watch them die” “the patient does not die of anasarca, he dies of MOF” DON’T FLUID OVERLOAD ! Give Fluids cautious Give the right fluids

12. Chicken? Egg?

13. Chicken Global View - PIRO • Patient factors – Predisposing conditions • Infection – Inflammation – Immunedeficiency-Ischemia-Iatrogenic • Response to stimulus - Reperfusion • Organ Failure • Genetic ?

14. To answer these questions we need multicentre studies !

15. Certainties in Life • World Congress every 2 years • Next Meeting will be in Belgium • Next venue will be in Brussels ?, Antwerp?, Ghent?, Bruges? • Number of participants will increase from 50 – 160 – 300?

16. The more you look the more you see The more you see, the more you learn The more you learn, the more you know The more you know, the more you see

17. Time is an issue Time is tissue

18. LiDCO NiCO2 CEDVi Monitor Ideal Situation ? PiCCO Tonometer Evita 4 HemoSonic

19. Thanks Shadow people Thank You all Thanks Faculty WSACS You Monastery Germany Meditation Michael WCACS We’ll Be Back!!!