IntraAbdominal Hypertension IAH

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Intra-Abdominal Hypertension (IAH)
The ARDS of the gut!
By Tim Wolfe, MD Email twolfe_at_wolfetory.com
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Disclosure

• Tim Wolfe, MD
• Associate Professor, University of Utah SOM
• Department Surgery, Division Emergency Medicine
• Clinical Practice in the community
• Conflict of interest
• Founder, Vice President, Medical DirectorWolfe
  Tory Medical
• Manufacturer of the AbViser Intraabdominal
  pressure monitoring kit
• This lecture is about IAH and ACS, not the AbViser

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• Have you ever seen a critically ill patient
  become progressively more swollen and edematous
  after fluid resuscitation?
• Have any of your ICU patients developed renal
  failure requiring dialysis?
• Have you ever seen a patient develop multiple
  organ failure and die?

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What was their intra-abdominal pressure?

• Have you ever seen a critically ill patient
  become progressively more swollen and edematous
  after fluid resuscitation?
• Have any of your ICU patients developed renal
  failure requiring dialysis?
• Have you ever seen a patient develop multiple
  organ failure and die?

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Case Septic child

• 5 y.o. female presenting with septic syndrome
• Treatment Fluids, antibiotics, vasopressors
• 24 hours into therapy develops worsening
  hypotension, oliguria, hypoxemia, hypercarbia.
  PIP rises from 20 to 40 cm
• IAP 26 mm Hg decompressive
  laparotomy
• Immediate resolution of renal, pulmonary and
  hemodynamic compromise
• 7 days later abdomen closed. Alive and well now.

DeCou, J Ped Surg 2000
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Case Aspiration patient

• 77 y.o. male with sepsis. Transferred to ICU
  where he required intubation, developed
  hypotension
• 10 liters IVF overnight, Norepi 1.0 mcg/kg/min.
• Anuric (35 ml urine in 8 hours). Lactate 4.6
• IAP 31 mm Hg. KUB massively distend small and
  large bowel. US shows no free ascitic fluid.
• Surgeon consulted for possible decompressive
  surgery
• Rx NGT, Rectal Tube, oral cathartics,
  neuromuscular blockade
• 1 hour later IAP 12 mm Hg, UOP 210 ml,
  norepinephrine discontinued.

Cheatham, WSACS 2006
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Case Dyspnea in ER

• 67 y.o. female with dyspnea and agitation
• Hypotensive, agitated, HP suggest liver dz
• IVF resuscitation, intubation, sedation
• Worsened over next 4-6 hours - Difficult to
  ventilate, hypoxic/hypercarbic, hypotension, no
  UOP.
• IAP 45 mm Hg, abdominal ultrasound showed tense
  ascites paracentesis of 4500 cc fluid
  (IAP 14)
• Immediate resolution of renal, pulmonary and
  hemodynamic compromise.
• Pathology shows malignant effusion pancreatic
  CA.
• Care withdrawn at later time and allowed to
  expire.

Etzion, Am J EM 2004
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Case Points

• Trauma is not required for ACS to develop
• Intra-abdominal hypertension and ACS occur in
  many settings (PICU, MICU, SICU, CVICU, NCC, OR,
  ER).
• IAP measurements are clinically useful Help to
  determine if IAH is contributing to organ
  dysfunction (i.e. useful if normal or abnormal)
• Spot IAP check results in delayed diagnosis
• Waiting for clinically obvious ACS to develop
  before checking IAP changes urgent problem to
  emergent one.
• Medical interventions are often all that is
  needed
• IAP monitoring will allow early detection and
  early intervention for IAH before ACS develops.

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Outline / Objectives

• Definition what is it?
• Causes
• Physiologic Manifestations
• Incidence
• Impact on Outcome / Impact of intervention
• Detection
• Bladder pressure monitoring
• Common Questions about monitoring
• Management / Treatment MEDICAL vs surgical
• Cost Analysis
• Conclusion early detection saves lives/money

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DefinitionsWCACS, Antwerp Belgium 2007

• Intra-abdominal Pressure (IAP) Intrinsic
  pressure within the abdominal cavity
• Intra-abdominal Hypertension (IAH) A sustained
  IAP gt 12 mm Hg (often causing occult ischemia)
  without obvious organ failure
• Abdominal Compartment Syndrome (ACS) IAH gt 20 mm
  Hg with at least one organ dysfunction or failure

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Physiologic Insult/Critical Illness

• Ischemia

Inflammatory (SIRS) response
Fluid resuscitation
Capillary leak
Tissue Edema (Including bowel wall and
mesentery)
Intra-abdominal hypertension
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Who is at risk for IAH - Fluids!

• The unifying feature of IAH
• FLUIDS! Shock requiring aggressive
  resuscitation with crystalloid fluids
• Crystalloid based, preload driven, goal oriented
  shock resuscitation is the standard of care in
  North America
• Sepsis Surviving sepsis guidelines
• Trauma ACLS guidelines
• Burn - Parkland formula
• Major abdominal surgery - Pre-operative loading
• Hypotension-any cause Fluid loading at core of
  Rx

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Fluids!

• Where does 5 liters go in the human body?
• The brain?
• The lung?
• The skin/soft tissue?
• The gut/mesentery.

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The fluid goes Right Here!!
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Intra-abdominal Hypertension Abdominal
Compartment Syndrome

• Physiologic Sequelae

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Physiologic Sequelae

• Cardiovascular
• Increased intra-abdominal pressures causes
• Compression of the vena cava with reduction in
  venous return to the heart
• Elevated ITP with multiple negative cardiac
  effects
• The result
• Decreased cardiac output increased
  SVR
• Increased cardiac workload
• Decreased tissue perfusion, decreased ScvO2
• Misleading elevations of CVP and PAWP
• Cardiac insufficiency Cardiac arrest

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IAH and the cardiovascular system

• Hemodynamic pressure measurements changes
• ? CVP and PCWP
• Elevations occur due to pressure transmission
  across diaphragm, not necessarily related to
  fluid status

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Physiologic Sequelae

• Pulmonary
• Increased intra-abdominal pressures causes
• Elevation of the diaphragms with reduction in
  lung volumes, stiffening of thoracic cage,
  reduced alveolar inflation, increased intersitial
  fluid (lymp obstruction)
• The result
• Elevated intrathoracic pressure, stiffer chest
  wall
• Increased peak pressures, Reduced tidal volumes
• Intersitial edema, Atelectasis, hypoxia,
  hypercarbia
• Ventilator Induced lung injury/Barotrauma
• Cytokine release pro-inflammatory response
• Non-pulmonary ARDS

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Physiologic Sequelae Lung
Normal
?ITV, ?ITP
IAH
ATX
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Physiologic Sequelae

• Gastrointestinal
• Increased intra-abdominal pressures causes
• Compression / Congestion of mesenteric veins and
  capillaries (capillary flow 25 mm arterial down
  to 15 mm venous)
• Reduced cardiac output to the gut
• The result
• Decreased gut perfusion, increased gut edema and
  leak
• Ischemia, necrosis, cytokine release, neutrophil
  priming
• Bacterial translocation
• Development and perpetuation of SIRS
• Further increases in intra-abdominal pressure

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Physiologic Sequelae

• Renal
• Elevated intra-abdominal pressure causes
• Reduced cardiac output/perfusion pressure to
  kidneys
• Increased proximal tubular pressure (resists
  filtration)
• Compression of renal veins, parenchyma
• The Result
• Reduced blood flow to kidney
• Decreased glomerular filtration rate (GFR)
• Renal congestion and edema
• Renal failure, oliguria/anuria

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Physiologic Sequelae

• Neuro
• Elevated intra-abdominal pressure causes
• Increases in intrathoracic pressure
• Increases in superior vena cava (SVC) pressure
  with reduction in drainage of SVC into the thorax
• The Result
• Increased central venous pressure and IJ pressure
• Increased intracranial pressure
• Decreased cerebral perfusion pressure
• Cerebral edema, brain anoxia, brain injury
• Maryland Shock Trauma unit often decompresses
  abdomens in patients with intractable
  intra-cranial hypertension

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Physiologic Sequelae

• Direct impact of IAP on common pressure
  measurements
• IAP elevation causes immediate increases in ICP,
  IJP and CVP (also in PAOP)

15 liter bag placed on abdomen (Citerio 2001)
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Circling the Drain
Intra-abdominal Pressure Mucosal Breakdown (
Multi-System Organ Failure) Bacterial
translocation, Cellular Apoptosis, Necrosis Acido
sis
Decreased O2 delivery Anaerobic metabolism
Capillary leak Free radical formation
MSOF
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How common is this syndrome?
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How common is this syndrome?
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How common Shock with fluid resuscitation

• Requeira, 2008 Intraabdominal hypertension in
  patients with septic shock.
• 83 incidence of IAP gt 12 mm Hg in septic shock
• 51 incidence of IAP gt 20 mm Hg in septic shock
• Daugherty, 2007 Abdominal compartment syndrome
  is common in medical intensive care unit patients
  receiving large volume resuscitation.
• 85 of patients with 5 liters positive fluid
  balance had IAH
• 30 had IAP gt 20 with organ failure (abdominal
  compartment syndrome)

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How good is clinical judgment for detecting
elevated IAP?

• Prospective, blinded trial - Staff physician
  judgment
• Results lt 50 of the time was the clinician able
  to determine when IAP was elevated.
• findings suggest that more routine measurements
  of bladder pressure

Kirkpatrick, Can J Surg 2000
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Does IAH / ACS affect patient outcome?
Mixed Med-Surg population

• IAH predicted mortality
• IAH gt 12 mortality 38.8
• No IAH - mortality 22.2

Malbrain, Crit Care Med, 2005
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Does IAH intervention affect patient outcome?
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Does IAH/ACS protocol driven intervention affect
patient outcome?

• Cheatham 2007 Is the evolving management of
  IAH/ ACS improving survival? Acta Clinica Belgica
  2007

• Mortality
• ? 21 (almost half)
• Open Abdomens
• 28 to 15 (almost half)
• time open 15 days
• Hospital LOS
• ? 10 days

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Does IAP/IAH protocol driven monitoring affect
patient outcome?

• Kimball 2009 A prospective evaluation of
  protocolized management of intraabdominal
  hypertension and ACS, Acta Clinica Belg 2009
• Data on 600 high risk monitored cases (not all
  had IAH or ACS)

• Mortality
• ? 18 relative risk
• Open Abdomens
• ? 40 relative risk
• ICU LOS
• 4 days
• Ventilator Days
• ? 4.3 days

12 fewer decompressions
?4 fewer ICU/vent days per patient
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Does IAH / ACS affect patient outcome?

• Points
• IAH / ACS is common in the ICU environment
  (including yours).
• IAH and ACS increase morbidity, mortality ICU
  length of stay.
• Early, protocol driven interventions improve
  survival reduce organ failure without
  increasing cost of care (shorter ICU and hospital
  LOS)
• However
• Clinical signs of IAH are unreliable and only
  show up late in the clinical course ..SO
• Early monitoring (TRENDING) detection of IAH
  with early intervention is needed to obtain
  optimal outcomes.

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Intra-Abdominal Pressure Monitoring
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Intra-Abdominal Pressure Monitoring
The reference standard for intermittent IAP
measurement is via the bladder with a maximal
instillation volume of 25 ml sterile saline.
WSACS.org
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Home Made Pressure Transducer Technique

• Home-made assembly
• Transducer
• 2 stopcocks
• 1 60 ml syringe,
• 1 tubing with saline bag spike / luer connector
• 1 tubing with luer both ends
• 1 needle / angiocath
• Clamp for Foley
• Assembled sterilely, used in proper fashion!

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Home Made IAP Kits

• Home Made IAP monitoring
• Ingenious for proof of concept in research
  setting
• Inadequate for routine use in broad ICU setting

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Home Made IAP Kits

• Unfortunately There are problems with home-made
  Kits.
• Nurses (and doctors) are not engineers
• Lack of quality control things go wrong at
  worst possible times
• Lack of Standardization Bad data may be worse
  than no data
• Data Reproducibility Bad data may be worse than
  no data
• Usability problems - hampers trending, prevents
  routine use
• Time Consuming - hampers trending, prevents
  routine use
• Sterility issues CAUTI concerns can outweigh
  IAP concerns

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Home Made Pressure Transducer Technique

• PROBLEMS
• Home-made
• No standardization - confidence problem with data
• Sterility issues
• Time consuming therefor its use is late and
  infrequent due to the hassle factor (i.e. not
  monitoring - waiting for ACS)
• Data reproducibility errors - what are the
  costs / morbidity of inaccurate or delayed
  information?
• Other Needle stick, Recurrent penetration of
  sterile system, Leaks, re-zeroing problems,
  failure to trend

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Bladder Pressure Monitoring How to do it

• Commercially available devices
• Foley Manometer (Bladder manometer)
• CiMon (Gastric)
• Spiegelberg (Gastric)
• AbViser (Bladder transduction)
• IAP monitor (Bladder transduction)
• Advantages Simple, Standardized, Reproducible,
  Time efficient, Sterile

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Reproducibility Study
Inter-observer Scatterplot (r 0.95, p lt 0.001)

• Nursing driven study with 89 different nurses
  participating.
• Excellent intra- and inter- observer
  reproducibility

Kimball, Int Care Med 2007
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Common Questions How much fluid should be
infused into bladder?
Non-compliant bladder Measured pressure
increases as volumes exceed 50 ml of infusion
Compliant bladder Measured pressure changes very
little with higher volumes of fluid infusion
IAP Measured (mm Hg)
WSACS Max volume 25 ml, 1 ml/kg in children.
Volume of infusion (ml)
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Common Question How do I recognize appropriate
IAP transduction onto my monitor?

• Proper transduction clues
• Respiratory variation noted (subtle at low
  pressures)
• Oscillation test positive
• Reproducible over several measurements

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Common Questions Do patients with open
abdomens need to be monitored?

• YES!
• There is no such thing as an open abdomen
  outside the O.R. just expanded abdomen
• By the very fact they are open suggests they
  have a very high capillary permeability problem
• Gracias 2002 found 25 incidence of recurrent ACS
  in open abdomens
• You have already committed a fortune in resources
  and time to this patient take the added step to
  monitor their IAP

6 hours post op IAP24
Post dressing release IAP12
24 hours later IAP12
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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Concern UTI can cause sepsis. CAUTI is not
  reimbursable
• Infection control statements Closed system is
  required to reduce UTI risk, bladder pressure
  monitoring violates closed system concept
• Contrary concern Everything is medicine is
  based on risk benefit analysis
• What is the risk of UTI versus the risk of
  missing IAH/ACS?
• How do we resolve this - What is the actual data?

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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Actual Data
• The Basis for the closed system recommendation
• Kunin NEJM 1966
• Observational trial of drain tube and bag
  (attached after Foley placed, disconnected for
  appropriate clinical indications)
• Results Fewer CAUTI compared to historical
  method of allowing Foley to drain into open jar
• Wong, CDC guidelines 1980
• Expert opinion piece used Kunin 1966 as
  literature support
• Never updated despite 29 years of additional
  research

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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Subsequent Research Data Closed sealed systems
  versus breaking the seal demonstrate no
  difference in CAUTI risk. (This is different from
  an open jar)
• Six prospective randomized controlled trials
  (level 1 evidence), one non-randomized trial
• Over 4000 patients randomized (two trials with
  1500 each)
• All studies compared open (not connected) vs
  closed (pre-connected, tamper seal) drain system
• All studies had many patients who had tubing
  disconnected (one mandated every 3 day drain
  tube/bag replacement)
• Results NO DIFFERENCE in CAUTI

So what does cause CAUTI?
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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Maki, Engineering out the risk of infection with
  urinary catheters, Emerg Inf Control 2001

Infections in which biofilm does not play a role
are probably caused by mass transport of
intraluminal contents into the bladder by
retrograde reflux of microbe laden urine when a
collection system is manipulated.
(Loop)
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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Cheatham, Intravesicular pressure monitoring does
  not cause urinary tract infection. Int Care Med
  2006
• Compared ICU patients getting IAP monitoring to
  those who did not get IAP monitoring
• CAUTI rate 7.9 versus 6.5 per 1000 cath days
  (PN.S.) despite higher acuity and mortality in
  the IAP group.
• Ejike, IAP monitoring in Children. Crit Care Med
  2008
• Compared ICU patients getting IAP monitoring
  using the AbViser IAP monitor to national
  baseline rates of CAUTI.
• CAUTI rate
• IAP monitoring 0.2 per 1000 catheter days
• National baseline 5.5 per 1000 catheter days

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Common Questions What is the risk of UTI from
transvesicular IAP monitoring?

• Conclusions
• Transvesicular monitoring of IAP carries little
  risk of CAUTI.
• Failure to monitor and detect IAH/ACS carries a
  high risk to patient so risk benefit analysis
  suggests monitoring needs to be done regardless.
  (analogy dont intubate due to VAP risk)
• Closed system myth may have some merit (aseptic
  technique), but is not defended by evidence based
  medicine and is over-blown. Obviously we need to
  be careful, but not paranoid.
• Manipulation of the urinary drain tube with
  repeated dumping of old urine back into the
  patients bladder IS a modifiable risk we can
  impact.

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Management of IAH and ACS
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WSACS IAH/ACS Guidelineswww.wsacs.org 2009
Assessment algorithm
Management algorithm
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Assessment Algorithm2007
UUMC Nurse is empowered to enter any patient
fulfilling criteria
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IAH Management 2009
Medical management (23 of 25 interventions)
Surgical management
WSACS.ORG 2008
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IAH Medical Management

• Improve Abdominal Wall compliance
• Shifts pressure-volume curve to right, reducing
  IAP for the same volume.

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IAH/ACS Management Positioning
Stretch out
Vasquez, 2007
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IAH/ACS Management Paralysis
Kimball, WCACS 2007
IAP
UOP
De Waele, Crit Care Med 2003
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IAH Medical Management

• Evacuate intraluminal contents, intra-peritoneal
  fluid collections
• Reduces total volume in abdomen moving patient
  down the curve regardless of compliance.

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IAH/ACS Management Evacuate Bowel, Peritoneal
Fluids
Stool
Air
Abscess
Ascites
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IAH/ACS Management Evacuate Bowel, Peritoneal
Fluids

• Sun, 2006 Indwelling peritoneal catheter vs
  conservative measures in fulminant acute
  pancreatitis.
• 110 cases of severe fulminant pancreatitis - RCT
• Control group Routine ICU supportive care
• Study group Routine ICU supportive care PLUS
• IAP monitoring (mean pressure 21 mm Hg on day 1)
• Indwelling peritoneal drain catheter (drain 1800
  cc on day 1)
• Outcome
• Control - 20.7 mortality, 28 day hospital
  LOS
• Study group - 10.0 mortality (plt0.01), 15 day
  LOS

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IAH Medical Management
Vidal 2008

• Optimize fluid administration
• Reduces bowel and mesenteric edema.

Sepsis induced Capillary permeability
Bowel edema
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IAH/ACS Management Consider hemodialysis

• Oda, 2005 Management of IAH in patients with
  severe acute pancreatitis using continuous
  hemofiltration.
• 17 cases of severe pancreatitis and IAH
• Treated with hemofiltration when IAP 15 mm,
  PRIOR to developing renal insufficiency
  (maintained adequate serum oncotic pressure with
  albumin)
• Results
• Interleukin (IL-6) cytokine levels cut in half
• Reduced vascular permeability and interstitial
  edema
• Mean IAP value dropped from 15 mm to less than 10
  mm
• 16 of 17 patients discharged alive without
  complication

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IAH/ACS Management Consider Hemofiltration

• Fluid Overloaded Post CVVH

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IAH Medical Management

• Optimize systemic/regional perfusion
• Balanced resuscitation
• Enough fluid but not too much
• Vasoactive support to enhance perfusion

APP
Cheatham, Malbrain 2007
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IAH Surgical Management

• Decompressive Laparotomy
• Err on the side of early vs late intervention
• Less bowel edema or cell damage, better chance of
  early closure and early recovery.
• Be aware that delaying care until this
  complication occurs is VERY expensive more
  expensive the longer you wait
• Vanderbilt costs for open abdomen (Vogel 2007)
• Same admission closure - 150,000 (Cheatham data
  suggests gt200,000)
• Failure to close on initial admission 250,000
  (estimate nearly as much over next year by time
  ventral hernia finally repaired).

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IAH/ACS Management Decompressive Laparotomy
Rigid Abdomen in ACS
Post decompressive laparotomy
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Decompressive Laparotomy

• Delay in abdominal decompression may lead to
  intestinal ischemia
• Decompress Early!

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Decompressive Laparotomy
Post-operative dressing
Several days post-op
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Surgical Management of Compartment Syndromes

• Compartment
• Cranium
• Chest
• Pericardium
• Limb

Pathophysiology ICP elevation Tension
pneumothorax Cardiac tamponade Extremity
compartment syndrome
Surgical Management Craniotomy, etc.. Chest
tube Pericardiocentesis Fasciotomy
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Compartment Syndromes versus Hypertension

• Abdominal compartment syndrome
• Emergent Surgical Disease.
• Intra-abdominal hypertension
• Urgent Medical Disease.

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Cost analysis

• Is IAP monitoring and intervention cost effective?

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Cost analysis

• Compartment syndrome risk comparison
• The Cranium Fall, hit head, LOC, vomiting but
  alert
• Is it worth the cost of a head CT? (Standard of
  Care)
• Incidence is less than 5 positive
• Less than 0.5 need ANY intervention
• The Abdomen ICU patient with major fluid
  resuscitation (5 liters positive at 24 hours or
  less)
• Is it worth the cost of measuring their IAP?
• Incidence of IAH is 85
• 30 will have ACS

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Cost analysis IAP monitoring impact on resource
utilization.

• Prospective interventional trial data
• Length of Stay How much is one day in the
  ICU/hospital?
• Cheatham 10 fewer days in hospital
• Sun - 13 fewer days in hospital
• Kimball 4 fewer days in ICU
• Ventilator Days Do ventilated patients consume
  more resources?
• Cheatham fewer ventilator days
• Kimball 4 fewer days
• Abdominal decompression - How much is one
  decompression?
• Cheatham 13 fewer decompressions
• Kimball 11 fewer decompressions (1/month less)

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Cost analysis

• Prospective protocol driven interventional trial
  data Kimball 2009
• Design 600 patients prospectively
  monitored/treated with IAH protocol over 4 years
  compared to prior year
• Results comparing prior year to last year data
• Length of Stay 4.1 fewer days in ICU per the
  109 patients monitored
• 447 fewer ICU days (_at_ 3000/day 1.3 million)
• Abdominal decompression - 12 fewer decompressions
  
• 12 fewer decompressions/year (mean charges for
  these patients gt150,000 1.8 million)
• Estimated total reduced charges 3.1 million
• Actual total yearly cost for monitoring devices
  9265

75
Cost analysis IAP monitoring impact on resource
utilization.

• Other more difficult to quantify costs
• Opportunity costs (think waitress with a table)
• Longer ICU LOS leads to inability to admit
  another patient to that bed.
• ICU charges are far higher during first few days
  of admission so in terms of business, long ICU
  LOS leads to losses in terms of new patient
  billing.
• Mortality costs
• Higher death rate without treatment leads to loss
  of that person from productive life in society.
  What is the economic value of a human life?
• What is a reasonable cost to save one life?

76
Summary Is IAP monitoring and intervention cost
effective?

• IAH is very common in fluid resuscitated patients
• IAH cannot be clinically detected
• IAH/ACS outcome is time dependent.
• Delayed detection/intervention consumes more
  resources
• Delayed detection/intervention results in higher
  mortality.
• Aggressive intervention leads to reduced costs
  with better outcomes.
• So.

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Final Thought

• Do NOT wait for signs of ACS to be present before
  you decide to check IAP
• By then the patient has one foot in the grave!
• You have lost your opportunity for medical
  therapy
• The costs of saving this patient are now HUGE
• Monitor ALL high risk patients early and often
• TREND IAP like a vital sign
• Intervene early, before critical pressure
  develops

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Questions?

• IAH and ACS Educational Web sites
• www.abdominal-compartment-syndrome.org
• WSACS.org
• My email
• twolfe_at_wolfetory.com

Via Ferrata Tridentina - Italy
79
Additional slides if more than one hour exists

• Slides beyond this can be added as needed to
  lengthen lecture beyond 1 hour

80
No such thing as an Open Abdomen in the ICU

• Open Abdomen Vac-pac dressing placed in OR. Now
  6 hours post-op
• MAP70 HR114 IAP24
• UOP lt 30 cc/ hour, PIP 60 cm H2O
• Lactate 6.5
• Abdominal dressing firm and bulging
• Vacuum pack is removed, replaced with silo
• Dramatic bowel evisceration
• MAP70 HR96 IAP12
• UOP gt100 cc/ hour PIP 30 cm H2O

81
No such thing as an Open Abdomen in the ICU

• 24 hours into ICU stay
• Worsened bowel edema
• However
• MAP 79
• IAP 12
• Lactate 1.9

Note expansion of viscera
82
Does IAH intervention affect patient outcome?

• Cheatham 2007, Is the evolving management of IAH/
  ACS improving survival? Acta Clinica Belgica
• Introduced management protocol in 2005, compared
  before and after data
• Open abdomens decreased from 28 to 15 (medical
  management)
• When they do open, they do it sooner (do not wait
  for ACS)
• Days to closure decreased from mean of 21 days to
  6 days
• Successful closure during primary visit improved
  from 1/3 to 2/3
• Ventilator days decreased
• Length of stay decreased from 28 days to 18 days
• Survival improved from 51 to 72

83
IAH in neuro patients

• Joseph 2004 Decompressive laparotomy to treat
  intractable intracranial hypertension
• 17 patients with intractable ICP despite maximal
  therapy (including decompressive craniectomy in
  14)
• Mean ICP 30 mm Hg, Mean IAP 27 mm Hg
• All 17 underwent decompressive laparotomy
• 100 had drop in the ICP immediately or in few
  hours
• To mean of 17 mm Hg
• 11 had persistent reduction in ICP
• These 11 all survived and with good neurologic
  outcome

84
Normal Abdominal CT
Normal kidney
Note that abdomen is oval, not round
Inferior Vena Cava
85
Abdominal CT in ACS Renal
compression
Kidneys are compressed, patient is anuric
Pickhardt, AJR 1999
Note that abdomen is round, not oval
Retroperitoneal hemorrhage
Flattened Inferior Vena Cava
86
How common is this syndrome?

• Malbrain, Intensive Care Medicine (2004)

These data are for ALL ICU patients. MUCH higher
if you use a protocol to select high risk
patients.
87
How common Septic Patients

• Efstathiou et al, Intensive Care Med 200531
  supp1 1 S183 Abs 703

These data are for ALL sepsis patients. MUCH
higher if you look only at major fluid
resuscitation.
88
Does IAH / ACS affect patient outcome? Renal
IAH is a KEY promoting factor of acute renal
failure.

• Dalfino 2008

89
Does IAH intervention affect patient outcome?

• Ivatury, J Trauma, 1998 Intra-abdominal
  hypertension after damage control surgery.
• 70 patients monitored for IAP gt 18 mm Hg (25 cm
  H2O)
• 25 had facial closure at time of surgery
• 52 developed IAP gt 18 mm Hg
• 39 Died
• 45 cases had abdomen left open
• 22 developed IAP gt 18 mm Hg
• 10.6 Died

90
Does IAH intervention affect patient outcome?

• Sun, 2006 Indwelling peritoneal catheter vs
  conservative measures in fulminant acute
  pancreatitis.
• 110 cases of severe fulminant pancreatitis - RCT
• Control group Routine ICU supportive care
• Study group Routine ICU supportive care PLUS
• IAP monitoring (mean pressure 21 mm Hg on day 1)
• Indwelling peritoneal drain catheter (drain 1800
  cc on day 1)
• Outcome
• Control - 20.7 mortality, 28 day hospital
  LOS
• Study group - 10.0 mortality (plt0.01), 15 day
  LOS

91
Does IAH intervention affect patient outcome?
Mortality 31
Mortality 18

• Ennis, 2008 Goal directed fluid resuscitation in
  major burn injury improves outcomes.
• Goal Reduce resuscitation morbidity of ACS
• Control group Standard Parkland formula (before
  protocol)
• Study group Hemodynamic goal directed therapy
• Avoided continuous fluid resuscitation aimed at
  maintaining UOP once CVP (or PCWP) and ScvO2 were
  optimized and IAP was up.
• I.E. - let the kidneys fail rather than cause
  ACS
• Outcome
• Control - 36 mortality /or ACS
• Study group - 18.0 mortality /or ACS

92
Does IAH intervention affect patient outcome?

• Cheatham 2007, Is the evolving management of IAH/
  ACS improving survival? Acta Clinica Belgica
• Introduced management protocol in 2005, compared
  before and after data
• Open abdomens decreased from 28 to 15 (medical
  management)
• When they do open, they do it sooner (do not wait
  for ACS)
• Days to closure decreased from mean of 21 days to
  6 days
• Successful closure during primary visit improved
  from 1/3 to 2/3
• Ventilator days decreased
• Length of stay decreased from 28 days to 18 days
• Survival improved from 51 to 72

93
IAH/ACS Management Colloids

• OMara, 2005 Prospective randomized evaluation
  of IAP with crystalloid and colloid resuscitation
  in burns
• 31 cases with gt25 burn plus inhalation or gt40
  burn without inhalation
• Randomized to saline vs plasma
• Results post resuscitation
• Crystalloid IAP mean 26.5 mm Hg
• Plasma IAP mean 10.6 mm Hg

94
Conclusion - Is IAP monitoring and intervention
cost effective?

• The cost of monitoring intra-abdominal pressure
  early is far outweighed by the savings in
  clinician time, organ function, hospital days and
  lives saved.
• JUST DO IT!

95
The risk of not measuring IAP

• Late Monitoring Late Recognition
• Late Recognition Late Intervention
• Late Intervention Limited Treatment Options
• Limited Options Poor Outcomes

96
Who is at risk for IAH?

• Despite a diverse range of associated
  conditions the unifying feature of IAH appears
  to be the presence of shock requiring aggressive
  resuscitation with crystalloid fluids
• Kirkpatrick, J Am coll Surg 2006

97
Causes of Intra-abdominal Pressure (IAP) Elevation

• Major abdominal / retroperitoneal problem
• Ischemic insult / SIRS requiring fluid
  resuscitation with a positive fluid balance of 5
  or more liters within 24 hours (10 lb weight
  gain)
• Where does all that fluid go?

98
Ischemic Time and Cell survival
Aerobic metabolism
Baseline cellular oxygen requirement
Anaerobic metabolism
Irreversible Cellular Apoptosis or necrosis
Rivers Early goal directed therapy for sepsis
lecture
99
Ischemic time matters

• Extremely time critical (Golden hour - minutes
  matter)
• Cardiopulmonary arrest (5 minutes)
• Major trauma (The golden hour)
• Acute myocardial infarction (time is muscle
  90 min DTB)
• Stroke (Brain attack 3 hour time window)
• Severe ICP elevation (cranial compartment
  syndrome)
• Tension pneumothorax, pericardial tamponade
  (thoracic compart syndrome)
• Time critical (6 hours - hours matter)
• Severe Sepsis (Surviving sepsis total body
  ischemia)
• IAH-ACS (Surviving fluid resuscitation total
  body ischemia)
• Ischemic limb (embolism, extremity compartment
  syndrome)
• Mesenteric ischemia (arterial embolism, IAH-ACS)

100
WSACS IAH/ACS Guidelines
Risk Factors
Something so wrong in the abdomen or
retroperitoneum that they need an ICU bed (and
probably got a lot of fluid)
Got a lot of fluid
www.wsacs.org 2008
101
Cost analysis IAP monitoring impact on resource
utilization.

• Two Studies have looked at LOS reduction with
  early aggressive IAH intervention (Cheatham 2007,
  Sun 2006)
• 10-13 days reduction in LOS
• 10-20 absolute increase in survival
• Assume low end of 1000-2000/day savings
• Save at least 10,000-20,000 per patient with
  IAH who has early monitoring and protocol driven
  care.
• Open up ICU bed sooner
• Increase survival
• Reduce very expensive surgical intervention

102
Does IAH intervention affect patient outcome?

• Cheatham 2007, Is the evolving management of IAH/
  ACS improving survival? Acta Clinica Belgica
• Introduced management protocol in 2005, compared
  before and after data
• Open abdomens decreased from 28 to 15 (medical
  management)
• When they do open, they do it sooner (do not wait
  for ACS)
• Days to closure decreased from mean of 21 days to
  6 days
• Successful closure during primary visit improved
  from 1/3 to 2/3
• Ventilator days decreased
• Length of stay decreased from 28 days to 18 days
• Survival improved from 51 to 72

103
Does IAH / ACS affect patient outcome?

• Al-Bahrani, 2008 Clinical relevance of
  intra-abdominal hypertension in severe acute
  pancreatitis.
• 18 cases of severe pancreatitis
• 7 (39) cases with IAP lt 15 mm Hg
• 14 mortality
• Mean ICU LOS 4 days
• 11 (61) cases with IAP gt 15 (all over 20) mm Hg
  
• 45 mortality
• Mean ICU LOS 21 days

104
What intra-abdominal pressures are concerning?
Pressure (mm Hg) Interpretation 0-5
Normal 5-10 Common in most
ICU patients gt 12 (Grade I)
Intra-abdominal hypertension 16-20 (Grade II)
Dangerous IAH - begin non- invasive
interventions gt21-25 (Grade III)
Impending abdominal compartment
syndrome - strongly consider
decompressive laparotomy The IAH grades have
been revised downward as the detrimental impact
of elevated IAP on end-organ function has been
recognized WSACS.org
105
Fluid-Column Manometry

• Problems
• Failure to pay extreme attention to detail may
  lead to errors
• Siphon effect leads to false elevations
• Inadequate volume of infusion will lead to
  falsely low measurements
• CAUTI Risk - Need to infuse urine back into
  patient

Sedrak 2002
106
Ischemic time matters

• Extremely time critical (Golden hour - minutes
  matter)
• Cardiopulmonary arrest (5 minutes)
• Major exsanguinating trauma
• Acute myocardial infarction (time is muscle)
• Stroke (beyond 3 hours intervention worsens
  outcome)
• Severe ICP elevation (cranial compartment
  syndrome)
• Tension pneumothorax, pericardial tamponade
  (compartment syndromes in thorax)
• Time critical (6 hours - hours matter)
• Septic shock (total body ischemia)
• IAH-ACS (total body ischemia time is tissue)
• Ischemic limb (embolism, compartment syndrome)
• Mesenteric ischemia (arterial embolism, IAH-ACS)

107
Ischemic time matters

• Extremely time critical (Golden hour - minutes
  matter)
• Cardiopulmonary arrest (5 minutes)
• Major trauma
• Acute myocardial infarction
• Stroke
• Severe ICP elevation (cranial compartment
  syndrome)
• Tension pneumothorax, pericardial tamponade
  (compartment syndromes in thorax)
• Time critical (6 hours - hours matter)
• Septic shock (total body ischemia)
• IAH-ACS (total body ischemia)
• Ischemic limb (embolism, compartment syndrome)
• Mesenteric ischemia (arterial embolism, IAH-ACS)

With the exception of IAH/ACS is anyone ignoring
these disease processes for hours let alone
days? Why are we ignoring IAH/ACS?