Intra-abdominal Hypertension - Wendy R. Greene, MD
Summary
TLDRIn this presentation, Dr. Linda Green discusses intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) through case studies. She explains how elevated intra-abdominal pressure can affect multiple organs, leading to severe complications such as renal failure, hypoxemia, and multi-system organ failure. Dr. Green highlights the importance of accurate pressure measurement, early intervention, and management options like paracentesis, decompression, and surgical procedures. She stresses that ACS can develop in any patient and emphasizes the need for prompt monitoring to prevent life-threatening outcomes.
Takeaways
- 🤔 Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are critical issues that can develop in various patients, not just trauma cases.
- 👩⚕️ A 67-year-old female with liver disease experienced worsening conditions, including difficulty with ventilation, hypoxemia, and hypotension. Intra-abdominal pressure measured at 45 mmHg, leading to a diagnosis requiring paracentesis.
- 💡 Paracentesis was performed, removing 4500cc of fluid, which reduced intra-abdominal pressure and resolved the patient's pulmonary, renal, and hemodynamic issues.
- 👨⚕️ A 37-year-old male developed an ileus with massive bowel distention but no free fluid. Intra-abdominal pressure was 31 mmHg, and an NG tube decompression was used to relieve the pressure.
- 📏 Intra-abdominal pressure is measured using a Foley catheter, ensuring the patient is supine, and the transducer is zeroed appropriately. Normal pressure is between 5-10 mmHg.
- ⚠️ Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure exceeds 20 mmHg, causing organ dysfunction and decreased abdominal perfusion pressure.
- 🧠 ACS impacts multiple organs, causing decreased cardiac output, hypoxemia, renal dysfunction, and elevated intracranial pressure due to reduced blood flow.
- 🔄 Primary ACS is caused by intra-abdominal processes, while secondary ACS arises from factors like aggressive resuscitation.
- 🩺 Treatment includes neuromuscular blockade, ventilator support, decompressive surgery, and supportive management. Surgical decompression may involve temporary wound closures.
- 🚨 Early detection of intra-abdominal hypertension is crucial, as delayed intervention can turn urgent problems into emergencies, resulting in multi-organ failure.
Q & A
What is intra-abdominal hypertension (IAH) and how is it measured?
-Intra-abdominal hypertension (IAH) is an elevated pressure within the abdominal cavity, typically measured using a Foley catheter with sterile saline infusion. The patient should be supine, relaxed, and the transducer zeroed appropriately. Normal intra-abdominal pressure is between 5-10 mmHg.
What are the stages of intra-abdominal hypertension?
-Intra-abdominal hypertension is classified into four grades based on severity: Grade 1 (12-15 mmHg), Grade 2 (16-20 mmHg), Grade 3 (21-25 mmHg), and Grade 4 (greater than 25 mmHg).
What is abdominal compartment syndrome (ACS) and how does it develop?
-Abdominal compartment syndrome (ACS) occurs when intra-abdominal pressure exceeds 20 mmHg, leading to organ dysfunction. It can result from primary intra-abdominal issues or secondary causes like aggressive fluid resuscitation.
How does intra-abdominal hypertension affect the body systems?
-Intra-abdominal hypertension affects multiple systems, including cardiovascular (decreased cardiac output), respiratory (reduced chest wall compliance, hypoxemia), renal (renal vein compression, decreased urine output), and even the brain (elevated intracranial pressure).
What is the role of paracentesis in managing intra-abdominal hypertension?
-Paracentesis is a procedure to remove fluid from the abdominal cavity, commonly used when ascites is present. It can rapidly reduce intra-abdominal pressure, improving respiratory, renal, and cardiovascular function.
What are the recommended steps to manage intra-abdominal hypertension and abdominal compartment syndrome?
-Management includes neuromuscular blockade, ventilatory support, hemodynamic monitoring, and potentially surgical decompression. In milder cases, decompression with an NG tube may be sufficient, while more severe cases may require surgical intervention like laparotomy.
How does intra-abdominal pressure influence abdominal perfusion pressure?
-Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure. A pressure lower than 60 mmHg indicates poor organ perfusion and a risk of organ dysfunction.
What are the typical symptoms of abdominal compartment syndrome?
-Symptoms of abdominal compartment syndrome include difficulty in ventilation, hypoxemia, hypercarbia, hypotension, reduced urine output, and organ dysfunction.
How can intra-abdominal hypertension lead to multi-system organ failure?
-As intra-abdominal pressure increases, perfusion to organs decreases, causing reduced cardiac output, respiratory dysfunction, renal failure, and impaired blood flow, ultimately leading to multi-system organ failure if not managed promptly.
Why is early detection of intra-abdominal hypertension crucial?
-Early detection allows for timely interventions, such as fluid removal or decompression, preventing progression to abdominal compartment syndrome, which is more difficult to manage and associated with higher complications and mortality.
Outlines
🩺 Case Study: Managing Intra-abdominal Hypertension
The speaker, Linda Green, introduces herself and expresses gratitude to the Southeastern Critical Care Summit for the opportunity to discuss intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). She begins with a case study of a 67-year-old female with liver disease presenting to the emergency department. Despite initial resuscitation, the patient's condition worsens, showing symptoms like hypotension, hypoxia, and no urine output. Upon discovering an intra-abdominal pressure of 45, the team performs a paracentesis, removing 4500 cc of fluid, which immediately improves the patient's renal, pulmonary, and circulatory status. This case emphasizes the critical role of intra-abdominal pressure management in treating such patients.
🧑⚕️ Case Study: Decompressing Large and Small Bowel Distension
Linda Green presents a second case involving a 37-year-old male transferred to the MICU with hypotension. After ruling out ascites through ultrasound, the patient’s intra-abdominal pressure is found to be 31 due to massive large and small bowel distension, indicative of an ileus. The treatment strategy focuses on decompression, beginning with less invasive NG tube suctioning, which successfully reduces the pressure and improves the patient's output. This case highlights that open abdominal surgeries carry risks and should be avoided if possible, emphasizing the importance of decompression techniques to manage intra-abdominal pressure effectively.
📊 Understanding Intra-abdominal Pressure (IAP) and Measurement
This section covers the fundamentals of intra-abdominal pressure (IAP), including proper measurement techniques using a Foley catheter with sterile saline. The speaker explains that normal IAP should range between 5-10 mmHg. The grading system for intra-abdominal hypertension (IAH) is based on pressure levels, with grades 1 to 4 ranging from 12 mmHg to over 25 mmHg. Elevated IAP can have severe systemic effects on organs, leading to multi-organ dysfunction and even abdominal compartment syndrome (ACS) when pressure surpasses 20 mmHg. The section also explains the differences between acute, chronic, and subacute IAH.
🫁 Systemic Impact of Intra-abdominal Compartment Syndrome
Linda Green delves into the systemic consequences of intra-abdominal compartment syndrome (ACS), explaining how it affects various organs and systems. High intra-abdominal pressure (IAP) leads to reduced cardiac output, impaired lung compliance, hypoxemia, hypercarbia, and renal dysfunction. The reduced perfusion and impaired venous return can cause multi-organ failure, necessitating urgent intervention. Supportive management may include neuromuscular blockade, ventilatory support, hemodynamic support, and in severe cases, surgical decompression of the abdomen to relieve pressure and prevent further damage.
💡 Recommendations and Management Approaches for IAH and ACS
The final section provides insights into the management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Linda Green discusses how trauma is not a necessary precursor for the development of ACS and emphasizes that it can occur in any unit. Key strategies include early measurement of intra-abdominal pressure, continuous monitoring, and timely intervention to prevent the escalation from urgent to emergent conditions. The talk closes with the importance of early detection and management to reduce the risk of life-threatening complications, despite the lack of consensus on specific therapeutic interventions such as diuretics or renal replacement therapy.
Mindmap
Keywords
💡Intra-abdominal hypertension (IAH)
💡Abdominal compartment syndrome (ACS)
💡Paracentesis
💡Decompressive laparotomy
💡Intra-abdominal pressure (IAP)
💡Hypoxemia
💡Ascites
💡Renal failure
💡Neuromuscular blockade
💡Foley catheter
Highlights
Introduction to intra-abdominal hypertension and abdominal compartment syndrome, with no disclosures.
Case 1: A 67-year-old female with liver disease and pleurisy, presenting with hypotension, hypoxia, and zero urine output. Intra-abdominal pressure measured at 45.
Management of Case 1: Paracentesis performed to remove 4500 mL of fluid, reducing intra-abdominal pressure to 14, resulting in immediate improvement in renal, pulmonary, and overall status.
Case 2: A 37-year-old male with hypotension and intra-abdominal pressure of 31, diagnosed with ileus and bowel dilatation.
Management of Case 2: Initial approach with NG tube decompression reduced intra-abdominal pressure from 31 to 12, with subsequent clinical improvement.
Definition of intra-abdominal pressure: The pressure within the abdominal cavity, typically measured using a Foley catheter and sterile saline, with normal pressures between 5 to 10 mmHg.
Grading intra-abdominal pressure severity: A 1 to 4 grading system, with pressures greater than 25 classified as grade 4.
Intra-abdominal hypertension classification: Acute, chronic, or subacute, with pressures greater than 12 potentially impacting organ function.
Abdominal compartment syndrome: Defined by intra-abdominal pressures greater than 20 mmHg combined with organ dysfunction and perfusion pressures below 60.
Primary vs. Secondary abdominal compartment syndrome: Primary caused by intra-abdominal issues, while secondary arises from conditions like fluid resuscitation.
Effects of abdominal compartment syndrome: It impacts multiple organ systems, including decreased cardiac output, impaired ventilation, and reduced renal function.
Supportive management strategies: Includes neuromuscular blockade, ventilator support, and hemodynamic support. Surgical decompression may involve paracentesis, decompressive laparotomy, or temporary wound closure.
Challenges in management: No strong recommendations for pharmacologic interventions or renal replacement therapy in managing intra-abdominal hypertension.
Key takeaway: Early measurement and intervention for intra-abdominal hypertension are crucial to prevent progression to abdominal compartment syndrome.
Importance of monitoring: Continuous intra-abdominal pressure monitoring recommended for early detection and timely intervention, rather than relying on spot checks.
Transcripts
good morning everybody I'm Linda green
and I wanted to thank the southeastern
critical care summit for the opportunity
to talk about intra-abdominal
hypertension and abdominal compartment
syndrome and I do not have any
disclosures let's take the first case
you have a 67 year old female who
presents to the emergency department of
the history of liver disease
unfortunately here at five teens out in
my I see you see a lot of liver disease
this person came in with new onset
pleurisy Disney a-- and agitation
hypotensive despite I'd include
resuscitation they've now become
intubated and we've got them sedated and
company unfortunately they become they
start to worsen over the next four to
six hours they become difficult it
ventilate the alarms are going off
everybody's running in the room could
just stop the alarms from going on and
off they become hypoxic type of carbon
hypotension and then urine outlet of
course is zero we check your
intra-abdominal pressures there 45 we go
ahead and get have down the whole town
and it shows the sightings what is your
next diet stock diagnostic or next
management step I'll give you a moment
to think about it and here we go
this person has tips societies what is
the treatment of paracentesis
let's get that fluid off let's try to
remove that extra pressure we have a
problem and we can treat it we take on
4500 BC and the pressures go down to 14
everybody bleep out breathe and side
relief and there's immediate resolution
the renal status pulmonary and even and
compromise results
everybody feels good about themselves
let's take this next case we have a 37
year old male
preyed on the general medicine floor
transfer to the MICU and was intubated
and hypotensive live the fluid
resuscitation they're very seriousiy now
they're only with it they're enduring
what are your next steps let's get an
ultrasound
KTV and do an intra-abdominal pressure
measurement the older sound it shows no
free acidic food first case there was a
lot of acidic food to go after this one
there isn't now find the KB it's
massively distended large and small
bowel internal pressures are 31 what is
this diagnosis and what are your next
steps in management alright let's move
on
it's an ileus large and small bowel
dilatation no evidence of obstruction so
the surgery team was comforted I'm very
happy to come and take your console dr.
Breen could you please decompress this
person I I knew that a decompressive
laughing Roger the class ii was
takeaways ticket before we do that let's
see if we can try an NG tube
decompression some record tube
decompressions
or without this t we can get some of
this air and gas out of there one hour
later intra-abdominal pressure goes down
to 12 then you're an output increases
and the north whatever is discontinued
we know that if we open this patient up
and give them an open abdomen there are
a lot of complications that can occur is
not as benign a process as you might
think and some of those of you who've
seen an entertaining or a Pittsburgh
fistula
you know so what is intra-abdominal
pressure it is the pressure within the
abdominal cavity and how do you measure
it accurately make sure that this person
has no abdominal muscle contractions
that means paralysis you want to check
it the Internet
raishin that the patient is supine and
the transducer is zero appropriately
this is a measurement with a Foley
catheter in there he was still 25
development sterile saline and you're
very happy to see that the pressure
should be somewhere between 5 to 10
millimeters of virgin we also need to
greatly so we could communicate how
severe this interim normal how high this
internal pressure is is it a 1 to 4
system 1b 12 to 15 greater than 25 is a
4 now when we have greater than 12 and
we have intra-abdominal pressure we can
great them all so whether it's a hyper
acute because you laughed and push real
quickly or because it's chronic and
could you're pregnant and you've got
this internal pressure or somewhere in
between which is what we deal with the
acute and subacute populations now with
that internal pressure is elevated to
the point that it affects the organ this
caucus organ dysfunction greater than 20
millimeters of mercury plus or minus
abdominal pressure Abdullah perfusion
pressures that are less than 60 then
that would be abdominal compartment
syndrome if you think about it in the
brain we have the cerebral perfusion
pressure and we realize that you can use
the mean arterial pressure minus the
internal pressure to get your abdominal
perfusion pressure and we want to
perfuse our ordinance when we think
about classifying abdominal compartment
syndrome we think about primary
secondary causes primary being a primary
intra-abdominal process or the secondary
is coming from attitude resuscitation in
some of our patients and this will
affect every system in the body
decreased cardiac output increase
systemic vascular resistance reduced
chest wall compliant in tidal volume
resulting in hypoxemia and hypercarbia
will have renal vein compression would
result in decreased venous return the
expenses here in blood flow impaired
ability to
like acid and elevated intracranial
pressures every organ is affected so
when you have decreased perfusion
decreased preload that have decreased
cardiac output and reduced blood flow to
the organs and you'll end up with
multi-system organ failure so what do we
do
supportive management would be
neuromuscular blockade ventilator
support he would Adamic support and look
for surgical decompression whether it's
a permit a new strain to remove that
glue like we did in the first case a
decompressive sealing I to me and
sometimes we just have to go to the
bedside and open up the abdomen and if
there were sutures in there before just
cut them and put in a temporary wound
back closure to allow for that flute
removal and expansion of the beats of
the pressure so there is a society the
World Association for abdominal
departments and repeat believers of
society there is and they have said that
we there are no recommendations inspired
I Rennicks people think ultra measure
Diaries these people often that'll make
them better they couldn't give that
recommendations for that what about
renal replacement therapy you know no
recommendations for that either and then
hemodynamically stable patient who has
who has interim government hypertension
and acute resuscitation has been
completed and the inciting issues have
been controlled so what is the price
that leave with trauma is not required
for abdominal part Macedo to develop it
can occur in any unit and the
measurement is helpful but don't wait to
the last minute spot checks are often
erroneous because you wait too long and
if you wait too long it becomes an
urgent from the changes an emergent
problem
urgent problem into the emergent problem
and interrupt nominal pressure monitors
will allow early detection and early
intervention for interrupt on
hypertension thank you very much
you
[Applause]
you
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