Intra-abdominal Hypertension - Wendy R. Greene, MD

Summary

In 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

00:00

🩺 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.

05:00

🧑‍⚕️ 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.

Keywords

💡Intra-abdominal hypertension (IAH)

Intra-abdominal hypertension refers to increased pressure within the abdominal cavity. In the video, it is discussed as a condition that can impair organ function, leading to complications such as decreased cardiac output and renal failure. IAH is critical to the video's theme, as managing this pressure is a primary concern in critical care settings, illustrated by the cases of patients with elevated intra-abdominal pressures.

💡Abdominal compartment syndrome (ACS)

Abdominal compartment syndrome is a severe form of intra-abdominal hypertension where the elevated pressure leads to multi-system organ failure. The speaker uses case studies to demonstrate how this syndrome affects various bodily systems, including respiratory and renal function, and stresses the importance of early detection and intervention.

💡Paracentesis

Paracentesis is a procedure to remove excess fluid from the abdominal cavity, which helps reduce intra-abdominal pressure. In the first case discussed, a patient with ascites undergoes paracentesis, reducing pressure and improving respiratory and renal function. This procedure highlights the critical role of fluid management in treating intra-abdominal hypertension.

💡Decompressive laparotomy

Decompressive laparotomy is a surgical procedure that involves opening the abdomen to relieve pressure. It is presented as a last-resort treatment in cases of severe intra-abdominal hypertension or abdominal compartment syndrome. The video emphasizes that while this procedure can be life-saving, it also carries significant risks, such as infections and fistulas.

💡Intra-abdominal pressure (IAP)

Intra-abdominal pressure is the pressure within the abdominal cavity, measured in millimeters of mercury (mmHg). The video explains the importance of measuring IAP to assess the severity of intra-abdominal hypertension and guide treatment. A Foley catheter is typically used to measure IAP, as mentioned in the video.

💡Hypoxemia

Hypoxemia refers to low oxygen levels in the blood, which can result from high intra-abdominal pressure that restricts lung expansion. In the video, one of the patients experiences difficulty breathing and hypoxemia due to intra-abdominal hypertension, illustrating how the condition can impair respiratory function.

💡Ascites

Ascites is the accumulation of fluid in the peritoneal cavity, often seen in patients with liver disease. In the first case, ascites is a significant factor contributing to the patient's intra-abdominal hypertension. The video uses this condition to demonstrate how paracentesis can relieve pressure and improve organ function.

💡Renal failure

Renal failure, or kidney failure, is the inability of the kidneys to filter waste from the blood. Intra-abdominal hypertension can compress the renal veins, leading to reduced blood flow and renal failure, as seen in the patients described in the video. Early intervention to reduce intra-abdominal pressure is essential to prevent this outcome.

💡Neuromuscular blockade

Neuromuscular blockade refers to the use of medication to induce muscle paralysis, which is often used in patients with severe intra-abdominal hypertension to prevent abdominal muscle contractions that could worsen the condition. The video suggests this as part of supportive management for patients with elevated intra-abdominal pressures.

💡Foley catheter

A Foley catheter is a device inserted into the bladder to measure intra-abdominal pressure. The video emphasizes the importance of accurate IAP measurement using a Foley catheter, especially in supine patients, to diagnose intra-abdominal hypertension and monitor the effectiveness of treatments like paracentesis or decompression.

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