INTRAABDOMINAL HYPERTENSION IN

PRACTICE

Authors: F. Iordache, Ioana Grințescu, Alina Prodan, D. Surdeanu

History Intraabdominal pressure (IAP) was, at first,

measured via rectum (Braune, Germany 1865) and the interrelation between IAP and respiratory failure was demonstrated (Henricius, 1890).

Kron et al. (Ann Surg 1984) performed surgical decompression in 11 cases with oliguria.Seven patients survived with renal function restored.In other 4 cases with renal failure but without

decompression died, all of them having renal failure.

Background Abdominal compartment syndrome (ACS) has

an incidence of 2-9%. Up to 15% of these cases are registered in intensive care units.

ACS is present in 1% of polytrauma patients. It seems that besides polytrauma the most

frequent cause of ACS is severe acute pancreatitis (SAP).

Early prevention and early decompression in those cases seems beneficial. In cases with intraabdominal hypertension (IAH) and SAP early decompression could be helpful. In these cases the first 5 days are critical.

Objectives The present study aimed analyzing the presence of

intraabdominal hypertension and the development of abdominal compartment syndrome in an intensive care unit patients and the most frequent causes involved. Also, the evolution of these cases was recorded in regard with these data.

As a secondary objective we aim to demonstrate and highlight the importance of measuring and monitoring the intraabdominal pressure in critical care patients and to reevaluate the role of clinical assessment.

Material and method A prospective study was designed.

Patients in ICU considered at risk of developing ACS were included.

Measurement of intraabdominal pressure was done by Foley method.

Clinical blind assessment of IAH was performed by one of the authors.

Demographic, clinical and patient major parameters were statistically analyzed.

In this study an elevated intraabdominal pressure was considered above 12 mm Hg (intraaabdominal hyperpressure – IAH)

ACS definition was the one agreed internationally (WSACS).

Results and discussion A total of 57 ICU patients were included. All of them

had Foley catheters. From this group 7 cases were excluded, 2 cases because of refusal and 5 because of transfers in other units.

Abdominal pressure was measured routinely once daily and a blind comparison with clinical assessment of IAH was also performed.

APACHE II and SOFA scores were calculated. In SAP established criteria for severity were used.

Data regarding surgical intervention were collected. There was a sex ratio of M:F of 1:1.4. Average age was 55+18 ani with a median of 53 years.

Cases in study (50 patients)

Sex ratio - 1:1,4, Average age: 55+18 years

In our study the first cause of elevated IAP was severe acute pancreatitis (SAP) and trauma was second.

From 50 cases in study in 23 patients (46%) an elevated IAP was recorded.

Intraabdominal pressure in 50 cases

Pressure value

12-15 mm Hg

15-20 mm Hg

> 20 mm Hg Total

No. patients 23 16 11 50

% 46 32 22 100

Comparing data

Intraabdominal pressure

Our study Efstathiou et al. (2005)

I (12-15 mm Hg) 46% 58%

II (15-20 mm Hg) 32% 29%

III (>20 mm Hg) 22% 13%

In 11 patients an IAP above 20 mm Hg was demonstrated. All these patients were diagnosed with ACS. Ten were male and only one woman developed ACS. The difference can be explained by the different pathologies involved.

In 29 cases a surgical procedure of performed. In those with high IAP this was also an indication for surgery, albeit not alone. There were 15 deaths in those admitted to surgery 9 of them being with ACS (global mortality - 55%).

From 21 patients without surgery only 4 have survived (global mortality – 81%)

Mortality for different values of IAP

IAP Deaths (no. patients)

Survivors (no. patients)

Total (no. patients)

12-15 mm Hg 14 9 23

15-20 mm Hg 10 6 16

>20 mm Hg (ACS)

8 3 11

Total 32 18 50

Mortality in patients with surgical procedure performed (aetiology)

Mortality is correlated with IAP value but the pathology involved is also an important factor into the equation. The mortality in cases with ACS in this study was 73%. Hence, prevention of ACS is extremely important.

Clinical assessment of IAP Vs intravesical measurement (no. patients)

Clinical assessment of IAP was blindly done by one of the authors (FI). Clinical assessment of IAP was correct in 71% (35 cases) but an important number of cases with high IAP were missed. As others have proved, based on our data we consider clinical evaluation unreliable in the assessment of IAP.

In patients with SAP with 2 exception all were having an IAP over 15 mm Hg. As a matter fact the main aetiology registered in our cases was SAP. We can only speculate, although others have demonstrated, that a high IAP is an useful tool in indicating early decompression.

From the 12 patients with SAP in 10 cases a surgical procedure was performed.

There were 9 deaths in this subgroup.

Prevalence of ACS in SAP

No. of patients with SAP and IAP 12-15mm Hg

No. of patients with SAP and IAP >20mm Hg

Total

2 (17%) 10 (83%) 12

Vacuum pack

Conclusion Severe acute pancreatitis and trauma are

the main causes of abdominal compartment syndrome.

Objective measurement of the abdominal pressure is mandatory for establishing IAH diagnostic, clinical assessment being inadequate.

Measuring IAP is the main diagnostic step in preventing ACS or deciding for decompression therapy.