Intraabdominal hypertension

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Transcript of Intraabdominal hypertension

Intraabdominal hypertension - diagnostic and clinical considerations

Intraabdominal hypertension in practice

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

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HistoryIntraabdominal 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.

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BackgroundAbdominal 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.

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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.

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Material and methodA 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.

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In this study an elevated intraabdominal pressure was considered above 12 mm Hg (intraaabdominal hyperpressure IAH)ACS definition was the one agreed internationally (WSACS).

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Results and discussionA 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.

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Cases in study (50 patients)

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

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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.

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Intraabdominal pressure in 50 casesPressure value12-15 mm Hg15-20 mm Hg> 20 mm HgTotalNo. patients23161150%463222100

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Comparing dataIntraabdominal pressureOur studyEfstathiou et al. (2005)I (12-15 mm Hg)46%58%II (15-20 mm Hg)32%29%III (>20 mm Hg)22%13%

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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.

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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%)

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Mortality for different values of IAPIAPDeaths (no. patients)Survivors (no. patients)Total (no. patients)12-15 mm Hg1492315-20 mm Hg10616>20 mm Hg (ACS)8311Total321850

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Mortality in patients with surgical procedure performed (aetiology)

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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.

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

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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.

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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.

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From the 12 patients with SAP in 10 cases a surgical procedure was performed. There were 9 deaths in this subgroup.

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Prevalence of ACS in SAPNo. of patients with SAP and IAP 12-15mm HgNo. of patients with SAP and IAP >20mm HgTotal2 (17%)10 (83%)12

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Vacuum pack

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ConclusionSevere 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.

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Chart12426141412622

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Sheet1%Trauma24SAP26Peritonitis14Tumors14Intest. obstr.12Ascitis6Burns2Mesenteric ischemia2

Chart19411

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Sheet1Column1SAP9Tumors4Cirrhosis1Uterine tumor1To resize chart data range, drag lower right corner of range.

Chart13515

Column1

Sheet1Column1Correct35Incorrect15To resize chart data range, drag lower right corner of range.