Intraabdominal hypertension & ACS

Intra-Abdominal Hypertension (IAH) : 

Intra-Abdominal Hypertension (IAH) The ARDS of the gut! By: Tim Wolfe, MD Email: twolfe@wolfetory.com

Disclosure : 

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 Director:Wolfe Tory Medical Manufacturer of the AbViser Intraabdominal pressure monitoring kit This lecture is about IAH and ACS, not the AbViser

Slide 3: 

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?

What was their intra-abdominal pressure? : 

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?

Case: Septic child : 

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

Case: Aspiration patient : 

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

Case: Dyspnea in ER : 

Case: Dyspnea in ER 67 y.o. female with dyspnea and agitation Hypotensive, agitated, H&P 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

Case Points : 

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.

Outline / Objectives : 

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

DefinitionsWCACS, Antwerp Belgium 2007 : 

DefinitionsWCACS, Antwerp Belgium 2007 Intra-abdominal Pressure (IAP): Intrinsic pressure within the abdominal cavity Intra-abdominal Hypertension (IAH): A sustained IAP > 12 mm Hg (often causing occult ischemia) without obvious organ failure Abdominal Compartment Syndrome (ACS): IAH > 20 mm Hg with at least one organ dysfunction or failure

Physiologic Insult/Critical Illness : 

Physiologic Insult/Critical Illness Ischemia Inflammatory (SIRS) response Capillary leak Tissue Edema (Including bowel wall and mesentery) Intra-abdominal hypertension Fluid resuscitation

Who is at risk for IAH - Fluids! : 

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

Fluids! : 

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

Slide 14: 

The fluid goes Right Here!!

Intra-abdominal Hypertension &Abdominal Compartment Syndrome : 

Intra-abdominal Hypertension &Abdominal Compartment Syndrome Physiologic Sequelae

Physiologic Sequelae : 

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

IAH and the cardiovascular system : 

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

Physiologic Sequelae : 

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

Physiologic Sequelae: Lung : 

Physiologic Sequelae: Lung IAH Normal ATX ITV, ITP

Physiologic Sequelae : 

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

Physiologic Sequelae : 

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, edema, oliguria/anuria, ARF LOSS of UOP as a resuscitation indicator!

Physiologic Sequelae : 

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

Physiologic Sequelae : 

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)

Slide 24: 

Circling the Drain Intra-abdominal Pressure Mucosal Breakdown (Multi-System Organ Failure) Bacterial translocation, Cellular Apoptosis, Necrosis Acidosis Decreased O2 delivery Anaerobic metabolism Capillary leak Free radical formation MSOF

How common is this syndrome? : 

How common is this syndrome?

How common is this syndrome? : 

How common is this syndrome?

How common – Shock with fluid resuscitation : 

How common – Shock with fluid resuscitation Requeira, 2008: Intraabdominal hypertension in patients with septic shock. 83% incidence of IAP > 12 mm Hg in septic shock 51% incidence of IAP > 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 > 20 with organ failure (abdominal compartment syndrome)

How good is clinical judgment for detecting elevated IAP? : 

How good is clinical judgment for detecting elevated IAP? Prospective, blinded trial - Staff physician judgment Results: < 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

Does IAH / ACS affect patient outcome? : 

Does IAH / ACS affect patient outcome? IAH predicted mortality IAH > 12 mortality 38.8% No IAH - mortality: 22.2% IAH predicted LOS Presence of IAH results in longer ventilator times, longer ICU times Malbrain, Crit Care Med, 2005 Mixed Med-Surg population

Does IAH intervention affect patient outcome? : 

Does IAH intervention affect patient outcome?

Does IAH/ACS protocol driven intervention affect patient outcome? : 

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

Does IAP/IAH protocol driven monitoring affect patient outcome? : 

Does IAP/IAH protocol driven monitoring affect patient outcome? 12 fewer decompressions 4 fewer ICU/vent days per patient Mortality  18% relative risk Open Abdomens  40% relative risk ICU LOS 4 days Ventilator Days  4.3 days 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)

Does IAH / ACS affect patient outcome? : 

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 morbidity without increasing cost of care (shorter LOS) ACS is exciting but rare, IAH is VERY common – so focus on IAH If you simply reduce IAP, increase UOP, mobilize fluid earlier you will allow ventilator weaning and get them extubated 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.

Intra-Abdominal Pressure Monitoring : 

Intra-Abdominal Pressure Monitoring

Intra-Abdominal Pressure Monitoring : 

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

“Home Made” Pressure Transducer Technique : 

“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!

“Home Made” IAP Kits : 

“Home Made” IAP Kits Home Made IAP monitoring Ingenious for proof of concept in research setting Inadequate for routine use in broad ICU setting with multiple providers

“Home Made” IAP Kits : 

“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

Bladder Pressure Monitoring: How to do it : 

Bladder Pressure Monitoring: How to do it Use a prepackaged Kit : Advantages – Simple, Standardized, Reproducible, Time efficient, Sterile, produced with tight quality control

Reproducibility Study : 

Reproducibility Study Inter-observer Scatterplot (r = 0.95, p < 0.001) Kimball, Int Care Med 2007 Nursing driven study with 89 different nurses participating. Excellent intra- and inter- observer reproducibility

Common Questions: How much fluid should be infused into bladder? : 

Common Questions: How much fluid should be infused into bladder? Volume of infusion (ml) IAP Measured (mm Hg) 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 WSACS: Max volume 25 ml, 1 ml/kg in children.

Common Question: How do I recognize appropriate IAP transduction onto my monitor? : 

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

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

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: IAP=24 Post dressing release: IAP=12 24 hours later: IAP=12

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

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)

Management of IAH and ACS : 

Management of IAH and ACS

WSACS IAH/ACS Guidelineswww.wsacs.org 2009 : 

WSACS IAH/ACS Guidelineswww.wsacs.org 2009 Assessment algorithm Management algorithm

Assessment Algorithm2007 : 

Assessment Algorithm2007 UUMC: Nurse is empowered to enter any patient fulfilling criteria

IAH: Management 2009 : 

IAH: Management 2009 WSACS.ORG Medical management (23 of 25 interventions) Surgical management

IAH: Medical Management : 

IAH: Medical Management Improve Abdominal Wall compliance Shifts pressure-volume curve to right, reducing IAP for the same volume.

IAH/ACS Management : Positioning : 

IAH/ACS Management : Positioning Vasquez, 2007 Stretch out

IAH/ACS Management: Paralysis : 

IAH/ACS Management: Paralysis De Waele, Crit Care Med 2003 UOP Kimball, WCACS 2007 IAP Step 4 – Just prior to surgery Only for IAP > 20 Brief duration, daily “holiday”

IAH: Medical Management : 

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

IAH/ACS Management : Evacuate Bowel, Peritoneal Fluids : 

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

IAH/ACS Management : Evacuate Bowel, Peritoneal Fluids : 

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 (p<0.01), 15 day LOS

IAH: Medical Management : 

IAH: Medical Management Optimize fluid administration: Reduces bowel and mesenteric edema. Bowel edema Vidal 2008 Sepsis induced Capillary permeability

IAH/ACS Management: Consider hemodialysis : 

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

IAH/ACS Management: Consider Hemofiltration : 

IAH/ACS Management: Consider Hemofiltration Fluid Overloaded Post CVVH

IAH: Medical Management : 

IAH: Medical Management Optimize systemic/regional perfusion: “Balanced resuscitation” Enough fluid – but not too much Vasoactive support to enhance perfusion Cheatham, Malbrain 2007 APP

IAH: Surgical Management : 

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 >$200,000) Failure to close on initial admission $250,000++ (estimate nearly as much over next year by time ventral hernia finally repaired).

IAH/ACS Management: Decompressive Laparotomy : 

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

Decompressive Laparotomy : 

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

Decompressive Laparotomy : 

Decompressive Laparotomy Post-operative dressing Several days post-op

Surgical Management of Compartment Syndromes : 

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

Compartment Syndromes versus Hypertension : 

Compartment Syndromes versus Hypertension Abdominal compartment syndrome = Emergent Surgical Disease. Intra-abdominal hypertension = Urgent Medical Disease.

Cost analysis : 

Cost analysis Is IAP monitoring and intervention cost effective?

Cost analysis : 

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

Cost analysis: IAP monitoring impact on resource utilization. : 

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 - $150,000 - $200,000 + charges? Cheatham – 46 % fewer decompressions Kimball – 40 % fewer decompressions (1/month less)

Cost analysis : 

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 (@ 3000/day = $1.3 million) Abdominal decompression - 12 fewer decompressions 12 fewer decompressions/year (mean charges for these patients >$150,000 = $1.8 million) Estimated total reduced charges = $3.1 million Actual total yearly cost for monitoring devices: $9265

Cost analysis: IAP monitoring impact on resource utilization. : 

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?

Summary: Is IAP monitoring and intervention cost effective? : 

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……………….

Final Thought : 

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

Questions? : 

Questions? IAH and ACS Educational Web sites: www.abdominal-compartment-syndrome.org WSACS.org FREE CME: www.oaccm.org My email: twolfe@wolfetory.com Via Ferrata Tridentina - Italy

Additional slides if more than one hour exists : 

Additional slides if more than one hour exists Slides beyond this can be added as needed to lengthen lecture beyond 1 hour

No such thing as an “Open Abdomen” in the ICU : 

No such thing as an “Open Abdomen” in the ICU “Open Abdomen” Vac-pac dressing placed in OR. Now 6 hours post-op: MAP=70 HR=114 IAP=24 UOP < 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 MAP=70 HR=96 IAP=12 UOP >100 cc/ hour PIP = 30 cm H2O

No such thing as an “Open Abdomen” in the ICU : 

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

Does IAH intervention affect patient outcome? : 

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%

IAH in neuro patients : 

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”

Normal Abdominal CT : 

Normal Abdominal CT Inferior Vena Cava Note that abdomen is oval, not round Normal kidney

Abdominal CT in ACS – Renal compression : 

Retroperitoneal hemorrhage Note that abdomen is round, not oval Kidneys are compressed, patient is anuric Pickhardt, AJR 1999 Abdominal CT in ACS – Renal compression Flattened Inferior Vena Cava

How common is this syndrome*? : 

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.

How common – Septic Patients* : 

How common – Septic Patients* Efstathiou et al, Intensive Care Med 2005;31 supp1 1: S183 Abs 703 * These data are for ALL sepsis patients. MUCH higher if you look only at major fluid resuscitation.

Does IAH / ACS affect patient outcome? : Renal : 

Does IAH / ACS affect patient outcome? : Renal “ IAH is a KEY promoting factor of acute renal failure.” Dalfino 2008

Does IAH intervention affect patient outcome? : 

Does IAH intervention affect patient outcome? Ivatury, J Trauma, 1998: Intra-abdominal hypertension after damage control surgery. 70 patients monitored for IAP > 18 mm Hg (25 cm H2O) 25 had facial closure at time of surgery: 52% developed IAP > 18 mm Hg 39% Died 45 cases had abdomen left “open”: 22% developed IAP > 18 mm Hg 10.6% Died

Does IAH intervention affect patient outcome? : 

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 (p<0.01), 15 day LOS

Does IAH intervention affect patient outcome? : 

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

Does IAH intervention affect patient outcome? : 

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%

IAH/ACS Management: Colloids : 

IAH/ACS Management: Colloids O’Mara, 2005: Prospective randomized evaluation of IAP with crystalloid and colloid resuscitation in burns 31 cases with >25% burn plus inhalation or >40% 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

Conclusion - Is IAP monitoring and intervention cost effective? : 

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!

The risk of not measuring IAP : 

The risk of not measuring IAP Late Monitoring = Late Recognition Late Recognition = Late Intervention Late Intervention = Limited Treatment Options Limited Options = Poor Outcomes

Who is at risk for IAH? : 

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

Causes of Intra-abdominal Pressure (IAP) Elevation : 

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?

Ischemic Time and Cell survival : 

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

Ischemic time matters : 

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)

WSACS IAH/ACS Guidelines : 

WSACS IAH/ACS Guidelines www.wsacs.org 2008 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 Risk Factors

Cost analysis: IAP monitoring impact on resource utilization. : 

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

Does IAH intervention affect patient outcome? : 

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%

Does IAH / ACS affect patient outcome? : 

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 < 15 mm Hg: 14 % mortality Mean ICU LOS 4 days 11 (61%) cases with IAP > 15 (all over 20) mm Hg: 45 % mortality Mean ICU LOS 21 days

What intra-abdominal pressures are concerning? : 

What intra-abdominal pressures are concerning? Pressure (mm Hg) Interpretation 0-5 Normal 5-10 Common in most ICU patients > 12 (Grade I) Intra-abdominal hypertension 16-20 (Grade II) Dangerous IAH - begin non- invasive interventions >21-25 (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

Fluid-Column Manometry : 

Fluid-Column Manometry Sedrak 2002 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

Ischemic time matters : 

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)

Ischemic time matters : 

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?

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

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

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?

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 (P=N.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 Common Questions: What is the risk of UTI from transvesicular IAP monitoring?

Bladder Pressure Monitoring: How to do it : 

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