abdominal compartment syndrome and its method of measurement

1. SPEAKER – DR. ARUN KUMAR MAURYA
MODERATOR – DR. R. B. SINGH

2. •The overall prevalence of IAH was 58.8% (IAP >12 mm Hg).
•Prevalence was 65% in surgical patients and 54.4% in medical
patients.
•However, the medical patients had a higher prevalence of an
increased IAP (>15 mm Hg) than did the surgical patients (29.8% vs
27.5%).
•Medical patients had a higher prevalence of ACS than did the
surgical patients (10.5% vs 5%)
•Compared with patients without IAH, patients with IAH were sicker
and had a higher mortality rate (53% vs 27%; P = .02).
•ACS developed in 10 patients (12%), and 8 of the 10 (80%) died.
INCIDENCE & PREVALENCE

3. 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 ACS –strongly
consider decompressive laparotomy
IAP INTERPRETATION

4. DIAGNOSIS
• The diagnosis of IAH/ACS is dependent upon the accurate and
frequent measurement of IAP.
• Usually patients is in the ICU on artificial ventilation. Therefore,
symptoms are not apparent . Hence it should be suspected in all the
unstable critically ill patients with abdominal, cardiovascular and
respiratory signs who fail to improve in spite of adequate
resuscitation.
• Progressive oliguria and increased ventilatory requirements are
also common in patients with ACS.

5. • Radiological investigations – plain x-ray of chest & the
abdomen, USG or CT scan of abdomen are insensitive to the
presence of increased of IAP . However, they can illustrate the
cause of IAP ( bleeding, hematoma, ascites or abscess ) and may
offer clue for management (paracentesis or drainage of
collections).

7. WSACS
GUIDELINES
CHEATHAM, ICM 2006

8. RISK FACTOR FOR IAH / ACS AS PROPOSED BY
THE WCACS :
1. RELATED TO DIMINISHED ABDOMINAL WALL COMPLIANCE
• Mechanical ventilation
• Use of peep
• High body mass index
• Pneumoperitoneum
• Abdominal vascular surgery, especially with tight abdominal
closures
• Prone and other body positioning
• Burns with abdominal eschars

9. 2. RELATED TO INCREASED INTRAABDOMINAL CONTENTS
• Gastroparesis / gastric distention / ileus
• Abdominal tumor
• Retroperitoneal / abdominal wall hematoma
3. RELATED TO ABDOMINAL COLLECTIONS OF FLUID, AIR OR BLOOD
• Liver dysfunction with ascites
• Abdominal infection ( pancreatitis, peritonitis, abscess,….)
• Hemoperitoneum
• pneumoperitoneum

10. 4. RELATED TO CAPILLARY LEAK AND FLUID
RESUSCITATION
• Acidosis ( ph below 7.2 )
• Hypothermia ( core temperature below < 33*c )
• Polytransfusion ( >10 units PRBC/24 hours) / trauma
/massive fluid resuscitation ( > 5 liters / 24 hours)
• Sepsis
• Coagulopathy
• Major burn

11. IAP MEASUREMENT TECHNIQUES
1. BLADDER ( GOLD STANDARD)
INTERMITTENT
• Harrahill technique
• Iberti and co-worker technique
• Cheatham and Safcsak technique
• The Holtech Foley manometer
technique
• Kron technique
• AbViser valve
• Malbrain modification system
CONTINUOUS
• 3 way Foley catheter
• T- Doc air charge catheter

12. 2. GASTRIC
INTERMITTENT
• NG tube
• Gastric tonometer
CONTINUOUS
• CiMon ( Pulsion medical systems)
• Spiegelberg (Gastric)
3. RECTAL 4. VAGINAL 5. IVC
6. DIRECT PERITONEAL PRESSURE
• via CV line or peritoneal drain
• Compass vascular access pressure transducer

13. MANAGEMENT PROTOCOLE
• IAP is usually measured indirectly via the patient's bladder. The
changes in intravesical pressure demonstrate an accurate reflection
of intra-abdominal pressure (IAP).
• Patients with two or more risk factors for IAH should have a
baseline IAP performed and if elevated should have continued serial
measurements.
• IAP is measured 4 hourly or more frequently if IAP >12mmHg or
the patient is hypotensive, has decreased urine output or a tense
abdomen.
• An increased IAP reading should be rechecked to ensure there is not
a technical problem e.g. a blocked catheter.

14. • If IAP > 12mmHg then medical management of IAH should be
instituted in a timely manner to prevent further morbidity and
mortality. Renal impairment can occur with IAP as low as 10-
15mmHg.
• IAP should be expressed in mmHg and measured at end-expiration in
the complete supine position after ensuring that abdominal muscle
contractions are absent and with the transducer zeroed at the level of
the midaxillary line.
• Medical management will involves improving systemic perfusion,
measures to reduce IAP, and in refractory cases early abdominal
decompression. Excessive fluid administration should be avoided as it
is strongly associated with ACS. The patients need close clinical
monitoring of organ function.

15. PROCEDURE FOR INTRA-ABDOMINAL PRESSURE
MONITORING
EQUIPMENT REQUIRED
• Foley© urine catheter of appropriate size
• Urine bag for drainage of urine
• 2 x 3 way tap
• Connector (leur lock to catheter tip)
• Pressure transducer and tubing
• 50ml leur lock syringe
• 10ml or 30ml leur lock syringe
• Sterile 0.9% sodium chloride
• Clamp

16. PREPARATION OF MONITORING EQUIPMENT
• Perform hand hygiene.
• Using an aseptic non-touch technique, prime the transducer set and
monitoring lines with 0.9% sodium chloride only
• The tubing must be free of kinks and air bubbles.
• Connect catheter to the drainage bag with connector and 3 way taps
• All connections should be securely luer locked.
• All transducer monitoring lines should be clearly labelled.
• Urine flow into the drainage bag should be uninterrupted except
during IAP measurement.

17. • Fill the bladder with 1ml/kg ( maximum 25mls ) of 0.9% sodium
chloride using the syringe. The volume of fluid in the bladder
should be constant for each measurement.
• Close the stopcock of the syringe and allow 30-60seconds for
equilibrium to occur. Obtain the mean pressure reading upon end
expiration (this minimizes the effects of pulmonary pressures).
• The abdominal blood flow should produce fluctuations in the
waveform. Air in the system or kinking of the monitoring lines may
dampen the waveform.

18. IAP MEASUREMENT
INTRAVESICAL TECHNIQUE -- THE GOLD STANDARD
A. INTERMITTENT IAP MEASUREMENT TECHNIQUE –
KRON AND CO-WORKERS TECHNIQUE –
• A closed sterile system. it involves disconnecting the patient’s Foley
catheter and instilling 50–100 ml of saline using a sterile field.
• After reconnection, the urinary drainage bag is clamped distal to the
culture aspiration port.
• For each individual IAP measurement a 16-gauche needle is then used to
Y-connect a manometer or pressure transducer.
• The symphysis pubis is used as reference line.

19. IBERTI AND CO-WORKERS TECHNIQUE
• First time use a closed system .
• By Using a sterile technique they infused an
average of 250 ml of normal saline through the
urinary catheter to purge catheter tubing and
bladder.
• The bladder catheter is clamped and a 20G
needle is inserted through the culture aspiration
port for each IAP measurement.
• The transducer is zeroed at the symphysis and
mean IAP is read after a 2-min equilibration
period.

21. CHEATHAM AND SAFCSAK TECHNIQUE –
• A revision of Kron’s original technique.
• A standard intravenous infusion set is connected to 1,000 ml of normal
saline, two stopcocks, a 60-ml Luer-lock syringe and a disposable pressure
transducer.
• An 18-gauche plastic intravenous infusion catheter is inserted into the
culture aspiration port of the Foley catheter and the needle is removed.
• The infusion catheter is attached to the pressure tubing and the system
flushed with saline.
Advantages and disadvantages -- after a couple of days because the culture
aspiration port membrane can become leaky or the catheter kinky, leading to
false IAP measurement. ideal for screening and monitoring.

22. MODIFIED CHEATHAM AND SAFCSAK TECHNIQUE
• A ramp with three stopcocks is inserted in the drainage tubing connected to a
Foley catheter.
• A standard infusion set is connected to a bag of 1,000 ml of normal saline
and attached to the first stopcock.
• A 60-ml syringe is connected to the second stopcock and the third stopcock
is connected to a pressure transducer via rigid pressure tubing.
• The system is flushed with normal saline and the pressure transducer is
zeroed at the symphysis pubis (or the midaxillary line when the patient is in
complete supine position).
• After opening the stopcocks to the pressure transducer mean IAP can be read
from the bedside monitor.

23. • Advantages -- This technique has the same advantages as the
Cheatham technique, with a required nursing time less than 2 min
per measurement,
• a minimized risk of urinary tract infection and sepsis since it is a
closed sterile system,
• the possibility of repeated measurements is less and reduced cost.
• Since it is a needle-free system it does not interfere with the culture
aspiration port and the risk of injuries is absent.
• This technique can be used for screening or for monitoring for a
longer period of time (2–3 weeks).

24. MANOMETRY
• A quick idea of the IAP can also be obtained in a patient
without a pressure transducer connected by using his
own urine as the transducing medium, first described by
Nurse Harrahill.
• clamps the Foley catheter just above the urine collection
bag.
• The tubing is then held at a position of 30–40 cm above
the symphysis pubis and the clamp is released.

25. • The IAP is indicated by the height (in
cm) of the urine column from the
pubic bone.
• The meniscus should show
respiratory variations.
• This rapid estimation of IAP can only
be done in case of sufficient urine
output. In an oliguric patient 50 ml
saline can be injected as priming.

26. THE FOLEY MANOMETER TECHNIQUE
• A 50 ml container fitted with a bio-filter for venting is inserted
between the Foley catheter and the drainage bag.
• The container fills with urine during drainage; when the container is
elevated, the 50 ml of urine flows back into the patient’s bladder, and
IAP can be read from the position of the meniscus in the clear
manometer tube between the container and the Foley catheter.
• Advantages and disadvantages -- It allows repeated measurements,
is very cost-effective and fast, with minimal manipulation.
• The great advantage with the Foley manometer is that the volume re-
instilled into the bladder is standardised at 50 ml; therefore, it is
preferred over the other manometry techniques.

27. • A major drawback is blocking
of the bio-filter, leading to
overestimation of IAP.
• They can easily be done two-
hourly together with and
without interfering with urine
output measurements.
Moreover, the risk of infection
and needle stick injury is
absent.

28. THE U-TUBE TECHNIQUE
• With the U-tube technique,
the catheter tubing was
raised approximately 60 cm
above the subject to form a
U-tube manometer, and IVP
was measured as the height
of the meniscus of urine
from the pubic symphysis.
• it can be used as a quick
screening method.

30. AbViser Intra-Abdominal Pressure Monitoring Kit
• Closed system in-line with the
Foley catheter
• Once attached it is left in place
during entire time IAP is measured.
• 30 seconds to measure IAP
• Standardized measurement
• No reproducibility errors

32. Complications
• Infection of the bladder
• Fever
• Vomiting
• General malaise
• Frequency
• Local pain
• Dysuria
Urine culture and sensitivity is the gold standard for diagnosis if an
infection is suspected

33. “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 in proper
fashion

34. PROBLEMS:
• Home-made:
– No standardization
– Sterility issues
• Time consuming
• Data reproducibility errors
• Needle stick
• Recurrent penetration of sterile system,
• Leaks
• Re-zeroing problems

35. GASTRIC TECHNIQUE
• By means of a Nasogastric or
gastrostomy tube and this method can be
used when the patient has no Foley
catheter in place, or when accurate bladder
pressures are not possible due to the
absence of free movement of the bladder
wall.
• In case of bladder trauma, peritoneal
adhesions, pelvic haematomas or fractures,
abdominal packing, or a neurogenic
bladder, IVP may overestimate IAP, and
the procedure used for the bladder can then
be applied via the stomach.

36. OESOPHAGEAL BALLOON CATHETER
• An oesophageal balloon catheter is inserted
into the stomach. When the balloon is in the
stomach, the whole respiratory IAP pressure
wave will be positive and increasing upon
inspiration in case of a functional
diaphragm.
• If the balloon is too high in the thorax the
pressure will flip from positive to negative
on inspiration measuring oesophageal or
pleural pressure instead. A standard three-
way stopcock is connected to a pressure
transducer.

37. • All air is evacuated from the balloon with a glass syringe and 1–2 ml
of air reintroduced to the balloon. The balloon is connected via a
“dry” system to the transducer, the transducer itself is NOT
classically connected to a pressurized bag and not flushed with
normal saline in order to avoid air/fluid interactions.
• The transducer is zeroed to atmosphere and IAP is read end
expiratory.
• Advantages and disadvantages -- A disadvantage is that the air in
the balloon gets resorbed after a couple of hours so that
“recalibration” of the balloon is necessary with a 2–5 ml glass syringe
for continuous measurement, this might cause inaccurate
measurement.

38. RECTAL PRESSURE
• It can be obtained by means of an open rectal catheter with a continuous
slow irrigation (1 ml/ min), but special fluid-filled balloon catheters are
used more routinely.
• Advantages and disadvantages -- the residual faecal mass can block the
catheter-tip opening leading to overestimation of IAP. cannot be used in
patients with lower gastro-intestinal bleeding or profound diarrhoea.
• The fluid-filled balloon catheters are more expensive and stay in place for a
longer period of time, interfere with gastro-intestinal transit and can cause
erosions and even necrosis of the anal sphincter and rectal ampulla.
• Finally these techniques have not been validated in the ICU setting.
• This technique has no clinical implications in the ICU setting.

39. UTERINE PRESSURE
• Mostly done with the same catheters as for
the rectal route.
• Uterine pressures are used routinely by
gynecologists during pregnancy and labour.
• Most classically a standard so-called “intra-
uterine pressure catheter” (IUPC) is used for
this purpose.
• Uterine pressures are mostly obtained by
means of a closed special fluid-filled balloon
catheter (as for rectal pressure).
• Disadvantages -- can not be used on patients
with gynaecological bleeding or infection.

40. INFERIOR VENA CAVA PRESSURE
• A normal central venous line is inserted into the inferior vena
cava via the left or right femoral vein.
• The intra-abdominal position of the catheter is confirmed by
portable lower abdomen X-ray, and confirmation of a rise in
IAP following external abdominal pressure.
• A three-way stopcock is connected to the distal lumen, one end
is connected to a pressure transducer via arterial tubing and the
other end is connected to a pressurized infusion bag of 1,000 ml
saline.
• The transducer is zeroed at the midaxillary line with the patient
in the supine position and IAP is read end-expiratory as with
CVP.

41. Advantages and disadvantages --
Risk of (possible catheter-related)
bloodstream infections and septic
shock.
The initial placement is more time-
consuming.
The major advantages are that a
continuous trend can be obtained, it
does not interfere with urine output,
and it could be used in bladder-trauma
patients.

42. NEWER TECHNIQUE
Nasogastric polyfunctional catheter
Balloon tipped catheter for measuring urethral pressure
Piezoresistive pressure measurement (PRM)
Water capsule pressure measurement (WCM)
Microchip transducer tipped catheters -- They can either be placed via
the rectal, uterine, vesical or gastric route. These catheters can either
have a 360 membrane pressor sensor in the organ (rectum, uterus,
bladder, stomach) connected to an external transducer in a reusable cable
or they can have a fibre-optic in vivo pressure transducer in the tip of the
catheter itself. These catheters provide true zero in-situ calibration.

43. CONCLUSION
An analysis of the advantages and disadvantages, as well as a cost projection, for each IAP
measurement technique and supports the view that:
(1) There is no gold standard;
(2) It is difficult to compare the different techniques;
(3) Cost-effectiveness is an issue;
(4) IVP can be used as an estimation for IAP as a screening method to identify patients at
risk via manometry;
(5) IVP can be used as an estimation for IAP for initial follow-up either with the Cheatham
or revised bladder technique;
(6) For (multicenter) study purposes, surgical patients, trauma patients, patients at risk for
IAH and difficult ICU patients, like mechanically ventilated patients with one or more
other organ failures (assessed by SOFA score).

44. COLLABORATIVE MANAGEMENT
• Pharmacological -- fluid resuscitation, antibiotics, medication to
support cardiac output
• Technical -- ventilatory support, crrt, ibp monitoring, abg analysis,
blood glucose monitoring
• Medical – PC drainage, NG tube insertion, laxative usage, pain relief
and muscle relaxants, damage control resuscitation
• Surgical – decompressive laparotomy, fasciotomy, bagota bag,
vacume assisted closure (VAC).

45. The “Bogota Bag” – A 3 L IV bag,
open and sterilized and applied to the
abdominal opening

49. MEDICAL TREATMENT OPTIONS TO REDUCE IAP
1. Improve abdominal wall compliance
• sedation & analgesia
• neuromuscular blockade
• avoid HOBE > 30 degree
2. Evacuate intraluminal contents
• nasogastric decompression
• rectal decompression
• gastro-/colo-prokinetic agents

50. 3. Evacuate abdominal fluid collections
• Paracentesis
• Percutaneous drainage
4. Correct positive fluids balance
• Avoid excessive fluid resuscitation
• Diuretics
• Colloids/hypertonic fluids
• Hemodialysis / ultra filtration

51. 5. Organ support
• Maintain APP > 60mmmhg with vasopressors
• Optimize ventilation, alveolar recruitment
• Use transmural airway(tm) pressures
• Pplattm = Pplat - IAP