Abdominal Perfusion Pressure as a Prognostic Marker in Intra-abdominal Hypertension

  • M. Malbrain

Abstract

Elevated intra-abdominal pressure (IAP) is a continuum from intra-abdominal hypertension (IAH) to abdominal compartment syndrome (ACS) and has considerable impact on end-organ function [1]. However, no data are available on IAP from large prospective clinical trials. Many thresholds have been proposed as the critical value for IAP in guiding decompression. Recent publications have improved our understanding of the pathophysiological mechanisms. We are now aware that even slight elevations in IAP of 10 mmHg may have a tremendous impact on end-organ function [1]. However, it is probably not the absolute value of IAP but the acuity of increase in IAP or the trend over time that is predictive for outcome. Most of the published studies relate to the hemodynamically stable patient or laboratory animal without prior insult. Extrapolation of these results to a critically ill patient or to a trauma patient who may have experienced episodes of shock and resuscitation and hence of ischemia-reperfusion (I/R) injury, may be incorrect. Co-morbidities play an important role in aggravating the effects of raised IAP such as pre-existing chronic renal failure, massive hemorrhage, hypovolemia, positive end-expiratory pressure (PEEP), or pre-existing cardiomyopathy, and these may reduce the threshold of IAH that causes clinical manifestations of ACS. Indeed, the critical IAP value differs from patient to patient and from time to time. A prognostic parameter that could help us in following these patients and guiding therapy would be very helpful. This chapter will focus on abdominal perfusion pressure (APP), defined as mean arterial pressure (MAP) minus IAP, as such a possible parameter.

Keywords

Sequential Organ Failure Assessment Pulmonary Capillary Wedge Pressure Cerebral Perfusion Pressure Sequential Organ Failure Assessment Score Abdominal Compartment Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Malbrain MLNG (2001) Intra-abdominal pressure in the intensive care unit: Clinical tool or toy? In: Vincent JL (ed) Yearbook of Intensive Care and Emergency Medicine. Springer, Berlin, pp 547–585Google Scholar
  2. 2.
    Dworkin LD, Brenner BM (1996) The renal circulations. In: Brenner BM (ed) The Kidney, 5th edn. WB Saunders, Philadelphia, pp 247–285Google Scholar
  3. 3.
    Le Roith D, Bark H, Nyska M, Glick SM (1982) The effect of abdominal pressure on plasma antidiuretic hormone levels in the dog. J Surg Res 32: 65–69PubMedCrossRefGoogle Scholar
  4. 4.
    Hamilton BD, Chow GK, Inman SR, Stowe NT, Winfield HN (1998) Increased intra-abdominal pressure during pneumoperitoneum stimulates endothelin release in a canine model. J Endourol 12: 193–197PubMedCrossRefGoogle Scholar
  5. 5.
    Bradley SE, Bradley GP (1947) The effect of increased intra-abdominal pressure on renal function in man. J Clin Invest 26: 1010–1022PubMedCrossRefGoogle Scholar
  6. 6.
    Cheatham ML (1999) Intra-abdominal hypertension and abdominal compartment syndrome. New Horiz 7: 96–115Google Scholar
  7. 7.
    Malbrain MLNG (2000) Abdominal pressure in the critically ill. Curr Opin Crit Care 6: 1729CrossRefGoogle Scholar
  8. 8.
    Shenasky JH, Gillenwater JY (1972) The renal hemodynamic and functional effects of external counterpressure. Surg Gynecol Obstet 134: 253–258PubMedGoogle Scholar
  9. 9.
    Stone HH, Fulenwider JT (1977) Renal decapsulation in the prevention of post-ischemic oliguria. Ann Surg 186: 333–355CrossRefGoogle Scholar
  10. 10.
    Sugrue M, Jones F, Janjua KJ, Deane SA, Bristow P, Hillman K (1998) Temporary abdominal closure: a prospective evaluation of its effects on renal and respiratory function. J Trauma 45: 914–921PubMedCrossRefGoogle Scholar
  11. 11.
    Sugrue M, Jones F, Deane SA, Bishop G, Bauman A, Hillman K (1999) Intra-abdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg 134: 1082–1085PubMedCrossRefGoogle Scholar
  12. 12.
    Ulyatt DB (1992) Elevated intra-abdominal pressure. Australian Anaesth: 108–114Google Scholar
  13. 13.
    Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EFJ (2000) Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension. J Trauma 49: 621–627PubMedCrossRefGoogle Scholar
  14. 14.
    Overholt RH (1931) Intraperitoneal pressure. Arch Surg 22: 691–703CrossRefGoogle Scholar
  15. 15.
    Kron JL, Harman PK, Nolan SP (1984) The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 199: 28–30PubMedCrossRefGoogle Scholar
  16. 16.
    Iberti TJ, Lieber CE, Benjamin E (1989) Determination of intra-abdominal pressure using a transurethral bladder catheter: clinical validation of the technique. Anesthesiology 70: 47–50PubMedCrossRefGoogle Scholar
  17. 17.
    Cheatham ML, Safcsak K (1998) Intraabdominal pressure: a revised method for measurement. J Am Coll Surg 186: 594–595PubMedCrossRefGoogle Scholar
  18. 18.
    Sugrue M, Buist MD, Lee A, Sanchez DJ, Hillman KM (1994) Intra-abdominal pressure measurement using a modified nasogastric tube: description and validation of a new technique. Intensive Care Med 20: 588–590PubMedCrossRefGoogle Scholar
  19. 19.
    Schein M, Wittmann DH, Aprahamian CC, Condon RE (1995) The abdominal compartment syndrome: the physiological and clinical consequences of elevated intra-abdominal pressure. J Am Coll Surg 180: 745–753PubMedGoogle Scholar
  20. 20.
    Bloomfield J-GL, Ridings PC, Blocher CR, Marmarou A, Sugerman HJ (1997) A proposed relationship between increased intra-abdominal pressure, intrathoracic, and intracranial pressure. Crit Care Med 25: 496–503PubMedCrossRefGoogle Scholar
  21. 21.
    Burch JM, Moore EE, Moore FA, Franciose R (1996) The abdominal compartment syndrome. Surg Clin North Am 76: 833–842PubMedCrossRefGoogle Scholar
  22. 22.
    De Mendonca A, Vincent JL, Suter PM, et al (2000) Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score. Intensive Care Med 26: 915–921PubMedCrossRefGoogle Scholar
  23. 23.
    Malbrain MLNG, Debaveye Y, Bertieaux S (2000) Effects of abdominal compression and decompression on cardiorespiratory function and regional perfusion. Intensive Care Med 26 (suppl 3 ): S264 (Abst)Google Scholar
  24. 24.
    Malbrain MLNG, De Coninck J, Debaveye Y, Delmarcelle D (2001) Optimal preload markers in intra-abdominal hypertension. Intensive Care Med 27 (suppl 2 ): S202 (Abst)Google Scholar
  25. 25.
    Richardson JD, Trinkle JK (1976) Hemodynamic and respiratory alterations with increased intra-abdominal pressure. J Surg Res 20: 401–404PubMedCrossRefGoogle Scholar
  26. 26.
    Luca A, Cicera I, Barcia-Pagan JC, et al (1993) Hemodynamic effects of acute changes in intra-abdominal pressure in patients with cirrhosis. Gastroenterology 104: 222–227PubMedGoogle Scholar
  27. 27.
    Steinman M, da Silva LE, Coelho IJ, et al (1998) Hemodynamic and metabolic effects of CO2 pneumoperitoneum in an experimental model of hemorrhagic shock due to retroperitoneal hematoma. Surg Endosc 12: 416–420PubMedCrossRefGoogle Scholar
  28. 28.
    Kitano Y, Takata M, Sasaki N, Zhang Q, Yamamoto S, Miyasaka K (1999) Influence of increased abdominal pressure on steady-state cardiac performance. J Appl Physiol 86: 16511656Google Scholar
  29. 29.
    Chang MC, Miller PR, D’Agostino R, Meredith JW (1998) Effects of abdominal decompression on cardiopulmonary function and visceral perfusion in patients with intra-abdominal hypertension. J Trauma 44: 440–445PubMedCrossRefGoogle Scholar
  30. 30.
    Cheatham ML, Safcsak K, Block EF, Nelson LD (1999) Preload assessment in patients with an open abdomen. J Trauma 46: 16–22PubMedCrossRefGoogle Scholar
  31. 31.
    Ridings PC, Bloomfield GL, Blocher CR, Sugerman HJ (1995) Cardiopulmonary effects of raised intra-abdominal pressure before and after intravascular volume expansion. J Trauma 39: 1071–1075PubMedCrossRefGoogle Scholar
  32. 32.
    Malbrain MLNG (1999) Abdominal pressure in the critically ill: measurement and clinical relevance. Intensive Care Med 25: 1453–1458PubMedCrossRefGoogle Scholar
  33. 33.
    Malbrain MLNG, for the CIAH study group (2001) Incidence of intra-abdominal hypertension in the ICU and its relation with fluid balance, organ failure and 28 day mortality. Intensive Care Med 27 (suppl 2 ): S176 (Abst)Google Scholar
  34. 34.
    Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Monthous CA (2000) Negative fluid balance predicts survival in patients with septic shock. Chest 117: 1749–1754PubMedCrossRefGoogle Scholar
  35. 35.
    Pelosi P, Brazzi L, Gattinoni L (2001) Measuring intra-abdominal pressure in the intensive care setting. In: Vincent JL (ed) Yearbook of Intensive Care and Emergency Medicine. Springer, Berlin, pp 586–595Google Scholar
  36. 36.
    Ivatury RR, Sugerman HJ (2000) Abdominal compartment syndrome: A century later, isn’t it time to pay attention? Crit Care Med 28: 2137–2138PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2002

Authors and Affiliations

  • M. Malbrain

There are no affiliations available

Personalised recommendations