Intra-Abdominal

Hypertension
Trina Banerjee
Outline

 Definitions/Categories/Stages
 Incidence
 Causes
 Diagnosis
 Pathophysiology
 Treatment
Definitions I

 Intra-abdominal pressure (IAP):

– Pressure within the abdominal cavity
– <5-7 mm Hg, with upper limit 12 mm Hg

 Abdominal Perfusion Pressure (APP):

– MAP (mean arterial pressure) – IAP
– Normal is 60 mm Hg and above
Definitions II

 Intra-abdominal Hypertension (IAH):

– IAP >10-12 on three different
measurements or
– APP<60mmHg on two separate
occassions

 Abdominal CompArtment Syndrome

(ACS):
– Subcategory of IAH
– Sustained IAP>20 with organ dysfunction
Categories

 Primary :
– Either Hyperacute (second to minutes) or
Acute (Hours)
– Results from abdominal trauma
 Secondary:
– Either Subacute (days) or Chronic
(Months )
– Results from extrabdominal causes
Stages

 Stage I : 12-15

 Stage II : 16-20

 Stage III : 21-24

 Stage IV : >25
Incidence

 In mixed ICU population the incidence

of IAH can be 30-50%

 In mixed ICU populations the

incidence of ACS can be 4-8%
Causes

 Conditions that Decrease abdominal

wall compliance
 Conditions that increase intraluminal
contents
 Conditions related to abdominal
collections of fluid, air, or blood
 Conditions related to capillary leak and
fluid resucitation
Decreased abdominal
wall compliance
 Mechanical ventilation
 PEEP
 Basal pneumonia
 High BMI
 Pneumoperitoneum
 Abdominal surgery with tight closure
 Anti-shock garments
 Prone positioning
 Abdominal wall bleeding or rectus sheath
hematomas
 Correction of large hernias, gastroschisis, or
omphocele
 Burns with abdominal eschars
Increased Intraluminal
Contents
 Gastroparesis
 Gastric distension
 Ileus
 Volvulus
 Colonic pseudo-obstruction
 Abdominal tumor
 Retroperitoneal/Abdominal wall hematoma
 Enteral feeding
 Abdominal wall tumor
 Damage control laparotomy
Collections of fluid, air, or
blood
 Ascites
 Abdominal infection
 Hemoperitoneum
 Pneumoperitoneum
 Laparoscopy with excesive inflation
pressures
 Major trauma
 PD
Capillary leak and fluid
resucitation
 pH<7.2
 Hypothermia
 Coagulopathy
 Polytransfusion
 Sepsis
 Transfusions with capillary leak
 Major burns
Diagnosis
 Physical Exam:
– Highly inaccurate
 Direct:
– Intraperitoneal catheter attached to a pressure
transducer
 Indirect:
– Transduction of a bladder, colonic, gastric, or
uterine pressure from a balloon
– Measure at end expiration in the supine position
with absent abdominal wall contractions, at the
level of the midaxillary line at the iliac crest after
the instillation of a volume of 20-25 cc
Pathophysiology
General
Pathophysiology I
 The Pressure in ACS decreases venous
return:
– Increased IAP compromises venous return, by
compressing the portal vein and IVC.
– There is also increased afterload because of the
increased abdominal pressure and thoracic
pressure.
– Cardiac output then goes down (this occurs at a
IAP of 10), and therefore oxygen delivery
 This leads to decreased arterial pressure, resulting in
deceased MAP
General
Pathophysiology II
 Decreased MAP causes Ischemic
Organs:
– Organs become ischemic and then swell. Local
release of lactate and adenosine.
– Abdominal viscera swelling limits diaphragmatic
movement, which limits alveolar recruitment.
There is hypoxia and hypercapnia. Increased
intrathoracic pressure which further limits
venous return. It also increases central venous
pressure. It also compresses the heart
– The venous return sits in the liver and kidneys
Intest. Pathophysiology

 The rise in pressure causes decreased

blood flow to the gut, resulting in
bacterial translocation

 Can result in abdominal wall ischemia

Liver Pathophysiology

 There is decreased blood flow to the

liver causing impaired hepatocellular
function
 Liver dysfunction starts at a IAP of 10
– Decreased hepatic artery flow, decreased
venous portal flow, increase in the
portacollateral circulation
– Reduced lactate clearance, altered
glucose metabolism, altered
mitochondrial function
Brain Pathophysiology

 Cerebral perfusion pressure decreases

because of the increase in
intrathoracic pressure, resulting in an
obstruction of cerebral venous outflow
Renal Pathophysiology I

 IAP Thresholds:
– Reduction in renal plasma flow and GFR
starting at IAP 15-20 mm Hg
– Oliguria starts at 15mmHg
– Anuric above 30 mm Hg
– Numbers refer to a normovolemic patient.
In a septic patient the numbers may be
lower
Renal Pathophysiology II
 Pre-renal, Renal, and Postrenal
– Pre-renal:
 Cardiovascular dysfuntion, both from decreased
venous return and from compression of the heart, and
from increased afterload
 Increase in ADH response, and can be an Increase in
renin/aldosterone/and plasma catecholamines
– Renal:
 Increased pressure on the kidneys and release of
inflammatory markers
– Post-renal:
 Direct compression of the ureters
 A study in the Annals of Surgery in 1982 did not
improve with the insertion of ureteral stents
Calculations

 IAP may affect the kidneys more than

changes in MAP
– RPP=MAP-IAP
– FG=GFR-IAP=(MAP-IAP)-IAP=MAP-
2(IAP)
Time Frame

 Mean time from IAH to ARF is 2.7 days

 May take between 0-35 days

Archives of Surgery 1999
Study
 Tried to determine if IAH was an
independent risk factor for AKI
 263 after abdominal surgery
 Elevated IAP was =/>18mmHg
 32.7% of patients with IAH developed
AKI
 Mean time between onset of IAH and
AKI 2.7 +/- 6.5 days
Intensive Care Medicine
2008 Study
 Determine at what IAP AKI develops
 123 patients admitted > 24 hours in a
MICU
 Bladder Pressure Q24 hours
 Renal failure associated with IAH if
time interval <48 hours
 37 patients (30%) developed IAH
 16 in the IAH group developed AKI
 Threshold of IAH 12mmHg
Treatment
General Principles

 Serial monitoring of IAP

 Optimization of systemic perfusion
 Medical procedures to reduce IAP
 Prompt surgical decompression for
refractory ACS
Serial Monitoring of IAP

 High risk patients every 4-6 hours

 IAH >12, increase monitoring to
hourly or continuous while treatment
is being implemented
 Discontinue when the risk factors of
IAH go away or there are no signs of
acute organ dysfunctino and IAH
measurements have been less than
10-12 for 24-48 hours
Optimization of systemic
perfusion
 Fluids increase circulating blood
volume

 Too much fluid may result in IAH

 To get around this, some practioners

have been using hypertonic solutions
Journal of Trauma 2006
Study
 Determine if Hypertonic fluids
decrease risk of IAH
 48 patients admitted to the burn unit
between 2002 and 2004 with
burns>40% of their body
 Patients were given either hypertonic
LR (14) or LR (22).
 IAH was a IAP greater than 30mmHg.
 Journal of Trauma 2006
Study
 LR was given at 4mls/kg per percentage
of TBSA per 24 hours with a goal of 0.5-
1ml/kg per hour
 IAH was a IAP greater than 30mmHg
 Hypertonic LR had 40% less volume
infused than the group with the LR
Journal of Trauma 2006
Study
 14% of patients in the hypertonic LR
group developed IAH vs. 50% of the
patients in the LR group

 Serum sodium between 136 and

138meq/L 24 hours after injury in the
LR group and 150.7+/-10meq/L in the
HLS group, which then decreased to
an acceptable level within 2 hours
Medical procedures to
reduce IAP
 Bowel Decompression

 Decrease Intra-abdominal Fluid

 Increase Abdominal Compliance

 Correction of Capillary Leak

Bowel Decompression

 Bowel obstruction through either ileus

or other causes leads to bowel dialtion
and mucosal edema, which will
increase the intra-abdominal pressure
 Correct Electrolytes, stop medications
that impair bowel motility, can use
gastro-kinetcs (reglan and
erythromycin) or colo-kinetics
(neostigmine)
Decrease Intra-
abdominal Fluid

 May be done with lasix/albumin

 May be done with CRRT

Increase abdominal
Compliance
 Muscle relaxants

 Fentanyl may increase IAH

Correction of Capillary
Leak
 Low dose dobutamine corrects
intestinal mucosal perfusion
Prompt surgical
decomporession for
refractory ACS
 50% mortality rate, but 100% without
decompression

 If the abdominal pressure is dropped

too quickly there can be reperfusion
injury