CONSIDER ABDOMINAL

COMPARTMENT SYNDROME IN
PATIENTS WITH REFRACTORY
HYPOTENSION

CINDY H. HSU, MD, PHD

• Intra-abdominal hypertension (IAH) and
abdominal compartment syndrome (ACS)
are increasingly recognized in critically ill
ED and intensive care unit patients

• Often delayed  the complexity of the

clinical presentation and limitations of
the physical exam  significant increases
in morbidity and mortality.
• The critical component in the recognition and
diagnosis  “elevated intra-abdominal pressure
(IAP)”.
• The normal IAP is ~5 to 7 mm Hg.
• IAH is defined by a sustained, or repeated,
elevation in IAP
• IAH is classified into four categories:
– Grade I, IAP 12 to 15 mm Hg;
– Grade II, IAP 16 to 20 mm Hg;
– Grade III, IAP 21 to 25 mm Hg
– Grade IV, IAP >25 mm Hg.

World Society of the Abdominal Compartment Syndrome

(WSACS)
 Abdominal Compartement Syndrome
• ACS is a sustained IAP >20 mm Hg with new
organ dysfunction or failure
– Primary ACS  abdominopelvic cause and frequently
requires surgical or interventional radiologic treatment.
– Secondary ACS  not originate from the
abdominopelvic region and is often seen in patients
requiring massive fluid resuscitation.
– Recurrent ACS represents the recurrence of ACS despite
resolution of a prior episode that was treated with
medical or surgical therapy
Measurements
• Trans–bladder pressure measurements  gold standard to
determine IAP. Bladder pressure measurements
• Performed at the end of expiration with the patient in a
supine position. The transducer should be zeroed at the
iliac crest in the midaxillary line.
• Approximately 25 mL of saline is then instilled into the
bladder.
• ensure there are no abdominal muscle contractions, as
these can falsely elevate the IAP. Measure
• IAP approximately every 4 hours; however, measurements
can be performed at shorter intervals if the IAP is >12 mm
Hg.
• The WSACS recommends a protocolized method for
monitoring and measuring IAP if the patient has two or
more risk factors for ACS (Table 40.1) or has new or
progressive organ failure
KNOW THE THRESHOLDS FOR RED
BLOOD CELL TRANSFUSION IN THE
CRITICALLY ILL

MICHAEL C. SCOTT, MD
• Shock is considered by many to be the
prototypical derangement of the critically ill.
– Our bedside treatment goals so focused on blood
pressure and cardiac output ,forgeting its most
basic level is defined by a deficit between oxygen
delivery and oxygen demand at the cellular level.
– our interventions are aimed at correcting this
imbalance.
• Administration of blood transfusions as a way
of augmenting oxygen delivery in the critically
ill patient.
• Research has questioned the traditional practice
of red blood cell transfusion to increase oxygen
delivery

– May harm  transfusion reactions such as hemolytic

reactions, transfusion-associated lung injury, and
direct infection

– Meta-analysis of observational studies  red blood

cell transfusion to be an independent predictor of
mortality, nosocomial infection, acute respiratory
distress syndrome, and multiorgan dysfunction
syndrome.
• studies have greatly simplified the approach
to transfusion in the nonhemorrhaging
critically ill patient.
– critically ill patients without specific symptoms
attributable to anemia should not be transfused
for hemoglobin values greater than 7 g/dL.
– Another trial trials showed no benefit in using a
hemoglobin transfusion trigger of 10 g/dL.
– Most clinicians use a hemoglobin of 7 g/dL as the
transfusion trigger in nonhemorrhaging ICU
critically ill patients without evidence of acute
ischemia
• Patients with acute coronary syndrome (ACS)
or CVA have generally been excluded from
most transfusion studies
– cannot be proved that these areas of ischemia
would not resolve with an increased hemoglobin
level and oxygen-carrying capacity.
• Current guidelines from the Society of Critical
Care Medicine-Eastern Association for Surgery
of Trauma,
– transfusion may be beneficial in patients with an
ACS and hemoglobin value less than 8 g/dL
KNOW HOW TO CARE FOR THE
ICU BOARDER IN YOUR ED

JOSHUA D. FARKAS, MD, MS

• Critically ill patients in emergency department
(ED) is rapidly growing  a prolonged length of
stay can significantly impact the mortality

• The value of high-quality supportive care

cannot be overstated, and it should be initiated
in the ED while awaiting transfer to the
intensive care unit (ICU)
AVOID EXCESS FLUID ADMINISTRATION

• Critically ill patients can gain ~1 L of fluid per day

due to a myriad of sources lead to an excessively
positive fluid balance.
• excess fluid can cause severe edema and lead to
severe complications
• Avoiding unnecessary fluid administration is
critical. unless the patient is truly volume
depleted.
• In addition to indiscriminate fluid boluses,
“maintenance fluids” should also be avoided
AVOID UNNECESSARY BLOOD TRANSFUSION
• Blood transfusion can cause complications, including
volume overload, immunosuppression, transfusion
reactions, and transfusion-related acute lung injury.
• Nonbleeding ICU patients generally should not be
transfused unless they have a hemoglobin <7 mg/dL
• Transfusing two units of blood at a time should also be
avoided
• A trial investigating upper gastrointestinal hemorrhage
showed that a hemoglobin threshold of 9 mg/dL increased
mortality compared to a hemoglobin threshold of 7 mg/dL
for blood transfusion.
 AVOID OVERSEDATION AND UNDERTREATMENT
OF PAIN IN THE INTUBATED PATIENT
• Once the acute resuscitation phase has ended, the goal
for intubated patients is to be awake and comfortable
on the ventilator.
• Compared to deep sedation, lighter levels of sedation
reduce delirium and the duration of intubation.
• The majority of intubated patients experience pain.
• A common error in pain management of the critically ill
provide a sedative. Most sedative medications provide
no analgesia and will not provide adequate comfort
uless near coma-inducing levels.
• The key to achieving an awake and
comfortable state typically
• Opioid (e.g., fentanyl 25 to150 mcg/h),
– which will relieve pain while providing some
sedation. Opioids are the recommended first-line
agents for analgesia in the critically ill.
• Sedative medication.
– Benzodiazepines
– evidence shows increase the risk of delirium
and duration of mechanical ventilation.
– The advantage  less hypotension than do other
sedatives, so they may remain useful in refractory
shock.
• Propofol
– frequently used sedative.
– High doses of propofol may cause hypotension
and increase the risk of propofol infusion
syndrome.
– These complications may be avoided by
combining a low-dose propofol infusion (e.g., up
to 30 mcg/kg/min) with a moderate-dose opioid.
• Patients with persistent agitation despite an
opioid and sedative,
– atypical antipsychotics may be a helpful
adjunctive therapy.
– More sedating agents (e.g., quetiapine and
olanzapine) are generally used at night to reduce
sleep-wake cycle disturbance.
– Dexmedetomidine is another sedative option. The
primary advantage  does not suppress
respirations, so that it may be used to bridge the
patient through the extubation process
– Drawbacks of dexmedetomidine
• Cost, hemodynamic fluctuations, and a risk of
tachyphylaxis and withdrawal if used at high doses for
more than 4 to 5 days
 AVOID NONSTEROIDAL ANTI-INFLAMMATORY
MEDICATIONS

• NSAIDs increase the risk of renal failure and

increase the risk of stress ulceration. It is
generally best to avoid these unless a specific
indication exists (e.g., pericarditis).
 AVOID DEEP VEIN THROMBOSIS
• Patients should receive deep vein thrombosis
(DVT) prophylaxis unless they are actively
bleeding or have other contraindications.
• Common approaches include unfractionated
heparin (e.g., 5,000 IU every 8 hours) or low
molecular weight heparin (e.g., enoxaparin 40 mg
daily).
• In renal failure, low molecular weight heparin is
contraindicated.
• Recall that heparin is weight based, so morbidly
obese patients need proportionally higher doses
(e.g., 0.25 mg/kg enoxaparin every 12 hours)