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Jan J. De Waele - Latest news on abdominal pressure monitoring – November 17th 2012

Latest news on abdominal pressure monitoring

Jan J. De Waele MD PhDSurgical ICU

Ghent University HospitalGhent, Belgium.


IAP monitoring??


Introduction• Fluid (over)load important contributor to

IAH• IAH and ACS identified as causes of organ

dysfunction in critical care

• IAP monitoring essential• Sole diagnostic tool


Mon

itor I

AP•

Low

inde

x of

su

spic

ion

Prevent IAH• Operating theatre• Judicious fluid resuscitation • Open abdomen treatment

Medical management•IAP reducing strategies•Incorporate IAH in patient

management

Surgical m

anagemen

t•W

hen IAP>25m

mH

g•

Fulminant

deteriorationIAH management

in the ICU


IAP measurement


IAP measurement basics

Supine positionNo muscle contractionsOnly 25mL or lessTransvesicular approach


Femoral vein pressure?

De Keulenaer BL, Intensive Care Med 2011

FVP cannot be used as a surrogate measure of IAP unless IAP is above 20 mmHg.


What is normal IAP?• Normal IAP 5-7mmHg• Effect of body weight?


IAP and HOB positioningMost patients are nursed in 30-45°HOBEffect of positioning?


IAP and prone positioning

• Zero reference level?• Abdominal support


IAP and PEEP


Pitfalls

Zero reference level• Inter-observer

differences• Mark the IAP

reference level on the patient!


Pitfalls

Mass lesions in the pelvis – external compression


The abdomen as a hydraulic system

Is the abdomen a liquid filled container?


IAP determinants

Gravity

Solid organs, fluid and gasRelevantDependent on volume and densityPascal’s law

Wall tension

• Abdominal wall + diaphragm• Relevant if compliance is low


IAP determinants

Gravity Wall tension


IAP

High compliance


IAP

Low compliance


So what?


Explains organ dysfunction dynamics in IAH

First symptoms→ Kidney→ Hemodynamics

Later→ Respiratory


Explains effect of positioning

Effect of HOB elevation?

IAP 16


Explains effect of positioning

Effect of HOB elevation?


Predicts effect of therapy

Role of abdominal decompression→ = increase in compliance of abdominal wall


Conclusion• IAP measurement established

• IAP determinants• Pitfalls

• IAP measurement is simple• Effect of ICU interventions on IAP minimal

• Be careful when proning• New paradigms for *unexplained*

observations and therapy


Thank you for your attention

Email: [email protected]: @JanDeWaeleMD