news on intra-abdominal hypertension – focus on fluids and hemodynamics

News on intra-abdominal

hypertension – focus on fluids and

hemodynamics

World Society of the Abdominal Compartment Syndrome Secretary – Inneke De laet President – Jan De Waele

Conflicts of interest

Fluids and intra-abdominal pressure (IAP): what’s

new?Inneke De laet

ZNA Stuivenberg

What is IAP? DefinitionsEntity Definition

Intra-abdominal pressure (IAP)

IAP is the steady-state pressure concealed within the abdominal cavity

Intra-abdominal hypertension (IAH)

IAH is defined by a sustained or repeated pathological elevation in IAP ≥ 12mmHg

Abdominal compartment syndrome (ACS)

ACS is defined as a sustained IAP > 20mmHg (with or without an APP < 60mmHg) that is associated with new organ dysfunction/ failure.

Primary IAH/ACS Primary ACS is a condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention

Secondary IAH/ACS Secondary ACS refers to conditions that do not originate from the abdominopelvic region

Recurrent IAH/ACS Recurrent ACS refers to the condition in which ACS redevelops following previous surgical or medical treatment of primary or secondary ACS

Effect on organ function

Pulmonary:intrathoracic pressure

PIP Paw Cdyn paO2 paCO2 Qs/Qt Vd/Vt

CNS:ICP CPP

Visceral:Feeding intolerance

SMA blood flow mucosal blood flow

pHi

Abdominal Wall:compliance

rectus sheath blood flow

Renal:diuresis

renal blood flow RVR GFR

Cardiac:CVP PCWP SVR CO

venous returnHR= MAP=

Hepatic:portal blood flow lactate clearance

mitochondrial function

IAH

Prospective observational study in mechanically ventilated mixed ICU patients

IAP is associated with mortality

Reintam A et al., Intensive Care Med 2008, 34: 1624-31.

Conclusions:

Among mixed ICU patients, … and the volume of crystalloids used in their initial resuscitation appear to be important considerations in determining risk of IAH/ACS

Risk factors for IAH … among mixed ICU patients included obesity, sepsis, abdominal surgery, ileus development and fluid resuscitation.

Relationship fluids and IAP

WSACS medical management algorithm

www.wsacs.org

Evacuating intraluminal

contents

Evacuating extraluminal

contents

Improving abdominal compliance

Controlling fluid

balance

Optimizing systemic /regional perfusion

Patient develops IAH (IAP>12mmHg)

Determine which mechanism(s) is/are most likely to benefit the

patient

GoalsTo ensure adequate tissue perfusion and

oxygenation

To limit the amount of crystalloid

resuscitation

To remove excess fluids from the body

Techniques

Goal directed resuscitation?

Colloids?Hypertonic solutions?

Diuretics?Ultrafiltration?

How to deal with IAP and fluids

Limiting crystalloid resuscitation

Some data in patients with SAP, e.g.

Retrospective analysis of 47 patients with SAP

3 groups: Low ratio group: crystalloid colloid ratio of <1,5 Middle ratio group: crystalloid colloid ratio of

1,5-3 High ratio group: crystalloid colloid ratio of >3

Colloids to reduce fluid requirement?

Chang YS et al. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013 Jan: 25(1): 48-51

Choice of fluids: colloids

Low ratio Middle ratio High ratio

Number of patients 13 15 19

Mechanical ventilation after 24h (%)

23,1 20.0 68.0*

PaO2/FiO2 (mmHg) 260.3+/-25.7

280.6+/-24.8 180.7+/-26.3*

IAP (mmHg) 13.1+/-3.3 13.4+/-3.5 16.8+/-3.6*

Fluid retention (mL) 1865+/-300 1887+/-282 2834+/-631*

Crystalloid volume in 24h (mL)

2124+/-477 2308+/-416 3611+/-798*

Volume infused/72h (mL) 9400+/-1051

9036+/-982 11 941+/-1161*

28d Survival (%) 61.5 86,7 36.8*Chang YS et al. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2013 Jan: 25(1): 48-51

*: statistically significant

Too many data about adverse outcomes with synthetic colloids

Adverse effects of excessive crystalloid resuscitation are well documtented

There seems to be a need for a solution with colloid properties without the complications

So, back to the natural colloids (plasma, albumin)?

Colloids to reduce fluid requirement?

Plasma: the “new” colloid?

O'Mara MS et al, J Trauma 2005, 58(5):1011-1018.

Crystalloid Plasma p-value

Nr of patients 15 16

Volume perfused (24h) 22.1 ± 12.8 12.3 ± 9.3 0.02

Urine output (mL/kg/h) 0.77 ± 0.21 0.76 ± 0.33 0.6

Admission IAP (mmHg) 5.9 ± 2.7 5.9 ± 3.5 0.95

Peak IAP (mmHg) 32.5 ± 9.5 16.4 ± 7.4 <0.0001

Peak creatinine (mg/dL) 1.90 ± 1.00 1.48 ± 0.92 0.23

Base excess/deficit -1.7 ± 5.5 1.2 ± 3.2 0.07

Choice of fluids: plasma?

RCT in patients with SAP comparing 3 fluid regimens: Control group: Ringer’s lactate + HES (2:1), routine

resuscitation EGDT 1 group: Ringer’s lactate + HES, EGDT (CVP, MAP,

diuresis, ScvO2 or SvO2) EGDT 2 group: Ringer’s lactate, HES, 2 units of FFP daily

for 3 days, EGDT

n=200 Results: Wang MD et al. Chin Med J (Engl) 2013 May: 126(10): 1987-8


Wang MD et al. Chin Med J (Engl) 2013 May: 126(10): 1987-8

Secondary outcomes: Ventilation days: control > EGDT 1 > EGDT

2 ICU length of stay: control > EGDT 1 >

EGDT 2 Fluid resuscitation: control = EGDT 1 >

EGDT 2 Cumulative fluid balance: control = EGDT

1 > EGDT 2 Negative fluid balance on day 3 was

achieved only in the EGDT 2 group


Pro: Should avoid complications associated with synthetic

molecules May be biologically active

Con: Expensive Limited availability May be biologically active (possibility of immunologic

complications, inflammatory complications, TRALI, TEE…)

Use of plasma as a colloid

Only 1 retrospective study on PAL treatment No prospective data in resuscitation settings

incorporating IAP

Surviving Sepsis Campaign Guidelines 2013: “we suggest the use of albumin in the resuscitation of severe sepsis and septic shock when patients require substantial amounts of crystalloids.”

Controversy remains about methodology of studies supporting these recommendations

Use of albumin to limit crystalloids

Removing excess fluid

Conservative fluid strategies seem to impact outcome

EA LC EA LL EI LC EI LL0

10

20

30

40

50

60

70

80

Mortality (%)

1 2 3 4 5 6

5.8

8.59.8109.8

9

5.6

8.5

11.512.8

13.614.2

Cumulative fluid balance (L)

Survivors Non survivors

Murphy et al, Chest 2009: 136B(1): 102-109

Can diuretics be used?

Pro: Can achieve fluid removal

Questions: Renal function? Will injured kidney(s) respond? Haemodynamic tolerance?

Works in ADHF

Befo

re0

0.5

1

1.5

2

2.5IAP>8mmHg IAP<8mmHg

Seru

m C

reati

ine

(mg

/dL)

Befo

reAf

ter

0

2

4

6

8

10

12IAP>8mmHg IAP<8mmHg

IAP

(m

mH

g)

Mullens et al, J Am Coll Card 2008; 51 (3): 300-306

Hypothesis: Combined therapy with PEEP, albumin and frusemide Should mobilize interstitial fluid to the vascular

compartment and evacuate fluids through diuresis

Retrospective matched control case series (n=114)

PAL treatment

Baseline characteristics Control group

PAL group P-value

APACHE II 22.7 ± 11.1 22.9 ± 11.4 0.934

PaO2/FiO2 ratio (mmHg) 256.5 ± 152.7

174.5 ± 84.5 0.001

IAP (mmHg) 8.0 ± 3.7 10.0 ± 4.2 0.013

Results

PaO2/FiO2 ratio (mmHg) -123 ± 166.4 99.9 ± 110.5 <0.001

Change in IAP (mmHg) 1.8 ± 3.8 -0.4 ± 3.6 0.007

Cumulative fluid balance (L) 8027 ± 5254 -1451 ± 7761

<0.001

EVLWI (mL/kg) -1.1 ± 3.7 -4.2 ± 5.6 0.006

Serum creatinine (mg/dL) -0.5 ± 2.0 -0.1 ± 1.1 0.171

SOFA cardiovascular -0.5 ± 1.9 -1.2 ± 2.0 0.087

PAL treatment and outcome

Cordemans C et al. Ann Intens Care 2012, 2(Suppl 1): S15

BUMIAP study

Number of patients /patient days

266 / 869

Age 60.2 ± 15.4 years

APACHE II score 22.2 ± 7.3

IAP 13.2 ± 4.0 mmHg

Fluid balance after 1 day of bumetanide

+1509 ± 1938 mL

Patients with/without IAH 62.3 / 48.4 %

Retrospective study on all patients receiving loop diuretics while monitoring IAP (Ghent University Hospital)

In patients with IAH and negative fluid balance, IAP was significantly decreased after 24h of bumetanide (difference -1.32mmHg ± 0.50, p<0.001)

Pro: Can be applied in patients with AKI Can achieve fluid removal

Con: Hemodynamic consequences? Adverse effect on renal function or renal recovery? Riisk of catheter related and RRT related

complications

Alternative: ultrafiltration

If the diuretics don’t work

Mullens et al. J Card Fail 2008; 14 (6): 508-514

DL Follow up 0h 6h 12h 18h 24h0

5

10

15

20

25

30

IAP (mmHg)

0h 6h 12h 18h 24h0

5

10

15

20

25

30

35

IAP (mmHg)

Kula et al.Intens Care Med 2004; 30: 2138-2139

Fluid balance (L)

0 -0.4 -4.4

-6.2

+.6 -0.9 -2.1 -4.8

CRRT: some small reports

Crystalloid fluid resuscitation is the most important risk factor for secondary IAH/ACS

Secondary IAH/ACS carries a high morbidity and mortality

We need better fluid strategies to limit the amount of crystalloid resuscitation

We need prospective studies on albumin (and plasma?) used as add-on resuscitation for patients with distributive shock requiring large amounts of crystalloids

Conclusions

news on intra-abdominal hypertension – focus on fluids and hemodynamics

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