This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
The incidence of acute gastrointestinal injury (AGI) after colorectal surgery is low when laparoscopic techniques are used. While elevated intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) are associated with AGI grade II, little is known about the relation between increased IAP during laparoscopy and subsequent AGI.
To assess the impact of increased IAP during laparoscopic colorectal surgery on the incidence of postoperative AGI.
Material and methods
Sixty-six patients (41 men and 25 women) with colorectal cancer undergoing elective laparoscopic colorectal surgery were randomized into 3 groups, according to different IAP levels during CO2 pneumoperitoneum (10 mm Hg, 12 mm Hg and 15 mm Hg). We recorded the incidence of AGI after surgery by assessing the following parameters: time to first flatus/defecation, time to first bowel movement, time to tolerance of semi-liquid food and the occurrence of vomiting/diarrhea. Moreover, inflammatory mediators were measured before the induction of CO2 pneumoperitoneum and on postoperative day 1.
Acute gastrointestinal injury occurred in 15 (27.3%) patients. In all 3 study groups, the elevation of IAP during CO2 pneumoperitoneum did not significantly increase the occurrence of symptoms of AGI, vomiting or diarrhea. Lower IAP levels did not significantly accelerate recovery of gastrointestinal function or shorten postoperative hospital stay. The changes in serum IL-6 after surgery did not correlate with the value of IAP.
The level of IAP elevation during laparoscopic colorectal surgery does not increase the occurrence of AGI after surgery.
laparoscopic surgery; intra-abdominal pressure; colorectal carcinoma; acute gastrointestinal injury; postoperative recovery; inflammatory mediators
To determine intra-abdominal pressure (IAP) and to evaluate the reproducibility of IAP-measurements using the Foley Manometer Low Volume (FMLV) in term uncomplicated pregnancies before and after caesarean section (CS), relative to two different reference points and to non-pregnant values.
Observational cohort study.
Secondary level referral center for feto-maternal medicine.
Term uncomplicated pregnant women as the case-group and non-pregnant patients undergoing a laparoscopic assisted vaginal hysterectomy (LAVH) as control group.
IAP was measured in 23 term pregnant patients, before and after CS and in 27 women immediately after and 1 day after LAVH. The midaxillary line was used as zero-reference (IAPMAL) in all patients and in 13 CS and 13 LAVH patients, the symphysis pubis (IAPSP) was evaluated as additional zero-reference. Intraobserver correlation (ICC) was calculated for each zero-reference. Paired student's t-tests were performed to compare IAP values and Pearson's correlation was used to assess correlations between IAP and gestational variables.
Main outcome measures
ICC before and after surgery, IAP before and after CS, IAP after CS and LAVH.
The ICC for IAPMAL before CS was lower than after (0.71 versus 0.87). Both mean IAPMAL and IAPSP were significantly higher before CS than after: 14.0±2.6 mmHg versus 9.8±3.0 mmHg (p<0.0001) and 8.2±2.5 mmHg versus 3.5±1.9 mmHg (p = 0.010), respectively. After CS, IAP was not different from values measured in the LAVH-group.
IAP-measurements using FMLV is reproducible in pregnant women. Before CS, IAP is increased in the range of intra-abdominal hypertension for non-pregnant individuals. IAP significantly decreases to normal values after delivery.
Variability of body weight (BW) and height calls for indexation of volumetric hemodynamic parameters. Extravascular lung water (EVLW) has formerly been indexed to actual BW (BWact) termed EVLW-index (EVLWI). In overweight patients indexation to BWact might inappropriately lower indexed EVLWIact. Several studies suggest indexation of EVLWI to predicted BW (EVLWIpred). However, data regarding association of EVLWIact and EVLWpred to mortality and PaO2/FiO2 are inconsistent. Two recent studies based on biometric database-analyses suggest indexation of EVLWI to height (EVLWIheight). Therefore, our study compared the association of un-indexed EVLW, EVLWIheight, EVLWpred and EVLWIact to PaO2/FiO2 and Oxygenation index (OI = mean airway pressure*FiO2*/PaO2).
A total of 2119 triplicate transpulmonary thermodilutions (TPTDs; PiCCO; Pulsion Medical-Systems, Germany) were performed in 50 patients from the evaluation, and 181 patients from the validation groups. Correlations of EVLW and EVLWI to PaO2/FiO2, OI and ROC-AUC-analyses regarding PaO2/FiO2<200 mmHg (primary endpoint) and OI>10 were performed.
In the evaluation group, un-indexed EVLW (AUC 0.758; 95%-CI: 0.637-0.880) and EVLWIheight (AUC 0.746; 95%-CI: 0.622-0.869) provided the largest ROC-AUCs regarding PaO2/FiO2<200 mmHg. The AUC for EVLWIpred was smaller (0.713). EVLWIact provided the smallest AUC (0.685). This was confirmed in the validation group: EVLWIheight provided the largest AUC (0.735), EVLWIact (0.710) the smallest. In the merged data-pool, AUC was significantly greater for EVLWIheight (0.729; 95%-CI: 0.674–0.784) compared to all other indexations including EVLWIact (ROC-AUC 0.683, p = 0.007) and EVLWIpred (ROC-AUC 0.707, p = 0.015). The association of EVLW(I) was even stronger to OI compared to PaO2/FiO2. In the merged data-pool, EVLWIheight provided the largest AUC regarding “OI>10” (0.778; 95%-CI: 0.713–0.842) compared to 0.739 (95%-CI: 0.669–0.810) for EVLWIact and 0.756 (95%-CI: 0.688–0.824) for EVLWIpred.
Indexation of EVLW to height (EVLWIheight) improves the association of EVLW(I) to PaO2/FiO2 and OI compared to all other indexations including EVLWIpred and EVLWIact. Also considering two recent biometric database analyses, EVLWI should be indexed to height.
Pulmonary coagulopathy is a hallmark of lung injury following inhalation trauma. Locally applied heparin attenuates lung injury in animal models of smoke inhalation. Whether local treatment with heparin benefits patients with inhalation trauma is uncertain. The present trial aims at comparing a strategy using frequent nebulizations of heparin with standard care in intubated and ventilated burn patients with bronchoscopically confirmed inhalation trauma.
The Randomized Controlled Trial Investigating the Efficacy and Safety of Nebulized HEParin versus Placebo in BURN Patients with Inhalation Trauma (HEPBURN) is an international multi-center, double-blind, placebo-controlled, two-arm study. One hundred and sixteen intubated and ventilated burn patients with confirmed inhalation trauma are randomized to nebulizations of heparin (the nebulized heparin strategy) or nebulizations of normal saline (the control strategy) every four hours for 14 days or until extubation, whichever comes first. The primary endpoint is the number of ventilator-free days, defined as days alive and breathing without assistance during the first 28 days, if the period of unassisted breathing lasts for at least 24 consecutive hours.
As far as the authors know, HEPBURN is the first randomized, placebo-controlled trial, powered to investigate whether local treatment with heparin shortens duration of ventilation of intubated and ventilated burn patients with inhalation trauma.
NCT01773083 (http://www.clinicaltrials.gov), registered on 16 January 2013.
Recruiting. Randomisation commenced on 1 January 2014.
Inhalation trauma; Pulmonary coagulopathy; Nebulization; Heparin; Mechanical ventilation
Introduction. Nexfin (Bmeye, Amsterdam, Netherlands) is a noninvasive cardiac output (CO) monitor based on finger arterial pulse contour analysis. The aim of this study was to validate Nexfin CO (NexCO) against thermodilution (TDCO) and pulse contour CO (CCO) by PiCCO (Pulsion Medical Systems, Munich, Germany). Patients and Methods. In a mix of critically ill patients (n = 45), NexCO and CCO were measured continuously and recorded at 2-hour intervals during the 8-hour study period. TDCO was measured at 0–4–8 hrs. Results. NexCO showed a moderate to good (significant) correlation with TDCO (R2 0.68, P < 0.001) and CCO (R2 0.71, P < 0.001). Bland and Altman analysis comparing NexCO with TDCO revealed a bias (± limits of agreement, LA) of 0.4 ± 2.32 L/min (with 36% error) while analysis comparing NexCO with CCO showed a bias (±LA) of 0.2 ± 2.32 L/min (37% error). NexCO is able to follow changes in TDCO and CCO during the same time interval (level of concordance 89.3% and 81%). Finally, polar plot analysis showed that trending capabilities were acceptable when changes in NexCO (ΔNexCO) were compared to ΔTDCO and ΔCCO (resp., 89% and 88.9% of changes were within the level of 10% limits of agreement). Conclusion. we found a moderate to good correlation between CO measurements obtained with Nexfin and PiCCO.
Although intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are associated with substantial morbidity and mortality among critically ill adults, it remains unknown if prevention or treatment of these conditions improves patient outcomes. We sought to identify evidence-based risk factors for IAH and ACS in order to guide identification of the source population for future IAH/ACS treatment trials and to stratify patients into risk groups based on prognosis.
We searched electronic bibliographic databases (MEDLINE, EMBASE, PubMed, and the Cochrane Database from 1950 until January 21, 2013) and reference lists of included articles for observational studies reporting risk factors for IAH or ACS among adult ICU patients. Identified risk factors were summarized using formal narrative synthesis techniques alongside a random effects meta-analysis.
Among 1,224 citations identified, 14 studies enrolling 2,500 patients were included. The 38 identified risk factors for IAH and 24 for ACS could be clustered into three themes and eight subthemes. Large volume crystalloid resuscitation, the respiratory status of the patient, and shock/hypotension were common risk factors for IAH and ACS that transcended across presenting patient populations. Risk factors with pooled evidence supporting an increased risk for IAH among mixed ICU patients included obesity (four studies; odds ratio (OR) 5.10; 95% confidence interval (CI), 1.92 to 13.58), sepsis (two studies; OR 2.38; 95% CI, 1.34 to 4.23), abdominal surgery (four studies; OR 1.93; 95% CI, 1.30 to 2.85), ileus (two studies; OR 2.05; 95% CI, 1.40 to 2.98), and large volume fluid resuscitation (two studies; OR 2.17; 95% CI, 1.30 to 3.63). Among trauma and surgical patients, large volume crystalloid resuscitation and markers of shock/hypotension and metabolic derangement/organ failure were risk factors for IAH and ACS while increased disease severity scores and elevated creatinine were risk factors for ACS in severe acute pancreatitis patients.
Although several IAH/ACS risk factors transcend across presenting patient diagnoses, some appear specific to the population under study. As our findings were somewhat limited by included study methodology, the risk factors reported in this study should be considered candidate risk factors until confirmed by a large prospective multi-centre observational study.
Kynurenic acid (KYNA) is one of the end products of tryptophan metabolism. The aim of this study was to analyse plasma KYNA concentration in septic shock patients (SSP) with acute kidney injury (AKI) undergoing continuous veno-venous haemofiltration (CVVH). Changes in KYNA content were compared to alterations in the levels of procalcitonin (PCT), C-reactive protein and lactate. Adult SSP with AKI were examined. Measurements were conducted at seven time points: before beginning CVVH and at 6, 12, 24, 48, 72 and 96 h after the beginning of CVVH. Based on clinical outcomes, the data were analysed separately for survivors and non-survivors. Twenty-seven patients were studied. CVVH was associated with reduced plasma KYNA concentration only in survivors. Plasma KYNA concentration correlated with the levels of lactate and PCT only in survivors. (1) CVVH reduced plasma KYNA concentration only in survivors; (2) lack of this reduction may predict fatal outcomes in SSP.
kynurenic acid; inflammatory markers; continuous veno-venous haemofiltration; septic shock; acute kidney injury
To update the World Society of the Abdominal Compartment Syndrome (WSACS) consensus definitions and management statements relating to intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS).
We conducted systematic or structured reviews to identify relevant studies relating to IAH or ACS. Updated consensus definitions and management statements were then derived using a modified Delphi method and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidelines, respectively. Quality of evidence was graded from high (A) to very low (D) and management statements from strong RECOMMENDATIONS (desirable effects clearly outweigh potential undesirable ones) to weaker SUGGESTIONS (potential risks and benefits of the intervention are less clear).
In addition to reviewing the consensus definitions proposed in 2006, the WSACS defined the open abdomen, lateralization of the abdominal musculature, polycompartment syndrome, and abdominal compliance, and proposed an open abdomen classification system. RECOMMENDATIONS included intra-abdominal pressure (IAP) measurement, avoidance of sustained IAH, protocolized IAP monitoring and management, decompressive laparotomy for overt ACS, and negative pressure wound therapy and efforts to achieve same-hospital-stay fascial closure among patients with an open abdomen. SUGGESTIONS included use of medical therapies and percutaneous catheter drainage for treatment of IAH/ACS, considering the association between body position and IAP, attempts to avoid a positive fluid balance after initial patient resuscitation, use of enhanced ratios of plasma to red blood cells and prophylactic open abdominal strategies, and avoidance of routine early biologic mesh use among patients with open abdominal wounds. NO RECOMMENDATIONS were possible regarding monitoring of abdominal perfusion pressure or the use of diuretics, renal replacement therapies, albumin, or acute component-parts separation.
Although IAH and ACS are common and frequently associated with poor outcomes, the overall quality of evidence available to guide development of RECOMMENDATIONS was generally low. Appropriately designed intervention trials are urgently needed for patients with IAH and ACS.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-013-2906-z) contains supplementary material, which is available to authorized users.
Intra-abdominal hypertension; Abdominal compartment syndrome; Critical care; Grading of Recommendations, Assessment, Development, and Evaluation; Evidence-based medicine; World Society of the Abdominal Compartment Syndrome
AIM: To determine the influence of intra-abdominal pressure (IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period.
METHODS: Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study. IAP monitoring was performed via both a balloon-tipped nasogastric probe [intragastric pressure (IGP), CiMON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure (IBP), UnoMeterAbdo-Pressure Kit, UnoMedical, Denmark] on five consecutive stages: (1) after tracheal intubation (AI); (2) after ventral hernia repair; (3) at the end of surgery; (4) during spontaneous breathing trial through the endotracheal tube; and (5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages.
RESULTS: The IAP (measured via both techniques) increased on average by 12% during surgery compared to AI (P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube (P < 0.01). In parallel, the gradient between РаСО2 and EtCO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/FiO2 decreased by 30% one hour after tracheal extubation (P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20% (P < 0.025). At all stages, we observed a significant correlation between IGP and IBP (r = 0.65-0.81, P < 0.01) with a mean bias varying from -0.19 mmHg (2SD 7.25 mmHg) to -1.06 mm Hg (2SD 8.04 mmHg) depending on the study stage. Taking all paired measurements together (n = 133), the median IGP was 8.0 (5.5-11.0) mmHg and the median IBP was 8.8 (5.8-13.1) mmHg. The overall r2 value (n = 30) was 0.76 (P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mmHg (2SD 4.2 mmHg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing ΔIBP and ΔIGP (n = 117).
CONCLUSION: During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/FiO2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.
Intra-abdominal pressure; Gastric pressure; Bladder pressure; Intra-abdominal hypertension; Hernia; Oxygenation; Respiratory function
The study aimed to develop a gastrointestinal (GI) dysfunction score predicting 28-day mortality for adult patients needing mechanical ventilation (MV).
377 adult patients from 40 ICUs with expected duration of MV for at least 6 h were prospectively studied. Predefined GI symptoms, intra-abdominal pressures (IAP), feeding details, organ dysfunction and treatment were documented on days 1, 2, 4 and 7.
The number of simultaneous GI symptoms was higher in nonsurvivors on each day. Absent bowel sounds and GI bleeding were the symptoms most significantly associated with mortality. None of the GI symptoms alone was an independent predictor of mortality, but gastrointestinal failure (GIF)—defined as three or more GI symptoms—on day 1 in ICU was independently associated with a threefold increased risk of mortality. During the first week in ICU, GIF occurred in 24 patients (6.4 %) and was associated with higher 28-day mortality (62.5 vs. 28.9 %, P = 0.001). Adding the created subscore for GI dysfunction (based on the number of GI symptoms) to SOFA score did not improve mortality prediction (day 1 AUROC 0.706 [95 % CI 0.647–0.766] versus 0.703 [95 % CI 0.643–0.762] in SOFA score alone).
An increasing number of GI symptoms independently predicts 28 day mortality with moderate accuracy. However, it was not possible to develop a GI dysfunction score, improving the performance of the SOFA score either due to data set limitations, definition problems, or possibly indicating that GI dysfunction is often secondary and not the primary cause of other organ failure.
Gastrointestinal symptoms; Gastrointestinal dysfunction; Intensive care; Outcome
The intra-abdominal pressure (IAP) is an important clinical parameter that can significantly change during respiration. Currently, IAP is recorded at end-expiration (IAPee), while continuous IAP changes during respiration (ΔIAP) are ignored. Herein, a novel concept of considering continuous IAP changes during respiration is presented.
Based on the geometric mean of the IAP waveform (MIAP), a mathematical model was developed for calculating respiratory-integrated MIAP (i.e. MIAPri=IAPee+i⋅ΔIAP), where 'i' is the decimal fraction of the inspiratory time, and where ΔIAP can be calculated as the difference between the IAP at end-inspiration (IAPei) minus IAPee. The effect of various parameters on IAPee and MIAPri was evaluated with a mathematical model and validated afterwards in six mechanically ventilated patients. The MIAP of the patients was also calculated using a CiMON monitor (Pulsion Medical Systems, Munich, Germany). Several other parameters were recorded and used for comparison.
The human study confirmed the mathematical modelling, showing that MIAPri correlates well with MIAP (R2 = 0.99); MIAPri was significantly higher than IAPee under all conditions that were used to examine the effects of changes in IAPee, the inspiratory/expiratory (I:E) ratio, and ΔIAP (P <0.001). Univariate Pearson regression analysis showed significant correlations between MIAPri and IAPei (R = 0.99), IAPee (R = 0.99), and ΔIAP (R = 0.78) (P <0.001); multivariate regression analysis confirmed that IAPee (mainly affected by the level of positive end-expiratory pressure, PEEP), ΔIAP, and the I:E ratio are independent variables (P <0.001) determining MIAP. According to the results of a regression analysis, MIAP can also be calculated as
We believe that the novel concept of MIAP is a better representation of IAP (especially in mechanically ventilated patients) because MIAP takes into account the IAP changes during respiration. The MIAP can be estimated by the MIAPri equation. Since MIAPri is almost always greater than the classic IAP, this may have implications on end-organ function during intra-abdominal hypertension. Further clinical studies are necessary to evaluate the physiological effects of MIAP.
Monitoring hepatic blood flow and function might be crucial in treating critically ill patients. Intra-abdominal hypertension is associated with decreased abdominal blood flow, organ dysfunction, and increased mortality. The plasma disappearance rate (PDR) of indocyanine green (ICG) is considered to be a compound marker for hepatosplanchnic perfusion and hepatocellular membrane transport and correlates well with survival in critically ill patients. However, correlation between PDRICG and intra-abdominal pressure (IAP) remains poorly understood. The aim of this retrospective study was to investigate the correlation between PDRICG and classic liver laboratory parameters, IAP and abdominal perfusion pressure (APP). The secondary goal was to evaluate IAP, APP, and PDRICG as prognostic factors for mortality.
A total of 182 paired IAP and PDRICG measurements were performed in 40 critically ill patients. The mean values per patient were used for comparison. The IAP was measured using either a balloon-tipped stomach catheter connected to an IAP monitor (Spiegelberg, Hamburg, Germany, or CiMON, Pulsion Medical Systems, Munich, Germany) or a bladder FoleyManometer (Holtech Medical, Charlottenlund, Denmark). PDRICG was measured at the bedside using the LiMON device (Pulsion Medical Systems, Munich, Germany). Primary endpoint was hospital mortality.
There was no significant correlation between PDRICG and classic liver laboratory parameters, but PDRICG did correlate significantly with APP (R = 0.62) and was inversely correlated with IAP (R = -0.52). Changes in PDRICG were associated with significant concomitant changes in APP (R = 0.73) and opposite changes in IAP (R = 0.61). The IAP was significantly higher (14.6 ± 4.6 vs. 11.1 ± 5.3 mmHg, p = 0.03), and PDRICG (10 ± 8.3 vs. 15.9 ± 5.2%, p = 0.02) and APP (43.6 ± 9 vs. 57.9 ± 12.2 mmHg, p
< 0.0001) were significantly lower in non-survivors.
PDRICG is positively correlated to APP and inversely correlated to IAP. Changes in APP are associated with significant concomitant changes in PDRICG, while changes in IAP are associated with opposite changes in PDRICG, suggesting that an increase in IAP may compromise hepatosplanchnic perfusion. Both PDRICG and IAP are correlated with outcome. Measurement of PDRICG may be a useful additional clinical tool to assess the negative effects of increased IAP on liver perfusion and function.
Little is known about the effects of renal replacement therapy (RRT) with fluid removal on intra-abdominal pressure (IAP). The global end-diastolic volume index (GEDVI) and extravascular lung water index (EVLWI) can easily be measured bedside by transpulmonary thermodilution (TPTD). The aim of this study is to evaluate the changes in IAP, GEDVI and EVLWI in critically ill patients receiving slow extended daily dialysis (SLEDD) or continuous venovenous haemofiltration (CVVH) with the intention of net fluid removal.
We performed a retrospective cohort study in ICU patients who were treated with SLEDD or CVVH and in whom IAP was also measured, and RRT sessions were excluded when the dose of vasoactive medication needed to be changed between the pre- and post-dialysis TPTD measurements and when net fluid loss did not exceed 500 ml. The TPTD measurements were performed within 2 h before and after SLEDD; in case of CVVH, before and after an interval of 12 h.
We studied 25 consecutive dialysis sessions in nine patients with acute renal failure and cardiogenic or non-cardiogenic pulmonary oedema. The GEDVI and EVLWI values before dialysis were 877 ml/m² and 14 ml/kg, respectively. Average net ultrafiltration per session was 3.6 l, with a net fluid loss 1.9 l. The GEDVI decreased significantly during dialysis, but not more than 47.8 ml/m² (p = 0.008), as also did the EVLWI with 1 ml/kg (p = 0.03). The IAP decreased significantly from 12 to 10.5 mmHg (p < 0.0001).
Net fluid removal by SLEDD or CVVH in the range observed in this study decreased IAP, GEDVI and EVLWI in critically ill patients although EVLWI reduction was modest.
Uncalibrated semi-invasive continous monitoring of cardiac index (CI) has recently gained increasing interest. The aim of the present study was to compare the accuracy of CI determination based on arterial waveform analysis with transpulmonary thermodilution. Fifty patients scheduled for elective coronary surgery were studied after induction of anaesthesia and before and after cardiopulmonary bypass (CPB), respectively. Each patient was monitored with a central venous line, the PiCCO system, and the FloTrac/Vigileo-system. Measurements included CI derived by transpulmonary thermodilution and uncalibrated semi-invasive pulse contour analysis. Percentage changes of CI were calculated. There was a moderate, but significant correlation between pulse contour CI and thermodilution CI both before (r2 = 0.72, P < 0.0001) and after (r2 = 0.62, P < 0.0001) CPB, with a percentage error of 31% and 25%, respectively. Changes in pulse contour CI showed a significant correlation with changes in thermodilution CI both before (r2 = 0.52, P < 0.0001) and after (r2 = 0.67, P < 0.0001) CPB. Our findings demonstrated that uncalibrated semi-invasive monitoring system was able to reliably measure CI compared with transpulmonary thermodilution in patients undergoing elective coronary surgery. Furthermore, the semi-invasive monitoring device was able to track haemodynamic changes and trends.
Achievement of a negative fluid balance in patients with capillary leak is associated with improved outcome. We investigated the effects of a multi-modal restrictive fluid strategy aiming for negative fluid balance in patients with acute lung injury (ALI).
In this retrospective matched case-control study, we included 114 mechanically ventilated (MV) patients with ALI. We compared outcomes between a group of 57 patients receiving PAL-treatment (PAL group) and a matched control group, abstracted from a historical cohort. PAL-treatment combines high levels of positive end-expiratory pressure, small volume resuscitation with hyperoncotic albumin, and fluid removal with furosemide (Lasix®) or ultrafiltration. Effects on extravascular lung water index (EVLWI), intra-abdominal pressure (IAP), organ function, and vasopressor therapy were recorded during 1 week. The primary outcome parameter was 28-day mortality.
At baseline, no significant intergroup differences were found, except for lower PaO2/FIO2 and increased IAP in the PAL group (174.5 ± 84.5 vs 256.5 ± 152.7, p = 0.001; 10.0 ± 4.2 vs 8.0 ± 3.7 mmHg, p = 0.013, respectively). After 1 week, PAL-treated patients had a greater reduction of EVLWI, IAP, and cumulative fluid balance (-4.2 ± 5.6 vs -1.1 ± 3.7 mL/kg, p = 0.006; -0.4 ± 3.6 vs 1.8 ± 3.8 mmHg, p = 0.007; -1,451 ± 7,761 vs 8,027 ± 5,254 mL, p < 0.001). Repercussions on cardiovascular and renal function were limited. PAL-treated patients required fewer days of intensive care unit admission and days on MV (23.6 ± 15 vs 37.1 ± 19.9 days, p = 0.006; 14.6 ± 10.7 vs 25.5 ± 20.2 days, respectively) and had a lower 28-day mortality (28.1% vs 49.1%, p = 0.034).
PAL-treatment in patients with ALI is associated with a negative fluid balance, a reduction of EVLWI and IAP, and improved clinical outcomes without compromising organ function.
abdominal pressure; extravascular lung water; fluid balance; fluid management; capillary leak; organ failure; treatment; conservative late fluid management; albumin; PEEP.
The aim of this study was to determine whether intra-abdominal pressure (IAP) monitoring using the FoleyManometer (Holtech Medical, Charlottenlund, Denmark) increases the risk of urinary tract infection (UTI).
A retrospective database review was conducted.
The study was conducted in the 12-bed medical intensive care unit of ZNA Stuivenberg Hospital (Antwerp, Belgium), a tertiary hospital.
There were 5,890 patients admitted to the medical intensive care unit of which 1,097 patients underwent intrabladder pressure (IBP) monitoring as estimate for IAP.
Crude and adjusted UTI rates were compared among patients undergoing IAP measurements with three different intrabladder methods: a modified homemade technique, a FoleyManometer with 35 ml reservoir, and a FoleyManometer low volume (FoleyManometerLV) with less than 10 ml priming volume.
Measurements and results
Four consecutive time periods of 24 months were defined and compared with regard to IAP measurement: period 1 (2000-2001), during which IAP monitoring was not used routinely (which serves as a control group), was compared with period 2 (2002-2003), using a modified homemade technique; period 3 (2004-2005), introducing the FoleyManometer; and finally period 4 (2006-2007), in which the FoleyManometerLV was introduced. The incidence of IBP measurements increased from 1.4% in period 1 to 45.4% in period 4 (p < 0.001). At the same time, the Simplified Acute Physiology Score (version 2) (SAPS-II) increased significantly from 24.4 ± 21.5 to 34.9 ± 18.7 (p < 0.001) together with the percentage of ventilated patients from 18.6% to 40.7% (p < 0.001). In total, 1,097 patients had IAP measurements via the bladder. The UTI rates were adjusted for disease severity by multiplying each crude rate with the ratio of control versus study patient SAPS-II probability of mortality. Crude and adjusted UTI rates per 1,000 catheter days (CD) were on average 16.1 and 12.8/1,000 CD, respectively, and were not significantly different between the four time periods.
Intrabladder pressure monitoring as estimate for IAP either via a closed transducer technique or the closed FoleyManometer technique seems safe and does not alter the risk of UTI in critically ill patients.
intra-abdominal pressure; abdominal compartment syndrome; abdominal hypertension; FoleyManometerLV; intensive care; intravesical pressure; intrabladder pressure; urinary tract infection
Capillary leak in critically ill patients leads to interstitial edema. Fluid overload is independently associated with poor prognosis. Bedside measurement of intra-abdominal pressure (IAP), extravascular lung water index (EVLWI), fluid balance, and capillary leak index (CLI) may provide a valuable prognostic tool in mechanically ventilated patients.
We performed an observational study of 123 mechanically ventilated patients with extended hemodynamic monitoring, analyzing process-of-care variables for the first week of ICU admission. The primary outcome parameter was 28-day mortality. ΔmaxEVLWI indicated the maximum difference between EVLWI measurements during ICU stay. Patients with a ΔmaxEVLWI <−2 mL/kg were called 'responders'. CLI was defined as C-reactive protein (milligrams per deciliter) over albumin (grams per liter) ratio and conservative late fluid management (CLFM) as even-to-negative fluid balance on at least two consecutive days.
CLI had a biphasic course. ΔmaxEVLWI was lower if CLFM was achieved and in survivors (−2.4 ± 4.8 vs 1.0 ± 5.5 mL/kg, p = 0.001; −3.3 ± 3.8 vs 2.5 ± 5.3 mL/kg, p = 0.001, respectively). No CLFM achievement was associated with increased CLI and IAPmean on day 3 and higher risk to be nonresponder (odds ratio (OR) 2.76, p = 0.046; OR 1.28, p = 0.011; OR 5.52, p = 0.001, respectively). Responders had more ventilator-free days during the first week (2.5 ± 2.3 vs 1.5 ± 2.3, p = 0.023). Not achieving CLFM and being nonresponder were strong independent predictors of mortality (OR 9.34, p = 0.001 and OR 7.14, p = 0.001, respectively).
There seems to be an important correlation between CLI, EVLWI kinetics, IAP, and fluid balance in mechanically ventilated patients, associated with organ dysfunction and poor prognosis. In this context, we introduce the global increased permeability syndrome.
abdominal pressure; extravascular lung water; fluid balance; fluid management; capillary leak; organ failure; prognosis
Rationale. Elevated intra-abdominal pressure (IAP) may compromise respiratory and cardiovascular function by abdomino-thoracic pressure transmission. We aimed (1) to study the effects of elevated IAP on pleural pressure, (2) to understand the implications for lung and chest wall compliances and (3) to determine whether volumetric filling parameters may be more accurate than classical pressure-based filling pressures for preload assessment in the setting of elevated IAP. Methods. In eleven pigs, IAP was increased stepwise from 6 to 30 mmHg. Hemodynamic, esophageal, and pulmonary pressures were recorded. Results. 17% (end-expiratory) to 62% (end-inspiratory) of elevated IAP was transmitted to the thoracic compartment. Respiratory system compliance decreased significantly with elevated IAP and chest wall compliance decreased. Central venous and pulmonary wedge pressure increased with increasing IAP and correlated inversely (r = −0.31) with stroke index (SI). Global end-diastolic volume index was unaffected by IAP and correlated best with SI (r = 0.52). Conclusions. Increased IAP is transferred to the thoracic compartment and results in a decreased respiratory system compliance due to decreased chest wall compliance. Volumetric filling parameters and transmural filling pressures are clearly superior to classical cardiac filling pressures in the assessment of cardiac preload during elevated IAP.
Background. Intravesical pressure (IAPivp) measurement is considered to be the gold standard for assessment of intra-abdominal pressure (IAP). This study evaluated a new minimally invasive IAP monitoring device (CiMON) against three other devices in a wide range of clinically relevant IAP and in different body positions in healthy pigs. Methods. The CiMON catheter (IAPCiM) and another balloon-tipped catheter (IAPspie) were positioned into the stomach. Fluid-filled catheters were used for direct intraperitoneal (IAPdir) and IAPivp measurement. Both in supine and 25° head-of-bed positions, IAP was increased from baseline to 30 mmHg. At every IAP level, 4 IAP measurements were recorded simultaneously. Mean differences and the limits of agreement were calculated. Results. Bias between IAPCiM and IAPspie was nearly zero with very good agreement, both in supine and 25° position. In supine position, IAPCiM slightly overestimated IAPivp and IAPdir by 1.5 and 2.1 mmHg with reasonable agreement. In 25° position, IAPCiM underestimated IAPivp and IAPdir by 1.0 and 0.5 mmHg, again with reasonable agreement. Conclusions. Agreement between IAPCiM and IAPspie was very good, while good-to-moderate agreement exists between IAPCiM and IAPdir or IAPivp. Simplicity, continuous monitoring, and the combination with a feeding tube should lead to further clinical studies, evaluating this new CiMON device.
Acute gastrointestinal (GI) dysfunction and failure have been increasingly recognized in critically ill patients. The variety of definitions proposed in the past has led to confusion and difficulty in comparing one study to another. An international working group convened to standardize the definitions for acute GI failure and GI symptoms and to review the therapeutic options.
The Working Group on Abdominal Problems (WGAP) of the European Society of Intensive Care Medicine (ESICM) developed the definitions for GI dysfunction in intensive care patients on the basis of the available evidence and current understanding of the pathophysiology.
Definitions for acute gastrointestinal injury (AGI) with its four grades of severity, as well as for feeding intolerance syndrome and GI symptoms (e.g. vomiting, diarrhoea, paralysis, high gastric residual volumes) are proposed. AGI is a malfunctioning of the GI tract in intensive care patients due to their acute illness. AGI grade I = increased risk of developing GI dysfunction or failure (a self-limiting condition); AGI grade II = GI dysfunction (a condition that requires interventions); AGI grade III = GI failure (GI function cannot be restored with interventions); AGI grade IV = dramatically manifesting GI failure (a condition that is immediately life-threatening). Current evidence and expert opinions regarding treatment of acute GI dysfunction are provided.
State-of-the-art definitions for GI dysfunction with gradation as well as management recommendations are proposed on the basis of current medical evidence and expert opinion. The WGAP recommends using these definitions for clinical and research purposes.
Electronic supplementary material
The online version of this article (doi:10.1007/s00134-011-2459-y) contains supplementary material, which is available to authorized users.
Gastrointestinal function; Failure; Symptoms; Feeding intolerance; Intensive care; Definitions; Classification
Prone ventilation (PV) is a ventilatory strategy that frequently improves oxygenation and lung mechanics in critical illness, yet does not consistently improve survival. While the exact physiologic mechanisms related to these benefits remain unproven, one major theoretical mechanism relates to reducing the abdominal encroachment upon the lungs. Concurrent to this experience is increasing recognition of the ubiquitous role of intra-abdominal hypertension (IAH) in critical illness, of the relationship between IAH and intra-abdominal volume or thus the compliance of the abdominal wall, and of the potential difference in the abdominal influences between the extrapulmonary and pulmonary forms of acute respiratory distress syndrome. The present paper reviews reported data concerning intra-abdominal pressure (IAP) in association with the use of PV to explore the potential influence of IAH. While early authors stressed the importance of gravitationally unloading the abdominal cavity to unencumber the lung bases, this admonition has not been consistently acknowledged when PV has been utilized. Basic data required to understand the role of IAP/IAH in the physiology of PV have generally not been collected and/or reported. No randomized controlled trials or meta-analyses considered IAH in design or outcome. While the act of proning itself has a variable reported effect on IAP, abundant clinical and laboratory data confirm that the thoracoabdominal cavities are intimately linked and that IAH is consistently transmitted across the diaphragm - although the transmission ratio is variable and is possibly related to the compliance of the abdominal wall. Any proning-related intervention that secondarily influences IAP/IAH is likely to greatly influence respiratory mechanics and outcomes. Further study of the role of IAP/IAH in the physiology and outcomes of PV in hypoxemic respiratory failure is thus required. Theories relating inter-relations between prone positioning and the abdominal condition are presented to aid in designing these studies.
Outcome studies in patients with acute kidney injury (AKI) have focused on differences between modalities of renal replacement therapy (RRT). The outcome of conservative treatment, however, has never been compared with RRT.
Nine Belgian intensive care units (ICUs) included all adult patients consecutively admitted with serum creatinine >2 mg/dl. Included treatment options were conservative treatment and intermittent or continuous RRT. Disease severity was determined using the Stuivenberg Hospital Acute Renal Failure (SHARF) score. Outcome parameters studied were mortality, hospital length of stay and renal recovery at hospital discharge.
Out of 1,303 included patients, 650 required RRT (58% intermittent, 42% continuous RRT). Overall results showed a higher mortality (43% versus 58%) as well as a longer ICU and hospital stay in RRT patients compared to conservative treatment. Using the SHARF score for adjustment of disease severity, an increased risk of death for RRT compared to conservative treatment of RR = 1.75 (95% CI: 1.4 to 2.3) was found. Additional correction for other severity parameters (Acute Physiology And Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA)), age, type of AKI and clinical conditions confirmed the higher mortality in the RRT group.
The SHARF study showed that the higher mortality expected in AKI patients receiving RRT versus conservative treatment can not only be explained by a higher disease severity in the RRT group, even after multiple corrections. A more critical approach to the need for RRT in AKI patients seems to be warranted.