Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 7  |  Issue : 2  |  Page : 107-113

Incidence and prognostic significance of intra-abdominal pressure in critically ill patients


Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Egypt

Date of Submission14-Jul-2013
Date of Acceptance24-Oct-2013
Date of Web Publication31-May-2014

Correspondence Address:
N M Elsharnouby
Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1687-7934.133307

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  Abstract 

Background
Elevated intra-abdominal pressure is frequently found among different populations of critically ill patients and may contribute to both morbidity and mortality. Various risk factors such as abdominal surgery, massive fluid resuscitation, and ileus have been proposed to contribute to the development of intra-abdominal hypertension/abdominal compartmental syndrome. This study was conducted to evaluate the incidence and prognostic significance of intra-abdominal hypertension in critically ill patients.
Materials and methods
Forty patients who met the inclusion criteria were included in this prospective cohort study. Patient characteristics were recorded on admission. Intra-abdominal pressure was measured using Foley bladder catheter by modified Kron technique described by Cheatham and Safcsak, The intra-abdominal pressure (IAP) was measured in supine and hemodynamically stable position every 6 hours for the first 24 hours and then twice daily, thereafter, the mean intra-abdominal pressures were defined as the mean of these daily measurements. Intra-abdominal hypertension was defined as an intra-abdominal pressure of over 12 mmHg, severe elevation as an intra-abdominal pressure of over 15 mmHg, and abdominal compartmental syndrome as a pressure of over 20 mmHg with evidence of at least one organ failure.
Results
In the study group, 47% were admitted for medical causes. Age (P < 0.0001), Acute Physiology and Chronic Health Evaluation (APACHE) score (P < 0.0001), and Sequential Organ Failure Assessment (SOFA) score (P < 0.0001) were highly significant with regard to the outcome. Nine patients (22.5%) did not survive; the mean age (61 ± 8 vs. 44 ± 12 years), APACHEII score (30 vs. 22), and SOFA score (6 vs. 4) were higher in the non- survivors group, significantly affecting the outcome. The mean intra-abdominal pressure during the 25 days of intensive care unit (ICU) stay was higher in the non-survivors group (17 ± 2). In addition, the occurrence of intra-abdominal hypertension was higher in the non-survivors group. The mean intra-abdominal pressure during the 25 days of intensive care unit (ICU) stay was higher in the nonsurvival group (17 ± 2). In addition, the occurrence of intra-abdominal hypertension was higher in the nonsurvival group. On admission, the mean age (P = 0.006), APACHE II score (P = 0.001), SOFA score (P < 0.001), and mean intra-abdominal pressure greater than 12 (P = 0.001), as well as the occurrence of intra-abdominal hypertension during ICU stay (P = 0.008), were independent predictors of mortality. The nonsurviving patients had a significantly higher SOFA score on admission and a significantly higher SOFA score during ICU stay.
Conclusion
The incidence of intra-abdominal pressure greater than 12 mmHg was high in critically ill patients, and its presence on admission or the occurrence of intra-abdominal hypertension is a prognostic factor for mortality during the ICU stay.

Keywords: Abdominal compartmental syndrome, Acute Physiology and Chronic Health Evaluation II score, critically ill patients, intensive care unit stay, intra-abdominal hypertension, intra-abdominal pressure, mortality, Sequential Organ Failure Assessment score


How to cite this article:
Abdelkalik M A, Elewa G M, Kamaly A M, Elsharnouby N M. Incidence and prognostic significance of intra-abdominal pressure in critically ill patients. Ain-Shams J Anaesthesiol 2014;7:107-13

How to cite this URL:
Abdelkalik M A, Elewa G M, Kamaly A M, Elsharnouby N M. Incidence and prognostic significance of intra-abdominal pressure in critically ill patients. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 Oct 22];7:107-13. Available from: http://www.asja.eg.net/text.asp?2014/7/2/107/133307


  Introduction Top


Elevated intra-abdominal pressure is frequently found among different populations of critically ill patients and may contribute to both morbidity and mortality [1],[2]. The increased awareness of the incidence and prognostic effect along with the advances in the diagnosis and management of both intra-abdominal hypertension (IAH) and abdominal compartment compartment syndrome (ACS), may lead to improvement in survival in those patients [3,4]. Studies have found that the gold standard for indirect measurement of intra-abdominal pressure is the intra-abdominal bladder method [5].

In critically ill patients, the intra-abdominal pressure ranges from 5 to 7 mmHg [6],[7] and is affected by severity of the disease, ranging from 10 to 20 mmHg in patients suffering from sepsis, those who have undergone abdominal surgery, and organ failure [8,9]. Abdominal perfusion pressure, calculated as the mean arterial pressure minus intra-abdominal pressure, may be used to predict visceral perfusion, as well as resuscitation end point [10], which is superior to other resuscitation endpoints such as arterial pH, base deficit, arterial lactate, and hourly urinary output [11].

Intra-abdominal hypertension is defined as a sustained or repeated pathologic elevation of intra-abdominal pressure greater than 12 mmHg [1],[5]. Intra-abdominal hypertension is graded as follows:

Grade I Intra-abdominal pressure 12-15 mmHg.

Grade II Intra-abdominal pressure 16-20 mmHg.

Grade III Intra-abdominal pressure 21-25 mmHg.

Grade IV Intra-abdominal pressure greater than 25 mmHg, according to the grading by Cheatham and colleagues [5],[12].

Various risk factors such as abdominal surgery or trauma; massive fluid resuscitation (>3500 ml/24 h); ileus; respiratory, renal, or liver dysfunction; hypothermia; acidosis; anemia; oliguria; and hyperlactatemia have been proposed to contribute to the development of intra-abdominal hypertension/ACS [5],[8],[13],[14],[15],[16],[17].

This study was conducted to evaluate the incidence and prognostic significance of intra-abdominal hypertension in critically ill patients.


  Materials and methods Top


After approval of the research by the ethical committee and obtaining written informed consent from the patients' legal guardians, 40 patients who were consecutively admitted to the ICU in Ain Shams University Hospital during a 6-month period were included in this prospective cohort study. Patients were included in the study if they were older than 15 years, admitted for more than 24 h, and required bladder catheterization. Patients were excluded from the study if they were younger than 15 years, had a known bladder tumor or congenital bladder malformations, had undergone previous urinary bladder constructive operations, or had contraindications to urinary bladder catheterization.

On admission, patient characteristics, such as age; sex; cause of admission (medical or surgical type, or trauma); Acute Physiology and Chronic Health Evaluation (APACHE) score [18]; Sequential Organ Failure Assessment (SOFA) score [19]; etiological factors such as abdominal surgery, hemoperitoneum, abdominal infection, massive fluid resuscitation, and ileus; and predisposing conditions such as hypothermia, acidosis, polytransfusion, coagulopathy, sepsis, liver dysfunction, pneumonia, and bacteremia were recorded [5],[8],[13],[14],[15],[16],[17].

All patients received standard protocol of Intensive Care Unit management in Ain Shams University Hospital. Patients were given intravenous fluids resuscitation, antimicrobials, stress ulcer prophylaxis (proton pump inhibitor), enteral nutrition, analgesic, antipyretics, and prophylactic low molecular weight heparin if indicated. During the study period careful neurological and cardiac examinations was conducted daily for all patients. Routine ECG, non-invasive blood pressure monitoring, and continuous invasive blood pressure was used if indicated, S P O 2 as well as hourly CVP, and UOP were also monitored. Central venous blood gas sampling was done to monitor oxygenation. Arterial lactate concentrations and blood gases were recorded twice daily. Patients were mechanically ventilated if they met the criteria of mechanical ventilation and weaned upon improvement according to protocols.

Intra-abdominal pressure was measured with a Foley bladder catheter using the modified Kron technique as described by Cheatham and Safcsak [20]. Intra-abdominal pressure was measured in a supine and hemodynamically stable position every 6 h for the first 24 h and then twice daily; thereafter, the mean intra-abdominal pressure was defined as the mean of these daily measurements. Intra-abdominal hypertension was defined as an intra-abdominal pressure over 12 mmHg, severe elevation as an intra-abdominal pressure over 15 mmHg, and ACS as a pressure over 20 mmHg with evidence of at least one organ failure [8],[21],[22].

Routine laboratory investigations were performed including complete blood picture, liver function tests, renal function tests, estimation of arterial lactate level, and measurement of serum electrolyte levels.

Predisposing (risk) factors for intra-abdominal hypertension were abdominal surgery or trauma; high volume of fluid resuscitation (>3500 ml/24 h); ileus; pulmonary, renal, or liver dysfunction; damage control laparotomy; hypothermia; acidosis; anemia, oliguria; and hyperlactatemia. The SOFA score was recorded throughout the study period, which ended with death, discharge, or at 25 days, whichever came first.

Definition of predisposing and etiological risk factors were as follows:

  1. Abdominal surgery (with or without laparoscopy, hernia reduction, or tight closure).
  2. Hemoperitoneum caused by either intraperitoneal or retroperitoneal bleeding.
  3. Abdominal infection such as peritonitis, pancreatitis, or any other infection.
  4. High volume of fluid resuscitation (>3500 ml/24 h).
  5. Ileus (mechanical, paralytic, or pseudo-obstructive), defined by abdominal distension, absence of bowel sounds, or failure of enteral feeding as evidenced by a high gastric residual volume of more than 1000 ml in 24 h.
  6. Acidosis, defined as arterial pH less than 7.2.
  7. Hypothermia, defined as a core temperature less than 33°C.
  8. Polytransfusion, defined as transfusion of greater than 6 U of packed RBCs in 24 h.
  9. Coagulopathy, defined as platelet count less than 50,000/mm 3 or an activated partial thromboplastin time more than twice the normal, or an International Normalized Ratio of greater than 1.5.
  10. Sepsis, defined by the American-European consensus definition.
  11. Liver dysfunction such as compensated or decompensated cirrhosis or other liver cell failure with the presence of ascites [9].


Various etiological predisposing (risk) factors, SOFA score intra-abdominal bladder pressure measurement were recorded and related to the outcome survivors and non-survivors.

Data collection and statistical analysis were carried out using SPSS version 15 (SPSS Inc., Chicago, Illinois, USA); continuous variables were measured in terms of mean (SD) and categorical variables were measured as frequency and percentage. Continuous variables were compared using Student's t-test for normally distributed variables, whereas the Mann-Whitney test was used for the non-normally distributed variables. Ordinal variables were compared using nonparametric tests. The occurrence of intra-abdominal hypertension on mortality was measured using Kaplan-Meier for time-dependent variables. P-values less than 0.05 were considered statistically significant.


  Results Top


The mean age in the study group was 48 years (13). There was a male predominance of 65%. The median APACHE II score on admission was 22, whereas, SOFA score in first 24 hours was 5. The mean duration of ICU stay was 14 ± 6 days; mortality in the study group was 22.5% [Table 1].
Table 1: Descriptive data

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In the study group, 47% were admitted for medical causes [Table 2]. In the entire study group, age (P < 0.0001), APCHE score (P < 0.0001), and SOFA score (P < 0.0001) were highly significant with regard to the outcome, whereas sex (P = 0.06) was not significantly associated with mortality.
Table 2: Cause of admission in the study group

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In the whole study group, the mean intra-abdominal bladder pressure on admission was 12 (6). Sixty percent had a mean intra-abdominal pressure greater than 12 mmHg. Abdominal compartmental syndrome was present in 12.5% of the study population, and three patients had undergone decompressive laparotomy. The mean intra-abdominal pressure on admission was highly significant to the outcome (P < 0.001; [Table 3]).
Table 3: Admission intra-abdominal pressure distribution among the study group

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In the whole study group, the most common etiological factor was a combination of more than one cause (25%) [Table 4], whereas the most common predisposing factor was a combination of more than one factor (25%) [Table 5].
Table 4: Etiological factors on admission for intra-abdominal hypertension within the study group

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Table 5: Predisposing factors for intra-abdominal hypertension<

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Nine patients (22.5%) did not survive. The mean age (61 ± 8 vs. 44 ± 12 years), APACHEII score (30 vs. 22), and SOFA score (6 vs. 4) were higher in the non-survivors group, significantly affecting the outcome. There was a male predominance in both groups, with 77% in the non-survivors group and 61% in the survivors group. The mean length of ICU stay was not statistically significant between the survivors (13 ± 6) and non-survivors (14 ± 5) groups (p = 0.08), [Table 6].
Table 6: Patients' descriptive data in survivors and non-survivors

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The mean intra-abdominal pressure during the 25 days of ICU stay was higher in the non-survivors group [17 (2)] compared with the survivors group [10 (3)]. In addition, the occurrence of intra-abdominal hypertension was higher in the non-survivors group group [Table 7]. On admission, the patient age (P = 0.006), APACHE II score (P = 0.001), SOFA score (P < 0.001), and the mean intra-abdominal pressure greater than 12 mmHg (P = 0.001), as well as the occurrence of intra-abdominal hypertension during ICU stay (P = 0.008), were independent predictors of mortality. In our study, two patients with intra-abdominal pressure less than 12 mmHg did not survive, whereas 39% of the patients with intra-abdominal pressure above 12 mmHg did not survive [Table 8] and [Figure 1]. The SOFA score was significantly related to occurrence of intra-abdominal hypertension during ICU stay [Figure 2] and outcome [Table 9].
Figure 1:

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Figure 2:

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Table 7: Mean intra-abdominal pressure during the 25 days in the ICU in survivors and non-survivors groups and the significance to the outcome

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Table 8: Mean intra-abdominal bladder pressure during the 25 days in the ICU in survivors and non-survivors groups (frequency)

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Table 9: Median SOFA score in the study group during the 25 days in the ICU and the signifi cance to the outcome

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  Discussion Top


Intra-abdominal hypertension, abdominal compartmental syndrome and their effect on critical illness survival are increased in recognition. In this single-center prospective study on critically ill patients, the mean age was 48 ± 13 years. There was a male predominance of 65%; median APACHE II score was 22, whereas, SOFA score on admission was 5. The mean duration of ICU stay was 14 ± 6 days; mortality in the study group was 22.5%. The cause of admission was medical in 47%, surgical in 18%, and trauma in 35%.

In this study we used intra-abdominal bladder pressure to measure intra-abdominal pressure, which was confirmed by studies to be the gold standard for measurement. We found that both the mean intra-abdominal pressure during the 25 days of ICU stay and the occurrence of intra-abdominal hypertension during the ICU stay were higher in the non-survivors group. Of the study group, 60% had a mean intra-abdominal pressure greater than 12 mmHg. On admission, the mean age, APACHE II, SOFA score, the mean intra-abdominal pressure greater than 12 mmHg, and the occurrence of intra-abdominal hypertension during ICU stay were independent predictors of mortality.

Other studies such as those by Balogh et al. [14] and Biancofiore et al. [23] also found that increased intra-abdominal pressure was a predictor of mortality, although they conducted their study on a different population with very high intra-abdominal pressure. Malbrain et al. [9]., found that intra-abdominal hypertension on the first day was not an independent risk factor for mortality, whereas the occurrence of intra-abdominal hypertension during the ICU stay was an independent risk factor for mortality However, Malbrain and colleagues measured the intra-abdominal pressure twice daily and defined the mean intra-abdominal pressure as the mean of the two daily measurements [9]; this was different from our protocol as we measured the intra-abdominal pressure every 6 h on the first day and twice daily thereafter, and the mean intra-abdominal pressure was defined as the mean of these measurements. In addition, their study was a multicentre study including a larger group of critically ill patients.

Considered to be a semi-closed compartment with reduced compliance, changes in the abdominal cavity volume cause an increase in the intra-abdominal pressure [20],[24],[25], which may lead to reduced perfusion to various organs by the direct mechanical effect and to multiorgan failure [26]. In our study, 39% of the patients with intra-abdominal pressure above 12 mmHg did not survive. The non-surviving patients had a significantly higher SOFA score on admission and during the ICU stay. An intra-abdominal pressure of greater than 20 mmHg has been shown to be critical and to cause impairment in respiratory, cardiovascular, splanchnic, neurologic, and renal functions in several studies [14],[27],[28],[29],[30]. We found that patients admitted with intra-abdominal pressure greater than 12 mmHg suffered multiple organ impairment, mainly pulmonary, renal, and liver dysfunction, which manifested as an increase in the SOFA score during the ICU stay, and if the patient did not respond to treatment this was associated with mortality. However, none of the scoring systems used in assessment of the critically ill patients include intra-abdominal pressure in its measurements, although previous studies have proven an association between increased intra-abdominal pressure and mortality in surgical and trauma patients [28],[31],[32].

In the present study, the mean length of ICU stay was not different among groups. We used a 12 mmHg cutoff value to define intra-abdominal hypertension, in accordance with the study by Malbrain et al. [9], which was based on the animal study conducted by Diebel et al. [33],[34] together with other studies who found increased risk of multi-organ affection with the increased intra-abdominal pressure, manifested as decrease urine output, cardiovascular or pulmonary dysfunctions [26],[35].

In our study group, abdominal surgery, fluid resuscitation, ileus, hemoperitonium, and the presence of more than one etiological factor were independent predictors of intra-abdominal hypertension. In addition, acidosis, coagulopathy, liver dysfunction, polytransfusion, sepsis, and a combination of more than one predisposing factor were independent predictors of intra-abdominal hypertension. The most common etiological factor was a combination of more than one cause; further, the most common predisposing factor was a combination of more than one factor. Similarly Malbrain et al. [9] found that independent predictors for the development of intra-abdominal hypertension on admission were abdominal surgery, fluid resuscitation, ileus, and liver dysfunction. Nagappan et al. [36] found that acidosis, hypothermia, polytransfusion, coagulopathy, sepsis, liver diseases, and positive-pressure ventilation predispose to intra-abdominal hypertension in both patients with surgical and non-surgical diseases of the abdomen.

High volume of fluid resuscitation increases the risk for intra-abdominal hypertension as a part of the inflammatory response that results in increased vascular permeability, sequestration of fluid, bowel edema, and decreased perfusion in the splanchnic area [17]. Liver dysfunction increase intra-abdominal pressure through the presence of ascites [37], whereas ileus causes an increase in intra-abdominal pressure through a direct mechanical effect [38],[39].

This study has some limitations; although it was a prospective cohort study, it was a single-center study and thus included only 40 patients, and it does not prove whether the increase in intra-abdominal pressure is directly or indirectly related to survival. We recommend that clinicians measure intra-abdominal pressure on the admission day in critically ill patients and daily in those with either risk factors or intra-abdominal pressure greater than 12 mmHg, as well as in those patients who suffer clinical deterioration of their condition, as intra-abdominal hypertension may be an early indicator of organ impairment; thus, early diagnostic investigation and therapeutic interventions may help improve the outcome. Further studies are warranted on the effect of volume of installed fluids and the different methods used for intra-abdominal bladder pressure measurements to improve its accuracy. We conclude that the incidence of intra-abdominal pressure greater than 12 mmHg is high in critically ill patients, and the presence on admission or the occurrence of intra-abdominal hypertension is a prognostic factor for survival during the ICU stay.


  Acknowledgements Top


Conflicts of interest

None declared.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]


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