news on intra-abdominal hypertension – focus on fluids and hemodynamics
TRANSCRIPT
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News on intra-abdominal
hypertension – focus on fluids and
hemodynamics
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World Society of the Abdominal Compartment Syndrome Secretary – Inneke De laet President – Jan De Waele
Conflicts of interest
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Fluids and intra-abdominal pressure (IAP): what’s
new?Inneke De laet
ZNA Stuivenberg
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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
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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
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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.
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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
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WSACS medical management algorithm
www.wsacs.org
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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
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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
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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
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Limiting crystalloid resuscitation
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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
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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
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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
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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?
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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
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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
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Choice of fluids: plasma?
Wang MD et al. Chin Med J (Engl) 2013 May: 126(10): 1987-8
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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
Choice of fluids: plasma?
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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
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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
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Removing excess fluid
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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
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Can diuretics be used?
Pro: Can achieve fluid removal
Questions: Renal function? Will injured kidney(s) respond? Haemodynamic tolerance?
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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
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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
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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
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PAL treatment and outcome
Cordemans C et al. Ann Intens Care 2012, 2(Suppl 1): S15
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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)
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In patients with IAH and negative fluid balance, IAP was significantly decreased after 24h of bumetanide (difference -1.32mmHg ± 0.50, p<0.001)
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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
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If the diuretics don’t work
Mullens et al. J Card Fail 2008; 14 (6): 508-514
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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
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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