Ipertensione addominale:intervento diagnostico-terapeutico

F. Cavaliere

U.C.S.C., Rome

Pressione intra-addominale:la palpazione non è uno strumento adeguato

Prospective, blinded trial - Staff physician judgment

Results: < 50% of the time was the clinician able to determine when IAP was elevated.

Kirkpatrick AW, Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients? Can J Surg, 43, 207, 2000

Come misurare la pressione addominale

Diametro sagittale addominaleKahn and Pavkov, 2011

Pressione nella vena femorale De Keulenaer BL et al, 2011

Pressione intragastrica Chiumello D, 2011

Gold standard:Pressione vescicale

Studies should adopt the trans-bladder technique as the standard IAP measurement

We recommend use of protocolized monitoring and management of IAP versus not

La pressione vescicale va misurata:

• col trasduttore vicino alla cresta iliaca a livello della linea medio-ascellare

• 30 – 60 secondi dopo aver iniettato in vescica meno di 25 mL di SF

• esprimendola in mmHg

(1 mmHg = 1.36 cmH2O)

La pressione vescicale va misurata…

IAP

a fine espirazione

In posizione supina

iniettando in vescica meno di 25 mL di SF

Inclinazione del letto

Abdominal compartment syndrome (ACS)

Una sindrome definita come:

• una pressione endoaddominale stabilmente sopra 20 mmHg

• associata ad una o più disfunzioni d’organo

MalbrainML, CheathamML, Kirkpatrick A, et al. Results fromthe international conference of experts on intra-abdominalhypertension and abdominal compartment syndrome. I.Definitions. Intensive Care Med 2006;32:1722e1732.

Ipertensione addominale & sindrome compartimentale addominale

Abdominal compartment syndrome

• Primaria (causa primaria addominale)

– Rottura di aneurismi dell’aorta addominale, traumi addominali, emorragie retroperitoneali

– Ascite massiva, rumori ovarici giganti, ematomi rettali

• Secondaria (causa extra-abdominale)

– Politrauma

– Ustioni gravi

– Infusioni massive

• Terziaria (ricorrente)

Carr JA, J Am Coll Surg 2013

Due pazienti che hanno sviluppato l’ACS durante ECMO A-V

• Grave ipotensione arteriosa dopo 72 ore di ECMO• Migliomento dopo laparotomia per sospetta ischemia intestinale• Pressione addominale dopo la laparotomia 19 mmHg

• Grave ipotensione arteriosa dopo 36 ore di ECMO• Pressione addominale 35 mmHg• Exitus prima della laparotomia decompressiva

Aspetto comune è stata l’infusione massiva di fluidi per mantenere flussi ematici adeguati

IAP > 12 mmHg per oltre 4 ore

69 pazienti sottoposti a cardiochirugia elettiva

23 (31.8%) hanno developed the IAH group

We recommend measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or injured patient

updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome

• high BMI

• abdominal surgery

• liver dysfunction/ascites

• hypotension/vasoactive therapy

• respiratory failure

• excessive fluid balance

Carr JA, J Am Coll Surg 2013

Holodinsky JK, et Al. Crit Care 17, R249, 2013

Risk factors for intra-abdominal hypertension and abdominal compartment syndrome

IAH9 studies1519 pts

ACS6 studies974 pts

Imaging in IAH: CT or sonographic findingsin 21 patients with proved ACS

Patel A et al: Abdominal compartment syndrome. AJR Am J Roentgenol 2007; 189:1037-1043

Anteroposterior and lateral IVC diameters in bowel obstruction

Cavaliere F, Biomed Res Int, 2013

Renal resistance

RI = Resistive Index

peak systolic velocity – end diastolic velocity

peak systolic velocity

Normal value < 0.70

Abnormal values may suggest:

•Increased vascular resistance

•Increased intrarenal pressure

CVP and PCWP increase due to pressure transmission across diaphragm

–Transmural PAOP = PAOP -0.5*IAP

–Transmural CVP = CVP -0.5*IAP

IAH and the cardiovascular system

IAH: Management 2013

Trattamentomedico

Monitoraggio IAP (ogni 4 ore)

Trattamentochirurgico

A. Evacuate intraluminal contents

Patofisiologia dell’ileo dinamico

Madl C, Druml W, Best Pract & Res Clin Gastroenterol 17, 445, 2003

Pseudo-obstruction in the critically ill

• reflex motor inhibition in response to noxious stimuli

• excess sympathetic (inhibitory) motor input (intestine does not contract);

• excess parasympathetic (excitatory) motor input (intestine does not relax)

• decreased parasympathetic (excitatory) motor input (intestine does not contract)

• excess stimulation by endogenous or exogenous opioids;

• inhibition of nitric oxide (NO) release from inhibitory motoneurons (intestine does not relax)

Delgado-Aros S, Camilleri M, Best Pract & Res Clin Gastroenterol 17, 427, 2003

Impiego di procinetici

Prostigmine 0.4-0.8 mg/h for 24 hours(van der Spoel JI, 2001)

Prostigmine 2 mg in 3-5 min (Ponec RJ, 1999)

The WSACS SUGGESTS that neostigmine may be used for the treatment of establised colonic ileus not responding to other simple measures and inducing IAH (GRADE 2D).

Contraindications:• heart rate <60 bpm• systolic blood pressure < 90 mmHg• active bronchospasm• serum creatinine concentration > 3 mg/dl• signs of bowel perforation.

Evacuazione del contenuto intestinale

• Altri procinetici:

metoclopramide, cisapride, eritromicina, antagonisti degli oppioidi, clisteri evacuativi, lassativi

• Farmaci da evitare perché riducono la perfusione intestinale:

adrenalina, noradrenalina, dopamina, vasopressina

• Riduzione o sospensione della nutrizione enterale

Madl C, Druml W, Best Pract & Res Clin Gastroenterol 17, 445, 2003

B. Evacuate intra abdominal space - occupying lesions

C. Improve abdominal wall compliance

C. Improve abdominal wall compliance

Sturini, Int Care Med 2008

L’ampiezza delle variazioni della pressione endoaddominale durante ventilazione

meccanica sono indicative della compliance

C. Improve abdominal wall compliance

Possibile impiego di miorilassanti

De Waele, Crit Care Med 2003

Kimball, WCACS 2007No recommendations by WSACS guidelines

D. Optimize fluid administration

1. Impiego del rapporto 1:1 trasangue e plasma

2. Impiego di colloidi Vs cristalloidi

3. Bilancio in parità dalla 3^ giornata

4. Diuretici / CVVHDF

No recommendations by WSACS guidelines

E. Optimize systemic and regional perfusion

Abdominal perfusion pressure:

APP = MAP - IAP

It seems prudent to maintain APP above 60 mmHg, although hard prospective evidence for this statement is still lacking

Malbrain MLNG, Best Practice & Research Clinical Anaesthesiology 2013

No recommendations by WSACS guidelines

Does patienthave primary

ACS?

Patient hassecundary or recurrent ACS

Is IAP > 20mmHg with progressive organ failure ?

Perform/reviseabdominal

decompression withtemporary abdominal

closure

No

Yes

Yes

Yes

Se la risposta alla terapia medica è insufficiente non va perso tempo!

Grazie per l’attenzione