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- •Contents
- •Contributors
- •Abbreviations
- •Foreword
- •Introduction
- •(Very) brief history of IAP
- •Further reading
- •Introduction
- •Background
- •The abdominal wall
- •The relation between IAP and IAV – compliance and elastance
- •Key points
- •Key points
- •Further reading
- •Measure IAP at the end of expiration
- •IAP is (usually) measured in the bladder
- •IAP can be measured through routes other than the bladder
- •IAP can be measured with fluid-filled or air-filled systems
- •IAP should be measured against a reference level
- •Instillation of fluid in the bladder is required
- •The temperature of the instillation fluid should be controlled
- •The patient’s body position is important
- •Supine versus semi-recumbent position
- •Prone position
- •Other positions
- •The effect of positive end expiratory pressure (PEEP) on IAP
- •Key points
- •Further reading
- •Introduction
- •Clinical estimation of IAP
- •Measurement of IAP is safe
- •Measurement of IAP is reproducible
- •Routes for IAP measurements
- •Transvesicular route
- •Transgastric route
- •Alternative routes
- •Modalities of IAP measurements
- •Available methods for IAP measurement
- •Intermittent IAP measurement
- •Transvesicular: Harahill method
- •Transvesicular: AbViserTM IAP Monitoring Kit
- •Transvesicular: Bard IAP® Monitoring Device
- •Transvesicular: Biometrix
- •Transvesicular: PreOx IAP Adapter
- •Transgastric: gastric tube or Collee method
- •Transgastric: gastric balloon method
- •Continuous IAP measurement
- •Continuous transvesicular IAP measurement
- •Continuous IAP monitoring – CiMON (Pulsion Medical Systems)
- •The IAP-Catheter and IAP-Monitor (Spiegelberg)
- •Key points
- •Further reading
- •Introduction
- •The pitfalls
- •Pitfalls related to the patient
- •Positioning of the patient
- •The awake patient
- •Intra-abdominal space-occupying lesions
- •Obesity
- •Children
- •Pitfalls related to the measurement technique
- •Zero reference level
- •Gastric route
- •Infusion volume
- •Infusion temperature
- •Frequency of IAP measurement
- •Pitfalls related to the interpretation of data
- •Key points
- •Further reading
- •What is abdominal compliance?
- •Why is abdominal compliance important?
- •Implications for clinical practice
- •How does decreased abdominal wall compliance lead to IAH?
- •Is this clinically important?
- •Can I and should I measure abdominal compliance in my patient?
- •How do I know when abdominal wall compliance is decreased?
- •How do I know when abdominal wall compliance is increased?
- •Key points
- •Further reading
- •Introduction
- •Measuring IAV
- •IAV in clinical practice
- •Is IAV relevant?
- •IAV and primary IAH
- •IAV and secondary IAH
- •Other ways in which IAV has an impact on IAH
- •Key points
- •Further reading
- •Introduction
- •Capillary dynamics
- •Capillary leak in the critically ill patient
- •IAP and the three hits model of shock
- •The ebb phase
- •The global increased permeability syndrome
- •Consequences of IAH and ACS in the patient with severe acute pancreatitis
- •When it starts to get better (day 3)
- •Key points
- •Further reading
- •Introduction
- •Why and when do patients with severe acute pancreatitis develop IAH and ACS?
- •Diagnosis of IAH and ACS in the patient with severe acute pancreatitis
- •Prevention of IAH and ACS in the patient with severe acute pancreatitis
- •Treatment of IAH and ACS in the patient with severe acute pancreatitis
- •Surgery
- •Feeding
- •When can the clinician stop considering IAH in patients with severe acute pancreatitis?
- •Key points
- •Further reading
- •Introduction
- •IAP in children
- •Normal values of IAP in children
- •Measurement of IAP in children.
- •Outcomes of IAP in children
- •IAH and ACS in children
- •Diagnosis of IAH and ACS in children
- •Management of IAH and ACS in children
- •Key points
- •Further reading
- •Introduction
- •Types of ACS in trauma patients
- •Incidence
- •The ‘bloody’ vicious circle and IAH
- •Conservative management of the patient with abdominal trauma
- •IAH in the patient with an open abdomen
- •Key points
- •Further reading
- •Introduction
- •Incidence
- •Consequences of IAH in the patient with severe burns
- •Monitoring IAP in the burn patient
- •IAH prevention in the burn patient
- •Urine output as an indicator during resuscitation of the burn patient
- •Treatment of IAH in the burn patient
- •Key points
- •Further reading
- •Introduction
- •Normal values of IAP in obese patients
- •IAP and chronic morbidity in the obese patient
- •Systemic hypertension
- •Pseudotumour cerebri
- •Respiratory morbidity
- •Incisional hernia
- •Key points
- •Further reading
- •Introduction
- •Pregnancy and IAP
- •Peritoneal dialysis and IAP
- •IAP during iatrogenic pneumoperitoneum
- •IAP in the haematological patient
- •Any other conditions leading to IAP?
- •Gastroenterology
- •Respiratory
- •Neurology
- •Cardiology
- •Gynaecology
- •Reconstructive surgery
- •Orthopaedics
- •Miscellaneous
- •Key points
- •Further reading
- •Introduction
- •Pathophysiology
- •Overall cardiovascular effects of IAH
- •IAH and preload
- •IAH and contractility
- •IAH and afterload
- •Implications for clinical practice
- •Filling pressures are inaccurate with IAH
- •What about volumetric monitoring?
- •Abdominal perfusion pressure (APP)
- •IAP and responsiveness to fluid
- •Key points
- •Further reading
- •Introduction
- •IAH and acute lung injury
- •IAH and lung distension
- •IAH and pulmonary oedema
- •IAP and mechanical ventilation
- •IAP and pulmonary hypertension
- •Key points
- •Further reading
- •Introduction
- •Incidence
- •Critical IAP in relation to renal function
- •The impact of IAH-induced kidney failure
- •Implications for clinical management
- •Diagnosis of AKI in patients with IAH?
- •Prevention of IAH-induced kidney injury?
- •How do I treat the patient with IAH-induced AKI?
- •Key points
- •Further reading
- •Introduction
- •How does IAH lead to intracranial hypertension?
- •Importance of the impact of IAH on ICP
- •Conditions associated with increased IAP and ICP
- •Implications for clinical management
- •Prevention of IAH-induced raised ICP
- •Treatment of IAH when ICP is raised
- •Key points
- •Further reading
- •The liver and IAH
- •Gastrointestinal function and IAH
- •The abdominal wall and IAH
- •Endocrine function and IAH
- •Key points
- •Further reading
- •Introduction
- •Multiple organ dysfunction syndrome
- •IAH as a marker of gastrointestinal dysfunction
- •Implications for clinical practice
- •Key points
- •Further reading
- •Introduction
- •Abdominal compartment syndrome
- •Other compartment syndromes
- •Hepatic compartment syndrome
- •Renal compartment syndrome
- •Pelvic compartment syndrome
- •Cardiac compartment syndrome
- •Intracranial compartment syndrome
- •Intraorbital compartment syndrome
- •Limbs or extremity compartment syndrome
- •Polycompartment syndrome
- •Key points
- •Further reading
- •Decreased abdominal wall compliance leads to IAH
- •Measuring abdominal compliance
- •Preventing decreased C-abd
- •Increasing abdominal wall compliance
- •Key points
- •Further reading
- •How do intraluminal contents lead to IAH?
- •Ileus and IAH
- •Enteral feed
- •Evacuation of intraluminal content
- •Surgical intervention
- •Key points
- •Further reading
- •Introduction
- •What are the causes of abdominal fluid collections leading to IAH?
- •What about more factors leading to IAH or ACS?
- •Implications for clinical management
- •Do all fluid collections require drainage?
- •How to drain abdominal fluid collections safely?
- •Which catheter should be used for draining fluid collections leading to IAH?
- •When is PCD to be avoided?
- •When does the patient need a (decompressive) laparotomy?
- •Key points
- •Further reading
- •Introduction
- •How does systemic inflammation lead to (secondary) IAH?
- •Incidence
- •Consequences of secondary IAH
- •Implications for clinical management
- •How to prevent development of secondary IAH?
- •What are the possible interventions for capillary leak syndrome?
- •How is capillary leak prevented or diminished?
- •How are fluids used in the patient at risk for IAH?
- •How is volume status and fluid responsiveness assessed in patients with IAH?
- •What fluids to use?
- •How is fluid overload associated with secondary IAH treated?
- •Key points
- •Further reading
- •Introduction
- •Octreotide in IAH
- •CNAP devices
- •Traditional Chinese medicine
- •Melatonin treatment
- •Nutrition
- •Key points
- •Further reading
- •Introduction
- •Can abdominal decompression treat ACS?
- •Is surgical decompression safe?
- •Surgery is for all patients
- •What surgical methods can be applied?
- •Should abdominal decompression be the only cure for ACS?
- •Implications for clinical management
- •When should surgical treatment be considered?
- •Can abdominal decompression be performed in the ICU?
- •What are the pitfalls when decompressing the abdomen in ACS?
- •Is decompression an option when only IAH is present?
- •Does every patient require TAC after decompressive laparotomy?
- •Key points
- •Further reading
- •Introduction
- •Characteristics of an ideal TAC
- •Negative pressure therapy measures
- •Implications for clinical management
- •What TAC technique is to be preferred?
- •Where to change the TAC
- •When to change the TAC
- •When to remove the TAC
- •Temporary abdominal closure techniques
- •Skin closure-only TAC
- •Synthetic cover-only TAC
- •Negative pressure TAC
- •Fascial approximation techniques
- •Key points
- •Further reading
- •Natural history of IAH shows that short-lived IAH can be tolerated by some patients
- •Continuous, hassle-free IAP measurement makes recognition of the problem easy
- •Prevention is better than therapy
- •Medical management is the gold standard for IAH
- •Decompressive laparotomy will no longer be a therapy for ACS
- •Open abdomen therapy is used selectively in the high-risk patient and for the shortest time possible
- •Epidemiology
- •Index



Intra-Abdominal Hypertension

CORE CRITICAL CARE
Series Editor
Dr Alain Vuylsteke
Papworth Hospital
Cambridge, UK
Assistant Editor
Jo-anne Fowles
Papworth Hospital
Cambridge, UK
Other titles in the series
Delirium in Critical Care
Valerie Page and E. Wesley Ely
ISBN 9780521132534
Forthcoming titles in the series
Clinical Information Systems in Critical Care
Cecily Morrison, Matthew R. Jones and Julie Bracken
ISBN 9780521156745
Renal Replacement Therapy in Critical Care
Patrick Honoré and Oliver Joannes-Boyau
ISBN 9780521145404

Intra-Abdominal
Hypertension
MANU MALBRAIN, MD, PHD
Ziekenhuis Netwerk Antwerpen (ZNA) Stuivenberg, Antwerp.
He is an ESICM Chris Stoutenbeek Award winner and the
Founding President of The World Society of the Abdominal
Senior Lecturer at Ghent University and intensivist
Director of ICU and High Care Burn Unit,
Compartment Syndrome (WSACS).
JAN DE WAELE, MD, PHD
at Ghent University Hospital, Ghent.
He is President of the WSACS (2013–2015).

University Printing House, Cambridge CB2 8BS, United Kingdom
Cambridge University Press is part of the University of Cambridge.
It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.
www.cambridge.org
Information on this title: www.cambridge.org/9780521149396
© Manu Malbrain and Jan De Waele 2013
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2013
Printed in the United Kingdom by CPI Group Ltd, Croydon CR0 4YY
A catalogue record for this publication is available from the British Library
Library of Congress Cataloging in Publication data
Malbrain, Manu, 1965–
Intra-abdominal hypertension / Manu Malbrain, Jan De Waele.
p. ; cm. – (Core critical care)
Includes bibliographical references.
ISBN 978-0-521-14939-6 (pbk.)
I. De Waele, Jan II. Title. III. Series: Core critical care.
[DNLM: 1. Intra-Abdominal Hypertension. WI 900]
RC691
0
3–dc23
616.1
2013005145
ISBN 978-0-521-14939-6 Paperback
Cambridge University Press has no responsibility for the persistence or
accuracy of URLs for external or third-party internet websites referred to
in this publication, and does not guarantee that any content on such
websites is, or will remain, accurate or appropriate.
Every effort has been made in preparing this book to provide accurate and
up-to-date information which is in accord with accepted standards and practice
at the time of publication. Although case histories are drawn from actual cases,
every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors and publishers can make no warranties that the
information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors,
editors and publishers therefore disclaim all liability for direct or consequential
damages resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the
manufacturer of any drugs or equipment that they plan to use.

CONTENTS
List of contributors page viii
List of abbreviations x
Foreword xiii
Section 1 Understanding intra-abdominal
hypertension: what
to worry about? 1
1 What is intra-abdominal pressure? 3
2 Definitions 14
3 Principles of IAP management 25
4 Systems available to measure IAP 34
5 Pitfalls of IAP monitoring 52
Section 2 Underlying predisposing conditions:
when to worry? 57
6 Decreased abdominal compliance 59
7 Increased abdominal content 69
8 Capillary leak and fluid resuscitation 76

vi Contents
Section 3 Specific conditions: when to worry more? 91
9 Pancreatitis 93
10 Children 100
11 Trauma 106
12 Burns 112
13 Obesity 118
14 Pregnancy and others 122
Section 4 Consequences of intra-abdominal
hypertension: why to worry? 129
15 Cardiovascular system and IAH 131
16 Respiratory system and IAH 141
17 Renal system and IAH 147
18 Central nervous system and IAH 153
19 Other organs and IAH 159
20 How to define gastrointestinal failure? 164
21 Polycompartment syndromes 170
Section 5 Treatment 179
22 Improvement of abdominal wall compliance 181
23 Evacuation of intraluminal contents 185
24 Evacuation of abdominal fluid collections 189
25 Correction of capillary leaks and fluid balance 194

Contents vii
26 Specific treatments for IAH and ACS 204
27 Surgical treatment 212
28 Open abdomen management and temporary
abdominal closure 219
Section 6 The future 227
29 The future of IAH and ACS 229
Index 234

CONTRIBUTORS
Definitions (Section 1)
MICHAEL L. CHEATHAM Department of Surgical
Education, Orlando Regional Medical Center, Orlando,
FL, USA
Principles of IAP Measurement (Section 1), Specific
Treatments (Section 5)
BART L. DE KEULENAER Department of Intensive Care,
Fremantle Hospital, WA, Australia
Decreased Abdominal Compliance (Section 2), Increased
Abdominal Content (Section 2), Central Nervous System
(Section 4), Renal System (Section 4), Improvement of
Abdominal Wall Compliance (Section 5), Correction of
Capillary Leak (Section 5)
INNEKE DE LAET Department of Intensive Care, Ziekenhuis
Netwerk Antwerpen, ZNA Stuivenberg, Antwerpen,
Belgium
Capillary Leak and Fluid Resuscitation (Section 2)
MICHAEL FRANCIS DITILLO AND LEWIS J. KAPLAN Department
of Surgery, Yale University School of Medicine, New Haven,
CT, USA
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