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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1126_Библиотеки_им_академика_М_И_Перельмана
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34
Figure 18. Patient mounted view of the device and close up of the manifold and conical connection pieces.
Reprinted with permission from ref. 1: Malbrain ML. Different techniques to measure intra-abdominal
pressure (IAP): Time for a critical reappraisal. Intensive Care Med 2004; 30(3):357-371.
Abdominal Compartment Syndrome
stopcock are then turned “on” to the patient, and thus turned “off” to IV tubing and the
syringe. The third stopcock already being turned “on” to the transducer and patient allows then
immediate IAP reading on the monitor (Fig. 18).
In case of a damped signal the flush test should be repeated. After correct reading the third
stopcock is turned “on” to the patient and “off” to the transducer, the clamp is removed, the
bladder allowed to drain, and the volume of saline utilised is subtracted from the patient’s urine
output for that hour.
Sugrue described a similar modified closed system for repeated measurements via the bladder using a T-piece bladder pressure device.
35
Firstly, it is important to observe universal precautions and aseptic techniques at all times. The patient requires a urinary catheter. After removing the giving set from the transducer, prime the transducer with sterile saline solution,
ensuring all air bubbles are removed. Connect to the side port on the bladder T-piece and turn
the white tap “off”.
Clean the urinary catheter and drainage tubing connection with alcohol. Insert the bladder
T-piece pressure device between the catheter and drainage tubing. The drainage tubing needs
to be clamped. This can be achieved by bending it over and inserting into the barrel of a 10 mL
syringe.
50 mLs of sterile saline solution is then injected into the bladder. Connect the pressure
monitoring cable to the transducer. Select the appropriate label on the monitor. The patient
should be supine for the IAP measurements. The transducer is placed in line with the iliac
crest, at the mid axillary line. This position should be marked with a reference line in order to
reduce intra- and inter-observer variability. Next the pressure transducer needs to be zeroed.
Turn the tap “off” to the patient and zero the transducer. “Open” the tap to the patient and
35Intra-Abdominal Pressure Measurement Techniques
monitoring system in order to get the reading. When the reading has been recorded unclamp
the 10 mL syringe from the drainage tubing and remember to deduct 50 mLs from the next
hour’s urine output measurement. We will now show a step by step explanation for this technique illustrated with photographs (Fig. 19, steps 1-8).
Advantages and Disadvantages
It has the same inconveniencies related to a fluid-filled system as described with the Kron,
Iberti or Cheatham technique. This technique has the same advantages as the Cheatham technique with a required nursing time less than 2 minutes per measurement, a minimized risk of
urinary tract infection and sepsis since it is a closed sterile system, the possibility of repeated
measurements and reduced cost. Since it is a needle-free system it does not interfere with the
culture aspiration port and the risk of injuries is absent. This technique can be used for screening or for monitoring for a longer period of time (2 to 3 weeks).
The Revised Closed System Continuous Measurement Technique
(Malbrain and Sugrue)
1
In an anuric patient continuous IAP recordings are possible via the bladder using a closed
system connected to the Foley catheter after the culture aspiration port or directly to the Foley
catheter using a conical connection piece connected to a standard pressure transducer via pressure tubing (Fig. 20).
After initial “calibration” of the system with 50 mL of saline and zeroing at the sypmhysis
pubis the transducer is taped at the symphysis or thigh and a continuous IAP reading can be
obtained. Daily calibration can be done in oliguric patients after voiding of rest diuresis.
Description
Size 18 F standard three-way catheters is inserted into the patient. The continuous IAP
measurement was performed via the irrigation port of the three-way catheter, in which continuous sterile normal irrigation was maintained at 2 mL/h and connected through a two-way
stopcock and normal saline filled tubing to a pressure transducer placed in-line with the iliac
crest at the mid axillary line. The transducer is zeroed and the continuous IAP measurement is
recorded on the bedside monitor.
Advantages and Disadvantages
This technique does not require any major change in the present practice apart from the use
of three-way urinary catheters. The monitoring is continuous and does not interfere with the
urinary flow through the drainage port of the catheter. This also reduces the potential risk for
urinary tract infection. The continuous measurement of IAP also makes it possible to monitor
the abdominal perfusion pressure (APP). This method has the advantage in that it includes the
patient’s hemodynamics to a certain extent. This method is also time saving for nursing and
medical staff. One of the disadvantages of this method is the price difference between the
two-way and three-way Foley catheters.
Intermittent IAP Measurement with the AbViser™ (Wolfe Tory)
Description
The AbViser™ is a sterile two-way valve that is placed between the Foley catheter and the
urine collection bag (www.wolfetory.com). One side of the valve is connected to the drainage
tubing and the other side to a 3-way stopcock and pressure transducer via arterial pressure
tubing. The 3-way stopcock is then connected to an infusion syringe and saline infusion bag
via a double check valve. Between IAP measurements urine can drain freely trough the AbViser™
valve in the “drain” position. When doing an IAP measurement the AbViser™ valve is turned
into the “measure” position, 50 mL of sterile saline is aspirated from the saline infusion bag and
injected into the bladder via the double check valve. Then the IAP can be read on the monitor
screen (Fig. 21).
36
Abdominal Compartment Syndrome
Figure 19. Step 1) Preparation showing a close up of
the T-piece and pressure transducer used for IAP
monitoring. Step 2) Close-up of the T-piece inserted in sterile conditions between the standard
Foley catheter and the urinary drainage system. Step
3) A 2- or 3-way stopcock is connected to the free
Luer-lock connection of the mounted T-piece, arterial pressure tubing is connected to the pressure
transducer. Step 4) Close up of the mounted T-piece
and pressure transducer. Step 5) Instillation of 50
1
mL of sterile saline solution with the urinary catheter clamped distal to the culture aspiration port.
Figure continued on next page.
2
3
4
5
Figure 19. Continued. Step 6) IAP measurement
showing T-piece, pressure transducer and urinary
catheter. Step 7) The pressure transducer is positioned at the midaxillary line and the reference point
is marked to reduce inter- and intra-observer variability. Step 8) The transducer is positioned and
zeroed with the patient in the supine position and
the actual reading is shown on the monitor. In this
patient with temporary abdominal closure the IAP
value was 9 mm Hg.
37Intra-Abdominal Pressure Measurement Techniques
6
7
8
Advantages and Disadvantages
This technique allows IAP measurements to be performed in a more consistent, standardized way, basically it resembles the modified techniques allowing repeated measurements with
a T-piece or ramp with stopcocks as presented above. It has however all other inconveniences
that come with any fluid filled system. Although it is much more expensive, it does not allow
IAP measurements to be performed that are more accurate and reproducible than the other
intermittent techniques, since it is practically based on the same principles. Furthermore until
now no clinical data is available.
Conclusion
In conclusion, if one wants to use IBP as estimate for IAP the Cheatham or revised techniques are preferred over the Kron or Iberti technique. The revised methods for IAP measurement via the bladder maintain the patient’s Foley catheter as a closed system, limiting the risk
of infection. Since these are needle-free system they also avoid the risks of needle stick injury
38
Figure 20. Close up view of a closed needle-free system for continuous intra-abdominal pressure measurement in an anuric patients, using a conic connection piece (Conical Connector with female or male lock
fitting, B Braun, Melsungen, Germany, REF: 4896629 or 4438450) connected to a standard pressure
transducer via pressure tubing. Reprinted with permission from ref. 1: Malbrain ML. Different techniques
to measure intra-abdominal pressure (IAP): Time for a critical reappraisal. Intensive Care Med 2004;
30(3):357-371.
Abdominal Compartment Syndrome
Figure 21. IAP measurement with the AbViser™.
39Intra-Abdominal Pressure Measurement Techniques
Figure 22. The classic manometer technique.
and overcome the problems of leakage and catheter knick in the method described by Cheatham.
They are more cost-effective, and facilitate repeated measurements of IAP.
Manometry
The Classic Technique (Malbrain and Harrahill)
Description
A quick idea of the IAP can also be obtained in a patient without a pressure transducer
connected by using his own urine as transducing medium, first described by nurse Harrahill.
One clamps the Foley catheter just above the urine collection bag. The tubing is then held at a
position of 30 to 40 centimetres above the symphysis pubis and the clamp is released (Figs. 22,
23).
2,17,36
2,17,36
Figure 23. Patient set-up of the classic manometer technique.
40
Figure 24. The U-tube manometer technique.
Abdominal Compartment Syndrome
The IAP is indicated by the height (in cm) of the urine column from the pubic bone. The
meniscus should show respiratory variations. This rapid estimation of IAP can only be done in
case of sufficient urine output. In an oliguric patient 50 mL saline can be injected as priming.
Advantages and Disadvantages
It has all the inconveniencies that come along with a fluid-filled system as described before.
However since it is needle-free it poses no risks for injuries. It allows repeated measurements, is
very inexpensive and fast with minimal manipulation. Harrahill has described a technique,
which is a simpler method of IAP measurement. It resembles central venous pressure manometry performed in the days before transducers. This technique has the advantage that it can be
performed by any member of the health care team at the bedside, and also outside an intensive
care location. The diagnosis of raised IAP can be made quickly and easily. This technique also
has the potential of being available worldwide. It is a cheaper method and would be suitable for
resource limited countries. However, care must be taken to ensure that the urinary catheter
system used has an air inlet to avoid the generation of erroneously high pressures due to a
closed system. If no air-inlet is available the drainage system needs to be disconnected probably
increasing the risk of infection. When using this technique a conversion has to be made from
cm H
O to mm Hg and introduces the potential risk for error.37 Since the volume reinstilled
2
into the bladder is not constant raising questions on accuracy and reproducibility, it has limited
clinical implications.
The U-Tube Technique (Lee)
38
Description
In a recent animal study Lee and coauthors compared direct insufflated abdominal pressure
with indirect bladder, gastric and inferior vena cava pressures.
38
IBP was measured by both the
standard and U-tube technique (Fig. 24).
With the U-tube technique, the catheter tubing was raised approximately 60 cm above the
animal to form a U-tube manometer, and IBP was measured as the height of the meniscus of
urine from the pubic symphysis. The authors found a good correlation between the U-tube
pressure and other direct and indirect techniques.
Advantages and Disadvantages
It has the same advantages and inconveniences as the classic “Harrahill” technique, as with
the previous technique the clinical validation is poor. The major advantage of this technique is
that the volume reinstilled into the bladder is more stable (but still not well defined) so it can
be used as a quick screening method.
41Intra-Abdominal Pressure Measurement Techniques
Figure 25. FoleyManometer first and second generation prototypes. ©Holtech Medical. Reprinted with
permission from ref. 1: Malbrain ML. Different techniques to measure intra-abdominal pressure (IAP):
Time for a critical reappraisal. Intensive Care Med 2004; 30(3):357-371.
The FoleyManometer Technique (Holtech)
1,39
Description
In 2002 we tested a prototype (Holtech Medical, Copenhagen, Denmark, www.holtechmedical.com) for IAP measurement using the patients’ own urine as pressure transmitting
medium.
1,39
A 30 mL container fitted with a bio-filter for venting is inserted between the Foley
catheter and the drainage bag (Figs. 25-33).
The container fills with urine during drainage; when the container is elevated, the clamp
between the FoleyManometer and the biofilter is released and 30 mL urine flows back into the
patient’s bladder. The zero-reference mark is directly positioned at the symphysis pubis and
IAP can be read from the position of the meniscus in the clear manometer tube between the
container and the Foley catheter. This manometer tube has units in mm Hg (initially in cm
H
O) (Fig. 28).
2
We found a good correlation between the IAP obtained via the FoleyManometer and the
“gold standard” in 119 paired measurements (R
2
= 0.71, p<0.0001). The analysis according to
Figure 26. Urine drainage and IAP measurement with first FoleyManometer prototype.
42
Figure 27. Drainage with second FoleyManometer prototype.
Figure 28. Close up view of the fourth generation FoleyManometer.
Figure 29. Patient mounted view of the
FoleyManometer inserted between the Foley
catheter and the urinary drainage bag.
Abdominal Compartment Syndrome
Figure 30. Bed mounted view on the
FoleyManometer, note the horizontal position
of the drainage tubing, preventing intermittent
blocking of urine flow and incomplete bladder
emptying.
Figure 31. IAP measurement with FoleyManometer.
43Intra-Abdominal Pressure Measurement Techniques
Figure 32. Close up view of the urine column and meniscus. In this patient the IAP was 12 cm H
version of the FoleyManometer units are in mm Hg so that
conversions from cm H
sary.
O to mm Hg is no longer neces-
2
O. In the latest
2
Bland and Altman showed that both measurements were almost identical with a mean bias of
0.17±0.8 (SD) mm Hg (95% CI 0.03 to 0.3).
Advantages and Disadvantages
The FoleyManometer has no major disadvantages. It allows repeated measurements, is very
cost-effective and fast with minimal manipulation, and the 0 mm Hg pressure reference at the
symph. pubis is confirmed at each IAP determination. Product refinement and multicentric
validation has been done so that this technique can be used in a clinical setting.
Conclusion
The manometry techniques give a rapid and cost-effective idea of the magnitude of IAP and
may be as accurate as other direct and indirect techniques. They can easily be done 2-hourly
together with and without interfering with urine output measurements. Moreover, the risk of
infection and needle stick injury is absent. Multicentre validation is currently undertaken,
making them ready for general clinical usage.
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