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44
Abdominal Compartment Syndrome
Figure 33. FoleyManometer instructions.
Stomach
The Classic Intermittent Technique (Collee)
Background and Description
The IAP can also be measured by means of a nasogastric or gastrostomy tube and this
method can be used when the patient has no Foley catheter in place, or when accurate bladder
pressures are not possible due to the absence of free movement of the bladder wall.
Basically it is the same technique as described by Kron but applied to the stomach. A normal nasogastric tube is inserted into the stomach (PharmaPlast Duodenal Tube Levin, 14 F
40,41
45Intra-Abdominal Pressure Measurement Techniques
Figure 34. The classic Collee technique.
122 cm, Maersk Medical A/S, Denmark) (Fig. 34). The intragastric position of the tube is
confirmed by aspiration of gastric juice, auscultation of air insufflation into the stomach, portable chest/upper abdomen X-ray, and confirmation of a rise in IAP following external epigastric pressure.
A three-way stopcock is connected to the nasogastric tube, one end is connected to a pressure transducer via arterial tubing and the other end is connected to a infusion bag of 1000 mL
saline. All air is aspirated from the stomach and 100 mL of saline is injected. The transducer is
zeroed at the midaxillary line with the patient in the supine position and IAP is read
end-expiratory.
In case of head elevation, bladder trauma, peritoneal adhesions, pelvic haematomas or fractures, abdominal packing, a contracted or neurogenic bladder, IBP may overestimate IAP, and
the procedure used for the bladder can then be applied via the stomach.
40,41
Advantages and Disadvantages
Same inconveniences as with every fluid-filled system. Another disadvantage is that gastric
pressures might interfere with the migrating motor complex or with nasogastric feeding. Furthermore all air needs to be aspirated from the stomach before measuring IAP, something that
is difficult to verify.
The advantages are that it is cheap, does not interfere with urine output, and the risk for
infection and needle-stick injuries is absent. This cost-effective technique is ideal for screening.
The Semi-Continuous Technique with a Tonometer (Sugrue)
42,43
Background and Description
Sugrue and coauthors assessed the accuracy of measuring simultaneous IBP and IAP via the
balloon of a gastric tonometer during laparoscopic cholecystectomy.
42
They found a good cor-
relation between both methods. This technique allows to obtain a trend.
A pressure volume curve of the gastric tonometer balloon at 37˚C was obtained to confirm
that instillation of 3 mL of air allows the balloon to act as a pressure transducer. Each balloon
was individually checked prior to insertion. A gastric tonometer with a balloon attached was
inserted in all patients (“TRIP” TGS tonometry catheter, 16 F with stopcock 122 cm x 5.3
mm, Tonometrics Inc, Bethesda, USA and Datex-Engstrom Division, Instrumenatrium Corp,
Helsinki, Finland). The intragastric position of the tonometer will be confirmed by aspiration
of gastric juice, auscultation of air insufflation into the stomach, portable chest/upper abdomen X-ray, and confirmation of a rise in IAP following external epigastric pressure. To measure
46
Figure 35. The tonometer technique.
Abdominal Compartment Syndrome
regional pCO2 and intramucosal pH the balloon is filled with 6 mL of air and is distended and
measurements are obtained via a tonocap monitor (Fig. 35).
To read IAP, 3 mL of air is withdrawn of the tonometer balloon immediately after a pCO2
sampling cycle by turning the stopcock from “syringe off ” to “T-piece off ” and aspirating 3
mL of air from the balloon. Then the stopcock is turned back to “syringe off” and IAP is read
end-expiratory after zeroing of the transducer at the mid-axillary line with the patient in the
supine position. To measure prCO2 again the stopcock is turned to “T-piece off” again and
the 3 mL of air are reinjected into the balloon. The stopcock is then turned to “syringe off” for
measuring pCO2.
We recently validated these results and found good correlation between the classic gastric
method, the tonometer method and IBP.
43
Simultaneous IAP via the tonometer (IAPtono)
and PrCO2 measurement was also possible (Fig. 36).
Advantages and Disadvantages
Measurement via the tonometer balloon limits the risks and has major advantages over the
standard intravesical method: no infection risk and no interference with estimation of urine
output. Simultaneous measurement of IAP and PrCO
is possible, however only in an inter-
2
mittent way. Since it is air-filled it has none of the disadvantages associated with fluid-filled
systems: no problem with zero-reference, over- or underdamping or body position. A possible
disadvantage is the effect on interpretation of IAP values by the Migrating Motor Complex.
Recording the “diastolic” value of IAP at end-expiration can solve this problem (Fig. 36). Other
problems are that a 5 mL glass syringe is needed and that no data is available on effects of
enteral feedings on these IAP measurements. This technique could be used for study purposes
and clinicians interested in simultaneous PrCO
The Revised Semi-Continuous Technique (Malbrain)
, pHi and IAP monitoring.
2
1
Description
An oesophageal balloon catheter is inserted into the stomach (Oesophageal balloon catheter
set, adult size with PTFE coated stylet, Ackrad Laboratories, Inc, Cranford NJ, USA REF:
47Intra-Abdominal Pressure Measurement Techniques
Figure 36. Simultaneous IAP tracings obtained from the stomach via a tonometer balloon (IAPtono) and
via the bladder (IAPves). Respiratory and ECG artefacts are more pronounced in the stomach due to
proximity of the heart and lungs. Correct IAP should be read at end-expiration.
47-9005, see at www.ackrad.com/products/c-balloon_catheter.cfm or Compliance catheter
female or male, International Medical Products BV, Zuthpen, Netherlands, distributed by Allegiance, REF: 84310). The intragastric position of the tube is confirmed by portable chest/
upper abdomen X-ray, and confirmation of a rise in IAP following external epigastric pressure
or by a rapid oscillation test. When the balloon is correctly in the stomach, the whole respiratory IAP pressure wave will be positive and the positive pressure will increase upon inspiration
with a functional diaphragm. If the balloon is too high in the thorax the pressure will flip from
positive to negative on inspiration measuring oesophageal or pleural pressure instead of IAP.
The preferred position for the procedure is to place the patient in a 30˚ Fowler position. The
catheter is advanced to the 55-60 cm marks which places the balloon in the stomach (the
International Medical Products catheter has no marks) (Figs. 37, 38).
A standard 3-way stopcock is connected to the now “nasogastric” tube and one end is connected to a pressure transducer via arterial tubing. All air is evacuated from the balloon with a
glass syringe and 1 mL of air reintroduced to the balloon. A glass syringe is recommended to
minimize the risk of pulling a negative pressure inside the catheter prior to reintroducing the 1
mL air. The negative pressure will use up much of the volume and the balloon may not get
enough air to get inflated. The balloon is connected via a “dry” system to the transducer, the
transducer itself is NOT classically connected to a pressurized bag and NOT flushed with
normal saline in order to avoid air/fluid interactions. The transducer is zeroed to atmosphere
and IAP is read end-expiratory. By using this technique the cost of IAP is further reduced
depending on the catheter used, moreover a semi-continuous trend can be obtained (Fig. 39).
Advantages and Disadvantages
A disadvantage is that the air in the balloon gets resorbed after a couple of hours, so that
“recalibration” of the balloon is necessary with a 2 to 5 mL glass syringe for continuous
48
Figure 37. The revised semi-continuous technique. 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
measurement, this might cause inaccurate measurement if the nurse waits too long for
recalibration or if the reinstilled volume is not exactly the same as the previous one. It is less
time-consuming and has all the advantages of an air-filled system (cfr tonometer). By using this
technique the cost of IAP is further reduced depending on the catheter used. Moreover, a
semi-continuous measurement of IAP as a trend over time is possible. The oesophageal balloon
catheter price ranges from €15 (International Medical Systems, The Netherlands) to €55
(Ackrad, USA). This technique is ideal for monitoring for a longer period of time, however
when using multiple tubes the risk of sinusitis or infection needs to be evaluated in the future.
The Continuous Fully-Automated Technique (Spiegelberg)
Description
IAP Measurement with the Air-Pouch System (www.spiegelberg.de). The IAP-Catheter is
introduced like a nasogastric tube, it is equipped with an air pouch at the tip. The catheter has
one lumen that connects the air-pouch with the IAP-Monitor and one lumen that takes the
guide wire for introduction. The pressure transducer, the electronic hardware, and the device
for filling the air-pouch are integrated in the IAP-Monitor. On the digital display the mean
pressure and the amplitude of the pressure wave are shown. At the monitor output both the
mean pressure and the pulsatile signal are available. Once every hour the IAP-Monitor opens
the pressure transducer to atmospheric pressure for automatic zero adjustment. The air-pouch
is then filled with the exact air volume required for accurate pressure transmission (about 0.1
Figure 38. Close-up view of the esophageal balloon catheter.
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.
49Intra-Abdominal Pressure Measurement Techniques
Figure 39. A trend of 24 hour IAP and APP recordings obtained with an esophageal balloon placed in the
stomach (Ackrad). Note the resorption of air after a couple of hours with loss of IAP signal, confirming the
need for recalibration. 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.
mL). Initial validation in ICU patients and laparoscopic surgery showed good correlation with
the standard IBP method (Fig. 40).
44
The IAP-Monitor can be used in a stand-alone fashion, with an ICU monitor, or with the
Spiegelberg: APP-Monitor. The guide wire is coated with PTFE for easy introduction. The
IAP-Catheter is supplied sterile for single use (Figs. 41-46).
Recently Schachtrupp and coauthors used the same technique to directly measure IAP in a
porcine model and found a very good correlation between the air pouch system and direct
insufflator pressure (R
ment (-4.5 to 5.4 mm Hg) (Fig. 47).
2
0.99) with a mean bias of 0.5±2.5 mm Hg and small limits of agree-
45
Advantages and Disadvantages
This technique has no major disadvantage except that validation in humans is still in its
infant stage. The advantages are those related to other gastric and air-filled methods. In summary it is simple, fast, accurate, reproducible, and fully automated, so that a real continuous
24 hour trend can be obtained (Figs. 43, 45). This technique is not suited for screening but is
best for continuous fully automated monitoring for a long period of time. Since it is less prone
to errors and most cost-effective if in place for a longer period of time this technique has a lot
of potential in becoming the future standard for multicentre research purposes. Recently another device (the CiMON, Fig. 48) became commercially available allowing simultaneous measurement of both intrathoracic and intragastric pressure (www.pulsion.com).
Conclusion
The revised methods via the stomach have the advantage to be free of interference caused by
wrong transducer positions since they do not need the creation of a conductive fluid column as
they use air as transmitting medium. The last described fully automated technique (Spiegelberg
and CiMON) also gives a continuous tracing of IAP together with abdominal perfusion pressure (APP) in analogy with intracranial pressure and cerebral perfusion pressure, allowing both
parameters to be monitored as a trend over time. The APP is calculated by substracting IAP
from the mean arterial blood pressure. Recent data showed the importance of APP as a superior
50
Abdominal Compartment Syndrome
Figure 40. The Spiegelberg IAP catheter.
marker in IAH to titrate better our resuscitation in patients with IAH and ACS hence avoiding
end-organ failure and associated morbidity and mortality.
Rectal Pressure
47
17,46
Description
Rectal pressures are used routinely as estimate for IAP during urodynamic studies to calculate the transmural detrusor muscle pressure as IBP minus IAP.
47,48
Rectal pressures can be
obtained by means of an open rectal catheter with a continuous slow irrigation (1 mL/min),
but special fluid-filled balloon catheters are used more routinely, although more expensive.
First the catheter has to be prepared by putting a 3-way stopcock and a 5 mL syringe with
saline on the “FILL” end of the catheter. This step is easily accomplished with the catheter held
so that the balloon is pointed upward. Using the syringe, water is infused into the catheter. This
action forces the air inside to rise and then discharge out of the lumen extension labeled “PURGE
ONLY”. After all the air has been flushed through the balloon and catheter, the cap on the
lumen extension labeled “PURGE ONLY” is closed. The balloon is collapsed by withdrawing
the water from the catheter with the syringe.
The 3-way stopcock is then turned “OFF” to the catheter that is now ready for insertion.
The balloon-tipped catheter is placed 10 to 15 cm in the rectum or vagina/uterus and taped in
place. The stopcock is set “ON” to the syringe and approximately 1 to 1.5 mL of saline is
infused into the balloon with the syringe (Fig. 49).
The 3-way stopcock is then turned “OFF” to the catheter and a standard Pressure Transducer is inserted on the last free connection of the stopcock with pressure tubing. The 3-way
stopcock is turned “OFF” to the syringe and “ON” to the Pressure Transducer and “ON” to
the catheter. The pressure waveforms are observed on the channels recording IAP and pdet
(detrusor pressure). At the beginning of a cystic myogram (CMG), when the bladder is (presumably) empty, it is recommended that the starting pdet (detrusor) pressure is “0” mm Hg. To
achieve this value, pabd (abdominal pressure) must equal IBP (pdet = IBP-IAP). To change the
pdet value add water to lower it or remove water to raise it. This is done with the 3-way
stopcock turned so that all three ports are open. After doing so the pressure changes can be
observed while adjusting the water content of the balloon. After finishing the stopcock is turned
“OFF” to the syringe as it was initially. Remember that adding water decreases pdet (increases
IAP) and removing water increases pdet (decreases IAP) (Fig. 50).
Advantages and Disadvantages
The major problem with the open catheter is that residual faecal mass can block the catheter
tip opening leading to overestimation of IAP. Other disadvantages of this technique are that it
Figure 41. The Spiegelberg IAP monitor.
Figure 42. Combination of the Spiegelberg IAP and
APP monitor allowing continuous fully automated
monitoring. IAP: intra-abdominal pressure; ABP:
arterial blood pressure; APP: abdominal perfusion
pressure.
Figure 43. Connection
of the IAP signal to the
bedside monitor allowing to obtain a continuous IAP and APP
trend for further reference.
51Intra-Abdominal Pressure Measurement Techniques
Figure 44. Correlation
between intragastric
(IAPgas) pressure
obtained with the
Spiegelberg IAP catheter versus direct insufflation pressure during
laparoscopy. Adapted
from ref. 44, Malbrain
ML. Validation of a
novel fully auto-mated
continuous method
to measure intraabdominal pressure.
Intensive Care Med
2003; 29[Supplem
1]:S73.
52
Figure 45. A continuous trend of 24 hour IAP and APP recordings obtained with the Spiegelberg balloontipped IAP catheter placed in the stomach. Note the absence of resorption of air due to automated recalibration
every hour. Note also the effect of CAPD fluid inflow on IAP. 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. CAPD: chronic ambulatory peritoneal dialysis.
Figure 46. Options for the future, a catheter allowing gastric nutrition or emptying together with IAP
monitoring.
Abdominal Compartment Syndrome
Figure 47. Low bias and reasonable limits of agreement between
direct insufflator pressure and
Spiegelberg balloon catheter
(ACM). Adapted from ref. 45:
Schachtrupp A, Tons C, Fackeldey
V et al. Evaluation of two novel
methods for the direct and continuous measurement of the
intra-abdominal pressure in a porcine model. Intensive Care Med
2003; 29(9):1605-1608.
53Intra-Abdominal Pressure Measurement Techniques
Figure 48. Close-up view of the CiMON monitor (compartmental intrathoracic intra-abdominal monitoring) displaying the intra-abdominal pressure (IAP); the intrathoracic pressures (ITP) and the
transdiaphragmatic pressure (TDP).
is more difficult, implicates more manipulation, is intermittent, cannot be used in patients
with lower gastro-intestinal bleeding or profound diarrhoea. There is also a great reluctance
among nurses to use it. Since it is fluid-filled it has all the problems associated with an hydrostatic fluid column, but since it is needle free it decreases patient and healthcare worker infections or injuries. The fluid-filled balloon catheters are more expensive and, even though could
theoretically stay in place for a longer period of time, interfere with gastro-intestinal transit and
can cause erosions and even necrosis of the anal sphincter and rectal ampulla. Finally these
techniques have not been validated in the ICU setting. This technique has no clinical implications in the ICU setting.
Figure 49. Uterine or rectal catheter set-up.
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