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Hemodynamic optimization in intra-abdominal hypertension
Jan J. De Waele MD PhDSurgical ICU
Ghent University HospitalGhent, Belgium.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
IntroductionHemodynamics?Blood pressureCardiac functionMacro-circulation
Micro-circulation and end-organ function may still be affected despite
“normal hemodynamics”
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
IAH affects the cardiovascular system
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Cardiac output
IAP
Vascular compression Thoracic pressure Organ compression
Preload Contractility Afterload
Renin Aldosteron
Cardiac compressionVenous return
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH is different
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
How does IAH affect preload
Cheatham ML et al., Acta Clin Belg Suppl 2007, 98-112.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
IAH and preload monitoring
1. Intrathoracic pressure increase• Diaphragm elevation
Affected:• Central venous pressure• PAOP• Pleural pressure
• SVV, PPV
IAP ↑
ITP ↑
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
IAH and preload monitoring2. Inferior vena cava flow decrease• Direct pressure on IVC
Affected:• Passive leg raising
(PLR)
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
IAH and preload monitoring3. Cardiac volumes decrease• Diaphragm elevation –
cardiac compression
Affected:• GEDV, ITBV• LVEDA
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
CVP/PAOP
After Malbrain et al. Current Opinion Crit Care 2004; 10(2): 132-145
Malbrain Hering Schachtrupp *
Renner *0
5
10
15
20
25CVP
Baseline IAH
Malbrain Hering Renner *0
5
10
15
20
25
30PAOP
Baseline IAH
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
SVV and PPV
Duperret S, Intensive Care Med 2007 33: 163-171.
NormovolemiaHypovolemia
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
SVV and PPV
Jacques D, Crit Care 2011 15: R33.
NormovolemiaHypovolemia
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
GEDV
Malbrain Hering Schachtrupp Hachenberg0
200
400
600
800
1000
1200
Baseline
IAH
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Prediction of fluid responsiveness
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
Passive leg raising
Malbrain ML, Crit Care Med 2010 38: 1912-5.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
Passive leg raising• 31 fluid
responsive patients
• 48% false negative
• IAP >16mmHg ideal cutoff
Mahjoub Y, Crit Care Med 2010 38: 1824-9.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload evaluation in IAH
LVEDA
Vivier E et al. Br J Anaesth 2006; 96: 701–7
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload and IAH: conclusion
Application of IAH→ Volumetric parameters decrease→ Barometric parameters increase→ Dynamic indices suggest fluid
responsiveness but may be false negative (PLR)
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Optimizing preload in IAH
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Preload optimization in IAH
Fluid responsiveness = fluid depletion?
• Signs of hypoperfusion?• Avoid treating numbers
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Practical implications for IAH patients
IAH mimicks • Fluid overload• Fluid requirement • Fluid responsiveness
→ SVV and PPV• Accept higher tresholds• Avoid fluid overload – vicious cycle!
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Practical implications for IAH patients
IAH mimicks • Fluid overload• Fluid requirement • Fluid responsiveness
→ CVP/PAOP• Use transmural pressure?
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Practical implications for IAH patients
→ Use transmural filling pressures!
CVPTM = CVP - IAP/2
PAOPTM = PAOP - IAP/2
ITP
CVP PAOP
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Practical implications for IAH patients
IAH mimicks • Fluid overload• Fluid requirement • Fluid responsiveness
→ Passive leg raising• Beware of false negative results• Not to be used at all?
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
The most effective method for hemodynamic optimization is reducing
the intra-abdominal pressure
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Targets for medical management
Improve abdominal wall
compliance
Evacuate intraluminal
contents
Evacuate intra-abdominal fluid
collections
Correct positive fluid balance
Optimize systemic and regional
perfusion
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
www.wsacs.org
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
PCD as an alternative for laparotomy
Cheatham ML, Chest 2011 140: 1428-35.
• 31 patients• 54y, 65% male• APACHE II 24• SOFA 8
• Indication for PCD• ACS 71%• IAH 23%• Hemoperitoneum 6%
• Matched to open decompression patients
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
PCD as an alternative for laparotomy
Cheatham ML, Chest 2011 140: 1428-35.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Laparotomy remains effective
Chiara O, Minerva Anestesiol 2011 77: 457-62.
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Before I came here I was confused about this subject. Having listened to your lecture I am still confused. But on a higher level.
Enrico Fermi
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Take home messages
• IAH affects the cardiovascular system • All methods of preload evaluation are
influenced by IAH• Fluid administration not to used lightly• Lowering IAP is the best method for
hemodynamic optimization
3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele
Thank you for your attention
Email: [email protected]: @CriticCareDoc
