1. QUICK ASSESSMENT OF INTRA-ABDOMINAL PRESSURE FOR BETTER DECISION MAKING IN CASES OF ACUTE ABDOMEN IN RURAL SETUP
Dr Sankalp Dwivedi
Professor surgical discipline
and
Dean Academic Affairs
MMIMSR, Maharishi Markandeshwar University Mullana, Ambala, India

2. INTRODUCTION
Intra-abdominal hypertension (IAH) is the steady-state pressure concealed within the abdominal cavity
Early recognition of IAH is of extreme importance to prevent devastating complications

3. In cases of critically ill adults, the IAP is around 5-7mmHg
In IAH cases, the IAP becomes greater than 12 mm Hg
In cases of Abdominal compartment syndrome (ACS) the IAP is usually ≥20 mm Hg With dysfunction of at least one thoraco-abdominal organ

4. GRADING
World Society of Abdominal Compartment Syndrome (WSACS, 2006) classified IAH as
Grade IAP (mm of Hg)
Grade I
Grade II
Grade III
Grade IV >25
Grades III and IV (IAP >20 mm) classified ACS when associated with new organ dysfunction or failure

5. Options available for IAP measurement

6. DIRECT MEASUREMENT Intraperitoneal catheter inserted for
ascites drainage
peritoneal dialysis
Intraperitoneal pressure transducer
During laparoscopic surgery

7. INDIRECT MEASUREMENT Intra-vesical pressure Intra-gastric pressure
Inferior vena cava
Airway pressure measurements
Rectal pressure
Intra-uterine pressure

8. WHAT WE PREFERRED ???
Intra-vesical pressure (IVP) monitoring through Foley's manometer

9. Why IVP??? Validated and widely accepted for clinical use
Feasible at ICU and normal ward for quick assessment
Compliant Bladder wall functions as passive reservoir and transducer of IAP
IVP measurements may not accurately reflect intra-abdominal pressure in neurogenic bladder, abdominal packing or adhesions

10. OBJECTIVES OF STUDY
To measure intra abdominal pressure via IVP monitoring in acute surgical abdomen for early pick up of IAH/ACS

11. METHODOLOGY A Prospective Study planned after ethical clearance
30 patients of acute surgical abdomen who were suspected IAH/ACS selected randomly

12. INCLUSION CRITERIA
All admitted patients of acute abdomen with suspected IAH/ACS due to
Perforation peritonitis
Acute intestinal obstruction
Acute Pancreatitis
Abdominal sepsis/ Septic Shock
Blunt trauma abdomen

13. EXCLUSION CRITERIA
Patients in whom Foley’s Catheter cannot be introduced
Diagnosed patients of non surgical Acute abdomen
Acute renal failure
Chronic renal failure
Abdominal packing or adhesions

14. KEY PARAMETERS Intra-Vesical Pressure (IVP)
Abdominal perfusion pressure (APP)
CT Scan criteria

15. IVP Foley Manometer method The IAP/IVP
The measuring tube inserted between the catheter and the collecting bag
The tube elevated with the base at the symphysis pubis
Maximum bladder instillation mL of sterile saline
The IAP/IVP
Expressed in millimeters of mercury (mm Hg)
Measured at end-expiration in the complete supine position
After ensuring that abdominal muscle contractions are absent
And that the transducer zeroed at the level of the mid-axillary line

16. APP More accurate predictor of visceral perfusion
APP = MAP – IAP
More accurate predictor of visceral perfusion
A potential endpoint for resuscitation

17. CT SCAN CRITERIA Elevated Diaphragm Compression IVC and Renal Vein
Hemo-peritoneum/ Ascites Small-Bowel Dilatation
Round Belly Sign Bilateral Inguinal Herniation
Shock Bowel Gastric Distention
Mosaic liver perfusion with trauma

18. OBSERVATION

19. AGE AND SEX 2.38 0.67 Age Male Female Chi square P value 10-20 4(13.3)
1(3.3)
2.38
0.67
21-30
8(26.7)
31-40
5(16.7)
41-50
3(10.0)
>50
0(0.0)
Total
21(70.0)
9(30.0)

20. CAUSE & RISK FACTORS

21. PRESENTATION- ACUTE PAIN

22. OTHER SYMPTOMS

23. VITAL STATUS Variable Total IAH ACS Pulse/ min 112.60±17.45 112.0±17.6
112.0±17.6
125.3±22
Systolic BP
111.87±19.64
109.6±18
100±30
Diastolic BP
68.07±13.51
68±12.6
56±19.6
RR /min
22.80±3.43
23.3±3.2
24±6.9
Temp/ .F
99.81±1.32 --

24. STATUS OF ABDOMEN

25. BLOOD ANALYSIS Early renal compromise Variable IAH (≥12 mmHg IAP)
ACS(≥20 mmHg IAP)
Normal (<12mmHg IAP)
Mean S.Urea
86.1 ±23.89
102.3±19.17
52+14
Mean S.Creatinine
3.4±1.67
3.95±0.55
Early renal compromise

26. IAP ( mm/Hg) Number of patients Mean SD F value P value 0 Day 0hrs 30
Number of patients
Mean SD
 F value
P value 
0 Day
0hrs 30
13.36
4.20
0.34
0.96
8hrs
13.11
4.19
16hrs
13.35
4.14
Total 90
13.27
4.13
1 Day 29
12.92
3.89
0.20
0.82 28
12.51
3.76
12.29
3.88 85
12.58
3.81
3Day
11.15
3.41
0.11
0.90
10.70
3.94
10.83
3.97 84
10.90
3.74

27. IAP ACCORDING TO WSACS GRADE IAP(mm of Hg) Frequency% I 12-15 26.6 II
16-20
33.3
III
21-25 10 IV
≥25

28. PATTERN OF IAP (mm/Hg) IAH ACS Non- IAH Mean SD Pvalue N 0DAY 0hrs
Mean SD
Pvalue N
0DAY
0hrs
14.73
2.83
0.92
19.00
2.98
0.74
8.72
2.10
0.69
8hrs
14.38
2.57
19.73
2.40
8.36
1.65
16hrs
14.52
2.27
20.73
2.68
9.13
1.99
Total
14.55
2.52
19.82
2.45
8.75
1.88
1 Day
13.81
2.23
0.97
19.97
1.97
0.76
8.91
1.94
0.82
13.96
2.39
18.50
4.24
8.43
1.38
13.99
2.66
17.75
4.17
8.48
1.89
total
13.92
2.38
18.91
2.87
8.60
1.71
3Day
12.24
2.60
0.8
17.05
1.06
0.85
7.79
1.23
0.73
11.59
2.92
7.28
1.77
12.04
3.08
2.12
7.36
1.40
11.96
2.82
18.02
2.30
7.47
1.44

29. MAP ( mm/Hg) N Mean SD F value P-value 0 Day 0hrs 30 68.77 8.65 0.054
0.95
8hrs
69.50
8.85
16hrs
69.33
9.58
Total 90
69.20
8.94
1 Day 28
70.32
7.36
0.04
0.96
70.79
8.13
70.82
7.40 84
70.64
7.55
3Day
72.93
7.47
0.05
72.82
7.44
73.00
7.79
72.92
7.48

30. APP ( mm/Hg) Number of patients Mean SD F value P-value 0Day 0hrs 30
Number of patients
Mean SD
F value
P-value
0Day
0hrs 30
55.41
11.87
0.05
0.95
8hrs
56.39
11.60
16hrs
55.99
12.70
Total 90
55.93
11.93
1Day 28
57.60
9.37
0.07
0.93
58.28
9.57
58.53
9.64 84
58.14
9.42
3Day
61.78
9.27
0.01
0.99
62.12
9.55
62.17
10.66
62.02
9.73

31. PATTERN Of APP (mm/Hg) IAH ACS Non -IAH N Mean SD pvalue P-value 0 Day
IAH
ACS
Non -IAH N
Mean SD
pvalue
P-value
0 Day
0hrs
53.60
11.01
0.92
39.00
11.43
0.97
64.50
4.34
0.65
8hrs
54.57
10.66
40.27
11.08
65.42
4.30
16hrs
53.06
10.45
37.60
14.74
66.47
5.11
Total
53.76
10.52
38.96
10.91
65.50
4.52
1 Day
55.43
9.39
0.88
45.30
0.71
0.78
64.42
4.45
0.67
56.81
10.18
47.00
6.36
63.57
5.35
55.26
8.95
48.25
2.90
65.82
6.53
55.84
9.36
46.85
3.41
64.65
5.43
3Day
59.76
8.98
0.95
53.95
12.37
67.32
7.13
60.05
8.65
52.00
20.51
68.28
59.08
10.35
50.00
15.56
69.54
5.03
59.64
9.15
51.98
12.89
68.42
5.73

32. USG ABDOMEN

33. CT SCAN FINDINGS IN IAH / ACS

34. ASSOCIATED ORGAN DYSFUCTIONS

35. MEDICAL THERAPY Variable No. of cases Percent Chi-square P-value
Isotonic Crystalloids 30
100.0
47.2
0.00**
Hypertonic Crystalloids 6
20.0
Colloids 18
60.0
Colloids with Fursamide .0
Oxygen support 22
73.3
Neuromuscular Blockadge
Prokinetic(motility) 24
80.0
Venovenous Dialysis 1
3.3

37. SURGICAL SUPPORT Variable No. of cases Percent Chi-square P-value
Midline laparotomy 26
86.7
0.16
0.67
Transverse laparotomy 1
3.3
SlAF
Open drain 2
6.6
Drain with Lapartomy

38. OUTCOME

40. COMPLICATIONS

41. Variable
Total
IAH
ACS
Non IAH
ICU stay
4.93±3.41
5.16±4.10
2.33±2.08
4.22±2.27
Hospital Stay
15.37±12.00
16.83±14.24
8.33±6.35
14.77±7.50

42. CONCLUSION Raised IAP is a hidden threat to acute surgical abdomen
Majority of IAH/ACS cases are abdominal sepsis due to gut perforation or obstruction
Measurement of IAP may be the quick help in such chases to pick up IAH/ACS and treat them appropriately

43. REFERENCES
Manu Malbrain; Abdominal compartment syndrome; F1000 Medicine Reports 2009, 1:86
Dariusz Onichimowski1,2, Iwona Podlińska1, Sebastian Sobiech1, Robert Ropiak3 Measurement of intra-abdominal pressure in clinical practice; Anaesthesiology Intensive Therapy, 2010,XLII,2;
D. Turnbull1*, S. Webber2, C. H. Hamnegard3 and G. H. Mills2 Intra-abdominal pressure measurement: validation of intragastric pressure as a measure of intra-abdominal pressure British Journal of Anaesthesia 98 (5): 628–34 (2007)
Jens Otto*1, Daniel Kaemmer1, Marcel Binnebösel1, Marc Jansen1, Rolf Dembinski2, Volker Schumpelick1 and Alexander Schachtrupp1; Direct intra-abdominal pressure monitoring via piezoresistive pressure measurement: a technical note; BMC Surgery 2009, 9:5
Malbrain ML, Deeren DH. Effect of bladder volume on measured intravesical pressure: a prospective cohort study. Crit Care 2006; 10(4): 98.
Zhao-Xi Sun, Hai-Rong Huang, Hong Zhou; Indwelling catheter and conservative measures in the treatment of abdominal compartment syndrome in fulminant acute pancreatitis; World J Gastroenterol 2006 August 21; 12(31)
Jens Otto, Daniel Kaemmer, Marcel Binnebösel, Marc Jansen, Rolf Dembinski, Volker Schumpelick and Alexander Schachtrupp Direct intra-abdominal pressure monitoring via piezoresistive pressure measurement: a technical note; BMC Surgery 2009, 9:5
Jian-cang Hong-chen Kong-han Qiu-ping Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians J Zhejiang Univ-Sci B (Biomed & Biotechnol) (2):
Mentula P, Hienonen P, Kemppainen E, Lippaniemi A. Surgical Decompression for Abdominal Compartment Syndrome in severe acute pancreatitis. Arch Surg 2010;145(8):
Lee RK. Intraabdominal hypertension and abdominal compartment syndrome: a comprehensive review. Crit Care Nurse 2012;32(1):19-32.
Kim IB, Prowle J, Baldwin I, Bellomo R. Incidence, risk factors and outcome associations of intra-abdominal hypertension in critically ill patients. Anaesth Int Care 2012;40:79-89.
Zhou JC, Zhau HC, Pan KH, Zu QP. Current recognition and management of intra-abdominal hypertension and abdominal compartment syndrome among tertiary Chinese intensive care physicians. J Zhejiang Univ 2011;12(2):
Hill L, Hill B, Miller M, Michell WL. The effect of intra-abdominal hypertension on gastrointestinal function. South Afr J Crit Care 2011; 27(1):12-19.

44. Additional therapy THANK YOU Additional therapy Brachytherapy or
Photodynamic therapy
Described for malignant pleural mesothelioma
Could be applied for SFTP
Reports of this are rare and
Effectiveness is uncertain.
THANK YOU