1. Hemodynamic optimization in intra- abdominal hypertension Jan J. De Waele MD PhD Surgical ICU Ghent University Hospital Ghent, Belgium.

2. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Introduction Hemodynamics? Blood pressure Cardiac function Macro-circulation Micro-circulation and end-organ function may still be affected despite “normal hemodynamics”

3. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele IAH affects the cardiovascular system

4. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Cardiac output  IAP  Vascular compression Thoracic pressure  Organ compression Preload  Contractility  Afterload  Renin  Aldosteron  Renin  Aldosteron  Cardiac compression Venous return 

5. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Preload evaluation in IAH is different

6. 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.

7. 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 ↑

8. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele IAH and preload monitoring 2. Inferior vena cava flow decrease Direct pressure on IVC Affected: Passive leg raising (PLR)

9. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele IAH and preload monitoring 3. Cardiac volumes decrease Diaphragm elevation – cardiac compression Affected: GEDV, ITBV LVEDA

10. 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

11. 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. Normovolemia Hypovolemia

12. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Preload evaluation in IAH SVV and PPV Jacques D, Crit Care 2011 15: R33. Normovolemia Hypovolemia

13. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Preload evaluation in IAH GEDV

14. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Prediction of fluid responsiveness

15. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele

16. Preload evaluation in IAH Passive leg raising Malbrain ML, Crit Care Med 2010 38: 1912-5.

17. 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.

18. 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

19. 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)

20. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Optimizing preload in IAH

21. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Preload optimization in IAH Fluid responsiveness = fluid depletion? Signs of hypoperfusion? Avoid treating numbers

22. 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!

23. 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?

24. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Practical implications for IAH patients → Use transmural filling pressures! CVP TM = CVP - IAP/2 PAOP TM = PAOP - IAP/2 ITP  CVP  PAOP 

25. 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?

26. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele The most effective method for hemodynamic optimization is reducing the intra-abdominal pressure

27. 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

28. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele www.wsacs.org

29. 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

30. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele PCD as an alternative for laparotomy Cheatham ML, Chest 2011 140: 1428-35.

31. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Laparotomy remains effective Chiara O, Minerva Anestesiol 2011 77: 457-62.

32. 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

33. 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

34. 3rd IFAD – Hemodynamic optimization in IAH – Jan J. De Waele Thank you for your attention Email: Jan.DeWaele@UGent.be Twitter: @CriticCareDoc