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

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