Aggressive Surveillance and Early Catheter-Directed Therapy in the Management of Intra-Abdominal Hypertension

Abstract

Trauma patients represent a heterogeneous group at risk for the development of both primary and secondary abdominal compartment syndrome (ACS). Our study aims at identifying these individuals early in their course and placing an intra-abdominal catheter to reduce intra-abdominal pressure before the serious hemodynamic consequences of ACS occur. During a 10-month period, 12 patients were identified who developed intra-abdominal hypertension. Patients who received 12 L or more of intravenous fluids in the first 24 hours of their resuscitation or received 500 mL/hr of intravenous fluids for more than 4 consecutive hours were considered at risk and had intra-abdominal pressure readings via bladder catheters every 4 hours. After resuscitation, patients were given a physical examination and intra-abdominal pressures were taken every 4 hours or when clinically necessary. When abdominal compartment pressures (ACPs) exceeded 20 mm Hg or the abdominal perfusion pressure (APP = mean arterial pressure-ACP) fell below 50 mm Hg, a diagnostic peritoneal lavage catheter was placed. Fluid volume and type drained, abdominal pressures, heart rate, mean arterial pressure, and pulmonary compliance were recorded. If adequate control of abdominal compartment pressures was not achieved, the patients were managed with a traditional decompressive laparotomy. Readings taken 30 minutes after placement of the peritoneal catheter showed an average decrease in ACP of 8.0 mm Hg (p = 0.01); an increase in APP of 13.8 mm Hg (p = 0.14); an increase in static pulmonary compliance of 8.1 mL/cmH2O (p = 0.16); and an increase in mean arterial pressure of 5.8 mm Hg (p = 0.52). Ten of the twelve patients were managed nonoperatively. Four patients failed to have their APP improve to >50 mm Hg with the catheter. Two of these patients underwent laparotomy, with one survivor and one mortality secondary to infarcted small bowel. Two did not undergo laparotomy, with one dying of cerebral herniation and the other having care withdrawn. Eight of the twelve patients required intra-abdominal catheters early in their admission (in the first 32 hours), with 7 of 8 surviving. Four patients received intra-abdominal catheters later than day 4 in their admission. All of those four patients died, three within 24 hours. Overall, 5 of the 12 patients died. Intra-abdominal catheter placement is a reasonable first step in the early management of ACS. It may prevent a portion of patients from progressing to hemodynamically significant ACS and prevent the complications of managing an open abdominal wound. Also, the late intra-abdominal hypertension may be a prognostic indicator of an impending rapid clinical deterioration. Further prospective investigation is warranted to determine whether this method reduces overall morbidity and mortality in critically ill patients.