Abstract
BackgroundThe importance of intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) in cirrhotic patients with septic shock is not well studied. We evaluated the relationship between IAP and APP and outcomes of cirrhotic septic patients, and assessed the ability of these measures compared to other common resuscitative endpoints to differentiate survivors from nonsurvivors.MethodsThis study was a post hoc analysis of a randomized double-blind placebo-controlled trial in which mean arterial pressure (MAP), central venous oxygen saturation (ScvO2) and IAP were measured every 6 h in 61 cirrhotic septic patients admitted to the intensive care unit. APP was calculated as MAP - IAP. Intra-abdominal hypertension (IAH) was defined as mean IAP ≥ 12 mmHg, and abdominal hypoperfusion as mean APP < 60 mmHg. Measured outcomes included ICU and hospital mortality, need for renal replacement therapy (RRT) and ventilator- and vasopressor-free days.ResultsIAH prevalence on the first ICU day was 82%, and incidence in the first 7 days was 97%. Compared to patients with normal IAP, IAH patients had significantly higher ICU mortality (74.0% vs. 27.3%, p = 0.005), required more RRT (78.0% vs. 45.5%, p = 0.06) and had lower ventilator- and vasopressor-free days. On a multivariate logistic regression analysis, IAH was an independent predictor of both ICU mortality (odds ratio (OR), 12.20; 95% confidence interval (CI), 1.92 to 77.31, p = 0.008) and need for RRT (OR, 6.78; 95% CI, 1.29 to 35.70, p = 0.02). Using receiver operating characteristic curves, IAP (area under the curve (AUC) = 0.74, p = 0.004), APP (AUC = 0.71, p = 0.01), Acute Physiology and Chronic Health Evaluation II score (AUC = 0.71, p = 0.02), but not MAP, differentiated survivors from nonsurvivors.ConclusionsIAH is highly prevalent in cirrhotic patients with septic shock and is associated with increased ICU morbidity and mortality.
Highlights
The importance of intra-abdominal pressure (IAP) and abdominal perfusion pressure (APP) in cirrhotic patients with septic shock is not well studied
Prevalence and incidence of intra-abdominal hypertension (IAH) and characteristics of the patients according to IAH The studied patients had the following characteristics (Table 1): age = 59.0 ± 13.0 years, 58% were men, hepatitis C was the most common cause of cirrhosis (44%) with mean Child-Pugh score of 11.6 and most patients had ascites (94%) and hepatic encephalopathy (76%)
On the stepwise logistic regression analysis, none of the studied variables was associated with IAH, including fluid balance on day 1 (OR, 1.28/l increment; 95% confidence interval (CI), 0.90 to 1.81)
Summary
Patients and setting This study was conducted in a 21-bed closed medicalsurgical ICU of a tertiary care hospital with an active liver transplant service. The trial, performed between April 2004 and October 2007, included 75 adult patients and was approved by the hospital’s Institutional Review Board [19] It excluded patients who had hypovolemic or hemorrhagic shock, known adrenal insufficiency, prior steroid use or contraindication for steroids [19]. To examine the association between IAP and APP and different endpoints, we used multivariate logistic regression analysis to adjust for the following variables: age, APACHE II, Child-Pugh score, requirement for mechanical ventilation, creatinine, INR, fluid balance on day 1 and hydrocortisone therapy. Survival analysis was performed using Kaplan-Meier curves to examine the time-dependent mortality difference stratified by different hemodynamic targets (MAP ≥ 65 and < 65 mmHg, ScvO2 ≥ 70% and < 70% and IAP and APP ≥ and < the best cut-offs on the ROC curve analysis)
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