Original Article
New Technique of Direct Intra-abdominal Pressure Measurement Elena Risin,1,2 Boris Kessel,2 Noah Lieberman,1 Michael Schmilovich,3 Itamar Ashkenazi3 and Ricardo Alfici,3 Department of Anesthesiology, 2Trauma Unit, and 3Surgery B Department, Hillel Yaffe Medical Center, Hadera, Israel.
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OBJECTIVE: To determine the efficacy of 14-Fr PVC round drain in the direct measurement of intraabdominal pressure. METHODS: Fifty consecutive patients undergoing elective laparoscopic surgery in a tertiary teaching hospital were included in this pilot study. Patients underwent laparoscopic cholecystectomy, appendectomy, splenectomy, colectomy and Nissen fundoplication. After creation of pneumoperitoneum and insertion of the trocars as indicated by the operation, a 14-Fr PVC round drain was inserted into the abdominal cavity via one of the laparoscopic ports. It was then connected under sterile conditions to the invasive blood pressure measurement system. Intra-abdominal pressure was gradually increased. Intraabdominal pressures as measured through the round PVC drain were compared to those measured by the laparoscopic insufflator at 5, 8, 12 and 24 mmHg. RESULTS: Two hundred measurements using each of the two methods were performed and correlated. The correlation coefficient was 0.996. No complications were observed with this new technique. CONCLUSION: Direct measurement of intra-abdominal pressure using 14-Fr PVC round drain is a newly described technique that is simple, fast and credible. Future investigation will be needed to confirm the reliability of this method during postoperative follow-up of intra-abdominal pressures in selected patients. [Asian J Surg 2006;29(4):247–50] Key Words: abdominal compartment syndrome, abdominal hypertension, direct measurements, intraabdominal pressure monitoring, intravesical pressure
Introduction Early determination of elevated intra-abdominal pressure may be crucial in various clinical situations,1–4 including in trauma patients.5 Elevation of intra-abdominal pressure appears before development of adverse complications, defined as abdominal compartment syndrome (ACS).1–8 Intra-abdominal pressures are commonly measured via the urinary bladder.9,10 This method may be limited and
unreliable in the presence of severe pelvic fractures and in those with abdominal packing. Direct measurement of intra-abdominal pressure is an alternative to measurements made via the urinary bladder and may be more helpful in selected cases. Previously described methods of direct measurement were very invasive (via femoral vein or inferior vena cava11,12) or sophisticated (gastric tonometry13), and therefore not practical.
Address correspondence and reprint requests to Dr Elena Risin, Department of Anesthesiology, Hillel Yaffe Medical Center, P.O. Box 169, Hadera 38100, Israel. E-mail:
[email protected] ● Date of acceptance: 13 January 2006 © 2006 Elsevier. All rights reserved.
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In this article, we present a new technique allowing direct intra-abdominal pressure measurement via 14-Fr PVC round drain. This is a practical technique since drainage drains are commonly used in a variety of abdominal operations.
Methods This study was authorized by the institutional review board (Declaration of Helsinki) of Hillel Yaffe Medical Center, and all patients signed an informed consent form. The study protocol included laparoscopic cholecystectomy, appendectomy, splenectomy, colectomy and Nissen fundoplication. Patients with body mass index of more than 35 were excluded from this study.
After creation of pneumoperitoneum and insertion of trocars as dictated by the operative technique, a 14-Fr PVC round drain was inserted into the abdominal cavity through the epigastric port. It was then connected under sterile conditions to the invasive blood pressure measurement system (Single Channel Blood Pressure Set: Arterial line—W/UTR-Disposable Transducer Infuset & 3 cc/hour Flush Device; Biometrix Ltd., Jerusalem, Israel) (Figure 1). Intra-abdominal pressure was gradually increased and stabilized on 5 mmHg, as determined by the laparoscopic insufflator (Electronic Insufflator IS 2500; Contec Medical, Tel Aviv, Israel). Intra-abdominal pressure was measured through the round drain. Intra-abdominal pressure was then raised to 8 mmHg, as determined by the insufflator. Intra-abdominal pressure was again measured through the round drain. Similarly, pressures were compared between the two systems at 12 and then at 24 mmHg, the insufflator being the reference measurement. All patients were followed postoperatively in the ward and 1 week later during their visit to the outpatient clinic. All cases of infectious complications were noted. Correlation coefficient test was used for statistical analysis.
Results
Figure 1. The measuring system includes a 14-Fr round PVC drain that is introduced through one of the trocars. This PVC drain is then connected to an invasive blood pressure measurement system.
Pressure (mmHg)
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Fifty consecutive patients undergoing elective laparoscopic surgery were included in this study. There were 32 males (64%) and 18 females (36%). Mean age was 48 years. Type of laparoscopic procedures included 32 cholecystectomies, nine colectomies, five splenectomies, three Nissen fundoplications and one interval appendectomy. Intra-abdominal pressures were simultaneously measured and recorded at different levels of pressure: 5, 8, 12 and 24 mmHg (Figure 2).
Insufflator 14-Fr PVC round drain
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10
0 1
11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 171 181 191 201 Individual measurements
Figure 2. Intra-abdominal pressures measured via a 14-Fr PVC round drain at different intra-abdominal pressures as measured by a laparoscopic insufflator.
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■ DIRECT INTRA-ABDOMINAL PRESSURE MEASUREMENT ■
Two hundred simultaneous measurements were performed and compared. Measurements made through the round PVC drain were positively correlated with measurements made by the insufflator (the correlation coefficient was 0.996). Most of the pressures measured with the round drain were the same as those measured with the insufflator. The maximum deviation was 1 mmHg. These deviations appeared 11 times out of 50 measurements at 5 mmHg, 10 times out of 50 measurements at 8 mmHg, 13 times out of 50 measurements at 12 mmHg and six times out of 50 measurements at 24 mmHg. There were no complications that could be attributed to the use of this technique.
Discussion Increased intra-abdominal pressure, also known as intraabdominal hypertension, is being increasingly recognized in critically ill patients, especially in the trauma setting. At the end of the 19th century, Burt and Marey described the negative influence of abdominal hypertension on the respiratory system. In 1890, Heinicus examined the influence of intra-abdominal pressure elevation in laboratory animals. He found that elevation of intra-abdominal pressure as high as 27–46 mmHg was fatal and postulated that the cause of death was acute respiratory failure. In 1911, Emerson described acute cardiac failure following acute abdominal hypertension.14 In the past 20 years, the aetiology and physiological changes caused by intraabdominal hypertension have been clarified.3–6,15,16 Early determination of elevated intra-abdominal pressure has resulted in more appropriate management of patients with significant trauma. Intra-abdominal pressure is normally 0 mmHg, but may rise to 15 mmHg after abdominal surgery. Intraabdominal hypertension is defined as intra-abdominal pressure higher than 15–20 mmHg. Elevation of intraabdominal pressure beyond 25 mmHg will lead to multiple adverse effects in all of the vital systems. These changes are defined as ACS.1–4,6 ACS has been shown to decrease cardiac output despite normovolaemia and normal ejection fraction.17 Additionally, it elevates central venous and pulmonary capillary wedge pressures. The cause of acute renal failure is thought to be multifactorial, mostly due to renal vein compression or renal parenchyma and decreased cardiac output as well.18,19 Other negative effects of ACS include
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increased intracranial pressure20 and depression of intestinal mucosal blood flow.21 Left untreated, ACS is a life-threatening condition.7 Early determination of intra-abdominal pressure is crucial in various clinical situations, especially in trauma. It is generally agreed that an intravesicular approach is the superior and preferred form of measurement. Most severely injured patients are routinely followed with intra-abdominal pressures measured via their urinary catheters. In some patients, this form of measurement is limited and may even be incorrect in predicting elevated intra-abdominal pressures. These cases include patients treated with damage control laparotomy and abdominal packing. Other patients, in whom the intravesical route of pressure measurement is not appropriate, include those with tense pelvic haematoma or urine bladder rupture.22 In a busy trauma centre, patients with severe pelvic fractures, stomach or urine bladder rupture are seen every week, causing a therapeutic challenge of early detection of ACS. Limitations to the intravesical form of measurement have led investigators to explore new ways to evaluate intra-abdominal pressure. Direct measurement of intraabdominal pressure using a catheter inserted into the inferior vena cava is possible but invasive and is prone to complications. Prolonged measurements may lead to inferior vena cava thrombosis. For this reason, inferior vena cava pressure monitoring has fallen into disfavour. Other approaches, like transrectal or transgastric, are unfavourable, or, like techniques based on piezoelectric effect, very expensive. Round PVC drains are commonly used in surgical practice. Direct measurements made through these drains may be an alternative in cases where other intra-abdominal pressure measuring methods are limited or contraindicated. This study was performed to examine the possibility of using the round PVC drain for direct intra-abdominal pressure measurement. For validation of this method, we chose the laparoscopic insufflator, in the same fashion, in which validation of the intravesicular form of measurement was confirmed. We concluded that measuring abdominal pressure through a round PVC drain is both easy and reliable. Our study was limited to patients who underwent elective laparoscopic surgery. It is clear that pneumoperitoneum and a clean, elective and calm peritoneal cavity does not simulate stormy abdomen and ACS in all aspects. In this paper, only the preliminary results of using this new technique are presented. In future, the
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PVC drain may be left intraoperatively when elevation of intra-abdominal pressure is expected according to the general status of the patient or operative findings. Future investigation should be aimed at confirming the reliability of this technique in the postoperative period. Direct measurement of intra-abdominal pressure via a 14-Fr PVC round drain is a newly described technique that is simple, fast and credible. Validation of this technique should be performed in postoperative patients.
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