Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension

Abstract

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. With the aim of improving the outcomes for patients with IAH/ACS, the World Society of the Abdominal Compartment Syndrome recently updated its clinical practice guidelines. In this article, we review the association between a positive fluid balance and outcomes among patients with IAH/ACS and how optimisation of fluid administration and systemic/regional perfusion may potentially lead to improved outcomes among this patient population. Evidence consistently associates secondary IAH with a positive fluid balance. However, despite increased research in the area of non-surgical management of patients with IAH and ACS, evidence supporting this approach is limited. Some evidence exists to support implementing goal-directed resuscitation protocols and restrictive fluid therapy protocols in shocked and recovering critically ill patients with IAH. Data from animal experiments and clinical trials has shown that the early use of vasopressors and inotropic agents is likely to be safe and may help reduce excessive fluid administration, especially in patients with IAH. Studies using furosemide and/or renal replacement therapy to achieve a negative fluid balance in patients with IAH are encouraging. The type of fluid to be administered in patients with IAH remains far from resolved. There is currently insufficient evidence to recommend the use of abdominal perfusion pressure as a resuscitation endpoint in patients with IAH. However, it is important to recognise that IAH either abolishes or increases threshold values for pulse pressure variation and stroke volume variation to predict fluid responsiveness, while the presence of IAH may also result in a false negative passive leg raising test. Correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. Controlled studies determining whether the above medical interventions may improve outcomes among those with IAH/ACS are urgently required.

Abdominal compliance

“…To avoid excessive fluid overload and abdominal wall edema after the initial period of resuscitation in the critically ill, a rather restrictive fluid management plan is important because there is evidence that a cumulative positive fluid balance by Day 3 is associated with increased morbidity and mortality. 58 Apart from the judicious use of fluid, fluid removal can be achieved by a furosemide infusion and or via renal replacement therapy. 58 Percutaneous catheters are increasingly used to drain intra-abdominal fluids and have shown to successfully reduce IAP levels in patients with secondary ACS caused by pancreatitis, liver cirrhosis with ascites, and after massive fluid resuscitation in patients with burns and sepsis.…”

“…58 Apart from the judicious use of fluid, fluid removal can be achieved by a furosemide infusion and or via renal replacement therapy. 58 Percutaneous catheters are increasingly used to drain intra-abdominal fluids and have shown to successfully reduce IAP levels in patients with secondary ACS caused by pancreatitis, liver cirrhosis with ascites, and after massive fluid resuscitation in patients with burns and sepsis. 59,60 Different modes and ventilatory pressures may have different impacts, but patient-ventilator asynchrony has probably the most negative effect on AC.…”

A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients

“…This chapter focuses on the treatment of IAH/ACS in terms of treatment aimed at reducing IAP. It is important to realize that the presence of IAH/ACS may lead to changes in general ICU management [45]. Respiratory management is affected since studies have shown that higher ventilation pressures (both PEEP and plateau pressures) can be used safely in patients with increased IAP and may be warranted in order to maintain alveolar recruitment [46].…”

Abdominal pressure and gastrointestinal function: an inseparable couple?

“…Fluid resuscitation may improve blood pressure and cardiac output in patients with IAH but may also further increase IAP, thereby decreasing APP and starting a vicious cycle [72]. Often vasoactive drugs are used to stabilize systemic hemodynamic variables in these patients.…”

“…As soon as hemodynamic stability is achieved after the resuscitation phase, there should be a transition to a more conservative fluid management and a 'late goal directed fluid removal' (de-resuscitation) [72].…”