Intra-abdominal pressure: an integrative review

Milanesi, Rafaela; Caregnato, Rita Catalina Aquino

doi:10.1590/S1679-45082016RW3088

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Review • Einstein (São Paulo) 14 (3) • Jul-Sep 2016 • https://doi.org/10.1590/S1679-45082016RW3088 copy

Intra-abdominal pressure: an integrative review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

There is a growing request for measuring intra-abdominal pressure in critically ill patients with acute abdominal pain to be clarified. Summarizing the research results on measurement of vesical intra-abdominal pressure and analyzing the level of evidence were the purposes of this integrative literature review, carried out based on the databases LILACS, MEDLINE and PubMed, from 2005 to July 2012. Twenty articles were identified, in that, 12 literature reviews, 4 descriptive and exploratory studies, 2 expert opinions, one prospective cohort study and one was an experience report. The vesical intra-abdominal pressure measurement was considered gold standard. There are variations in the technique however, but some common points were identified: complete supine position, in absence of abdominal contracture, in the end of expiration and expressed in mmHg. Most research results indicate keeping the transducer zeroed at the level of the mid-axillary line at the iliac crest level, and instill 25mL of sterile saline. Strong evidence must be developed.

Intra-abdominal hypertension; Monitoring, physiologic; Nursing care; Intensive care

Objetives	Features	Results
To investigate IAP and IAH knowledge, recognition and management in Italian ICUs⁽²⁴⁾	Type: exploratory-descriptive study	IAP was measured in 51 ICUs. Lack of IAP measurement was due to lack of a specific kit or unawareness of the technique. The intravesical method was the only one employed. Frequency of serial measurements: every 4 hours in the presence of risk factors (64.7%), or in emergency surgical procedures (21.5%)
	Place: Italy
	Sample: 77 physicians in charge of ICUs
	Instrument: questionnaire comprising 9 close-ended questions
To assess knowledge of ACS, clinical application of IAP measurement, measurement methods and frequency, and criteria for decompressive laparotomy⁽²⁵⁾	Type: exploratory-descriptive study	IAP was measured by 104 interviewees in suspected cases of IAH/ACS (93.9%). The intravesical method was the only one employed. Frequency: 44.2% in the presence of clinical suspicion; 26.9% every 4 to 8 hours; 15.4% every zero to 4 hours; 10.9% every 12 hours; 2.9% once every 24 hours
	Place: United Kingdom
	Sample: 137 physicians in charge of ICUs
	Sample: 137 physicians in charge of ICUs
To assess physician’s knowledge of ACS and respective management characteristics⁽¹⁵⁾	Type: exploratory-descriptive study	IAP was measured in patients clinically predisposed to ACS (51.4%) using the intravesical method (97%), with instillation of 60-100mL of fluid (54.3%), at 4-to-8-hour intervals (60%). Methodological issues were among the major doubts reported in questionnaires
	Place: Brazil
	Sample: 90 physicians working at 10 ICUs in
	Rio de Janeiro
	Instrument: questionnaire comprising 12 close-ended questions
To determine the current level of understanding and clinical management of IAH/ACS among intensivists working in Chinese hospitals⁽¹⁶⁾	Type: exploratory-descriptive study	IAP was measured by 75 physicians in suspected cases of IAH (88%); the intravesical method was used (100%) with patients in the supine position (97.3%) and using 50-100 mL of fluid (46.7%); the pubic symphysis was taken as the zero-reference point (68%). Out of 33 physicians not measuring IAP, 36.4% were not able to interpret results and 27.3% had never admitted patients suffering from IAH
	Place: China
	Sample: 108 physicians
	Instrument: questionnaire comprising 20 close-ended questions

Objectives	Features	Results
To provide clinical update for accurate ACS diagnosis and for adequate management and intervention, with particular emphasis on intensive care⁽⁵⁾	Type: literature review	Simple, low cost; measurements in mmHg, at end-expiration, supine position, absence of abdominal contractions. Instillation of 25mL, transducer zeroed at mid-axillary line level and connected to 3-way stopcock inserted between vesical catheter and drainage bag. Measured in the presence of two or more risk factors every 4-6 hours; every hour in severe organ dysfunction. Discontinued in absence of acute organ dysfunction or if IAP <10mmHg for 24-48 hours
	Place: Brazil
To provide updated information, discuss organ dysfunction mechanisms, technique, therapeutic recommendations and treatment⁽⁷⁾	Type: literature review	Reference standard for intermittent measurement. Volume: 20-25mL. Expressed in mmHg, measured at end-expiration, in complete supine position, in the absence of abdominal muscle contractions, with transducer zeroed at mid-axillary line level. Recent studies investigated effects of different zero-reference points and elevated head position
	Place: Belgium
To give a broad overview of IAH/ACS, the role of nurses in assessment, monitoring and collaborative management⁽⁸⁾	Type: literature review.	Physical examination not sensitive for IAH detection. Intravesical method is the gold standard for indirect measurement, despite variations; technique adopted is: 20-25mL instillation volume, supine position, zero-reference point at pubic symphysis level, every 4-6 hours in patients at risk, until underlying cause resolution is obtained and IAP ≤12mmHg for 24-48 hours
	Place: United States
To serve as reference for recommendations defined at the III World ACS Conference⁽⁹⁾	Type: experience report	Twelve consensus definitions. About the technique: reference standard for intermittent measurement; in mmHg, at end-expiration, in complete supine position, in the absence of abdominal muscle contractions, transducer zeroed on the mid-axillary line, at iliac crest level, 25mL maximum saline solution instillation volume
	Place: Belgium
To describe diagnostic criteria, risk populations, monitoring techniques and IAH/ACS management⁽¹⁰⁾	Type: literature review	Gold standard due to reliability, simplicity and low invasiveness. Measured at end-expiration, zeroed at phlebostatic axis level, instillation of 25-50mL. Transient increase in sedation suggested to reduce interferences. Potential routine protocol: every 2 hours for the first 8 hours following ICU admission; every 4 hours over the next 8 hours; and every 8 hours over the following 24 hours
	Place: United States
To review risk factors for IAH/ACS, related conditions, pathophysiology, diagnostic methods and therapeutic advancements⁽¹¹⁾	Type: literature review	Physical examination and diagnosis have low sensitivity for IAH detection. Intravesical method simple, reliable, reproducible, minimally invasive, low cost, measured at end-expiration, in supine position, zero-reference point on the mid-axillary line at iliac crest level, in the absence of abdominal contractions, instillation of 25mL saline solution
	Place: Spain
To provide a general overview and present historical aspects, definitions, pathophysiology and suggestions for IAH/ACS management⁽¹²⁾	Type: literature review	Physical examination and imaging modalities not sensitive for IAH detection. Safe, efficient monitoring: ≥2 risk factors, one baseline measurement; if IAH, serial measurements. Intravesical method is simple, low cost, thought to be the gold standard. Measurements taken with patient in supine position
	Place: Greece
To present currently accepted consensus definitions regarding IAH and ACS diagnosis and treatment⁽¹³⁾	Type: literature review	Clinical assessment has low sensitivity in detection of increased IAP. Intravesical method more widely employed due to simplicity, low cost and minimal risk. Expressed in mmHg (=1.36cmH₂O), at end-expiration, in complete supine position, in the absence of abdominal muscle contractions, zero-reference point at mid-axillary line level, instillation volume ≤25mL
	Place: Belgium
To discuss etiology, epidemiological data, measurement techniques, diagnosis, complications, prevention and treatment⁽¹⁴⁾	Type: literature review	Worldwide acceptance due to simplicity and minimal cost, but technique varies. Measured in mmHg, at end-expiration, in complete supine position, in the absence of abdominal contractions, with transducer zeroed at mid-axillary line level and maximal saline solution instillation volume of 25mL
	Place: Belgium
Not mentioned⁽¹⁷⁾	Type: literature review	Clinical assessment inaccurate for IAH detection. Measure: upon admission of critically-ill patient, in the presence of risk factors or clinical deterioration. Other hollow organs were described, but none as simple and user-friendly as the bladder. Patient in supine position, pressure module zeroed on the mid-axillary line at iliac crest level
Not mentioned⁽¹⁷⁾	Place: United States
To discuss etiology, epidemiological data, IAP measurement, diagnosis, complications, prevention and treatment options for ACS⁽¹⁸⁾	Type: literature review	Physical examination and imaging modalities inaccurate for diagnosis but indicate causes. IAP measured at one site is assumed to reflect IAP as a whole. Intravesical method is the gold standard due to simplicity and minimal cost. Several tools have been developed, such as Foley Manometer or AbViser stopcock. Continuous technique has been described, but is not widely used
	Place: Belgium
Not mentioned⁽¹⁹⁾	Type: literature review	Patients must be in complete supine position and abdominal muscle contraction must be absent; transducer is zeroed at pubic symphysis or mid-axillary line level. Instillation of 25mL of sterile saline solution; values obtained must be expressed in mmHg
Not mentioned⁽¹⁹⁾	Place: Spain
Not mentioned⁽²⁰⁾	Type: literature review	Clinical assessment has low sensitivity (40%) for IAH estimation. IAP increasingly employed due to relevance of early IAH detection and management; transducer zeroed at pubis level. Original technique employed 50-100mL but recent study reported better correlation with IAP when 50mL are used
Not mentioned⁽²⁰⁾	Place: Chile
Not mentioned⁽²⁸⁾	Type: specialist’s opinion	Despite increased attention given to topic, general clinical application has not been established to date. Current consensus on ideal measurement method or time point is lacking. Future research efforts should aim to improve consensus definitions concerning IAH and ACS
Not mentioned⁽²⁸⁾	Place: Belgium

Objetives	Features	Results
To assess the effect of different saline instillation volumes during intravesical pressure measurement⁽²⁶⁾	Type: prospective cohort study	The intravesical method is the gold standard for indirect measurement. Volumes described ranged from 50 to 300mL. Authors concluded: >50mL may overestimate true IAP; 25mL may be enough; vesical compliance varies within and between patients; a uniform, standardized, accurate and reproducible method is required for multicenter studies
	Place: Belgium
	Sample: 13 sedated patients submitted to mechanical ventilation
To describe the significance of saline infusion volume standardization in IAP monitoring⁽²⁷⁾	Type: specialist’s opinion	The intravesical method is the standard technique for indirect measurement, but there’s little standardization in literature. The most accurate volume is not clear. Small volumes tend to be employed, as discussed in the studies by Malbrain et al.⁽²⁶⁾ (25mL) and Waele et al.⁽⁹⁾ (10mL), given IAP overestimation is directly proportional to larger volumes.
	Place: Canada

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[1] Corresponding author
: Rafaela Milanesi – Avenida Francisco Trein, 596 – Cristo Redentor – Zip code: 91350-200 – Porto Alegre, RS, Brazil – Phone: (55 51) 3357-2000 – E-mail: mrafaela@ghc.com.br