Intra-Abdominal Pressure Evaluation in Intensive Care: A Review

This report provides a comprehensive literature review on intra-abdominal pressure (IAP) in critically ill patients within the intensive care unit (ICU). It explores the significance of IAP, including the risks and prevalence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), and its implications for decision-making regarding monitoring strategies. The review examines various risk factors associated with IAH, such as increased body mass index, liver ascites, abdominal surgery, and respiratory failure. It also emphasizes the importance of IAP monitoring in specific patient populations, including those with severe burns, acute pancreatitis, and trauma. The report highlights the role of healthcare providers, particularly nurses, in evaluating IAP and managing patients at risk of ACS and IAH. The study also includes the etiology of IAP, methods for measuring IAP, and the significance of nursing evaluation, interventions, and observations. Ultimately, the review underscores the critical importance of IAP evaluation in improving patient outcomes in the ICU.

Running Head: INTRA-ABDOMINAL PRESSURE
Intra-abdominal Pressure
Student’s Name
University Affiliation
Date

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Abstract
Intra-abdominal pressure (IAP) is rarely measured as well as monitored by default in intensive
care unit (ICU). The literature review will summarize the present empirical evidence on the
significance of Intra-abdominal Pressure, risk and prevalence of intra-abdominal hypertension
(IAH) in aiding decision making for intra-abdominal pressure monitoring in the intensive care
unit. The paper will review documents which other peer reviewed articles on intra-abdominal
pressure evaluation in critically ill patients. It should be noted that intra-abdominal hypertension
takes place relatively many patients in intensive care unit. Greater body index (BMI), liver
ascites, abdominal surgery, excessive fluid balance, respiratory failure, as well as hypotension
therapy are intra-abdominal hypertension risk factors in critically ill patients. Intra-abdominal
pressure monitoring is firmly supported in ventilated individuals having serious burns, serious
acute pancreatitis, severe trauma, ruptured aortic aneurysm, and liver dysfunction. In conclusion
the paper will critically present the significance of evaluation of intra-abdominal pressure in
critically ill patients in intensive care unit, the significance of intra-abdominal pressure to the
healthcare providers such as nurse.
Key words: intra-abdominal pressure, intra-abdominal hypertension, abdominal compartment
syndrome, monitoring and intensive care unit.

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LITERATURE REVIEW; INTRA-ABDOMINAL PRESSURE (IAP) IN CRITICALLY ILL
PATIENTS IN INTENSIVE CARE UNIT
Introduction and background information
Compliance of abdominal wall combined with the abdominal content defines the intra-
abdominal pressure (IAP). Usually, the values of IAP in individuals breathing impulsively is
atmospheric or sub-atmospheric (Aydin et al., 2014). Even though the terms abdominal
compartment syndrome (ACS) and IAP are known for numerous years, there has been confusion
in their difference. It should be noted that intra-abdominal hypertension (IAH) is considered as a
value of IAP causing a pathophysiological impact on organ system, as well as ACS is an
outcome of IAH impact over some period of time.
Increased abdominal pressure is often found among groups of critically ill individuals and
can lead to both mortality and morbidity (Tyagi et al., 2018). The rise in awareness of the
prognostic effect as well as incidence together with the progress in the management and
diagnosis of both ACS and IAH, can result in enhancement in survival in such patients (Coţofană
et al., 2018). Empirical research have found out that the ideal standard for indirect evaluation of
IAP is the intra-abdominal bladder method.
The effect of enhanced IAP in different human body organs has been the subject of
various studies for the past 100 years. In 1911, Emerson first observed the cardiovascular
mortality as well as morbidity linked with elevated IAP (Coţofană et al., 2018). Nevertheless, the
acknowledgement of abdomen as a compartment and the notion of IAP leading to ACS have just
received attention recently. Intra-abdomen pressure is described as the pressure hidden in human
abdominal cavity. Even though intra-abdominal pressures can physiologically reach increased

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values momentarily up to 81 mm Hg, these values usually cannot be endured for long periods of
time. Normal intra-abdominal pressure is usually estimated 6-8 mm Hg in critically ill older
adults. IAH is described as an IAP which is above the 13 mm Hg (Svorcan et al., 2017).
IAH is linked to a 12-fold rise in death rates relative to individuals without IAH. The
adverse impacts of IAH happen long before the display of compartment syndrome (Stojanovic et
al., 2019). Thus, abdominal compartment syndrome should be seen as the end outcome of a
developing, unchecked rise in IAP from different disorders which consequently results in
numerous organ dysfunction. Prompt growth of IAH results in ACS, that is defined as an IAP
higher than 20 mm Hg having at least a single new organ system failure or dysfunctional.
Increased intra-abdominal pressure produces various derangements both in extra and intra-
abdominal organs (Santos et al., 2017). Even though serious effects on ling as well as kidney
have been well acknowledged, subsequent researches have documented an effect on virtually
each organ except the adrenal human glands.
The diagnosis of IAH and ACS are progressively recognized as a vital paradigm shift in
caring for individuals who are critically ill. ACS and IAH may impact on perfusion of an organ
leading to dysfunctional of the organ as well as eventually can be life threatening to individuals
who are critically ill (Ozgunay et al., 2018). The concept of ACS and IAH was identified in the
early 1900s and late 1800s, nevertheless, the effects on individuals’ physiological condition has
only been noted in last two decades (Demarchi et al., 2014). The case is linked to the
enhancement changes and clinical practices in treatment shifts in individuals experiencing
traumatic injury as well as those having serious illness. In spite of the rise in awareness as well
as guideline recommendations there is few or restricted empirical studies relating to the
significance of intra-abdominal pressure as well as the role of healthcare providers when taking

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care of individuals having ACS and IAH and there remains opposition on adopting regular
monitoring and screening practices. The pathology is a regular occurrence in patients who are
critically ill as well as vital for healthcare providers to frequently check IAP to establish serious
outcomes and be pre-emptive in the management of individuals who are at risk. In a research
study conducted by Hunt (Hunt, 2017), a total of 54 papers were reviewed.
The search initially entailed 815 articles, 225 duplicates, 216 did not meet the criterion of
inclusion while 373 were not included anchored on a criterion established in review of literature.
In the study, materials retrieved from various sources containing valuable data were analyzed
under the themes like etiology of IAH, approaches of measuring IAP, manifestation of ACS and
the significance of nursing evaluation, interventions and observation. IAP and ACS have the
potential to change the perfusion of organs as well as render them dysfunctional. According to
(Hunt, 2017), Individuals who were in intensive care unit and more particularly individuals
having trauma related occurrence were established to be at high risk of suffering from ACS.
Hunt established that there are succinct management guidelines as well as definitions for ACS as
well as IAH created by consensus models and documented by the World Society of Abdominal
Compartment Syndrome (WSACS) (Kirkpatrick et al., 2013). The research acknowledged the
standard for measurement of IAP which is dome through bladder using Modified Kron approach.
The study by Hunt, 2017, indicated that critical care healthcare providers measure IAP
using modified kroon approach, therefore, playing a vital role in the identification as well as
management of ACS and IAH. In spite of significance of this role, the literature review has
identified that healthcare providers’ knowledge concerning ACS and IAH is limited. To refine
and establish approaches for ACS and IAH management, a research was carried of critical care
healthcare providers’ knowledge of ACS and IAH in the Australian setting.

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Discussion
Etiology of IAP
There are numerous physiological features which have the potential to change a person’s
IAP. The features can be grouped as those which are linked to; a reduction in compliance in the
abdominal wall, a rise in intraluminal components and a seepage in capillary or fluid
resuscitation. Even though there are no models of risk prediction which can aid in identifying
ACS or IAH, increased peak ventilation pressures, reduced output of urine, coagulopathy,
acidosis, as well as hypothermia have been established in several researches as the vital
indicators of an enhanced death rates (Abdelkalik et al., 2014). The same researches highlight
early management and recognition of hypothermia acidosis and coagulopathy could lead to an
overall decrease in the death rates.
Measurement of IAP
IAP measurement is inexpensive, simple, accurate and safe method in finding out the
presence of IAH. The WSACS has recommended the application of standardized method and
protocol in spite this recommendation across healthcare organizations there is minimal
standardization of the protocols of evaluation. The approaches are determined by the
measurement reproducibility and accuracy, constraints of budget for employees training and
equipment as well as the ease of the application of the selected measurement method.
Traditionally physical measurement and observation of the abdominal girth were applied to find
out the presence of intra-abdominal hypertension (Ozgunay et al., 2018). This technique of
measurement is not accurate because of the high risk of variability as well as the minimal inter-
rater reliability. Numerous models to evaluate IAP entail intra rectal, intra gastric, inferior vena

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cava as well as through a urinary indwelling pressure in the catheter monitoring organ systems
(Demarchi et al., 2014). The WSACS calls for the application of Kron model as the ideal
standard of intra-abdominal pressure monitoring.
The Kron technique evaluates the IAP through pressure measurement in the bladder
utilizing a maximum instillation of 26 ml of saline which is sterile. It should be noted that the
measurement of IAP is obtained using the transducer positioned as well as zeroed along the mid-
axillar as well as iliac crest. It is also taken with the individual in a horizontal angle, end-
expiration as well as with an instillation amount not above 25 mL of saline particularly for
bladder method.
The measurement guidelines accuracy which is stipulated by the WSACS has been under
debate and challenged by various scholars. More currently, the development of continuous intra-
abdominal pressure monitoring has been highlighted to be greater to the intermittent method
(Demarchi et al., 2014). The continuous technique enables for continuous evaluation of the IAP
though the bladder as well as reduces the risk of missing increment of IAP because of timing that
can happen with intermittent method. It should be noted that continuous techniques have been
applied through gastric route as well as invasive direct evaluation, yet measurements utilizing
these methods have shown poor reproducibility. Nevertheless, a current empirical study
indicated comparable outcomes between conventional Kron method as well as continuous direct
intra-abdominal method. The consensus of the continuous measurement of bladder intra-
abdominal pressure to the present ideal standard of measurement of intermittent is accurate and
reliable. The measurements of continuous intra-abdominal pressure method needs insertion of
the more resource intensive three way catheter that might be the reason of its restricted
application.

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IAP monitoring indications
There is a huge argument concerning the usability of absolute ranges of IAP in the
management of individuals who are critically ill (Depauw et al., 2019). As stated by numerous
researchers, an IAP greater than 20 mmHg has the potential to cause physiological changes in
individuals who are critically ill (Depauw et al., 2019). Nevertheless, there are also individuals
having this similar elevation in intra-abdominal pressure which indicate no such derangement.
Because of the variations in medical presentations, there is usually inadequate clinical awareness
thus failure to identify IAH and ACS (Depauw et al., 2019). The WSACS has established
conclusive evidence anchored on IAP evaluation, ACS and IAH management algorithms as well
as a non-operative management algorithm to enhance management and awareness of individuals
at risk of abdominal compartment syndrome and intra-abdominal hypertension.
Recognizing individuals at risk of the first step in the identification as well as
identification of these pathologies. It should be noted that it is vital that individuals are tested for
the presence of ACS or IAH after being taken to the ICU and moreover in the presence of
progressive or new organ dysfunction. The WSACS stipulates the evaluation for risk factors of
ACS and IAH after being taken into the ICU. Post evaluation of more risk factors available or if
there is a progressive or new organ dysfunction then a standard measurement of IAP ought to be
undertaken after which evaluation algorithm should be executed. If there is presence of IAH
medical arrangement should be executed to reduce intra-abdominal pressure, measurements
should be taken between four and six hours or continuously. For individuals with an increased
intra-abdominal pressure monitoring should take place throughout the individual’s critical
illness.

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Implications for healthcare (nursing) practice in the intensive care unit
Despite the different literature debating ACS and IAH, there is few and limited
information specific to the health care especially for individuals with ACS or IAH. Individuals
having ACS or IAH will be most often faced in intensive care unit, high dependency units,
emergency departments, as well as coronary care units (Yang et al., 2015). Presently, it has been
suggested to expand monitoring of ACS as well as IAH monitoring above conventional ICUs to
allow prompt detection of health worsening in vulnerable individuals; therefore enhance
individual outcome. The intricate presentation of individuals having ACS or IAH needs an
elaborate practice nurse’s healthcare expertise as well as thorough monitoring. Elaborate practice
nurses have superior decision making and assessment skills which is significant in a frequently
unpredictable critical care settings (Wever et al., 2016). Advanced nursing practice enables
healthcare providers to show elevated health discretion, independence as well as responsibility
when managing, examining/recognizing ACS or IAH. Particular healthcare management is
emphasizing on examining functionality of organs, vital signs, pain management, and perfusions
to the reduced limits, examination of wound drainage as well as output, continuous examination
for reoccurrence of ACS or IAH as well as offering support to individuals.
Conclusion
The paper offers a detailed and comprehensive review and overview of the significance of
monitoring of intra-abdominal pressure for the critically ill patients in the intensive care unit.
The paper has also provided the articles which have used each one and context in which they
have been used. All the papers that I have reviewed have had the aim of answering my subject;
significance of IAP monitoring in critically ill patients in ICU. This rigorous and thorough

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literature review offers guidance for policymakers, researchers, healthcare providers interested in
understanding IAP measuring and monitoring in critically ill patients.

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