Intra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with
increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal
hypertension and arterial lactate concentration in severe sepsis patients was analysed.
Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis
patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk
factors for IAH.
Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley catheter
placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same
time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05
was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%)
had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg.
Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus
1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients).
Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group.
Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with consequent
multi-organ failure, and for timely application of efficacious therapeutic procedures

DANIJELA BANDIĆ-PAVLOVIĆ

MARIO PAVLEK

MIRJANA MIRIĆ

MLADEN PERIĆ

ROBERT BARONICA

ŽELJKO DRVAR

English

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 25www.signavitae.comCorrelation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patientsABSTRACTIntra-abdominal hypertension (IAH) in severe sepsis patients with consequent multiple organ failure is associated with increased arterial lactate levels. In this nonrandomized, prospective control trial, the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients was analysed.    Thirty-eight patients undergoing major abdominal surgery with confirmed severe sepsis constituted the severe sepsis patients group. Control group included thirty-eight patients undergoing elective abdominal surgery with at least two risk factors for IAH.Intra-abdominal pressure (IAP) was assessed in both groups every six hours during the first 72 hours, through a Foley cat-heter placed in the urinary bladder. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lactate levels in arterial blood, SvO2 and CVP were assessed. Data were compared using Student’s t test. P <0.05 was considered statistically significant. In the sepsis group, 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group, all patients had IAP up to 7mmHg. Arterial blood lactate levels were significantly increased in severe sepsis patients with IAP >16mmHg (4,2mmol/L versus 1,2mmol/L, P<0.05) compared to the control group. Mortality in severe sepsis patients with IAH was 24.5% (10 patients). Arterial blood lactate levels were significantly higher in severe sepsis patients IAH >16mmHg compared to control group. Continuous IAP monitoring in severe sepsis patients is important for early detection of splanchnic hypoperfusion with con-sequent multi-organ failure, and for timely application of efficacious therapeutic procedures.PAVLEK MARIO(  ) • DRVAR ŽELJKO •MIRIĆ MIRJANA •BARONICA ROBERT • BANDIĆ-PAVLOVIĆ DANIJELA •PERIĆ MLADENZagrebačka cesta 128 10000 Zagreb, CroatiaPhone/Fax: +385915627952 E-mail: mario.pavlek@yahoo.comDRVAR ŽELJKO • MIRIĆ MIRJANA • PAVLEK MARIO • BARONICA ROBERT • BANDIĆ-PAVLOVIĆ DANIJELA • PERIĆ MLADEN   SIGNA VITAE 2014; 9 (Suppl 1): 25 - 28Key words: intra-abdominal hyper-tension, arterial lactate concentrati-on, sepsisIntroductionIntra-abdominal pressure (IAP) is defined as a steady state pressure of the abdo-minal cavity. The prevalence of intra-abdominal hypertension (IAH) in severe sepsis patients ranges from 20-55%. IAH with consequent splanchnic hypo-perfusion and multiple organ failure is associated with increased lactate levels in arterial blood. IAH was defined as a sustained or repeated pathological ele-vation of intra-abdominal pressure (IAP) for >12mmHg and was graded into 4 levels – level 1: 12-15mmHg; level 2: 16-20mmHg; level 3: 21-25mmHg; level 4: >25mmHg. (1) Abdominal compar-tment syndrome (ACS) is defined as a sustained IAP >20mmHg with or witho-ut abdominal perfusion pressure (APP) <60mmHg, which is associated with new organ dysfunction. (2)  IAH com-presses mesenteric veins, which impairs venous flow from the intestine and cau-ses intestinal oedema. Consequently, hypoperfusion, decreased intramucosal pH and bowel ischemia develops. (3, 4)We are presenting the results of a prospective two-year non-randomi-sed controlled trial  conducted at the Department of Anaesthesiology, Rea-nimatology and Intensive Care at the University Hospital Centre in Zagreb. The correlation between intra-abdo-minal hypertension and arterial lactate concentration in severe sepsis patients was analysed. Materials and methodsThe study was a prospective non-ran-domized controlled trial, which included patients who underwent urgent major 26 www.signavitae.comabdominal surgery and were treated at the Department of Anaesthesiolo-gy, Reanimatology and Intensive Care at the University Hospital Centre in Zagreb, Croatia, between March 2010 and April 2012. A total number of 76 critically ill patients were divided into two groups. The severe sepsis patients group included 38 patients (22 male, age 45±6, APACHE II score 19±4 and 16 female, age 42±7, APACHE II score 18±2) who underwent major abdomi-nal surgery and met standard interna-tional criteria for severe sepsis. (5-7) The control group included 38 patients (23 male, age 47±6, APACHE II score 18±3 and 15 female, age 43±5, APA-CHE II score 17±2) undergoing major abdominal surgery with at least two risk factors for IAH. Risk factors for IAH are presented in Table 1. The exclusion criteria were: patients <18years of age, pregnancy, allergy, patients with traumatic injuries to the urethra or the bladder, contraindication for femoral artery catheterisation, ina-bility to obtain informed consent from patient and BMI ≥32kg/m2.All patients were sedated with midazo-lam (0.05-0.15mg/kg/h). Analgesia was maintained with sufentanyl (0.2-0.6μg/kg). Vecuronium bromide (0.1mg/kg) in intermittent dosing schedule was used for adequate muscular relaxation for two reasons: to eliminate spontaneous breathing and to decrease oxygen con-sumption. All patients were intubated and mechanically ventilated (Evita R XL, Drager, Lubeck, Germany) using bip-hasic positive airway pressure (BIPAP) mode. Ventilator settings were: frac-tional inspired oxygen (FiO2) 0.4-0.8; respiratory rate (RR) 12-18/min, Phigh 15-25cmH2O, Plow 5-8cmH2O, Thigh 2-5 seconds and Tlow 0.5-1.0 seconds. Patients in both groups had PiCCO haemodynamic monitoring. Circulatory unstable patients had vasoactive phar-macological support (noradrenalin, 0.6-1.8μg/kg/min) and their Sequenti-al Organ Failure Assessment (SOFA) score was calculated. IAP was assessed in both groups of patients every six hours during the first 72 hours through a Foley catheter pla-ced in the urinary bladder with instillati-on volume of 50 ml of sterile 0.9% NaCl. IAP was measured at end-expiration in the complete supine position after ensuring that abdominal muscle con-tractions are absent and with the CVP scale zeroed at the level of symphysis pubis line and readings in cmH2O were converted into mmHg by multiplicati-on with 0.74. IAH was diagnosed with two consecutive measurements of IAP >12mmHg. At the same time lacta-te levels in arterial blood, SvO2 and CVP were assessed. The presence of microorganism(s) in blood culture was verified as well.  Data were compared using Student’s t test and p<0.05 was considered statistically significant. ResultsIn the severe sepsis group 25 patients (65.8%) had IAP >12mmHg, 10 patients (26.3%) had IAP >16mmHg and three patients (7.9%) had IAP >20mmHg. In the control group all patients had IAP up to 7mmHg. Lactate levels in arterial blood were significantly increased in the severe sepsis patients group with IAP >16mmHg (4.2mmol/L versus 1.2mmol/L; p <0.05) compared to the control group (figure 1). Other haemodynamic parameters that were measured showed no statistically significant difference between the severe sepsis group and the control patients group (table 2).  Generally, mortality in severe sepsis patients with IAH was 24.5 % (10 patients).DiscussionThe primary objective of this study was to test the correlation between intra-abdominal hypertension and arterial lactate concentration in severe sep-sis patients.  As already described in Table 1. Risk factors for intra-abdominal hypertensionFactors1    Obesity2    Pancreatitis3    Gastrointestinal bleeding4    Liver dysfunction5    Acidosis6    Metabolic derangement/organ       failure7    Shock8    Hypotension9    Respiratory failure10  ALI/ARDS11  Fluid restitution (>3,5L crystalloid       or colloid)    ALI, acute lung injury; ARDS, acute res-piratory distress syndromeIAP, intra-abdominal pressureFigure 1. Arterial blood lactate concentration in the severe sepsis patient group and the control group 27www.signavitae.comthe Results section, there is a positive correlation between the two investiga-ted indicators, which is in accordance with data from literature. Splanchnic ischemia detection in patients with IAH is also a problem when measures of global oxygen transport such as ScvO2 and serum lactate are used in sepsis evaluation. In these patients IAP moni-toring provides an earlier splanchnic hypoperfusion risk warning compared to mixed ScvO2. (8) In severe sepsis patients the important question is volume restitution in order to achieve haemodynamic stabilisation of patients with a diminished possibility of IAH development.The question is what type of soluti-ons should be preferred: crystaloid or colloid.Reintam et al. noted that 45% of the severe sepsis population developed IAH. IAH presence was a marker for a higher mortality rate (50%) compared to sepsis patients who did not deve-lop IAH (19%). (9) Sugre et al. showed that elevated IAP (>18mmHg) was an independent predictor of renal failure, ranking up with hypotension, age and sepsis in a large cohort of surgical ICU patients. (10) Malbrain et al. found that even elevations of IAP >12mmHg in a mixed population of ICU patients were an independent risk factor for organ dysfunction and mortality (39% vs 22%). (11) Daugherty et al. noted that the majority of patients in their medical ICU population who developed IAH were patients with sep-tic shock. Patients with IAH had a higher mortality rate (70% vs. 50%) and longer ICU length of stay (21 vs. 12 days). (12) A therapeutic approach, beside the conservative approach, includes surgical decompression when the intra-abdominal pressure is 20mmHg or greater, taking into consideration the potential benefits and the perioperative risk related to this procedure in each individual case. ConclusionContinuous IAP monitoring in severe sepsis patients is important for early detection of splachnic hypoperfusion and consequent multi-organ failure as well as for the timely application of effi-cacious therapeutic procedures.Lactate levels in arterial blood were significantly higher in severe sepsis patients with IAH >16mmHg compared to control group patients without IAH. However, that measure is a late indica-tor of irreversible systemic hypoxia. Table 2. Other haemodynamic parameters measured in both groupsVariable Severe sepsis patient groupControl group p valueMAP (mmHg) 77.6±8.5 83.3±12.5 0.012HR (bpm) 97.5±19.7 94.2±19.4 0.659CI (l/min/m2) 3.2±1.8 3.5±1.2 0.248SVRI (dyn·s·cm2· m2)   1180±391 1248±269 0.032GEDVI (ml/m2) 782±178 791±124 0.316CVP (mmHg) 11±3 10±2 0.219ScvO2 (%) 77±4 71±2 0.038CI, cardiac index; CVP, central venous pressure; GEDVI,  global end-diastolic volume index; HR, heart rate; MAP, mean arterial pressure; ScvO2, central venous oxygen saturation; SVRI, systemic vascular resistance index28 www.signavitae.comREFERENCES1. Malbrain ML, Chiumello D, Pelosi P et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple center epidemiological study. Crit Care Med 2005; 33:315-22.2. Regueira T, Bruhn A, Hasbun P, Aguirre M, Romero C et al. Intraabdominal hypertension: Incidence and association with organ dysfunction during early septic shock. Journal of Critical Care; doi: 10.1o16/j.jcrc.2007.12.013.3. Cheatham ML, Malbrain ML, Kirkpatrick A, et al. Results from the International Conference of Experts on Intraabdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med 2006;32:1722-32.4. Regueira T, Bruhn A, Hasbun P, Aguirre M, Romero C et al. Intraabdominal hypertension: Incidence and association with organ dysfunction during early septic shock. Journal of Critical Care doi: 10.1016/j.jcrc.2007.12.013.5. Dellinger P, Mitchell M, Rhodes A, Annane D, Gerlach H et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. JAMA 2012;308(16):1641-1650. DOI 10.1097/CCM.06013e31827e83af.20126. Levy MM, Dellinger RP, Townsend SR, Linde-Zwirble WT, Marshall JC, Bion J, Schorr  C, Artigas A, Ramsay G, Beale R, Parker MM, Gerlach H, Reinhart K, Silva E, Harve M, Regan S, Angus DC. Surviving sepsis campaign.Crit Care Med.2010;38(2): 367-74.7. Levy MM, Fink MP, Marshall JC et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 2003 Apr; 31(4):1250-6.8. Schwarte LA, Scheeren TW, Lorenz C et al. Moderate increase in intraabdominal pressure attenuates gastric mucosal oxygen saturation in patients undergoing laparascopy. Anesthesiology 2004;100(5):1081-7.9. Reintam A, Parm P, Kitus R, Kern R Starkkopf J. Intra-abdominal hypertension as a risk factor of death in patients with severe sepsis or septic shock. Critical Care 2007;11(2):319.10. Sugrue M, Jones F, Deane SA, Bishop G, Bauman A, Hillman K. Intra-abdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg1999;134(10):1082-5.11. Malbrain M, Chiumello D, Pelosi P, et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple center epidemiological study. Critical Care Med 2005;33(2):315-22.12. Daugherty EL, Hongyan L, Taichman D, Hansen-Flaschen J, Fuchs BD. Abdominal compartment syndrome is common in medical inten-sive care unit patients receiving large-volume resuscitation. Journal of intensive care medicine 2007;22(5):294-9.

Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

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Correlation between intra-abdominal hypertension and arterial lactate concentration in severe sepsis patients

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