Hemodynamic effects of increased intra-abdominal pressure in critically ill children

Silveira, Letícia G.T; Brocca, Isabela C; Moraes, Erika S; Brandão, Marcelo B; Nogueira, Roberto J.N; Souza, Tiago Henrique de

doi:10.1016/j.jped.2020.11.002

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ORIGINAL ARTICLE • J. Pediatr. (Rio J.) 97 (05) • Sep-Oct 2021 • https://doi.org/10.1016/j.jped.2020.11.002 copy

Hemodynamic effects of increased intra-abdominal pressure in critically ill children

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To evaluate the influence of intra-abdominal pressure on the cardiac index (CI) at different intra-abdominal hypertension grades achieved when performing an abdominal compression maneuver (ACM). Evaluating the effectiveness of the ACM in distending the left internal jugular vein (LIJV).

Methods:

Prospective observational study conducted in the PICU of a quaternary care teaching hospital. Participants underwent the ACM and the IAP was measured with an indwelling urinary catheter. At each IAH grade reached during the ACM, the CI was measured by transthoracic echocardiography and the LIJV cross-sectional area (CSA) was determined by ultrasonography.

Results:

Twenty-four children were included (median age and weight of 3.5 months and 6.37 kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65 L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8. (IQR 3.12−4.03), 3.38 L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8. (IQR 3.04−3.73), 3.16 L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8. (IQR 2.70−3.53), 2.89 L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8. (IQR 2.38−3.22), and 2.42 L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8. (IQR 1.91−2.79), respectively. A 25% increase in the LIJV CSA area was achieved in 14 participants (58%) during the ACM.

Conclusion:

The ACM significantly increases IAP, causing severe reversible impairment in the cardiovascular system and is effective in distending the LIJV in just over half of the subjects. Even low levels of HIA can result in significant cardiac dysfunction in children. Therefore, health professionals should be aware of the negative hemodynamic repercussions caused by the increased IAP.

KEYWORDS
Intra-abdominal hypertension; Abdominal compartment syndrome; Central venous catheterization; Hemodynamics; Pediatric intensive care; Children

Variables	All (²⁴24 Sakka SG, Huettemann E, Petrat G, Meier-Hellmann A, Schier F, Reinhart K. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhaphy in small children. Br J Anaesth. 2000;84:330–4.)	Responders (¹⁴14 Pearson EG, Rollins MD, Vogler SA, Mills MK, Lehman EL, Jacques E, et al. Decompressive laparotomy for abdominal compartment syndrome in children: before it is too late. J Pediatr Surg. 2010;45:1324–9.)	Non-responders (¹⁰10 Advanced Life Support Group. Advanced paediatric life support: a practical approach to emergencies. 6th ed. Manchester UK: Wiley-Blackwell; 2016. p. 384.)	Signiﬁcance^a a Mann-Whitney U test.
Age (months)	3.50 (3.00−10.50)	3.50 (3.00−11.00)	3.50 (2.00−10.00)	p = 0.859
Weight (kg)	6.37 (5.18−8.00)	6.50 (5.60−8.50)	5.70 (5.00−7.20)	p = 0.412
Stature (cm)	61.5 (58.5−68.5)	62.5 (59.00−69.0)	60.0 (58.0−64.0)	p = 0.558
PIM2 (%)	1.5 (0.5−6.5)	2.8 (0.3−8.0)	1.2 (0.6−4.8)	p = 0.680
MAP (cmH₂0)	9.80 (9.45−10.25)	10.00 (9.80−10.50)	9.45 (8.90−9.80)	p = 0.027
Baseline IAP (mmHg)	7.50 (6.62−8.27)	6.99 (5.51–8.09)	8.09 (7.35−8,46)	p = 0.217
Baseline CI (L/min/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8.)	3.65 (3.12−4.03)	3.72 (2.96−4.12)	3.53 (3.29−3.89)	p = 0.660
Baseline LIJV CSA (cm²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8.)	0.32 (0.25−0.50)	0.34 (0.23−0.51)	0.31 (0.29−0.49)	p = 0.769
Baseline SVi (mL/m²2 Horoz OO, Yildizdas D, Asilioglu N, Kendirli T, Erkek N, Anil AB, et al. The prevalance of and factors associated with intra-abdominal hypertension on admission day in critically Ill pediatric patients: A multicenter study. J Crit Care. 2015;30:584–8.)	28.68 (25.27−33.19)	29.61 (25.59−33.15)	27.36 (24.95−36.25)	p = 0.558
Baseline HR (min⁻¹1 Thabet FC, Ejike JC. Intra-abdominal hypertension and abdominal compartment syndrome in pediatrics. A review. J Crit Care. 2017;41:275–82.)	126.5 (124.0−144.5)	125.5 (124.0−146.0)	133.0 (124.0−143.0)	p = 0.660
Baseline VTI (cm)	16.70 (16.05−19.27)	16.42 (15.95−119.20)	16.92 (16.40−19.60)	p = 0.348

Variables	Baseline	Intra-abdominal pressure values				Significance^a a Friedman’s test (difference between IAH grade I, II and III for all participants) and Wilcoxon signed-rank test (difference between IAH grade III and IV, N = 10), respectively.
Variables	Baseline	IAH Grade I	IAH Grade II	IAH Grade III	IAH Grade IV	(N = 10)
LIJV CSA (cm²)	0.32 (0.25−0.50)	0.35 (0.30−0.55)	0.40 (0.33−0.57)	0.42 (0.32−0.62)	0.46 (0.32−0.63)	p < 0.001; p = 0.687
HR (bpm)	126.5 (124.0−144.5)	128.5 (119.5−144.0)	132.0 (116.0−148.0)	133.0 (119.5−148.5)	126.0 (85.0−137.0)	p = 0.142; p = 0.734
VTI (cm)	16.70 (16.05−19.27)	15.82 (14.60−17.67)	14.47 (13.72−16.75)	12.92 (12.32−13.95)	12.45 (11.65−14.35)	p < 0.001; p = 0.006
CI (L/min/m²)	3.65 (3.12−4.03)	3.38 (3.04−3.73)	3.16 (2.70−3.53)	2.89 (2.38−3.22)	2.42 (1.91−2.79)	p < 0.001; p = 0.004
SVi (mL/ m²)	28.68 (25.27−33.19)	27.31 (23.82−29.59)	25.54 (21.92−28.07)	21.69 (19.23−24.71)	21.13 (18.53−23.66)	p < 0.001; p = 0.006

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[1] * Corresponding author. E-mail: tiago.souza@hc.unicamp.br (T.H. de Souza).