Intra-abdominal hypertension and abdominal compartment syndrome in the critically ill liver cirrhotic patient-prevalence and clinical outcomes. A multicentric retrospective cohort study in intensive care

Rui Pereira, Maria Buglevski, Rui Perdigoto, Paulo Marcelino, Faouzi Saliba, Stijn Blot, Joel Starkopf, Rui Pereira, Maria Buglevski, Rui Perdigoto, Paulo Marcelino, Faouzi Saliba, Stijn Blot, Joel Starkopf

Abstract

Background: Liver cirrhosis and ascites are risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); however, data is scarce. We aimed to determine the prevalence of IAH/ACS in a population of critically ill cirrhotic patients with acute medical illness in intensive care and to assess for risk factors and clinical outcomes.

Methods: This was a multicentric retrospective cohort study including two general ICUs and pooled data from a multicentric study between January 2009 and October 2019.

Results: A total of 9,345 patients were screened, and 95 were included in the analysis. Mean age was 56.7±1.3 years, and 79% were male. Liver cirrhosis etiology included alcohol in 45.3% and alcohol plus hepatitis C virus in 9.5%. Precipitating events included infection in 26% and bleeding in 21% of cases. Mean severity score MELD and SAPS II were 26.2±9.9 and 48.5±15.3, respectively, at ICU admission. The prevalence of IAH and ACS was respectively 82.1% and 23.2% with a mean value of maximum IAP of 16.0±5.7 mmHg and IAH grades: absent 17.9%, I 26.3%, II 33.7%, III 17.9%, and IV 4.2%. Independent risk factors for IAH were alcoholic cirrhosis (p = 0.01), West-Haven score (p = 0.01), and PaO2/FiO2 ratio (p = 0.02); as well as infection (p = 0.048) for ACS. Overall, 28-day mortality was 52.6% associated with higher IAP and ACS, and independent risk factors were MELD (p = 0.001), white blood cell count (p = 0.03), PaO2/FiO2 ratio (p = 0.03), and lactate concentration (p = 0.04) at ICU admission.

Conclusions: This study demonstrates a very high prevalence of IAH/ACS in the critically ill cirrhotic patient in intensive care. Increased IAP and ACS were associated with severity of disease and adverse outcomes and independent risk factors for IAH were alcoholic cirrhosis, hepatic encephalopathy and PO2/FiO2 ratio, as well as infection for ACS. Early diagnosis, prevention, and treatment of IAH/ACS might improve outcome in critically ill cirrhotic patients.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1. Patient flowchart.
Fig 1. Patient flowchart.
Patients with liver cirrhosis were considered eligible and were excluded if surgical type ICU admission or absence of IAPm. Abbreviations: AbSeS–Abdominal Sepsis Study: Epidemiology of Etiology and Outcome; ACS–Abdominal Compartment Syndrome; ICU–Intensive Care Unit; IAH–Intra-abdominal Hypertension; IAPm–Intra-Abdominal Pressure measure.
Fig 2. Distribution of IAH grades for…
Fig 2. Distribution of IAH grades for maximum intra-abdominal pressure and mortality rates in critically ill liver cirrhotic patients.
Abbreviations: IAH–Intra-abdominal hypertension; ICU–intensive care unit.
Fig 3. Distribution of IAH grades for…
Fig 3. Distribution of IAH grades for mean intra-abdominal pressure and mortality rates in critically ill liver cirrhotic patients.
Abbreviations: IAH–Intra-abdominal hypertension; ICU–intensive care unit.

References

    1. Kirkpatrick AW, Roberts DJ, De Waele J, Jaeschke R, Malbrain MLNG, De Keulenaer B, et al.. Intra-abdominal hypertension and the abdominal compartment syndrome: Updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med [Internet]. 2013. July 15;39(7):1190–206. Available from: . 10.1007/s00134-013-2906-z
    1. Kyoung K-H, Hong S-K. The duration of intra-abdominal hypertension strongly predicts outcomes for the critically ill surgical patients: a prospective observational study. World J Emerg Surg. 2015. December;10(1):22. 10.1186/s13017-015-0016-7
    1. Malbrain MLNG, Chiumello D, Pelosi P, Wilmer A, Brienza N, Malcangi V, et al.. Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med [Internet]. 2004. May 1 [cited 2018 Nov 13];30(5):822–9. Available from: . 10.1007/s00134-004-2169-9
    1. Malbrain MLNG, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, 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. February;33(2):315–22. 10.1097/01.ccm.0000153408.09806.1b
    1. Reintam Blaser A, Regli A, De Keulenaer B, Kimball EJ, Starkopf L, Davis WA, et al.. Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients—A Prospective Multicenter Study (IROI Study). Crit Care Med. 2019;47(4):535–42. 10.1097/CCM.0000000000003623
    1. Padar M, Blaser AR, Talving P, Lipping E, Starkopf J. Abdominal compartment syndrome: Improving outcomes with a multidisciplinary approach–a narrative review [Internet]. Vol. 12, Journal of Multidisciplinary Healthcare. Dove Medical Press Ltd.; 2019. [cited 2021 Mar 19]. p. 1061–74. Available from: /pmc/articles/PMC6927564/. 10.2147/JMDH.S205608
    1. Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, et al.. The management of ascites in cirrhosis: Report on the consensus conference of The International Ascites Club. Hepatology. 2003;38(1):258–66. 10.1053/jhep.2003.50315
    1. European Association for the Study of the Liver, Ginés P, Angeli P, Lenz K, M??ller S, Moore K, et al.. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology Sep, 2010. p. 397–417.
    1. Blot S, Antonelli M, Arvaniti K, Blot K, Creagh-Brown B, de Lange D, et al.. Epidemiology of intra-abdominal infection and sepsis in critically ill patients: “AbSeS”, a multinational observational cohort study and ESICM Trials Group Project. Intensive Care Med. 2019;.
    1. Olson JC, Kamath PS. Acute-on-chronic liver failure: concept, natural history, and prognosis. Curr Opin Crit Care [Internet]. 2011. April [cited 2017 Nov 24];17(2):165–9. Available from: . 10.1097/MCC.0b013e328344b42d
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med [Internet]. 1985. October [cited 2018 Aug 30];13(10):818–29. Available from: .
    1. Gall JR, Lemeshow S, Saulnier F. A New Simplified Acute Physiology Score (SAPS II) Based on a European/North American Multicenter Study. JAMA J Am Med Assoc. 1993;. 10.1001/jama.270.24.2957
    1. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al.. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;.
    1. Kim WR, Biggins SW, Kremers WK, Wiesner RH, Kamath PS, Benson JT, et al.. Hyponatremia and mortality among patients on the liver-transplant waiting list. N Engl J Med. 2008;. 10.1056/NEJMoa0801209
    1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med. 1985;13(10):818–29.
    1. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PCJ. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000. April;31(4):864–71. 10.1053/he.2000.5852
    1. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al.. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013. June;144(7):1426–37, 1437.e1-9. 10.1053/j.gastro.2013.02.042
    1. Cheatham ML, Malbrain MLNG, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al.. Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. II. Recommendations. In: Intensive Care Medicine. 2007. p. 951–62. 10.1007/s00134-007-0592-4
    1. Malbrain MLNG, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, et al.. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. In: Intensive Care Medicine [Internet]. Intensive Care Med; 2006. [cited 2020 Aug 24]. p. 1722–32. Available from: . 10.1007/s00134-006-0349-5
    1. De Laet IE, Malbrain MLNG, De Waele JJ. A Clinician’s Guide to Management of Intra-Abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients [Internet]. Vol. 24, Critical Care. BioMed Central Ltd.; 2020 [cited 2020 Sep 30]. p. 97. Available from: . 10.1186/s13054-020-2782-1
    1. Nadim MK, Durand F, Kellum JA, Levitsky J, O’Leary JG, Karvellas CJ, et al.. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. In: Journal of Hepatology [Internet]. Elsevier B.V.; 2016. [cited 2020 Sep 30]. p. 717–35. Available from: . 10.1016/j.jhep.2015.10.019
    1. Al-Dorzi HM, Tamim HM, Rishu AH, Aljumah A, Arabi YM. Intra-abdominal pressure and abdominal perfusion pressure in cirrhotic patients with septic shock. Ann Intensive Care. 2012. July;2012:S4. 10.1186/2110-5820-2-S1-S4
    1. Arabi YM, Aljumah A, Dabbagh O, Tamim HM, Rishu AH, Al-Abdulkareem A, et al.. Low-dose hydrocortisone in patients with cirrhosis and septic shock: A randomized controlled trial. CMAJ. 2010. December 14;182(18):1971–7. 10.1503/cmaj.090707
    1. De Laet I, Citerio G, Malbrain MLNG. The influence of intra-abdominal hypertension on the central nervous system: Current insights and clinical recommendations, is it all in the head? In: Acta Clinica Belgica. 2007. p. 89–97.
    1. Deeren DH, Dits H, Malbrain MLNG. Correlation between intra-abdominal and intracranial pressure in nontraumatic brain injury. Intensive Care Med. 2005. November;31(11):1577–81. 10.1007/s00134-005-2802-2
    1. Youssef AM, Jahromi AH, Vijay CG, Granger DN, Alexander JS. Intra-abdominal hypertension causes reversible blood-brain barrier disruption. In: Journal of Trauma and Acute Care Surgery. J Trauma Acute Care Surg; 2012. p. 183–8. 10.1097/TA.0b013e31822a3254
    1. Dabrowski W. Changes in intra-abdominal pressure and central venous and brain venous blood pressure in patients during extracorporeal circulation. Med Sci Monit [Internet]. 2007. December [cited 2020 May 29];13(12):CR548–54. Available from: .
    1. Citerio G, Vascotto E, Villa F, Celotti S, Pesenti A. Induced abdominal compartment syndrome increases intracranial pressure in neurotrauma patients: A prospective study. Crit Care Med. 2001;29(7):1466–71. 10.1097/00003246-200107000-00027
    1. Marinis A, Argyra E, Lykoudis P, Brestas P, Theodoraki K, Polymeneas G, et al.. Ischemia as a possible effect of increased intra-abdominal pressure on central nervous system cytokines, lactate and perfusion pressures. Crit Care. 2010. March 15;14(2).
    1. Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure [Internet]. Vol. 36, Journal of Cerebral Blood Flow and Metabolism. Nature Publishing Group; 2016. [cited 2020 Apr 23]. p. 1338–50. Available from: . 10.1177/0271678X16648711
    1. Depauw PRAM, Groen RJM, Van Loon J, Peul WC, Malbrain MLNG, De Waele JJ. The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal. Vol. 161, Acta Neurochirurgica. Springer-Verlag Wien; 2019. p. 855. 10.1007/s00701-019-03868-7
    1. Weil D, Levesque E, McPhail M, Cavallazzi R, Theocharidou E, Cholongitas E, et al.. Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis. Ann Intensive Care. 2017. December;7(1):33. 10.1186/s13613-017-0249-6
    1. Pereira R, Bagulho L, Cardoso FS. Acute-on-chronic liver failure syndrome—clinical results from an intensive care unit in a liver transplant center. Rev Bras Ter intensiva [Internet]. 2020. [cited 2020 Jun 25];32(1):49–57. Available from: . 10.5935/0103-507x.20200009
    1. Verdelho M, Perdigoto R, Machado J, Mateus É, Marcelino P, Pereira R, et al.. Acute-on-Chronic Liver Failure: A Portuguese Single-Center Reference Review. GE Port J Gastroenterol [Internet]. 2018. January [cited 2019 Mar 20];25(1):18–23. Available from: . 10.1159/000478988
    1. Cardoso FS, Abraldes JG, Sy E, Ronco JJ, Bagulho L, Mcphail MJ, et al.. Lactate and number of organ failures predict intensive care unit mortality in patients with acute‐on‐chronic liver failure. Liver Int [Internet]. 2019. March 19 [cited 2019 Aug 14];39(7):liv.14083. Available from: . 10.1111/liv.14083
    1. Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Ginès P, et al.. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol. 2014. November;61(5):1038–47. 10.1016/j.jhep.2014.06.012
    1. Levesque E, Hoti E, Jiabin J, Dellamonica J, Ichai P, Saliba F, et al.. Respiratory impact of paracentesis in cirrhotic patients with acute lung injury. J Crit Care. 2011. June;26(3):257–61. 10.1016/j.jcrc.2010.08.020
    1. Phillip V, Saugel B, Ernesti C, Hapfelmeier A, Schultheiß C, Thies P, et al.. Effects of paracentesis on hemodynamic parameters and respiratory function in critically ill patients. BMC Gastroenterol. 2014. January 27;14(1):18. 10.1186/1471-230X-14-18
    1. Mayr U, Karsten E, Lahmer T, Rasch S, Thies P, Henschel B, et al.. Impact of large volume paracentesis on respiratory parameters including transpulmonary pressure and on transpulmonary thermodilution derived hemodynamics: A prospective study. PLoS One. 2018. March 1;13(3). 10.1371/journal.pone.0193654
    1. Mayr U, Fahrenkrog-Petersen L, Batres-Baires G, Herner A, Rasch S, Schmid RM, et al.. Large-volume paracentesis effects plasma disappearance rate of indo-cyanine green in critically ill patients with decompensated liver cirrhosis and intraabdominal hypertension. Ann Intensive Care. 2018. December 1;8(1). 10.1186/s13613-018-0422-6
    1. Umgelter A, Reindl W, Wagner KS, Franzen M, Stock K, Schmid RM, et al.. Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: A prospective uncontrolled trial. Crit Care. 2008. January 15;12(1). 10.1186/cc6765
    1. Pereira, Rui (Hospital Curry Cabral C. Continuous Passive Paracentesis for Intra-abdominal Hypertension—Full Text View— [Internet]. [cited 2020 May 29]. Available from: .

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