Supplement 9.Abdominal Perfusion Pressure

Should We Use Abdominal Perfusion Pressure (APP) as a Resuscitation Endpoint?

APP, which may be thought of as an intra-abdominal analogue to cerebral perfusion pressure, is defined as mean arterial presure (MAP) minus IAP. This measure has previously been suggested to be a more accurate predictor of visceral perfusion and a better endpoint for resuscitation than IAP or MAP alone [[1, 2]].

Evidence Summary:

We identified no relevant APP management RCTs or meta-analyses. However, among 12 available observational studies of patients with IAH or ACS, the majority reported that a reduced APP may be a poor independent prognostic factor among critically ill patients (Table 3) [[2-7], [8-13]]. However, many of these studies enrolled heterogeneous populations of intensive care unit (ICU) patients and were assessed to be of low quality due to risk of bias and indirectness.

Reccomendation:

The WSACS could make NO RECOMMENDATION regarding the use of APP in the resuscitation/management of the critically ill/injured.

Rationale for Recommendation:

Although reduced APP may be a poor prognostic factor among those with IAH, it remains unclear if improving or increasing APP results in improved outcomes. Future interventional trials comparing APP versus IAP as a resuscitation endpoint are required before any recommendations can be made.

Summary of Findings Table for Abdominal Perfusion Pressure.

IAH management strategies that use APP compared to IAH management strategies that do not consider APP for critically ill patients with IAH
Outcomes / No of Participants
(studies)
Follow up / Quality of the evidence
(GRADE) / Relative effect
(95% CI) / Anticipated absolute effects
Risk with IAH management strategies that do not consider APP / Risk difference with IAH management strategies that use APP (95% CI)
Mortality / 0
(1 study2) / ⊕⊝⊝⊝
VERY LOW
due to risk of bias, indirectness / OR 0.94
(0.88 to 0.99)1 / Study population
See comment / -
Moderate
-
Acute renal failure / 0
(1 study) / ⊕⊝⊝⊝
VERY LOW
due to risk of bias, indirectness / OR 3.41
(2.02 to 4.93)3 / Study population
See comment / -
Moderate
-
APP: Abdominal perfusion pressure; CI: Confidence interval; IAH: Intra-abdominal hypertension; and OR: Odds ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1 OR adjusted for Acute Physiology and Chronic Health Evaluation-II (APACHE-II) and McCabe score.
2 Only one study is presented as it examined the prognostic implications of APP among a mixed population of medical and surgical patients, and many other studies did not present their data in a way that could easily be represented in a summary of findings table.
3 Factors included in analyses were IAH, APACHE-II score, filtration gradient, surgical admission, sepsis, age, systemic arterial hypotension, diabetes mellitus, chronic renal disease, liver disease.

Summary of Studies

A summary of Studies is available online at Supplement A3. Summary of Studies related to the Abdominal Prefusion Pressure

References

1.Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A, (2006) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med 32: 1722-1732

2.Cheatham ML, White MW, Sagraves SG, Johnson JL, Block EFJ, (2000) Abdominal perfusion pressure: A superior parameter in the assessment of intra-abdominal hypertension. J Trauma 49: 621-627

3.Malbrain M (2002) Abdominal perfusion pressure as a prognostic marker in Intra-abdominal hypertension: Fact or Fiction? In: Vincent JL (ed) Yearbook of IINtensive Care and Emergency Medicine. Springer, pp. 792-914

4.Bieda K, Pukacki F, Zielinski M, Sobczynski P, Oszkinis G, Hartman-Sobczynska R, Majewski W, (2011) Utility of measurements of abdominal perfusion pressure as a measure of isovolemic status and intestinal perfusion in patients with ruptured aortic aneurysm. Pol Przegl Chir 83: 443-448

5.Regueira T, Bruhn A, Hasbun P, Aguirre M, Romero C, Llanos O, Castro R, Bugedo G, Hernandez G, (2008) Intra-abdominal hypertension: incidence and association with organ dysfunction during early septic shock. J Crit Care 23: 461-467

6.Vidal MG, Ruiz Weisser J, Gonzalez F, Toro MA, Loudet C, Balasini C, Canales H, Reina R, Estenssoro E, (2008) Incidence and clinical effects of intra-abdominal hypertension in critically ill patients. Critical care medicine 36: 1823-1831

7.Ke L, Ni HB, Tong ZH, Li WQ, Li N, Li JS, (2011) Intra-abdominal pressure and abdominal perfusion pressure: which is a better marker of severity in patients with severe acute pancreatitis. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 15: 1426-1432

8.Atila K, Terzi C, Ozkardesler S, Unek T, Guler S, Ergor G, Bora S, Gulay H, (2009) What is the role of the abdominal perfusion pressure for subclinical hepatic dysfunction in laparoscopic cholecystectomy? Journal of laparoendoscopic & advanced surgical techniques Part A 19: 39-44

9.Dabrowski W, Wacinski P, Visconti J, (2009) Abdominal perfusion pressure and coronary arterial perfusion pressure in patients undergoing coronary artery bypass graft surgery. Experimental and clinical cardiology 14: e84-88

10.Dabrowski W, Rzecki Z, (2009) Intra-abdominal and abdominal perfusion pressure in patients undergoing coronary artery bypass graft surgery. Acta Clinica Belgica 64: 216-224

11.Reintam A, Parm P, Kitus R, Kern H, Starkopf J, (2008) Primary and secondary intra-abdominal hypertension--different impact on ICU outcome. Intensive care medicine 34: 1624-1631

12.Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, Keulenaer BL, Daelemans R, Jacquet L, Laterre PF, Frank G, de Souza P, Cesana B, Gattinoni L, (2005) Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multi-center epidemiological study. Crit Care Med 33: 315-322

13.Dalfino L, Tullo L, Donadio I, Malcangi V, Brienza N, (2008) Intra-abdominal hypertension and acute renal failure in critically ill patients. Intensive care medicine 34: 707-713