IntraAbdominal Pressure Monitoring

1
Intra-Abdominal Pressure Monitoring
With the AbViser
By Tim Wolfe, MD Email twolfe_at_wolfetory.com
2
Intra-Abdominal Pressure Monitoring
The reference standard for intermittent IAP
measurement is via the bladder with a maximal
instillation volume of 25 ml sterile saline.
WSACS.org
3
Home Made IAP Kits

• Home Made IAP monitoring
• Ingenious for proof of concept in research
  setting
• Inadequate for routine use in broad ICU setting

4
Home Made IAP Kits

• Unfortunately There are problems with home-made
  Kits.
• Nurses (and doctors) are not engineers
• Lack of quality control things go wrong at
  worst possible times
• Lack of Standardization Bad data may be worse
  than no data
• Data Reproducibility Bad data may be worse than
  no data
• Usability problems - hampers trending, prevents
  routine use
• Time Consuming - hampers trending, prevents
  routine use
• Sterility issues CAUTI concerns can outweigh
  IAP concerns

5
Home Made IAP Kits

• Usability Issues
• Definition of Usability
• Evaluation of the human-technologic interface to
  assess how easy a technology is to use.
• It Evaluates two concepts
• Efficacy - Does the technology work when used
  in a routine setting
• Satisfaction data Did the end user like the
  method or was it difficult to use?
• Point
• A good idea that is difficult to use/
  un-satisfying to the end user will RARELY be
  adopted outside the research setting it will
  never become a routine standard.

6
Home Made IAP Kits

• Who are we kidding?
• Isnt our goal to make IAP monitoring a standard?
• Outside a research setting and the rare highly
  motivated ICU what is the probability of these
  homemade concepts becoming a standard and truly
  impacting critical care?
• Is the few dollars saved worth the huge dollars
  lost in delays?
• Do you actually believe these kits are reliable
  (outside your expert hands?)

7
WSACS leaders appear to doubt the reliability of
home made kits

• We have all seen the magic drop or rise in CVP
  at changes of nurse shifts, the same can happen
  with IAP
• Malbrain, Intensive Care Med 2004
• The current literature on intra-abdominal
  pressure has failed to evaluate inter- and
  intra-observer variability, which we know is an
  important aspect of day-to-day use of tests and
  equipment in ICU
• Sugrue, Intensive Care Med 2002

8
Potential IAP monitoring problems recognized by
others

• Accurate, repeatable measurements of
  intra-abdominal pressure (IAP) are necessary to
  ensure proper management of patients at risk for
  intra-abdominal hypertension (IAH).
• Fusco, J Trauma 2001
• Preassembled kits significantly reduce setup
  time, reduce the margin for monitoring error by
  maintaining consistency of this portion of the
  setup, and reduce the risk of system
  contamination during assembly
• Darovic, Fluid filled monitoring systems 2002

9
SOLUTION
AbViser AutoValve

Intra-Abdominal Pressure Monitoring Device
10
How to Use the AbViser

• One Step Infusion of saline into bladder
• Aspirate 20 ml saline into the syringe.
• Compress the syringe to infuse the saline.
• Read the IAP
• Repeat as needed

Measure
Drain
Thats all no valves or clamps or easily made
errors
11
AbViser AutoValve in Measure Mode

• Measure Mode
• Pressure transduction lumen is open
• Balloon (diaphragm) inflates with saline
  injection- Occluding drain lumen and directing
  fluid into bladder.
• After approximately 90 seconds the balloon
  automatically deflates and fluid drains normally

AutoValve in Measure Mode
Pressure Transduction
Foley
Drain Occluded
Infusion
Diaphragm inflated
12
AbViser AutoValvein Drain Mode
Diaphragm Deflated

• Drain Mode
• AutoValve Diaphragm is deflated
• Urinary drain lumen is open
• This allows continuous drainage of the urine.

Foley
Drain
AutoValve in Drain Mode
13
AbViser Reproducibility Study
Inter-observer Scatterplot (r 0.95, p lt 0.001)

• Nursing driven study with 89 different nurses
  participating.
• Excellent intra- and inter- observer
  reproducibility

Kimball, Int Care Med 2007
14
Does IAP/IAH protocol driven monitoring affect
patient outcome?

• Kimball 2009 A prospective evaluation of
  protocolized management of intraabdominal
  hypertension and ACS, Acta Clinica Belg 2009
• Data on 600 high risk monitored cases (not all
  had IAH or ACS)

• Mortality
• ? 18 relative risk
• Open Abdomens
• ? 40 relative risk
• ICU LOS
• 4 days
• Ventilator Days
• ? 4.3 days

12 fewer decompressions
?4 fewer ICU/vent days per patient
15
AbViser Intra-Abdominal pressure monitoring kit

• Features and Advantages
• Proven accuracy and reproducibility Proven in
  clinical setting (Kimball Int Care Med 2007)
• Preassembled kit reduces error and
  contamination risks, provides quality control
• Ease of use End user (nurse) becomes an
  advocate for IAP monitoring due to simplicity and
  speed
• Standardization reduces potential errors
  (Kimball Int Care Med 2007, Cheatham Crit Care
  Med 2009, De Keulenaer Int Care Med 2009 )
• Outcomes Improved outcomes with frequent easy
  monitoring and protocol intervention (Kimball,
  Acta Clin Belg 2009)