Intra-abdominal pressure and possible ways of its drug correction after emergency laparotomy
Keywords:intra-abdominal pressure, intra-abdominal hypertension, laparotomy, hemodynamics, inflammation, simethicone, metoclopramide, neostigmine, peristalsis, postoperative period
Introduction. Postoperative disorders of gastrointestinal tract (GIT) motility are often after abdominal operations. Postoperative enteroparesis is usually accompanied by the raise of intra-abdominal pressure (IAP).
Materials and methods. After approval of research by bioethics committee and informed consent 52 patients were prospectively divided in 2 groups depending on the type of postoperative intensive care. Patients underwent operations on abdominal cavity by laparotomy incision on the subject of peritonitis. Patient of the 1 (control) group (n=27) after operation received stimulation of GIT with metoclopramide and simethicone. In the 2 group (n=25) patients received metoclopramide and simethicone. Patients were comparable on age, sex, concomitant pathology, ASA class (IIE-IIIE) and the type of operative intervention (laparotomy on the subject of peritonitis). IAP level was studied before operation and at 1,2,3 days after it. IAP was measured by indirect method trough the urinary bladder. The values recommended by the World society of abdominal compartment syndrome were considered as the normal IAP level. Perfuse pressure (PP) in abdominal cavity was calculated by formula: PP=MAP-ICP where MAP – mean arterial pressure. There were also studied indices of the central and peripheral hemodynamics, inflammation markers (leukocytes, fibrinogen level, IL-1α, TNFα, IL-10, leukocytic index of intoxication was calculated). The final point of research was 28 day after operation when we evaluated mortality and life quality on Rancho Los Amigos scale.
Results and discussion. We registered the raise of IAP in 63.1% of patients. The value of intra-abdominal pressure exceeded an upper limit of the normal one by 58,5% (р <0,001). Among patients with high IAP 83% had intra-abdominal hypertension (IAH) of 1 degree, 17% - of 2 degree. The development of 3 and 4degree IAH were not observed before operation. PP remained within the normal.
Correlative analysis revealed an influence of high IAP on the cardiac muscle activity because between IAP and the left ventricle capacity (R=0,53, p=0,04), left ventricle work (R=0,4, p=0.13) were formed the moderate correlations that testified an overload of cardiac muscle as an effect of high IAP. The direct high correlation between IAP and IL-1α (R=0,82, p=0,08) also testified an influence of IAP on inflammation development. The moderate positive correlation between IAP and potassium level (R=0,46, p=0,02) testified the role of ion-dependent mechanisms in formation of high IAP.
In a day after operation IAP was high in 92,6 % of patients of the 1 group. The mean IAP level exceeded normal by 66.6 % (p<0.001). Considering the structure of IAP value there was revealed that 63 % of examined persons had the high IAP that did not attend ICH of 1 degree26,9 % – ICH of the 1 degree, 2,7 % – ICH of the 2 degree, 7,4 % - had the normal values. At this stage of examination PP remained within normal but we observed decrease of this index by 8,1% (р=0,022) comparing to preoperative level. In the 2 group in a day after operation IAP was high in 72 % of patients. The mean IAP value exceeded an upper normal limit by 40.1 % (p<0.001). In37.5 % of patients of the 2 group took place the high IAP that did not attend ICH of 1 degree,37.5 % – ICH of 1 degree, 12.5 % – ICH of 2 degree, 25 % – the normal values. The raise of IAP was accompanied with the change of PP which level decreased by 8,1 % (р=0,012) comparing to preoperative one.
Correlative analysis revealed an influence of IAP on cardiovascular system because in 1 day after operation the moderate positive correlation was formed between IAP and the minute volume of blood circulation (R=0,69, p=0,027), heart index (R=0,61, p=0,06).
The maximal raise of IAP in patients of all groups was observed at the 2 day after operation. 100% patients of all groups had the high IAP. Its mean value exceeded normal by 68,5 % (р<0,001) in the 1 group, by 48,5 % (р<0,001) – in the 2 group.
In 3 days after operation IAP decreased in both groups. In the 1 group the high IAP value was in 58.8 % of patients and its mean value decreased by 19.1 % (p=0.011) comparing to preoperative level and exceeded normal by 27 % (р=0,037). Among them 47 % had the high IAP that did not attend ICH of 1 degree, 11.8 % - ICH of 1 41.2 % – normal IAP values. In the 2 group 75 % patients had normal IAP values. In the rest of patients its level did not attend ICH of 1 degree.
Correlative analysis demonstrated the direct correlation between IAP value and heart rate (R=0,63, p=0,02), potassium level and IAP (R=0,65, p=0,05) in 3 days after operation.
Lethality did not differ in both groups. 100 % of patients of the 2 group and absolute majority of patients of the 1 group attended the VIII life quality level on RLAS scale at 28 day after operation
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