University of Colorado Hospital Nursing Practice Guideline

Intensive Care: Intra-Abdominal Pressure Monitoring

G137N14 1
Related Policies and Procedures:
Pressure Line Management
Insertion, Removal, and Care of an Indwelling Urinary Catheter
Approved by:
Nursing Practice Guidelines Subcommittee
Critical Care Quality Improvement Committee
Effective: 4/03
Revised: 6/14
Description: This guideline describes the implementation, nursing care, and documentation
of Intra-abdominal Pressure (IAP) monitoring. A consistent standard method of monitoring intra-
abdominal pressure (IAP) is necessary to optimize patient care. IAP can be monitored with either
a two-way or three-way indwelling urinary catheter. Pressure trends are to be monitored and
treated accordingly to avoid organ failure.
Accountability: University of Colorado Hospital Critical Care Department Physicians and
Nursing Staff, who are responsible for the care, assessment, and documentation of the patient
with intra-abdominal pressure monitoring.
Definitions:
Intra-abdominal pressure (IAP): the pressure concealed within the abdominal cavity. Normal IAP
is approximately 0-5 mmHg.
Intra-abdominal Hypertension (IAH): a sustained or repeated pathologic elevation of IAP >=
12mmHg
Abdominal Compartment Syndrome (ACS): a sustained IAP >20mmHg (with or without an APP
< 60 mmHg) that is associated with new organ dysfunction / failure
Abdominal Perfusion Pressure (APP): Mean Arterial Pressure (MAP) Intra-abdominal Pressure
(IAP). Superior to other end points in predicting survival and should be maintained >50-60.
Indications: Critically-ill patients with new or progressive organ dysfunction should be
screened for IAH/ACS risk factors. If two or more risk factors (see appendix A) are present, a
baseline IAP measurement should be obtained by checking IAP every 1-2 hours until a baseline
trend is established. If IAH is present, serial IAP measurements should be performed until organ
function has improved. Patients receiving aggressive fluid resuscitation (>5 L/24 hours) and/or
have significant capillary leak are at significant risk of IAH and should have IAP monitoring.
See appendix A. IAH Assessment Algorithm and B. IAH/ACS Management Algorithm.
Contraindications: Risk versus benefit should be discussed with the physician before
measurements are taken in these specific patients: bladder trauma, bladder surgery, and
neurogenic bladder.

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Practice Guidelines:
A. Monitoring IAP using Abvisor (recommended way):
1. Equipment needed for Abviser:
a. 1 bag of 500mL Normal Saline
b. 1 Abviser Kit
c. 1 bedside monitor interface pressure module and cable
d. 4x4s if connecting transducer to patient
e. 1 chloroprep
2. Procedural Step for Abviser
a. Gather appropriate equipment.
b. Utilize body substance isolation and aseptic technique.
c. Connect pressure monitoring module and cable into bedside monitor.
d. Open Abviser kit.
e. Place sterile drape under foley.
f. Take saline spike and insert into 500ml normal saline bag and prime the system.
g. Using aseptic technique, disconnect foley drainage bag from foley catheter and
connect to the barbed end of the Abviser autovalve.
h. Connect the foley drainage bag to opposite side of Abviser autovalve.
i. Mount transducer to either the patient or to a pole. If attaching to patient place
4x4 underneath the transducer to protect the skin.
j. Zero the transducer by placing atmospheric port at the level of the iliac crest in
the mid-axillary line. Mark this level on the patient with an X for consistency.
k. Assure urinary catheter is draining freely and bladder is empty.
l. Position the patient supine and ensure the patient is free of active abdominal
contractions. If the patient cannot tolerate supine positioning, the angle of the
head of bed should be recorded on the electronic health record (EHR) and repeat
measurements must be taken at the same angle every time.
m. Retract the plunger of the syringe on the system to aspirate 20 ml of saline
solution. Instill 20ml of saline into the urinary catheter in 10 seconds.
n. Allow the measurement to equilibrate and read pressure 30-60 seconds post
instillation at end expiration. If reading is obtained too soon after instillation the
IAP may be falsely elevated due to reflexive contraction of the bladder.
o. After 2 minutes the fluid will drain automatically from the catheter, confirm that
the autovalve has opened and urine is draining normally.
p. Document value on EHR. Subtract 20 ml from urine output for the hour.
q. Notify provider of elevated pressure readings (IAP 12 mmHg). Serial
measurements should be taken so increases in pressure can be detected. Discuss
appropriate monitoring intervals with provider.
r. If IAP 12mmHg, discuss with the provider initial treatment options (See
Appendix B). If considering surgical intervention, re-evaluate IAP with the use of
a neuromuscular blocking agent or muscle relaxant before a surgical consult is
requested.


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B. IAP monitoring when not using Abvisor:
1. Equipment needed if not using Abviser kit:
a. 1 bag 500 ml Normal Saline
b. 1 pressure monitoring transducer with tubing and pressure bag
c. 1 bedside monitor interface pressure module and cable
d. 1 30 ml luer lock syringe
e. 1 hemostat
f. 1 three-way stopcock (not for three-way catheter)
g. 1 blue IV line adapter (only for three-way catheter)
h. 1 alcohol swab

2. Procedural steps (for not using Abviser and a two-way indwelling
urinary catheter):
a. Gather appropriate equipment.
b. Utilize body substance isolation and aseptic technique.
c. Connect pressure monitoring module and cable into the bedside monitor.
d. Attach three-way stopcock and 30 ml syringe into pressure line distal to
transducer.
e. Prime transducer circuit, and attach transducer to bedside monitor pressure
module.
f. Zero the transducer by placing the atmospheric port at the level of the iliac crest
mid-axillary line. Mark this level on the pt with an x for consistency.
g. Assure urinary catheter has been draining freely and the bladder is empty.
h. Clean luer lock sampling port with alcohol swab and attach three-way stopcock.
i. Clamp indwelling catheter immediately distal to sampling port.
j. Turn stopcock off to urinary catheter.
k. Instill 25 ml of Normal Saline into 30 ml syringe by flushing the pressure system.
l. Position the patient supine and ensure the patient is free of active abdominal
contractions. If the patient cannot tolerate supine positioning, the angle of the
head of bed should be recorded on electronic record and repeated measurements
must be taken at the same angle every time.
m. Turn stopcock off to transducer. Instill 25 mL of Normal Saline into the urinary
catheter. Larger instillations of volumes were found to falsely elevate IAP by
over distending the bladder (Cheatham).
n. Turn stopcock off to syringe and open to monitor pressure waveform. Read the
pressure 30 to 60 seconds post instillation at end expiration. If reading is obtained
too soon after NS instillation the IAP may be falsely elevated due to reflexive
contraction of the bladder.
o. Release hemostat and set three-way stop cock to prevent additional fluid from
entering the bladder. For serial measurements keep system closed.
p. Document value on electronic record. Subtract 25 ml from urine output for the
hour.
q. Notify provider of elevated pressure readings (IAP 12 mmHg). Serial
measurements should be taken so increases in pressure can be detected. Discuss
appropriate monitoring intervals with provider.
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r. If IAP 12mmHg, discuss with the provider initial treatment options (See
Appendix B). If considering surgical intervention, re-evaluate IAP with the use of
a neuromuscular blocking agent or muscle relaxant before a surgical consult is
requested.

C. Procedural steps (for three-way indwelling urinary catheter):
Follow above steps except replace three way stopcock with blue IV line adaptor.

References:
1. Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare
Infection Control Practices Advisory Committee (HICPAC). (2009). Guideline for
prevention of catheter-associated urinary tract infections 2009. Retrieved April 14, 2012,
from the Centers for Disease Control and Prevention website:
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf (LOE 7)
2. Lynn-McHale Wiegand, D, & Gallagher, J. (2011). Chapter 106: Intra-abdominal pressure
monitoring. American Association of Critical Care Nurses (AACN) Procedure Manual for
Critical Care, Sixth Edition, 967-980. (LOE 8)
3. World Society of the Abdominal Compartment Syndrome. (2007). Intra-abdominal
Hypertension (IAH) Assessment Algorithm. Retrieved April 14, 2012, from
http://wsacs.org/Images/IAH_algorithm.pdf (LOE 8)
4. World Society of the Abdominal Compartment Syndrome. (2007). Intra-abdominal
Hypertension (IAH) / Abdominal Compartment Syndrome (ACS) Management Algorithm.
Retrieved April 14, 2012, from http://wsacs.org/Images/ACS_management.pdf (LOE 8)
5. Hershberger, R. C., Hunt, J. L., Arnoldo, B. D., & Purdue, G. F. (2007). Abdominal
compartment syndrome in the severely burned patient. Journal of Burn Care and Research,
28(5), 708-714. (LOE 4)
6. De Waele, J. J., De laet, I., De Keulenaer, B., Widder, S., Kirkpatrick, A. W., Cresswell, A.
B., et al. (2008). The effect of different reference transducer positions on intra-abdominal
pressure measurement: A multicenter analysis. Intensive Care Medicine, 34(7), 1299-1303.
(LOE 4)
7. Malbrain, M. L. N. G., Cheatham, M. L., Kirkpatrick, A., Sugrue, M., Parr, M., De Waele, J.,
et al. (2006). Results from the International Conference of Experts on Intra-abdominal
Hypertension and Abdominal Compartment Syndrome: I. Definitions. Intensive Care
Medicine, 32(11), 1722-1732. Retrieved October 10, 2011, from
http://wsacs.org/consensus.php (LOE8)
8. Cheatham, M. L., Malbrain, M. L. N. G., Kirkpatrick, A., Sugrue, M., Parr, M., De Waele, J.,
et al. (2007). Results from the International Conference of Experts on Intra-abdominal
Hypertension and Abdominal Compartment Syndrome: II Recommendations. Critical Care
Medicine, 33(6), 951-962. Retrieved October 10, 2011, from http://wsacs.org/concensus.php
(LOE8)
9. Malbrain, M. L. N. G., Chiumello, D., Pelosi, P., Bihari, D., Innes, R., Ranieri, V. M., et al.
(2005). Incidence and prognosis of intraabdominal hypertension in a mixed population of
critically ill patients: A multiple-center epidemiological study. Critical Care Medicine 33(2),
315-322. (LOE 4)
10. Gallagher, J. (2010). Intra-abdominal hypertension: Detecting and managing a lethal
complication of critical illness. AACN Advanced Critical Care 21(2), 205-217. (LOE 7)
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11. Lee, R. K. (2012). Intra-abdominal hypertension and abdominal compartment syndrome: A
comprehensive overview. Critical Care Nurse, 32(1), 19-31. (LOE 7)
12. Cheatham, M. L., & Safcsak, K. (2010). Is the evolving management of intra-abdominal
hypertension and abdominal compartment syndrome improving survival? Critical Care
Medicine, 38(2), 402-407. Retrieved November 15, 2011, from MD Consult database. (LOE
4)
13. Shuster, M. H., Haines, T., Sekula, L. K., Kern, J., & Vasquez, J. A. (2010, July). Reliability
of intrabladder pressure measurement in intensive care. American Journal of Critical Care,
19, e29-e39. Retrieved October 10, 2011, from AACN database. (LOE 4)
14. Vidal, M. G., Weisser, J. R., Gonzalez, F., Toro, M. A., Loudet, C., Balasini, C., et al.
(2008). Incidence and clinical effects of intra-abdominal hypertension in critically ill
patients. Critical Care Medicine, 36(6), 1823-1831. Retrieved November 15, 2011, from MD
Consult database. (LOE 4)
15. Campbell, M.L. (2011) American Association of Critical Care Nurses: Procedure Manual for
Critical Care. Procedure 106 . St Louis, MO: Saunders: Elsevier. (LOE 1)
16. Convatec. (2012). Abviser, Intra-Abdominal Monitoring System. Retrieved from
http://abviser.com. (LOE 8)


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