The physiological effects of elevated intra-abdominal pressure following aneurysm repair

Objectives: elevated intra-abdominal pressure (IAP) may cause widespread organ dysfunction (abdominal compartment syndrome) through effects on the respiratory, cardiac, renal and gastro-intestinal systems. The aim of this study was to document IAP following aneurysm surgery, and to determine the effect of IAH on outcome. Design: prospective observational study. Setting: University Hospital. Subjects: the patient cohort comprised 75 patients undergoing infra-renal aneurysm repair (53 non-ruptured [40 conventional - 1 death, 13 endovascular] and 22 conventionally repaired ruptured AAA - 8 deaths). IAP was quantified by bladder manometry at the termination of the procedure and at 24h intervals in patients who remained intubated. Physiological indices of organ function were recorded. Statistical analysis utilized the unpaired t-test, Fischer's exact test and Pearson's correlation. Results: IAP was significantly higher at abdominal closure following ruptured aneurysm repair 15.4 mmHg [SE 1.6]) than conventional (10.5 [0.89]) or endovascular elective repair (6.4 [1.0]) of non-ruptured AAA. The sensitivity and specificity of IAP to predict subsequent mortality was analysed using a receiver characteristic operating curve. This analysis demonstrated that a cut off of 15 mmHg was the most useful for indicating patients at risk (sensitivity 0.66, specificity 0.79). Physiological indices of organ dysfunction (pH[p = 0.027], base excess [p = 0.005], peak inspiratory pressure [p = 0.0015], CVP and urine output [p = 0.0029]) were significantly impaired in patients with IAP greater than or equal to 15 mmHg, in comparison to patients with lower pressures. IAP correlated significantly with indices of cardiac (CVP p = 0.038), respiratory (PaO2/FiO(2), p = 0.026), and renal function (urine output p = 0.046). Conclusions: these data suggest that the management of IAH may have a role following repair of ruptured AAA. High intra-abdominal pressures rarely complicate elective or endovascular aneurysm repair.