Can femoral venous pressure be used as an estimate for standard vesical intra-abdominal pressure measurement?

Intra-abdominal hypertension (IAH) is highly prevalent in critically ill patients admitted to the intensive care unit and is associated with an increased morbidity and mortality. The present study investigated whether femoral venous pressure (FVP) can be used as a surrogate parameter for intra-abdominal pressure (IAP) measured via the bladder in IAH grade II (IAP <20 mmHg) or grade III (IAP ≥20 mmHg). This was a single-centre prospective study carried out in a tertiary adult intensive care unit. IAP was measured via the bladder with a urinary catheter with simultaneous recording of the FVP via a femoral central line. If the IAP was <20 mmHg external weight to a maximum of 10 kg was applied to the abdomen with subsequent measurements of IAP and FVP. Eleven patients were enrolled into the study. IAH (IAP >12 mmHg) was identified in five patients (42%) and abdominal compartment syndrome (ACS, IAP >20 mmHg with new onset organ failure) in two (18%) with all-cause study mortality of 18%. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 21 ± 5, Simplified Acute Physiology (SAPS 2) score 49 ± 8, and Sequential Organ Failure Assessment (SOFA) score 9 ± 3. At baseline the bias between IAP and FVP was 3.2 with a precision of 3.63 mmHg (limits of agreement [LA] -4.1, 10.4). At 5 kg and 10 kg, the bias was 2.5 with a precision of 3.92 mmHg (LA -5.4, 10.3) and 2.26 mmHg (LA -2.1, 7.0) respectively. A receiver operating characteristic analysis for FVP to predict IAH showed an area under the curve of 0.87 (95% confidence interval 0.74-0.94, P=0.0001). FVP cannot be recommended as a surrogate measure for IAP even at IAP values above 20 mmHg. However, an elevated FVP was a good predictor of IAH.

A systematic review and individual patient data meta-analysis on intra-abdominal hypertension in critically ill patients: the wake-up project. World initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!).

Intra-abdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. The aim of this paper was to evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intra-abdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (N.=712), absence of information on ICU outcome (N.=195), age <18 or >95 years (N.=131). Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

A Systematic Review And Individual Patient Data Meta-Analysis On Intraabdominal Hypertension In Critically Ill Patients: The Wake-Up Project World Initiative on Abdominal Hypertension Epidemiology, a Unifying Project (WAKE-Up!).

Background: Intraabdominal hypertension (IAH), defined as a pathologically increase in intraabdominal pressure, is commonly found in critically ill patients. While IAH has been associated with several abdominal as well as extra-abdominal conditions, few studies have examined the occurrence of IAH in relation to mortality. Objective: To evaluate the prognostic role of IAH and its risk factors at admission in critically ill patients across a wide range of settings and countries. Data sources: An individual patient meta-analysis of all available data and a systematic review of published (in full or as abstract) medical databases and studies between 1996 and June 2012 were performed. The search was limited to "clinical trials" and "randomized controlled trials", "adults", using the terms "intraabdominal pressure", "intraabdominal hypertension" combined with any of the terms "outcome" and "mortality". All together data on 2707 patients, representing 21 centers from 11 countries was obtained. Data on 1038 patients were not analysed because of the following exclusion criteria: no IAP value on admission (n=712), absence of information on ICU outcome (n=195), age <18 or > 95 years (n=131). Results: Data from 1669 individual patients (19 centers from 9 countries) were analyzed in the meta-analysis. Presence of IAH was defined as a sustained increase in IAP equal to or above 12 mmHg. At admission the mean overall IAP was 9.9±5.0 mmHg, with 463 patients (27.7%) presenting IAH with a mean IAP of 16.3±3.4 mmHg. The only independent predictors for IAH were SOFA score and fluid balance on the day of admission. Five hundred thirteen patients (30.8%) died in intensive care. The independent predictors for intensive care mortality were IAH, SAPS II score, SOFA score and admission category. Conclusions: This systematic review and individual patient data meta-analysis shows that IAH is frequently present in critically ill patients and it is an independent predictor for mortality.

Intra-abdominal pressure measurements in lateral decubitus versus supine position.

OBJECTIVE: Intra-abdominal pressure (IAP) has traditionally been measured in the supine position, however, measuring the pressure in lateral semi-recumbent position has not been studied. DESIGN: A single centre prospective 1-day study. PATIENTS: 10 patients admitted for more then 24 hours who were mechanically ventilated and had an indwelling urinary catheter. METHODS: Inclusion criteria included were age > 18 years, sedated to a RASS score of -5 and mechanically ventilated. The pressures were measured via the bladder with the mid-axillary line as zero reference point. When patients were nursed in lateral decubitus, pressures were measured and compared immediately to the supine position. RESULTS: 10 patients were included with a total of 60 measurements.The male/female ratio was 9:1 with a mean APACHE Pi score of 11.5 [95% CI 4.8-22.4], SAPS 2 of 31.5 [95% CI 8.9-35.8] and SOFA score of 4.0 [95% CI 1.8-7.2]. Four patients were medical and 6 were surgical. The mean IAP at different time intervals (morning, afternoon and evening) in lateral and supine position were 10.9 +/- 2.0 (in mmHg) vs 6.6 +/- 3.2 (SD with p < 0.001); 11.0 +/- 4.0 vs 5.4 +/- 2.2 (p < 0.0005) and 11.6 +/- 3.8 vs 7.8 +/- 3.0 (p< 0.001). Overall, the LSP did not change significantly (p= 0.76), but the SP did (p=0.006) with the afternoon reading being significantly lower than the evening measurement. However, the trend in the difference (LSP minus SP) was not significant (p=0.43). CONCLUSION: There was a significant statistical difference in the pressures measured in LSP versus SP.The LSP position should not be used to measure IAP.

What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure?

PURPOSE: To describe what is defined as normal intra-abdominal pressure (IAP) and how body positioning, body mass index (BMI) and positive end-expiratory pressure (PEEP) affect IAP monitoring. METHODS: A review of different databases was made (Pubmed, MEDLINE (January 1966-June 2007) and EMBASE.com (January 1966-June 2007)) using the search terms of "IAP", "intra-abdominal hypertension" (IAH), "abdominal compartment syndrome" (ACS), "body positioning", "prone positioning", "PEEP" and "acute respiratory distress syndrome" (ARDS). Prior to 1966, we selected older articles by looking at the reference lists displayed in the more recent papers. RESULTS: This review focuses on the concept that the abdomen truly behaves as a hydraulic system. The definitions of a normal IAP in the general patient population and morbidly obese patients are reviewed. Subsequently, factors that affect the accuracy of IAP monitoring, i.e., body position (head of bed elevation, lateral decubitus and prone position) and PEEP, are explored. CONCLUSION: The abdomen behaves as a hydraulic system with a normal IAP of about 5-7 mmHg, and with higher baseline levels in morbidly obese patients of about 9-14 mmHg. Measuring IAP via the bladder in the supine position is still the accepted standard method, but in patients in the semi-recumbent position (head of the bed elevated to 30 degrees and 45 degrees ), the IAP on average is 4 and 9 mmHg, respectively, higher. Future research should be focused on developing and validating predictive equations to correct for supine IAP towards the semi-recumbent position. Small increases in IAP in stable patients without IAH, turned prone, have no detrimental effects. The role of prone positioning in the unstable patient with or without IAH still needs to be established.

Tuberculosis: epidemiology, manifestations, and the value of medical imaging in diagnosis.

Mycobacterial infections have been shown to be increasing in number worldwide, mainly due a global increase in developing countries, the increased number of patients with HIV infection and AIDS disease worldwide, an increasing number of elderly patients and the emergence of multidrug resistant tuberculosis. Inhalation is the predominant pathway of Mycobacterium tuberculosis (M. tuberculosis) infection, making pulmonary tuberculosis the most common form of tuberculosis. Tuberculosis may arise either from a recent infection with M. tuberculosis, or from the reactivation of dormant bacilli, years or decades after initial infection. Extrapulmonary tuberculosis mainly results from reactivation of a tuberculous focus after hematogenous dissemination or lymphogenous spread from a primary, usually pulmonary focus. Tuberculosis may demonstrate a variety of radiological features depending on the organ site involved and may mimick other pathologies. The final diagnosis of tuberculous disease mainly depends on the detection of the causative organism on histopathological examination, culture and polymerase chain reaction-based assay for mycobacterial DNA on material obtained during bronchoscopic washings, fine needle aspiration cytology (FNAC) or biopsy.

CT and MR imaging of gastrointestinal tuberculosis.

The purpose of this study was to describe the CT and MR imaging findings of tuberculosis of the gastrointestinal tract. Abdominal and pelvic CT scans and MRI studies of 6 patients with histopathological and microbiological proven intestinal tuberculosis were reviewed by two radiologists in consensus. Location and pattern of bowel wall involvement, signal intensities in relation to the normal bowel wall, pattern of enhancement and associated abdominal abnormalities were evaluated. Gastrointestinal tract tuberculosis may be limited to one bowel segment, with the cecum and ileocecal valve as the predominant site of disease, or may involve multiple bowel segments. Asymmetric thickening of the bowel wall is a common finding. Associated findings include pericecal and mesenteric fat stranding, regional lymphadenopathy showing peripheral, heterogeneous and/or homogeneous enhancement patterns and less commonly, tuberculous 'dry plastic' peritonitis. On magnetic resonance (MR) imaging, tuberculous bowel involvement results in intermediate decreased signal intensities on T1-weighted images, and intermediate increased, slight heterogeneous signal intensities on T2-weighted images. On contrast-enhanced images, slight heterogeneous enhancement is seen.

Vascular involvement secondary to tuberculosis of the abdomen.

Although involvement of the abdomen is a common site of extrapulmonary tuberculosis, involvement of abdominal vessels with complications is rare after infections with Mycobacterium tuberculosis (M. tuberculosis). Vascular complications may result from direct involvement by M. tuberculosis of the vascular wall or may occur as a consequence of local spreading from a tuberculous mass. We describe the imaging findings in two patients with proven tuberculosis of the abdomen and significant vascular complications. In one patient, "dry plastic" peritonitis and tuberculous lymphadenopathy at the level of the porta hepatis with subsequent encasement and compression of the portal vein resulted in prestenotic dilatation and varicose formation in the upper abdomen. In the other patient, bulky necrotic tuberculous lymphadenopathy, located at the splenic hilum, resulted in encasement with stenosis of the splenic vessels and subsequent splenic infarction.

Tuberculosis of the spine: CT and MR imaging features.

Tuberculosis (TB) remains endemic in most of the developing countries. However, a resurgence of tuberculosis has also been reported in the past decades in developed countries, not only in the lungs, but also in extrapulmonary sites, e.g. the vertebral column. Vertebral TB is most often found in the lower thoracic and upper lumbar regions. Diagnosis is often difficult; clinical findings are usually non-specific and radiologic features may mimic those of other bacterial, fungal, inflammatory and neoplastic diseases. However, recognition and understanding of the radiological findings may help in diagnosis. Two distinct patterns of vertebral tuberculosis may be seen: the classic finding of spondylodiscitis, characterized by destruction of two or more contiguous vertebrae and opposed end plates, disk infection, and commonly a paraspinal mass or collection. The second pattern, increasing in frequency, is a atypical form of spondylitis without disk involvement.The value of CT and MR imaging are discussed in the diagnostic workup of vertebral tuberculosis. A positive culture or histopathologic analysis of CT-guided needle aspiration or biopsy specimens is required in the absence of pulmonary manifestations of tuberculosis for definitive diagnosis and adequate treatment.

Abdominal tuberculous lymphadenopathy: MRI features.

The aim of this study was to describe the MRI features of abdominal tuberculous lymphadenopathy. MRI studies of 13 patients with abdominal tuberculous lymphadenopathy were reviewed with regard to anatomic distribution and size. Signal intensities, in relation to abdominal wall muscle, on unenhanced T1- and T2-weighted images and patterns of contrast enhancement of lymphadenopathy were evaluated in each patient. In each patient, the largest lymph node with the same imaging characteristic was evaluated. The upper paraaortic region was the most common site of involvement (n=12 patients), followed by the lesser omentum (n=10 patients), the anterior pararenal space (n=9 patients), the lower paraaortic area (n=8 patients), the small bowel mesentery (n=6 patients), the greater omentum (n=2 patients) and the originating site of the inferior mesenteric artery (n=2 patients). The mean lymph node size was 1.8 cm (range 0.5-5 cm). The overall mean lymph node number per patient was 16 (range 2-50). A total of 41 lymph nodes were evaluated in 13 patients. On T2-weighted images, 40 lesions were hyperintense and one lesion was isointense. Nine hyperintense lesions showed a hypointense peripheral rim and seven internal heterogeneïty. Perinodal T2-hyperintensity was present in 23 lesions. The latter finding was valid for all patients. On T1-weighted images, 30 lesions were hypointense and 11 isointense. Nine hypointense lesions demonstrated a hyperintense peripheral rim, and six were heterogeneous. Contrast-enhanced fat-suppressed T1-weighted images demonstrated predominant peripheral enhancement in 28 lesions: (1) peripheral uniform, thin (n=19); (2) thick irregular, complete (n=3); and (3) conglomerate group of nodes showing peripheral and central areas of rim enhancement (n=6). Heterogeneous and homogeneous enhancement was present in ten and three lesions, respectively. Combinations of enhancing patterns in the same nodal group and different nodal groups were seen in eight and nine patients, respectively. Abdominal tuberculous lymphadenopathy may show a variety of signal intensities and patterns of contrast enhancement on MRI. Lymphadenopathy, hypointense on T1-weighted, hyperintense on T2-weighted images with perinodal hyperintensity, and predominant peripheral rimlike enhancement may suggest the diagnosis of tuberculosis.

Clinical and radiological deterioration in a patient with AIDS.

Paradoxical clinical deterioration of miliary tuberculosis, characterized by pulmonary and abdominal manifestations, is reported in a patient with the acquired immunodeficiency syndrome, after initiation of treatment with highly active antiretroviral therapy. Paradoxical reaction was attributed to partial restoration of cell-mediated immunity related to highly effective antiretroviral therapy. Because tuberculosis has a high prevalence in HIV patients and tuberculosis is often characterized by miliary spreading of disease in these patients, it is important to recognize this phenomenon.

Percutaneus translumbar inferior vena cava venous access in an intensive care patient.

We report the case of a critically ill 30-year-old chronic haemodialysis patient with a history of intravenous substance abuse whose intravenous access sites had become exhausted. She subsequently underwent elective insertion of a percutaneous translumbar inferior vena caval paired Tesio catheter and peripherally inserted central catheter (PICC line). This technique has been used successfully in patients who require longstanding central venous access (hyperalimentation, chemotherapy, chronic renal hemodialysis patients). This approach could be an alternative where the standard access routes have become non-viable.

Tuberculosis of the pancreas: MRI features.

OBJECTIVE: The purpose of this study was to describe the MRI features of tuberculosis of the pancreas. CONCLUSION: Pancreatic tuberculosis can be focal or diffuse. If focal, it presents as a sharply delineated mass located in the pancreatic head, showing heterogeneous enhancement. Lesions are hypointense on fat-suppressed T1-weighted images and a mixture of hypo- and hyperintense on T2-weighted images. The appearances of common bile duct and main pancreatic duct are normal. Diffuse involvement is characterized by pancreatic enlargement with narrowing of the main pancreatic duct and heterogeneous enhancement. Signal intensity abnormalities indicating diffuse involvement include hypointensity on fat-suppressed T1-weighted images and hyperintensity on T2-weighted images.

Considerations for planning and implementation.

Installing Picture Archiving and Communication System (PACS) has very wide implications on the radiology department and the hospital as a whole. PACS is an entire hospital investment, which will change many professionals' working practices. Its selection and implementation must involve all the groups it will affect and this demands an appropriate approach. Developing processes that establish the needs of the users, support strategic initiatives, and address risk management is not a minor undertaking. The development of a plan that provides PACS selection committees with a step-by-step roadmap to seek and procure PACS best suited to their workflow is a valuable tool. This review considers the process of planning and implementation for PACS.

Picture archiving and communication system--Part one: Filmless radiology and distance radiology.

Picture archiving and communication system (PACS) is a collection of technologies used to carry out digital medical imaging. PACS is used to digitally acquire medical images from the various modalities, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and digital projection radiography. The image data and pertinent information are transmitted to other and possibly remote locations over networks, where they may be displayed on computer workstations for soft copy viewing in multiple locations, thus permitting simultaneous consultations and almost instant reporting from radiologists at a distance. Data are secured and archived on digital media such as optical disks or tape, and may be automatically retrieved as necessary. Close integration with the hospital information system (HIS)--radiology information system (RIS) is critical for system functionality. Medical image management systems are maturing, providing access outside of the radiology department to images throughout the hospital via the Ethernet, at different hospitals, or from a home workstation if teleradiology has been implemented.

Tuberculous epididymitis associated with abdominal lymphadenopathy (2004:1b).

Although the predominant form of tuberculosis is pulmonary disease, an increasing number of cases with extra-pulmonary involvement have been reported. The diagnosis of extra-pulmonary tuberculosis is often difficult because of its protean clinical manifestations and non-specific laboratory findings. Abdominal lymph node involvement may be present alone or in combination with involvement of the gastrointestinal tract, peritoneum, and solid viscera. Tuberculous epididymitis occurs sporadically and represents a specific secondary subacute or chronic inflammatory process involving the epididymis. We present the imaging findings in a patient with tuberculous epididymitis associated with abdominal tuberculous lymphadenopathy.

Picture archiving and communication system--part 2 cost-benefit considerations for picture archiving and communication system.

Picture archiving and communication system (PACS) has become an important component of many radiology departments. PACS is expected to make the departments more efficient, reduce operating costs, and improve the communication between the radiologist and the referring physician. Even if the cost-savings are not substantial because of the capital expense of PACS, cost justification is very important in demonstrating the substantial advantages of PACS at either little or no additional expense. Some cost-benefit considerations for PACS are discussed in relation to a hospital-wide implementation.

Picture archiving and communication system: the impact of filmless and distance radiology.

The progressive spread of Picture Archiving and Communication System (PACS) in medical imaging constitutes some of the major changes in the radiology and hospital environment during the past decade. The major benefit of PACS resides in its ability to communicate images and reports to referring physicians in a timely and reliable fashion. Filmless radiology offers the opportunity to redesign departmental and enterprise-wide workflow with increase in efficiencies of technologists, clerical staff and radiologists. PACS may improve patient care by providing real-time radiology and by enabling teleradiology. These technologies and the changing environment in radiology may force the radiologists to become more directly involved in the triage and management decisions for the patient. Occasional consultations, regularly scheduled consultation services, and multidisciplinary clinical discussions including a radiologist may help directing physicians to the best sequence of examinations to resolve a clinical problem.