Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

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

Abstract

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° and 45°), 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.

This is a preview of subscription content, log in to check access.

Fig. 1

References

  1. 1.

    Malbrain ML, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, De Keulenaer BL, Daelemans R, Jacquet L, Laterre PF, Frank G, de Souza P, Cesana B, Gattinoni L, Malbrain MLNG, Chiumello D, Pelosi P, Bihari D, Innes R, Ranieri VM, Del Turco M, Wilmer A, Brienza N, Malcangi V, Cohen J, Japiassu A, De Keulenaer BL, Daelemans R, Jacquet L, Laterre P-F, Frank G, de Souza P, Cesana B, Gattinoni L (2005) Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 33:315–322 Comment in: Crit Care Med 2005 Sep;33(9):2150; author reply 2150–2153, Crit Care Med 2005 Feb;33(2):447–449

  2. 2.

    Malbrain ML, Chiumello D, Pelosi P, Wilmer A, Brienza N, Malcangi V, Bihari D, Innes R, Cohen J, Singer P, Japiassu A, Kurtop E, De Keulenaer BL, Daelemans R, Del Turco M, Cosimini P, Ranieri M, Jacquet L, Laterre PF, Gattinoni L, Malbrain MLNG, Chiumello D, Pelosi P, Wilmer A, Brienza N, Malcangi V, Bihari D, Innes R, Cohen J, Singer P, Japiassu A, Kurtop E, De Keulenaer BL, Daelemans R, Del Turco M, Ranieri M, Jacquet L, Laterre P-F, Gattinoni L (2004) Prevalence of intra-abdominal hypertension in critically ill patients: a multicentre epidemiological study. Intensive Care Med 30:822–829

  3. 3.

    Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D’Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A, Malbrain MLNG, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D’Amours S, Wendon J, Hillman K, Johansson K, Kolkman K, Wilmer A (2006) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. I. Definitions. Intensive Care Med 32:1722–1732

  4. 4.

    Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J, Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D’Amours S, Wendon J, Hillman K, Wilmer A (2007) Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. II. Recommendations. Intensive Care Med 33:951–962

  5. 5.

    Malbrain ML, De Laet I, Cheatham M (2007) Consensus conference definitions and recommendations on intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS): the long road to the final publications, how did we get there? Acta Clin Belg Suppl 62:44–59

  6. 6.

    Malbrain ML, Vidts W, Ravyts M, De Laet I (2008) Acute intensitinal distress sydrome: the importnace of intra-abdminal pressure. Minerva Anesthesiol 74:657–673

  7. 7.

    Kirkpatrick AW, Brenneman FD, McLean RF, Rapanos T, Boulanger BR (2000) Is clinical examination an accurate indicator of raised intra-abdominal pressure in critically injured patients? Can J Surg 43:207–211 [see comment]

  8. 8.

    Sugrue M, Bauman A, Jones F, Bishop G, Flabouris A, Parr M, Stewart A, Hillman K, Deane SA (2002) Clinical examination is an inaccurate predictor of intraabdominal pressure. World J Surg 26:1428–1431

  9. 9.

    Fusco MA, Martin RS, Chang MC (2001) Estimation of intra-abdominal pressure by bladder pressure measurement: validity and methodology. J Trauma 50:297–302

  10. 10.

    Iberti TJ, Lieber CE, Benjamin E (1989) Determination of intra-abdominal pressure using a transurethral bladder catheter: clinical validation of the technique. Anesthesiology 70:47–50

  11. 11.

    Yol S, Kartal A, Tavli S, Tatkan Y (1998) Is urinary bladder pressure a sensitive indicator of intra-abdominal pressure? Endoscopy 30:778–780

  12. 12.

    Iberti TJ, Kelly KM, Gentili DR, Hirsch S, Benjamin E (1987) A simple technique to accurately determine intra-abdominal pressure. Crit Care Med 15:1140–1142

  13. 13.

    Malbrain ML (2004) Different techniques to measure intra-abdominal pressure (IAP): time for a critical re-appraisal. Intensive Care Med 30:357–371 [see comment]

  14. 14.

    Chastre J, Fagon JY (2002) Ventilator-associated pneumonia. Am J Respir Crit Care Med 165:867–903

  15. 15.

    Bonten MJ, Kollef MH, Hall JB (2004) Risk factors for ventilator-associated pneumonia: from epidemiology to patient management. Clin Infect Dis 38:1141–1149

  16. 16.

    Fowler G (1900) Diffuse septic peritonitis, with special reference to a new method of treatment, namely, the elevated head and trunk posture, to facilitate drainage into the pelvis, with a report of nine consecutive cases of recovery. The Medical Record, New York, pp 617–623

  17. 17.

    Defloor T, De Bacquer D, Grypdonck MH (2005) The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 42:37–46

  18. 18.

    Knox DM, Anderson TM, Anderson PS (1994) Effects of different turn intervals on skin of healthy older adults. Adv Wound Care 7(1):48–52, 54–56

  19. 19.

    Rushmer R (1946) The nature of intraperitoneal and intrarectal pressure. Am J Physiol:242–249

  20. 20.

    Duomarco JLRR (1947) La pression intra-abdominal en el hombre. El Ateneo, Buenos Aires

  21. 21.

    Campbell EJ, Green JH (1953) The variations in intra-abdominal pressure and the activity of the abdominal muscles during breathing: a study in man. J Physiol (Lond) 122:282–290

  22. 22.

    Mills JN (1950) The pressures developed in abdomen and thorax during the Flack tests. J Physiol (Lond) 111:368–375

  23. 23.

    Decramer M, De Troyer A, Kelly S, Zocchi L, Macklem PT (1984) Regional differences in abdominal pressure swings in dogs. J Appl Physiol 57:1682–1687

  24. 24.

    Loring SH, Yoshino K, Kimball WR, Barnas GM (1994) Gravitational and shear-associated pressure gradients in the abdomen. J Appl Physiol 77:1375–1382

  25. 25.

    Tzelepis GE, Nasiff L, McCool FD, Hammond J (1996) Transmission of pressure within the abdomen. J Appl Physiol 81:1111–1114

  26. 26.

    Wagoner G (1926) Studies on intra-abdominal pressure. Am J Med Sci 171:697–707

  27. 27.

    Overholt R (1931) Intraperitoneal pressure. Arch Surg 22:691–700

  28. 28.

    Kron IL, Harman PK, Nolan SP (1984) The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg 199:28–30

  29. 29.

    Chionh JJ, Wei BP, Martin JA, Opdam HI (2006) Determining normal values for intra-abdominal pressure. ANZ J Surg 76:1106–1109

  30. 30.

    Sanchez NC, Tenofsky PL, Dort JM, Shen LY, Helmer SD, Smith RS (2001) What is normal intra-abdominal pressure? Am Surg 67:243–248

  31. 31.

    Sugerman H, Windsor A, Bessos M, Wolfe L (1997) Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity. J Intern Med 241:71–79

  32. 32.

    Lambert DM, Marceau S, Forse RA, Lambert DM, Marceau S, Forse RA (2005) Intra-abdominal pressure in the morbidly obese. Obes Surg 15:1225–1232

  33. 33.

    Arfvidsson B, Eklof B, Balfour J (2005) Iliofemoral venous pressure correlates with intraabdominal pressure in morbidly obese patients. Vasc Endovascular Surg 39:505–509

  34. 34.

    Sugerman HJ, DeMaria EJ, Felton WL 3rd, Nakatsuka M, Sismanis A (1997) Increased intra-abdominal pressure and cardiac filling pressures in obesity-associated pseudotumor cerebri. Neurology 49:507–511

  35. 35.

    Sugerman HJ Effects of increased intra-abdominal pressure in severe obesity. Surg Clin North Am 81:1063-1075

  36. 36.

    Mullens W, Abrahams Z, Skouri HN, Francis GS, Taylor DO, Starling RC, Paganini E, Tang WH (2008) Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol 51:300–306

  37. 37.

    Sussman AM, Boyd CR, Williams JS, DiBenedetto RJ (1991) Effect of positive end-expiratory pressure on intra-abdominal pressure. South Med J 84:697–700

  38. 38.

    Hazebroek EJ, Haitsma JJ, Lachmann B, Steyerberg EW, de Bruin RW, Bouvy ND, Bonjer HJ (2002) Impact of carbon dioxide and helium insufflation on cardiorespiratory function during prolonged pneumoperitoneum in an experimental rat model 16:1073–1078

  39. 39.

    Kotzampassi K, Paramythiotis D, Eleftheriadis E (2000) Deterioration of visceral perfusion caused by intra-abdominal hypertension in pigs ventilated with positive end-expiratory pressure. Surg Today 30:987–992

  40. 40.

    Guimaraes HPSA, Leal PHR, Barcelos GK, Resque Ap, Amaral JL (2003) Influence of the increase of positive end-expiratory pressure (PEEP) on the intra-abdominal pressure. Intensive Care Med 29:S55

  41. 41.

    Ashraf A, Conil JM, Georges B et al (2008) Relation between ventilatory pressures and intra-abdominal pressure. Crit Care 12:P324

  42. 42.

    Malbrain MDY, Bertieaux S (2000) Effect of abdominal compression and decompression on cardiorespiratory function and regional perfusion. Intensive Care Med 26:S264

  43. 43.

    Ferrer CPE, Molina E (2008) Higher PEEP levels result in small increases in intraabdominal pressure in critical care patients. Intensive Care Med 34:S140

  44. 44.

    Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A (1998) Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Am J Respir Crit Care Med 158:3–11 [see comment]

  45. 45.

    McBeth PBZD, Widder S, Cheatham M, Zengerink I, Glowa J, Kirkpatrick AW (2007) Effect of patient postioining on intraabdominal pressure monitoring. Am J Surg 193:644–647

  46. 46.

    Cheatham MLDWJ, De Keulenaer B, Widder S, Kirkpatrick A, Creswell B, Malbrain M, Bodnar Z, Meija J, Reis R, Parr M, Schulze R, Compano S, the WSACS Clinical Trials Group (2007) Effect of body position on intra-abdominal pressure measurement: a multicenter analysis. Acta Clin Belgica 62:246

  47. 47.

    Vasquez DG, Berg-Copas GM, Wetta-Hall R, Vasquez DG, Berg-Copas GM, Wetta-Hall R (2007) Influence of semi-recumbent position on intra-abdominal pressure as measured by bladder pressure. J Surg Res 139:280–285

  48. 48.

    Malbrain MVMN, Verbrugghe W, Daelemans R, Lins R (2003) Effects of different body positions on intra-abdominal pressure and dynamic respiratory compliance. Crit Care 29:1177–1181

  49. 49.

    Cobb WS, Burns JM, Kercher KW, Matthews BD, James Norton H, Todd Heniford B (2005) Normal intraabdominal pressure in healthy adults. J Surg Res 129:231–235

  50. 50.

    De Keulenaer BL, De Backer A, Schepens DR, Daelemans R, Wilmer A, Malbrain ML (2003) Abdominal compartment syndrome related to noninvasive ventilation. Intensive Care Med 29:1177–1181

  51. 51.

    Douglas WWRK, Froukje MB, Sessler AD, Marsh HM (1973) Improved oxygenation in patients with acute respiratory distress syndrome. Am Rev Respir Dis 115:559–566

  52. 52.

    Takata M, Wise RA, Robotham JL (1990) Effects of abdominal pressure on venous return: abdominal vascular zone conditions. J Appl Physiol 69:1961–1972

  53. 53.

    Hering R, Vorwerk R, Wrigge H, Zinserling J, Schroder S, von Spiegel T, Hoeft A, Putensen C (2002) Prone positioning, systemic hemodynamics, hepatic indocyanine green kinetics, and gastric intramucosal energy balance in patients with acute lung injury. Intensive Care Med 28:53–58

  54. 54.

    Kiefer P, Morin A, Putzke C, Wiedeck H, Georgieff M, Radermacher P (2001) Influence of prone position on gastric mucosal–arterial PCO2 gradients. Intensive Care Med 27:1227–1230

  55. 55.

    Chiumello D, Cressoni M, Racagni M, Landi L, Li Bassi G, Polli F, Carlesso E, Gattinoni L (2006) Effects of thoraco-pelvic supports during prone position in patients with acute lung injury/acute respiratory distress syndrome: a physiological study. Crit Care 10:R87

  56. 56.

    Matejovic M, Rokyta R Jr, Radermacher P, Krouzecky A, Sramek V, Novak I (2002) Effect of prone position on hepato-splanchnic hemodynamics in acute lung injury. Intensive Care Med 28:1750–1755

  57. 57.

    Michelet P, Roch A, Gainnier M, Sainty JM, Auffray JP, Papazian L (2005) Influence of support on intra-abdominal pressure, hepatic kinetics of indocyanine green, extravascular lung water during prone positioning in patients with ARDS: a randomized crossover study. Crit Care 9:R251–R257 [see comment; erratum appears in Crit Care. 2005 Aug;9(4):308]

  58. 58.

    De Keulenaer BLCG, Maddox I, Powell B, Jenkins I (2007) Intraabdominal pressure measurements in lateral decubitus and supine position. Acta Clin Belg Suppl 62:269

  59. 59.

    Sugerman H, Windsor A, Bessos M, Kellum J, Reines H, DeMaria E (1998) Effects of surgically induced weight loss on urinary bladder pressure, sagittal abdominal diameter and obesity co-morbidity. Int J Obes Relat Metab Disord 22:230–235

Download references

Author information

Correspondence to B. L. De Keulenaer.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

De Keulenaer, B.L., De Waele, J.J., Powell, B. et al. What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure?. Intensive Care Med 35, 969–976 (2009). https://doi.org/10.1007/s00134-009-1445-0

Download citation

Keywords

  • Intra-abdominal hypertension
  • Abdominal compartment syndrome
  • Body positioning
  • Prone positioning
  • PEEP and ARDS