Effect Head of Bed Elevation on Intra-Abdominal Pressure (IAP) in Critically Ill Patients.
Effect Head of Bed Elevation on Intra-Abdominal Pressure (IAP) in Critically Ill Patients
Made Oka Ari Kamayani1, F. Sri Susilaningsih2, Titin Mulyati3
1
Lecturer at Nursing Program, Medical Faculty, Universitas Udayana, madeokaari@gmail.com
2
Lecturer at Nursing Faculty, Universitas Padjadjaran
3
Nurse at General Intensive Care Unit (GICU) Hasan Sadikin General Hospital
ABSTRACT
Critically ill patients, which are on mechanical ventilation, present with higher intra-abdominal pressure
(IAP) values when PEEP is applied and should be monitored very closely. Persistently increases IAP to 12 mmHg or
greater can be affected to all body systems and the effects can lead to multisystem organ failure and death. In the
intensive care unit, most ventilated patients are nursed with the head of the bed elevated (HOB) at 30° to 45° to
reduce the risk of ventilator-associated pneumonia and gastric reflux. HOB elevation is limited when the patient has
femoral site and hemodynamic monitoring, the bed can be raised up to 15 to 30. IAP is most commonly measured
via the bladder with the patient in the supine position. Use of the supine position in patients receiving mechanical
ventilation increases the risk of aspiration pneumonia developing.
A quasi-experimental of quantitative study was conducted in General Intensive Care Unit (GICU) RSUP
Dr. Hasan Sadikin. A total of 23 patients on mechanical ventilation were included. Patient had IAP measured first
while positioned supine without any head of bed elevation, after the patient positioned supine with HOB elevation
15 and again after the patient positioned supine with HOB elevation 30.
In the supine position, mean IAP was 11.9 ± 4.2 cmH 2O. In the HOB elevation 15, mean IAP was 12.6 ±
4.4 cmH2O. In the HOB elevation 30, mean IAP was 14.5 ± 5.2 cmH2O. When analysed with post hoc pair wise
comparisons, the difference of IAP between the supine position and HOB elevation 15 was not statistically
significant (p>0.05), the difference of IAP between the HOB elevation 15 and HOB elevation 30 was statistically
significant (p2 day
Frequency (%)
2 (8.7)
5 (21.7)
1 (4.3)
4 (17.4)
11 (47.8)
14 (60.9)
9 (39.1)
10 (43.5)
13 (56.5)
Based on Table 4.1 . it can be seen the age of the respondents are most common in the age range 40-65
years as many as 11 respondents ( 47.8 % ). By sex, the majority of respondents are male as many as 14
respondents ( 60.9 % ). The age of the respondents are most common in the age range 40-65 years as
many as 11 respondents ( 47.8 % ) . By sex, the majority of respondents are male as many as 14
respondents ( 60.9 % ). Based long day care at the time of measurement GICU IAP, as many as 13
respondents ( 56.5 % ) were treated > 2 days.
Tabel 4.2. The Average Value of the measurement of IAP (Repeated Anova )
Position Measurement IAP
Average of IAP + SD
p
(in cmH2O)
Supination
11.9 ± 4.2
HOB elevation 15
12.6 ± 4.4
HOB elevation 30
14.5 ± 5.2
0.01
Based on the table 4.2. can be seen the value of p 0.01 ( less than 0.05 ) means that there are differences
in measurement results IAP in the supine position , HOB elevation 15 and 30. To determine the position
of the different IAP measurement then performed a post hoc analysis Paired Wise Comparisons.
Tabel 4.3. Post hoc pair wise comparisons
Position Measurement IAP
The average difference of IAP
(dalam cmH2O, IK 95%)
0.7 (0.3 - 1.7)
Supinasi vs HOB elevation 15
HOB elevation 15 vs HOB 1.9 (0.8 – 2.9)
elevation 30
p
0.48
0.00
Based on the table 4.3. p-value measurement can be seen IAP supination and HOB elevation 15 is 0.48 (
greater than 0.05 ) means there is no difference in the measurement results IAP in the supine position and
HOB elevation 15. P-value measurement of IAP position HOB elevation 15 and HOB elevation 30 is
0.00 (less than 0.05) means that there are differences in measurement results IAP in a position HOB
elevation 15 and HOB elevation 30.
DISCUSSION
The results are consistent with research Cresswell et al. (2012) LIAP value at HOB elevation 30 higher
than the supine position. The results are consistent with research Rooban, Regli, Davis, Keulenaer (2012),
IAP is measured using a pressure bladder is affected by the change in position from a supine position to
position HOB elevation 30. There is an average increase of IAP measurement results at HOB position
30 elevation than the supine position.
Results of this study are also consistent with research McBeth et al. (2007) conducted a study to compare
the results of measurements of IAP via intravesical at an angle ranging from 0-45. The result showed
that the increase in IAP was significantly associated with an increased HOB elevation, significant changes
occur in the position of HOB elevation> 20. Recommendations to improve the development of the
abdominal wall covering to avoid the prone position and avoid positions HOB elevation of more than 20
(Lee, 2012).
Based on the research results Rooban, Regli, Davis, Keulenaer (2012), found that IAP is measured using a
pressure bladder is affected by the change in position from a supine position to position HOB elevation
30. There is an average increase of IAP measurement results at HOB position 30 elevation than the
supine position. Based on the research results Shuster, Sekula, Kern, Vazquez (2011), the IAP measured
through the bladder at HOB 30 elevation is higher than the measured pressure in the supine position with
25 mL of normal saline instillation.
Upright position gives rise to severe hydrostatic caused by abdominal organs and the body's tendency to
suppress bladder (Cresswell, AB et al., 2012). Intra-abdominal pressure will rise if the volume of acute
abdominal cavity increases and exceeds the capacity of its (Feliciano & Moore, 1996 in Soemarko, 2004).
According, Waele, Powell, Malbrain (2009) in Rooban, Regli, Davis, Keulenaer (2012), an increase in
IAP between supination and HOB elevation 30 not yet clearly known, the possibility of increasing
pressure on the entire abdomen or indicates a pressure gradient in the abdomen caused by fluid flow or
hydrostatic pressure on the abdominal organs due to pressure on the bladder or redistributing a localized
pressure differences.
HOB position 15 elevation on an increase in the average IAP compared to the supine position, but when
performed statistical tests, the average increase is not significant. This is probably due to the position 15
HOB elevation occurs contraction of the muscles of the abdomen are minimal effect on suppression
muscles of the abdominal wall and bladder pressure were minimal so it does not cause a significant
increase in IAP measurement results.
Pascal's Law which states that the pressure exerted on the liquid in the enclosed space is passed in all
directions with equal size. This pressure is called hydrostatic pressure (hydrostatic pressure). The amount
of pressure is affected by gravity (Fairman, 1996). Hydrostatic weight gain caused by the organs of the
abdomen at HOB position 15 elevation is not too large so that pressure is passed into the bladder is not
too big .
CONCLUSION
There was no difference in the measurement values IAP supine position and HOB HOB elevation 15.
HOB elevation 15 a safe position for the measurement of IAP because it does not cause an increase in
IAP measurement results. There are differences in the measurement position value IAP HOB elevation
15 and HOB elevation 30. The results of this research prove there was no difference in the value of IAP
in the supine position and HOB elevation 15 so that it can be used as evidence based position
measurement of IAP using HOB elevation 15 to prevent aspiration.
REFERENCES
Anderson, R. (2007). Revision of the Procedure for Monitoring Intra-abdominal Pressure. Critical Care
Nurse, 27:67-70.
Bulechek, G.M. et al. (2013). Nursing Intervention Classification (NIC). United Stated of America,
Elsevier Inc.
Cheatam, M.L. (2009). Abdominal Compartment Syndrome: Pathophysiology and Definitions.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 17, 10.
doi:10.1186/1757-7241-17-10.
Cheatam, M.L. et al. (2009). The Impact of Body Position on Intra-Abdominal Pressure Measurement: A
Multicenter
Analysis.
Critical
Care
Medicine,
37
(7):
2187-90.
doi:
10.1097/CCM.0b013e3181a021fa.
Cresswell, A.B. (2012). The Effect of Body Position on Compartmental Intra-Abdominal Pressure
Following Liver Transplantation. Annals of Intensive Care, 2 (Suppl 1).
Dharma, K. K. (2011). Metodelogi Penelitian Keperawatan: Panduan Melaksanakan dan Menera pkan
Hasil Penelitian. Jakarta, Trans Info Media.
Dillon, A., Munro, C.L., Grap M.J. (2002). Nurses' Accuracy in Estimating Backrest Elevation.
American Journal of Critical Care, 11, 34-37.
Fairman, J.G. (1996). Pascal's Principle and Hydraulics. Melalui www.grc.nasa.gov. (21/07/2014).
Hudak C.M. & Gallo B.M. (2010). Critical Care Nursing: A Holistic Approach . Philadelphia: J.B.
Lippincott Company.
Jakob, S.M., Knuesel, R., Tenhunen, J.J., Pradl, R., Takala, J. (2010). Increasing Abdominal Pressure
with and without PEEP: Effects on Intra-Peritoneal, Intra-Organ and Intra-Vascular Pressures.
BMC Gastroenterology, 10:70.
Lee, S.K. (2012). Intra-abdominal Hypertension and Abdominal Compartment Syndrome: A
Comprehensive Overview. Critical Care Nurse, 32, 19-32. doi: 10.4037/ccn2012662.
McBeth, P.B. et al. (2007). Effect of Patient Positioning on Intra-Abdominal Pressure Monitoring. The
American Journal of Surgery, 193, Issue 5 , 644-647.
Rooban, N., Regli, A., Davis, W.A., Keulenaer, B.L.D. (2012). Comparing Intra-Abdominal Pressures in
Different Body Positions Via A Urinary Catheter and Nasogastric Tube: A Pilot Study. Annals of
Intensive Care, 2 (Suppl 1), S11.
Shuster, M.H., Sekula, L.K., Kern, J.C., Vazquez, J.A. (2011). Measuring Intrabladder Pressure With the
Head of the Bed Elevated 30º: Evidence to Support a Change in Practice. American Journal of
Critical Care, 20 (4), 80-89. doi: 10.4037/ajcc2011744.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2008). Brunner & Suddarth’s Textbook of
Medical Surgical Nursing. Philadelphia , Lippincott Williams & Wilkins.
Soemarko, M. (2004). Hubungan Peningkatan Tekanan Intravesika Urinaria dengan Perdarahan
Intraperitoneal akibat Trauma Tumpul Abdomen. Jurnal Kedokteran Brawijaya , 20, 25-29.
Urden, L. D., Stacy, K.M., Lough, M.E. et al. (2010). Critical Care Nursing. USA, Mosby Elsevier.
Waele, D., Laet, D., Malbrain, M.L.N.G. (2007) . Rational Intraabdominal Pressure Monitoring: How To
Do It?. Acta Clinica Belgica , 62, Supplement 1, 16-25.
Made Oka Ari Kamayani1, F. Sri Susilaningsih2, Titin Mulyati3
1
Lecturer at Nursing Program, Medical Faculty, Universitas Udayana, madeokaari@gmail.com
2
Lecturer at Nursing Faculty, Universitas Padjadjaran
3
Nurse at General Intensive Care Unit (GICU) Hasan Sadikin General Hospital
ABSTRACT
Critically ill patients, which are on mechanical ventilation, present with higher intra-abdominal pressure
(IAP) values when PEEP is applied and should be monitored very closely. Persistently increases IAP to 12 mmHg or
greater can be affected to all body systems and the effects can lead to multisystem organ failure and death. In the
intensive care unit, most ventilated patients are nursed with the head of the bed elevated (HOB) at 30° to 45° to
reduce the risk of ventilator-associated pneumonia and gastric reflux. HOB elevation is limited when the patient has
femoral site and hemodynamic monitoring, the bed can be raised up to 15 to 30. IAP is most commonly measured
via the bladder with the patient in the supine position. Use of the supine position in patients receiving mechanical
ventilation increases the risk of aspiration pneumonia developing.
A quasi-experimental of quantitative study was conducted in General Intensive Care Unit (GICU) RSUP
Dr. Hasan Sadikin. A total of 23 patients on mechanical ventilation were included. Patient had IAP measured first
while positioned supine without any head of bed elevation, after the patient positioned supine with HOB elevation
15 and again after the patient positioned supine with HOB elevation 30.
In the supine position, mean IAP was 11.9 ± 4.2 cmH 2O. In the HOB elevation 15, mean IAP was 12.6 ±
4.4 cmH2O. In the HOB elevation 30, mean IAP was 14.5 ± 5.2 cmH2O. When analysed with post hoc pair wise
comparisons, the difference of IAP between the supine position and HOB elevation 15 was not statistically
significant (p>0.05), the difference of IAP between the HOB elevation 15 and HOB elevation 30 was statistically
significant (p2 day
Frequency (%)
2 (8.7)
5 (21.7)
1 (4.3)
4 (17.4)
11 (47.8)
14 (60.9)
9 (39.1)
10 (43.5)
13 (56.5)
Based on Table 4.1 . it can be seen the age of the respondents are most common in the age range 40-65
years as many as 11 respondents ( 47.8 % ). By sex, the majority of respondents are male as many as 14
respondents ( 60.9 % ). The age of the respondents are most common in the age range 40-65 years as
many as 11 respondents ( 47.8 % ) . By sex, the majority of respondents are male as many as 14
respondents ( 60.9 % ). Based long day care at the time of measurement GICU IAP, as many as 13
respondents ( 56.5 % ) were treated > 2 days.
Tabel 4.2. The Average Value of the measurement of IAP (Repeated Anova )
Position Measurement IAP
Average of IAP + SD
p
(in cmH2O)
Supination
11.9 ± 4.2
HOB elevation 15
12.6 ± 4.4
HOB elevation 30
14.5 ± 5.2
0.01
Based on the table 4.2. can be seen the value of p 0.01 ( less than 0.05 ) means that there are differences
in measurement results IAP in the supine position , HOB elevation 15 and 30. To determine the position
of the different IAP measurement then performed a post hoc analysis Paired Wise Comparisons.
Tabel 4.3. Post hoc pair wise comparisons
Position Measurement IAP
The average difference of IAP
(dalam cmH2O, IK 95%)
0.7 (0.3 - 1.7)
Supinasi vs HOB elevation 15
HOB elevation 15 vs HOB 1.9 (0.8 – 2.9)
elevation 30
p
0.48
0.00
Based on the table 4.3. p-value measurement can be seen IAP supination and HOB elevation 15 is 0.48 (
greater than 0.05 ) means there is no difference in the measurement results IAP in the supine position and
HOB elevation 15. P-value measurement of IAP position HOB elevation 15 and HOB elevation 30 is
0.00 (less than 0.05) means that there are differences in measurement results IAP in a position HOB
elevation 15 and HOB elevation 30.
DISCUSSION
The results are consistent with research Cresswell et al. (2012) LIAP value at HOB elevation 30 higher
than the supine position. The results are consistent with research Rooban, Regli, Davis, Keulenaer (2012),
IAP is measured using a pressure bladder is affected by the change in position from a supine position to
position HOB elevation 30. There is an average increase of IAP measurement results at HOB position
30 elevation than the supine position.
Results of this study are also consistent with research McBeth et al. (2007) conducted a study to compare
the results of measurements of IAP via intravesical at an angle ranging from 0-45. The result showed
that the increase in IAP was significantly associated with an increased HOB elevation, significant changes
occur in the position of HOB elevation> 20. Recommendations to improve the development of the
abdominal wall covering to avoid the prone position and avoid positions HOB elevation of more than 20
(Lee, 2012).
Based on the research results Rooban, Regli, Davis, Keulenaer (2012), found that IAP is measured using a
pressure bladder is affected by the change in position from a supine position to position HOB elevation
30. There is an average increase of IAP measurement results at HOB position 30 elevation than the
supine position. Based on the research results Shuster, Sekula, Kern, Vazquez (2011), the IAP measured
through the bladder at HOB 30 elevation is higher than the measured pressure in the supine position with
25 mL of normal saline instillation.
Upright position gives rise to severe hydrostatic caused by abdominal organs and the body's tendency to
suppress bladder (Cresswell, AB et al., 2012). Intra-abdominal pressure will rise if the volume of acute
abdominal cavity increases and exceeds the capacity of its (Feliciano & Moore, 1996 in Soemarko, 2004).
According, Waele, Powell, Malbrain (2009) in Rooban, Regli, Davis, Keulenaer (2012), an increase in
IAP between supination and HOB elevation 30 not yet clearly known, the possibility of increasing
pressure on the entire abdomen or indicates a pressure gradient in the abdomen caused by fluid flow or
hydrostatic pressure on the abdominal organs due to pressure on the bladder or redistributing a localized
pressure differences.
HOB position 15 elevation on an increase in the average IAP compared to the supine position, but when
performed statistical tests, the average increase is not significant. This is probably due to the position 15
HOB elevation occurs contraction of the muscles of the abdomen are minimal effect on suppression
muscles of the abdominal wall and bladder pressure were minimal so it does not cause a significant
increase in IAP measurement results.
Pascal's Law which states that the pressure exerted on the liquid in the enclosed space is passed in all
directions with equal size. This pressure is called hydrostatic pressure (hydrostatic pressure). The amount
of pressure is affected by gravity (Fairman, 1996). Hydrostatic weight gain caused by the organs of the
abdomen at HOB position 15 elevation is not too large so that pressure is passed into the bladder is not
too big .
CONCLUSION
There was no difference in the measurement values IAP supine position and HOB HOB elevation 15.
HOB elevation 15 a safe position for the measurement of IAP because it does not cause an increase in
IAP measurement results. There are differences in the measurement position value IAP HOB elevation
15 and HOB elevation 30. The results of this research prove there was no difference in the value of IAP
in the supine position and HOB elevation 15 so that it can be used as evidence based position
measurement of IAP using HOB elevation 15 to prevent aspiration.
REFERENCES
Anderson, R. (2007). Revision of the Procedure for Monitoring Intra-abdominal Pressure. Critical Care
Nurse, 27:67-70.
Bulechek, G.M. et al. (2013). Nursing Intervention Classification (NIC). United Stated of America,
Elsevier Inc.
Cheatam, M.L. (2009). Abdominal Compartment Syndrome: Pathophysiology and Definitions.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 17, 10.
doi:10.1186/1757-7241-17-10.
Cheatam, M.L. et al. (2009). The Impact of Body Position on Intra-Abdominal Pressure Measurement: A
Multicenter
Analysis.
Critical
Care
Medicine,
37
(7):
2187-90.
doi:
10.1097/CCM.0b013e3181a021fa.
Cresswell, A.B. (2012). The Effect of Body Position on Compartmental Intra-Abdominal Pressure
Following Liver Transplantation. Annals of Intensive Care, 2 (Suppl 1).
Dharma, K. K. (2011). Metodelogi Penelitian Keperawatan: Panduan Melaksanakan dan Menera pkan
Hasil Penelitian. Jakarta, Trans Info Media.
Dillon, A., Munro, C.L., Grap M.J. (2002). Nurses' Accuracy in Estimating Backrest Elevation.
American Journal of Critical Care, 11, 34-37.
Fairman, J.G. (1996). Pascal's Principle and Hydraulics. Melalui www.grc.nasa.gov. (21/07/2014).
Hudak C.M. & Gallo B.M. (2010). Critical Care Nursing: A Holistic Approach . Philadelphia: J.B.
Lippincott Company.
Jakob, S.M., Knuesel, R., Tenhunen, J.J., Pradl, R., Takala, J. (2010). Increasing Abdominal Pressure
with and without PEEP: Effects on Intra-Peritoneal, Intra-Organ and Intra-Vascular Pressures.
BMC Gastroenterology, 10:70.
Lee, S.K. (2012). Intra-abdominal Hypertension and Abdominal Compartment Syndrome: A
Comprehensive Overview. Critical Care Nurse, 32, 19-32. doi: 10.4037/ccn2012662.
McBeth, P.B. et al. (2007). Effect of Patient Positioning on Intra-Abdominal Pressure Monitoring. The
American Journal of Surgery, 193, Issue 5 , 644-647.
Rooban, N., Regli, A., Davis, W.A., Keulenaer, B.L.D. (2012). Comparing Intra-Abdominal Pressures in
Different Body Positions Via A Urinary Catheter and Nasogastric Tube: A Pilot Study. Annals of
Intensive Care, 2 (Suppl 1), S11.
Shuster, M.H., Sekula, L.K., Kern, J.C., Vazquez, J.A. (2011). Measuring Intrabladder Pressure With the
Head of the Bed Elevated 30º: Evidence to Support a Change in Practice. American Journal of
Critical Care, 20 (4), 80-89. doi: 10.4037/ajcc2011744.
Smeltzer, S.C., Bare, B.G., Hinkle, J.L., Cheever, K.H. (2008). Brunner & Suddarth’s Textbook of
Medical Surgical Nursing. Philadelphia , Lippincott Williams & Wilkins.
Soemarko, M. (2004). Hubungan Peningkatan Tekanan Intravesika Urinaria dengan Perdarahan
Intraperitoneal akibat Trauma Tumpul Abdomen. Jurnal Kedokteran Brawijaya , 20, 25-29.
Urden, L. D., Stacy, K.M., Lough, M.E. et al. (2010). Critical Care Nursing. USA, Mosby Elsevier.
Waele, D., Laet, D., Malbrain, M.L.N.G. (2007) . Rational Intraabdominal Pressure Monitoring: How To
Do It?. Acta Clinica Belgica , 62, Supplement 1, 16-25.