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CHAPTER 115: The Transplant Patient 1087

TABLE 114-3 Nonsurgical Therapeutic Options for Treatment of intra- • Marinis A, Argyra E, Lykoudis P, et al. Ischemia as a possible effect
abdominal Hypertension and Abdominal Compartment Syndrome of increased intra-abdominal pressure on central nervous system
Improve abdominal wall compliance cytokines, lactate and perfusion pressures. Crit Care. 2010;14:R31.
Remove abdominal binders • Mullens W, Abrahams Z, Francis GS, et al. Importance of venous
Adequate analgesia and sedation congestion for worsening of renal function in advanced decom-
pensated heart failure. J Am Coll Cardiol. 2009;53:589-596.
Neuromuscular blockade • Sosa Garcia J, Perez Calatayud A, Carrillo Esper R. Prevalence of
Reduce elevation of head of bed to <30° intraabdominal hypertension and abdominal compartment syn-
Evacuate intraluminal contents drome in an intensive care unit. Chest. 2014;145:193A.
Gastric decompression • Valenza F, Chevallard G, Porro GA, et al. Static and dynamic
https://kat.cr/user/tahir99/
Colonic decompression components of esophageal and central venous pressure during
Promotility agents intra-abdominal hypertension. Crit Care Med. 2007;35:1575-1581.
• Vivier E, Metton O, Piriou V, et al. Effects of increased intra-abdominal
Evacuate abdominal fluid collections pressure on central circulation. Br J Anaesth. 2006;96:701-707.
Paracentesis
Percutaneous drainage
Correct positive fluid balance REFERENCES
Avoid excessive volume resuscitation Complete references available online at www.mhprofessional.com/hall
Diuretic administration
Renal replacement therapy with ultrafiltration
Other organ support
CHAPTER The Transplant Patient
Goal-directed volume resuscitation
Adapted with permission from Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal hypertension and 115 Laveena Munshi
Low-tidal-volume mechanical ventilation
Damon C. Scales
the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from John T. Granton
the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. July 2013;39(7):1190-1206.

to IAP may improve oxygenation in concomitant ARDS and ACS and KEY POINTS
68
also lowers left ventricular afterload. 41 • Advancements in immunosuppression, transplant techniques,
Following implementation of nonsurgical therapies for IAH and
ACS, close monitoring of IAP, airway pressures, hemodynamics, renal antimicrobials, postoperative management and support, bridging
techniques, and extracorporeal life support have had an enormous
function, and intracranial pressure is indicated to reduce the risk of impact on morbidity and mortality of transplant recipients over
multiorgan failure. Failure to reduce IAP or improve organ function the past few decades.
with nonsurgical therapies may require prompt surgical decompression.
• Although some generalizations can be made regarding the manage-
ment of transplant patients, organ-specific considerations based on
KEY REFERENCES the particular allograft transplanted are critically important.
• Infections can reactivate in an immunocompromised recipient who
• Cheatham ML, Safcsak K. Percutaneous catheter decompres-
sion in the treatment of elevated intraabdominal pressure. Chest. has been previously exposed. Alternatively, a naïve recipient may
2011;140:1428-1435. acquire an infection following the transplant of an organ from a sero-
positive donor. Infections in transplant recipients can progress rapidly
• Cheng J, Wei Z, Liu X, et al. The role of intestinal mucosa injury and hence must be promptly recognized and appropriately treated.
induced by intra-abdominal hypertension in the development of
abdominal compartment syndrome and multiple organ dysfunc- • Risks and benefits of sustained immunosuppressive therapy must
tion syndrome. Crit Care. 2013;17:R283. be balanced in transplant recipients. Though immunosuppressive
drugs are essential to prevent allograft rejection, they also increase
• Daugherty EL, Hongyan L, Taichman D, et al. Abdominal com- the risk of infection and neoplasm.
partment syndrome is common in medical intensive care unit
patients receiving large-volume resuscitation. J Intensive Care Med. • Immunosuppressive drugs have significant side effects and many
2007;22:294-299. have important drug-drug interactions that must be recognized by
the intensivist.
• De Keulenaer BL, De Waele JJ, 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. 2009;35:969-976.
• Kirkpatrick AW, Roberts DJ, De Waele J, et al. Intra-abdominal INTRODUCTION
hypertension and the abdominal compartment syndrome: updated Organ transplantation has become a cornerstone in the management
consensus definitions and clinical practice guidelines from the of end-stage organ dysfunction. Since the 1960s, important scien-
World Society of the Abdominal Compartment Syndrome. tific advances have greatly improved our understanding of transplant
Intensive Care Med. 2013;39:1190-1206. immunology. Innovations in transplant techniques have allowed for a
• Mahjoub Y, Touzeau J, Airapetian N, et al. The passive leg- remarkable change in survival of this population. Immunosuppressive
raising maneuver cannot accurately predict fluid responsiveness and antimicrobial therapies have markedly decreased the incidence and
in patients with intra-abdominal hypertension. Crit Care Med. severity of allograft rejection and overwhelming infection.
2010;38:1824-1829. In the early decades of transplant, all forms of organ transplantation
necessitated intensive postoperative monitoring; however, in recent

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