879072

research-article2019
JDMXXX10.1177/8756479319879072Journal of Diagnostic Medical SonographyGolshani et al.

Original Research
Journal of Diagnostic Medical Sonography

Inpatient Evaluation of Intra-

2020, Vol. 36(1) 12­–17
© The Author(s) 2019
Article reuse guidelines:
abdominal Pressure Completed sagepub.com/journals-permissions
DOI: 10.1177/8756479319879072
https://doi.org/10.1177/8756479319879072

With a Urinary Catheter as journals.sagepub.com/home/jdm

Compared With Ultrasonographic

Vessel Measurements

Keihan Golshani, MD1, Reza Azizkhani, MD1,

and Fereidon Foroutan, MD1

Abstract
Background: The purpose of this study was to evaluate the diagnostic value of ultrasonography as compared with
intra-abdominal pressure (IAP) measured with a urinary catheter.
Methods: This was a cross-sectional study. The participants consisted of 146 patients hospitalized in the emergency
wards of two hospitals in Isfahan (2017-2018). Following measurement of IAP through a urinary catheter,
ultrasonographic measurement of the inferior vena cava (IVC) diameter, internal jugular vein diameter, common
femoral vein (CFV) diameter, and ratio between the IVC and abdominal aortic diameters was completed. Correlation
between these methods of measurements for IAP was investigated.
Results: There was a significant positive correlation between intrabladder pressure and the right internal jugular vein
(RIJV) and CFV (P < .001, R > 0). There was also a reverse significant correlation between intrabladder pressure and
RIJV, IVC, IVC:aorta diameter, systolic blood pressure, and tricuspid annular plane systolic excursion (P < .001, r < 0).
RIJV, CFV, and tricuspid annular plane systolic excursion were suitable predictors for the estimation of intrabladder
pressure or IAP (P < .05), but IVC, IVC:aorta, and systolic blood pressure were not suitable factors for estimating IAP
(P > .05).
Conclusion: Ultrasonographic measurement is a noninvasive method for determining IAP.

Keywords
intra-abdominal pressure, ultrasonography, urinary catheter, noninvasive assessment

Intra-abdominal pressure (IAP) is defined as the steady-
state pressure concealed within the abdominal cavity
and resulting from the interaction between the abdomi-
nal wall and viscera. IAP changes are dependent on the
respiratory phase and abdominal wall resistance.1 In
healthy individuals in a supine position, normal IAP
ranges from 0 to 6.5 mm Hg.2,3 IAP may reach 15 mm
Hg in cases that are not of a serious pathologic condi-
tion (e.g., obesity).1 IAP may temporarily increase for
brief periods following some activities, including
weight lifting, valsalva maneuver, or coughing.4 Intra-
abdominal hypertension (IAH) is defined as sustained
or repeated IAP elevation >12 mm Hg and has a higher
mortality rate than that of patients without IAH.4 IAH is
associated with adverse effects on organ function both
inside and outside the abdominal cavity, including
lungs, heart and arteries, kidney, and the digestive sys-
tem. Abdominal compartment syndrome refers to IAH
>20 mm Hg and is associated with end-organ dysfunc-
tion.5,6 Several risk factors are noted for abdominal
compartment syndrome, including postoperative com-
plications (bleeding, infusion of carbon dioxide into the
abdomen during laparoscopy, etc.) and nonsurgical
complications (intra-abdominal tumors, pneumoperito-
neum, prone condition, peritoneal dialysis, etc.).5,6
Therefore, measuring IAP to prevent complications
caused by high-risk changes in IAP is vital, especially in
cases prone to develop elevated IAP caused by
1
Department of Emergency Medicine, School of Medicine, Isfahan
University of Medical Sciences, Isfahan, Iran
Received May 11, 2019, and accepted for publication September 5, 2019.
Corresponding Author:
Fereidon Foroutan, MD, School of Medicine, Isfahan University of
Medical Sciences, Hezar Jarib, Isfahan, 8534362515, Iran.
Email: fforoutan46@gmail.com
Golshani et al.
the aforementioned risk factors. Various invasive and
noninvasive methods have been proposed for taking IAP
measurements. IAP can be measured with a direct tech-
nique through the peritoneal catheter. Despite precise
measurement, it is an invasive technique with potential
side effects on the patient.7,8 Invasive techniques have
been proposed for IAP measurement, including measur-
ing intrabladder pressure, intragastric pressure, intraco-
lonic pressure, and intrauterine pressure.9,10 Intrabladder
pressure measurement is one of the fastest ways for mea-
suring IAP, and approximately 90% of cases of intra-
abdominal measurements are taken this way worldwide.9–11
A urinary catheter is inserted into the bladder for intrablad-
der pressure measurement.11 Measurement of central
venous pressure (CVP) is another technique for recording
IAP measurements. Its association with API was high-
lighted in various studies.11–13 Other noninvasive tech-
niques have been proposed for determining IAP, including
ultrasonographic measurements of the inferior vena cava
(IVC) diameter, the internal jugular vein (IJV) diameter,
the common femoral vein (CFV) diameter, and the ratio
between the IVC diameter and the abdominal aortic
diameter. Association of these measurable indices with
CVP allows for these methods to be used to make an IAP
measurement.14–17 Precision of these techniques varies in
different situations. For example, measurement of IVC
diameter may be difficult or imprecise in cases of com-
plications attributed to heart failure, pericardial fluid,
abdominal mass, critically ill patients, or abdominal dis-
tension following fluid accumulation in the abdominal
cavity. In such cases, other methods can be used, and
complementary studies can be carried out to achieve
more precise results.17,18
The tricuspid annular plane systolic excursion
(TAPSE) method is one of these techniques that is com-
monly used to determine the right ventricle function in
the systolic phase and its association with CVP.19 Since
the various studies comparing these methods of mea-
surement have shown different results, the aim of this
study was to evaluate the diagnostic value of ultrasonog-
raphy at the inpatient’s bedside to compare with the
intrabladder method with urine bladder catheterization
in the diagnosis of IAP.
Methods
This was a cross-sectional study conducted during an
inpatient admission. The participants consisted of 146
patients hospitalized in the emergency wards of two
hospitals in Isfahan (2017-2018). The inclusion criteria
were that patients had a urine bladder catheter and con-
sented to the study. Exclusion criteria were patients
without a urinary catheter and an inability to sleep in a
supine position.
13
Table 1. Intra-abdominal Pressure Grading.
Grading of Intra-abdominal Pressure Amount, mm Hga
Normal abdominal pressure 0-5
Abdominal compression
Grade I 12-15
Grade II 16-20
Grade III 21-25
Grade IV >25
a
1 cm H2O = 0.74 mm Hg.
The proposal was approved, and a necessary license
was obtained from the Ethics Committee of Isfahan
University of Medical Sciences. Informed consent forms
were obtained from all patients. The patients were
selected via a nonprobability sampling. Basic informa-
tion (age, sex, and history of disease) was collected and
recorded in the patient’s record. Standard monitoring was
applied to each patient (electrocardiography, systolic and
diastolic blood pressure, respiratory rate, and heart rate).
Given that the patients had catheters, the drainage bag
was removed, and 60 mL of normal saline was injected
into the urinary catheter in a sterile fashion. After 30 to 60
seconds, the venous tube was connected to the catheter
and placed vertically at a 90° angle to the pelvis of the
patient. The pubic symphysis was considered as a zero
point for measurement. The clamp was opened to raise
the fluid column within the intravenous set. Maximum
fluid height inside the tube was measured. Distribution of
IAP was specified by the centimeters of water converted
to millimeters of mercury (Table 1).
Intrabladder pressure was also measured and recorded.
If IAP was >20 mm Hg, other symptoms were recorded,
such as decreased urine output, decreased blood pressure,
respiratory distress, and hypoxia. If two of the listed
symptoms were noted and an elevated IAP detected, the
patient was definitively diagnosed with abdominal com-
partment syndrome by the researcher.
Following IAP measurement through the bladder
catheter, ultrasonographic measurement of the IVC
diameter, the IJV diameter, the CFV diameter, and the
ratio between the IVC diameter and the abdominal aor-
tic diameter were completed. An individual trained in
ultrasonography made the measurements but was not
aware of the IAP measurement results obtained through
the bladder catheter.
The protocol included all patients sleeping in the
supine position with the ultrasound transducer placed
below the xiphoid (1.5 cm below the diaphragm) to
examine the IVC. The IVC diameter decreases and blood
flow increases during normal inhalation. Changes in the
ratio between the IVC diameter during inhalation and
exhalation was more noticeable in patients with high
14 Journal of Diagnostic Medical Sonography 36(1)

Table 2. Diameter Variations of the Inferior Vena Cava linear probe was used to measure the ratio of the abdomi-
During Patient Breathing. nal aortic diameter to the IVC diameter.
Changes During Right Atrial
Diameter, cm Breathing, cm H2O Pressure Statistical Analysis
<1.5 Full collapse 0-5 The sample size was 146 based on a study by Malik et al.20
1.5-2.5 >50% collapse 5-10 Collected data were entered into SPSS (v 24; IBM).
1.5-2.5 <50% collapse 11-15
Quantitative data were reported as mean ± SD and qualita-
>2.5 <50% collapse 16-20
tive data as n (%). Diagnostic value tests, Pearson correla-
>2.5 Unchanged >20
tion coefficient, and multiple regression were used for data
analysis. The significance level was <.05 in all analyses.
intra-arterial blood pressure than in normal individuals.
M-mode tracing was used to calculate the minimum IVC Results
diameter during respiration (see Table 2). The SonoSite
In this study, 77 men and 63 women with a mean age of
Edge ultrasound system (W/L38xi; FUJIFILM SonoSite)
57.14 ± 15.32 years participated. The mean systolic blood
was used portably to conduct the imaging.
pressure in patients was 115.01 ± 24.54 mm Hg, and the
The high-frequency linear transducer was used to
intrabladder pressure was 16.07 ± 7.43 mm Hg. The mean
measure the diameter of the CFV while the patient was in
internal diameter of the vein was 1.72 ± 0.33 cm; IVC
the supine position. The femoral vein lies within the fem-
diameter, 1.91 ± 0.72 cm; CFV diameter, 1.59 ± 0.70 cm;
oral triangle in the inguinal-femoral area. The distal bor-
aorta, 2.54 ± 0.67 cm; TAPSE, 1.18 ± 0.38 cm; and
der of this area is formed by the inguinal ligament. The
IVC:aorta, 0.66 ± 0.31. In 50 (35.7%) patients, the IVC
CFV, artery, and nerve lie within the triangle from medial
was collapsed; in 77 (55%), it was more or less than 50%
to lateral borders.
collapsed; and in 12 (8.6%), it was unchanged.
The CFV was located, and the changing vein diameter
In addition, the IAP was normal in 33 (23.6%) cases,
and blood flow velocity were recorded with inhalation
grade I in 55 (39.3%), grade II in 21 (15%), grade III in
and exhalation. Femoral vein diameter ≤0.8 cm is a pre-
19 (13.6%), and grade IV in 12 (8.6%). Based on Pearson
dictor of CVP <10 cm. A CFV diameter >1 cm is a predic-
correlation, there was no significant correlation between
tor of elevated CVP. A CFV diameter >1.2 cm is a
age and diameter of the aorta with intrabladder pressure
definitive predictor of elevated CVP. A CVP >12 mm Hg
(P = .88). However, there was a significant positive cor-
is considered elevated CVP.11–13
relation between intrabladder pressure and RIJV and
The transducer was placed at the vertex of the sterno-
CFV (P < .001, R > 0). There was also an inverse correla-
cleidomastoid muscle triangle (composed of clavicular
tion between intrabladder pressure and IVC, IVC:aorta,
and sternal muscles; the heads of the muscle attach to
SBP, and TAPSE (P < .001, r < 0) (Table 3).
each other near the larynx) to examine the IJV. The IJV
Based on multivariate regression, RIJV, CFV, and
diameter was measured with a high-frequency (5-10
TAPSE are prognostic factors for predicting intrabladder
MHz) linear probe with respect to respiration.
pressure or IAP (P < .05), but IVC, IVC:aorta, and SBP are
TAPSE was measured at the apical four-chamber view
not suitable factors for estimating IAP (P > .05) (Table 4).
or subxiphoid view. This is considered to be the best view
Based on multiple regression, IAP can be measured
to observe the size of the right ventricle in contrast to the
with RIJV per the following formula:
left ventricle. The normal ratio of the right:left ventricle is
6.10:1. Right ventricular hypertrophy (also called right Intra - abdominal
ventricular enlargement) happens when the right and left
pressure ( mm Hg ) = 4.3 + 9.13 * RIJV ( cm )
ventricles have the same size at the atrioventricular valve.
Flattening of the interventricular septum (D-shaped left
ventricle) is another finding consistent with elevated right Also, IAP can be measured with CFV per the following
ventricle pressure. Apex-to-base left ventricular shorten- formula:
ing is the best and most advanced parameter for assess-
ment of global right ventricular function. TAPSE is Intra - abdominal
defined as the total excursion of the tricuspid annulus pressure ( mm Hg ) = 5.16 * CFV ( cm ) + 4.34
from end diastole to end systole, and it is measured typi-
cally at the lateral annulus with M-mode. It should be Finally, based on the analysis of variance test for
noted that TAPSE >1.6 cm was considered normal func- imported models, these were chosen to determine over-
tion; values between 1 and 1.5 cm, mild-moderate; and all prediction and, specifically, the effect of intrablad-
values <1 cm, severe dysfunction. A low-frequency curved der pressure (Table 5).
Golshani et al. 15

Table 3. Correlation Between Bladder Pressures and Other Measurements.

RIJV IVC CFV Aorta TAPSE IVC:Aorta Age SBP

r 0.87 −0.83 0.94 0.14 −0.76 −0.66 0.01 −0.64
P value <.001 <.001 <.001 .09 <.001 <.001 .88 <.001

Abbreviations: CFV, common femoral vein; IVC, inferior vena cava; RIJV, right internal jugular vein; SBP, systolic blood pressure; TAPSE, tricuspid
annular plane systolic excursion.

Table 4. Coefficients Based on Variables Within the Study.a

95.0% CI for B

Unstandardized Coefficients, B t P Value Lower Bound Upper Bound

(Constant) −4.206 −1.670 .097 −9.192 0.779
RIJV 9.244 8.930 .000 7.195 11.292
IVC 1.230 1.847 .067 −0.088 2.548
CFV 5.191 11.246 .000 4.278 6.105
TAPSE −4.476 −5.656 .000 −6.043 −2.910
SBP −0.006 −0.671 .504 −0.022 0.011

Abbreviations: CFV, common femoral vein; IVC, inferior vena cava; RIJV, right internal jugular vein; SBP, systolic blood pressure; TAPSE, tricuspid
annular plane systolic excursion.
a
Dependent variable: bladder pressure. R2 value: 0.97.

Table 5. Analysis of Variance for the Proposed Model.a
Model 1 df Mean Square F P Value
Regression 5 1331.019 440.609 <.001b
Residual 127 3.021
Total 132
a ated with compartment syndrome or increased IAP.16
Dependent variable: bladder pressure.
b
Predictors: (constant), systolic blood pressure, femoral, age, sex,
inferior vena cava:aorta, tricuspid annular plane systolic excursion,
aorta, right internal jugular vein, inferior vena cava.
Discussion
Based on the results of this study, with increased
intrabladder pressure or IAP, as expected, the measure-
ments of the IVC, IVC:aorta, and TAPSE were decreased.
Likewise, the measurements of the CFV, RIJV, and aortic
diameter were unchanged. In this study, utilizing ultraso-
nographic measurement parameters was a more appro-
priate and noninvasive method than using a urine catheter
for estimating IAP. Comparatively, regression analysis
demonstrated that the RIJV, CFV, and TAPSE were
prognostic factors for estimating IAP. However, the use
of IVC:aorta and IVC or SBP is not a predictive factor
for predicting IAP. Ultrasonography is a noninvasive
cost-effective method for estimating IAP and may be a
better technique.21 Bauman et al. demonstrated a corre-
lation between the collapsing of the IVC and IJV and
spontaneous breathing; however, there was no correla-
tion between IVC collapsing and positive ventilation
pressure. Interestingly, decreasing IVC diameter was
associated with increasing IAP.16 According to their work,
there was a significant reverse correlation between IVC
and IAP that occurred in both spontaneous breathing and
respiration with positive ventilation, which was higher in
inhalation alone. In that study, IVC collapse was associ-
Foley urinary catheter is one of the most widely used
methods for measurement of IAP. Fusco et al. demon-
strated that injection of 50 mL of normal saline into a
Foley catheter delivers more reliable results than injec-
tion of a lower volume of fluid.22 In this study, 60 mL of
normal saline was injected into the Foley catheter to
obtain results that are more reliable. Ultrasonographic
measurement of IAP is more reliable than catheteriza-
tion. Blaivas showed that ultrasonographic measure-
ment of IAP in patients with compartment syndrome is
more advantageous than other methods.23 A study by
Cavaliere et al. indicated that ultrasonographic mea-
surement of the IVC diameter is preferable to measure-
ment of the diameter of other intra-abdominal veins for
IAP determination.24 Decreased diameter or collapsed
veins indicated IAP elevation. This result is consistent
with the results of this study, which showed that IVC
decreases as IAP increases. IVC is more useful than
other ultrasonographic markers for IAP assessment.
Sixteen healthy individuals were examined in the
Cavaliere et al. study in which IAP elevation was simu-
lated with external pressure. The results showed that
ultrasonography and IVC examination were the best
16
methods for IAP determination. Sugrue et al. also
assessed the efficacy of varied methods for making an
IAP measurement but preferred ultrasonographic mea-
surements and emphasized their use.25 The results of the
former studies were consistent with the results of this
study. Therefore, sonographic measurement of IAP is
superior over other methods.
Conclusion
The results of this study and other studies demonstrated
that the ultrasonographic measurement of IAP is a useful
and efficient method for IAP measurement. This is nonin-
vasive method devoid of catheterization, which makes it
a more tolerable measurement technique for patients.
Therefore, it is suggested that ultrasonographic indices of
IVC, RIJV, CFV, and TAPSE be used for IAP measure-
ment in patients prone to develop IAP elevation.
Limitations of the study were the small sample size, lack
of assessment of other effective factors in IAP, and lim-
ited studies in this area of research. Therefore, it is highly
recommended that similar studies be conducted with
larger sample sizes to examine this noninvasive method.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Fereidon Foroutan https://orcid.org/0000-0002-1445-1190
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