Abstract
Background
Dynamic monitoring of intra-abdominal pressure is a reliable basis for diagnosing intra-abdominal hypertension and abdominal compartment syndrome, which are independent risk factors for death. The latest evidence on abdominal pressure monitoring has been updated, but the gap between these updates and the actual practice of critical care nurses remains unknown. This study aimed to assess the behaviour and cognition of adult critical care nurses in China regarding intra-abdominal pressure measurement.
Methods
A national cross-sectional study of Chinese adult critical care nurses was conducted from May to August 2024 using a developed questionnaire. The survey assessed measurement methods, patient positioning, zero reference points, value reading timing, and nurses’ understanding of intra-abdominal pressure.
Results
A total of 1068 valid questionnaires were included. Of these, 768 (71.9%) respondents had measured intra-abdominal pressure. The main reason for not monitoring intra-abdominal pressure was a lack of training (60%). The bladder pressure was regarded as the gold standard by 754 (98.2%) participants, of whom 642 (85.1%) chose the traditional (intermittent) technique for intra-abdominal pressure measurement. The cognition score ranged from 2 to 19, the median was 9.0 with an interquartile range of 8.0, and associated factors included age, hospital level, education level, marital status, professional title, and number of years working in the clinic.
Conclusions
Adult critical care nurses in China exhibit inadequate overall cognition regarding intra-abdominal pressure monitoring, with particularly deficient understanding of fundamental concepts, including normal IAP thresholds, diagnostic criteria for intra-abdominal hypertension, and risk factor identification. It is imperative to enhance the focus on monitoring intra-abdominal pressure. Furthermore, it is essential to provide regular training for adult critical care nurses, grounded in the latest evidence, to elevate both the standardisation of procedures and the level of cognitive understanding in this area.
Clinical trial number
Not applicable.
Keywords: Cross-sectional studies, Intra-abdominal pressure, Intra-abdominal hypertension, Abdominal compartment syndrome, Critical care nursing, Nurses
Background
Intra-abdominal pressure (IAP) is the steady-state pressure within the abdominal cavity [1]. It is considered the sixth vital sign in critically ill patients, in addition to the four major vital signs and oxygen saturation. IAP increases with inspiration and decreases with expiration, directly affecting the volume of solid organs or hollow viscera (which may be empty or filled with air, liquid, or faecal matter). Other factors affecting IAP include the presence of ascites, blood or other space-occupying lesions (such as tumours or a gravid uterus), as well as conditions that limit expansion of the abdominal wall (such as burn eschars or third-space oedema). The normal IAP in healthy adults is 0–5 mmHg (1 mmHg = 0.133 kPa). However, in critically ill adults, the IAP is approximately 5–7 mmHg due to fluid retention, abdominal surgery, mechanical ventilation, and other factors [2, 3].
According to the Abdominal Compartment Society [2], intra-abdominal hypertension (IAH) is defined as persistent or repeated pathologic elevation of IAP ≥ 12 mmHg, graded as follows: Grade Ⅰ (IAP 12–15 mmHg), Grade Ⅱ (IAP 16–20 mmHg), Grade Ⅲ (IAP 21–25 mmHg), and Grade Ⅳ (IAP > 25 mmHg). Abdominal compartment syndrome (ACS) is defined as an IAP > 20 mmHg (with or without an abdominal perfusion pressure of < 60 mmHg) that is associated with new organ dysfunction or failure. Studies [3–6] show that 48.9–80% of critical care patients develop IAH during hospitalisation, with 2.7–51.7% developing ACS. Elevated IAP affects a wide spectrum of critically ill patients and carries a high risk of mortality and morbidity. IAH and ACS are independent predictors of mortality in critical care patients and are also associated with an increased incidence of ventilator-associated pneumonia and multiple organ failure [7–10]. IAP measurements provide a reliable basis for diagnosing IAH and ACS. Accurate and correct IAP measurement can help detect IAH early, preventing it from developing into ACS [11]. In addition, IAP-based early enteral nutrition therapy has an obvious advantage in critically ill patients [12].
IAP can be measured either directly via a catheter placed in the intraperitoneal cavity or indirectly via other intra-abdominal organs, including intravesical, intragastric, intracolonic, and intrauterine pressure [13–15]. The direct measurement method yields accurate results but is invasive, increasing the probability of abdominal infection in patients; thus, it is not recommended for routine use in clinical practice. Although several new measurement methods have been proposed [16–18], the intravesical method, also known as the bladder pressure method, is the gold standard non-invasive method recommended by the Abdominal Compartment Society; this is due to its objectivity, simplicity of operation, and low cost, and it is widely used and studied worldwide [2]. Thus, our study focused on the bladder pressure method.
Nurses play a critical role in the implementation of IAP measurement and the monitoring of abnormal results. While IAP monitoring requires physician orders in Chinese ICUs, nurses exercise full procedural autonomy: they independently assess how to perform measurements, interpret results, and initiate protocol-based interventions. The accuracy of the nurse’s measurement results and the appropriateness of their interpretation significantly impact patient outcomes. Consequently, the competence and expertise of nurses in measuring IAP are critically important. At present, published studies [19–21] have focused mainly on investigating healthcare staff’s knowledge of IAH and ACS, and few [22, 23] have focused on the behaviours related to IAP measurement in adult critical care nurses, which have limited sample sizes. In addition, the evidence [2, 3, 24–29] concerning IAP monitoring has been further updated, and we wanted to explore the gap between the updated evidence and actual practices in China. Therefore, this study aimed to determine the current situation of IAP monitoring and cognition of adult critical care nurses and to analyse the factors associated with these behaviours.
Methods
Study design and participants
This online cross-sectional study was conducted with adult critical care nurses in China between March 2024 and July 2024. All registered nurses who had worked in an adult intensive care unit for over 1 year were eligible to complete the questionnaire. The exclusion criteria were: (1) nurses in administrative positions, (2) nurses not on duty during the survey period, and (3) refresher and rotary nurses.
Survey questionnaire
The survey questionnaire was developed by Liu Beibei et al. [22] in 2023 and was used in tertiary general hospitals in Shandong Province, China. The content validity index was 0.967. The questionnaire included 45 items in three sections. The demographic characteristics of the participants were collected in the first Sect. (11 items), including age, sex, working years, title, education level, etc. The second section investigated the IAP measurement behaviour of adult critical care nurses, including the measurement methods, patient position, zero reference location, value reading timing, etc. (15 items). This section included single-choice and multiple-choice questions. The third section (19 items) assessed nurses’ understanding of IAP with single-choice and multiple-choice questions, focusing on their knowledge of the IAP/IAH and the factors affecting the accuracy of the measurement results. In this section, each question was scored one point, with a total possible score of 19 points. The higher the score, the better the understanding of IAP monitoring among adult critical care nurses.
Data collection
Data were collected using an open and free online survey website called the Wenjuanxing platform. We entered all the questions and answers into the website, and the content was presented as an electronic questionnaire by scanning a quick response code given by the platform. We contacted the nurse managers from intensive care units in 89 hospitals across 20 Chinese provinces through WeChat groups or emails, informed them of the survey’s purpose, content, and requirements in detail, and asked them to send the quick response code to nurses in each department to fill in the questionnaire. All respondents were required to complete all questions. If an answer was missed, the system would automatically pop up tips. Each IP address was limited to one response. The questionnaire could not be submitted before each answer was completed. Participants could withdraw from the study at any time, and their data would not be included. In addition, questionnaires with a completion time of less than 6 min were excluded. Nurses were invited based on their professional interest in optimising IAP monitoring practices. No material incentives were offered to participants, aligning with ethical principles of voluntary participation and minimising selection bias.
Data analysis
Two researchers independently checked the original data exported from the website separately, removed invalid data, and then used IBM SPSS version 25.0 for statistical analysis. Values are presented as medians and interquartile ranges for data that were not normally distributed for continuous variables. Categorical variables are expressed as frequencies and percentages (%) according to patient demographics. Comparisons between groups regarding cognition scores according to different demographic characteristics were performed using the Mann-Whitney U test or the Kruskal-Wallis Test. P values of less than 0.05 were considered statistically significant.
Results
Demographic characteristics of participants
Among 89 invited hospitals across 20 provinces, 73 hospitals in 19 provinces participated, including 55 tertiary hospitals (75.34%) and 18 secondary hospitals (24.66%). A total of 1117 questionnaires were received. After excluding questionnaires with a response time of less than 6 min, 1068 valid questionnaires were ultimately included. The sample comprised 876 (82%) female and 192 (18%) male participants, of whom 506 (47.4%) were specialist nurses. Further details of the demographic data are shown in Table 1.
Table 1.
Demographic characteristics of participants and univariate analysis of IAP cognition (n = 1068)
| Variables | Number (%) | Cognition scores (M(P25, P75)) | Z/H | P | |
|---|---|---|---|---|---|
| Total | 1068(100%) | 9(6,14) | |||
| Sex | Male | 192(18%) | 8(6,15.5) | -0.977a | 0.329 |
| Female | 876(82%) | 9(6.25,14) | |||
| Age | 18~ | 73(6.8%) | 9(6,14) | 26.497b | <0.001 |
| 24~ | 406(38%) | 8(5,14) | |||
| 30~ | 286(26.8%) | 8(6,11) | |||
| 36~ | 209(19.6) | 10(7,18) | |||
| > 41 | 94(8.8%) | 11(8,19) | |||
| Hospital level | Tertiary hospitals | 980(91.8%) | 9(6,16) | -3.690a | <0.001 |
| Secondary hospitals | 88(8.2%) | 7(6,9) | |||
| Education level | Associate | 132(12.4%) | 7(5,9) | 29.652b | <0.001 |
| Bachelor | 886(83%) | 9(6,15) | |||
| Master and Doctor | 50(4.7%) | 9(8,13.25) | |||
| Marital status | Single | 330(35.5%) | 8(6,14) | -3.378a | 0.001 |
| Married or living with a partner | 688(64.4%) | 9(7,16) | |||
| Professional title | Nurse | 157(14.7%) | 10(6,17) | 29.682b | <0.001 |
| Senior nurse | 384(36%) | 8(6,11.75) | |||
| Nurse-in-charge | 487(45.6%) | 9(7,14) | |||
| Associate chief nurse | 32(3%) | 9(8,17.75) | |||
| Chief nurse | 8(0.7%) | 10(7,13) | |||
| Clinical working years | 1 ~ 2 years | 89(8.3%) | 10(7,16) | 18.426b | <0.001 |
| 3 ~ 5 years | 244(22.8%) | 7(5,12) | |||
| 6 ~ 8years | 230(21.5%) | 8(6,13) | |||
| > 8 years | 505(47.3%) | 9(7,16) | |||
| Specialist nurse | Yes | 506(47.4%) | 9(7,17) | -6.046a | <0.001 |
| No | 562(52.6%) | 8(6,12) | |||
| Trained about IAP | Never | 212(19.9%) | 7(6,9) | 39.387b | <0.001 |
| Occasionally or Sometimes | 622(58.2%) | 9(6,16) | |||
| Often or Always | 234(21.9%) | 9(7,18) | |||
Note: a: Mann-Whitney U Test, b: Kruskal-Wallis Test. IAP: Intra-abdominal Pressure
Intra-abdominal pressure measurement behaviour of adult critical care nurses
Of the 1068 participants, 768 (71.9%) had measured IAP, and 300 (28.1%) participants did not. The reasons for not monitoring IAP included lack of training (60%), lack of related equipment (47.3%), insufficient understanding of relevant evidence (29.7%), lack of indication of IAP measurement (29.3%), lack of medical insurance and other related policy support (16.7%), lack of attention from managers (10%), and a complex operation process increasing nurses’ workload (9.7%).
Concerning the monitoring approach, the intravesical pressure of 754 (98.2%) participants was regarded as the gold standard. The IAP through the rectum, laparoscopy, inferior vena cava, and stomach was measured in only a few participants. For the monitoring methods used, among the participants in the transvesical (bladder) approach, 642 (85.1%) participants chose the traditional (intermittent) technique, 179 (23.7%) participants chose the continuous (pressure transducers) technique, and 175 (23.2%) chose urodynamic systems.
A total of 359 (47.6%) participants reported that they always comforted and explained the procedure to awake patients before measurement, while only a small number (1.6%) of participants never explained. In addition, more than half of the participants (70.7%) ensured the tube was free of bubbles and blockages before measurement.
Concerning patients’ position during measurement, 349 (46.3%) participants chose the “Completely supine position with straight legs”, which is consistent with guideline recommendations [2, 3, 24–26]. 343 (45.5%) respondents chose “Keep the same position as zeroing”. Similar numbers (6.1%) chose “head of bed ≤ 15° ” and “head of bed ≥ 30°”. For the zero reference location, almost half (50.8%) of the respondents chose the intersection point where the mid-axillary line crosses the iliac crest, which is recommended by the guidelines [2]. Approximately one-third (38.9%) of the study participants chose the pubic symphysis, and 78 (10.3%) chose the axillary midline level. In addition, 333 (44.2%) respondents marked the zero reference level for the patient to improve the measurement accuracy.
The guidelines[2.3] report that the volume of normal saline instilled in the bladder should not exceed 25 ml. Of the participants, 447 reported meeting the requirements, and the others instilled volumes above the current guidelines. For the temperature of the instilled saline, 204 (27.1%) respondents were aware of its influence, and 42 (5.6%) participants never considered the temperature. When continuous IAP monitoring was used, the majority (76.9%) of participants zeroed the pressure module before reading the monitor every time, and 2.8% never zeroed.
In this study, 60.7% of respondents read the value at end-expiration, but 20.7% did not consider the factor. A total of 24.9% of participants reported that they subtracted the positive end-expiratory pressure value from the measured IAP value for patients who could not disconnect from the ventilator. Additionally, 22.5% of nurses acknowledged the effect of positive end-expiratory pressure on IAP and recorded the values, while10.3% did not consider this effect. Only 15% of respondents waited 30–60 s after instillation before reading the IAP, and 13.4% did not focus on the waiting time. For more details regarding the IAP measurement behaviour of adult critical care nurses, refer to Table 2.
Table 2.
IAP measurement behaviour of adult critical care nurses(n = 1068)
| No. | Variable | Frequency | Percentage |
|---|---|---|---|
| 1 | Have measured IAP | ||
| Yes | 768 | 71.9% | |
| No | 300 | 28.1% | |
| 2 | Reasons why not measured | ||
| Lack of attention from managers | 30 | 10% | |
| Lack of training | 180 | 60% | |
| Lack of indication of measurement | 88 | 29.3% | |
| Insufficient understanding of relevant evidence | 89 | 29.7% | |
| Lack of medical insurance and other related policy support | 50 | 16.7% | |
| The complex operation process increases nurses’ workload | 29 | 9.7% | |
| Lack of related equipment | 142 | 47.3% | |
| 3 | Measurement approach | ||
| By abdominal puncture | 2 | 0.3% | |
| By laparoscopy | 2 | 0.3% | |
| By bladder | 754 | 98.2% | |
| By gastric | 6 | ||
| By rectum | 2 | 0.3% | |
| By the inferior vena cava | 2 | 0.3% | |
| 4 | Measurement methods | ||
| Traditional (intermittent) technique | 642 | 85.1% | |
| Continuous (pressure transducers) technique | 179 | 23.7% | |
| Urodynamic monitoring | 175 | 23.2% | |
| 5 | Comforted and explained to awake patients before measurement | ||
| Always | 365 | 47.5% | |
| Often | 200 | 26% | |
| Sometimes | 140 | 18.2% | |
| Occasionally | 50 | 6.5% | |
| Never | 13 | 1.7% | |
| 6 | Ensured the tube was free of bubbles and blockages | ||
| Always | 542 | 70.6% | |
| Often | 172 | 22.4% | |
| Sometimes | 42 | 5.5% | |
| Occasionally | 12 | 1.6% | |
| Never | 0 | 0 | |
| 7 | Patients body position when measuring | ||
| Completely supine position with straight legs | 353 | 46% | |
| Head of bed ≤ 15° | 48 | 6.3% | |
| Head of bed ≥ 30° | 16 | 2.1% | |
| Keep the same position as zeroing | 351 | 45.7% | |
| 8 | Zero reference point | ||
| Pubic symphysis | 297 | 38.7% | |
| The level of the axillary midline | 82 | 10.7% | |
| Intersection point where the mid-axillary line crosses the iliac crest | 389 | 50.7% | |
| 9 | Marked the zero reference level on the patient to improve the accuracy of measurement | ||
| Always | 337 | 43.9% | |
| Often | 205 | 26.7% | |
| Sometimes | 99 | 12.9% | |
| Occasionally | 90 | 11.7% | |
| Never | 37 | 4.8% | |
| 10 | Volume instilled into the bladder before measurement (ml) | ||
| ≤ 25 | 457 | 59.5% | |
| 26 ~ | 74 | 9.6% | |
| 51 ~ | 158 | 20.6% | |
| > 100 | 79 | 10.3% | |
| 11 | Noticed the influence of temperature | ||
| Always | 207 | 27% | |
| Often | 206 | 26.8% | |
| Sometimes | 131 | 17.1% | |
| Occasionally | 181 | 23.6 | |
| Never | 43 | 5.6% | |
| 12 | When to zero the pressure module? | ||
| Every time | 589 | 76.7% | |
| Every shift | 140 | 18.2% | |
| Every day | 16 | 2.1% | |
| Never | 23 | 3% | |
| 13 | How to deal with the effect of the positive end-expiratory pressure on IAP? | ||
| Never noticed the effect | 80 | 10.4% | |
| Noticed the effect, but do not know how to deal with | 139 | 18.1% | |
| Noticed the effect, recorded the positive end-expiratory pressure value | 170 | 22.1% | |
| Reduced the positive end-expiratory pressure to zero before reading the IAP value | 146 | 19% | |
| Temporarily disconnect the ventilator to read the IAP value | 41 | 5.3% | |
| Subtracted the positive end-expiratory pressure value from the read intra-abdominal pressure value | 192 | 25% | |
| 14 | Timing of reading the IAP value | ||
| Read the value at the end of exhalation | 465 | 60.5% | |
| Read the value at the end of inspiration | 143 | 18.6% | |
| Never noticed | 160 | 20.8% | |
| 15 | Waiting time after instillation (s) | ||
| < 15 | 147 | 19.1% | |
| 15 ~ | 374 | 48.7% | |
| 30 ~ | 117 | 15.2% | |
| > 60 | 28 | 3.6% | |
| Never noticed | 102 | 13.3% | |
Note: IAP: Intra-abdominal Pressure
Predictors of cognition of adult critical care nurses
The cognition scores for IAP monitoring ranged from 2 to 19, with a median of 9, a lower quartile of 6, and an upper quartile of 14. There were 10 items with an accuracy rate greater than 50%. Only 47% of participants thought the normal IAP in critically ill patients should be between 5 and 7 mmHg. Half (56%) of the participants understood the definition of IAH. More details about the cognition of adult critical care nurses regarding IAP are shown in Table 3, and the correct response rates for their understanding of IAP measurement are illustrated in Fig. 1. The univariate analysis results of IAP Cognition indicated that the associated factors encompassed age, hospital level, and various other factors, as illustrated in Table 1.
Table 3.
Cognition of adult critical care nurses regarding IAP (n = 1068)
| No. | Category | Question | Frequency | Percentage |
|---|---|---|---|---|
| 1 | Description | Which is the correct description of Intra-abdominal pressure? | ||
| Intra-abdominal pressure is a stable pressure state in the closed abdominal cavity.* | 896 | 83.9% | ||
| Intra-abdominal pressure is produced by the hydrostatic pressure of the abdominal viscera. | 93 | 8.7% | ||
| Intra-abdominal pressure decreased during inspiration and increased during expiration. | 29 | 2.7% | ||
| Intra-abdominal pressure is determined by abdominal wall compliance. | 50 | 4.7% | ||
| 2 | Description | Which is correct about the normal intra-abdominal pressure in critically ill patients? | ||
| 0–5 mmHg | 208 | 19.5% | ||
| 5–7 mmHg* | 502 | 47% | ||
| 8–10 mmHg | 269 | 25.2% | ||
| 11–13 mmHg | 89 | 8.3% | ||
| 3 | Description | Intra-abdominal hypertension refers to | ||
| Persistent or repeated pathological elevation of intra-abdominal pressure ≥ 10 mmHg. | 216 | 20.2% | ||
| Persistent or repeated pathological elevation of intra-abdominal pressure ≥ 11 mmHg. | 122 | 11.4% | ||
| Persistent or repeated pathological elevation of intra-abdominal pressure ≥ 12 mmHg.* | 598 | 56% | ||
| Persistent or repeated pathological elevation of intra-abdominal pressure ≥ 13 mmHg. | 132 | 12.4% | ||
| 4 | Description | How many grades of intra-abdominal hypertension can be divided? | ||
| 3 grades | 268 | 25.1% | ||
| 4 grades* | 688 | 64.4% | ||
| 5 grades | 79 | 7.4% | ||
| 6 grades | 33 | 3.1% | ||
| 5 | Description | Abdominal compartment syndrome (ACS) refers to the continuous increase of intra-abdominal pressure exceeding ____ mmHg (with or without peritoneal perfusion pressure < 60 mmHg), combined with new organ dysfunction or organ failure. | ||
| 15 mmHg | 143 | 13.4% | ||
| 20 mmHg* | 648 | 60.7% | ||
| 25 mmHg | 187 | 17.5% | ||
| 30 mmHg | 90 | 8.4% | ||
| 6 | Consequences | What are the mechanisms of organ dysfunction caused by intra-abdominal pressure? (multiple choice item) | ||
| The increased intra-abdominal pressure is directly transmitted to other chambers of the body.* | 353 | 33.1% | ||
| The increased intra-abdominal pressure is indirectly transmitted to other chambers of the body. | 587 | 55% | ||
| Increased intra-abdominal pressure affects systemic haemodynamics.* | 323 | 30.2% | ||
| Increased intra-abdominal pressure affects local haemodynamics. | 797 | 74.6% | ||
| 7 | Consequences | Increased intra-abdominal pressure will not lead to the following situations? | ||
| Increased myocardial compliance, increased cardiac output, and elevated blood pressure.* | 528 | 49.4% | ||
| Lung compliance decreased, pulmonary oedema, atelectasis, and hypoxemia. | 194 | 18.2% | ||
| Intracranial venous outflow obstruction, intracranial hypertension, and decreased cerebral perfusion. | 229 | 21.4% | ||
| Reduced renal blood flow, oliguria, anuria, and renal failure. | 117 | 11% | ||
| 8 | Factors related to IAH | What is the pathogenesis of the effect of elevated intra-abdominal pressure on the body? | ||
| Related to the oedema of damaged organs and the increase of extracellular fluid caused by direct compression, ischaemia-reperfusion injury, release of vasoactive substances, and increase of vascular.* | 630 | 59% | ||
| Related to the oedema of damaged organs and the increase of intracellular fluid caused by direct compression, ischaemia- reperfusion injury, release of vasoactive substances, increase of vascular. | 289 | 27.1% | ||
| Related to the increase of abdominal wall tension caused by the increase in abdominal contents. | 131 | 12.3% | ||
| Related to the decrease in abdominal wall tension and the increase in abdominal contents. | 18 | 1.7% | ||
| 9 | Factors related to IAH | What are the following factors that do not lead to increased intra-abdominal pressure? | ||
| Increased content of the abdominal cavity | 112 | 10.5% | ||
| Accumulation of abdominal contents | 98 | 9.2% | ||
| Increased abdominal wall compliance* | 546 | 51.1% | ||
| Capillary leakage and fluid resuscitation | 312 | 29.2% | ||
| 10 | Conditions for IAP monitoring | Which of the following situations does not require routine monitoring of intra-abdominal pressure? | ||
| When patients have abdominal pathological symptoms. | 111 | 10.4% | ||
| When patients have hypoperfusion or excessive fluid. | 247 | 23.1% | ||
| During enteral nutrition in patients with severe acute pancreatitis. | 192 | 18% | ||
| When patients have trauma leading to exposure of abdominal organs.* | 518 | 48.5% | ||
| 11 | Conditions for IAP monitoring | Which of the following situations is prohibited from monitoring intra-abdominal pressure by bladder measurement? | ||
| Abdominal surgery | 92 | 8.6% | ||
| Intraperitoneal Haemorrhage | 259 | 24.3% | ||
| Intestinal obstruction | 108 | 8.6% | ||
| Trendelenburg position ( lies supine, feet raised higher than their head)* | 609 | 57% | ||
| 12 | Conditions for IAP monitoring | How often do you routinely measure IAP when the patient’s IAP ≥ 12 mmHg? | ||
| Every 1 h | 116 | 10.9% | ||
| Every 2 ~ 3 h | 209 | 19.6% | ||
| Every 4 ~ 6 h* | 621 | 58.1% | ||
| Every 6 ~ 8 h | 122 | 11.4% | ||
| 13 | Technique of accurate IAH monitoring | What factors will affect the measurement of intra-abdominal pressure? (multiple choice item) | ||
| Patients body position* | 81 | 7.6% | ||
| Breath holding* | 141 | 13.2% | ||
| Infusion volume in bladder* | 103 | 9.6% | ||
| Zero reference level* | 203 | 19% | ||
| Mechanical ventilation* | 180 | 16.9% | ||
| Tension of abdominal muscle* | 155 | 14.5% | ||
| Patients wear a chest and abdomen belt* | 225 | 21.1% | ||
| Dysphoria* | 172 | 16.1% | ||
| 14 | Technique of accurate IAH monitoring | Which of the following operations increase the patient’s risk of urinary or intra-abdominal infection? | ||
| Strictly follow the aseptic principle. | 133 | 12.5% | ||
| Strictly disinfect each connection port of the pipeline. | 46 | 4.3% | ||
| Repeatedly opened the connection and injected with normal saline.* | 861 | 80.6% | ||
| Perineal care and catheterisation care | 28 | 2.6% | ||
| 15 | Technique of accurate IAH monitoring | What kind of situation does the patient have that should try to avoid the head of the bed elevation? | ||
| Grade Ⅰ IAH | 98 | 9.2% | ||
| Grade Ⅱ IAH | 231 | 21.6% | ||
| Grade Ⅲ IAH | 233 | 21.8% | ||
| Grade Ⅳ IAH* | 506 | 47.4% | ||
| 16 | Nursing care for patients with IAH | Do you think which method can accurately reflect the capacity status of the patient relatively when IAH happens? | ||
| Central venous pressure measured by the traditional (intermittent) technique | 217 | 20.3% | ||
| Pulmonary artery wedge pressure is measured by the traditional (intermittent) technique | 82 | 7.7% | ||
| Arterial blood pressure measured by pressure transducers | 182 | 17% | ||
| Thermodilution or left ventricular end-diastolic volume assessed by ultrasonography* | 587 | 55% | ||
| 17 | Nursing care for patients with IAH | Do you think which is the correct setting of ventilator parameters in patients with intra-abdominal hypertension? | ||
| The plateau pressure is < 30 cmH2O (1 cmH2O = 0.098 kPa). | 299 | 28% | ||
| The plateau pressure should be measured by oesophageal pressure or calculated by formula.* | 462 | 43.3% | ||
| PEEP was set at 70% of the intra-abdominal pressure. | 170 | 15.9% | ||
| PEEP was set at 30% of the intra-abdominal pressure. | 137 | 12.8% | ||
| 18 | Nursing care for patients with IAH | When the patient’s intra-abdominal pressure increased to_____, you will suggest to the doctor to implement measures to reduce intra-abdominal hypertension. | ||
| 7 mmHg | 45 | 4.2% | ||
| 12 mmHg | 369 | 34.6% | ||
| 16 mmHg* | 385 | 36% | ||
| 20 mmHg | 203 | 19% | ||
| 25 mmHg | 66 | 6.2% | ||
| 19 | Nursing care for patients with IAH | If intra-abdominal pressure continues to rise, which of the following measures can be taken? (multiple choice item) | ||
| Patients who received enteral nutrition should have received a reduction or suspension of enteral nutrition.* | 116 | 10.9% | ||
| Muscle relaxants* | 387 | 36.2% | ||
| A large amount of rehydration | 811 | 75.9% | ||
| Abdominal ultrasound examination* | 179 | 16.8% | ||
| Trendelenburg position | 565 | 52.9% | ||
| Haemodialysis/ultrafiltration* | 333 | 31.2% | ||
| Open abdomen* | 484 | 45.3% | ||
* The correct answer
IAP: Intra-abdominal Pressure
Fig. 1.
Correct response rates on cognition of IAP measurement among adult ICU nurses (n = 1086)
Discussion
This study aimed to determine the current state of adult critical care nurses’ behaviour in measuring IAP and cognition of IAP/ACS in China. To our knowledge, IAP monitoring is a critical parameter for early detection of IAH and ACS in at-risk critically ill patients, guiding timely intervention to prevent organ failure. Although many consensus and guidelines provide recommendations about measuring IAP correctly [2, 3, 24–26, 29], a gap remains between the evidence and the implementation in clinical practice. Besides, subtle differences in those recommendations (e.g., saline instillation volume, zero-reference level) contribute to practice variations, for instance, the World Society of Abdominal Compartment Syndrome (WSACS) recommends calibrating the transducer at the level of the midaxillary line, but it does not specify the precise location of the midaxillary line [2], whereas some guidelines suggest zeroing at the midaxillary-iliac crest [3, 25]. Such discrepancies can confuse health professionals, particularly when local adaptations are lacking [30]. Crucially, Chinese guidelines [24] and evidence summary [29, 31] provide unified, context-appropriate standards (e.g., strict ≤ 25 ml instillation, midaxillary-iliac crest zeroing). Nurses monitor IAP, so understanding their cognition and behaviour is critical. The influencing factors, the barriers to measure, and the details of the measurement process should also be determined. According to the results, more attention should be given to IAP in China; almost one-third of the participants did not measure IAP, and the primary reason was a lack of training (60%), which is consistent with Hunt et al.’ s Australian ICU survey (44.2%) [19] and Wise et al.’ s clinician report (48% unaware of IAH criteria) [21]. This means that the knowledge level of adult critical care nurses is insufficient, directly restricting behaviour changes. An earlier study [32] demonstrated that continuing education increased professional behaviour and improved patient management. Meanwhile, the high rate of reported ‘lack of training’ indicates inadequate institutional prioritisation, reflecting a lack of appreciation among physicians. If medical teams valued IAP monitoring, appropriate training and resources would be provided [20]. Thus, it is necessary to construct a regular IAP education and skills assessment according to the updated evidence. In addition, strengthening the supervision of implementation is needed to improve compliance and execution of IAP monitoring by nurses.
Incorrect operation behaviour affects the accuracy of the IAP measurement results. The results also showed that adult critical care nurses’ behaviour of IAP measurement needs further standardisation. Most nurses who measured IAP chose the intravesical method, of which the majority chose the traditional (intermittent) technique. There are three main measurement methods: the traditional (intermittent) technique, the continuous (pressure transducers) technique, and ambulatory urodynamic monitoring. At present, no research has compared these three methods in terms of measurement accuracy, and further research is needed in the future. This investigation revealed that 85.1% of the participants chose the traditional technique. Regarding the specific operation process, recent guidelines [3, 24–26, 29], consensuses [2, 24], and evidence summaries [29, 31] have provided clear recommendations, such as the patient’s body position when measuring, zero reference, and the volume of sterile saline instilled into the bladder. However, the correct answer rate for IAP measurement was not high in this study.
First, body position significantly affects IAP values [33]. When the patient cannot assume a supine position due to the limitation of their condition, the same position is recommended for each IAP measurement [3, 24]. However, fewer than half of the participants chose correctly. In this survey, only 50.7% of the participants selected the intersection between the midaxillary line and the iliac crest as the zeroing point recommended by guidelines [26–28, 34]. Additionally, less than half (43.9%) of participants marked the zero reference level on the patient for every measurement, which is recommended by one evidence summary [31]. The accuracy of IAP measurement is closely related to the reference point. Previous studies [35] have shown that selecting the level of the pubic symphysis and right atrium as the reference point could affect the results of the IAP measurement due to inaccurate positioning. When using the intersection as the reference point, the measured value is closest to the true value, and the point is easier to locate. Additionally, concerning the volume and temperature of sterile saline instilled into the bladder, some evidence [2, 3, 24, 36] suggests that excessive bladder perfusion may produce an iatrogenic increase in IAP, so the reference standard volume should not exceed 25 ml. Furthermore, cold, sterile saline will trigger bladder muscle spasms, resulting in deviation of the measurement results [37, 38]. Accordingly, measuring the IAP with saline at body temperature (35 ℃) is preferable. In our study, more than half (59.5%) of respondents selected the correct perfusion volume, and only 27% of the respondents always considered the temperature while monitoring IAP, which also reflects the nurses’ lack of knowledge on the other side.
Moreover, the IAP can be affected by ventilator-positive end-expiratory pressure, and nurses must read the value at end-expiration [34]. Most respondents (60.5%) followed this requirement, but a considerable proportion (20.8%) had never considered the problem. It is proposed that the IAP should be measured 30–60 s after instillation to allow for bladder detrusor muscle relaxation [2, 34]. Only a small portion (15.2%) of participants measured as needed, and 13.3% had never noticed the waiting time.
This study revealed that the overall understanding of IAP among adult critical care nurses was inadequate, and the score of the cognition was 9 (6,14), the lowest score was 2, and the highest score was 19. These scores were higher than those reported for Chinese paediatric critical care nurses, whose median score was 8.0 with an interquartile range of 7.0 to 8.0 [39]. This is probably because research on IAP in children began relatively recently, with the first consensus on paediatric IAH and ACS published in 2013 [2]. It may also be influenced by the varying training levels of hospitals across different regions. This study also revealed that adult critical care nurses were unfamiliar with the definition and management of IAH and ACS. Although clinicians are responsible for intervening in IAH and ACS, nurses should monitor IAP, interpret results, and inform the team promptly for further intervention to improve patient outcomes. Consequently, we recommend that hospital managers regularly adopt diverse training methods such as academic lectures and simulation exercises. The content should include concepts, risk factors, the influence of IAH and ACS on patients, specific steps of the measurement process, and other related knowledge.
We also found that nurses with higher educational levels, advanced professional titles, specialist nurse certificates, ages ≥ 41 years, working in tertiary hospitals, and training related to IAP always had higher cognitive scores, similar to the results of previous studies [22]. One explanation for these results could be that nurses with high-level professional titles and age ≥ 41 years had more work experience and training opportunities. Moreover, higher education nurses had better self-directed learning abilities, perhaps even without relevant training. In addition, the scores of nurses working in tertiary hospitals were higher than those of nurses working in secondary hospitals because high-level hospitals might set higher standards for nurses and have better education and training systems. This suggests that targeted and tailored education and assessment of IAP-related knowledge needs to be provided to adult critical care nurses according to their demographic characteristics.
Notably, although consensus and guidelines were achieved on the majority of statements and content related to IAP, significant variability existed. Between 2022 and 2023, WSACS carried out a global survey to gather the consensus of healthcare practitioners worldwide on existing and potential new statements for use in future guidelines [40]. The results showed that there was still no agreement regarding baseline IAP, measurement approach, and body position. Therefore, it is essential to conduct multi-centre, large-scale, and high-quality studies to further investigate the related controversial issues and support clinical practice. Furthermore, ongoing education, advocacy, and awareness initiatives grounded in the most current evidence regarding IAP among nursing professionals were highlighted.
Limitations
There are two limitations to this study. First, we did not analyse the differences in the scores of nurses in each specialised intensive care unit, such as the respiratory intensive care unit and the surgical intensive care unit, which could be influencing factors. Second, we did not use the random sampling method, and this survey did not cover all provinces in the country; thus, the results should be cautiously evaluated.
Conclusion
This study provides an overview of IAP monitoring in Chinese hospitals. The findings revealed that implementing IAP monitoring was not optimal and should receive more attention. The behaviour of adult critical care nurses in IAP measurement needs to be standardised, and their understanding must be improved. Hence, we suggest that (1) standardised IAP measurement procedures should be developed and publicised, and (2) a targeted and tailored education and management system for IAP monitoring should be constructed based on the existing evidence.
Acknowledgements
We would like to acknowledge all the adult intensive care nurses who participated in this cross-sectional study.
Abbreviations
- IAP
Intra-abdominal pressure
- IAH
Intra-abdominal hypertension
- ASH
Abdominal compartment syndrome
- WSACS
The Abdominal Compartment Society
Author contributions
Yu Kong: Investigation, Methodology, Data Collection, Writing-Original Draft. Tianying Chang: Conceptualisation, supervision, Writing-Review & Editing, Correspondence. Yanyan Cui: Investigation, Project Administration, Data Curation, Writing-Original Draft. Xianfei Ding: Investigation, Formal Analysis, Writing-Review & Editing. Wenhui Liu: Data Collection, Formal Analysis, Visualisation. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee of the First Affiliated Hospital of Zhengzhou University (ethics approval number: 2024-KY-1188). This survey was completely anonymous and confidential. All nurses involved in the survey provided informed consent and participated voluntarily.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
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Data Availability Statement
No datasets were generated or analysed during the current study.