From the Guidelines
Abdominal compartment syndrome (ACS) in patients with diabetic ketoacidosis (DKA) requires prompt recognition and management of both conditions simultaneously to prevent significant morbidity and mortality. For DKA, management goals include restoration of circulatory volume and tissue perfusion, resolution of hyperglycemia, and correction of electrolyte imbalance and acidosis, as outlined in the most recent guidelines 1. The treatment of DKA involves initiating insulin therapy with an IV insulin infusion at 0.1 units/kg/hour after an initial bolus of 0.1 units/kg, along with aggressive fluid resuscitation starting with normal saline at 15-20 mL/kg in the first hour, as supported by recent reviews 1. Monitoring glucose hourly and adding dextrose when glucose reaches 200-250 mg/dL while continuing insulin to clear ketones is also crucial, as noted in the guidelines 1. For ACS, measuring intra-abdominal pressure via bladder pressure monitoring, with pressures above 20 mmHg with new organ dysfunction defining ACS, is essential for diagnosis, as stated in the consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome 1. Medical management of ACS includes nasogastric decompression, sedation, neuromuscular blockade, and diuretics if the patient is fluid positive, as recommended in the guidelines 1. If these measures fail and intra-abdominal pressure exceeds 25 mmHg with organ dysfunction, surgical decompressive laparotomy is indicated, as emphasized in the guidelines 1. The connection between DKA and ACS stems from aggressive fluid resuscitation causing bowel edema, combined with gastroparesis and ileus from DKA-related electrolyte abnormalities, highlighting the need for careful monitoring of fluid status, abdominal distension, and organ function, as discussed in the literature 1. Key considerations in the management of DKA and ACS include:
- Individualization of treatment based on careful clinical and laboratory assessment 1
- Restoration of circulatory volume and tissue perfusion 1
- Resolution of hyperglycemia and correction of electrolyte imbalance and acidosis 1
- Treatment of any correctable underlying cause of DKA, such as sepsis or myocardial infarction 1
- Monitoring for complications, including hypoglycemia, hypokalemia, and hyperchloremia 1
- Careful consideration of the use of bicarbonate, which is generally not recommended 1.
From the Research
Abdominal Compartment Syndrome
- Abdominal compartment syndrome is defined as an intra-abdominal pressure above 20 mmHg with evidence of organ failure 2, 3
- It develops when the intra-abdominal pressure rapidly reaches certain pathological values, within several hours, and lasts for 6 or more hours 2
- The key to recognizing abdominal compartment syndrome is the demonstration of elevated intra-abdominal pressure, which is performed most often via the urinary bladder 2
Diagnosis and Treatment
- Intravesical pressure measurement is the standard diagnostic method for abdominal compartment syndrome 3
- Treatment is based on evacuation of the intraluminal content, identification and treatment of intra-abdominal lesions, improvement of abdominal wall compliance, and optimum administration of fluids and tissue perfusion 3
- Surgical decompression remains the gold standard for rapid, definitive treatment of fully developed abdominal compartment syndrome 2, 4
Relationship with DKA
- There is no direct evidence in the provided studies to suggest a relationship between abdominal compartment syndrome and diabetic ketoacidosis (DKA)
- However, it is possible that patients with DKA may be at risk of developing abdominal compartment syndrome due to the potential for intra-abdominal hypertension and organ failure associated with DKA 5
Multidisciplinary Approach
- A multidisciplinary approach is necessary for the intensive care and reconstructive needs of patients with abdominal compartment syndrome 6
- This approach should include medical, surgical, radiological, and nursing specialties to provide optimal care and improve outcomes for patients with abdominal compartment syndrome 6