How is intraabdominal compartment syndrome diagnosed and managed?

From the Guidelines

Intra-abdominal compartment syndrome (ACS) should be diagnosed and managed according to the latest consensus guidelines, which recommend measuring intra-abdominal pressure (IAP) when any known risk factor is present in a critically ill or injured patient. The diagnosis of ACS requires a sustained IAP of 20 mmHg or higher with evidence of new organ dysfunction, and the reference standard for intermittent IAP measurements is via the bladder with a maximal instillation volume of 25 mL of sterile saline 1.

Key Points in Diagnosis and Management

• IAP should be expressed in mmHg and measured at end-expiration in the supine position after ensuring that abdominal muscle contractions are absent and with the transducer zeroed at the level of the midaxillary line 1.
• Protocolized monitoring and management of IAP should be utilized when caring for the critically ill or injured.
• Management begins with treating the underlying cause while implementing medical strategies to reduce pressure, including nasogastric decompression, evacuation of intra-abdominal fluid collections, sedation, neuromuscular blockade, and optimizing body positioning.
• If these measures fail and the patient has sustained pressures above 20 mmHg with organ dysfunction, surgical decompressive laparotomy becomes necessary, using techniques such as negative pressure wound therapy to facilitate earlier abdominal fascial closure 1.
• Prevention strategies in high-risk patients include avoiding excessive fluid resuscitation and maintaining vigilant monitoring of intra-abdominal pressure every 4-6 hours.

Important Considerations

• The grading of intra-abdominal hypertension (IAH) is crucial, with Grade I being an IAP of 12-15 mmHg, Grade II an IAP of 16-20 mmHg, Grade III an IAP of 21-25 mmHg, and Grade IV an IAP above 25 mmHg 1.
• Early recognition of ACS is critical due to its high mortality rate, even with appropriate management.
• The use of percutaneous catheter drainage to remove fluid in those with IAH/ACS when technically possible is recommended, as an alternative to decompressive laparotomy or doing nothing 1.

From the Research

Diagnosis of Intraabdominal Compartment Syndrome

• Intraabdominal hypertension (IAH) is diagnosed when the intra-abdominal pressure (IAP) is more than 12 mmHg 2
• Abdominal compartment syndrome (ACS) is diagnosed when IAP rises above 20 mmHg 2
• Intravesical pressure measurement is the standard diagnostic method for ACS 2, 3
• Computed tomography (CT) may play a crucial role in detecting and characterizing pathological conditions that may lead to IAH 2
• CT findings common to ACS include tense infiltration of the retroperitoneum, extrinsic compression of the inferior vena cava, and massive abdominal distention 4

Management of Intraabdominal Compartment Syndrome

• Treatment of ACS is nearly always surgical decompression with temporary abdominal wall closure or open abdominal treatment 5
• Non-operative medical interventions may be performed early in the patient's course to reduce intra-abdominal pressure and decrease the need for surgical decompression 6
• Abdominal decompression can be life-saving when ACS is refractory to non-operative treatment and should be performed expeditiously 6
• The objectives of open abdomen management are to prevent fistula and to achieve delayed fascial closure at the earliest possible time 6
• A multidisciplinary focus is necessary for the intensive care and reconstructive needs of the patient 3

Key Considerations

• Intra-abdominal pressure monitoring should be performed in all patients at risk of intra-abdominal hypertension 6
• Kidney injury can frequently progress and is a parameter for considering abdominal decompression 3
• Having a biomarker for early damage would be ideal 3
• Surgical treatment is successful in the majority of cases 3