How is abdominal compartment syndrome managed?

Management of Abdominal Compartment Syndrome

Decompressive laparotomy is recommended as the definitive treatment for overt abdominal compartment syndrome (ACS) when medical management fails. 1

Diagnosis and Monitoring

• ACS is defined as sustained intra-abdominal pressure (IAP) >20 mmHg associated with new organ dysfunction 2
• Regular IAP monitoring is essential in high-risk patients:
  • Measure IAP at least every 4-6 hours in patients with IAH (IAP ≥12 mmHg) 1
  • Standard method: intravesical (bladder) pressure measurement 2
  • Consider continuous IAP monitoring in critically ill patients

Management Algorithm

1. Medical Management (First-Line)

For patients with IAH (IAP ≥12 mmHg):

• Evacuate intraluminal contents:

  • Nasogastric decompression
  • Rectal decompression
  • Prokinetic agents

• Evacuate intra-abdominal space-occupying lesions:

  • Percutaneous catheter drainage (PCD) for obvious intraperitoneal fluid 1
  • PCD is suggested over immediate decompressive laparotomy when technically feasible 1

• Improve abdominal wall compliance:

  • Adequate sedation and analgesia
  • Remove constrictive dressings/devices
  • Avoid head-of-bed elevation >30°

• Optimize fluid management:

  • Avoid positive fluid balance after initial resuscitation 1
  • Consider enhanced ratio of plasma to packed red blood cells for massive hemorrhage 1
  • Neutral to negative fluid balance once hemodynamically stable

2. Surgical Management

Indications for decompressive laparotomy:

• IAP >20 mmHg with new organ failure that has not responded to medical management 1
• Decompressive laparotomy is strongly recommended in cases of overt ACS 1

Temporary abdominal closure techniques:

• Negative pressure wound therapy (NPWT) is preferred for temporary abdominal closure 1
• Conscious efforts should be made to achieve early or same-hospital-stay abdominal fascial closure 1

Special Considerations

Trauma Patients

• Prophylactic use of open abdomen is suggested for trauma patients undergoing laparotomy with physiologic exhaustion 1
• Damage control approach with temporary abdominal closure may be necessary

Intra-abdominal Sepsis

• Open abdomen approach is not routinely recommended for patients with severe intraperitoneal contamination unless IAH is a specific concern 1
• In septic shock with incomplete source control, damage control surgery may be appropriate 1

Post-Bariatric Surgery

• Lower threshold for surgical intervention in post-bariatric surgery patients with acute abdominal symptoms and persistent tachycardia 1
• Surgery is mandatory within 12-24 hours to decrease morbidity and mortality rates 1

Outcomes and Complications

• Decompression results in significant improvements in:

  • Hemodynamic parameters (decreased heart rate, CVP)
  • Respiratory function (decreased peak inspiratory pressure, improved P/F ratio)
  • Renal function (increased urine output) 3

• Despite intervention, mortality remains high:

  • Overall mortality rate ~50% in adults following decompressive laparotomy 3
  • Early intervention before organ damage occurs improves outcomes 2

Pitfalls and Caveats

• Delaying decompression until multiple organ failure is established significantly worsens outcomes
• Temporary abdominal closure may be required for days to weeks; definitive closure often delayed 6-12 months 2
• Bioprosthetic meshes should not be routinely used in early closure of open abdomen 1
• Regular reassessment of IAP after interventions is crucial to evaluate treatment efficacy
• Kidney injury often progresses and should be monitored as a parameter for considering abdominal decompression 2