What is the treatment for abdominal compartment syndrome?

Treatment of Abdominal Compartment Syndrome

Decompressive laparotomy is the definitive treatment for abdominal compartment syndrome (ACS) when medical management fails. 1, 2

Diagnosis and Monitoring

• ACS is defined as sustained intra-abdominal pressure (IAP) >20 mmHg with new organ dysfunction/failure
• Measure IAP when risk factors are present in critically ill patients 1
• Use trans-bladder technique as standard measurement method 1
• Monitor IAP at least every 4-6 hours in patients with intra-abdominal hypertension (IAH, IAP ≥12 mmHg) 2

Management Algorithm

Step 1: Medical Management (for IAH or early ACS)

• Implement protocolized monitoring and management of IAP 1
• Target maintaining IAP <15 mmHg 1

Interventions to reduce IAP:

1. Evacuate intraluminal contents:

   • Insert nasogastric and/or rectal tubes 1, 2
   • Use prokinetic agents for established ileus 1
   • Consider neostigmine for colonic ileus not responding to other measures 1
   • Consider colonoscopic decompression when appropriate 1

2. Evacuate intra-abdominal space-occupying lesions:

   • Perform abdominal ultrasound to identify fluid collections 1
   • Use percutaneous catheter drainage (PCD) for intraperitoneal fluid when technically feasible 1
   • Consider surgical evacuation of lesions if necessary 1

3. Improve abdominal wall compliance:

   • Ensure optimal pain and anxiety relief 1
   • Consider brief trials of neuromuscular blockade as a temporizing measure 1
   • Adjust body position to minimize IAP 1
   • Remove constrictive dressings or abdominal eschars 1

4. Optimize fluid administration:

   • Avoid excessive fluid resuscitation 1, 2
   • Aim for zero to negative fluid balance after initial resuscitation 1, 2
   • Consider enhanced ratio of plasma to packed red blood cells for massive hemorrhage 1, 2

Step 2: Surgical Management (for ACS unresponsive to medical management)

Indications for decompressive laparotomy:

• IAP >20 mmHg with new organ failure that has not responded to medical management 1, 2
• Overt ACS unresponsive to medical interventions 1, 2, 3

Surgical approach:

• Full-thickness laparostomy (midline or transverse subcostal) 4
• Temporary abdominal closure using negative pressure wound therapy (NPWT) 1, 2
• Avoid routine use of bioprosthetic meshes in early closure 1, 2

Post-surgical management:

• Make conscious efforts to achieve early or same-hospital-stay abdominal fascial closure 1, 2
• Continue monitoring IAP and organ function 1

Special Considerations

Acute Pancreatitis

• Approximately 15% of patients with severe acute pancreatitis develop IAH or ACS 5
• Begin with medical interventions and percutaneous drainage where possible 5
• Surgical decompression is typically performed when IAP reaches 25-36 mmHg and is associated with organ dysfunction 6, 5

Trauma and Hemorrhage

• Lower threshold for prophylactic use of open abdomen in trauma patients with physiologic exhaustion 1
• Higher urgency for decompression in ruptured abdominal aortic aneurysm due to risk of continuous hemorrhage 6

Sepsis

• Do not routinely utilize open abdomen 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 2

Outcomes and Complications

• Decompressive laparotomy effectively reduces IAP and improves organ function 3
• In most patients, the abdomen cannot be closed immediately after decompression 3
• Significant morbidity is associated with surgical decompression and management of the open abdomen 4
• Overall survival rate is approximately 63% following decompressive laparotomy 3

Pitfalls and Caveats

• Delaying surgical decompression when indicated can lead to irreversible organ damage and increased mortality
• Not all patients with elevated IAP require surgical intervention - medical management should be attempted first
• The open abdomen creates significant management challenges including fluid losses, infection risk, and ventral hernia formation
• Reconstruction is typically performed 6-12 months after the last operation 7
• Clinical examination alone is inaccurate for detecting raised IAP - objective measurements are essential 1