How to decrease intraabdominal pressure after decompressive laparotomy for abdominal compartment syndrome?

Management of Intra-abdominal Pressure After Decompressive Laparotomy for ACS

Following decompressive laparotomy for abdominal compartment syndrome (ACS), a comprehensive approach including temporary abdominal closure with negative pressure wound therapy, aggressive fluid management targeting negative balance, and continued IAP monitoring is essential to prevent recurrent IAH and optimize outcomes.

Post-Decompressive Laparotomy Management Algorithm

Immediate Post-Surgical Management

• Temporary Abdominal Closure (TAC)

  • Implement negative pressure wound therapy (NPWT) as the preferred method for temporary closure 1
  • Avoid routine use of bioprosthetic meshes for early closure 1
  • Target maintaining IAP <15 mmHg with continued monitoring every 4-6 hours 1

• Fluid Management

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

Ongoing Medical Management to Reduce IAP

1. Gastrointestinal Decompression

   • Maintain nasogastric and/or rectal tubes to evacuate intraluminal contents 1
   • Use prokinetic agents for established ileus
   • Consider neostigmine for colonic ileus not responding to other measures 1

2. Percutaneous Drainage

   • Perform abdominal ultrasound to identify residual fluid collections 1
   • Use percutaneous catheter drainage (PCD) for accessible intraperitoneal fluid 2, 1
   • PCD can significantly reduce IAP and may prevent need for repeat decompression 2

3. Optimize Abdominal Wall Compliance

   • Ensure adequate pain control and sedation 1
   • Consider brief trials of neuromuscular blockade as a temporizing measure 1
   • Adjust body position to minimize IAP (e.g., reverse Trendelenburg) 1
   • Remove constrictive dressings or abdominal eschars 1

Monitoring Response

• Continue IAP monitoring every 4-6 hours 1
• Monitor organ function parameters:
  • Hemodynamics (MAP, CVP, cardiac index)
  • Respiratory function (P/F ratio, PIP, PEEP)
  • Renal function (hourly urinary output)

Definitive Abdominal Closure

• Make conscious efforts to achieve early or same-hospital-stay abdominal fascial closure 2, 1
• The longer the abdomen remains open, the greater the potential for morbidity 2
• Primary fascial closure may not be possible in all cases; delayed closure with mesh may be required 3

Outcomes and Considerations

• Despite decompression, IAP often remains elevated (mean post-decompression IAP ~13.5 mmHg) 4
• Mortality remains high (49.7% in adults, 60.8% in children) even after decompressive laparotomy 4
• Early decompression (within 24 hours of ACS onset) is associated with improved survival 5

Physiologic Effects to Monitor

Following decompression, expect:

• Decreased heart rate (average 12.2 beats/min) 4
• Decreased central venous pressure (4.6 mmHg) 4
• Decreased peak inspiratory pressure (10.1 cmH2O) 4
• Improved P/F ratio (increase by ~70) 4
• Increased urinary output (95.3 ml/h) 4

Pitfalls to Avoid

• Failing to continue IAP monitoring after decompression (recurrent IAH occurs frequently)
• Excessive fluid administration leading to worsening edema and IAH
• Premature fascial closure leading to recurrent ACS
• Delayed recognition of ongoing organ dysfunction despite decompression
• Neglecting nutritional support in patients with open abdomen

Remember that decompressive laparotomy is just the first step in managing ACS. Continued vigilance and aggressive management of factors contributing to IAH are essential for improving outcomes in these critically ill patients.