What is the recommended management for abdominal compartment syndrome?

Management of Abdominal Compartment Syndrome

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

Definition and Diagnosis

• ACS is defined as sustained intra-abdominal pressure (IAP) >20 mmHg with new organ dysfunction/failure
• IAP should be measured using the trans-bladder technique (standard method) when risk factors are present
• Clinical examination alone is inaccurate for detecting raised IAP; objective measurements are essential

Management Algorithm

Step 1: Monitoring and Initial Assessment

• Monitor IAP regularly (every 4-6 hours) in patients with risk factors or established IAH
• Target IAP <15 mmHg through medical management
• Assess for organ dysfunction (respiratory, cardiovascular, renal, neurological)

Step 2: Medical Management Options

Evacuate Intraluminal Contents:

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

Evacuate Intra-abdominal Space-Occupying Lesions:

• Perform abdominal ultrasound to identify fluid collections 2
• Use percutaneous catheter drainage (PCD) for intraperitoneal fluid when technically feasible 1, 2
• Consider surgical evacuation of lesions if necessary 1

Improve Abdominal Wall Compliance:

• Ensure optimal pain and anxiety relief 1, 2
• Consider brief trials of neuromuscular blockade as a temporizing measure 1, 2
• Adjust body position to minimize IAP 1
• Remove constrictive dressings or abdominal eschars 2

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 ongoing hemorrhage 1, 2

Step 3: Surgical Management

• Decompressive laparotomy is indicated when:

  1. IAP >20 mmHg with new organ failure unresponsive to medical management 1, 2
  2. Overt ACS unresponsive to medical interventions 1, 2

• Surgical options:

  1. Full decompressive laparotomy (standard approach) 1
  2. Midline fasciotomy (may be less invasive alternative in selected cases) 3
  3. Temporary abdominal closure using negative pressure wound therapy (NPWT) 2

• Early decompression (within 24 hours of ACS onset) is associated with improved survival 2

Step 4: Post-Decompression Management

• Continue monitoring IAP and organ function post-surgically 2
• Make conscious efforts to achieve early or same-hospital-stay abdominal fascial closure 2
• Bioprosthetic meshes should not be routinely used in early closure of open abdomen 1

Special Considerations

• In trauma patients with physiologic exhaustion, consider prophylactic use of open abdomen 1
• For patients with severe intraperitoneal contamination undergoing emergency laparotomy for intra-abdominal sepsis, routine use of open abdomen is not recommended unless IAH is a specific concern 1

Outcomes and Prognosis

• Surgical decompression significantly reduces IAP (average reduction from 26 mmHg to 13 mmHg) 4
• Organ function typically improves following decompression 4
• Despite intervention, mortality remains high (approximately 37-50%) 4, 5
• Many patients cannot undergo immediate fascial closure after decompression and may require delayed repair or planned ventral hernia management 4

Pitfalls and Caveats

• Delaying decompression when indicated can lead to irreversible organ damage and increased mortality
• The open abdomen created by decompression carries significant morbidity and requires specialized management
• Ventilator management must be adjusted in patients with IAH/ACS, as uncorrected plateau pressures may lead to inappropriate ventilator adjustments 2
• Continuous monitoring after intervention is essential as recurrent ACS can develop