What is the management of abdominal compartment syndrome?

Management of Abdominal Compartment Syndrome

Decompressive laparotomy is strongly recommended as the definitive treatment for abdominal compartment syndrome (ACS) with organ dysfunction, as it immediately decreases intra-abdominal pressure (IAP) and improves organ function. 1

Diagnosis and Monitoring

• ACS is defined as IAP >20 mmHg with associated new organ dysfunction 1
• Regular IAP monitoring is essential in high-risk patients, with measurements recommended every 4-6 hours 2
• Intravesical (bladder) pressure measurement is the standard diagnostic method for IAP 3
• Abdominal perfusion pressure (APP = MAP - IAP) may be considered as a resuscitation endpoint, similar to cerebral perfusion pressure 1

Medical Management Algorithm

First-Line Interventions (IAP ≥12 mmHg)

• Optimize analgesia and sedation to improve abdominal wall compliance 1
• Consider brief trials of neuromuscular blockade as a temporizing measure 1
• Adjust body position to minimize IAP effects 1
• Implement enteral decompression using nasogastric or rectal tubes for gastric or colonic distension 1
• Consider neostigmine for established colonic ileus not responding to other measures 1

Fluid Management

• Implement protocols to avoid positive cumulative fluid balance after initial resuscitation 1
• Consider enhanced ratios of plasma to packed red blood cells for massive hemorrhage resuscitation 1
• No definitive recommendations exist for diuretics, renal replacement therapy, or albumin administration to mobilize fluid 1

Minimally Invasive Options

• Percutaneous catheter drainage (PCD) is recommended for removal of intraperitoneal fluid when technically feasible 1
• PCD may alleviate the need for decompressive laparotomy in some cases 1

Surgical Management

Indications for Decompressive Laparotomy

• Overt ACS (IAP >20 mmHg with new organ dysfunction) that doesn't respond to medical management 1
• Mortality remains high (up to 50%) even after decompression, highlighting the importance of timely intervention 1

Surgical Approach Considerations

• For trauma patients with physiologic exhaustion, prophylactic use of open abdomen is suggested 1
• Open abdomen approach is not routinely recommended for patients with severe intraperitoneal contamination unless IAH is a specific concern 1
• Temporary abdominal closure options include:
  • Vacuum-assisted closure (VAC) techniques, which may offer advantages over Bogota bag for temporary closure 4
  • VAC appears to allow faster decrease in incision width and earlier primary fascial closure 4

Definitive Closure

• Protocolized efforts should be made to achieve early or same-hospital-stay abdominal fascial closure 1
• Bioprosthetic meshes should not be routinely used in early closure of open abdomen 1
• The longer the abdomen remains open, the greater the potential for morbidity, including visceral adhesions, loss of soft tissue coverage, and enteric fistulae 1

Special Considerations

• Body position affects IAP-ICP (intracranial pressure) relationship, requiring individualized positioning in patients with concurrent brain injury 2
• Kidney injury frequently progresses in ACS and can be a parameter for considering abdominal decompression 3
• Surgical decompression has been shown to significantly improve hemodynamic variables within 48 hours post-surgery 5

Common Pitfalls

• Delayed recognition of ACS can lead to irreversible organ damage 6
• Overresuscitation with fluids can contribute to IAH development 1
• Failure to monitor IAP in high-risk patients may result in missed diagnosis 6
• Underestimating the need for a multidisciplinary approach involving intensive care and reconstructive specialists 3