What are the management guidelines for abdominal compartment syndrome (ACS)?

Management Guidelines for Abdominal Compartment Syndrome (ACS)

Surgical decompression is strongly recommended for patients with ACS (IAP ≥20 mmHg with new organ dysfunction) that is refractory to medical management (GRADE 1D). 1

Definitions and Diagnosis

• Abdominal compartment syndrome (ACS): IAP ≥20 mmHg with new organ dysfunction 1
• Intra-abdominal hypertension (IAH): IAP ≥12 mmHg 1
• Measure IAP at least every 4-6 hours or continuously in at-risk patients 1
• Intravesical pressure measurement is the standard diagnostic method 2

Management Algorithm

Step 1: Initial Assessment and Monitoring

• Measure IAP at least every 4-6 hours in critically ill patients 1
• Titrate therapy to maintain IAP <15 mmHg (GRADE 1C) 1
• Monitor for signs of organ dysfunction 1

Step 2: Medical Management for IAH (IAP ≥12 mmHg)

A. Evacuate Intraluminal Contents:

• Insert nasogastric and/or rectal tube 1
• Initiate gastro-colonic prokinetic agents (GRADE 2D) 1
• Administer enemas (GRADE 1D) 1
• Consider colonoscopic decompression (GRADE 1D) 1
• Discontinue enteral nutrition if IAP continues to rise 1

B. Evacuate Intra-abdominal Space-Occupying Lesions:

• Perform abdominal ultrasound to identify lesions 1
• Remove constrictive dressings and abdominal eschars 1
• Consider percutaneous catheter drainage (GRADE 2C) 1
• Consider surgical evacuation of lesions (GRADE 1D) 1

C. Improve Abdominal Wall Compliance:

• Ensure adequate sedation and analgesia (GRADE 1D) 1
• Consider neuromuscular blockade (GRADE 1D) 1
• Optimize patient positioning (GRADE 2D) 1

D. Optimize Fluid Administration:

• Avoid excessive fluid resuscitation (GRADE 2C) 1
• Aim for zero to negative fluid balance by day 3 (GRADE 2C) 1
• Consider using hypertonic fluids and colloids 1
• Consider hemodialysis/ultrafiltration for fluid removal 1

E. Optimize Systemic and Regional Perfusion:

• Implement goal-directed fluid resuscitation 1
• Consider judicious diuresis once patient is hemodynamically stable 1

Step 3: Surgical Management for ACS

• Surgical decompression is indicated when IAP ≥20 mmHg with new organ dysfunction that is refractory to medical management (GRADE 1D) 1, 3
• Decompressive laparotomy effectively reduces IAP and improves organ function 3
• Temporary abdominal closure (TAC) techniques are often required after decompression 3, 4
• Negative pressure devices can facilitate management of the open abdomen 4

Phases of Open Abdomen Management

1. Acute phase (24-48 hours): Initial decompression and stabilization 4
2. Intermediate phase (48 hours to 10 days): Ongoing management of the open abdomen 4
3. Reconstruction phase (from 10 days to final closure): Definitive closure or planned ventral hernia repair 4

Special Considerations

• In most cases, the abdomen cannot be closed immediately after decompression 3
• Planned ventral hernia repair may be required at a later stage (6-12 months after the last operation) 3, 2
• Negative pressure wound therapy increases the rate of primary fascial closure 4
• Kidney injury is a common complication and can be a parameter for considering abdominal decompression 2

Common Pitfalls and Caveats

• Delayed recognition of ACS can lead to increased morbidity and mortality 5
• Aggressive fluid resuscitation is the most common risk factor for developing ACS in surgical and trauma patients 5
• Patients with abdominal trauma have a higher risk of developing IAH 5
• Certain surgical interventions (damage control surgery, abdominal aortic aneurysm repair, liver transplantation) carry higher risk of IAH 5
• Early intervention is crucial before irreversible organ damage occurs 2