What is the management of abdominal compartment syndrome in a patient with an Abthera (Negative Pressure Wound Therapy) wound vac?

Management of Abdominal Compartment Syndrome in a Patient with Abthera Wound VAC

If abdominal compartment syndrome (ACS) develops in a patient already on Abthera negative pressure wound therapy (NPWT), you must immediately reduce the negative pressure settings or temporarily discontinue suction, while simultaneously implementing aggressive medical management to reduce intra-abdominal pressure (IAP) below 20 mmHg. 1

Immediate Recognition and Monitoring

• Measure IAP immediately via trans-bladder technique when ACS is suspected (IAP ≥20 mmHg with new organ dysfunction) 1, 2
• Continue monitoring IAP at least every 4-6 hours or continuously while the patient remains critically ill 3
• The presence of Abthera NPWT does not eliminate the risk of recurrent or persistent ACS—in fact, excessive negative pressure can contribute to elevated IAP 1

Critical First Step: Adjust the Negative Pressure

In the presence of coagulopathy or high risk of bleeding (or elevated IAP), down-regulate the negative pressure, balancing the therapeutic necessity of NPWT against the risk of worsening IAP or hemorrhage 1. This is a crucial but often overlooked intervention—the suction itself may be contributing to compartment syndrome by drawing fluid into the abdomen or restricting abdominal wall compliance.

Stepwise Medical Management Algorithm

Before proceeding to surgical decompression, implement the following interventions in sequence 1, 3:

Step 1: Improve Abdominal Wall Compliance

• Optimize sedation and analgesia to reduce abdominal wall muscle tone 1, 2, 3
• Consider brief trial of neuromuscular blockade as a temporizing measure 1, 2
• Adjust body position to minimize IAP (avoid excessive head elevation if tolerated) 1, 2
• Remove any constrictive dressings around the Abthera system 1

Step 2: Evacuate Intraluminal Contents

• Insert or ensure patency of nasogastric and rectal tubes 1, 3
• Administer enemas for colonic decompression 3
• Consider colonoscopic decompression if ileus persists 3
• Consider neostigmine for established colonic ileus not responding to other measures 1, 2
• Discontinue enteral nutrition if IAP remains ≥20 mmHg 1

Step 3: Optimize Fluid Management

• Implement protocols to achieve zero to negative fluid balance after initial resuscitation is complete 1, 2, 3
• Avoid excessive fluid resuscitation 3
• Consider judicious diuresis or ultrafiltration/hemodialysis once hemodynamically stable 1

Step 4: Evacuate Intra-abdominal Fluid Collections

• Perform abdominal ultrasound to identify fluid collections or occupying lesions 1
• Consider percutaneous catheter drainage (PCD) if obvious intraperitoneal fluid is present—this may alleviate the need for surgical decompression 1, 2

When Medical Management Fails: Surgical Decompression

If IAP remains ≥20 mmHg with persistent new organ dysfunction despite the above interventions, proceed immediately to decompressive laparotomy 1, 2, 3. This is a Grade 1D recommendation—the evidence is weak, but the clinical imperative is strong given mortality rates up to 50% even with intervention 2.

Surgical Approach

• Perform full decompressive laparotomy, not just adjustment of the existing open abdomen 1, 2
• Re-apply Abthera NPWT after decompression, as negative pressure wound therapy with continuous fascial traction is the preferred technique for temporary abdominal closure 1
• Set negative pressure at lower settings initially (consider 50-75 mmHg rather than standard 125 mmHg) to avoid recurrent ACS 1

Ongoing Management After Decompression

Re-exploration Timing

• Plan re-exploration within 24-48 hours after decompression, with shorter intervals if the patient shows non-improvement or hemodynamic instability 1
• At each re-exploration, reassess for source control, bowel viability, and potential for fascial approximation 1

Closure Strategy

Make protocolized efforts to achieve early or same-hospital-stay abdominal fascial closure 1, 2. The longer the abdomen remains open, the greater the risk of visceral adhesions, enteroatmospheric fistulae, and loss of abdominal domain 1, 2.

• Target fascial closure within 7 days if possible, as failure to close early increases morbidity, mortality, and fistula formation 4
• Continue Abthera NPWT with mesh-mediated fascial traction between re-explorations 1, 4
• Do NOT routinely use bioprosthetic meshes for early closure—they should not be the first-line approach 1, 2

Nutritional Support

• Initiate immediate and adequate nutritional support—open abdomen patients are hypermetabolic with significant nitrogen loss 1
• Start early enteral nutrition as soon as the gastrointestinal tract is viable and functional 1

Common Pitfalls to Avoid

1. Failing to recognize that NPWT itself can contribute to ACS: The negative pressure can worsen IAP, particularly if set too high or if there is limited intraperitoneal fluid to remove 1

2. Delaying decompression while pursuing prolonged medical management: If IAP remains ≥20 mmHg with organ dysfunction after initial medical interventions, do not wait—mortality increases with delayed surgical intervention 2

3. Over-resuscitation with fluids: This is a major contributor to IAH/ACS development and recurrence 2. Transition to negative fluid balance as soon as initial resuscitation goals are met 3

4. Leaving the abdomen open too long: Beyond 7-10 days, fascial closure rates drop dramatically and complications increase 4. Be aggressive about closure attempts at each re-exploration 1