What is the treatment for abdominal compartment syndrome?

Treatment of Abdominal Compartment Syndrome

Decompressive laparotomy is the definitive treatment for abdominal compartment syndrome (ACS) when intra-abdominal pressure (IAP) exceeds 20 mmHg with new organ dysfunction that fails to respond to medical management. 1, 2

Immediate Recognition and Initial Steps

• Measure IAP immediately via trans-bladder technique when ACS is suspected (IAP ≥20 mmHg with new organ dysfunction). 2
• Implement protocolized monitoring of IAP with serial measurements in all critically ill patients with risk factors for ACS. 1
• If the patient has an open abdomen with negative pressure wound therapy (NPWT), immediately reduce or temporarily discontinue suction settings, as excessive negative pressure can contribute to elevated IAP. 2

Medical Management Algorithm (Before Surgical Decompression)

Attempt these interventions sequentially before proceeding to surgery:

Optimize Abdominal Wall Compliance

• Ensure optimal pain control and sedation to reduce abdominal wall muscle tone. 1, 2
• Consider brief trials of neuromuscular blockade as a temporizing measure (though evidence is weak, this can buy time). 1, 2
• Adjust body position to minimize IAP effects (avoid head-down positioning). 1, 2

Decompress Intraluminal Contents

• Insert or ensure patency of nasogastric and rectal tubes when the stomach or colon are dilated. 1, 2
• Administer enemas for colonic decompression. 2
• Consider neostigmine for established colonic ileus not responding to simpler measures. 1, 2
• Discontinue enteral nutrition if IAP remains ≥20 mmHg. 2

Optimize Fluid Balance

• Implement protocols to avoid positive cumulative fluid balance after initial resuscitation is complete—overresuscitation is a major contributor to IAH/ACS. 1, 2
• Consider judicious diuresis or ultrafiltration/hemodialysis once hemodynamically stable (though formal recommendations cannot be made due to limited evidence). 1, 2

Minimally Invasive Drainage

• Perform abdominal ultrasound to identify fluid collections. 2
• Use percutaneous catheter drainage (PCD) to remove intraperitoneal fluid when technically feasible—this may alleviate the need for decompressive laparotomy in select cases. 1, 2

Surgical Decompression: When and How

Indications for Decompressive Laparotomy

Proceed immediately to decompressive laparotomy when:

• IAP remains >20 mmHg with persistent new organ dysfunction despite maximal medical management. 1, 2
• The patient has overt ACS with progressive organ failure. 1, 2, 3

Critical caveat: Even with decompression, mortality remains high (up to 50%), emphasizing the importance of early intervention before irreversible organ damage occurs. 1, 2, 4

Surgical Technique

• Perform full decompressive laparotomy (midline or transverse subcostal approach), not just adjustment of existing open abdomen. 2, 5
• Leave the abdomen open with temporary abdominal closure after decompression. 1, 2
• Apply negative pressure wound therapy (NPWT) as the preferred technique for temporary abdominal closure—this is superior to other methods like Bogota bag. 1, 2, 6

Post-Decompression Management

Ongoing Care

• Plan re-exploration within 24-48 hours after decompression, with shorter intervals if the patient shows non-improvement or hemodynamic instability. 2
• Make protocolized efforts to achieve early or same-hospital-stay abdominal fascial closure—the longer the abdomen remains open, the greater the risk of complications including visceral adhesions, loss of soft tissue coverage, and enteric fistulae. 1, 2
• Continue NPWT with mesh-mediated fascial traction between re-explorations. 2

What NOT to Do

• Do NOT routinely use bioprosthetic meshes for early closure of the open abdomen—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. 2
• Start early enteral nutrition as soon as the gastrointestinal tract is viable and functional. 2

Special Populations

Trauma Patients with Physiologic Exhaustion

• Use prophylactic open abdomen versus intraoperative fascial closure in trauma patients undergoing damage control laparotomy who are physiologically exhausted. 1, 2

Intra-Abdominal Sepsis

• Do NOT routinely utilize open abdomen for patients with severe intraperitoneal contamination undergoing emergency laparotomy for intra-abdominal sepsis unless IAH is a specific concern. 1

Massive Hemorrhage

• Use enhanced ratios of plasma to packed red blood cells (balanced resuscitation) for massive hemorrhage to avoid worsening IAH from crystalloid overload. 1, 2