In a patient with sustained intra‑abdominal pressure of 23 mm Hg causing multi‑system organ dysfunction, what treatment should the nurse anticipate?

Treatment for Sustained IAP of 23 mm Hg

A patient with sustained intra-abdominal pressure (IAP) of 23 mm Hg and multi-system organ dysfunction meets criteria for abdominal compartment syndrome (ACS) and requires immediate abdominal decompression via decompressive laparotomy. 1, 2

Understanding the Clinical Scenario

An IAP of 23 mm Hg with organ dysfunction definitively meets the diagnostic threshold for ACS, which is defined as sustained IAP >20 mm Hg with new organ failure 1. This is a surgical emergency requiring definitive intervention, not conservative management alone.

Treatment Algorithm

Immediate Surgical Decompression

• Decompressive laparotomy is the definitive treatment for overt ACS with organ dysfunction 1, 2
• The World Society of the Abdominal Compartment Syndrome provides a Grade 1D recommendation (strong consensus) for surgical decompression in cases of ACS versus strategies that do not use decompressive laparotomy 1
• Medical management alone is insufficient at this pressure threshold with organ failure—delaying surgery while attempting conservative measures significantly increases mortality 2

Pre-Operative Temporizing Measures

While preparing for surgery, implement these bedside interventions 1, 3:

• Enteral decompression: Insert nasogastric tube on continuous suction and place rectal tube for colonic decompression 1, 3, 2
• Optimize sedation and analgesia to reduce abdominal wall muscle tone 1, 3
• Consider brief neuromuscular blockade as a bridge to surgery 1, 2
• Avoid excessive fluid resuscitation—target mean arterial pressure ≥65 mm Hg with vasopressors rather than crystalloids, as additional fluids worsen bowel edema and IAP 2

Role of Percutaneous Catheter Drainage (PCD)

• PCD may be considered only if obvious intraperitoneal fluid is present on bedside ultrasound and can potentially avoid the need for laparotomy in select cases 1
• The World Society of the Abdominal Compartment Syndrome suggests PCD (Grade 2C) when technically feasible, as it may alleviate the need for decompressive laparotomy 1
• However, PCD is not appropriate for intraluminal gastrointestinal distention—it only works for free intraperitoneal fluid collections 3, 4
• Successful PCD requires drainage of >1,000 mL and IAP reduction >9 mm Hg within 4 hours; failure to meet these thresholds mandates urgent laparotomy 4

Post-Decompression Management

After surgical decompression 2, 5:

• Leave the abdomen open with temporary abdominal closure using negative pressure wound therapy 1, 2
• Continue IAP monitoring every 4-6 hours to detect recurrent intra-abdominal hypertension, targeting IAP <15 mm Hg 1, 2
• Implement strict fluid balance protocols aiming for zero to negative fluid balance by day 3 post-decompression 2
• Plan re-exploration within 24-48 hours for reassessment and potential staged closure 2

Why Close Monitoring Alone Is Inadequate

• Close monitoring without intervention is appropriate only for IAH (IAP 12-20 mm Hg) without organ dysfunction 1, 6
• Once IAP exceeds 20 mm Hg and new organ failure develops, the patient has progressed from intra-abdominal hypertension to abdominal compartment syndrome, which requires active decompression 1
• Physical examination alone has low sensitivity for detecting elevated IAP and cannot guide management decisions 3, 6

Critical Pitfalls to Avoid

• Do not delay surgery waiting for medical management to work—at IAP >20 mm Hg with organ failure, medical therapy alone is insufficient and mortality increases with each hour of delay 2
• Do not aggressively fluid resuscitate beyond initial stabilization, as this worsens bowel edema and IAP, creating a vicious cycle 2
• Do not attempt percutaneous drainage for intraluminal bowel distention—PCD only works for free intraperitoneal fluid 3
• Do not rely on clinical examination to assess IAP—bladder pressure measurement is required 3, 6

Prognosis

Even with appropriate and timely decompressive laparotomy, mortality for ACS remains 40-50%, emphasizing the critical importance of early recognition and immediate intervention 2, 5.