Approach Considerations
If abdominal compartment syndrome is suspected, the focus of prehospital care is to immediately transport the patient to the emergency department. Remove any constricting garments. Do not place anything on the patient's abdomen (eg, external defibrillators, bundles of blankets, oxygen tanks).
Avoid overly aggressive fluid resuscitation, especially in extremity injuries. The overresuscitated patient is much more likely to develop abdominal compartment syndrome, and often the prehospital setting is where this begins. [39]
In the emergency department, the first priority of the ED physician is to consider the diagnosis in any patient with the appropriate mechanisms of injury or pathology. Abdominal compartment syndrome will be missed unless it is in the differential diagnosis.
Therapy should include fluid resuscitation and transfusion if needed, as well as surgical consultation. A comprehensive, evidence-based approach to the management of abdominal compartment syndrome that includes early use of an open abdomen has been shown to reduce mortality. [47] A group in Taiwan (Chen et al) used laparoscopic decompression successfully in blunt abdominal trauma patients who had an IAP of 25-35 cm H2 O. [48]
The World Society of the Abdominal Compartment Syndrome has noted that that correct fluid therapy and perfusional support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension. [49, 1]
Pharmacologic therapy is less effective than mechanical drainage. Pressors have a role but may not be equally effective in treating abdominal compartment syndrome. Dobutamine was shown to be superior to dopamine in restoring intestinal mucosal perfusion in a porcine model. [50]
Inpatient care in acute abdominal compartment syndrome is directed by critical care physicians and surgeons. If an ICU patient experiences decompensation, abdominal compartment syndrome should be reexamined as a potential cause.
IAH may be an ongoing process in any patient with pathology producing intra-abdominal fluid loss. Repeat or continuous IAP measurement is indicated. The abdomen should be clear of any heavy objects.
Consultations may be indicated with a general surgeon, orthopedic surgeon, obstetrician/gynecologist, and vascular surgeon.
Reperfusion Syndrome
Secondary effects of abdominal compartment syndrome occur immediately after evacuation. Many cases of hypotension and even asystole have been observed. Theories to explain these effects include washout of products of anaerobic metabolism (eg, lactic acid), which may be directly tissue toxic, and suddenly decreased systemic vascular resistance (SVR). Volume resuscitation immediately before decompression has been shown to significantly decrease these events.
Adding mannitol and sodium carbonate (NaCO3) to the IV fluid bolus may decrease the toxicity of reperfusion syndromes.
Further Outpatient Care
Outpatient care is directed at the primary etiology of abdominal compartment syndrome. Chronic abdominal compartment syndrome requires lifelong medications and lifestyle changes, which may include the following.
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Diuretics
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Fluid restriction
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Weight loss
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Avoidance of alcohol
Transfer
Consider transfer of any patient who requires services not available at the current facility. Patients with abdominal compartment syndrome frequently require admission to the ICU. Any patient with documented abdominal compartment syndrome requires an emergent surgical consultation. Surgical services of multiple disciplines may be consulted. If a surgeon is not immediately available, the patient must be transferred.
Transfer is indicated for any patient meeting local trauma center guidelines.
Deterrence/Prevention
Preventing abdominal compartment syndrome is much more effective than treating it. The literature is replete with recommendations directed primarily at postsurgical care regarding prevention of abdominal compartment syndrome.
Primary fascial closure has been prospectively demonstrated to significantly increase the incidence of abdominal compartment syndrome after laparotomy, specifically in patients who have undergone damage-control surgery. Various types of surgical mesh are helpful to decrease the incidence of abdominal compartment syndrome.
Prevention is also focused on earlier treatment of IAH. Many authors now recommend managing IAH before full abdominal compartment syndrome develops. This can only be accomplished by proactive IAP measurement and monitoring.
Controlled, randomized studies have highlighted the possibility of preventing abdominal compartment syndrome by avoiding pure crystalloid resuscitation in trauma and burn patients. O'Mara et al demonstrated a significantly lower IAP in burn patients resuscitated with a colloid combination of fresh frozen plasma and lactated Ringer solution versus lactated Ringer solution alone, given by the Parkland formula. [51]
At a large Japanese burn center, Oda et al demonstrated hypertonic lactated saline could be used in smaller volumes to maintain adequate urine output and significantly reduce the rate of abdominal compartment syndrome and associated morbidity. [52]
Medical Care
Hecker et al described 5 treatment columns for intra-abdominal hypertension/acute compartment syndrome [7] :
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Intraluminal evacuation
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Intra-abdominal evacuation
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Improvement of abdominal wall compliance
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Fluid management
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Improved organ perfusion
If conservative therapy fails, emergency laparotomy is the most effective therapeutic approach to achieve abdominal decompression. [31, 7, 47, 48, 1, 9, 3]
Multiple reports document the efficacy of paracentesis in burn patients who develop abdominal compartment syndrome. Although not prospectively validated, it appears to be a superior alternative to decompressive laparotomy in this patient population. It may be performed quickly at bedside and avoids potential complications associated with larger incisions. Paracentesis is also extremely useful in patients with chronic abdominal compartment syndrome from large-volume ascites.
Surgical Care
Laparotomy decompression
Laparotomy is usually performed when the IAP reaches 25-36 mm Hg in cases of acute pancreatitis. [6, 48, 53] The incidence of ACS resulting from severe acute pancreatitis has been reported to be 4-27%, with a mortality of 50-75% in patients with severe acute pancreatitis who develop ACS. [54]
In cases of a ruptured abdominal aortic aneurysm, there is greater urgency for decompression laparotomy because of the possibility of continuous hemorrhage. [6, 48, 53] The reported incidence of ACS following open repair of ruptured abdominal aortic aneurysm is 4 to 20%, with increased morbidity and mortality associated with delayed treatment. [55, 56]
Recommendations vary regarding whether surgical treatment should be delayed in patients with severe burns. [6, 48, 53] In severely burned patients, the prevalence of ACS is estimated to be 4.1-17%. [57, 58]
