Epidemiology: massive splenomegaly with abdominal compartment syndrome has been reported in association with myelofibrosis (Am J Hematol, 2005) [MEDLINE]
Transmission of Intra-Abdominal Pressure to the Thorax
Studies Indicate that Approximately Half of the Intra-Abdominal Pressure is Transmitted to the Plateau Pressure on the Ventilator (J Trauma Acute Care Surg, 2013) [MEDLINE]
Therefore, the plateau pressure on the ventilator should be corrected down for this effect in the setting of abdominal compartment syndrome, to give a “true” plateau pressure
Note: pressure measurements require conversion of abdominal pressure (in mm Hg) to plateau pressure (in cm H20): 1 cm H20 = 0.736 mm Hg
Example: intra-abdominal pressure of 25 mm Hg = 33.97 cm H20
Measuring Esophageal Pressure May Be Used as a Surrogate for Pleural Pressure (NEJM, 2008) [MEDLINE]: this may facilitate higher levels of PEEP, if required for oxygenation
Bladder Pressure (via Foley Catheter) (see Foley Catheter)
Normal Intra-Abdominal Pressure
Intra-Abdominal Pressure is Approximately 5-7 mm Hg in Critically Ill Adults (Intensive Care Med, 2013) [MEDLINE]
Bladder Pressure in Abdominal Compartment Syndrome: usually >20-25 mm Hg
Bladder Pressure Correlates with Intra-Abdominal Pressure (Endoscopy, 1998) [MEDLINE]
Recommendations (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]
Intra-Abdominal Pressure Should Be Measured When Any Known Risk factor for Intra-Abdominal Hypertension or Abdominal Compartment Syndrome Exists (Grade 1C Recommendation)
Clinical Definitions (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]
Intra-Abdominal Pressure is the Steady-State Pressure Concealed within the Abdominal Cavity
Abdominal Compliance
Measure of the Ease of Abdominal Expansion, Which is Determined by the Elasticity of the Abdominal Wall and Diaphragm
Abdominal Compliance should be expressed as the change in intra-abdominal volume per change in IAP
Via Foley Catheter within the Urinary Bladder (with a Maximal Volume of 25 mL of Sterile Saline) (see Foley Catheter)
Intra-Abdominal Pressure Should Be Expressed in mm Hg and Measured at End-Expiration in the Supine Position After Ensuring that Abdominal Muscle Contractions are Absent (with the Transducer Zeroed at the Level of the Mid-Axillary Line)
Intra-Abdominal Pressure is Approximately 5-7 mm Hg in Critically Ill Adults
Intra-Abdominal Hypertension is Defined as Sustained or Repeated Pathological Elevation in Intra-Abdominal Pressure ≥12 mm Hg
Grade I Intra-Abdominal Hypertension: intra-abdominal pressure 12-15 mm Hg
Grade II Intra-Abdominal Hypertension: intra-abdominal pressure 16-20 mm Hg
Grade III Intra-Abdominal Hypertension: intra-abdominal pressure 21-25 mm Hg
Grade IV Intra-Abdominal Hypertension: intra-abdominal pressure >25 mm Hg
Abdominal Compartment Syndrome is Defined as a Sustained Intra-Abdominal Pressure >20 mm Hg (with or without an Abdominal Perfusion Pressure <60 mm Hg) Which is Associated with New Organ Dysfunction/Failure
Abdominal Perfusion Pressure = Mean Arterial Pressure – Intra-Abdominal Pressure
Definition of Syndromes
Primary Intra-Abdominal Hypertension or Abdominal Compartment Syndrome
Condition associated with injury or disease in the abdominopelvic region that frequently requires early surgical or interventional radiological intervention
Secondary Intra-Abdominal Hypertension or Abdominal Compartment Syndrome
Condition that does not originate from the abdominal-pelvic region
Recurrent Intra-Abdominal Hypertension or Abdominal Compartment Syndrome
Condition in which intra-abdominal hypertension or abdominal compartment syndrome recurs following previous surgical or medical treatment of primary or secondary intra-abdominal hypertension or abdominal compartment syndrome
Polycompartment Syndrome: condition where two or more anatomical compartments have elevated compartmental pressures
Other Definitions
Open Abdomen
One that requires a temporary abdominal closure due to the skin and fascia not being closed after laparotomy
Lateralization of the Abdominal Wall
Phenomenon where the musculature and fascia of the abdominal wall, most exemplified by the rectus abdominus muscles and their enveloping fascia, move laterally away from the midline over time
Increased Intra-Abdominal Pressure, Which is Consequently Transmitted to the Thorax
Decreased Venous Return/Decreased Preload, Resulting in Decreased Cardiac Filling
Increased Afterload
Diagnosis
Central Venous Pressure (CVP): increased (without increased right end-diastolic volume) -> may lead to spurious interpretation of CVP measurements
Pulmonary Capillary Wedge Pressure (PCWP): increased (without increased left end-diastolic volume) -> may lead to spurious interpretation of PCWP measurements
Cardiac Output (CO): decreased
Systemic Vascular Resistance (SVR): increased
Treatment
Intravenous Fluid Administration Administration May Worsen Bowel Wall Edema, Exacerbating the Abdominal Compartment Syndrome
Renal Artery Vasoconstriction and Vein Compression
Resulting in Decreased Renal Blood Flow
Kidneys are Early Sensors for the Presence of Abdominal Compartment Syndrome
Increases in Abdominal Pressure as Low as 12 mm Hg May be Associated with Acute Kidney Injury (Acta Clin Belg, 2007) [MEDLINE]
Sustained Intra-Abdominal Pressure >20 mm Hg in Association with New Organ Dysfunction are Associated with AKI in >30% of Cases (Arch Surg, 1999) [MEDLINE] (Intensive Care Med, 2007) [MEDLINE]
The Liver’s Ability to Remove Lactic Acid is Impaired by Increased Intra-Abdominal Pressure as Small by as Little as 10 mm Hg (Gastroenterology, 1993)[MEDLINE] (J Trauma, 1998) [MEDLINE]
This Occurs Even in the Presence of a Normal Cardiac Output and Mean Arterial Blood Pressure
Clinical
Lactic Acidosis May Clear More Slowly than Expected, Despite Adequate Resuscitation
Multiple Compartment Syndrome
Epidemiology
Occurs in the Setting of Polytrauma
Physiology
Intravenous Fluid Administration and Acute Lung Injury Increase Intra-Abdominal and Intrathoracic Pressures
These lead to increased intracranial pressure after traumatic brain injury
Additional Intravenous Fluids Administered to Maintain Cerebral Perfusion or Increased Ventilatory Support to Treat Acute Lung Injury Further Raise the Intracranial Pressure
These Mechanisms Can Result in a Cycle that Culminates in Multiple Compartment Syndrome
Lowers Intra-Abdominal Pressure and Intracranial Pressure [MEDLINE]
Treatment
Supine Position
Rationale
Avoid elevation of head of bed and proning, as both increase intra-abdominal pressure
Ventilator Management
Decrease Tidal Volume (VT)
Instituting a decrease in tidal volume has traditionally been recommended to decrease extrinsic pressure on the abdominal compartment
However, Studies Indicate that Approximately Half of the Intra-Abdominal Pressure is Transmitted to the Plateau Pressure on the Ventilator (J Trauma Acute Care Surg, 2013) [MEDLINE]: therefore, the plateau pressure should be corrected down for this effect in the setting of abdominal compartment syndrome, to give a “true” plateau pressure
Note: pressure measurements require conversion of abdominal pressure (in mm Hg) to plateau pressure (in cm H20): 1 cm H20 = 0.736 mm Hg
Example: intra-abdominal pressure of 25 mm Hg = 33.97 cm H20
Consequently, if the Corrected Plateau Pressure is Acceptable, a Decrease in Tidal Volume May Not Be Warranted
This is especially true in a patient with severe metabolic acidosis and inability to compensate with current mechanical ventilation settings, where decreasing the tidal volume may worsen the compensation for acidosis
Sedation with Neuromuscular Blockade
Rationale
Both may reduce intra-abdominal pressure in patients who are dyssynchronous with the ventilator
Bogota Bag: plastic bag over opened abdominal wall
Definitive Closure: can usually be performed within 48 hrs
Management Recommendations (World Society of Abdominal Compartment Syndrome Guidelines, 2013) (Intensive Care Med, 2013) [MEDLINE]
Recommendations
Decompressive Laparotomy is Recommended in Critically Ill Adults with Overt Abdominal Compartment Syndrome Over Strategies that Do Not Use Decompressive Laparotomy (Grade 1D Recommendation)
In ICU patients with Open Abdominal Wounds, Conscious and/or Protocolized Efforts are Recommended to Obtain an Early or at Least Same-Hospital-Stay Abdominal Fascial Closure (Grade 1D Recommendation)
In Critically Ill/Injured Patients with Open Abdominal Wounds, Strategies Utilizing Negative Pressure Wound Therapy are Recommended (Grade 1C Recommendation)
Suggestions
Potential Contribution of Body Position to Elevated Intra-Abdominal Pressure Should Be Considered in Patients with (or at risk of) Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 2D Recommendation)
Use Reverse Trendelenburg Position, as Required
Enteral Decompression with Nasogastric or Rectal Tubes Should Be Used When Stomach or Colon are Dilated in the Presence of Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 1D Recommendation)
Neostigmine Should Be Used for the Treatment of Established Colonic Pseudo-Obstruction Not Responding to Other Simple Measures and Associated with Intra-Abdominal Hypertension (Grade 2D Recommendation)
Sedation/Analgesia/Paralysis
Critically Ill or Injured Patients Should Receive Optimal Pain and Anxiety Relief (Grade 2D Recommendation)
Brief Neuromuscular Blockade as a Temporizing Measure Should Be Considered in the Treatment of Intra-Abdominal Hypertension/Abdominal Compartment Syndrome (Grade 2D Recommendation)
Resuscitation Strategy
Avoid Positive Cumulative Fluid Balance in the Critically Ill or Injured Patient with (or at risk of) Intra-Abdominal Hypertension/Abdominal Compartment Syndrome After the Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed (Grade 2C Recommendation)
Enhanced Ratio of Plasma/Packed Red Blood Cells Should Be Used for Resuscitation of Massive Hemorrhage (Grade 2D Recommendation)
Percutaneous Catheter Drainage
Percutaneous Catheter Drainage Should Be Used to Remove Fluid (with Obvious Intraperitoneal Fluid) in those with Intra-Abdominal Hypertension/Abdominal Compartment Syndrome When this is Technically Feasible (Grade 2C Recommendation)
Percutaneous Catheter Drainage Should Be Used to Remove Fluid (with Obvious Intraperitoneal Fluid) in those with Intra-Abdominal Hypertension/Abdominal Compartment Syndrome When this is Technically Feasible, as Compared to Immediate Decompressive Laparotomy as this May Alleviate the Need for Decompressive Laparotomy (Grade 2D Recommendation)
In Patients Undergoing Laparotomy for Trauma Suffering from Physiologic Exhaustion Should Be Treated with Prophylactic Use of Open Abdomen, as Compared to Intraoperative Abdominal Fascial Closure and Expectant Intra-Abdominal Pressure Management (Grade 2D Recommendation)
Open Abdomen Should Not Be Routinely Used for Patients with Severe Intraperitoneal Contamination Undergoing Emergency Laparotomy for Intra-Abdominal Sepsis Unless Intra-Abdominal Hypertension is a Specific Concern (Grade 2B Recommendation)
Bioprosthetic Mesh Should Not Be Routinely Used in the Early Closure of the Open Abdomen, as Compared to Alternative Strategies (Grade 2D Recommendation)
No Recommendations
No Recommendation Regarding Use of Abdominal Perfusion Pressure in the Resuscitation or Management of the Critically Ill or Injured Patient
Techniques to Mobilize Fluid
No Recommendation Regarding Use of Diuretics to Mobilize Fluids in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After the Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
No Recommendation Regarding the Use of Renal Replacement Therapy to Mobilize Fluid in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After the Acute resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
No Recommendation Regarding the Administration of Albumin to Mobilize Fluid in Hemodynamically Stable Patient with Intra-Abdominal Hypertension After Acute Resuscitation Has Been Completed and the Inciting Issues Have Been Addressed
No Recommendation Regarding the Prophylactic Use of the Open Abdomen in Non-Trauma Acute Care Surgery Patient with Physiologic Exhaustion vs Intraoperative Abdominal Fascial Closure and Expectant IAP Management
No Recommendation Regarding use of an Acute Component Separation Technique to Facilitate Earlier Abdominal Fascial Closure
Prognosis
Untreated
Universally Fatal
Treated
Organ System Dysfunction Resolves in 93% of Cases
Survival Rate: 59%
References
General
Oliguria from high intra-abdominal pressure secondary to ovarian mass. Crit Care Med. 1987;15:78-79
Cardiovascular, pulmonary and renal effects of massively increased intra-abdominal pressure in critically-ill patients. Crit Care Med. 1989;17:118-121
Intra-abdominal hypertension is an independent cause of postoperative renal impairment. Arch Surg 1999; 134:1082–1085 [MEDLINE]
Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med. 2000;162:134-138
Prospective study of the incidence and outcome of intra-abdominal hypertension and the abdominal compartment syndrome. Br J Surg. 2002;89:591-596
Myelofibrosis-associated massive splenomegaly: a cause of increased intra-abdominal pressure, pulmonary hypertension, and positional dyspnea. Am J Hematol. 2005 Oct;80(2):128-32 [MEDLINE]
Results from the International Conference of Experts on Intra-abdominal Hypertension and the Abdominal Compartment Syndrome II. Intensive Care Med 2007;33:951-962 [MEDLINE]
Abd Compt Syndrome: World Society of Abd Compt Syndrome (WSACS), Intensive Care Med 2006: 32(11): 1722-1732, 2007: 33(6): 951-962
Renal implications of increased intraabdominal pressure: are the kidneys the canary for abdominal hypertension? Acta Clin Belg Suppl 2007:119 –130 [MEDLINE]
Abdominal compartment syndrome: a concise clinical review. Crit Care Med. 2008 Apr;36(4):1304-10. doi: 10.1097/CCM.0b013e31816929f4 [MEDLINE]
Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–2104 [MEDLINE]
Influence of abdominal pressure on respiratory and abdominal organ function. Curr Opin Crit Care. 2012 Feb;18(1):80-5. doi: 10.1097/MCC.0b013e32834e7c3a [MEDLINE]
Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med. 2013 Jul;39(7):1190-206. doi: 10.1007/s00134-013-2906-z. Epub 2013 May 15 [MEDLINE]
Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747–757 [MEDLINE]
Etiology
Increased intra-abdominal, intrathoracic, and intracranial pressure after severe brain injury: multiple compartment syndrome. J Trauma 2007 Mar; 62(3):647-656 [MEDLINE]
Diagnosis
Is urinary bladder pressure a sensitive indicator of intra-abdominal pressure? Endoscopy. 1998 Nov;30(9):778-80 [MEDLINE]
Clinical
Hemodynamic effects of acute changes in intra-abdominal pressure in patients with cirrhosis. Gastroenterology. 1993;104(1):222 [MEDLINE]
Effects of intra-abdominal hypertension on hepatic energy metabolism in a rabbit model. J Trauma. 1998;44(3):446 [MEDLINE]
