Continuing Education Activity

Abdominal compartment syndrome (ACS) is a serious condition that occurs when the pressure in the abdominal cavity rises above 20 mmHg and causes end-organ damage. Persistently elevated intra-abdominal pressures (IAP) can cause long-term organ dysfunction and can be potentially fatal if not promptly recognized and treated. Many cases of elevated IAP go unrecognized because a physical exam is not sensitive in detecting this condition; therefore, it is essential to understand the risk factors and associated treatments of ACS. This review activity focuses on the pathophysiology, evaluation, diagnosis, and management of this condition, emphasizing the critical role of the interprofessional team in recognizing and treating ACS.

Objectives:

• Evaluate patients with significant fluid shifts, especially those with associated clinical instability, for abdominal compartment syndrome by routinely measuring intra-abdominal pressure and utilizing established criteria from the World Society of Abdominal Compartment Syndrome (WSACS) guidelines.

• Assess and evaluate the impact of elevated intra-abdominal pressure on surrounding organ systems, recognizing the potential for multi-organ dysfunction, and incorporate this holistic perspective into abdominal compartment syndrome management decisions.

• Select appropriate interventions, whether medical or surgical, based on the patient's clinical presentation and IAP measurements, aiming for timely and effective abdominal compartment syndrome management.

• Communicate effectively with interdisciplinary healthcare teams to ensure coordinated care and timely interventions for patients at risk or diagnosed with abdominal compartment syndrome.

Introduction

Compartment syndrome can occur in any anatomical area with increased pressure in a confined body space, resulting in poor blood flow, cellular damage, and eventual organ dysfunction. These compartments are restricted by muscles and fascia, limiting the compartment's ability to expand as pressure progressively increases. Abdominal compartment syndrome (ACS) is especially well-studied due to its prevalence in critically ill patients and the potential for multisystem organ failure.[1][2][3] 

The World Society of Abdominal Compartment Syndrome (WSACS) was created in 2004. This society standardized the definitions and guidelines for evaluating and treating ACS, as this disease process is often underdiagnosed in the medical field.[4][5] The intra-abdominal pressure (IAP) is the steady-state pressure within the abdomen. The average normal adult IAP ranges from 0 to 5 mm Hg, while IAP can be elevated up to 5 to 7 mm Hg in critically ill patients. Both patient body habitus and chronic medical conditions can influence the patient's baseline IAP; thus, they must be considered during ACS evaluation. Elevated IAP can lead to intra-abdominal hypertension (IAH), defined as IAP ≥ 12 mm Hg, but is not synonymous with ACS. ACS can occur when IAP is  >20 mm Hg. However, the beginning phases of organ dysfunction can occur before IAP reaches 20 mm Hg.[4][5] 

Failure to recognize and immediately manage ACS can lead to poor prognosis and is recognized as an independent predictor of mortality. High clinical suspicion with protocolized monitoring and management should be implemented when treating critically ill patients, especially those with significant fluid shifts. This diagnosis should always be considered in patients with tense and distended abdomens and associated clinical instability. The abdomen is one of many anatomically confined spaces within the body. All compartments within the body are connected to multiple organ systems through physiologic systems; thus, increased IAP will also affect the surrounding areas and can lead to multiple organ dysfunction.[6] With prompt identification of the causes of ACS and early interventions, organ dysfunction can be reversible.[6][7]

Etiology

Abdominal compliance is primarily determined by the elasticity of the abdominal wall and diaphragm. Increased intra-abdominal pressure can cause vasculature dysfunction, including loss of vasomotor tone and compromised endothelial intercellular junctions. IAH also causes increased antidiuretic hormone release, further increasing volume retention.[8]

As IAH is viewed as a physiologic continuum. The WSACS recommended that IAH be divided into four grades as follows:[5]

• Grade I: IAP 12-15 mm Hg
• Grade II: IAP 16-20 mm Hg
• Grade III: IAP 21-25 mm Hg
• Grade IV: IAP >25 mm Hg

Intra-abdominal hypertension in the presence of organ dysfunction raises suspicion for ACS. Surgical procedures that carry an especially high risk of developing IAH include liver transplantation, damage control surgery, repair of abdominal aortic aneurysm, and large abdominal hernia repairs.[9] Other etiologies must be considered in addition to surgery as potential causes of ACS, which can be classified as primary or secondary. Primary ACS causes include blunt or penetrating trauma, intra-abdominal hemorrhage, abdominal aortic aneurysm rupture, abdominal adhesions, intestinal obstruction, tumor formation, and retroperitoneal hematoma. Secondary causes do not originate from intra-abdominal disease, including pregnancy, ascites, ileus, intra-abdominal sepsis, and large-volume fluid resuscitation.[10] Intra-abdominal pressures can be chronically elevated in pregnancy, cirrhosis, obesity, intra-abdominal malignancy, and peritoneal dialysis.[6][11][12][13] Those with higher body mass index can be expected to have higher baseline IAP between 9 to 14 mm Hg due to the restrictive effect of adipose tissue.[14]

The causes of IAH and ACS can be broken down into the following categories:[15][16][17]

Diminished abdominal wall compliance: abdominal surgery, intra-abdominal adhesions, major trauma, major burns, mechanical ventilation, obesity.

Increased intraluminal volume: gastroparesis, gastric distension, ileus, constipation, toxic megacolon, volvulus.

Increased extraluminal abdominal volume: hemoperitoneum, pneumoperitoneum, severe pancreatitis, liver failure with ascites, retroperitoneal or intra-abdominal tumors, intra-abdominal abscesses, laparoscopy with excessive insufflation pressures, peritoneal dialysis.

Capillary leak/fluid resuscitation: damage control surgery, bacteremia, systemic inflammation, coagulopathy, sepsis, massive fluid administration, blood product transfusion.

Epidemiology

ACS can develop in all ICU and critically ill patients. The Incidence, Risk Factors, and Outcomes of Intra-Abdominal Hypertension in Critically Ill Patients (IROI Study) was a prospective study that revealed 34% of patients to have IAH on the day of admission, which increased to 48.9% within 14 days. The development of IAH within the observed period was associated with mortality.[18] In another identified series of mixed ICU populations, 32% of patients were found to have IAH and 4% to have ACS.[19]

Pathophysiology

Elevated intra-abdominal pressures can affect multiple organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and nervous systems.[20][21]

Cardiovascular System

The cardiovascular system can be affected in multiple ways due to elevated IAP. IAH can cause compression of the inferior vena cava, reducing venous blood return to the heart and causing lower extremity edema. Decreased venous return can also lead to reduced cardiac output, resulting in less blood and oxygen delivery to peripheral tissues. Additionally, the increased IAP causes the diaphragm to move upwards, which raises the intra-thoracic pressures and places direct pressure on the heart, ultimately decreasing ventricular compliance.

Pulmonary System

Elevated intrathoracic pressures limit pulmonary compliance, thus decreasing tidal volume and functional residual capacity and increasing pulmonary vascular resistance. Airway pressures increase, and patients can have difficulties ventilating. Alveoli exhibit atelectasis, increasing the dead space. Thus, gas exchange is adversely affected as less oxygen is transported and more carbon dioxide is retained, leading to hypoxemia and hypercarbia. 

Renal System

IAH can compromise the renal system by decreasing renal arterial and venous blood flow, affecting the glomerular filtration rate and ultimately causing acute kidney injury and subsequent reduction in urine output. Blood is diverted from the renal cortex, further impairing renal function. The renin-angiotensin-aldosterone system is activated, leading to increased systemic vascular resistance through angiotensin II and increased reabsorption of water and sodium mediated by aldosterone. Studies indicate that oliguria can occur at an IAP of 15 mm Hg and anuria at pressures of 30 mm Hg. 

Gastrointestinal System

Decreased abdominal compliance with increased IAP leads to decreased splanchnic blood flow, causing tissue hypoxia, increased capillary permeability, and edema. Further insult propagates the body's inflammatory response, exacerbates intestine malperfusion, and increases the risk of bacterial translocation and infection. The hepatic system is also affected as decreased hepatic flow leads to impaired metabolism and clearance, contributing to metabolic acidosis. 

Nervous System 

Elevated IAP also decreases venous drainage from the brain, which increases intracranial pressure and decreases cerebral blood flow. Increased PaCO2 also causes increased arterial blood flow to the brain, further increasing intracranial pressure.[10][21][22]

History and Physical

ACS is usually only observed in critically ill patients and is more frequently diagnosed in the intensive care unit (ICU) than in the emergency department. Of note, physical examination is not a reliable indicator of ACS, even when performed by experienced clinicians, so objective measurements are necessary in any patient with risk factors for IAH.[9][23] If a patient has penetrating abdominal trauma, has received large amounts of fluid resuscitation, or has undergone extensive abdominal surgery, there should be a high clinical suspicion for ACS. Diagnosing ACS can be challenging as ICU patients may have a range of extra-abdominal organ failures. Patients may also be intubated and unable to communicate their symptoms, so thorough monitoring of IAP, chart review to obtain past medical history, and overall clinical picture are essential for diagnosis.[9]

Evaluation

Imaging modalities are not standard practice for the diagnosis of ACS. However, imaging can show early indicators of IAH that may ultimately lead to ACS, such as peritoneal-to-abdominal height ratio >0.52,  a maximal anteroposterior to transverse abdominal diameter ratio of >0.8, bowel wall thickening, elevation of the diaphragm, narrowing of the vena cava <3 mm, and a large amount of intra-abdominal fluid.[9] 

The most accurate method to confirm the diagnosis is measuring the intra-abdominal pressure. The IAP should be measured anytime there is a known IAH risk. IAP measurement can be achieved using both direct and indirect methods. Direct methods include using pressure transducers (eg, Veress needle during laparoscopic surgery) or intraperitoneal catheters (eg, peritoneal dialysis catheter). These methods are highly accurate but are invasive.

The most accepted method of measuring IAP is the use of indirect IAP measurements through intravesicular catheter pressures. This is the most practical approach due to its widespread availability and limited invasiveness. This technique involves aseptic clamping of the Foley catheter and connecting the Foley to a 3-way stopcock adjusted to the level of the mid-axillary line at the iliac crest to zero the transducer. 25 cc of sterile saline is then injected into the bladder. Measurements should be taken at end-expiration with the patient in a complete supine position. [5][14] Bladder pressures below 5 mm Hg are expected in healthy patients. Pressures between 10 to 15 mm Hg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mm Hg are highly suspicious of ACS and should be correlated clinically. It is recommended that pressure measurements be trended every 6 hours to identify worsening IAH when there is potential for the development of ACS. Contraindications to using bladder pressures include bladder trauma, neurogenic bladder, benign prostatic hypertrophy, and pelvic hematoma.[24][25]  Pelvic fracture, bladder hematoma, and peritoneal adhesions will lead to inaccurate measurements.[23]

If bladder measurements are unavailable, other screening methods for IAH include placement of a central line to measure IVC pressure, manometry through a Jackson-Pratt drain, and intragastric pressure measurement through a nasogastric tube. These are not well-validated and not commonly used methods.[23]

Treatment / Management

Choosing the appropriate intervention and timing of the intervention is determined by the etiology of the elevated IAP, the duration of increased IAP, and the degree of organ dysfunction. Not every patient with ACS will immediately need surgical decompression, as nonsurgical interventions can decrease intra-abdominal volume and ultimately improve IAP. If clinically indicated, intraluminal volume can be reduced with nasogastric decompression, rectal tube decompression, or endoscopic decompression. Percutaneous drainage can reduce extraluminal volume in the case of ascites or hematoma.[5][20][23] Abdominal wall compliance can be improved with adequate sedation and neuromuscular blockade, removal of constrictive dressings, and eschar release, among other options. Other recommendations made by the WSACS include optimizing fluid administration, resuscitating with hypertonic products or colloids, consideration of hemodialysis or ultrafiltration, and goal-directed resuscitation.[5] However, the quality of evidence is low and needs to be considered when using conservative measures.[14] 

Percutaneous catheter drainage is a viable option for ACS caused by increased extraluminal abdominal volume. It is far less invasive than a surgical laparotomy and can also be used temporarily if surgical decompression is not an immediate option. Excess extraluminal abdominal volume is caused by excess air, fluid, or blood in the abdominal cavity.[20] 

If conservative medical management does lead to improved IAH and further organ damage is noted, surgical decompression using emergent laparotomy should be considered.[2][26] With surgical abdominal decompression, organ dysfunction may also improve rapidly, as most organ dysfunction is seen as a direct sequelae from compromised blood flow or mechanical obstruction.[27][28] After surgical decompression, the abdominal fascia may be left open temporarily. The open wound is often covered by a negative pressure dressing system, which helps minimize the risks of infections and fistulas, decreases insensible losses, and prevents retraction of the fascia. With clinical improvement, the patient can return to the operating room within several days for further evaluation and attempted fascial closure, which can be achieved with mesh or primary closure techniques.[6][9] However, some of these approaches may not be feasible at all facilities due to limited resources.[29]

Although surgical decompression is considered a definitive treatment for ACS, it can be associated with many complications, especially when the abdomen wall is left open. Some complications include fistula formation, protein loss by drainage of peritoneal fluid, abdominal wall retraction with ventral hernia development, and wound infection. In addition, up to 20% of surgical decompression is associated with recurrent ACS either due to ongoing causative agents or inadequate lowering of IAP.[23]

Despite extensive literature published on ACS, the ideal timing for surgical decompression is debatable. Early pursuit of surgical intervention can exacerbate stress on the patient from the surgery itself. Thus, the consensus within the medical community is to consider surgery when multiple conservative management treatments have not improved the patient's condition.[7]

Differential Diagnosis

The differential diagnosis for ACS includes mesenteric ischemia, ruptured abdominal aortic aneurysm, toxic megacolon, acute appendicitis, and acute diverticulitis.

Prognosis

If left untreated, abdominal compartment syndrome can be fatal, and delayed treatment is associated with high mortality rates. IAH has been identified as an independent predictor of mortality, with each grade associated with worsening outcomes.[9][19] Many series report that the resulting multiorgan failure can delay recovery for weeks or months, even with treatment. Prolonged need for mechanical ventilation, dialysis, and more extended hospital stays are also common in these patients.

Complications

ACS complications include the following:

• Renal failure
• Bowel ischemia
• Respiratory distress or failure
• Increased cranial pressure
• Cardiac failure
• Potential death

Deterrence and Patient Education

The keys to preventing ACS development are, first and foremost, to measure IAP in any patient with risk factors, especially ICU patients. Other practices to minimize IAH are judicious use of IV fluids and blood products; avoiding a significantly positive fluid balance; using low tidal volumes in mechanical ventilation; using intestinal prokinetic medications to avoid ileus or constipation; and minimizing enteral feedings. 

Enhancing Healthcare Team Outcomes

The diagnosis and management of ACS require an interprofessional team approach. The condition can present subtly, and the diagnosis can easily be missed. ACS is very common in medical and surgical ICUs, with many studies showing an IAH prevalence of 30% to 40%. One survey of specialists found that non-surgical specialists were comparatively less familiar with recognizing, diagnosing, and managing ACS than surgical specialists.[21][30] Ideally, monitoring all critically ill patients for ACS should be established as a routine practice among institutions; however, monitoring may be limited due to a lack of understanding or limited resources.[14] 

Overall, the outcomes for some patients with ACS can be poor due to effects on multiple organ systems and underlying comorbidities. However, those diagnosed and treated promptly with the involvement of the appropriate specialties have improved outcomes, and early treatment of ACS minimizes end-organ damage.[17] Thus, it is essential to involve general surgeons in caring for patients at high risk of developing or currently having an acute abdomen. Surgeons can assist with the workup management and monitor the patient in case the patient requires surgery.

Patients with ACS should be closely monitored in the ICU with intensivists familiar with the disease process. Pharmacists play a crucial role in enhancing pain management and sedation by identifying suitable medications for patients. Nurses must monitor vital signs, abdominal girth, wound care, and urine output. Critical team members include nutritionists, physical and occupational therapists, and respiratory therapists. Patients who develop ACS and need surgical intervention have a prolonged recovery and require long-term care. This further emphasizes the importance of a multidisciplinary approach to patient treatment in ACS.