Abdominal Compartment Syndrome


Article Author:
Richard Newman
Nalin Dayal


Article Editor:
Elvita Dominique


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
8/2/2019 8:47:28 PM

Introduction

Compartment syndrome occurs when pressures increase within a fixed cavity of the body; leading to ischemia, muscle damage, and organ dysfunction. These "fixed" spaces are constrained by muscular and fascial boundaries, which may have limited compliance when they become swollen.[1][2][3]

Intra-abdominal hypertension is defined as the sustained intra-abdominal pressure (IAP) above 12 mmHg. 

Abdominal compartment syndrome (ACS) is a severe illness seen in critically ill patients.  ACS results from the progression of steady-state pressure within the abdominal cavity to a repeated pathological elevation of pressure above (> 20mmHg) with associated organ dysfunction.  Failure to recognize and immediately manage ACS can lend to poor prognosis as ACS is recognized as an independent predictor of mortality.  High clinical suspicions with protocolized monitoring and management should be adapted when treating the critically ill, especially those with significant fluid shifts. This clinical diagnosis should be considered in patients with tense or distended abdomen with associated instability; however, it may also be seen without abdominal distention. 

The exact clinical conditions that define ACS are controversial. The dysfunction may present with respiratory concerns such as high peak airway pressure and inadequate ventilation and oxygenation or decreased urine output caused by falling renal perfusion, but these concerns are reversible with intervention. 

Abdominal Compartment Syndrome has medical and conservative management options, and treatment is aimed at identifying and treating the cause of the compartment syndrome. However, patients with clinical deterioration may require emergent surgical decompression.

Etiology

Abdominal Compartment Syndrome can be divided and classified into two groups, primary and secondary ACS. Primary ACS causes include abdominal blunt or penetrating trauma, hemorrhage, AAA rupture, intestinal obstruction, and retroperitoneal hematoma. Secondary causes include pregnancy, ascites, ileus, burns, intra-abdominal sepsis, and large-volume fluid replacement (> 3 Liters). Chronic causes of elevated intra-abdominal pressure include pregnancy, cirrhosis, obesity, intra-abdominal malignancy, and peritoneal dialysis. These are all causes of intra-abdominal hypertension, defined as repeated intra-abdominal pressures > 12 mm Hg. The presence of organ dysfunction in this setting due to compressive symptoms now confirms a diagnosis of Abdominal compartment syndrome.[4][5][6]

Studies have shown that mortality after ACS caused by AAA rupture neared 47%. The disease can become devastating once other organ systems become involved due to compression, and Primary ACS tends to have an increasingly worse outcome.

Epidemiology

ACS can develop in all ICU patients. In an identified series of mixed ICU population, 35% of ventilated patients were found to have IAH or ACS.  Risks factors include a plethora of medical conditions but may be classified based on abdominal wall mechanics.  Risk factors include those that reduce abdominal compliance, increase intra-abdominal contents, increase luminal contents or third space expansion, and cause a capillary leak. [7][8]

Pathophysiology

With intraperitoneal bleeding, trauma, or abscess, the physiologic response of inflammation and swelling can be held responsible for intra-abdominal hypertension. In the setting of intestinal obstruction, the dilated loops of bowels can cause compressive symptoms within the abdominal cavity. As abdominal pressure increases, the syndrome may begin to involve other organ systems due to further compression.

Intra-abdominal hypertension is graded from I to IV:

  • 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

Any evidence of continued intra-abdominal hypertension with organ failure is defined as ACS. However, the incidence of organ failure is highest in patients with Grade IV IAH. Organs typically affected include the heart, lungs, kidney.

Physiologic cardiac sequelae include decreased cardiac output and increased central venous pressure (CVP) due to Inferior vena cava (IVC) and portal vein compression, increase systemic vascular resistance (SVR) leads to hypotension. Pulmonary involvement can present as decreased thoracic volumes and elevated peak pressures from compression of the diaphragm, a decrease in P/F ratio and hypercarbia. Renal compression can lead to decreased GFR and low urine output. Visceral blood flow is also reduced.  Neurologic symptoms can include increased Intra-cranial pressure (ICP) from the elevated CVP due to IVC compression contributing to a decrease in cerebral perfusion pressure (CPP).

History and Physical

ACS is typically only seen in critically ill patients and will likely be a diagnosis made in the ICU setting, rather than in the ER. Clinical suspicion for abdominal compartment syndrome should be high in patients with penetrating abdominal trauma or surgical patients following extensive abdominal surgery. Patients may present with abdominal pain and distension. However, this is not a sensitive or specific finding. Patients in the ICU setting may present with a wide array of organ failure, not limited to the abdomen, which can make the diagnosis difficult.

The physical exam may reveal an increased abdominal girth, tense abdomen, cyanosis, wheezing, and difficulty breathing.

In abdominal compartment syndrome, the displacement of the diaphragm cephalad leads to compression of the thorax which causes an increase in work of breathing, ventilation/perfusion inequality, and increases in both peak and plateau pressures.

The tense abdomen also prevents venous return, resulting in elevated intracranial pressure and decreased cerebral perfusion pressure.

Evaluation

While imaging modalities may help in localizing a cause of the elevated abdominal pressure (bleeding, trauma, obstruction), they do not help make the specific diagnosis of abdominal compartment syndrome. The most accurate manner of confirming this diagnosis is from measured abdominal pressures. The IAP should be measured when any known risk intra-abdominal hypertension (IAH) is present.  This measurement can be achieved in many ways, including both direct and indirect methods. Direct methods include measurement of abdominal pressure using pressure transducers (e.g., veress needle during laparoscopic surgery) or intraperitoneal catheters (e.g., peritoneal dialysis catheter). Theses methods are highly accurate; however, they are limited by their invasiveness. The more commonly used method is an indirect measurement such as intravesicular catheter pressures (e.g., Foley catheter) which has become the gold standard due to its widespread availability and limited invasiveness. Trans-bladder technique involves using aseptic clamping the drainage tubing of the Foley then connecting the Foley to a three-way stop tap adjusted to the level of the mid-axillary line at the iliac crest to zero transducers follow by injecting 25cc of sterile saline into the bladder.  Measurements should be taken at end-expiration and complete supine position and expressed in mmHg.  Bladder pressures below 5mm Hg are expected in healthy patients. Pressures between 10 to 15 mmHg can be expected following abdominal surgery and in obese patients. Bladder pressures over 25 mmHg are highly suspicious of abdominal compartment syndrome and should be correlated clinically. It is recommended that pressure measurements be trended to show and recognize the worsening of intra-abdominal hypertension.

Contraindications to using bladder pressures include bladder trauma, neurogenic bladder, BPH, and pelvic hematoma. Bladder pressures may be inaccurate if the patient is not sedated or laying flat.[9][10]

Ct scan may reveal several things such as the collapse of the vena cava, round abdomen, bowel thickening and or bilateral inguinal herniation. The following grading system is used to categorize abdominal compartment syndrome:

  • Grade I: 10-15 cm H O

  • Grade II: 15-25 cm H O

  • Grade III: 25-35 cm H O

  • Grade IV, greater than 35 cm H O

Treatment / Management

Non-surgical therapeutic options for treatment of intra-abdominal hypertension involves an overall goal to improve the following: abdominal wall compliance with decreased muscle contraction, evacuation of luminal contents by decompression (NG tube), evacuation of abdominal fluid by drainage, and correction of positive fluid balance through goal-directed volume resuscitation.

The primary treatment for ACS is surgical decompression. However, the early use of non-surgical interventions may prevent progression of IAH to ACS. Early recognition involves supportive care to include keeping patients comfortable with pain well-controlled.  Decompressive procedures such as NG tube placement for gastric decompression, rectal tube placement for colonic decompression and percutaneous drainage of abscesses, ascites or fluid from the abdominal compartment. The neuromuscular blockade has been described to be used as a brief trial in an attempt to relax the abdominal musculature, leading to a significant decrease in abdominal compartment pressures in the ventilated ICU patient. If conservative and medical management does not resolve the IAH and further organ damage is noted, surgical decompression using emergent laparotomy may be considered.  [11][2]

After surgical laparotomy for compartment syndrome, the abdominal fascia may be closed using temporary closure devices such as (vacs, meshes, and zippers). The fascia can be appropriately closed after 5-7 days after the compartment pressures and swelling have decreased.

With surgical abdominal decompression, organ dysfunction may also improve rapidly as most organ dysfunction is seen as sequelae from compression. With less tension from the abdomen, the diaphragmatic excursion can increase, leading to improved ventilation and reduction of peak airway pressures. Compression of the IVC and circulatory system are relieved, leading to improved cardiac output and ability to wean patients off of vasopressor support. Acute kidney injury is reversed with less compression of the renal arteries and ureters.[12][13]

Differential Diagnosis

  • Mesenteric ischemia
  • Ruptured abdominal aortic aneurysm
  • Toxic megacolon
  • Acute appendicitis
  • Acute diverticulitis

Prognosis

If left untreated, abdominal compartment syndrome is fatal. Even delayed treatment is associated with very high mortality rates. Predictors of mortality include a history of diabetes and transfusion of a high volume of blood products. Many series reports that even with treatment, multi-organ failure can delay recovery for weeks or months. Prolonged need for mechanical ventilation, dialysis, and more extended hospital stays are common in these patients.

Complications

  • Renal failure
  • Bowel ischemia
  • Respiratory distress
  • Increased cranial pressure
  • Low cardiac output and shock

Postoperative and Rehabilitation Care

After decompression of the abdomen, many patients still require the following treatments:

  • Fluid restriction
  • Diuretics
  • Ambulation
  • DVT prophylaxis

Deterrence and Patient Education

To prevent abdominal compartment syndrome, many types of mesh are now available for abdominal closure that avoid tension on the abdominal contents. Some studies indicate that abdominal compartment syndrome is less likely to occur in patients resuscitated with FFP and lactate ringers compared to just a pure crystalloid.

Pearls and Other Issues

Current guidelines with which to be familiar (as presented by the World Society of the Abdominal Compartment Syndrome) include:

1) IAH is diagnosed by sustained or repeated elevation in IAP of =12 mm Hg

2) ACS is diagnosed when the IAP is >20 mm Hg, and is associated with organ dysfunction/failure

3) IAH 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

4) A trial of neuromuscular blockade can be used to alleviate compressive symptoms in ACS to while awaiting surgical decompression

Enhancing Healthcare Team Outcomes

The diagnosis and management of abdominal compartment syndrome require an interprofessional team approach. The condition can present in subtle ways, and the diagnosis can easily be missed. If the abdominal compartment syndrome is not diagnosed or treatment is delayed, the outcome is almost always fatal. Mortality rates of 20-70% have been reported in patients with blunt abdominal trauma, even with treatment. The reason for the high mortality is due to the early involvement of multiple organs. Also, the higher the abdominal pressure, the higher the mortality. Other factors associated with mortality include surgery lasting more than 2 hours, developing abdominal compartment syndrome within 48 hours of admission and an elevated lactic acid level despite treatment. Even those who survive have significant morbidity from residual deficits like renal failure, muscle wasting, respiratory distress, and liver dysfunction.

The Interprofessional Team

The diagnosis usually requires a systemic approach and discussion with the interprofessional team. Once the diagnosis is made, all patients require ICU care with continuous monitoring. A wound care nurse should assess the wound every day for healing and report to the clinician if there are any signs of infection or less than optimal healing. Since most patients are kept NPO, a dietary consult for TPN is necessary. Nurses should ensure that all patients have DVT and pressure sore prophylaxis. In addition, nurses need to weigh the patient daily, measure abdominal girth, assess urine output, and organ perfusion. If urine output declines, the nephrologist should be contacted and involved early in the care. Any deviation from normal parameters should be immediately conveyed to the interprofessional team. As the patient improves, physical therapy should be ordered to get the patient out of bed and encouraging ambulation.

Those who go on to develop chronic abdominal compartment syndrome need lifelong support and monitoring. The current recommendations focus on prevention of abdominal compartment syndrome. Various techniques for the closure of the abdomen, and even the fluid used to resuscitate the patient may make a difference in the outcome. [14][15]

The outcomes for most patients with abdominal compartment syndrome are poor. Those who are diagnosed and treated promptly do have good outcomes, but the recovery is often prolonged. Patients with multiorgan dysfunction have a long road to recovery, marked by wound breakdown, repeated hospitalization, and difficulty performing even the most basic daily living activities.[16] (Level V)


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Abdominal Compartment Syndrome - Questions

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A 68-year-old female presents to the emergency department due to difficulty breathing, abdominal distension, increasing difficulty urinating, and abdominal pain. The patient has a complicated medical history with a past medical history of uncontrolled diabetes, diverticulitis, abdominal aortic aneurysm of 3 cm, pancreatic pseudocysts, and CKD stage 5 from her diabetes for which she receives peritoneal dialysis. Patient's vitals are; respiratory rate 22/min, oxygen saturation 89%, BP 88/58mmHg, heart rate 110/min, and temperature 98.7F. A general surgery consult is called for concerns of a possible surgical abdomen. Urinalysis is negative for urinary tract infection, and the results of the diagnostic paracentesis are pending. Which part of the patient's past medical history might raise suspicion for possible abdominal compartment syndrome?



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A 28-year-old female is accidentally kicked in the abdomen by her horse. She is brought to the emergency department with severe abdominal pain. The triage nurse notes that her vitals are unstable and immediately consults with the emergency department physician to assess the patient. The patient is found to have an acute abdomen, and the general surgeon decides to perform an immediate exploratory laparotomy. The patient has a lacerated liver, ruptured spleen, and perforated transverse colon. The patient receives 22 units of packed red blood cells, 12 units of fresh frozen plasma, 12 liters of crystalloid, and 10 units of platelets. After surgery, she is taken to the ICU in relatively stable condition. Ten hours later, the nurse calls the resident surgeon on call to inform him that the patient's abdomen appears tense. Which of the following parameters warrants an immediate explorative laparotomy?



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A 36-year-old male is brought to the emergency department after being rolled over by a truck. The patient was without a helmet and did lose consciousness as a consequence of the accident. The patient is being seen by neurosurgery for a head injury, and he is currently intubated due to the poor GCS. The patient is in the intensive care unit, and his vitals have been stable throughout his admission to the hospital. A detailed inspection 24 hours later depicts an area of bruising over the patient's abdomen. In a ventilated patient, how can the pulmonary physiologic response to abdominal compartment syndrome manifest?



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A 56-year old female is admitted to the intensive care unit (ICU) due to hypotension and bleeding after she was involved in a motor vehicle accident. An ultrasound is performed, which shows splenic rupture. A laparotomy is carried out successfully, and the patient is stabilized. On the 3rd post-operative day, the patient complains of difficulty breathing, and her abdomen is tense and distended. The patient is tachycardic, hypertensive, and has a bladder pressure of 24 cm. Which of the following is the most appropriate next step in the management of this patient?



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A 76-year-old male in postoperative surveillance after a complicated exploratory laparotomy due to hypotension, after a motor vehicle accident, develops increasing abdominal pain with distension and difficulty breathing. What exam will best diagnose the suspected cause?



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Abdominal Compartment Syndrome - References

References

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Ampatzidou F,Madesis A,Kechagioglou G,Drossos G, Abdominal compartment syndrome after surgical repair of Type A aortic dissection. Annals of cardiac anaesthesia. 2018 Oct-Dec     [PubMed]
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