Abdominal Compartment Syndrome Management (WSACS 2013)

Algorithm Steps

1. ▶

   Start

   At-Risk Patient Identified

   Risk factors: Massive fluid resuscitation (>5L/24h), severe sepsis/septic shock, major abdominal surgery, trauma (especially with damage control), pancreatitis, ascites, ileus, abdominal distension, hypothermia, coagulopathy.

   1. ●

      Action

      Screen with IAP Measurement

      Measure intra-abdominal pressure (IAP) via bladder pressure: 1) Foley catheter in place. 2) Empty bladder, instill 25mL sterile saline. 3) Measure at end-expiration. 4) Patient supine, HOB ≤30°. 5) Zero at iliac crest/mid-axillary line. Normal IAP: 5-7 mmHg in critically ill.

      1. ◆

         Decision

         IAP Classification

         IAH defined as sustained IAP ≥12 mmHg. Grade I: 12-15 mmHg. Grade II: 16-20 mmHg. Grade III: 21-25 mmHg. Grade IV: >25 mmHg. ACS = IAP >20 mmHg with NEW organ dysfunction.

         1. ●

            Action

            IAP <12 mmHg - Normal

            Continue routine care. Consider repeat screening q4-6h if risk factors persist. Implement preventive measures: Avoid excessive fluid resuscitation, optimize analgesia, prokinetics if ileus.

            1. ✓

               Outcome

               IAH/ACS Resolved

               IAP normalized. Organ function restored. Continue monitoring during recovery.

         2. ●

            Action

            Grade I-II IAH (12-20 mmHg)

            Medical management protocol: 1) Optimize sedation/analgesia. 2) Consider neuromuscular blockade. 3) Avoid excessive fluid. 4) NG decompression. 5) Rectal tube/enema. 6) Diuretics if fluid overloaded. 7) Percutaneous drainage if intra-abdominal fluid collections.

            1. ●

               Action

               Medical Management Optimization

               Step 1: Evacuate intraluminal contents (NG, rectal tube). Step 2: Evacuate intra-abdominal fluid (paracentesis, percutaneous drainage). Step 3: Improve abdominal wall compliance (sedation, paralysis, positioning). Step 4: Optimize fluid balance (avoid over-resuscitation, consider hypertonic saline, diuretics). Step 5: Optimize systemic perfusion (vasopressors to maintain APP ≥60).

               1. ◆

                  Decision

                  Response to Medical Management?

                  Reassess IAP within 4-6 hours. Is IAP decreasing? Is organ function improving? Is APP ≥60 mmHg? If refractory ACS despite maximal medical therapy → decompressive laparotomy.

                  1. ●

                     Action

                     Medical Management Successful

                     Continue monitoring q4-6h. Gradually wean interventions. Address underlying cause. Watch for recurrence with further resuscitation.

                  2. ●

                     Action

                     Decompressive Laparotomy

                     Indication: Refractory ACS with organ dysfunction despite maximal medical therapy. Procedure: Midline laparotomy, leave abdomen open. Temporary abdominal closure (TAC): Negative pressure wound therapy (NPWT) with continuous fascial traction preferred. Goal: Relieve pressure, allow visceral edema to resolve.

                     1. ●

                        Action

                        Open Abdomen Management

                        1) NPWT with continuous mesh-mediated fascial traction (preferred). 2) Avoid lateral retraction of fascia. 3) Return to OR q24-72h for washout and attempted closure. 4) Goal: Primary fascial closure within 5-7 days. 5) Monitor for enteric fistula development. 6) Nutritional support essential.

                        1. ✓

                           Outcome

                           Plan for Abdominal Closure

                           Primary fascial closure if achievable. Component separation or mesh if needed. Planned ventral hernia if unable to close.

                  3. ⚠

                     Warning

                     ⚠️ Don't Delay Decompression

                     Mortality of ACS exceeds 50%. Each hour of delay with refractory ACS increases mortality. Once new organ dysfunction develops (especially renal failure with oliguria despite adequate MAP), surgical decompression should not be delayed.

         3. ●

            Action

            Grade III-IV IAH (>20 mmHg) or ACS

            ACS = IAP >20 mmHg + new organ failure (renal, respiratory, cardiovascular). Calculate APP (Abdominal Perfusion Pressure) = MAP - IAP. Target APP ≥60 mmHg. Aggressive medical management while evaluating for surgical decompression.