Abdominal Compartment Syndrome

First Things First (assess & treat for the following)

  • Recognize who is at risk
    • Patients after trauma with massive resuscitation or contamination, AAA repair, liver transplant, hepatic failure with ascites, retroperitoneal bleed, massive resuscitation after sepsis or burns, pancreatitis, bowel obstruction, intra-abdominal sepsis (diverticulitis, perforated ulcer, appendicitis), or ARDS.
  • Correct what can be corrected
    • Ongoing bleeding
      • Surgery or interventional radiology
      • Coagulopathy
    • Intra-abdominal sepsis
      • Drainage (open versus percutaneous)
      • Bowel resection
    • Decompress bowel if obstructed
      • NGT
      • Enemas
      • Prokinetic agents

History and Physical (assess for the following)

  • Assume in anyone with systemic signs of hypoperfusion and abdominal distention.
  • Affects all organ systems
    • Neuro
      • Increased ICP
    • Cardiovascular
      • Increased heart rate
      • Decreased BP
      • Decreased cardiac output (CO)
      • These are from decreased venous return
    • Pulmonary
      • Decreased FRC
      • Increased hypoxia
      • Worsening compliance
      • Increased pCO2
      • Increased plateau/peak airway pressures
    • Hepatic/Intestines
      • Decreased visceral perfusion and portal venous flow
      • Lactic acidosis
      • Bacterial translocation
      • Worsening coagulopathy due to decreased synthesis
    • Renal
      • Decreased GFR due to lack of blood flow
      • Decreased urine output
    • Skin and soft tissue
      • Decreased fascial blood flow
      • Decreased capillary refill
      • Can contribute to wound infections or dehiscence


  • Have low index of suspicion in patients developing signs of hypoperfusion.
    • Once suspected, measure bladder pressure.
      • Clamp Foley distally (towards collection bag).
      • Instill 25 mL saline into Foley catheter.
      • Measure with manometer or place pressure transducer to sampling port.
      • Pubic symphysis is reference point.
    • Intra-abdominal hypertension (IAH) = sustained intra-abdominal pressure >12 mmHg
      • 12-15 mmHg = Grade I IAH
      • 16-20 mmHg = Grade II IAH
      • 21-25 mmHg = Grade III IAH
      • >25 mmHg = Grade IV IAH
    • Abdominal compartment syndrome is IAH >20 mmHg plus end-organ dysfunction. It is not graded but is an all-or-nothing diagnosis.
      • Primary - occurs due to abdominal/pelvic process - bleed from trauma or ruptured vessel, liver transplant, retroperitoneal hemorrhage, or intra-abdominal sepsis
      • Secondary - occurs from resuscitation for an extra-abdominal process such as burns, sepsis, or ARDS
      • Recurrent - occurs after treatment of primary or secondary ACS following closure of decompressive laparotomy
    • Also monitor other measures of end-organ hypoperfusion
      • Creatinine
      • Base deficit
      • Lactate
      • Liver enzymes
      • CPK
      • ABGs
      • PT/PTT/INR
      • Urine output

General Management Principles

  • As with most ICU emergencies, IAH/ACS management centers around early diagnosis, correction of treatable conditions, and frequent re-assessment.

Specific Treatment

  • Intra-abdominal hypertension (bladder pressure >12 mmHg)
    • Improve abdominal wall compliance
      • Sedation and analgesia
      • Reverse Trendelenburg
      • Neuromuscular blockade
    • Minimize intra-abdominal volume
      • Bowel decompression with NGT and/or enemas
      • Paracentesis
      • GI prokinetics (metoclopramide, erythromycin, neostigmine)
    • Correct positive fluid balance
      • Avoid over-resuscitation
      • Diuretics (if blood pressure allows)
      • Hypertonic saline
      • Hemofiltration if oliguric
  • Abdominal compartment syndrome (IAH >20 mmHg + end-organ dysfunction)
    • Decompressive laparotomy
      • Consider early to improve outcome and rates of closure

Ongoing Assessment

  • Monitor bladder pressure until < 12 mmHg
  • Monitor end-organ function
    • Creatinine
    • Base deficit
    • Lactate
    • Liver enzymes
    • CPK
    • ABGs


  • If untreated or delay in diagnosis
    • Renal failure
    • Hypoxia
    • Hypercapnea
    • Visceral ischemia
    • Rhabdomyolysis
  • Related to therapy
    • Hernia
    • Enterocutaneous fistula


  • Jason S. Lees, MD

Abdominal Compartment Syndrome is a sample topic from the Pocket ICU Management.

To view other topics, please or .

Anesthesia Central is an all-in-one web and mobile solution for treating patients before, during, and after surgery. This collection of drugs, procedures, and test information is derived from Davis’s Drug, MGH Clinical Anesthesia Procedures, Pocket Guide to Diagnostic Tests, and PRIME Journals. .

Last updated: April 9, 2010