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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

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Last updated: April 9, 2010


"Abdominal Compartment Syndrome." Pocket ICU Management, PocketMedicine.com, Inc, 2010. Anesthesia Central, anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534157/all/Abdominal_Compartment_Syndrome.
Abdominal Compartment Syndrome. Pocket ICU Management. PocketMedicine.com, Inc; 2010. https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534157/all/Abdominal_Compartment_Syndrome. Accessed April 18, 2019.
Abdominal Compartment Syndrome. (2010). In Pocket ICU Management. Available from https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534157/all/Abdominal_Compartment_Syndrome
Abdominal Compartment Syndrome [Internet]. In: Pocket ICU Management. PocketMedicine.com, Inc; 2010. [cited 2019 April 18]. Available from: https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534157/all/Abdominal_Compartment_Syndrome.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Abdominal Compartment Syndrome ID - 534157 Y1 - 2010/04/09/ BT - Pocket ICU Management UR - https://anesth.unboundmedicine.com/anesthesia/view/Pocket-ICU-Management/534157/all/Abdominal_Compartment_Syndrome PB - PocketMedicine.com, Inc DB - Anesthesia Central DP - Unbound Medicine ER -