Intra-abdominal hypertension (defined as a sustained urinary bladder pressure > 12 mm Hg) may be an under-recognized problem in the ICU, especially in patients after abdominal surgery or who have gone massive volume resuscitation with blood and/or fluids (think hemorrhage, burns and sepsis). When high abdominal pressures (> 20 mm Hg sustained) cause organ failure and/or shock, it's called abdominal compartment syndrome.
The main accepted treatment for ACS has been laparotomy to decompress the abdomen; however, as Michael Cheatham and Karen Safcsak point out here, intensivists are often "unable to convince a surgeon to open the abdomen of patients manifesting IAH-related organ failure." Surgeons' reluctance is easy to understand, as mortality rates from ACS (without surgery) have been reported at 80%. Percutaneous drainage to decompress the abdomen is a consensus-supported option, but data on success have been sparse.
Cheatham (a surgical intensivist at Orlando Health) and Safcsak report their experience of 62 patients treated for IAH/ACS since 2002. These were almost all surgical, burn or trauma patients (87%); only 12% had sepsis or multiorgan failure as primary diagnoses. They had 31 patients who underwent percutaneous catheter decompression; they attempted to match them with 31 who underwent open surgical decompression. (They found these 31 out of 265 total who got laparotomies for ACS.) The percutaneous approach was ultrasound guided Seldinger-style placement of a 14 F pigtail catheter, drained to gravity.
- 81% of those treated with percutaneous catheter decompression (25 of 31) avoided surgery.
- 58% of those undergoing PCD survived to discharge, compared to 39% of those undergoing open surgical decompression (not stat.signficant).
- Predictors of success (avoiding surgery) were draining 1,000 mL or more, or a drop in intra-abdominal pressure by at least 9 mm Hg in the first 4 hours after catheter placement.
Despite the attempt at cohort-matching, this was still basically an old-timey surgical-literature style case series, with huge selection biases baked-in. It wasn't randomized, and the indications for decompression varied dramatically between cohorts. Fully one-quarter of those undergoing open surgical decompression as first-line got it as "damage-control" laparotomy -- vs. none in the PCD group. (Authors somewhat sneakily mention that this was the "only" difference between the two groups.) Besides that, 23% of the PCD group had only IAH, not full-blown ACS; only 6% of the laparotomy cohort were on this milder point on the disease spectrum.
Clinical Takeaway: Abdominal compartment syndrome is mainly a problem in post-surgical, trauma, and burn patients, and percutaneous decompression is a reasonable approach for patients not in hemorrhagic / hypovolemic shock (open surgical decompression achieves more rapid and definitive results). For any concern for IAH, transduce a bladder pressure. If IAH (>12 mm Hg) or ACS (>20 mm Hg + organ dysfunction) is present, there's fluid in the belly, and the patient is not in shock, ask interventional radiology or GI to place a pigtail catheter (or do it yourself). Failure to drain 1,000 mL and reduce intra-abdominal pressure by 9 mm in the first 4 hours should prompt urgent re-evaluation for open surgical decompression, according to these data.
Other strategies to treat IAH/ACS include:
- improving abdominal wall compliance through sedation, analgesia, and pharmacologic paralysis;
- evacuating intraluminal contents through nasogastric and rectal decompression;
- correcting positive fluid balance through the use of hypertonic fluids, colloids, and careful diuresis;
- supporting organ function with vasopressors and judicious goal-directed fluid resuscitation to maintain an abdominal perfusion pressure (APP) ≥ 60 mm Hg (calculated as mean arterial pressure − IAP); and
- early surgical intervention when IAP exceeds 25 mm Hg and progressive organ dysfunction is present.
Cheatham ML, Safcsak K. Percutaneous Catheter Decompression in the Treatment of Elevated Intraabdominal Pressure. CHEST 2011;140:1428-1435.