A 62-year-old female patient presents with fever, cough, and an infiltrate on her chest radiograph. She receives intravenous fluids and antibiotics, but her symptoms worsen, eventually requiring intubation for respiratory decompensation and vasopressors for presumed septic shock. The intensive care unit is full, so the patient remains in the emergency department. During this time, her condition worsens, and she develops new renal and hepatic injury. You wonder if there is something you may be missing. Could this patient have abdominal compartment syndrome? If so, how do you test for it, and what are the next steps in management?
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ACEP Now: Vol 39 – No 10 – October 2020Discussion
Abdominal compartment syndrome (ACS) is a disease that can lead to significant morbidity and mortality.1–3 However, it is not often considered in the emergency department. With high rates of ED boarding in many areas, it is essential for the ED clinician to be aware of this disease and monitor for it.
ACS is similar to limb compartment syndrome in that there is excessive pressure within a closed space (ie, the abdominal compartment), resulting in damage to the surrounding structures. This exists as part of a continuum beginning with elevated intra-abdominal pressure (IAP) and ending with organ dysfunction (see Table 1). There are numerous causes of ACS, but they mainly fall into four general categories: reduced abdominal wall compliance (eg, abdominal surgery, obesity), increased abdominal contents (eg, large-volume ascites, hemoperitoneum), increased intraluminal contents (eg, ileus, gastroparesis), or capillary leak (eg, sepsis, pancreatitis).4,5
Table 1: Grading of Intra-Abdominal Hypertension and Abdominal Compartment Syndrome
| IAH Grade | Intra-Abdominal Pressure |
|---|---|
| Grade I | 12–15 mm Hg |
| Grade II | 16–20 mm Hg |
| Grade III | 21–25 mm Hg |
| Grade IV | >25 mm Hg |
| Abdominal compartment syndrome | Sustained IAP >20 mm Hg with new organ dysfunction |
IAH, intra-abdominal hypertension; IAP, intra-abdominal pressure
Obtaining a relevant history may prove challenging because most patients with ACS are critically ill, and many are intubated. For patients who can provide a history, worsening abdominal pain, abdominal distension, or difficulty breathing (particularly when supine) may be reported.6,7 The physical examination is also limited in these patients; studies demonstrate a sensitivity of 40–60 percent and a specificity of 80–94 percent for ACS diagnosis.8,9 Abdominal distension and the absence of bowel sounds are associated with ACS, but their absence cannot exclude it.5 Therefore, clinicians should remember this condition for critically ill patients with worsening or refractory hypotensio and those with new organ failure.
Laboratory studies may demonstrate evidence of severe organ dysfunction, including elevations in lactate, creatinine, and liver markers.10 If obtained, a computed tomography scan of the abdomen and pelvis may demonstrate an increased anteroposterior diameter, inferior vena cava collapse, diaphragm elevation, renal vessel compression, thickened bowel wall, pneumoperitoneum, or inguinal hernias bilaterally.11–13 However, neither the history and physical examination nor advanced imaging is sufficient to exclude the diagnosis. Therefore, clinicians who are concerned about ACS should measure the IAP (see Table 2).
Table 2: Measuring IAP in Suspected ACS
| 1. Gather the following supplies: Foley catheterization kit, sterile gloves, 60-mL syringe filled with 25 mL of saline, curved hemostat, 1-L bag of fluid, and arterial line tubing and transducer kit (see Figure 1A). χαρετ−ριγητ |
| 2. Insert Foley catheter to drain all urine. |
| 3. Place the patient in the supine position and provide appropriate analgesia. |
| 4. Set up an arterial line, and prime with a 1-L bag of fluid. |
| 5. Attach the stopcock to a 60-mL syringe filled with saline at the end of the arterial line tubing. |
| 6. Clean the access port with an alcohol swab, and attach a three-way stopcock to the catheter access port (see Figure 1B). χαρετ−ριγητ |
| 7. Zero the pressure transducer at the level of the bladder, located at the iliac crest in the midaxillary line. |
| 8. Clamp the drainage bag of the Foley catheter just distal to the aspiration port. |
| 9. Instill a maximum of 25 mL of warm sterile saline into the bladder (see Figure 1C). χαρετ−ριγητ |
| 10. Turn the stopcock so the off position is now directed toward the 60 mL syringe. The syringe may now be removed. |
| 11. Unclamp the distal Foley catheter to allow air in the proximal tubing to pass into distal tubing. The tubing should then be clamped again. |
| 12. Before obtaining the IAP value, at least 30 seconds should pass with fluid in the bladder to ensure the detrusor muscle relaxes. |
| 13. After this period, obtain the bladder pressure at end-exhalation. |
| 14. Once the IAP is obtained, unclamp the Foley catheter. |
IAP, intra-abdominal pressure; ACS, abdominal compartment syndrome;
Adapted from Gottlieb et al.5
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