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4 7 4 20 04 BJ U IN TE RN AT IO NA L | 93 , 47 4 47 7 | doi:10.1111/j .1464-410X.2004.04654.x

ABDOMINAL COMPARTMENT SYNDROME

R. TAL

et al.

Abdominal compartment syndrome: urological aspectsR. TAL, D.M. LASK, J. KESLIN* and P.M. LIVNEInstitute of Urology and *General Intensive Care Unit, Rabin Medical Center, Golda-Hasharon Campus, Petah Tikva, and Sackler School of Medicine,

Tel Aviv University, Tel Aviv, Israel

Accepted for publication 9 August 2003

pathophysiology of elevated IAP. Currently,ACS is defined as the cardiovascular,pulmonary, renal, splanchnic, gastrointestinal,abdominal wall/wound and intracranialdisturbances resulting from an acute andrapid increase in IAP [2]. The normal IAP isatmospheric (zero) or sub-atmospheric(negative) when measured in spontaneouslybreathing animals [2]. Mechanical ventilationproduces a positive IAP close to the end-expiratory pressure, with values of up to

10 mmHg considered normal. Afterabdominal surgery pressures are typically315 mmHg [3]. ACS is diagnosed when theIAP is >25 mmHg in the presence of one ofthe following signs of clinical deterioration;oliguria, raised pulmonary pressure, hypoxia,decreased cardiac output, hypotension oracidosis. The diagnosis is confirmed whenabdominal decompression results in clinicalimprovement [4]. In current publications,different definitions for ACS are used.Meldrum et al. [5] defined ACS as an IAPof >20 mmHg complicated by one ofthe following: a peak airway pressureof >40 cmH2O, oxygen delivery index

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MEASURING THE IAP

Several methods of measuring IAP have beendescribed; Kron et al. [1] used intravesicalpressure to represent IAP, measuring theintravesical pressure with a manometerattached to a Foley catheter placed in thebladder. Cheatham et al. [13] revised thattechnique and described a closed-systemdevice that enabled repeated measurementsof the intravesical pressure and thereby, close,convenient and safe monitoring of the IAP.Johna et al. [14], comparing direct IAPmeasurements during laparoscopy withintravesical measurements, found that thebladder had higher pressures than theabdomen but the two were highly andpositively correlated in individual patients.Fusco et al. [15] showed that intravesical

pressure closely approximated IAP and thatthe instillation of 50 mL of liquid into thebladder improved the accuracy of the IAPmeasurement. Other techniques includeintragastric pressure measurement obtainedby nasogastric tube, and intrarectal pressureobtained by introducing a 12 F balloon-tippedcatheter into the rectum 810 cm above theanal verge, but these methods seem to betechnically less reliable [16]. Another methodof indirectly measuring IAP by inserting aninferior vena caval catheter was attempted inanimal models but it is not clinically usedbecause it is invasive [2]. Measuring the IAP isessential, as the clinical examination cannotreliably identify patients with elevated IAP.Kirkpatrick et al. [17] conducted a prospectiveblinded study and found that the sensitivityof the clinical examination was only 40%for an IAP of >10 mmHg, and 56% for>15 mmHg.

ACS and its pathophysiological derangementsappear above a critical IAP that varies amongpatients and even within a given patient.Burch et al. [18] described a grading systemfor IAP depending on the pressure (in cmH2O)

as follows: grade I, 1015; grade II, 1625;grade III, 2635; and grade IV, >35. Althoughphysiological changes could be detectedalready in association with grade I increases,decompression was clinically insignificantand unwarranted. The authors recommendedthat at higher pressures treatment should bedetermined on the basis of the patientsphysiological responses. Meldrom et al. [5],from their finding that renal dysfunction(defined as a urine output of

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with ACS are active bleeding requiringdamage control laparotomy and packing,combined abdominal and pelvic injuries,primary abdominal fascial closure (in contrastto mesh closure), massive bowel distensionsecondary to reperfusion injury after fluidresuscitation and resolution of shock, anduncontrolled intra-abdominal bleeding, notuncommonly caused by coagulopathy,necessitating re-exploration. The earlydiagnosis of ACS mandates close monitoringof IAP in every patient at risk, as it may occurwithin a few hours. In certain circumstancesthe development of ACS can be prevented bysimple measures such as avoiding tenseabdominal closure, but the presence of activebleeding poses a real challenge because of theconflict between the need to achieve pressureto tamponade the bleeding and to avoid

increasing the IAP. The treatment of ACS isprompt surgical decompressive laparotomyand temporary abdominal-wall closure usinga mesh or a Bogota bag (various techniquesare described but are beyond the scope of thisreview). Minimally invasive decompressiontechniques, i.e. laparoscopic andpercutaneous procedures, for selectedindications have been described but they arenot widely used [24,25]. Kopelman et al. [11]noted that survivors of ACS underwentsurgical decompression earlier than those notsurviving, and suggested that the length oftime a patient remains intra-abdominallyhypertensive is more significant than theabsolute increase in abdominal pressure. Earlyrecognition of predictive variables andidentifying patients at risk will hopefully leadto early treatment and avoid the morbidityand mortality associated with ACS.

SUMMARY

ACS is prevalent in various surgical conditionsand in a large percentage of critically illpatients. Measuring the IAP is important in

the early diagnosis of ACS and can be easilydone by measuring the intravesical pressure.ACS adversely affects many organ systems;the pathogenesis of renal dysfunction isprobably multifactorial, from a combinationof reduced cardiac output, reduced GFRmediated by secretion of renin andangiotensin, aldosterone-mediated waterreabsorption, increased renal parenchymalpressure and direct compression of the renalvein. Successful treatment requires a highindex of suspicion, prompt recognition andearly surgical abdominal decompression.

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Correspondence: Dr R. Tal, Institute ofUrology, Rabin Medical Center, Golda-Hasharon Campus, 7 Kakal St., 49372 PetahTikva, Israel.e-mail: raanant@post.tau.ac.il

Abbreviations: ACS, abdominal compartmentsyndrome; IAP, intra-abdominal pressure.