The abdominal compartment syndrome

The abdominal compartment syndrome (ACS) causes dysfunctions of various organs through a progressive unphysiologic increase of the intraabdominal pressure. While the primary ACS is a result of the underlying disease/injury, secondary ACS is caused by surgical interventions. In the severely injured patient intra- and/or retroperitoneal bleeding, edema of viscera due to systemic ischemia reperfusion injury following hemorrhagic shock, abdominal/pelvic packing, and laparotomy closure under tension lead to ACS. The clinical signs of ACS are a tense abdomen with a decreased abdominal wall compliance. Early signs of ACS are a rise in inspiratory pressure and oliguria. Manifest ACS results in anuria, respiratory failure, reduced intestinal perfusion, and low cardiac output syndrome. If untreated, patients die due to left ventricular failure. Diagnosis of ACS is made using the patient's history including the injury pattern, the symptoms, the time period between injury and the occurrence of organ dysfunctions, and the physiologic response to decompression. Frequent determinations of the bladder pressure represent the "golden standard" for early recognition of ACS. Decompressive laparotomy should be performed with a bladder pressure > or = 20 mmHg and rapidly restores impaired organ functions. In the case of a multiple injured patients in shock or with associated severe head injury decompressive laparotomy may even be carried out at a lower bladder pressure. The abdomen is left open. In most patients staged laparotomy is necessary. The final closure of the abdominal wall is carried out after the edema have resolved between day 6 and 8 after primary laparotomy.