Nonoperative management of patients with abdominal compartment syndrome

Background

Organ dysfunction attributable to intraabdominal hypertension, known as abdominal compartment syndrome (ACS), has been recognised as a source of morbidity and mortality in the ICU. Decompressive laparatomy is considered as the sole definite therapy of ACS. However, no randomised trial has been performed to assess the role of surgery.

We studied the characteristics and outcome of critically ill patients with ACS treated nonoperatively, and focused on the natural course of organ dysfunction.

Methods

We retrospectively studied patients with ACS (intra-abdominal pressure [IAP] ≥ 18 mmHg and at least one organ failure) admitted to our medical and surgical intensive care unit over two consecutive years (2001–2002). We focused on organ failure at the time of the raised IAP and on its evolution in patients who did not undergo a decompressive laparatomy.

Hemodynamic instability was defined as dependence on vasopressor therapy, respiratory failure as P/F <300 and renal failure as creatinine level >2 mg/dl or a 50% increase from baseline.

Results

We found 24 episodes of ACS in 23 patients that were managed nonoperatively. The mean age of patients was 57 ± 14.6 years. APACHE II score on admission was 22.8 ± 8.2. The highest detected IAP was 29 ± 8.2. ACS was found after intra-abdominal processes (pancreatitis, ischemic colitis, and other) in 47% (11/23) of cases, after abdominal surgery or trauma in one-third (8/23), and in a minority (4/23) after other conditions (such as burns). Hemodynamic instability was present in 87% (20/23) of cases, respiratory failure in 96% (22/23) and renal failure in 87% (20/23). The majority of patients had multiple organ failure (91% [21/23]).

Mortality was 26% (6/23), patients that died had a higher APACHE II score on admission (28.5 ± 8.3 vs 20.8 ± 7.4 in the survival group [P = 0.04]), but the incidence of organ failure and the highest recorded IAP were not significantly different.

At discharge, organ function returned to basic levels in all survivors (medium length of stay 13).

Conclusion

In a group of critically ill patients with ACS treated nonoperatively, the mortality was 26%. Patients that survived were discharged from the ICU without organ dysfunction. We conclude that selected patients with ACS may not require decompressive laparatomy, but will respond to nonoperative observation and supportive therapy.