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The Big Squeeze: Abdominal Hypertension and Compartment Syndrome

by Daria Ruffolo, DNP, RN, CCRN, ACNP-BC

Ever think of the abdominal cavity as a potential for catastrophic events?  We can envision the abdomen as a closed anatomical space that extends from the thorax to the pelvis, containing the spleen, liver, kidneys, stomach, small intestines, large intestines, pancreas, aorta, gallbladder, diaphragm, the inferior vena cava, and the lower portion of the esophagus.  Everything in its place and accounted for, what we fail to realize that when there are “interlopers” in the form of ascites, tumors, third spaced fluid or hemorrhage the space becomes overwhelmed.

When the pressure within this closed anatomic space becomes elevated to the point of compromising capillary perfusion, a compartment syndrome occurs.  Intra-abdominal hypertension (IAH) occurs when there is increased intra-abdominal pressure (IAP).  When this pressure is sustained then organ beds and tissue perfusion is compromised and this moves into Abdominal Compartment Syndrome (ACS) that can lead to multi-system organ failure and the death of the patient.

ACS has been studied for since the 19th C but just within the last 25 years have we come to understand the vast impact it has on our patients. Conditions that can cause IAH include cancer, shock, trauma, and sepsis.  The impact from the IAH and ACS includes impairment of ALL body systems as the abdominal contents press against the diaphragms the heart and lungs fail and the kidney and liver bed suffer from poor perfusion.

Unfortunately, sensitivity of clinical judgment and physical examination have been shown to be poor predictors of a patient’s IAP.  It is therefore essential for early serial IAP measurements to be done when diagnosing the presence of IAH in addition to guiding resuscitative therapy.  There are a variety of IAP measurement methods but intra-vesicular or bladder pressure have the most widespread adoption due to its simplicity, minimal cost, and low risk complications.

If any patient demonstrates significant elevations in IAP then immediate abdominal decompression should be performed.  This is best achieved in surgical patients by either creating or reopening the laparotomy incision and applying a temporary abdominal closure. It is crucial that IAP be accurately and timely assessed so that both IAH and abdominal compartment syndrome can be diagnosed and managed.  Since elevated IAP may occur insidiously and clinical examination is oftentimes inaccurate in determining whether IAH is present, IAP measurements are very important.

Next time you have an unstable patient, give a thought to the potential for the big squeeze as the cause!

See Daria Ruffolo, DNP, RN, CCRN, ACNP-BC speak in 2018 at a Skin, Bones, Hearts & Private Parts CME/CE Conference for NPs, PAs, MDs, and DOs.