REVIEW

Management of Abdominal Compartment Syndrome and the Open

Abdomen
M. Bjrck
*
, A. Wanhainen
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
WHAT THIS PAPER ADDS
The understanding of the epidemiology and pathophysiology of intra-abdominal hypertension and abdominal
compartment syndrome (ACS) has improved over the last two decades, and the creation of the World Society of
the ACS (www.wsacs.org) in 2004 was an important step forward. Several papers were published, reporting on
this clinical problem in association with vascular surgery, in particular open and endovascular aortic aneurysm
repair. This review summarizes contemporary knowledge in this eld.
Objectives: The management of the abdominal compartment syndrome (ACS) and the open abdomen (OA) are
important to improve survival after major vascular surgery, in particular ruptured abdominal aortic aneurysm
(RAAA). The aim is to summarize contemporary knowledge in this eld.
Methods: The consensus denitions of the World Society of the Abdominal Compartment Syndrome (WSACS)
that were published in 2006 and the clinical practice guidelines published in 2007 were updated in 2013.
Structured clinical questions were formulated (modied Delphi method), and the evidence base to answer those
questions was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation
(GRADE) guidelines.
Results: Most of the previous denitions were kept untouched, or were slightly modied. Four new denitions
were added, including a denition of OA and of lateralization of the abdominal wall, an important clinical
problem to approach during prolonged OA treatment. A classication system of the OA was added.
Seven recommendations were formulated, in summary: Trans-bladder intra-abdominal pressure (IAP) should be
monitored in patients at risk. Protocolized monitoring and management are recommended, and decompression
laparotomy if ACS. When OA, protocolized efforts to obtain an early abdominal fascial closure, and strategies
utilizing negative pressure wound therapy should be used, versus not. In most cases the evidence was graded as
weak or very weak. In six of the structured clinical questions, no recommendation could be made.
Conclusion: This review summarizes changes in denitions and management guidelines of relevance to vascular
surgery, and data on the incidence of ACS after open and endovascular aortic surgery.
2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
Article history: Received 21 July 2013, Accepted 7 December 2013, Available online XXX
Keywords: Abdominal aortic aneurysm, Abdominal compartment syndrome, Consensus guidelines, Grading of
recommendations, Intra-abdominal hypertension, Open abdomen, Rupture, Temporary abdominal
closure
INTRODUCTION
The understanding of the importance of intra-abdominal
hypertension (IAH) and abdominal compartment syn-
drome (ACS) in the pathophysiology of postoperative
complications after vascular surgery has increased over
time.
1,2
ACS is often a consequence of aggressive resusci-
tation after major bleeding, and in the rst paper naming
the condition the vascular surgeon Irving Kron described it
following ruptured abdominal aortic aneurysm (RAAA)
repair.
3
The association between IAH/ACS and colonic
ischemia after RAAA repair has been demonstrated in
several investigations,
4e9
and it seems that survival can be
improved if the hypoperfusion of the abdominal organs
created by IAH/ACS can be reversed in time.
4,8,9
The application of damage control principles
10
not only in
trauma, but also in emergency surgery, as well as the un-
derstanding of the advantage of whole blood rescuscita-
tion,
11
and the development of massive transfusion
protocols, are important recent advances in the manage-
ment of the bleeding vascular patient.
The creation of the multidisciplinary World Society of the
Abdominal Compartment Syndrome (WSACS; www.wsacs.
org) in 2004 was an important event, and was followed
* Corresponding author. M. Bjrck, Department of Surgical Sciences,
Vascular Surgery, Uppsala University, SE-751 85 Uppsala, Sweden.
E-mail address: martin@bjorck.pp.se (M. Bjrck).
1078-5884/$ e see front matter 2013 European Society for Vascular
Surgery. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ejvs.2013.12.014
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014
by the publication of consensus denitions in 2006
12
and of
clinical practice guidelines in 2007.
13
When those guidelines
were updated in 2012e2013, an evidence-based method-
ology was used,
14
offering an opportunity to repeat this
process with a vascular surgical perspective.
The aim of this review is to update the information on
IAH/ACS, taking advantage of this evidence-based meth-
odology, with focus on aspects of interest to vascular sur-
gical patients.
METHODS
The updated consensus guidelines are named Intra-
abdominal hypertension and the abdominal compartment
syndrome: updated consensus denitions and clinical
practice guidelines from the World Society of the Abdom-
inal Compartment Syndrome and were published in
Intensive Care Medicine in 2013.
14
The consensus panel
consisted of a multidisciplinary group, most of whom were
surgeons and/or intensivists. They rst identied 24 clini-
cally relevant issues, and then conducted a series of sys-
tematic and structured literature reviews to identify
relevant studies related to IAH or ACS. The updated
consensus denitions and management statements were
then derived, using a modied Delphi method, as well as
the Grading of Recommendations, Assessment, Develop-
ment, and Evaluation (GRADE) guidelines, respectively.
15,16
Questions were based on polling of the WSACS Executive
Committee, and were formulated according to the Patient,
Intervention, Comparison, Outcome, and study design
(PICO) format. Quality of evidence was graded from high (A)
to very low (D), and management statements from strong
recommendations (desirable effects clearly outweigh po-
tential undesirable ones) to weaker suggestions (potential
risks and benets of the intervention are less clear), or no
recommendation. Details of this complex methodology are
reported in the original publication, including multiple
supplementary web-published documents.
14
A dedicated
Pediatric Guidelines Sub-Committee was also created,
14
so
that, for the rst time, the denitions and guidelines could
also be adapted to children. Although the principles are the
same, all values and thresholds are different in children; for
details, please consult the original publication.
14
This review summarises the changes in denitions and
management guidelines of relevance to vascular surgery, as
well as data on the incidence of IAH/ACS after open and
endovascular aortic surgery.
RESULTS AND DISCUSSION
Revised denitions
In the 2006 consensus denitions document
12
from WSACS;
IAH and ACS were dened. For a non-intensivist it may seems
strange to dene a normal intra-abdominal pressure (IAP)
in a critically ill patient, but this is natural for intensivists who
have the perspective of the intensive care unit (ICU) popu-
lation, rather than of the general (healthy) population. The
updated document
14
has therefore kept the wording IAP is
approximately 5e7 mmHg in critically ill adults. What is
more important than this pseudo-normality is the deni-
tion of IAH: IAH is dened by a sustained or repeated
pathological elevation in IAP >12 mmHg. The words sus-
tained or repeated are important as a single value maybe
recorded when the patient is in pain and is therefore not
sufcient to dene the pathology. This upper threshold for
normality is important to consider in patients operated on
for RAAA, as it has been shown in multiple prospective
clinical studies that it is uncommon for the IAP to be
<12 mmHg in the early postoperative period after open
surgery.
7,8,17,18
Recommendation on the technique of howto
measure IAP has not changed since the 2004 publication.
12
The denition of ACS has undergone a minor change in
the updated version, the difference being that the sub-
denition of an abdominal perfusion pressure (APP)
<60 mmHg was removed, as the GRADE process found that
the evidence base for this subdenition was too weak. The
revised denition reads as follows: ACS is dened as a
sustained IAP >20 mmHg (with or without an APP
<60 mmHg) that is associated with new organ dysfunction/
failure. The APP is dened as the mean arterial pressure
(MAP) minus the IAP.
Note again the exact wording of the denition: a sus-
tained IAP >20 mmHg means that the measurement has
to be repeated at least once, and it needs to be associated
with new organ dysfunction/failure; in other words, with
a timely deterioration of vital organ function.
It should also be noted that the fact that there is insuf-
cient evidence to dene the ACS as an APP <60 mmHg
does not necessarily rule out that a patient with hypoten-
sion and an intermediate IAH (15e19 mmHg) and new or-
gan dysfunction or failure, may, in some cases, benet from
abdominal decompression. When there is no evidence, the
clinician may need to rely on clinical experience (Fig. 1).
Four new denitions were added to the updated
consensus document; two are of more basic scientic in-
terest, but two have clinical relevance. First, the open
abdomen (OA) was not dened previously, which created
some uncertainty in clinical research: The open abdomen is
one that requires a temporary abdominal closure due to the
skin and fascia not being closed after laparotomy. Second,
the importance of lateralization of the abdominal wall has
been highlighted by recent research (see below): Laterali-
zation of the abdominal wall is the phenomenon where the
musculature and fascia of the abdominal wall, most exem-
plied by the rectus abdominus muscles and their enveloping
fascia, move laterally away from the midline with time.
The incidence and predictors of IAH/ACS after aortic
surgery
The incidence will depend on several factors. The routines
for resuscitation are of paramount importance. Balogh
et al.
19
showed that the administration of crystalloids was
an independent risk factor for ACS in abdominal trauma
patients. Although this has not been shown specically in
AAA patients, there are strong reasons to believe that it is
true in any bleeding patient, and that a preoperative policy
2 M. Bjrck and A. Wanhainen
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014
of permissive hypotension may decrease the risk of IAH/
ACS. Mell et al.
11
showed that patients who received less
than one unit of plasma for every two units of red blood
cells during RAAA repair had a four times higher mortality
than those given more plasma, highlighting the importance
of a massive transfusion protocol. It is also reasonable to
believe that a unit that has a high proportion of survivors,
as well as a unit that records IAP routinely after AAA sur-
gery, will recognize IAH/ACS more often than those that
have higher mortality and do not measure IAP in every
patient.
With the introduction of endovascular aneurysm repair
(EVAR)
20,21
by Volodos in 1986, and the application of this
technology on patients with ruptured abdominal aortic
aneurysm (AAA), rst described by Ohki and Veith in
2000,
22
the management of RAAA repair has changed, but
how this has affected the incidence of IAH/ACS is contro-
versial. Screening for AAA,
23,24
will reduce the incidence of
AAA rupture, indirectly reducing the total incidence of ACS,
as operation for rupture is a strong risk factor for IAH/ACS
after AAA repair. In a multicentre prospective cohort study
in four Swedish hospitals the risk of requiring OA treatment
was 0.4% (2/455) after EVAR and 0.9% (3/303) after open
repair of an intact infrarenal AAA. Corresponding risks after
RAAA repair were 3.4% (3/86) after EVAR and 2.5% (14/115)
after open repair.
25
If measured consistently, an IAP >20 mmHg occurs in
about half of all patients after open repair of a RAAA, and
20% will go on to develop ACS.
17,18
In many series of pa-
tients operated on for RAAA with EVAR, a selection of more
circulatory stable patients took place, resulting, however, in
a lower incidence of IAH/ACS.
26
By comparison, the Zrich
group reported a higher incidence of ACS (20% [20/102]), a
result of the fact that they treat virtually all ruptured pa-
tients with EVAR and that they monitor IAP.
9
In conclusion,
IAH/ACS is a common problem after RAAA repair, in
particular in the unstable patient requiring massive trans-
fusions, irrespective of which method of repair is used.
In summary, as not many centers use EVAR as the stan-
dard method for operation on patients with RAAA, data are
scarce on exactly how common IAH/ACS is when patients
who are circulatory unstable are operated on with EVAR.
However, it is known that it is common and that it adversely
affects outcome. This is of particular importance given the
fact that patients treated with EVAR for RAAA often are in
such good condition that they are not treated in the ICU,
and many hospitals lack routines to measure IAP outside of
the ICU. Thus, a protocol to monitor the IAP during the rst
48 hours after endovascular RAAA repair is crucial. For this
purpose, the Foley Manometer method of measuring IAP is
ideal, as it can easily be applied in the postoperative, or
even the normal, ward.
Classication of the OA
A classication system for the OA was suggested in 2009,
with the following aims:
27
rst, to create uniform reporting
standards, facilitating comparisons of groups of patients,
studies, and meta-analyses, as an aid in clinical research;
and second, to serve as an educational aid, dening the
aims of different treatment modalities, and dening stra-
tegies. Such a classication system needs to be dynamic,
allowing the patient to move between different categories,
during an often prolonged treatment.
By June 2013 the classication system had been used in
nine prospective cohort studies, and 542 patients had been
classied. Two problems with the previous classication
system were identied: the lack of a precise denition of an
enteroatmospheric stulae (EAF), and the fact that an EAF
was graded as less severe than a frozen abdomen. These
problems were addressed in an amended classication,
28
which was added to the updated consensus denition
14
(Table 1).
Preventing xation, that is, deterioration from grade 1 to
grade 2e4, can be divided into two different aims: to pre-
vent the formation of adhesions between the bowel and
the abdominal wall, and to prevent the already mentioned
lateralization of the abdominal wall. One system of OA
treatment that fulls these criteria is the vacuum-assisted
wound closure and mesh-mediated fascial traction, rst
described in 2007.
28
This technique combines a plastic
sheath separating the intestines from the abdominal wall,
with suction for drainage, and a prolene mesh sutured to
the fascia to prevent lateralization of the abdominal wall
(Figs. 1 and 2). Multiple prospective cohort studies have
shown that this technique can achieve a primary delayed
Figure 1. This patient is an obese (110 kg) 70-year-old man with
chronic obstructive pulmonary disease, who was treated with
endovascular aneurysm repair electively despite unfavorable
anatomy. There was an acute rupture of the aneurysm, secondary
to a type I endoleak at the distal sealing zone, and the patient was
treated with an extension of the endograft covering the internal
iliac artery, with a good result. At this point, however, the patient
had a body weight of 125 kg, a mean arterial pressure of 70, an
intra-abdominal pressure of 18, and developed anuria, despite not
fullling the criteria of abdominal compartment syndrome.
Decompression laparotomy (DL) resulted in improved renal func-
tion, with urinary output of 300 mL/h in the rst few hours after
DL. The image was taken during the application of a VAC dressing,
prior to the application of the mesh for traction of the fascia.
European Journal of Vascular and Endovascular Surgery Volume - Issue - p. 1e9 Month/2014 3
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014
fascial closure rate of approximately 90% of those surviving
OA treatment, despite prolonged treatment, in median 15
days.
25,29e31
These studies include a large proportion of
patients treated with OA after AAA surgery.
Another technique is to use dynamic retention sutures
instead of a mesh to prevent lateralization, and one inves-
tigation reported an 87% fascial closure rate with this
technique in 160 non-vascular patients.
32
In this study,
however, a large proportion of the patients were treated
with OA <5 days, which was an exclusion criterion in the
previous study; those requiring >5 days of OA had a fascial
closure rate of only 67%,
32
indicating that the mesh may be
more effective in preventing lateralization during prolonged
OA treatment. A third alternative is the so-called Wittmann
patch,
33
which uses a non-permeable Velcro patch, thus
preventing lateralization, but not permitting an effective
drainage, and the technique does not include any preven-
tion of adhesions between the bowel and the abdominal
wall. Some system that prevents xation (adhesions) and
lateralization is necessary when OA treatment is prolonged
beyond 3e5 days.
Treatment/prevention of IAH/ACS after aortic surgery
The process of formulating structured clinical questions,
and evaluating the evidence base to answer those ques-
tions, is rather frustrating, as the evidence base often turns
out to be much weaker than anticipated (Table 2). The PICO
format of analyzing the questions is a creative and
demanding process.
34
Randomized controlled trials (RCTs)
are not only uncommon, but may lose some of their
anticipated strength if they are not perfectly designed. Well-
designed and conducted prospective cohort studies can
never reach a high grade of evidence quality, as there is no
comparator. This is the reason why many of the in-
terventions that are used in daily clinical practice, and feel
effective, cannot be recommended using evidence-based
methodology. It can be observed in Table 2 that even
when the interventions are recommended (grade 1), owing
to the consensus of the expert panels, the quality of evi-
dence is often low (C), or even very low (D). Furthermore,
the treatment guidelines are general. Some information on
how the guidelines could be applied to aortic surgery pa-
tients has therefore been added.
A controversial issue is whether it is best to leave all
patients open as routine after open repair of a RAAA, or if it
is better to close those patients who do not have a very
tense abdomen, and follow them closely in the post-
operative period. The strategy of leaving many patients
open was rst reported from the Mayo Clinic. They reported
having left 19% open after AAA repair (43/223).
35
A similar
experience was reported from Zrich.
9
There are pros and
cons with this strategy, and this issue should ideally be
addressed by a RCT. Based on the current knowledge, the
updated consensus document favours primary closure and
IAP monitoring. It can be noted in Table 2, recommenda-
tions 1 and 3: 1. We recommend measuring IAP when any
known risk factor for IAH/ACS is present in a critically ill or
injured patient, and 3. We recommend use of proto-
colized monitoring and management of IAP versus not.,
and that no recommendation #5 is: We could make no
recommendation regarding the prophylactic use of the
open abdomen, etc..
The policy in Uppsala is to leave the patients abdomen
open after open repair if the abdomen is tense and difcult
to close, which is the case in approximately 5e10% of
Figure 2. Schematic drawing of the vacuum-assisted wound
closure and mesh-mediated fascial traction technique.
28e30
1 tubing connected to the topical negative pressure source;
2 polyurethane foam; 3 polypropylene mesh sutured to the
fascial edges of the open abdominal wound, for traction;
4 plastic semipermeable sheet protecting the bowel and pre-
venting adhesions between 5 and 6; 5 bowel; 6 abdominal
wall.
Table 1. Classication of the open abdomen.
14
Grade Description
1 No xation
1A Clean, no xation
1B Contaminated, no xation
IC Enteric leak, no xation
2 Developing xation
2A Clean, developing xation
2B Contaminated, no xation
2C Enteric leak, no xation
3 Frozen abdomen
3A Clean, frozen abdomen
3B Contaminated, frozen abdomen
4 Established enteroatmospheric stula
a
Note.
a
In most cases the abdomen will be frozen when an established
enteroatmospheric stula (EAF) develops, even if the abdomen is
not frozen; this is the most serious and challenging situation (4).
An EAF is dened as a permanent enteric leak into the open
abdomen, associated with granulation tissue. An enteric leak that
is controlled by closure, exteriorization into a stoma, or a per-
manent enterocutaneous stula is considered clean.
4 M. Bjrck and A. Wanhainen
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014
Table 2. The nal 2013 World Society of the Abdominal Compartment Syndrome consensus management statements.
14
Recommendations
1. We recommend measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or
injured patient [GRADE 1C]
2. Studies should adopt the trans-bladder technique as the standard IAP measurement technique [not GRADED]
3. We recommend use of protocolized monitoring and management of IAP versus not [GRADE 1C]
4. We recommend efforts and/or protocols to avoid sustained IAH as compared to inattention to IAP
among critically ill or injured patients [GRADE 1C]
5. We recommend decompressive laparotomy in cases of overt ACS compared to strategies that do not use
decompressive laparotomy in critically ill adults with ACS [GRADE 1D]
6. We recommend that among ICU patients with open abdominal wounds, conscious and/or protocolized efforts
be made to obtain an early or at least same-hospital-stay abdominal fascial closure [GRADE 1D]
7. We recommend that among critically ill/injured patients with open abdominal wounds, strategies utilizing
negative pressure wound therapy should be used versus not [GRADE 1C]
Suggestions
1. We suggest that clinicians ensure that critically ill or injured patients receive optimal pain and
anxiety relief [GRADE 2D]
2. We suggest brief trials of neuromuscular blockade as a temporizing measure in the treatment of
IAH/ACS [GRADE 2D]
3. We suggest that the potential contribution of body position to elevated IAP be considered among patients
with, or at risk of, IAH or ACS [GRADE 2D]
4. We suggest liberal use of enteral decompression with nasogastric or rectal tubes when the stomach or colon
are dilated in the presence of IAH/ACS [GRADE 1D]
5. We suggest that neostigmine be used for the treatment of established colonic ileus not responding to other
simple measures and associated with IAH [GRADE 2D]
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6. We suggest using a protocol to try and avoid a positive cumulative uid balance in the critically ill or injured
patient with, or at risk of, IAH/ACS after the acute resuscitation has been completed and the inciting issues
have been addressed [GRADE 2C]
7. We suggest use of an enhanced ratio of plasma/packed red blood cells for resuscitation of massive hemorrhage
versus low or no attention to plasma/packed red blood cell ratios [GRADE 2D]
8. We suggest use of PCD to remove uid (in the setting of obvious intraperitoneal uid) in those with IAH/ACS
when this is technically possible compared to doing nothing [GRADE 2C]. We also suggest using PCD to remove
uid (in the setting of obvious intraperitoneal uid) in those with IAH/ACS when this is technically possible
compared to immediate decompressive laparotomy as this may alleviate the need for decompressive
laparotomy [GRADE 2D]
9. We suggest that patients undergoing laparotomy for trauma suffering from physiologic exhaustion
be treated with the prophylactic use of the open abdomen versus intraoperative abdominal fascial closure and
expectant IAP management [GRADE 2D]
10. We suggest not to routinely utilize the open abdomen for patients with severe intraperitoneal contamination
undergoing emergency laparotomy for intra-abdominal sepsis unless IAH is a specic concern [GRADE 2B]
11. We suggest that bioprosthetic meshes should not be routinely used in the early closure of the open abdomen
compared to alternative strategies [GRADE 2D]
No recommendations
1. We could make no recommendation regarding use of abdominal perfusion pressure in the resuscitation or
management of the critically ill or injured
2. We could make no recommendation regarding use of diuretics to mobilize uids in hemodynamically stable
patients with IAH after the acute resuscitation has been completed and the inciting issues have been addressed
3. We could make no recommendation regarding the use of renal replacement therapies to mobilize uid in
hemodynamically stable patients with IAH after the acute resuscitation has been completed and the inciting
issues have been addressed
4. We could make no recommendation regarding the administration of albumin versus not, to mobilize uid in
hemodynamically stable patients with IAH after acute resuscitation has been completed and the inciting issues
have been addressed
6 M. Bjrck and A. Wanhainen
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014
patients. Most patients with RAAA today are treated with
emergency EVAR. In all patients (open repair or EVAR) we
monitor IAP every 4 hours (more frequently if they develop
IAH), and perform early conservative treatment and
decompression on demand. The algorithm used in Uppsala
is summarized in Fig. 3.
Although the consensus process could not supply hard
evidence for individual measures, recommendation #4
5. We could make no recommendation regarding the prophylactic use of the open abdomen in non-trauma
acute care surgery patients with physiologic exhaustion versus intraoperative abdominal fascial closure and
expectant IAP management
6. We could make no recommendation regarding use of an acute component separation technique versus not
to facilitate earlier abdominal fascial closure
Note. IAP intra-abdominal pressure; IAH intra-abdominal hypertension; ACS abdominal compartment syndrome; ICU intensive
care unit; PCD percutaneous catheter drainage.
Figure 3. Algorithm for postoperative surveillance of intra-abdominal pressure (IAP) after ruptured or complicated abdominal aortic
aneurysm (AAA) repair of AAA. Note. IAH intra-abdominal hypertension; ACS abdominal compartment syndrome.
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states: We recommend efforts and/or protocols to avoid
sustained IAH as compared to inattention to IAP among
critically ill or injured patients. An example of such a pro-
tocol is the one used in Uppsala. The policy is to actively try
to prevent IAH/ACS by applying neuromuscular blockade
(NMB) if the patient is on a ventilator, and treat the patients
with 20% albumin solutions and furosemide or renal
replacement therapy, preventing OA treatment in many
patients, and shortening the time of OA treatment in
others.
8,36,37
An important issue is the timing of different
preventive actions. The Uppsala protocol is very restrictive
with the administration of crystalloids from the early
resuscitation period. Not all vascular surgeons are aware of
the fact that when 1 L of fractioned blood (erythrocytes,
plasma, and thrombocytes) is given, 4e500 mL of saline
solution is also added, making further administration of
crystalloids dangerous in a massive bleeding situation.
The next preventive measure is effective pain relief,
where an epidural is optimal. It is possible to give throm-
bocytes and to take the full responsibility for the risk of an
epidural bleed in such a situation. The reason why the ev-
idence base for suggestion #5 is so weak (Table 2) is
because it is not considered ethical to not give pain and
anxiety relief in this clinical situation, making comparative
studies impossible to perform. It is a common clinical
observation, however, that effective pain relief often re-
duces IAP by half in a patient who has IAH and abdominal
pain.
Early enteral nutrition is strategically important.
38
It will
help maintain the integrity of the mucosal barrier intact and
will stimulate bowel movements, but it is, of course,
important to check twice daily for accumulation, and to
drain the stomach if that happens.
The next step is the aforementioned NMB. Patients with
IAH who are on a ventilator reduce their IAP by w50%
after NMB, which is often sufcient to affect the urinary
output signicantly and reverse a situation of threatening
ACS. In a study of 191 patients requiring damage control
laparotomy for trauma, 92 who received NMB during the
rst 24 hours achieved primary fascial closure faster and
were more likely to achieve closure by day 7.
39
There are
no randomized data on purely vascular patients, but in a
randomized study from France 340 patients with severe
acute respiratory distress syndrome received NMB for 48
hours versus placebo.
40
Mortality was signicantly lower
in the group receiving NMB, and the rate of ICU-acquired
paresis did not differ. Thus, short-term NMB is safe and
effective.
Attention to avoid unnecessary uid overload is neces-
sary, and suggestion #6 focuses on the need to have a
protocol (Table 2). Although there are no data to establish
which strategy to use, a strategy is necessary and could be
agreed upon locally with those responsible at the ICU.
When decompression laparotomy has been decided
upon, NMB decreases bowel hypoperfusion while awaiting
decompression. It is also important to avoid hypovolemia in
this situation, as it may result in severe hypotension when
the abdomen is opened.
The main conclusion of the consensus document was
that there was a need to develop treatment protocols and
to do more and better research. Even if IAH/ACS is an
important clinical problem that needs to be addressed in
order to improve survival after aortic surgery, the numbers
are too small for single-centre studies to provide mean-
ingful data. There is a need for more multicenter and in-
ternational collaborations to answer the relevant clinical
questions. Specic studies on vascular surgical patients can
be designed, and it is also possible to perform sub-group
analyses of vascular surgical patients included in large
studies with more heterogeneous patient cohorts.
25
Most
of the work is still ahead of us.
CONFLICT OF INTEREST
Martin Bjrck is a member of the Executive Committee of
the World Society of Abdominal Compartment Syndrome
(website: wsacs.org).
FUNDING
None.
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European Journal of Vascular and Endovascular Surgery Volume - Issue - p. 1e9 Month/2014 9
Please cite this article in press as: Bjrck M, Wanhainen A, Management of Abdominal Compartment Syndrome and the Open Abdomen, European Journal
of Vascular and Endovascular Surgery (2014), http://dx.doi.org/10.1016/j.ejvs.2013.12.014