Abdominal Compartment Syndrome Management (WSACS 2013): At-Risk Patient Identified → Screen with IAP Measurement → IAP Classification → IAP <12 mmHg - N...
Pathway Overview
14 steps
14 total
Risk factors: Massive fluid resuscitation (>5L/24h), severe sepsis/septic shock, major abdominal surgery, trauma (especially with damage control), pancreatitis, ascites, ileus, abdominal distension, hypothermia, coagulopathy.
Measure intra-abdominal pressure (IAP) via bladder pressure: 1) Foley catheter in place. 2) Empty bladder, instill 25mL sterile saline. 3) Measure at end-expiration. 4) Patient supine, HOB ≤30°. 5) Zero at iliac crest/mid-axillary line. Normal IAP: 5-7 mmHg in critically ill.
IAH defined as sustained IAP ≥12 mmHg. Grade I: 12-15 mmHg. Grade II: 16-20 mmHg. Grade III: 21-25 mmHg. Grade IV: >25 mmHg. ACS = IAP >20 mmHg with NEW organ dysfunction.
Continue routine care. Consider repeat screening q4-6h if risk factors persist. Implement preventive measures: Avoid excessive fluid resuscitation, optimize analgesia, prokinetics if ileus.
IAP normalized. Organ function restored. Continue monitoring during recovery.
Medical management protocol: 1) Optimize sedation/analgesia. 2) Consider neuromuscular blockade. 3) Avoid excessive fluid. 4) NG decompression. 5) Rectal tube/enema. 6) Diuretics if fluid overloaded. 7) Percutaneous drainage if intra-abdominal fluid collections.
Step 1: Evacuate intraluminal contents (NG, rectal tube). Step 2: Evacuate intra-abdominal fluid (paracentesis, percutaneous drainage). Step 3: Improve abdominal wall compliance (sedation, paralysis, positioning). Step 4: Optimize fluid balance (avoid over-resuscitation, consider hypertonic saline, diuretics). Step 5: Optimize systemic perfusion (vasopressors to maintain APP ≥60).
Reassess IAP within 4-6 hours. Is IAP decreasing? Is organ function improving? Is APP ≥60 mmHg? If refractory ACS despite maximal medical therapy → decompressive laparotomy.
Continue monitoring q4-6h. Gradually wean interventions. Address underlying cause. Watch for recurrence with further resuscitation.
Indication: Refractory ACS with organ dysfunction despite maximal medical therapy. Procedure: Midline laparotomy, leave abdomen open. Temporary abdominal closure (TAC): Negative pressure wound therapy (NPWT) with continuous fascial traction preferred. Goal: Relieve pressure, allow visceral edema to resolve.
1) NPWT with continuous mesh-mediated fascial traction (preferred). 2) Avoid lateral retraction of fascia. 3) Return to OR q24-72h for washout and attempted closure. 4) Goal: Primary fascial closure within 5-7 days. 5) Monitor for enteric fistula development. 6) Nutritional support essential.
Primary fascial closure if achievable. Component separation or mesh if needed. Planned ventral hernia if unable to close.
Mortality of ACS exceeds 50%. Each hour of delay with refractory ACS increases mortality. Once new organ dysfunction develops (especially renal failure with oliguria despite adequate MAP), surgical decompression should not be delayed.
ACS = IAP >20 mmHg + new organ failure (renal, respiratory, cardiovascular). Calculate APP (Abdominal Perfusion Pressure) = MAP - IAP. Target APP ≥60 mmHg. Aggressive medical management while evaluating for surgical decompression.
WSACS 2013 Consensus Definitions and Clinical Practice Guidelines: Intra-Abdominal Hypertension and Abdominal Compartment Syndrome
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
Applicable Regions
Global: WSACS 2013 is the international consensus standard
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The Abdominal Compartment Syndrome Management (WSACS 2013) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSACS 2013 Consensus Definitions and Clinical Practice Guidelines: Intra-Abdominal Hypertension and Abdominal Compartment Syndrome.
This algorithm is based on WSACS 2013 Consensus Definitions and Clinical Practice Guidelines: Intra-Abdominal Hypertension and Abdominal Compartment Syndrome (DOI: 10.1007/s00134-013-2906-z).
Known limitations include: Bladder pressure measurement technique affects accuracy; Patient positioning affects readings (should be supine, head of bed ≤30°); Muscle relaxants affect readings - consider in ventilated patients; Does not address pediatric ACS thresholds; Open abdomen management requires specialized expertise. Individual patient factors may require deviation from these recommendations.
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