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Abdominal Compartment Syndrome — FRCA Final MCQ

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HardIntensive Care MedicineAbdominal Compartment SyndromeFRCA Final

A 38-year-old man weighing 82 kg has been in intensive care for 3 days with acute necrotising pancreatitis. He is intubated and ventilated, with worsening oxygenation and increasing airway pressures despite an FiO2 of 0.6 and PEEP of 10 cmH2O. His abdomen is tense and distended, and his urine output has fallen to 10 mL/hour. Repeated intra-abdominal pressure measurements via the urinary bladder are 28 mmHg. Deep sedation, neuromuscular blockade, nasogastric and rectal decompression, optimisation of fluid balance, and image-guided drainage of accessible intraperitoneal fluid have not reduced the pressure or improved organ function. What is the diagnosis and most appropriate next management?

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Correct answer: B — Abdominal compartment syndrome — perform urgent decompressive laparotomy and temporary abdominal closure

This is abdominal compartment syndrome: sustained intra-abdominal pressure above 20 mmHg accompanied by new organ dysfunction, here severe oliguria and worsening respiratory mechanics. An IAP of 28 mmHg is grade IV intra-abdominal hypertension, not “grade III ACS”; abdominal compartment syndrome itself is defined by the associated organ dysfunction rather than assigned that grade. Because medical measures, gastrointestinal decompression and percutaneous drainage have failed, urgent decompressive laparotomy with temporary abdominal closure is indicated. Ileus may contribute to the raised pressure but does not adequately describe the resulting multiorgan syndrome. Renal replacement therapy may support severe acute kidney injury but does not relieve the causative pressure. There is no evidence of haemorrhage or perforation, and delaying decompression for CT angiography would be inappropriate.

Reference: Kirkpatrick AW et al. Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Medicine. 2013;39:1190–1206. https://pubmed.ncbi.nlm.nih.gov/23673399/