A Clinician’s Guide to Management of Intra-abdominal Hypertension and Abdominal Compartment Syndrome in Critically Ill Patients

  • I. E. De laet
  • M. L. N. G. Malbrain
  • J. J. De WaeleEmail author
Part of the Annual Update in Intensive Care and Emergency Medicine book series (AUICEM)


Intra-abdominal hypertension (IAH) is common and associated with morbidity and mortality in critically ill patients. IAH exists along a continuum that begins with a mild asymptomatic elevation of intra-abdominal pressure (IAP) and extends to life-threatening abdominal compartment syndrome (ACS). In 2013, evidence-based guidelines were published on the definitions, diagnosis, and treatment of IAH and ACS. Even using these guidelines, making bedside decisions regarding management of individual patients with IAH/ACS remains challenging due to the wide variety of conditions associated with IAH/ACS, the varying degrees of associated organ dysfunction, and the large number of available treatment options. Using a simplified treatment paradigm, we advocate that the optimal treatment strategy should not be based purely on the degree of IAP alone, but on three critical elements: the magnitude of IAP, the degree and dynamics of organ dysfunction (or thus the impact of increased IAP), and the etiology of increased IAP. In this chapter, we propose a conceptual framework of how to diagnose and manage patients with IAH/ACS, taking into account patient physiology, current scientific evidence, and experience. In this practical and clinical approach, both the necessity and urgency of intervention are discussed.


Intra-abdominal hypertension Abdominal compartment syndrome Intra-abdominal pressure Abdominal Abdomen 



The authors would like to thank Drs. Bart De Keulenaer, Chialka Ejike, Adrian Regli, Annika Reintam, Andrew Kirkpatrick, and Derek Roberts for their contributions to this manuscript.


  1. 1.
    Malbrain ML, Cheatham ML, Kirkpatrick A, et al. Results from the International conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions. Intensive Care Med. 2006;32:1722–32.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration. Ann Surg. 1984;199:28–30.PubMedPubMedCentralCrossRefGoogle Scholar
  3. 3.
    Reintam Blaser A, Regli A, De Keulenaer B, et al. Incidence, risk factors, and outcomes of intra-abdominal hypertension in critically ill patients-a prospective multicenter study (IROI Study). Crit Care Med. 2019;47:535–42.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    De Keulenaer B, Regli A, De Laet I, Roberts D, Malbrain ML. What’s new in medical management strategies for raised intra-abdominal pressure: evacuating intra-abdominal contents, improving abdominal wall compliance, pharmacotherapy, and continuous negative extra-abdominal pressure. Anaesthesiol Intensive Ther. 2015;47:54–62.PubMedPubMedCentralGoogle Scholar
  5. 5.
    De Waele JJ, Malbrain ML, Kirkpatrick AW. The abdominal compartment syndrome: evolving concepts and future directions. Crit Care. 2015;19:211.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Cheatham ML, Malbrain ML, Kirkpatrick A, et al. Results from the International conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. II. Recommendations. Intensive Care Med. 2007;33:951–62.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Cheatham ML. Nonoperative management of intra-abdominal hypertension and abdominal compartment syndrome. World J Surg. 2009;33:1116–22.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Kirkpatrick AW, Roberts DJ, De Waele J, 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 Med. 2013;39:1190–206.PubMedPubMedCentralCrossRefGoogle Scholar
  9. 9.
    Struck MF, Reske AW, Schmidt T, Hilbert P, Steen M, Wrigge H. Respiratory functions of burn patients undergoing decompressive laparotomy due to secondary abdominal compartment syndrome. Burns. 2014;40:120–6.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    De Waele JJ, Hoste EA, Malbrain ML. Decompressive laparotomy for abdominal compartment syndrome—a critical analysis. Crit Care. 2006;10:R51.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Van Damme L, De Waele JJ. Effect of decompressive laparotomy on organ function in patients with abdominal compartment syndrome: a systematic review and meta-analysis. Crit Care. 2018;22:179.PubMedPubMedCentralCrossRefGoogle Scholar
  12. 12.
    De Waele JJ, Kimball E, Malbrain M, et al. Decompressive laparotomy for abdominal compartment syndrome. Br J Surg. 2016;103:709–15.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Malbrain ML, De Laet I, De Waele JJ, et al. The role of abdominal compliance, the neglected parameter in critically ill patients—a consensus review of 16. Part 2: measurement techniques and management recommendations. Anaesthesiol Intensive Ther. 2014;46:406–32.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Malbrain ML, Roberts DJ, De Laet I, et al. The role of abdominal compliance, the neglected parameter in critically ill patients—a consensus review of 16. Part 1: definitions and pathophysiology. Anaesthesiol Intensive Ther. 2014;46:392–405.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Chionh JJL, Wei BPC, Martin JA, Opdam HI. Determining normal values for intra-abdominal pressure. ANZ J Surg. 2006;76:1106–9.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    De Keulenaer BL, De Waele JJ, Powell B, Malbrain ML. What is normal intra-abdominal pressure and how is it affected by positioning, body mass and positive end-expiratory pressure. Intensive Care Med. 2009;35:969–76.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Frezza EE, Shebani KO, Robertson J, Wachtel MS. Morbid obesity causes chronic increase of intra-abdominal pressure. Dig Dis Sci. 2007;52:1038–41.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Lozada MJ, Goyal V, Osmundson SS, Pacheco LD, Malbrain MLNG. It’s high time for intra-abdominal hypertension guidelines in pregnancy after more than 100 years of measuring pressures. Acta Obstet Gynecol Scand. 2019;98:1486–8.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Umgelter A, Reindl W, Franzen M, Lenhardt C, Huber W, Schmid RM. Renal resistive index and renal function before and after paracentesis in patients with hepatorenal syndrome and tense ascites. Intensive Care Med. 2008;35:152–6.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Verbrugge FH, Dupont M, Steels P, et al. Abdominal contributions to cardiorenal dysfunction in congestive heart failure. J Am Coll Cardiol. 2013;62:485–95.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Depauw PRAM, Groen RJM, Van Loon J, Peul WC, Malbrain MLNG, De Waele JJ. The significance of intra-abdominal pressure in neurosurgery and neurological diseases: a narrative review and a conceptual proposal. Acta Neurochir. 2019;161:855–64.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Kyoung KH, Hong SK. The duration of intra-abdominal hypertension strongly predicts outcomes for the critically ill surgical patients: a prospective observational study. World J Emerg Surg. 2015;10:22.PubMedPubMedCentralCrossRefGoogle Scholar
  23. 23.
    De Waele JJ, De Laet I, Kirkpatrick AW, Hoste E. Intra-abdominal hypertension and abdominal compartment syndrome. Am J Kidney Dis. 2011;57:159–69.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Dalfino L, Tullo L, Donadio I, Malcangi V, Brienza N. Intra-abdominal hypertension and acute renal failure in critically ill patients. Intensive Care Med. 2008;34:707–13.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    De laet I, Malbrain ML, Jadoul JL, Rogiers P, Sugrue M. Renal implications of increased intra-abdominal pressure: are the kidneys the canary for abdominal hypertension? Acta Clin Belg Suppl. 2007;62(Suppl 1):119–30.CrossRefGoogle Scholar
  26. 26.
    De Laet IE, Malbrain M. Current insights in intra-abdominal hypertension and abdominal compartment syndrome. Med Int. 2007;31:88–99.Google Scholar
  27. 27.
    Malbrain ML, Roberts DJ, Sugrue M, et al. The polycompartment syndrome: a concise state-of-the-art review. Anaesthesiol Intensive Ther. 2014;46:433–50.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Petro CC, Raigani S, Fayezizadeh M, et al. Permissible intra-abdominal hypertension following complex abdominal wall reconstruction. Plast Reconstr Surg. 2015;136:868–81.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Thai H, Guerron AD, Bencsath KP, Liu X, Loor M. Fulminant Clostridium difficile enteritis causing abdominal compartment syndrome. Surg Infect. 2014;15:821–5.CrossRefGoogle Scholar
  30. 30.
    Ball CG, Kirkpatrick AW, Yilmaz S, Monroy M, Nicolaou S, Salazar A. Renal allograft compartment syndrome: an underappreciated postoperative complication. Am J Surg. 2006;191:619–24.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Gupte GL, Haghighi KS, Sharif K, et al. Surgical complications after intestinal transplantation in infants and children-UK experience. J Pediatr Surg. 2010;45:1473–8.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Malbrain ML, Peeters Y, Wise R. The neglected role of abdominal compliance in organ-organ interactions. Crit Care. 2016;20:67.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Blaser AR, Björck M, De Keulenaer B, Regli A. Abdominal compliance: a bench-to-bedside review. J Trauma Acute Care Surg. 2015;78:1044–53.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Ahmadi-Noorbakhsh S, Malbrain ML. Integration of inspiratory and expiratory intra-abdominal pressure: a novel concept looking at mean intra-abdominal pressure. Ann Intensive Care. 2012;2(Suppl 1):S18.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Al-Bahrani AZ, Darwish A, Hamza N, et al. Gut barrier dysfunction in critically ill surgical patients with abdominal compartment syndrome. Pancreas. 2010;39:1064–9.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Umgelter A, Reindl W, Wagner KS, et al. Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial. Crit Care. 2008;12:R4.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Latenser BA, Kowal-Vern A, Kimball D, Chakrin A, Dujovny N. A pilot study comparing percutaneous decompression with decompressive laparotomy for acute abdominal compartment syndrome in thermal injury. J Burn Care Rehabil. 2002;23:190–5.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Bunni J, Bryson PJ, Higgs SM. Abdominal compartment syndrome caused by tension pneumoperitoneum in a scuba diver. Ann R Coll Surg Engl. 2012;94:237–9.CrossRefGoogle Scholar
  39. 39.
    Oda J, Ueyama M, Yamashita K, et al. Effects of escharotomy as abdominal decompression on cardiopulmonary function and visceral perfusion in abdominal compartment syndrome with burn patients. J Trauma. 2005;59:369–74.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Tasdogan M, Memis D, Sut N, Yuksel M. Results of a pilot study on the effects of propofol and dexmedetomidine on inflammatory responses and intra-abdominal pressure in severe sepsis. J Clin Anesth. 2009;21:394–400.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    De Laet I, Hoste E, Verholen E, De Waele JJ. The effect of neuromuscular blockers in patients with intra-abdominal hypertension. Intensive Care Med. 2007;33:1811–4.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Cheatham ML, De Waele JJ, De Laet I, et al. The impact of body position on intra-abdominal pressure measurement: a multicenter analysis. Crit Care Med. 2009;37:2187–90.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Cheatham ML, Safcsak K. Is the evolving management of intra-abdominal hypertension and abdominal compartment syndrome improving survival. Crit Care Med. 2010;38:402–7.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Duchesne JC, Baucom CC, Rennie KV, Simmons J, McSwain NE Jr. Recurrent abdominal compartment syndrome: an inciting factor of the second hit phenomenon. Am Surg. 2009;75:1193–8.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Regli A, De Keulenaer B, De Laet I, Roberts D, Dabrowski W, Malbrain ML. Fluid therapy and perfusional considerations during resuscitation in critically ill patients with intra-abdominal hypertension. Anaesthesiol Intensive Ther. 2015;47:45–53.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Regli A, Pelosi P, Malbrain MLNG. Ventilation in patients with intra-abdominal hypertension: what every critical care physician needs to know. Ann Intensive Care. 2019;9:52.PubMedPubMedCentralCrossRefGoogle Scholar
  47. 47.
    Beurton A, Teboul JL, Girotto V, et al. Intra-abdominal hypertension is responsible for false negatives to the passive leg raising test. Crit Care Med. 2019;47:e639–47.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Malbrain MLNG, Van Regenmortel N, Saugel B, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D’s and the four phases of fluid therapy. Ann Intensive Care. 2018;8:66.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    De Laet I, Malbrain ML. ICU management of the patient with intra-abdominal hypertension: what to do, when and to whom? Acta Clin Belg Suppl. 2007;62(Suppl 1):190–9.CrossRefGoogle Scholar
  50. 50.
    Malbrain ML, Marik PE, Witters I, et al. Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice. Anaesthesiol Intensive Ther. 2014;46:361–80.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • I. E. De laet
    • 1
  • M. L. N. G. Malbrain
    • 2
    • 3
  • J. J. De Waele
    • 4
    Email author
  1. 1.Intensive Care Unit and High Care Burn UnitZiekenhuis Netwerk Antwerpen, ZNA StuivenbergAntwerpBelgium
  2. 2.Department of Intensive Care MedicineUniversity Hospital Brussels (UZB)JetteBelgium
  3. 3.Faculty of Medicine and PharmacyVrije Universiteit Brussel (VUB)Campus Jette, JetteBelgium
  4. 4.Department of Critical Care MedicineGhent University HospitalGhentBelgium

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