In spite of the diverse literature discussing IAH and ACS, there is limited literature specific to the nursing care for patients with IAH or ACS. Patients with IAH or ACS will be most frequently encountered in ICU, high dependency units (HDU), coronary care units (CCU) and emergency departments (ED). Recently, it has been proposed to expand IAP and ACS monitoring beyond traditional critical care areas to enable early detection of the clinical deterioration in in susceptible patients thus improve patient outcomes [
32,
39].
The complex presentation of patients with IAH or ACS requires an advanced practice nurse’s clinical expertise and vigilant monitoring is essential [
6,
21]. Advanced practice nurses possess superior assessment and decision making skills, critical thinking and communication expertise that is imperative in an often unpredictable critical care environment [
40]. Advanced nursing practice allows expert nurses to demonstrate increased clinical discretion, responsibility and autonomy when recognising, assessing, and managing patients with IAH or ACS [
41].
Specific nursing management is focused on assessing organ function, pain management, vital signs, perfusion to the lower extremities, assessment of wound drainage and output, ongoing assessment for reoccurrence of IAH or ACS and provision of support to patients and their families [
6,
42,
43].
Organ function
Due to the adverse effects of IAH and ACS on patient morbidity and mortality (See Table
2), there is a need for advanced practice nurses to assess and manage patients using evidence based protocols [
38].
Table 2
Adverse effects of intra abdominal hypertension (IAH) and abdominal compartment syndrome (ACS)
Cerebral | • An Increase in IAP forces the diaphragm up decreasing intra-thoracic space, increasing the intra-thoracic pressure. |
• Jugular venous pressure elevates. |
• Venous return decreases. |
• Intra cerebral pressure will increase. |
• Cerebral blood flow decreases. |
Cardiac function | • An increase in IAP causes increased pressure on the inferior vena cava, intra abdominal circulation and perfusion. |
• Venous return is impaired and peripheral oedema occurs. |
• Increase in central venous pressure. |
• Increased pulmonary artery wedge pressures as the myocardium is placed under an increasing workload. |
Respiratory function | • An increased in IAP forces the diaphragm up decreasing intra-thoracic space and restricts respiration. |
• Result in an increase in intra thoracic pressure particularly with mechanically ventilated patients. |
• Left uncorrected will result in a decrease in lung compliance, functional residual capacity a VQ mismatch and hypoxia. |
Renal function | • Defined as oliguria and anuria despite aggressive fluid resuscitation. |
• Increase in abdominal pressure decreases renal blood flow coupled with a reduction in cardiac output. |
• The rennin angiotensin system is activated further adding to intra- abdominal pressure and cardiac workload. |
Gastrointestinal function | • Increased intra- abdominal pressure results in an increase in vascular resistance and decreased cardiac output. |
• Results in a decrease in tissue perfusion. |
• Ultimately tissue ischemia. |
Peripheral perfusion | • Increased intra- abdominal pressure is said to increase femoral venous pressure increase peripheral vascular resistance and reduce femoral artery blood flow by up to 60%. |
Patients with ACS are often managed with pharmacological, technical, medical and surgical procedures [
11,
44,
45]. Pharmacological support for patients with IAH or ACS is multi-faceted and entails active and precise fluid resuscitation to maintain adequate circulating volume without fluid overloading, medications to support cardiac output in the event of decompensation and antibiotics to treat infections [
6,
42,
46‐
48]. In the context of a critical illness, technical support involves ventilator support, continuous renal replacement therapy (CRRT), invasive cardiac monitoring, arterial blood gas interpretation and intervention, blood glucose monitoring and treatment of electrolyte disturbances [
6,
42,
49].
A non- surgical approach is generally used in patients with no abdominal injuries and may involve the insertion of a percutaneous drain for fluid removal [
44,
48,
50,
51]. Current guidelines suggest that when IAH or ACS has been established and intra peritoneal fluid has been confirmed percutaneous drainage should be undertaken as it may negate the need for decompressive laparotomy [
11]. Other measures endorsed by the WSACS include the judicious use of fluids, endogastric tube insertion, laxative usage, pain relief and muscle relaxants [
6,
8,
11,
32,
48,
52]. Whilst other measures such as CRRT, diuretics and albumin are being used to manage patients the WSACS could make no recommendations regarding their use [
11,
49]. Another non-surgical approach to prevent and manage IAH and ACS is damage control resuscitation. Damage control resusitation is chacterised by permissive hypotension, limitation of crystalloid infusion and the administration of higher ratios of plasma and platelets to red blood cells [
17,
53]. The WSACS suggests a higher ratio of plasma and packed red blood cells as opposed to limited or no use [
11].
Surgical management involves decompression of the abdomen [
17,
54]. Decompression occurs in cases of trauma with abdominal injuries or where the patient’s clinical condition continues to deteriorate while using non-surgical management techniques. Decompression is aimed at restoring organ perfusion and ultimately organ function. Early surgical decompression of the abdomen is considered a therapeutic intervention and a definitive treatment for ACS and is performed when ACS is unresponsive to medical treatment options [
1,
10‐
12,
52]. This is recommended despite reported complications and 50% mortality rates [
11,
52]. Decompression often results in the abdomen being left open followed by other surgical procedures [
6,
10,
15,
32,
55‐
57]. Presumptive decompression should be considered at the time of laparotomy for patients who demonstrate risk factors for ACS [
7,
58]. After a decompression procedure where the abdomen is left opened there is limited literature guiding definitive abdominal closure. It has been suggested that closure is possible within 5–7 days of decompression if the patient underwent early decompression prior to the development of significant organ injury [
7,
58]. However, optimal timing of closure is dependent upon normalisation of IAP [
6].
Damage control laparotomy for trauma patients is used as a measure to control hemorrhage and restore metabolic function and is supported as a resuscitative procedure by the WSACS [
11,
17,
59]. Current guidelines suggest this method should be used when the patient is physiologically fatigued with the abdomen to remain prophylactically opened to avoid IAH [
11].
The role of the nurse is to assess, interpret and titrate therapy according to the patients’ organ function [
6,
42]. Nursing care of the patient with an open abdomen involves the management of complex wounds, negative pressure systems, assessment of vascular supply to the wound, wound drainage, dressing integrity, patient positioning, and assessing for recurrence of ACS [
6,
42]. Unless contraindicated, nasogastric feeding should be considered to optimise gastrointestinal function [
60,
61].