Abdominal compartment syndrome (ACS) is dened as sus­tained intra-abdominal pressure greater than 20mmHg that is associated with new organ dysfunction/failure [57–62]. ACS differs from intra-abdominal hypertension (IAH) which is a graded (I-IV) and sustained pathological elevation greater than 12mmHg. Symptoms of ACS are extensive and impact every major system within the human body. These include, but are not limited to, cardiovascular (hypotension), renal (acute kidney injury), and respiratory (failure) ele­ments. It is interesting to note that many of the dominant risk factors for developing ACS mirror the physiologic triggers for engaging in DCS/DCR [57, 58]. This observation sup­ports these physiologic variables (pH, base decit, core temperature) as clear markers for the absolute “sickest of the sick.” Closing the abdomen in patients manifesting physio­logic extremis often leads to ACS, as rst demonstrated by Morris Jr and colleagues in 1993 [59]. With closure, these authors described severe abdominal distension in concert with raised peak airway pressures, CO2 retention, and oligu­ria [59]. Their observed 63% mortality rate associated with reperfusion injury after unpacking was also dramatic, and currently emphasizes the importance of “recurrent” or “ter­tiary” ACS [60]. While the incidence of primary ACS has decreased dramatically over the past decade [57], continued vigilance is crucial to guard against secondary and recurrent ACS. Despite the increased understanding surrounding this anatomic and physiologic complication, it is clear that the actual practice of clinicians requires more education with regard to both monitoring and treating ACS [61]. This reality has led to a recent evidence-based update of both denitions of primary, secondary, and recurrent ACS, as well as of an expert society’s therapeutic recommendations [62]. More specically, in addition to multiple “suggestions,” the World Congress of the Abdominal Compartment Syndrome (WCACS) strongly recommends: (1) measuring IAP when any known risk factor for IAH/ACS is present in a critically ill or injured patient using a trans-bladder technique (GRADE 1C), (2) utilizing protocolized monitoring and management of IAP (GRADE 1C), (3) engaging in a decompressive lapa­rotomy for cases of overt ACS (GRADE 1D), (4) attempting to ensure same-hospital-stay abdominal fascial closure (GRADE 1D), and (5) utilizing negative suction therapy in patients with open abdominal cavities (GRADE 1D) [62]. It should also be noted that some patients may adequately respond to decompression (nasogastric, colonic, intraperito­neal (i.e., ascites), increased sedation, and/or paralysis as primary therapeutic maneuvers). Failure to resolve ACS with these medical therapies, however, should lead to rapid surgi­cal decompression. Measuring intra-abdominal pressures can be easily performed at the bedside with a three-way Foley catheter, pressure transducer, and intravenous tubing.

1. Damage control resuscitation incorporates princi­ples of early blood product transfusion, minimiza­tion of crystalloid administration, permissive hypotension, abbreviated operative interventions, and sustained critical care with early re-operation.