1. Introduction and Rationale

De-escalation of intensive therapies in Abdominal Compartment Syndrome (ACS) must strike a balance between minimizing iatrogenic harm and preventing rebound intra-abdominal hypertension (IAH). Safe transition requires continuity of monitoring and organ support as patients move to lower-acuity settings.

Goals of De-escalation:

• Taper sedation, neuromuscular blockade, and diuretics with regular intra-abdominal pressure (IAP) and organ function checks.
• Prevent rebound IAP elevations and secondary organ dysfunction.

Transition of Care Imperatives:

• Standardized handoff tools (e.g., SBAR: Situation, Background, Assessment, Recommendation) to convey IAP trends, therapies, and pending labs.
• Continue IAP monitoring and watch for delayed complications (infection, fistula, recurrent IAH).
• Engage multidisciplinary team: pharmacy, nutrition, physical therapy/occupational therapy (PT/OT), mental health, and nursing.

2. Weaning and De-escalation of Intensive Therapies

Systematic weaning of sedation, paralytics, and fluid therapies as ACS resolves promotes recovery and reduces ICU complications.

2.1 Sedation Weaning Protocols

• Use Richmond Agitation-Sedation Scale (RASS) or Sedation-Agitation Scale (SAS); target light sedation (RASS 0 to –2).
• Implement daily sedation interruption (“sedation vacation”) to assess neurologic status.
• Monitor for agitation, withdrawal, and IAP spikes during dose reductions.

2.2 Neuromuscular Blockade and Ventilator Liberation

• Discontinue paralytics when Train-of-Four (TOF) count is ≥2/4 twitches to restore spontaneous movement.
• Initiate spontaneous breathing trials (SBTs) when plateau pressure <30 cmH2O and oxygenation is stable.
• Assess extubation readiness; maintain a re-intubation plan given potential residual abdominal or respiratory compromise.

2.3 Fluid Balance and Diuretic Tapering

• Set individualized net negative fluid balance targets (e.g., –0.5 to –1 L/day).
• Gradually down-titrate loop diuretics (e.g., furosemide 20–80 mg IV bolus or 5–20 mg/hr infusion).
• Monitor intake/output, creatinine, electrolytes, and vital signs; avoid rapid volume shifts that could trigger acute kidney injury (AKI).

3. Conversion from IV to Enteral Medications

Early switch to enteral therapy restores gut integrity, reduces line-related risks, and facilitates discharge planning; absorption variability demands close efficacy monitoring.

3.1 Indications and Timing

• Ensure return of GI function: presence of bowel sounds, minimal gastric residuals, absence of significant ileus.

3.2 Enteral Access Considerations

• Select appropriate tube (nasogastric, orogastric, post-pyloric) based on aspiration risk and motility.
• Verify tube placement and compatibility of crushed versus liquid formulations.
• Avoid crushing extended-release or enteric-coated drugs.

3.3 Pharmacotherapy Considerations

3.3.1 Sedative Conversion

Mechanism: GABA-A agonism (benzodiazepine class).

Agents & Dosing: Lorazepam 0.5–2 mg PO q6–8h; clonidine 0.1–0.2 mg PO q8h as adjunct.

Monitoring: Sedation scales, blood pressure/heart rate; watch for accumulation in hepatic impairment.

Pitfall: Too-rapid conversion risks withdrawal and agitation.

3.3.2 Analgesic Conversion

Mechanism: Mu-opioid receptor agonism.

Agents & Dosing: Morphine PO (IV:PO ratio 1:3), oxycodone 5–10 mg PO q4–6h PRN.

Monitoring: Pain scores, respiratory rate, sedation.

Pitfall: Variable absorption—adjust dose for gut dysmotility.

3.3.3 Prokinetic Conversion

Mechanism: D2 receptor antagonism (metoclopramide).

Agent & Dosing: Metoclopramide 10 mg PO q6h.

Monitoring: GI motility, QTc interval, extrapyramidal signs.

Pitfall: Contraindicated in obstruction; risk of arrhythmias.

3.4 Monitoring Absorption and Efficacy

• Use therapeutic drug levels when available (e.g., anticonvulsants).
• Assess clinical endpoints: pain control, sedation depth, bowel movements.
• Revert to IV therapy if enteral route fails to meet targets.

4. Mitigating Post-ICU Syndrome (PICS)

Early implementation of the ABCDEF Bundle and supportive therapies minimizes long-term physical, cognitive, and psychological impairments after critical illness.

4.1 Risk Stratification

• High-risk features: age >65, prolonged sedation/ventilation (>7 days), ICU-acquired weakness.

4.2 ABCDEF Bundle Implementation

• A: Assess/manage pain (numerical/verbal scales + multimodal analgesia).
• B: Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT).
• C: Choice of sedation—favor non-benzodiazepines (propofol, dexmedetomidine).
• D: Delirium monitoring (CAM-ICU/ICDSC) and management.
• E: Early mobility—bed exercises progressing to ambulation.
• F: Family engagement—education and involvement during rounds.

4.3 Rehabilitation and Nutrition

• Initiate PT/OT early; define mobility milestones (sitting, standing, walking).
• Nutrition goals: protein 1.2–2.0 g/kg/day; 25–30 kcal/kg/day via enteral route.

4.4 Psychological and Cognitive Support

• Provide ICU diaries; refer to post-ICU clinics for cognitive and mental health follow-up.
• Engage family to support patient’s psychological recovery.

5. Medication Reconciliation and Discharge Counseling

Structured reconciliation, education, and communication ensure safe transitions, reduce errors, and empower patients/caregivers.

5.1 Reconciliation Process

• Compare pre-admission, ICU, and discharge medication lists.
• Identify and resolve duplications, omissions, and potential interactions.

5.2 Patient/Caregiver Education

• Review each medication’s indication, dose, schedule, side effects, and monitoring requirements.
• Provide written action plan and emergency contact information.

5.3 Communication Tools

• Use SBAR or electronic handoff templates to highlight critical medications and required labs.
• Emphasize high-risk medications (anticoagulants, immunosuppressants) and follow-up schedules.

6. Summary and Clinical Pearls

6.1 Key Take-Home Points

• Protocolized de-escalation and frequent IAP monitoring prevent rebound ACS and support recovery.
• Early IV-to-enteral conversion preserves gut integrity and facilitates discharge planning.
• ABCDEF Bundle implementation mitigates PICS and optimizes long-term outcomes.
• Comprehensive medication reconciliation and discharge counseling ensure safe care transitions.

6.2 Common Pitfalls

• Overly rapid diuretic taper risking hypovolemia or AKI.
• Inadequate monitoring of enteral drug absorption leading to subtherapeutic or toxic levels.
• Incomplete handoff of critical medications or pending laboratory follow-up.