How to Feed the Open Abdomen
Patients treated with damage control surgery develop a severe systemic inflammatory response associated with a catabolic state compounded by protein losses through the open abdomen. Diligence regarding nutrition provision is essential for optimal outcomes
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How to Feed the Open Abdomen Katie M. Love and Bryan R. Collier
Introduction Patients with hemorrhagic shock, severe sepsis, and necrotizing pancreatitis treated with damage control surgery develop a severe systemic inflammatory response characterized by release of pro-inflammatory mediators. Those with open abdomens represent the sickest, most inflamed, and most hypermetabolic cohort of surgical patients. The acute catabolic reaction associated with severe physiologic stress and inflammation results in muscle proteolysis with increased urinary nitrogen excretion and weight loss, compounded by an increased resting energy expenditure attributed to the large open wound. This severe catabolic pro-inflammatory cascade and physical loss of protein continues until the abdomen is closed. Enteral nutrition (EN) provided within 24–36 h after admission to the ICU has been advocated in critically ill surgical patients. This is thought to ameliorate immune suppression which is characterized by the cytokine-generated stress response at the level of the gut. EN is better than parenteral nutrition (PN). However, if PN is started there are fewer associated complications if it is started late, after 5–7 days post admission. In the open abdomen patient, higher protein and calorie requirements are usually present not only because of the hypermetabolic response, but also because of the physical loss of fluid and protein from the open abdomen and negative pressure K.M. Love (&) Acute Care Surgery: Trauma, Surgical Critical Care, Emergency General Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Avenue, Med. Ed. 3rd Floor Suite 304, Roanoke, VA 24014, USA e-mail: [email protected] B.R. Collier Acute Care Surgery: Trauma, Surgical Critical Care, Emergency General Surgery, Virginia Tech Carilion School of Medicine, 1906 Belleview Avenue, Med. Ed. 3rd Floor Suite 301, Roanoke, VA 24014, USA e-mail: [email protected] © Springer International Publishing Switzerland 2017 J.J. Diaz and D.T. Efron (eds.), Complications in Acute Care Surgery, DOI 10.1007/978-3-319-42376-0_5
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K.M. Love and B.R. Collier
dressing. Therefore, ongoing diligence regarding nutrition provision (EN, PN, or both) is essential for optimal outcomes in the open abdomen patient.
Admission Upon entering this patient’s abdomen, even the young surgeon knows that this patient is going to require multiple operative interventions and great attention to detail in all aspects of his critical care. His critical illness and hyperinflammatory or hypercatabolic state is compounded by the significant fluid, electrolyte, and protein losses from exposed viscera [1]. This immediate protein–calorie malnutrition develops with impairment of immune function, and subclinical multiple organ dysfunction will continue at least until his abdomen is closed [2]. Enteral nutrition (EN) provided within 24–36 h after ICU admission or initial operation is advocated. This early but lower than goal EN ameliorates the immune suppression and attenuates the syst
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