Intra-peritoneal Resuscitation in Trauma and Sepsis: Management Options for the Open Abdomen
Damage control surgery has been utilized as a means to provide life-saving bleeding and infection source control while limiting operative time to provide opportunities for ongoing resuscitation of the patient once the initial problem has been controlled.
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Intra-peritoneal Resuscitation in Trauma and Sepsis: Management Options for the Open Abdomen Glen A. Franklin, Nicole M. Garcia and Jason W. Smith
First described by Rotondo et al. [1], damage control surgery (DCS) has now become commonplace in the management of abdominal injuries. The combination of acidosis, hypothermia, and coagulopathy are well-known precedents to mortality and using an abbreviated surgical procedure with bleeding control and initial injury management followed by resuscitation, rewarming and correction of coagulopathy with delayed definitive surgery has been shown to improve patient outcomes [2, 3]. While, initially, DCS was limited to trauma patients, it is now being further utilized on patients with abdominal catastrophes such as sepsis, severe pancreatitis, and ruptured aneurysms. The development of abdominal compartment syndrome in post-resuscitation surgical patients and burn patients has also provided another category of complex patients with the open abdomen. The physiologic derangements that occur during these types of events lead to issues in fluid management, electrolyte restoration, tissue ischemia, and edema as well as enhanced inflammation. The ongoing resuscitation efforts frequently provide an opportunity for significant fluid shifts and tissue edema limiting the ability of the surgeon to primarily close the abdomen even after a few return trips to the operating room [4]. Patients with the open abdomen are quite ill and have a higher rate of postoperative complications even if they have primary closure. In a recent study by Bruns et al. [5], patient with non-trauma open abdomens had a 36 % six-month mortality with over two-thirds of the survivors requiring significant post-discharge medical care.
G.A. Franklin (&) N.M. Garcia J.W. Smith Department of Surgery, University of Louisville, 2nd Floor ACB, 550 S Jackson Street, Louisville, KY 40202, USA e-mail: [email protected]; [email protected] N.M. Garcia e-mail: [email protected] J.W. Smith 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_4
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For those patients who are not able to achieve primary fascia closure, a variety of options remain to provide temporary or permanent closure. While no formal classification or grading system exists for these complex abdominal wall defects, many closure techniques have been attempted and studied [6]. Prosthetic closure alone offers the ease of closure but often the highest rate of fistula formation and failure. Various techniques including a fascia bridge, component separation, and minimally invasive component separation have all been utilized with/without synthetic and biologic mesh. The development of a patient specific plan is paramount to success as these are not “one-size-fits-all” types of operative repairs. Providing primary fascial closure following DCS with an open abdomen clearly reduces
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