Nutritional support in patients following damage control laparotomy with an open abdomen
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REVIEW ARTICLE
Nutritional support in patients following damage control laparotomy with an open abdomen V. Bansal • R. Coimbra
Received: 12 November 2012 / Accepted: 1 April 2013 / Published online: 18 April 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Introduction Damage control laparotomy (DCL) and the open abdomen have been well accepted following either severe abdominal trauma or emergency surgical disease. As DCL is increasingly utilized as a therapeutic option, appropriate management of the post-DCL patient is important. Early caloric support by enteral nutrition (EN) in the critically ill patient improves wound healing and decreases septic complications, lung injury, and multisystem organ failure. However, following DCL, nutritional strategies can be challenging and, at times, even daunting. Conclusions Even though limited data exist, the use of early EN following DCL seems safe, provided that the patient is not undergoing active resuscitation or the bowel is not in discontinuity. It is unknown as to whether EN in the open abdomen reduces septic complications, prevents enterocutaneous fistula (ECF), or alters the timing of definitive abdominal wall closure. Future investigation in a prospective manner may help elucidate these important questions. Keywords Damage control laparotomy Open abdomen Enteral nutrition
severe intraoperative coagulopathy, prolonged metabolic acidosis, and abnormal coagulation profiles, seem to improve overall mortality, decrease blood transfusions, and decrease intensive care unit (ICU) length of stay and complications [1, 2]. The indications for DCL have broadened outside of abdominal trauma, in particular, to treat the consequences of abdominal compartment syndrome (ACS) and abdominal hypertension, leading to the concept of decompressive laparotomy [3, 4]. ACS may result from massive fluid resuscitation, severe burns, septic and hemorrhagic shock, mesenteric ischemia, vascular emergencies, acute pancreatitis, or even retroperitoneal space-occupying lesions, such as tumors or acute hemorrhage [5–7]. Recently, Miglietta et al. [8] have even advocated the use of DCL to treat refractory intracranial hypertension following traumatic brain injury. Therefore, with DCL increasing as a therapeutic option, appropriate management of the post-DCL patient is imperative. Indeed, several challenges exist in managing the open abdomen [9–11]. These challenges include: 1. 2.
Introduction 3. In the last two decades, the role of damage control laparotomy (DCL) following severe abdominal trauma has been intensely studied. Appropriate indications, including V. Bansal R. Coimbra (&) Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego Health Sciences, 200 West Arbor Drive, #8896, San Diego, CA 92103, USA e-mail: [email protected]
4.
Timing of abdominal wall closure and methods of temporary closure. Assessment of volume loss and fluid replacement strategies. Appropriate concomitant medications such as antibiotics and paralytic
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