An experience in the management of the open abdomen in severely injured burn patients.

Few descriptions of temporary abdominal closure for planned relaparotomy have been reported in burned patients. The purpose of this study is to describe our experience and outcomes in the management of burned patients with an open abdomen. The authors performed a retrospective review of all admissions to our burn center from March 2003 to June 2008, identifying patients treated by laparotomy with temporary abdominal closure. The authors collected data on patient demographics, indication for laparotomy, methods of temporary and definitive abdominal closure, and outcomes. Of 2,104 patients admitted, 38 underwent a laparotomy with temporary abdominal closure. Their median TBSA was 55%, and the incidence of inhalation injury was 58%. Abdominal compartment syndrome was the most common indication for laparotomy (82%) followed by abdominal trauma (16%). The in-hospital mortality associated with an open abdomen was 68%. Temporary abdominal closure was performed most commonly using negative pressure wound therapy (90%). Fascial closure was performed in 21 patients but was associated with a 38% rate of failure requiring reexploration. Of 12 survivors, fascial closure was achieved in seven patients and five were managed with a planned ventral hernia. Burned patients who necessitate an open abdomen management strategy have a high morbidity and mortality. Fascial closure was associated with a high rate of failure but was successful in a select group of patients. Definitive abdominal closure with a planned ventral hernia was associated with no increased mortality and remains an option when "tension-free" fascial closure cannot be achieved.

Pruritus ani: etiology and management.

Pruritus ani is a dermatologic condition characterized by an unpleasant itching or burning sensation in the perianal region. This article briefly discusses the incidence and classification of pruritus ani followed by a more lengthy discussion of primary and secondary pruritus ani. The important points are summarized and a simple algorithm is provided for the clinical management of pruritus ani.

Prophylaxis and management of wound infections after elective colorectal surgery: a survey of the American Society of Colon and Rectal Surgeons membership.

BACKGROUND: Postoperative wound infections are a widespread and costly problem, especially in colorectal surgery. Despite their prevalence, there are few data regarding appropriate management and prevention strategies. MATERIALS AND METHODS: In order to assess current attitudes and practices about this subject, and as a guide to designing a randomized trial to gather evidence in order to support data-driven protocol development, an e-mail survey was sent to the membership of the American Society of Colorectal Surgeons to assess current attitudes and practices pertaining to prevention and management of wound infections. RESULTS: Most respondents estimated that the wound infection rate in their own patients was much lower than commonly reported in the literature. Use of evidence-based perioperative strategies for reducing wound infection, such as the use of a wound protector, hyperoxygenation, and implementation of the Surgical Care Improvement Project guidelines, were far from universal. Management strategies varied widely, without apparent rational basis. CONCLUSION: Based on the practices and beliefs in the surgical community, it is our hope that a multi-institutional study can be carried out to objectify best practices in both the effective and cost-effective management of this common condition and to reduce the wide variation in the treatment of surgical site infections.

Abdominal complications after severe burns.

BACKGROUND: Abdominal catastrophe in the severely burned patient without abdominal injury has been described. We perceived an alarming recent incidence of this complication in our burn center, both during acute resuscitation and later in the hospital course. We sought to define incidence, outcomes, and associated factors, such as excessive resuscitation volume and treatment issues. STUDY DESIGN: We examined all severely burned military and civilian patients with abdominal pathology between March 2003 and February 2008. Data included age, gender, total body surface area burn, inhalation injury, Injury Severity Score, disposition, resuscitation volume, time from injury to diagnosis, use of recombinant factor VIIa, vasopressors, and early tube feedings. We assembled a Delphi panel of surgeons experienced in abdominal catastrophes to review these data. RESULTS: Among 1,825 patients admitted to the US Army Institute of Surgical Research Burn Center, 120 (6.6%) were diagnosed with abdominal pathology (burn size 48% +/- 19%), of which 51 (2.8%) had abdominal catastrophe. The majority of these occurred in the first days after injury with associated abdominal compartment syndrome (32 of 51) and increased linearly to burn size. We noted another group of patients who presented primarily with ischemic bowel later in the course, with the same clinical presentation. Resuscitation volume was 6.02 mL/kg/percent total body surface area burned. Vasopressors were used in 71% of patients and tube feedings in 57% before diagnosis. CONCLUSIONS: Abdominal catastrophe without abdominal trauma occurs in 2.8% of our population. Associated mortality was 78% without obvious cause. Delphi panel experts recommended more aggressive monitoring of abdominal compartment pressures and earlier operative management to improve outcomes.