Preventing loss of domain: a management strategy for closure of the "open abdomen" during the initial hospitalization.

BACKGROUND: In the management of the abdominal compartment syndrome resulting in an open abdomen, the so-called "planned ventral hernia" is considered an acceptable outcome. We describe a technique of surgical management of the abdominal wound that allows fascial closure in most cases during the initial admission. METHODS: Consecutive trauma patients with abdominal compartment syndrome managed with an open abdomen over a 3-year period were identified. Medical records and the trauma data registry were reviewed for demographics, injury characteristics, operative treatment, timing and type of wound management, closure of the abdomen, and outcome. RESULTS: From January 2004 to January 2007, 23 patients underwent management with an open abdomen. The mechanism of injury was blunt in 83% of patients and penetrating in 17%. All 18 survivors underwent primary fascial closure of the abdomen using a vacuum- and tie-assisted technique of wound closure. The mean time to closure was 11 +/- 4.4 days (range, 4-18 days). In all, 9 complications occurred in 7 patients, which included 1 reoperation for abscess after fascial closure. There was no dehiscence and no fistula. The Apache II score was 19.3 +/- 6.9 (range, 7-30), and the injury severity score was 32.3 + 10.6 (range, 9-50). CONCLUSIONS: A technique of managing the open abdomen that prevents fascial retraction results in a high primary closure rate with an acceptable rate of short-term complications.

The availability of circulating blood volume values alters fluid management in critically ill surgical patients.

BACKGROUND: This study evaluated whether commercially available blood volume measurements in critically ill surgical patients altered fluid management. METHODS: Patients admitted to the surgical intensive care unit of a tertiary care teaching hospital were prospectively evaluated. The frequency of changes in fluid management when results of blood volume measurements were available was determined. RESULTS: In a pilot study, the frequency of instances when measurement of blood volume would have altered fluid management was statistically significant (P = .0003). In 40 subsequent patients, treatment change occurred in 36% of instances when blood volume results were obtained (P < .001). In the majority, no immediate qualitative change in clinical status occurred, with a desirable clinical response in 39% and no negative treatment responses (P < .001). CONCLUSIONS: Blood volume measurements may assist in the management of critically ill surgical patients by providing a direct measure of intravascular volume. Further studies are warranted to determine its effect on outcome.