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.

Using transcutaneous oxygen pressure measurements as selection criteria for activated protein C use.

BACKGROUND: Limited resources and the expense of Activated Protein C (APC) (drotrecogin alfa) may contribute to the reluctance to utilize this drug in sepsis. Employing the PROWESS criteria resulted in absolute reduction in 28-day mortality of 6.1%, representing a relative risk reduction of 19.4%. Additional patient categorization and selection may lead to less frequent drug use with the same survival advantage. We used transcutaneous partial pressure of oxygen (PtcO2) as an indicator of microcirculatory perfusion to identify which septic patients may benefit from APC. METHODS: Nineteen patients consecutively admitted with severe sepsis or septic shock that fulfilled the PROWESS criteria for APC treatment. APC was administered to patients with the PROWESS selection criteria, only if the PtcO2 information demonstrated tissue ischemia. RESULTS: Nineteen patients met the PROWESS criteria. Ten patients demonstrated poor tissue perfusion using PtcO2 monitors and received APC. Nine patients had adequate tissue perfusion and did not receive APC. There were no differences in age, gender, APACHE II scores, lactate levels, or organ failure between the two groups. The 10 patients who received APC had a mortality of 3 of 10 (30%). The survivors of this group uniformly converted to PtcO2 values consistent with survival within 12 hours to 24 hours of drug administration. The nine patients who did not receive APC had a mortality of 2 of 9 (22%), not statistically significant from those who received the drug (p = 0.89). CONCLUSION: Withholding APC did not result in an increase in mortality from severe sepsis in those patients who demonstrated adequate PtcO2 values. The transcutaneous oxygen measurement may be a useful adjuvant in addition to the other selection criteria for better identification of patients who may benefit from APC.

Circulating blood volume measurements correlate poorly with pulmonary artery catheter measurements.

BACKGROUND: Determination of the intravascular volume status of a critically ill surgical patient is paramount for appropriate fluid and cardiovascular management. Many clinical parameters have been utilized to estimate intravascular volume but none are precise indicators of circulating blood volume. The purpose of this observational pilot study was to compare measured blood volume with hemodynamic parameters obtained from the pulmonary artery catheter and to determine if incorporation of these measurements altered treatment decisions in critically ill surgical patients. METHODS: Blood volume measurements were prospectively obtained in twenty surgical intensive care unit patients with a pulmonary artery catheter when intravascular volume status was deemed uncertain by traditional clinical parameters. RESULTS: There was a statistically significant, but weak, correlation between blood volume results and pulmonary artery occlusion pressure, but no correlation with central venous pressure, cardiac index, and stroke volume index. Blood volume information altered treatment in 21% of instances, and 5 of these 6 patients demonstrated a favorable clinical response. CONCLUSIONS: Circulating blood volume measurements may be useful in critically ill surgical patients when clinical appraisal of intravascular volume is uncertain. This remains to be validated in a larger, prospective randomized trial.

Percutaneous dilatational tracheostomy is as safe as open tracheostomy.

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.