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Sun JK, Lv C, Gao L, Mao W, Li W, Ke L. Nutrition therapy in critically ill patients with severe acute pancreatitis. Nutr Clin Pract 2024; 39:271-280. [PMID: 38357829 DOI: 10.1002/ncp.11135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Abstract
A significant proportion of patients (10%-20%) with acute pancreatitis develop severe acute pancreatitis characterized by pancreatic necrosis, systemic inflammation, and organ failure, commonly requiring intensive care unit (ICU) admission. In this specific population, nutrition therapy is more challenging than that in the general ICU population, primarily because of inevitable gastrointestinal involvement by pancreatic inflammation. In this review, we discussed several key aspects of nutrition therapy in this population, including key pathophysiology that may impede nutrition therapy, the timing and implementation of enteral nutrition and parenteral nutrition, the importance of specific nutrient supplements, and the long-term outcomes that may be addressed by nutrition therapy.
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Affiliation(s)
- Jia-Kui Sun
- Department of Critical Care Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Cheng Lv
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Lin Gao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Wenjian Mao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu Province, China
- Research Institute of Critical Care Medicine and Emergency Rescue At, Nanjing University, Nanjing, Jiangsu Province, China
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2
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Arvanitakis M, Ockenga J, Bezmarevic M, Gianotti L, Krznarić Ž, Lobo DN, Löser C, Madl C, Meier R, Phillips M, Rasmussen HH, Van Hooft JE, Bischoff SC. ESPEN practical guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2024; 43:395-412. [PMID: 38169174 DOI: 10.1016/j.clnu.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024]
Abstract
Both acute and chronic pancreatitis are frequent diseases of the pancreas, which, despite being of benign nature, are related to a significant risk of malnutrition and may require nutritional support. Acute necrotizing pancreatitis is encountered in 20 % of patients with acute pancreatitis, is associated with increased morbidity and mortality, and may require artificial nutrition by enteral or parenteral route, as well as additional endoscopic, radiological or surgical interventions. Chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis. Abdominal pain leading to decreased oral intake, as well as exocrine and endocrine failure are frequent complications of the disease. All of the above represent risk factors related to malnutrition. Therefore, patients with chronic pancreatitis should be considered at risk, screened and supplemented accordingly. Moreover, osteoporosis and increased facture risk should be acknowledged in patients with chronic pancreatitis, and preventive measures should be considered.
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Affiliation(s)
- Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, HUB Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Johann Ockenga
- Department of Gastroenterology, Endocrinology and Clinical Nutrition, Klinikum Bremen Mitte, Bremen, Germany
| | - Mihailo Bezmarevic
- Department of Hepatobiliary and Pancreatic Surgery, Clinic for General Surgery, Military Medical Academy, University of Defense, Belgrade, Serbia
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Željko Krznarić
- Department of Gastroenterology, Hepatology and Nutrition, Clinical Hospital Centre & School of Medicine, Zagreb, Croatia
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, School of Medicine, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Christian Madl
- Division of Gastroenterology and Hepatology, Krankenanstalt Rudolfstiftung, Krankenanstaltenverbund Wien (KAV), Vienna, Austria
| | - Remy Meier
- AMB-Praxis-MagenDarm Basel, Basel, Switzerland
| | - Mary Phillips
- Department of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Jeanin E Van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Stephan C Bischoff
- Institute of Nutritional Medicine, University of Hohenheim, Stuttgart, Germany
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3
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Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
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Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
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4
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Cha PI, Jou RM, Spain DA, Forrester JD. Placement of Surgical Feeding Tubes Among Patients With Severe Traumatic Brain Injury Requiring Exploratory Abdominal Surgery : Better Early Than Late. Am Surg 2020; 86:635-642. [PMID: 32683978 DOI: 10.1177/0003134820923302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES The purpose of this study was to identify trauma patients who would benefit from surgical placement of an enteral feeding tube during their index abdominal trauma operation. METHODS We performed a retrospective analysis of all patients admitted to 2 level I trauma centers between January 2013 and February 2018 requiring urgent exploratory abdominal surgery. RESULTS Six-hundred and one patients required exploratory abdominal surgery within 24 hours of admission after trauma activation. Nineteen (3% of total) patients underwent placement of a feeding tube after their initial exploratory surgery. On multivariate analysis, an intracranial Abbreviated Injury Scale ≥4 (odds ratio [OR] = 9.24, 95% CI 1.09-78.26, P = .04) and a Glasgow Coma Scale ≤8 (OR = 4.39, 95% CI 1.38-13.95, P = .01) were associated with increased odds of requiring a feeding tube. All patients who required a feeding tube had an Injury Severity Score ≥15. While not statistically significant, patients with an open surgical feeding tube compared with interventional radiology/percutaneous endoscopic gastrostomy placement had lower median intensive care unit length of stay, fewer ventilator days, and shorter median total hospital length of stay. CONCLUSIONS Trauma patients with severe intracranial injury already requiring urgent exploratory abdominal surgery may benefit from early, concomitant placement of a feeding tube during the index abdominal operation, or at fascial closure.
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Affiliation(s)
- Peter I Cha
- 6429 Division of General Surgery, Department of Surgery, Stanford University, CA, USA
| | - Ronald M Jou
- 14454 Division of General Surgery, Department of Surgery, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - David A Spain
- 6429 Division of General Surgery, Department of Surgery, Stanford University, CA, USA
| | - Joseph D Forrester
- 6429 Division of General Surgery, Department of Surgery, Stanford University, CA, USA
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5
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ESPEN guideline on clinical nutrition in acute and chronic pancreatitis. Clin Nutr 2020; 39:612-631. [DOI: 10.1016/j.clnu.2020.01.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
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Goh EL, Chidambaram S, Segaran E, Garnelo Rey V, Khan MA. A meta-analysis of the outcomes following enteral vs parenteral nutrition in the open abdomen in trauma patients. J Crit Care 2019; 56:42-48. [PMID: 31837600 DOI: 10.1016/j.jcrc.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/23/2019] [Accepted: 12/02/2019] [Indexed: 11/16/2022]
Affiliation(s)
- En Lin Goh
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom.
| | - Swathikan Chidambaram
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom.
| | - Ella Segaran
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
| | - Vanesa Garnelo Rey
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
| | - Mansoor Ali Khan
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
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Tian W, Huang Q, Yao Z, Huang M, Yang F, Zhao Y, Li J. A preliminary prospective study of patients who underwent vacuum-assisted and mesh-mediated fascial traction techniques for open abdomen management with negative fluid therapy: An observational study. Medicine (Baltimore) 2019; 98:e16617. [PMID: 31464898 PMCID: PMC6736416 DOI: 10.1097/md.0000000000016617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
It is unclear whether strategies targeting negative fluid balance are associated with facilitated early fascial closure. The present study investigated the effects of fluid removal therapy on early facial closure of open abdomen patients.A prospective study was conducted in patients who underwent open abdomen management with vacuum-assisted and mesh-mediated fascial traction technique. Therapeutic diuresis with torasemide was applied to cause negative fluid balance in the treatment group. The study and follow-up periods were 7 and 180 days, respectively. The observational indices included the intra-abdominal pressure, the number of days to closure, the type of closure, the septic complications, the duration of ventilation support, the duration of initial hospital stay, and the duration of intensive care unit (ICU) stay.A total of 27 patients were divided into the treatment (16 patients) and control (11 patients) groups. The median intra-abdominal pressure (IAP) of the patients of the control and the treatment groups was significantly lower at day 7 compared with the baseline value (P < .0001). IAP was lower in the treatment group compared with that noted in the control group, following day 4 of the fluid removal therapy (P < .05). The percentage weight loss in the treatment group was between 4.80% and 10.88%. The early closure rates were significantly higher in the treatment group compared with those in the control group (75.0% vs 18.2%, P = .0063).Fluid removal therapy combined with vacuum-assisted and mesh-mediated fascial traction provided a high early fascial closure rate for open abdomen patients.
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Affiliation(s)
- Weiliang Tian
- Department of Surgery, Jinling Hospital, Nanjing, China
| | - Qian Huang
- Department of Surgery, Jinling Hospital, Nanjing, China
| | - Zheng Yao
- Department of Surgery, Jiangning Hospital, Nanjing, China
| | - Ming Huang
- Department of Surgery, Jiangning Hospital, Nanjing, China
| | - Fan Yang
- Department of Surgery, Jinling Hospital, Nanjing, China
| | - Yunzhao Zhao
- Department of Surgery, Jinling Hospital, Nanjing, China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Nanjing, China
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8
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Yeh DD, Martin M, Sakran JV, Meier K, Mendoza A, Grant AA, Parks J, Byerly S, Lee EE, McKinley WI, McClave SA, Miller K, Mazuski J, Taylor B, Luckhurst C, Fagenholz P. Advances in nutrition for the surgical patient. Curr Probl Surg 2019; 56:343-398. [DOI: 10.1067/j.cpsurg.2019.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Bower KL, Collier BR. Update on Feeding the Open Abdomen in the Trauma Patient. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0212-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Yandell R, Wang S, Bautz P, Shanks A, O'Connor S, Deane A, Lange K, Chapman M. A retrospective evaluation of nutrition support in relation to clinical outcomes in critically ill patients with an open abdomen. Aust Crit Care 2018; 32:237-242. [PMID: 29903605 DOI: 10.1016/j.aucc.2018.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Optimising nutrition support in critically ill patients with an open abdomen is challenging. OBJECTIVES The aims of this study were to (i) quantify the amount and adequacy of nutrition support administered and (ii) determine any relationships that exist between mode of nutrition support delivery and clinical outcomes in critically ill patients with an open abdomen. METHODS A retrospective review of critically ill patients mechanically ventilated for at least 48 h with an open abdomen in a mixed quaternary referral intensive care unit. Enteral and parenteral nutrition (ml) administered daily to patients was recorded for up to 21 days. Length of stay in the intensive care unit and hospital and duration of mechanical ventilation (days) were reported. RESULTS Thirty patients were studied [14 male, 68 y (15-90 y), body mass index 25 kg/m2 (11-51 kg/m2), Acute Physiology and Chronic Health Evaluation II score 20 (7-41), energy goal 1860 kcal/d (1250-2712 kcal/d)]. Patients received 55% (0-117%) of energy goal and 56% (0-105%) protein goal from either enteral or parenteral nutrition. When enteral nutrition was delivered alone or in combination with parenteral nutrition, patients received 48% (0-146%) of their energy and 59% (19-105%) of their protein goal. Patients fed parenteral nutrition, either alone or as supplementary to enteral nutrition (n = 18), received more energy when compared with those who only received enteral nutrition (n = 9) [65 (27-117) vs 49 (15-89) % energy goal, P = 0.025]. Parenteral nutrition was associated with an increased length of stay in hospital [63 (45-156) vs 45 (17-93) d, P = 0.037]. CONCLUSION Patients with an open abdomen receive about half of their nutrition requirements when fed exclusively via the enteral route. Providing combination enteral and parenteral nutrition to reach nutritional goals may not result in better clinical outcomes for patients with an open abdomen.
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Affiliation(s)
- Rosalie Yandell
- Department of Nutrition and Dietetics, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia; Centre of Clinical Research Excellence (CRE) in Translating Science to Good Health, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia; Discipline of Acute Care Medicine, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia.
| | - Susan Wang
- Department of Critical Care Services, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia
| | - Peter Bautz
- Hepatobiliary Surgery, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia
| | - Alison Shanks
- Department of Nutrition and Dietetics, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia
| | - Stephanie O'Connor
- Department of Critical Care Services, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia; Discipline of Acute Care Medicine, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia
| | - Adam Deane
- Department of Critical Care Services, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia; Centre of Clinical Research Excellence (CRE) in Translating Science to Good Health, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia; Discipline of Acute Care Medicine, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia
| | - Kylie Lange
- Centre of Clinical Research Excellence (CRE) in Translating Science to Good Health, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia
| | - Marianne Chapman
- Department of Critical Care Services, Trauma Services, Royal Adelaide Hospital, Port Rd, Adelaide, 5000, Australia; Centre of Clinical Research Excellence (CRE) in Translating Science to Good Health, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia; Discipline of Acute Care Medicine, The University of Adelaide, Frome Rd, Adelaide, 5000, Australia
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Coccolini F, Roberts D, Ansaloni L, Ivatury R, Gamberini E, Kluger Y, Moore EE, Coimbra R, Kirkpatrick AW, Pereira BM, Montori G, Ceresoli M, Abu-Zidan FM, Sartelli M, Velmahos G, Fraga GP, Leppaniemi A, Tolonen M, Galante J, Razek T, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Peitzman A, Demetrashvili Z, Sugrue M, Di Saverio S, Martzi I, Soreide K, Biffl W, Ferrada P, Parry N, Montravers P, Melotti RM, Salvetti F, Valetti TM, Scalea T, Chiara O, Cimbanassi S, Kashuk JL, Larrea M, Hernandez JAM, Lin HF, Chirica M, Arvieux C, Bing C, Horer T, De Simone B, Masiakos P, Reva V, DeAngelis N, Kike K, Balogh ZJ, Fugazzola P, Tomasoni M, Latifi R, Naidoo N, Weber D, Handolin L, Inaba K, Hecker A, Kuo-Ching Y, Ordoñez CA, Rizoli S, Gomes CA, De Moya M, Wani I, Mefire AC, Boffard K, Napolitano L, Catena F. The open abdomen in trauma and non-trauma patients: WSES guidelines. World J Emerg Surg 2018; 13:7. [PMID: 29434652 PMCID: PMC5797335 DOI: 10.1186/s13017-018-0167-4] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 01/18/2018] [Indexed: 02/08/2023] Open
Abstract
Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Derek Roberts
- Department of Surgery, Foothills Medical Centre, Calgary, Canada
| | - Luca Ansaloni
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | | | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM)–Unicamp Campinas, Campinas, SP Brazil
| | - Giulia Montori
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Marco Ceresoli
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA USA
| | | | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Matti Tolonen
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Joseph Galante
- Trauma and Acute Care Surgery and Surgical Critical Care Trauma, Department of Surgery, University of California, Davis, USA
| | - Tarek Razek
- General and Emergency Surgery, McGill University Health Centre, Montréal, QC Canada
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ingo Martzi
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie Universitätsklinikum Goethe-Universität Frankfurt, Frankfurt, Germany
| | - Kjetil Soreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI USA
| | | | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON Canada
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | - Rita Maria Melotti
- ICU Department, Sant’Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Salvetti
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Surgery Department, University of Maryland School of Medicine, Baltimore, MD USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery Department, Niguarda Hospital, Milano, Italy
| | | | - Jeffry L. Kashuk
- General Surgery Department, Assuta Medical Centers, Tel Aviv, Israel
| | - Martha Larrea
- General Surgery, “General Calixto García”, Habana Medicine University, Havana, Cuba
| | | | - Heng-Fu Lin
- Division of Trauma, Department of Surgery, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China
| | - Mircea Chirica
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Catherine Arvieux
- Clin. Univ. de Chirurgie Digestive et de l’Urgence, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Camilla Bing
- General and Emergency Surgery Department, Empoli Hospital, Empoli, Italy
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital and Örebro University, Orebro, Sweden
| | | | - Peter Masiakos
- Pediatric Trauma Service, Massachusetts General Hospital, Boston, MA USA
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kaoru Kike
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Paola Fugazzola
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Matteo Tomasoni
- General Emergency and Trauma Surgery, Bufalini Hospital, Viale Giovanni Ghirotti, 286, 47521 Cesena, Italy
| | - Rifat Latifi
- General Surgery Department, Westchester Medical Center, Westchester, NY USA
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, The University of Western Australia & The University of Newcastle, Perth, Australia
| | - Lauri Handolin
- Trauma Unit, Helsinki University Hospital, Helsinki, Finland
| | - Kenji Inaba
- Division of Trauma and Critical Care, LAC+USC Medical Center, University of Southern California, California, Los Angeles USA
| | - Andreas Hecker
- General and Thoracic Surgery, Giessen Hospital, Giessen, Germany
| | - Yuan Kuo-Ching
- Acute Care Surgery and Traumatology, Taipei Medical University Hospital, Taipei City, Taiwan, Republic of China
| | - Carlos A. Ordoñez
- Trauma and Acute Care Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Sandro Rizoli
- Trauma and Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Carlos Augusto Gomes
- Hospital Universitário Terezinha de Jesus, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora (SUPREMA), Juiz de Fora, Brazil
| | - Marc De Moya
- Trauma, Acute Care Surgery, Medical College of Wisconsin/Froedtert Trauma Center, Milwaukee, WI USA
| | - Imtiaz Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Alain Chichom Mefire
- Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Ken Boffard
- Milpark Hospital Academic Trauma Center, University of the Witwatersrand, Johannesburg, South Africa
| | - Lena Napolitano
- Acute Care Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI USA
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore Hospital, Parma, Italy
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12
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Fagoni N, Piva S, Marino R, Chiarini G, Ferrari D, Grespi E, Bertuetti R, Barbieri S, Latronico N, Rasulo F. The IN-PANCIA Study: Clinical Evaluation of Gastrointestinal Dysfunction and Failure, Multiple Organ Failure, and Levels of Citrulline in Critically Ill Patients. J Intensive Care Med 2017; 35:279-283. [PMID: 29141526 DOI: 10.1177/0885066617742594] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE Gastrointestinal dysfunction and failure (GID and GIF) in critically ill patients are a common, relevant, and underestimated complications in ICU patients. The aims of this study were (1) to determine plasmatic levels of citrulline, glutamine, and arginine as markers of GID/GIF in critically ill patients with or without GID/GIF with or without multiple organ failure (MOF) and (2) to assess the role of intra-abdominal hypertension in these patient groups. MATERIALS AND METHODS This is a 1-year, monocentric (Italian hospital), prospective observational study. Inclusion criteria were adult patients with GID/GIF, with or without MOF. The GIF score was daily evaluated in 39 critically ill patients. Amino acids were measured at the time of GID or GIF. RESULTS We enrolled 39 patients. Nine patients developed GID and 7 GIF; 6 of patients with GID/GIF developed MOF. Citrulline was lower (P < .001) in patients with GID/GIF (11.3 [4.4] µmol/L), compared to patients without GID/GIF (22.4 [6.8] µmol/L); likewise, glutamine was lower in patients with GID/GIF, whereas arginine was nonstatistically different between the 2 groups. Intra-abdominal pressure was higher in patients affected by MOF (13.0 [2.2] mm Hg) than in patients with GIF/GID without MOF (9.6 [2.6] mm Hg) and compared to patients without GID/GIF (7.2 [2.1] mm Hg). CONCLUSIONS Both GID and GIF in critically ill patients are associated with low levels of citrulline and glutamine, which could be considered as markers of small bowel dysfunction. The higher the GIF score, the lower the citrulline levels. Patients affected by MOF had higher levels of intra-abdominal pressure.
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Affiliation(s)
- Nazzareno Fagoni
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Simone Piva
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Rosella Marino
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Giovanni Chiarini
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Daniela Ferrari
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Eleonora Grespi
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Rita Bertuetti
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Silvia Barbieri
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Nicola Latronico
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Frank Rasulo
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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13
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Chabot E, Nirula R. Open abdomen critical care management principles: resuscitation, fluid balance, nutrition, and ventilator management. Trauma Surg Acute Care Open 2017; 2:e000063. [PMID: 29766080 PMCID: PMC5877893 DOI: 10.1136/tsaco-2016-000063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/15/2017] [Accepted: 05/16/2017] [Indexed: 12/14/2022] Open
Abstract
The term "open abdomen" refers to a surgically created defect in the abdominal wall that exposes abdominal viscera. Leaving an abdominal cavity temporarily open has been well described for several indications, including damage control surgery and abdominal compartment syndrome. Although beneficial in certain patients, the act of keeping an abdominal cavity open has physiologic repercussions that must be recognized and managed during postoperative care. This review article describes these issues and provides guidelines for the critical care physician managing a patient with an open abdomen.
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Affiliation(s)
- Elizabeth Chabot
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ram Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
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14
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Coccolini F, Montori G, Ceresoli M, Catena F, Moore EE, Ivatury R, Biffl W, Peitzman A, Coimbra R, Rizoli S, Kluger Y, Abu-Zidan FM, Sartelli M, De Moya M, Velmahos G, Fraga GP, Pereira BM, Leppaniemi A, Boermeester MA, Kirkpatrick AW, Maier R, Bala M, Sakakushev B, Khokha V, Malbrain M, Agnoletti V, Martin-Loeches I, Sugrue M, Di Saverio S, Griffiths E, Soreide K, Mazuski JE, May AK, Montravers P, Melotti RM, Pisano M, Salvetti F, Marchesi G, Valetti TM, Scalea T, Chiara O, Kashuk JL, Ansaloni L. The role of open abdomen in non-trauma patient: WSES Consensus Paper. World J Emerg Surg 2017; 12:39. [PMID: 28814969 PMCID: PMC5557069 DOI: 10.1186/s13017-017-0146-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/25/2017] [Indexed: 12/19/2022] Open
Abstract
The open abdomen (OA) is defined as intentional decision to leave the fascial edges of the abdomen un-approximated after laparotomy (laparostomy). The abdominal contents are potentially exposed and therefore must be protected with a temporary coverage, which is referred to as temporal abdominal closure (TAC). OA use remains widely debated with many specific details deserving detailed assessment and clarification. To date, in patients with intra-abdominal emergencies, the OA has not been formally endorsed for routine utilization; although, utilization is seemingly increasing. Therefore, the World Society of Emergency Surgery (WSES), Abdominal Compartment Society (WSACS) and the Donegal Research Academy united a worldwide group of experts in an international consensus conference to review and thereafter propose the basis for evidence-directed utilization of OA management in non-trauma emergency surgery and critically ill patients. In addition to utilization recommendations, questions with insufficient evidence urgently requiring future study were identified.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery, Parma Maggiore hospital, Parma, Italy
| | | | - Rao Ivatury
- Trauma Surgery, Virginia Commonwealth University, Richmond, VA 23284 USA
| | - Walter Biffl
- Acute Care Surgery, The Queen’s Medical Center, Honolulu, HI 96813 USA
| | - Andrew Peitzman
- Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, 15213 USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, 92103 USA
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael’s Hospital, Toronto, ON Canada
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus, Haifa, Israel
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Marc De Moya
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | - George Velmahos
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA 02114 USA
| | | | - Bruno M. Pereira
- Faculdade de Ciências Médicas (FCM) – Unicamp Campinas, São Paulo, Brazil
| | - Ari Leppaniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | | | | | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, 98104 USA
| | - Miklosh Bala
- General Surgery Department, Hadassah Medical Centre, Jerusalem, Israel
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital/UMBAL/St George Plovdiv, Plovdiv, Bulgaria
| | | | - Manu Malbrain
- ICU and High Care Burn Unit, Ziekenhius Netwerk Antwerpen, Antwerpen, Belgium
| | | | | | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | | | - Ewen Griffiths
- Upper Gatrointestinal Surgery, Birmigham Hospital, Birmigham, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - John E. Mazuski
- Department of Surgery, School of Medicine, Washington University, Saint Louis, MO 63130 USA
| | - Addison K. May
- Departments of Surgery and Anesthesiology, Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN 37232 USA
| | - Philippe Montravers
- Département d’Anesthésie-Réanimation, CHU Bichat Claude-Bernard-HUPNVS, Assistance Publique-Hôpitaux de Paris, University Denis Diderot, Paris, France
| | | | - Michele Pisano
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Francesco Salvetti
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Tino M. Valetti
- ICU Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Thomas Scalea
- Trauma Surgery department, University of Maryland School of Medicine, Baltimore, MD 21201 USA
| | - Osvaldo Chiara
- Emergency and Trauma Surgery department, Niguarda Hospital, Milan, Italy
| | - Jeffry L. Kashuk
- General Surgery department, Assuta Medical Centers, Tel Aviv, Israel
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery dept., Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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15
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Prevalence and mortality of abdominal compartment syndrome in severely injured patients: A systematic review. J Trauma Acute Care Surg 2017; 81:585-92. [PMID: 27398983 DOI: 10.1097/ta.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Abdominal compartment syndrome (ACS) in severely injured patients is associated with high morbidity and mortality. Many efforts have been made to improve outcome of patients with ACS. A treatment algorithm for ACS patients was introduced on January 1, 2005 by the World Society of the Abdominal Compartment Syndrome. The aim of this study was to determine the prevalence and mortality rate of ACS among severely injured patients before and after January 1, 2005 using a systematic literature review. METHOD Databases of Embase, Medline (OvidSP), Web of Science, CINAHL, CENTRAL, PubMed publisher, and Google Scholar were searched for terms related to severely injured patients and ACS. Original studies reporting ACS in trauma patients were considered eligible. Data on study design, population, definitions, prevalence, and mortality rates were extracted. Pooled prevalence and mortality of ACS among severely injured patients were calculated for both time periods using inversed variance weighting assuming a random effects model. Tests for heterogeneity were applied. RESULTS A total of 80 publications were included. Prevalence of studies that finished enrolling patients before January 1, 2005 ranged from 0.5% to 36.4% and 0.0% to 28.0% in studies after that date. For severely injured patients admitted to the ICU, this range was 0.5% to 1.3% before 2005 and 0% in one publication in the second time period. For patients with visceral injuries, ACS prevalence ranged 1.0% to 20.0%; one study in the second time period reported 11.1%. The prevalence among severely injured patients who underwent trauma laparotomy ranged from 0.9% to 36.4% in the first time period. Two studies after January 1, 2005 reported ACS prevalence of 2.3% and 13.2%, respectively. The mortality rate in both time periods ranged between 0.0% and 100.0%. CONCLUSION The overall prevalence of ACS ranged from 0.0% to 36.4%. Future studies are needed to measure the effect of improved trauma care and effectiveness of the World Society of the Abdominal Compartment Syndrome Consensus Statements. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
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16
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Collier B, Guillamondegui O, Cotton B, Donahue R, Conrad A, Groh K, Richman J, Vogel T, Miller R, Diaz J. Feeding the Open Abdomen. JPEN J Parenter Enteral Nutr 2017; 31:410-5. [PMID: 17712150 DOI: 10.1177/0148607107031005410] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The purpose of this study was to determine if early enteral nutrition improves outcome for trauma patients with an open abdomen (OA). METHODS Retrospective review was used to identify 78 patients who required an OA for >or=4 hospital days, survived, and had available nutrition data. Demographic data and nutrition data comprising enteral nutrition initiation day and daily % target goal were collected. Patients were divided into 2 groups: early enteral feeding (EEN), initiated <or=4 days within celiotomy; and late enteral feeding (LEN; >4 days). Outcomes included infectious complications, early closure of the abdominal cavity (<8 days from original celiotomy), and fistula formation. RESULTS Fifty-three of 78 (68%) patients were men, with a mean age of 35 years; 74% had blunt trauma. Forty-three of 78 (55%) patients had EEN, whereas 35 of 78 (45%) had LEN. There was no difference with respect to demographics, injury severity, or infectious complication rates. Thirty-two of 43 (74%) patients with EEN had early closure of the abdominal cavity, whereas 17 of 35 (49%) patients with late feeding had early closure (p = .02). Four of 43 (9%) patients with EEN demonstrated fistula formation, whereas 9 of 35 (26%) patients with late feeding formed fistulae (p = .05). The EEN group had lower hospital charges (p = .04) by more than $50,000. CONCLUSIONS EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.
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Affiliation(s)
- Bryan Collier
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
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17
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Nutrition Therapy in Shock. CURRENT SURGERY REPORTS 2016. [DOI: 10.1007/s40137-016-0161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Abstract
Early provision of enteral nutrition (EN) in critically ill and injured patients has become standard practice in surgical intensive care units (ICUs) due to its proven role in reducing septic complications. Increasingly, intensivists are confronted with patients with an open abdomen due to the use of damage control surgery and the recognition of the abdominal compartment syndrome; the role and timing of EN in these challenging patients continue to be debated. Patients with an open abdomen are often among the sickest in the ICU and hence could benefit from early nutrition support. However, the exposed abdominal viscera can understandably create anxiety regarding the initiation of EN; there is theoretic concern over exacerbation of bowel distention with resultant inability to close the abdomen and an increased aspiration risk due to paralytic ileus. Recent studies have investigated the utility of EN in the patient with an open abdomen, addressing these clinical concerns. The goal of this clinical review is to provide guidance to physicians caring for these complex patients.
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Affiliation(s)
- Scott M Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, Colorado, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, Colorado, USA
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19
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Yin J, Wang J, Yao D, Zhang S, Mao Q, Kong W, Ren L, Li Y, Li J. Is it feasible to implement enteral nutrition in patients with enteroatmospheric fistulae? A single-center experience. Nutr Clin Pract 2015; 29:656-61. [PMID: 24920224 DOI: 10.1177/0884533614536587] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Published experience in feeding patients with enteroatmospheric fistulae is scarce. This study aimed to determine if enteral nutrition (EN) could be safely delivered in the presence of enteroatmospheric fistula. MATERIALS AND METHODS This is a retrospective descriptive study from a major fistula treatment center in China. Medical records of patients who developed enteroatmospheric fistulae in the open abdomen after abdominal trauma were reviewed. The timing of initiation and achievement of full strength (25 kcal/kg/d) EN after enteroatmospheric fistula were noted, as well as the incidence of feeding-associated complications and weaning of parenteral nutrition (PN). The outcomes of open abdomen and enteroatmospheric fistula were also noted. RESULTS Nine patients were included in this study. EN was successfully implemented in all patients. The median timing of initiation and achievement of full strength of EN after enteroatmospheric fistula was 9 (interquartile range [IQR], 3–22) and 27 (IQR, 22–43) days, respectively. Feeding-associated complications developed in 1 (11.1%) patient. All patients were liberated from PN at hospital discharge. Split-thickness skin grafting was performed in all patients, of whom 5 underwent successful delayed abdominal closure, and 4 were awaiting definitive closure. Repair or resection of enteroatmospheric fistula occurred in 8 (88.9%) patients. CONCLUSION This study showed that EN could be safely implemented in patients with enteroatmospheric fistulae without complicating the treatment of open abdomen and enteroatmospheric fistula.
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Affiliation(s)
- Jianyi Yin
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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20
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IROA: the International Register of Open Abdomen.: An international effort to better understand the open abdomen: call for participants. World J Emerg Surg 2015; 10:37. [PMID: 26279673 PMCID: PMC4537582 DOI: 10.1186/s13017-015-0029-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 07/23/2015] [Indexed: 11/10/2022] Open
Abstract
Actually the most common indications for Open Abdomen (OA) are trauma, abdominal sepsis, severe acute pancreatitis and more in general all those situations in which an intra-abdominal hypertension condition is present, in order to prevent the development of an abdominal compartment syndrome. The mortality and morbidity rate in patients undergone to OA procedures is still high. At present many studies have been published about the OA management and the progresses in survival rate of critically ill trauma and septic surgical patients. However several issues are still unclear and need more extensive studies. The definitions of indications, applications and methods to close the OA are still matter of debate. To overcome this lack of high level of evidence data about the OA indications, management, definitive closure and follow-up, the World Society of Emergency Surgery (WSES) promoted the International Register of Open Abdomen (IROA). The register will be held on a web platform (Clinical Registers®) through a dedicated web site: www.clinicalregisters.org. This will allow to all surgeons and physicians to participate from all around the world only by having a computer and a web connection. The IROA protocol has been approved by the coordinating center Ethical Committee (Papa Giovanni XXIII hospital, Bergamo, Italy). IROA has also been registered to ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT02382770).
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21
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Coccolini F, Biffl W, Catena F, Ceresoli M, Chiara O, Cimbanassi S, Fattori L, Leppaniemi A, Manfredi R, Montori G, Pesenti G, Sugrue M, Ansaloni L. The open abdomen, indications, management and definitive closure. World J Emerg Surg 2015; 10:32. [PMID: 26213565 PMCID: PMC4515003 DOI: 10.1186/s13017-015-0026-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 07/10/2015] [Indexed: 12/17/2022] Open
Abstract
The indications for Open Abdomen (OA) are generally all those situations in which is ongoing the development an intra-abdominal hypertension condition (IAH), in order to prevent the development of abdominal compartmental syndrome (ACS). In fact all those involved in care of a critically ill patient should in the first instance think how to prevent IAH and ACS. In case of ACS goal directed therapy to achieve early opening and early closure is the key: paradigm of closure shifts to combination of therapies including negative pressure wound therapy and dynamic closure, in order to reduce complications and avoid incisional hernia. There have been huge studies and progress in survival of critically ill trauma and septic surgical patients: this in part has been through the great work of pioneers, scientific societies and their guidelines; however future studies and continued innovation are needed to better understand optimal treatment strategies and to define more clearly the indications, because OA by itself is still a morbid procedure.
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Affiliation(s)
- Federico Coccolini
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | | | - Fausto Catena
- />General surgery Department, Ospedale Maggiore, Parma, Italy
| | - Marco Ceresoli
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Osvaldo Chiara
- />Niguarda Trauma Center, Ospedale Niguarda Ca’Granda, Milan, Italy
| | | | - Luca Fattori
- />Unità Operativa di Chirurgia d’Urgenza, Azienda Ospedaliera “San Gerardo”, Monza, Italy
| | - Ari Leppaniemi
- />Department of Abdominal Surgery, University of Helsinki, Helsinki, Finland
| | - Roberto Manfredi
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giulia Montori
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
| | - Giovanni Pesenti
- />Unità Operativa di Chirurgia d’Urgenza, Azienda Ospedaliera “San Gerardo”, Monza, Italy
| | - Michael Sugrue
- />Letterkenny Hospital and the Donegal Clinical Research Academy, Donegal, Ireland
- />University College Hospital, Galway, Ireland
| | - Luca Ansaloni
- />General Surgery Department, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy
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22
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Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chiara O, Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP, Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R, Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA, Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 2015; 10:35. [PMID: 26269709 PMCID: PMC4534034 DOI: 10.1186/s13017-015-0032-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023] Open
Abstract
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
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Affiliation(s)
- Massimo Sartelli
- Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy
| | - Fikri M. Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Luca Ansaloni
- General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Walter L. Biffl
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
| | - Fausto Catena
- Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Osvaldo Chiara
- Emergency Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | | | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Science, San Diego, USA
| | - Zaza Demetrashvili
- Department of Surgery, Tbilisi State Medical University, Kipshidze Central University Hospital, Tbilisi, Georgia
| | - Demetrios Demetriades
- Trauma, Emergency Surgery, Surgical Critical Care, University of Southern California, Los Angeles, USA
| | - Jose J. Diaz
- Shock Trauma Center, University of Maryland School of Medicine, Baltimore, USA
| | | | - Gustavo P. Fraga
- Division of Trauma Surgery, Hospital de Clinicas, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Wagih Ghnnam
- Department of Surgery Mansoura, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Sanjay Gupta
- Department of Surgery Government Medical College and Hospital, Chandigarh, India
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | | | - Victor Y. Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Reinhold Kafka-Ritsch
- Department of Visceral, Thorax and Transplant Surgery, University of Innsbruck, Innsbruck, Austria
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Rifat Latifi
- Department of Surgery, Trauma Research Institute, University of Arizona, Tucson, AZ USA
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea
| | - Michael McFarlane
- Department of Surgery, University Hospital of the West Indies, Kingston, Jamaica
| | - Sanjay Marwah
- Department of Surgery, Post-Graduate Institute of Medical Sciences, Rohtak, India
| | | | - Carlos A. Ordonez
- Department of Surgery, Fundación Valle del Lili, Hospital Universitario del Valle, Universidad del Valle, Cali, Colombia
| | - Gerson Alves Pereira
- Division of Emergency and Trauma Surgery, Ribeirão Preto Medical School, Ribeirão Preto, Brazil
| | - Haralds Plaudis
- Department of General and Emergency Surgery, Riga East Clinical University Hospital “Gailezers”, Riga, Latvia
| | - Vishal G. Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Jan Ulrych
- 1st Surgical Department of First Faculty of Medicine, General University Hospital, Prague Charles University, Prague, Czech Republic
| | | | | | - Maria Paula Garcia
- Centro de investigaciones clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Ernest E. Moore
- Department of Surgery, University of Colorado, Denver Health Medical Center, Denver, USA
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VAWCM-Instillation Improves Delayed Primary Fascial Closure of Open Septic Abdomen. Gastroenterol Res Pract 2014; 2014:245182. [PMID: 25548553 PMCID: PMC4273477 DOI: 10.1155/2014/245182] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/18/2014] [Indexed: 01/14/2023] Open
Abstract
Background. Failure to achieve delayed primary fascial closure (DPFC) is one of the main complications of open abdomen (OA), certainly when abdominal sepsis is present. This retrospective cohort study aims to evaluate the effect of combined therapy of vacuum-assisted mesh-mediated fascial traction and topical instillation (VAWCM-instillation) on DPFC in the open septic abdomen. Methods. The patients with abdominal sepsis who underwent OA using VAWCM were included and divided into the instillation and noninstillation (control) groups. The DPFC rate and other outcomes were compared between the two groups. Results. Between 2007 and 2013, 73 patients with open septic abdomen were treated with VAWCM-instillation and 61 cases with VAWCM-only. The DPFC rate in the instillation group was significantly increased (63% versus 41%, P = 0.011). The mortality with OA was similar (24.6% versus 23%, P = 0.817) between the two groups. However, time to DPFC (P = 0.003) and length of stay in hospital (P = 0.022) of the survivals were significantly decreased in the instillation group. In addition, VAWCM-instillation (OR 1.453, 95% CI 1.222–4.927, P = 0.011) was an independent influencing factor related to successful DPFC. Conclusions. VAWCM-instillation could improve the DPFC rate but could not decrease the mortality in the patients with open septic abdomen.
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Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study. World J Surg 2014; 37:2053-60. [PMID: 23674254 DOI: 10.1007/s00268-013-2087-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP). METHODS Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded. RESULTS Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved. CONCLUSIONS Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3-4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.
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Nutritional support in patients following damage control laparotomy with an open abdomen. Eur J Trauma Emerg Surg 2013; 39:243-8. [PMID: 26815230 DOI: 10.1007/s00068-013-0287-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 04/01/2013] [Indexed: 10/27/2022]
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 multi-system 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.
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Burlew CC. The open abdomen: practical implications for the practicing surgeon. Am J Surg 2012; 204:826-35. [PMID: 23000185 DOI: 10.1016/j.amjsurg.2012.04.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 04/23/2012] [Accepted: 04/23/2012] [Indexed: 12/13/2022]
Abstract
The open abdomen is a necessary sequela after damage-control surgery or abdominal compartment syndrome. Management of the patient in the intensive care unit continues to evolve, with considerations of fluid resuscitation, enteral nutrition, and supportive care. Management of the abdominal contents incorporates several basic techniques and considerations: appropriate temporary covering, enteric injury repair in most patients, placement of an anastomosis in an area of the abdomen with minimal manipulation without exposure to the atmosphere, acquiring enteral access for initiation of enteral nutrition, and ultimate abdominal closure. An understanding of these complex factors is instrumental for the practicing surgeon.
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Affiliation(s)
- Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center and the University of Colorado School of Medicine, Denver, CO, USA.
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Abstract
Since the mid-1990s the surgical community has seen a surge in the prevalence of open abdomens (OAs) reported in the surgical literature and in clinical practice. The OA has proven to be effective in decreasing mortality and immediate postoperative complications; however, it may come at the cost of delayed morbidity and the need for further surgical procedures. Indications for leaving the abdomen open have broadened to include damage control surgery, abdominal compartment syndrome, and abdominal sepsis. The surgical options for management of the OA are now more diverse and sophisticated, but there is a lack of prospective randomized controlled trials demonstrating the superiority of any particular method. Additionally, critical care strategies for optimization of the patient with an OA are still being developed. Review of the literature suggests a bimodal distribution of primary closure rates, with early closure dependent on postoperative intensive care management and delayed closure more affected by the choice of the temporary abdominal closure technique. Invariably, a small fraction of patients requiring OA management fail to have primary fascial closure and require some form of biologic fascial bridge with delayed ventral hernia repair in the future.
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Abstract
Adequate nutrition support is critical in the management of patients with an open abdomen. Despite the literature supporting its use in trauma patients, provider concerns and clinical controversies remain regarding the early administration and long-term sequelae of enteral nutrition (EN) therapy in these patients. The purpose of this article is to review the clinical concepts behind the use of the open abdomen, as well as examine the altered nutrition requirements associated with the maintenance of a temporary laparostomy. The rationale for early EN is described, as well as the pros and cons surrounding the use of supplemental parenteral nutrition in those patients unable to meet nutrition goals enterally in a reasonable time frame. Finally, an open abdomen nutrition support algorithm is provided as part of the critical care plan in these patients who represent the sickest of surgical patients.
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Affiliation(s)
- Nathan J Powell
- Vanderbilt University School of Medicine, Nashville, TN, USA
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One hundred percent fascial approximation can be achieved in the postinjury open abdomen with a sequential closure protocol. J Trauma Acute Care Surg 2012; 72:235-41. [DOI: 10.1097/ta.0b013e318236b319] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dutton WD, Diaz JJ, Miller RS. Critical care issues in managing complex open abdominal wound. J Intensive Care Med 2011; 27:161-71. [PMID: 21436165 DOI: 10.1177/0885066610396162] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Over the past 30 years, surgical specialties have introduced and expanded the role of open abdominal management in complicated operative cases, necessitating an intensivist's understanding of the indications and unique intensive care unit (ICU) issues related to the open abdomen. When presented with the open abdomen, resuscitation to correct shock is of primary concern. This is accomplished by correction of hypothermia, acidosis, and coagulopathy in trauma and adequate resolution of intra-abdominal hypertension or source control in general surgery. These patients typically require deep sedation and often paralysis and benefit from low-volume ventilatory strategies to prevent and treat acute lung injury. Antibiotics must be tailored to the clinical situation, but in most cases, 24 hours of perioperative treatment is all that is required. In cases of gross contamination and peritonitis, a 5- to 7-day course of broad-spectrum antibiotics may be of benefit.Adequate source control has been demonstrated to have the greatest impact on outcome and when the patient's clinical milieu dictates, bedside washouts. Enteral nutrition should be instituted as early as possible after intestinal continuity has been reestablished. Additional protein is required to account for losses from the open abdomen. Reconstruction may require staging, but in general, should proceed following resolution of shock and control of sepsis. Elevated multiorgan dysfunction score, Acute Physiology And Chronic Health Evaluation II (APACHE II), and a rise in peak inspiratory pressure portend poor source control and could result in failure of fascial closure. If unable to proceed to fascial closure, then considerations should be made for planned ventral hernia and subsequent abdominal wall reconstruction.
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Affiliation(s)
- William D Dutton
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37221, USA
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Abstract
Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. Although recently high-grade evidence on nutrition support in the critically ill population has been published, many controversies still exist. In obese patients, use of hypocaloric feedings with increased protein has been demonstrated to promote weight loss and improved glucose management. In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.
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Affiliation(s)
- Anthony T. Gerlach
- Department of Pharmacy, The Ohio State University Medical Center, Columbus, OH, USA
| | - Claire Murphy
- Department of Pharmacy, The Ohio State University Medical Center, Columbus, OH, USA
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Intra-abdominal hypertension: detecting and managing a lethal complication of critical illness. AACN Adv Crit Care 2010; 21:205-19. [PMID: 20431449 DOI: 10.1097/nci.0b013e3181d94fd5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Intra-abdominal hypertension occurs in 50% of all patients admitted to the intensive care unit and is associated with significant morbidity and mortality. Intra-abdominal hypertension is defined as a sustained, pathologic rise in intra-abdominal pressure to 12 mm Hg or more. Patients with intra-abdominal hypertension may progress to abdominal compartment syndrome. Early identification and treatment of this condition will improve patient outcome. Patients at risk for intra-abdominal hypertension include those with major traumatic injury, major surgery, sepsis, burns, pancreatitis, ileus, and massive fluid resuscitation. Predisposing factors include decreased abdominal wall compliance, increased intraluminal contents, increased peritoneal cavity contents, and capillary leak/fluid resuscitation.
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Byrnes MC, Reicks P, Irwin E. Early enteral nutrition can be successfully implemented in trauma patients with an "open abdomen". Am J Surg 2010; 199:359-62; discussion 363. [PMID: 20226910 DOI: 10.1016/j.amjsurg.2009.08.033] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 08/21/2009] [Accepted: 08/21/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of an "open abdomen" after a trauma laparotomy can complicate the nutritional management of injured patients. METHODS The medical records of patients admitted to an American College of Surgeons-verified level 1 trauma center were evaluated. The timing of nutritional support was noted. The method to obtain abdominal closure was also noted. RESULTS Twenty-three patients were included in the study. Enteral nutrition was successfully initiated in 52% of patients before fascial closure. Enteral nutrition was initiated 3.8 days after the initial laparotomy in these patients. All patients successfully achieved fascial and skin closure, obviating the need for delayed hernia repair or skin grafting. CONCLUSIONS Enteral nutrition can be successfully initiated in patients with "open abdomens." In our series, early enteral nutrition did not alter our ability to ultimately obtain fascial and skin closure.
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Affiliation(s)
- Matthew C Byrnes
- Department of Trauma, North Memorial Medical Center, Robbinsdale, MN, USA.
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Evaluating the potential role of nitric oxide as a mediator of hydrostatic edema mediated intestinal contractile dysfunction. J Surg Res 2010; 163:102-9. [PMID: 20605598 DOI: 10.1016/j.jss.2010.02.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2009] [Revised: 01/26/2010] [Accepted: 02/22/2010] [Indexed: 01/25/2023]
Abstract
BACKGROUND Administration of L-nil, a selective inhibitor of inducible nitric oxide synthase (iNOS), improves ileus in an animal model of resuscitation induced intestinal edema. The purpose of this study was to elucidate the iNOS/nitric oxide (NO) signal transduction pathway in intestinal edema. MATERIALS AND METHODS Male Sprague Dawley rats were divided into two groups; CONTROL and RESUS+VH (edema, 80 cc/kg normal saline (resuscitation) with mesenteric venous hypertension). iNOS mRNA and protein, iNOS activity, NO tissue levels, soluble guanylyl cyclase (sGC) expression, and cyclic guanosine monophosphate (cGMP) levels were measured. As a functional endpoint, we evaluated intestinal contractile strength and frequency in L-nil treated animals. RESULTS Edema was associated with increased iNOS mRNA and protein expression without subsequent increases in iNOS activity or tissue NO levels. There was no significant change in sGC expression or increase in cGMP induced by edema. Administration of L-nil did not decrease edema development or preserve contractile strength, but increased contractile frequency. CONCLUSION Hydrostatic intestinal edema is not associated with increased iNOS activity or tissue NO levels. Administration of L-nil in edema increases intestinal contractile frequency. This may represent a potential mechanism for the amelioration of ileus seen with the administration of L-nil.
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Abstract
OBJECTIVE To investigate the molecular mechanisms leading to edema-induced decreases in intestinal smooth muscle myosin light-chain phosphorylation. Intestinal interstitial edema often develops during abdominal surgery and after fluid resuscitation in trauma patients. Intestinal edema causes decreased intestinal contractile activity via decreased intestinal smooth muscle myosin light-chain phosphorylation, leading to slower intestinal transit. Interstitial edema development is a complex phenomenon, resulting in many changes to the interstitial environment surrounding intestinal smooth muscle cells. Thus, the mechanism(s) by which intestinal edema development causes intestinal dysfunction are likely to be multifactorial. DESIGN Randomized animal study. SETTING University laboratory. SUBJECTS Male Sprague-Dawley rats, weighing 250-350 g. INTERVENTION Studies were performed in a rat model in which a combination of mesenteric venous hypertension and administration of resuscitative fluids induces intestinal edema, mimicking the clinical setting of damage control resuscitation. MEASUREMENTS AND MAIN RESULTS Microarray analysis of edematous intestinal smooth muscle combined with an in silico search for overrepresented transcription factor binding sites revealed the involvement of nuclear factor-kappaB in edema-induced intestinal dysfunction. Nuclear factor-kappaB deoxyribonucleic acid binding activity was significantly increased in edematous intestinal smooth muscle compared with controls. Inhibition of nuclear factor-kappaB activation blocked edema-induced decreases in basal intestinal contractile activity. Inhibition of nuclear factor-kappaB activation also attenuated edema-induced decreases in myosin light-chain phosphorylation. CONCLUSIONS We conclude that intestinal edema activates nuclear factor-kappaB, which, in turn, triggers a gene regulation program that eventually leads to decreased myosin light-chain phosphorylation and, thus, decreased intestinal contractile activity.
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Gianotti L, Meier R, Lobo DN, Bassi C, Dejong CHC, Ockenga J, Irtun O, MacFie J. ESPEN Guidelines on Parenteral Nutrition: pancreas. Clin Nutr 2009; 28:428-35. [PMID: 19464771 DOI: 10.1016/j.clnu.2009.04.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 04/01/2009] [Indexed: 12/13/2022]
Abstract
Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5-7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided. PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased. When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered. In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.
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Affiliation(s)
- L Gianotti
- Department of Surgery, Milano-Bicocca University, San Gerardo Hospital, Monza, Italy
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Moore-Olufemi SD, Padalecki J, Olufemi SE, Xue H, Oliver DH, Radhakrishnan RS, Allen SJ, Moore FA, Stewart R, Laine GA, Cox CS. Intestinal edema: effect of enteral feeding on motility and gene expression. J Surg Res 2008; 155:283-92. [PMID: 19482297 DOI: 10.1016/j.jss.2008.08.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Revised: 07/29/2008] [Accepted: 08/01/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Edema formation, inflammation, and ileus in the intestine are commonly seen in conditions like gastroschisis, inflammatory bowel disease, and cirrhosis. We hypothesized that early enteral feeding would improve intestinal transit. We also wanted to study the impact of early enteral feeding on global gene expression in the intestine. DESIGN Rats were divided into Sham or Edema +/- immediate enteral nutrition (IEN). At 12 h, small intestinal transit via FITC-Dextran and tissue water were measured. Ileum was harvested for total RNA to analyze gene expression using cDNA microarray with validation using real-time PCR. Data are expressed as mean +/- SEM, n = 4-6 and (*), (**) = P < 0.05 versus all groups using ANOVA. RESULTS IEN markedly improved intestinal transit with minimal genetic alterations in Edema animals. Major alterations in gene expression were detected in primary, cellular and macromolecular metabolic activities. Edema also altered more genes involved with the regulation of the actin cytoskeleton. CONCLUSIONS Intestinal edema results in impaired small intestinal transit and globally increased gene expression. Early enteral nutrition improves edema-induced impaired transit and minimizes gene transcriptional activity.
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Affiliation(s)
- Stacey D Moore-Olufemi
- Department of Surgery, University of Texas-Houston Medical School, Houston, Texas 77030, USA
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Abstract
PURPOSE OF REVIEW The utilization of enteral nutrition in critically ill patients is frequently suboptimal. This may be due, in part, to ongoing controversies regarding appropriate use of enteral support, but there are also perceived barriers to its use even when there is good evidence that it can be given. This review was undertaken to outline some of these controversies and barriers to use of enteral nutrition in the ICU. RECENT FINDINGS Although the advantages of enteral nutrition may have been overstated, it remains preferable to parenteral nutrition for support of critically ill patients. Early initiation of enteral support is a reasonable approach. Many patients with perceived contraindications to enteral therapy are actually good candidates for its use. Frequent interruptions in enteral nutrition lead to suboptimal nutrient delivery, but might be overcome by use of specific protocols emphasizing safe and effective utilization of enteral support. SUMMARY Use of enteral nutritional support is recommended for critically ill patients requiring specialized nutritional support. Barriers to its use could be overcome by better educating providers about indications for use and by developing methods to avoid undue interruption of therapy.
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Dissanaike S, Pham T, Shalhub S, Warner K, Hennessy L, Moore EE, Maier RV, O'Keefe GE, Cuschieri J. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg 2008; 207:690-7. [PMID: 18954781 DOI: 10.1016/j.jamcollsurg.2008.06.332] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 06/10/2008] [Accepted: 06/17/2008] [Indexed: 01/25/2023]
Abstract
BACKGROUND Damage-control laparotomy has become increasingly common after operative resuscitation of severe hemorrhagic shock after injury. Despite increased use, uncertainty exists about the safety and timing of enteral nutrition. The purpose of this study was to determine the safety and effect of immediate enteral nutrition. STUDY DESIGN Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in adults with hemorrhagic shock after injury and were limited to patients with an open abdomen and no hollow viscus injury. The immediate enteral nutrition cohort was defined as initiation of enteral feeds within 36 hours after acute resuscitation completion. Multivariate stepwise logistic regression was used to evaluate factors associated with immediate enteral nutrition. RESULTS One hundred subjects met inclusion criteria; 32 immediate enteral nutrition and 68 nonimmediate enteral nutrition. Nearly all patients underwent fascial closure (93.8% immediate enteral nutrition versus 94.1% nonimmediate enteral nutrition), with an average closure day of 6.47 +/- 0.83 with immediate enteral nutrition and 8.55 +/- 0.85 with nonimmediate enteral nutrition (p = 0.129). No significant difference in multiorgan dyfunction syndrome, length of ventilator days, ICU days, hospital days, or mortality was seen between groups. The rate of pneumonia was significantly different: 14 (43.8%) in immediate enteral nutrition and 49 (72.1%) in nonimmediate enteral nutrition (p = 0.008). Immediate enteral nutrition remained independently associated with a reduction in pneumonia within our stepwise regression (odds ratio = 0.32; 95% CI, 0.13 to 0.79). CONCLUSIONS Immediate enteral nutrition after damage control appears safe, with no effect on abdominal closure rate. In addition, the reduction in pneumonia associated with immediate enteral nutrition suggests a tangible benefit. Immediate enteral nutrition should be considered in patients with open abdomens after severe trauma.
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Uray KS, Laine GA, Xue H, Allen SJ, Cox CS. Edema-induced intestinal dysfunction is mediated by STAT3 activation. Shock 2007; 28:239-44. [PMID: 17515852 DOI: 10.1097/shk.0b013e318033eaae] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Increased signal transducer and activator of transcription 3 (STAT3) activation has been shown to be associated with intestinal dysfunction. The purpose of this study was to investigate the role of STAT3 in edema-induced intestinal dysfunction. Intestinal edema was induced in male Sprague-Dawley rats by a combination of mesenteric venous hypertension and fluid resuscitation (RESUS + VH). Resuscitation fluid alone (RESUS), venous hypertension alone (VH), and sham-operated rats (CONTROL) were used as controls. Edema development, STAT3 DNA binding activity, nuclear translocation, and phosphorylation were measured in rat distal small intestinal muscularis. A significant amount of edema development was measured in the RESUS + VH rats compared with CONTROL and VH from 30 min to 6 h after surgery. Edema developed in the RESUS group at 30 min postsurgery but resolved before 2 h postsurgery. A significant increase in STAT3 DNA binding activity was observed from 30 min to 6 h after surgery in the edematous RESUS + VH group compared with nonedematous CONTROL. In addition, a significant increase in STAT3 nuclear translocation and phosphorylation was measured in the RESUS + VH group 2 and 6 h after surgery. No significant increases in STAT3 activation were observed in either the RESUS or VH groups compared with CONTROL. Rats in both the RESUS + VH and CONTROL groups were pretreated with AG490 (5 mg/kg, i.p.) to block STAT3 activation. Signal transducer and activator of transcription 3 inhibition attenuated edema-induced decrease in intestinal contractile activity and myosin light chain phosphorylation. We conclude from these data that edema-induced decreases in intestinal contractile activity are mediated, at least in part, by STAT3 activation.
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Affiliation(s)
- Karen S Uray
- Division of Pediatric Surgery, Department of Surgery, University of Texas Medical School at Houston, 6431 Fannin, Houston, TX 77030, USA.
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Uray KS, Laine GA, Xue H, Allen SJ, Cox CS. Intestinal edema decreases intestinal contractile activity via decreased myosin light chain phosphorylation. Crit Care Med 2006; 34:2630-7. [PMID: 16915113 DOI: 10.1097/01.ccm.0000239195.06781.8c] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the effects of interstitial edema on intestinal contractile activity. DESIGN Randomized animal study. SETTING University laboratory. SUBJECTS Male Sprague-Dawley rats. INTERVENTION Intestinal edema was induced in rats by a combination of fluid infusion and mesenteric venous hypertension. Rats were divided into four groups: CONTROL, sham; RESUS, saline infusion only; RESUS+VH, saline infusion and venous hypertension; and VH, venous hypertension only. Edema development, basal contractile activity, maximum agonist-induced contractile response (measured as total force generation during the first 2 mins after carbachol treatment), and myosin light chain phosphorylation were measured in the distal small intestine. MEASUREMENTS AND MAIN RESULTS The amount of interstitial fluid, indicated by the wet-to-dry ratio, increased significantly in both the RESUS and RESUS+VH groups as early as 30 mins after surgery compared with the CONTROL group. Whereas the tissue fluid remained significantly elevated in the RESUS+VH group up to 6 hrs after surgery, the RESUS group wet-to-dry ratios returned to CONTROL group levels by 2 hrs after surgery. Basal contractile activity was significantly less in the RESUS+VH group compared with either the RESUS group or the CONTROL group 6 hrs after surgery. Maximum contractile response decreased significantly in the RESUS+VH group compared with the RESUS group. Basal contractile activity and maximum contractile response did not change significantly in the VH group compared with the CONTROL group. The phosphorylated fraction of myosin light chain was significantly lower in the RESUS+VH group compared with the CONTROL group at 0.5, 2, and 6 hrs after surgery. CONCLUSION We conclude that edema decreases myosin light chain phosphorylation, leading to decreased intestinal contractile activity.
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Affiliation(s)
- Karen S Uray
- Division of Pediatric Surgery, Department of Surgery, University of Texas Medical School at Houston, TX, USA
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