The Wittmann Patch s a temporary abdominal closure device after decompressive celiotomy for abdominal compartment syndrome following burn

BACKGROUND

Abdominal compartment syndrome is frequently the result of aggressive fluid resuscitation after burn. Management of the open abdomen following decompressive celiotomy is a major problem.

METHODS

From 2004 to mid-2005, six patients required decompressive celiotomy after developing abdominal compartment syndrome as a result of burn. A Wittmann Patch as used to close the abdominal wound. Patients were re-explored when clinical parameters improved and the abdomen was closed, with long-term follow-up for the abdominal wound.

RESULTS

Of the six patients, five had thermal injury and one had electrical injury. The mean total body surface area affected for thermal burn was 78% and for electrical burn was 37%. Diagnosis of abdominal compartment syndrome was based on elevated bladder pressure and organ dysfunction. The patients were treated with decompressive celiotomy and Wittmann Patch closure. Survivors subsequently underwent primary abdominal closure, with no evidence of ventral hernia at long-term follow-up.

CONCLUSION

In burn cases with abdominal compartment syndrome, a Wittmann Patch ay prove a helpful method of temporary abdominal closure, followed by primary closure with no complications.

Abdominal compartment syndrome: the pressure is on

Find out how this sometimes deadly condition develops and what you can do to take the pressure off vulnerable organs.

Fluid management of the trauma patient

Hemodynamic instability in the trauma patient is most commonly secondary to blood loss and the accumulation of fluid in injured tissue. The etiologies of shock unrelated to hypovolemia must also be investigated. The treatment of hypovolemia in patients with non-cerebral trauma should begin with Ringer's lactate solution. Normal saline (0.9% sodium chloride) is appropriate for patients with head injury, alkalosis, or hyponatremia, but in large volumes may lead to metabolic acidosis. The role of colloids, hypertonic saline, and hemoglobin solutions in trauma resuscitation is unclear at the present time. Base deficit and lactate levels are useful as predictors of morbidity and mortality and can be used to guide resuscitation.

Use of controlled fascial tension and an adhesion preventing barrier to achieve delayed primary fascial closure in patients managed with an open abdomen

Open management of the abdomen has become an accepted technique for both the treatment and the prevention of abdominal compartment syndrome. It has also gained popularity as a treatment option in situations requiring multiple laparotomies such as uncontrolled intra-abdominal infections and severe abdominal injury necessitating damage control surgery. A significant number of patients managed with the open abdomen technique are unable to undergo complete abdominal wall closure and consequently develop large, complex anterior abdominal wall hernias. We report the use of a controlled fascial tensioning device, the Wittmann Patch (Starsurgical, Inc, Burlington, WI), in combination with an adhesion preventing barrier to allow for unhindered sequential medial advancement of the fascia toward the midline. The use of these 2 devices together may lead to a higher incidence of fascia-to-fascia abdominal wall closure than the use of fascial tension alone.

[Disturbances of protein C activity in abdominal sepsis: diagnostic and predictive importance]

BACKGROUND

Despite improved diagnostic modalities, potent antibiotics, modern intensive care, and aggressive surgical treatment, more than one third of patients still die of severe secondary peritonitis. Clinical difficulties in the treatment of abdominal sepsis were related to inherent problems of limited clinical signs and the rapid spread of infection. An inflammatory process is often well under way before the presence of clinical signs and symptoms of sepsis. The aim of this prospective study was to assess diagnostic and prognostic significance of protein C in abdominal sepsis.

METHODS

Twenty-two patients with severe intraabdominal infections with sepsis syndrome were treated surgically as compared to 15 patients with hernia repair (control group). During the study, the following parameters were analyzed daily: protein C, AT III, plasminogen, alfa-2 antiplasmin, HMWK, C5a and C5-B9 complement, C1-inhibitor, CRP. RESULTS. The mean APACHE II score was 17 points, with actual mortality rate of 23%. Each parameter evaluated in the abdominal sepsis group differed from the one evaluated in the control group to a great extent (p = 0.001). The results and multivariate regression statystical analysis confirmed the following parameters as sensitive biological markers of septic cascade (p < 0.0001-0.026): protein C, AT III, HMWK, C1-inhibitor and C5-B9 complement. According to the results the low level of protein C consistently correlated with disease severity and suggested the development of septic shock and poor outcome.

CONCLUSION

Early diagnosis of plasma proteolytic disturbances was very important, from the diagnostic and predictive point of view, in abdominal sepsis. According to the results protein C was the most significant marker of sepsis and early predictor of the outcome of septic complications during severe intraabdominal infections (r = 0.761; p = 0.0001).

The open abdomen: aetiology, classification and current management strategies

A new classification system has been devised for open abdominal wounds. This will help identify an appropriate management strategy, and indicate the associated morbidity and outcome. In all cases, early intervention is vital.

Elevated intra-abdominal pressure limits venous return during exercise inVaranus exanthematicus

The effects of treadmill exercise on components of the cardiovascular(venous return, heart rate, arterial blood pressure) and respiratory systems(minute ventilation, tidal volume, breathing frequency, oxygen consumption,carbon dioxide production) and intra-abdominal pressure were investigated in the Savannah monitor lizard, Varanus exanthematicus B., at 35°C. Compared with resting conditions, treadmill exercise significantly increased lung ventilation, gular pumping, intra-abdominal pressure, mean arterial blood pressure and venous return (blood flow in the post caval vein). However,venous return declines at high levels of activity, and mean arterial pressure and venous return did not attain peak values until the recovery period,immediately following activity. Elevating intra-abdominal pressure in resting lizards (via saline infusion) resulted in significant reductions in venous return when the transmural pressure of the post caval vein became negative (i.e. when intra-abdominal pressure exceeded central venous pressure). Together these results suggest that increments in intra-abdominal pressure compress the large abdominal veins and inhibit venous return. During locomotion, the physical compression of the large abdominal veins may represent a significant limitation to cardiac output and maximal oxygen consumption in lizards.

The abdominal compartment syndrome following aortic surgery

BACKGROUND

multi-organ failure is a leading cause of death following aneurysm surgery, especially in the emergency setting. Intra-abdominal hypertension is an important factor in the development of multi-organ failure. Prevention, early recognition and prompt treatment of abdominal hypertension and the abdominal compartment syndrome may reduce mortality following aneurysm surgery.

METHODS

a descriptive review of the literature from a Medline search.

RESULTS AND CONCLUSIONS

the abdominal compartment syndrome is the result of diverse physiological effects caused by increased intra-abdominal pressure. The syndrome has been most widely described in trauma victims, but occurs in patients following aortic surgery, particularly following ruptured aneurysm repair. Preventative therapy should be instituted to minimise its development in patients at risk, and monitoring of intra-abdominal pressure may allow prompt treatment of this condition.

Protein C as diagnostic and predictive biomarker of sepsis during severe intra-abdominal infections

Severe intra-abdominal infections (IAI) with sepsis syndrome are still associated with high mortality rate (20-60%). This prospective study refers to diagnostic and prognostic importance of protein C detection during severe abdominal sepsis. We treated surgically 22 patients with severe IAI (mostly diffuse peritonitis with sepsis syndrome) vs. 15 patients with hernia repair (control group). During the study the next parameters were analyzed: Protein C, AT III, plasminogen, alpha-2 antiplasmin, HMWK, C5a, C5-B9 complements C1-inhibitor, CRP. All the evaluated parameters were different between the study and control groups, with high statistical significance (p < 0.001). The results and multivariate statistical analysis revealed the following parameters as very sensitive and important biological markers of abdominal sepsis: Protein C, AT III, HMWK, C5-B9, C1-inhibitor (p < 0.0001-0.026). The clinical difficulties of intra-abdominal sepsis are due to inherent problems of the limited clinical signs and the complexity of the distribution of infection. Inflammatory process is often well under way before the clinical signs and symptoms of sepsis are present. Early diagnosis of plasma proteolytic disturbances is, from the diagnostic and predictive point of view, very important in abdominal sepsis. According to multivariate statistical analysis protein C is the most significant diagnostic marker of sepsis during severe IAI (p < 0.0001).