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177
function. This also applies for recruitment maneuvers for reopening dys- or atelec-
tatic lung areas [141]. For high respiration levels, resp. PEEP levels, to work, it is
generally necessary to have a sufficiently large nasopharyngeal tube (usually
0.5 mm more in circumference than the norm for the respective percentile) and a
(micro-)cuff. In this situation it is also necessary to regularly ensure air is not
trapped and the intrinsic PEEP is not increasing.
Since the probability of lung alteration combined with all potential risk factors is
very high, every further noxious agent, for example, a shearing trauma, must be
avoided when attempting to create low tidal volume ventilation (5–7 mL/kgKG/min)
for lung protection. The overwhelming majority of patients affected can be suffi-
ciently oxygenated and ventilated conventionally (as needed also accepting a potential
permissive hypercapnia (target, pH > 7.2 and plateau pressure < 30 cmH
2
O)) [142].
Only in special cases must nitrogen monoxide, high-frequency oscillation (HFO), or
even extracorporeal oxygenation be considered (and critically questioned) [143, 144].
Due to the open abdomen, patient mobility (including the prone position) is lim-
ited [145]. Because of this, consistent inspiratory gas conditioning and warming,
regular inhalation therapy with mucolytic and—where necessary—medicine dilat-
ing the bronchial tubes, and stringent physiotherapeutic secretion mobilization take
on prophylactic and therapeutic importance. With potential bacteria translocation in
mind, regular microbiological examinations of tracheal secretion should occur and
antibiosis adjusted early on.
14.4.5 Supportive Therapy
In IAH Grade I, deep analgosedation [146] (according to WHO recommendations)
can suffice; however, in IAH Grade II (at the latest) and when there is a laparostoma,
additional relaxation must be considered. In terms of more pronounced metaboliza-
tion, there is an earlier adjustment in children and adolescents than in adults. This
makes it necessary to regularly change the analgosedativa schemata with additions
and changes in substance groups (including benzodiazepine, opioids, barbiturates, α
1
-
agonists, dexmedetomidine, low-potency neuroleptics, antidepressants). Depending
on the necessary length of the laparostoma therapy, this can even turn into off-label
use of inhalative anesthetics (e.g., iso-/sevoflurane) via a vaporization system
(AnaConDa
®
) [147, 148] that can be combined with conventional respirators.
Although medicinal (e.g., macrogol) and interventional purgative measures
(e.g., gastric tube, intestinal tube, endoscopy) for reducing intraluminal vol-
umes are in the foreground of conservative IAH therapy (Table 14.3), minor
Table 14.4 ARDS net protocol for ventilation optimization in shock lung/ARDS [156]
FiO
2
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
PEEP [cmH
2
O] 5 5–8 8–10 10 10–14 14 14–18 18–24
According to the Horowitz index (PaO
2
/FiO
2
), there are three ARDS grades (I.°, <300; II.°, <200;
III.° < 300). Additional diagnosis criteria are bilateral infiltration and ruling out pulmonary hyper-
tension via echocardiography. In accordance with the respective oxygen needs, an increase in
PEEP applying the values in the table should be tested
14 Management of the Open Abdomen in PICU
178
mucosal feeding of intestinal villi should at least be attempted [149–153].
Laying a jejunal and duodenal tube as well as regularly administering enemas
and prokinetics (Naloxon, Metoclopramide, Erythromycine [154]) have proven
themselves as methods for overcoming gastroparesis and enteric paralysis,
which frequently accompany and are exacerbated by the combination of medi-
cines mentioned above. However, erythromycins [154] interact with various
immunosuppressants and are, therefore, contraindicated following a
transplantation.
Above all, the vast majority of energy required must initially be covered paren-
terally. In doing this, the composition of the total or partial parenteral nutrition must
be adjusted to the energy needs of the individual patient age and post-aggression
stage. Protein and fat can be metabolized 2–4 days after an operation (at the earli-
est). Micronutrients and vitamins should be substituted starting on the fifth to sev-
enth post-OP day. Deficiencies and insufficient substitution are monitored weekly
via enhanced laboratory monitoring [155]. Various workgroups have proclaimed the
positive effect of enriching glutamine, selenium, zinc, as well as immuno-nutrition
on the ICU outcome in adults; yet there is absolutely no evidence of this in
children.
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© Springer International Publishing AG, part of Springer Nature 2018
F. Coccolini et al. (eds.), Open Abdomen, Hot Topics in Acute Care Surgery
and Trauma, https://doi.org/10.1007/978-3-319-48072-5_15
P.M. Byers, MD, FACS
Dewitt Daughtry Department of Surgery, University of Miami Miller School of Medicine,
PO Box 016960 (D-40), Miami, FL 33101, USA
e-mail: pbyers@miami.edu
A.B. Peitzman, MD (
*)
Department of Surgery, University of Pittsburgh School of Medicine,
F-1281, UPMC-Presbyterian, Pittsburgh, PA 15213, USA
e-mail: peitzmanab@upmc.edu
15
Nutritional Support in Patients
with an Open Abdomen
Patricia Marie Byers and Andrew B. Peitzman
15.1 Metabolic Stress in the Critically Ill Patient
with an Open Abdomen
Our understanding of the metabolic response to critical illness and the response to
the open abdomen has evolved over the last several decades. These patients with an
open abdomen are highly catabolic. Malnutrition in this setting is defined by
Key Points (Fig. 15.3)
• Start enteral feedings in all open abdomen patients with intestinal continu-
ity as soon as they are hemodynamically resuscitated.
• Plan for post-pyloric enteral access at damage control follow-up
laparotomy.
• Start TPN if at least 60% of nutritional requirements are not met by day 4.
• Use an enteral therapy bundle and volume-based ordering to maximize
success with enteral feeding.
• Pay careful attention to protein support and micronutrient replacements.
• Try to enterally feed fistula patients as soon as possible, but start TPN after
resuscitation is complete with hypocaloric high-protein therapy.