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198
ab
Fig. 15.1 (a) Open abdomen 10 months following car crash, patient referred with multiple fistu-
lae. Note the upper gastric fistula which was caused by a gastrostomy tube placement via the skin
flap close to the granulation plate. (b) Note fistuloclysis with gastrojejunal feeding tube via gastric
fistula and ileostomy tube via small bowel fistula
Gastric access safely
achievable
Fig. 15.2 CT scan demonstrating the ability to determine safety for gastric access in open abdo-
men patient
P.M. Byers and A.B. Peitzman
199
15.6 Nutritional Support of the Enterocutaneous
and Enteroatmospheric Fistula Patient
Enteroatmospheric fistulae are often present in conjunction with the open abdomen,
as the result of failed intestinal anastomosis resulting in the open abdomen or the
development of enteroatmospheric fistulae as a late complication. Fistulae deep in
the peritoneal cavity cause peritonitis, and establishing adequate external drainage
is more difficult. Fistulae through or adjacent to a granulated fused visceral block
are also problematic [23]. Upon the development of this complication, patients
should be started early on parenteral nutrition. There is no need to delay the institu-
tion of parenteral nutrition, as it has been reported that 76% of patients will require
combination therapy for this illness [48]. Reoperative therapy for this complication
should be put off for 6–18 months as injury to bowel during these procedures can
convert a patient with Type II intestinal failure to Type III [49]. As soon as wound
management is possible and drainage is adequate, patients should be fed proximally
at a trickle rate to start. The early initiation of enteral feedings in open abdomen
patients with fistulae (within 14 days) is associated with decreased mortality [50].
Intestinal mapping can be done to give the feasibility of success of proximal feeding
and to establish availability of efferent limb for feeding [23]. The efferent limb of
the fistula should be evaluated to exclude any leak or obstruction, so that enteral
feeding can be started distally via “fistuloclysis” with elemental predigested formu-
las or fistula effluent [51] (see fistuloclysis access in Fig. 15.1).
In addition to aggressive calorie and protein support, support these patients with
high doses of minerals and vitamins to replace losses. Zinc, vitamin C, copper, folic
acid, and B12 should be monitored and replaced [23] (Table 15.7). Nutritional sup-
plements that support wound healing with glutamine and arginine can be utilized as
long as the patient is not in a state of severe sepsis. In addition, pharmacologic
adjuncts are often helpful and include antimotility agents, antisecretory agents,
bulking agents, and digestive supplements [23]. Octreotide should not be utilized
except for short-term indications when output must be controlled as with skin graft-
ing. Because it significantly decreases splanchnic and portal blood flow, it can
inhibit intestinal rehabilitation [52] (Fig. 15.3).
15.7 Choosing an Enteral Formula
Whey-based protein formulations are higher in leucine and thus may have an ana-
bolic advantage over soy- or casein-based formulas. Enteral formulas with 1.5 kcal/
mL result in significantly more calories being delivered in critically ill enterally fed
patients, without the adverse effects of increased gastric residual volumes or diar-
rhea [34, 53]. Some of these calorically dense formulas, however, may not have
adequate protein, so that protein modules are necessary to meet nitrogen require-
ments. These can be given even before caloric goals are met to reach protein goals
earlier. Because most formulas only contain 65% water, it may be necessary to
administer hypotonic enteral fluid boluses in patients without intravenous mainte-
nance fluid to avoid dehydration.
15 Nutritional Support in Patients with an Open Abdomen
200
Concentrated formulas with more than 1 kcal/mL usually accomplish this goal
by increasing fat calories. Do not routinely use formulas with 2 kcal/mL in critically
ill patients, as these formulas have high fat content and may promote an inflamma-
tory response [17]. However, recent animal studies have demonstrated that formulas
with more fat calories may mitigate intestinal mucosal injury caused by the air
exposure of the open abdomen [27]. Although volume losses are the common sce-
nario in the early phases of the open abdomen course, as the patient becomes more
chronic, volume restrictions due to underlying illness may become important. These
calorically and protein-dense formulas allow adequate nutritional support in patients
with these volume restrictions [17].
Patients with intestinal mucosal atrophy, those fed post-pylorically, and patients
with gastrointestinal fistulae may require semi-elemental or peptide formulations.
The use of immune-modulating formulas with arginine, glutamine, and nucleic
acids has been controversial; however, they may be considered for early use in
patients without sepsis [17]. There are also commercial products that have increased
fiber and fat calories for diabetics, formulas that have adjusted electrolyte composi-
tion and concentrated calories for renal failure, and those with amino acid and pro-
tein adjustments for hepatic insufficiency. These products are far more expensive
than the standard enteral products and should not be used without clear
indications.
Administer a soluble fiber product, such as apple pectin or guar gum, routinely
to all patients with a colon in continuity. Soluble fiber is a source of nutrition for the
colonocytes and helps maintain gut barrier function. In addition, soluble fiber helps
modulate and maintain a healthy colonic microbiome and thus helps to decrease the
number of pathogens that may be found in the colons of critically ill patients. The
recommended dose is up to 2.5–5 g every 6 h [17].
WAIT
INTESTINE IN
DISCONTINUITY,
INCONTROLLED
FISTULAE
OPEN ABDOMEN
DAY 2
INTESTINE IN
CONTINUITY
OBTAIN POST-PYLORIC ACCESS
AND START ENTERAL NUTRITION
USING BUNDLE
DAY 4
60% GOALS
TOLERATED
NO YES
CONTINUE ENTERAL
SUPPORT WITH
MONITORING AND GOAL
ADJUSTMENTS
DAY 3
START HIGH PROTEIN
HYPOCALORIC TPN
INTESTINAL CONTINUITY RESTORED
AND FISTULA EFFLUENT CONTROLLED
OBTAIN POST-PYLORIC ACCESS AND START
ENTERAL NUTRITION USING BUNDLE
WEAN TPN AND STOP WHEN 60-80%
GOALS MET
Fig. 15.3 Open abdomen. Nutritional support algorithm
P.M. Byers and A.B. Peitzman
201
15.8 Complications
The most common complication associated with the enteral route of feeding is mal-
nutrition due to serious underfeeding as a consequence of poor protocols and nurs-
ing techniques [54]. Aspiration is another serious complication of enteral feeding.
The risk can be mitigated by keeping the head of the bed elevated at 30 degrees
whenever possible. In patients demonstrating poor gastric emptying, post-pyloric
access should be considered. However, whenever there is abdominal distention and
evidence of severe feeding intolerance, tube feeding should be immediately
decreased or discontinued with the concern for nonocclusive intestinal necrosis.
Prompt recognition and surgical intervention for source control are needed for sal-
vage from this devastating and highly lethal complication [55].
There are multiple complications that can occur with enteral access. Naso-enteral
tubes can be incorrectly placed into the airway or become dislodged. Dislodgement
of percutaneous tubes can result in gastrointestinal contents or tube feeding leaking
into the peritoneal cavity. Finally, tube occlusion contributes greatly to underfeed-
ing and can be avoided with frequent flushing and appropriate nursing care of feed-
ing access tubes.
While underfeeding is the most common complication of enteral support, over-
feeding is often a complication of parenteral nutrition and has been demonstrated to
contribute to adverse outcomes. Overfeeding is associated with increased levels of
metabolic stress and is permissive of hepatic steatosis. Associated hyperglycemia is
associated with glycosuria, electrolyte derangements, hyperosmolarity, and an
increased incidence of infections. This should be treated aggressively by adjusting
carbohydrate calories and regulating insulin infusions to maintain blood sugars
under 180 mg/dL [56]. Although insulin may be added to the parenteral nutrition
formula at 50–60% of the previous day’s requirements, this should only be done in
stable patients who are not in flux with insulin resistance and should only cover the
caloric load delivered in the parenteral formula. Hypercarbic respiratory failure may
be induced by carbon dioxide production from excessive carbohydrate caloric loads.
If indirect calorimetry is utilized, the carbohydrate load should be limited to keep
the respiratory quotient <1. If indirect calorimetry is not available, the carbohydrate
load should be kept to ≤4 mg/kg/min.
To decrease the risk of catheter-related sepsis in patients receiving parenteral
nutrition, a dedicated access should be utilized for the parenteral nutritional prod-
ucts with protection from mixed use. Protocols utilizing alcohol and antibiotic locks
can also be used as preventative measures.
Take-Home Box
• Start enteral feedings in all open abdomens with intestinal continuity as
soon as they are hemodynamically resuscitated.
• 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.
15 Nutritional Support in Patients with an Open Abdomen
202
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P.M. Byers and A.B. Peitzman
205
© 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_16
R.K. Lee, DNP, ARNP, ACNP-BC, CCNS, CCRN
Intensive Care & Progressive Care Unit, Homestead Hospital,
975 Baptist Way, Homestead, FL 33033, USA
e-mail: rosemarl@baptisthealth.net
16
The Nursing Management of Open
Abdomen Patients
Rosemary Koehl Lee
16.1 Introduction
Florence Nightingale identified that the nurse’s role is to put the patient in the best
possible condition for nature to act [1]. The goal with the open abdomen patient is
to put them in the best possible condition in order to close the abdomen as soon as
feasible. The responsibility of the acute and critical care nurse is to provide safe
passage for patients and their families. Providing “safe passage” is a cornerstone for
nursing competencies based on the American Association of Critical Care Nurses
(AACN) Synergy Model [2]. The purpose of this chapter is to convey the nursing
management of the adult patient with an open abdomen (OA) so the patient and
family can progress to health and well-being.
16.2 Patient and Family Preparation
The patient requiring an open abdomen may be one that presented to the emergency
department and was urgently taken to surgery with minimal to no prep due to the
life-threatening situation. Alternately, the patient may have been monitored and
managed in the ICU for a medical cause of intra-abdominal hypertension (IAH),
until the interventions failed and abdominal compartment syndrome (ACS) ensued
and an open abdomen required.
Waking up from anesthesia with an open abdomen may be frightening for the
patient and family. Letting them know what to anticipate will decrease the fear.
Initially, the physician will inform them of the surgical plan, and the nurse may
reinforce the explanations. The Abdominal Compartment Society has excellent
206
information for patients on their website (http://www.wsacs.org/for-patients.html)
[3]. Below are some frequently asked patient questions and answers obtained from
the website:
Q. What is an “open abdomen?”
A. An operation where your doctor makes a large incision (cut) in your abdomen
(belly) and leaves this incision open to relieve the high pressure that is prevent-
ing your organs from working properly. You will need another operation (or
sometimes many) to close this incision when you are no longer sick. While your
abdomen is “open” in the hospital, you will have a special covering to protect
your organs. This operation is also known as “abdominal decompression.”
Q. Why is an open abdomen necessary?
A. Organ failure, such as your heart, lungs, or kidneys not working properly, is
the most common cause of death in the intensive care unit (ICU). Your doctors
and nurses will do everything possible to prevent your organs from failing. If
all other therapies fail, however, opening your abdomen may be the only way
to save your life.
Q. How can I tell whether my abdomen is “open” or “closed”?
A. To close an open abdomen, your surgeon will sew both the skin AND muscles
of your abdominal wall back together. Your abdomen is considered “closed”
when BOTH layers of the abdomen have been repaired. You may, however, be
too sick to close both layers at the same time. If this is so, your surgeon may sew
only your skin together (called a “skin-only” closure) leaving your muscles
apart to keep the pressure in your abdomen low. If this is not possible, your sur-
geon will take a piece of your skin (usually from the thigh) and place this over
your organs (called a “skin graft” closure). In either case, you will have a hernia
(a large bulge in your belly) until your surgeon feels you are ready to have
another operation to close the muscle layer as well. While you have a hernia, you
will need to follow the activity restrictions given to you by your surgeon. You
may also need to wear an abdominal “binder” or “belt” to support your abdomi-
nal wall. Until both the skin and muscles of your abdominal wall have been sewn
together, your doctors will consider your abdomen as being “open”.
Q. Why do I have an open abdomen?
A. Because you are/were so sick, your doctor had to open your abdomen to save
your life and prevent organ failure. In most patients, an open abdomen is tem-
porary and your abdomen should be able to be closed in the near future.
Ideally having a patient/family conference with the health-care team preopera-
tively will provide the opportunity for questions to be asked and answered.
Knowing what type of temporary abdominal closure (TAC) the surgeon will use
is important for the nurse to know. Please refer to Chap. 10 for the review of the
various types of TACs and their pros and cons. The surgeon should prepare the
health-care team on what type of TAC will be used, as the decision to leave the
abdomen open is usually made preoperatively. Most TAC’s need to be changed
every 48–72 h by the surgeon.
R.K. Lee
207
16.3 Postoperative Management in the ICU
Immediate postoperative recovery of the open abdomen patient is similar to any
major abdominal surgery, with a few exceptions. The standard practices in all major
surgery patients in the ICU would be to maintain hemodynamic stability, normo-
thermia, acid–base balance, hemostasis, and pain control. The patient most likely
will be supported on mechanical ventilation, with lung-protective strategies [4].
There may be multiple surgical drains and tubes connected to suction or drainage
devices. Patients with an open abdomen are still at risk for intra-abdominal hyper-
tension (IAH) and require intra-abdominal pressure (IAP) monitoring.
Managing Hemodynamics Fluid loss is a major problem with the OA patient. In
the first 24 h, the patient may require massive amounts of fluid and blood resuscita-
tion in order to maintain hemodynamic stability [5]. The role of the nurse is to
judiciously manage the IV fluids, blood products, and vasopressors while closely
monitoring the hemodynamic parameters and urine output. The patient is also at
risk for recurring abdominal compartment syndrome (ACS) and requires IAP
monitoring.
There is evidence to indicate that [6] in the presence of IAH, static hemodynamic
values, such as the central venous pressure (CVP) and the pulmonary capillary
wedge pressure can be artificially elevated. Dynamic hemodynamic values such as
stroke volume variation (SVV), pulse pressure variation (PPV), or global end-
diastolic volume (GEDV) are better at predicting fluid responsiveness. Both SVV
and PPV have limitations in their use. Assessing the changes in stroke volume (SV)
or stroke volume index (SVI) using the passive leg raise has also been used to assess
fluid responsiveness [7]. However, if IAH is present, the passive leg raise maneuver
will be inaccurate [8]. Ensure the physician ordering the fluid resuscitation and
vasopressors provides hemodynamic goals to be achieved and maintained. If using
the arterial blood pressure as an endpoint of resuscitation, it is better to use the mean
arterial pressure (MAP) than the systolic pressure [9].
Due to the substantial fluid losses, and the large amount of IV fluid intake, it is
important to maintain an accurate intake and output (I&O). Fluid losses would be
drained from the wound (surgical drains, negative pressure wound therapy), naso-
gastric tube, urine output, stool, fistula drainage (if present), and through diaphore-
sis. It is difficult to maintain an accurate I&O due to insensible losses like sweating
and fistulae that are not bagged. It is recommended to also obtain daily weights of
these patients to trend fluid retention [5].
Managing Intra-abdominal Hypertension (IAH)
A hands-on abdominal
assessment and measurement abdominal girth are not adequate indicators of IAH
[10]. Trending IAP measurements are better guides to the development of IAH
and ACS. A normal IAP in healthy subjects is 0–5 mm Hg; most critically ill
patients have pressures between 5 and 7 mm Hg. Intra-abdominal hypertension is
defined as a sustained or persistent elevation of the IAP of 12 mm Hg or greater.
Abdominal compartment syndrome is defined as a sustained IAP of 20 mm Hg or
16 The Nursing Management of Open Abdomen Patients