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208
greater with new onset organ failure. Refer to Chap. 3 for a more in-depth discus-
sion on how to properly measure IAP and what the significance of the readings is.
Measure the IAP every 4 h and more frequently if active interventions are taking
place to lower the IAP. The Abdominal Compartment Society recommends that
critical care units develop a protocolized approach to measuring IAP and manag-
ing IAH.
The Abdominal Compartment Society has developed a medical management
algorithm for the management of IAH (http://www.wsacs.org/images/algorithms/
IAH_ACS_medical_management_2014.pdf.) [11]. From the medical algorithm
nursing interventions can be gleaned. Many of these are basic nursing interventions
that may get lost in the high-tech environment of critical care.
• Nasogastric (NG)/orogastric tube (OG):
– Ensure the NG/OG is properly positioned in the lower half of the stomach by:
Reviewing radiology reports.
Aspirating of gastric contents.
Note that insufflation of air and auscultating the left upper quadrant for sounds
of air entry are not a recommended maneuver for tube placement. It gives
false reassurance as the tube may be in the esophagus or lung and give the
same sound [12].
• Ensure NG/OG tube is patent:
– If patient has continuous or intermittent gastric suction, ensure the expected
amount of aspirate is present. Maintain the suctions as ordered, and keep at
the prescribed settings.
– Irrigate the gastric tube as per unit policy. (See Fig. 16.1)
Fig. 16.1 This patient was being treated for peritonitis with an open abdomen and negative pres-
sure wound therapy. Prior to going to surgery for this dressing change, the patient’s IAP rose
gradually from 12 to 20 mm Hg. Upon removal of the dressing in surgery, the grossly distended
stomach was revealed. The patient’s nasogastric tube was removed and found to be occluded.
Upon placement of a new nasogastric tube, the stomach decompressed and IAPs returned to
10–12 mm Hg
R.K. Lee
209
• Prevent constipation:
– If the patient has an intact gut and is receiving enteral feedings, a bowel move-
ment should be expected at least every 3 days or sooner.
– Ensure patient has adequate enteral fluid intake to maintain stool consistency.
– Review abdominal film and CT reports for the presence of stool or fecal
impaction (see Fig. 16.2).
– If not contraindicated, digitally inspect for a fecal impaction.
– Most patients will be receiving opioids for pain which can cause constipation.
Ensure that an escalating bowel regimen has been ordered:
Stool softeners
Laxatives
Enemas
Nutrition Support Protein loss and malnutrition are problems of having an open
abdomen. In order to promote wound healing, nutritional support is required.
Depending on the patient’s underlying condition either enteral (EN) or parenteral
nutrition may be used. See Chap. 15 for a more in-depth discussion of nutritional
support. This section on nutrition will concentrate on the nursing management of
the enteral nutrition and will be based on the Society of Critical Care Medicine
(SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN)
[13] guidelines for nutritional support in the critically ill.
Enteral support should not be initiated in the hemodynamically unstable patient.
Patients with a MAP less than 50 mm Hg and on escalating doses of vasopressors
should not receive EN. Gastric feedings can be given safely to the critically ill
patient. If the patient is at high risk for aspiration a nasoduodenal or nasojejunal
feeding tube may be used. Small bowel feeding tubes may also be required depend-
ing on the location of a bowel injury or presence of a fistula.
• EN should be started as early as possible within 24–48 h. It is important to collabo-
rate with a dietitian or nutrition support team to identify the best feeding formula.
• Advancing the feeding to goal rate should be accomplished as quickly as possi-
ble within 24–48 h.
Fig. 16.2 Abdominal CT
scan showing bowel
distended with stool
16 The Nursing Management of Open Abdomen Patients
210
• Do not use gastric residual volumes (GRV) as part of a regular nursing routine.
GRV’s are not evidence based and do not correlate with feeding tolerance. It is
better to asses for signs of feeding intolerance.
– If GRVs are measured, it is recommended to not modify or stop the feeding
until the GRV is greater than 500 mL.
• Monitor the patient for signs of feeding intolerance:
– Vomiting
– Diarrhea
– Abdominal distention (increased IAP)
– Complaints of discomfort
– Decreased flatus
– Decreased bowel movements
– Greater than 500 mL GRV
• Minimize interruptions of EN feeds. Less than 50% of ICU patients reach and
maintain their target feeding goal. This has been found primarily due to nursing
care.
• Examples are:
– Stopping or decreasing feedings for GRVs less than 500 mL.
– Stopping feedings for nursing care, medical/surgical procedures or patient
transport
– Stopping feedings due to enteral medication requirements
It has been proposed [14, 15] that enteral feeds be prescribed as a daily goal
volume rather than as an hourly goal rate. This proposal gives the nurse the option
to temporarily increase the rate to meet the 24 h volume goal.
Mobility Early mobility for postoperative recovery has been a mainstay since
World War II. Nurses are aware of the benefits of mobility to all body systems. In
the acute postoperative phase of the open abdomen, the patient will require ventila-
tor support, sedation, and analgesia requiring the patient to be bedbound. Despite
hemodynamic instability, the patient may still be turned from side to side at least
every 2 h. It is recommended to use the right lateral position first as this is better
tolerated hemodynamically [16]. The lateral turns should be performed slowly to
allow the baroreceptors to equilibrate.
In order to minimize IAH, it is recommended to elevate the head of the bed
(HOB) no greater than 20 degrees. There has been research on the effects of various
body positions on IAH; unfortunately the best position is supine with the HOB flat.
Any bending of the torso will increase IAP readings [17]. This conundrum requires
the nurse to closely assess the patient’s response to position changes. Patients tend
to stabilize within 5–10 min of a position change.
Once the patient has recovered from the acute phase and the temporary
abdominal (TAC) closure is in place, it is important to initiate more aggressive
mobility. The ABCDEF bundle provides guidelines on how to do this safely (see
Table 16.1).
R.K. Lee
211
Integument The goal of the TAC is to contain and protect the abdominal contents
and minimize fluid and protein loss. It is the surgeon’s responsibility to change the
TAC, and it is the nurse’s responsibility to maintain it. One of the challenges is to
protect the skin from the drainage of the abdominal contents or the effluent from a
fistula. These fluids are caustic to the skin which cause pain and delayed healing.
Consulting a nurse specializing in wound care can assist the direct care nurse in
developing ingenious ways of trapping and bagging wound and fistula effluent [19].
This aids in patient comfort and ease as well as decreasing the family’s concern of
the cleanliness of the patient environment.
Psychosocial/Financial Having an open abdomen and its sequelae of multiple sur-
geries, ventral hernia, wound drainage, etc., can have a debilitating effect on the
patient and the family unit. Although most open abdomens can be closed within a
week, others may take longer such as 6 months to a year. The long-term open abdo-
men patient may be discharged with the abdomen closed with the abdominal skin;
however, the muscle and fascia are open underneath. This results in a large, unsightly
abdominal hernia that will be repaired at a future date. In a study looking at the
quality of life for these long-term patients [20], there was a high degree of depres-
sion (65%) and a concerning number with posttraumatic stress disorder (PTSD)
(22.5%), and 42% did not return to work. In a study by Clark [21] the effects of
insurance and race were studied as to their effects on outcomes of patients with an
open abdomen. Race did not have a significant effect on patient outcomes; however,
“self-pay” status had significant findings with an increased mortality rate. Knowing
this, it would behoove the nurse to get the social worker/case manager involved
early to deal with the anticipated financial and social issues upon discharge. The
patient should be screened for depression and PTSD prior to discharge, so the proper
therapy and pharmacological support may be started.
16.4 Summary
The purpose of this chapter was to present the unique nursing issues of the patient
with an open abdomen. Along with the rest of the chapters in this book, it is hoped
the nurse has been given the knowledge to put the patient in the best possible condi-
tion for nature to act and to provide safe passage to patients and their families.
Table 16.1 Components of the ABCDEF bundle (http://www.iculiberation.org) [18]
Bundle Component
A Assess, prevent, and manage pain
B Both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)
C Choice of analgesia and sedation
D Delirium: assess, prevent, and manage
E Early mobility and exercise
F Family engagement and empowerment
16 The Nursing Management of Open Abdomen Patients
212
References
1. Nightingale F. Notes on nursing: what it is and what it is not. London: Harrison; 1860.
2. Burns SM, editor. AACN essentials of critical care nursing. 3rd ed. New York: McGraw Hill;
2014.
3. Abdominal Compartment Society: http://www.wsacs.org/for-patients.html. Accessed on 1
September 2016.
4. Burlew CC. The open abdomen: practical implications for the practicing surgeon. Am J Surg.
2012;204:826–35.
5. Huang Q, Zhao R, Yue C, et al. Fluid volume overload negatively influences delayed primary
facial closure in open abdomen management. J Surg Res. 2014;187:122–7.
6. Malbrain M, DeWaele J. Cardiovascular system and IAH. In: Vuylsteke, editor. Intra-
abdominal hypertension: core critical care. Cambridge: Cambridge University Press; 2013.
p. 131–40.
7. McLean B. Chapter 22 goal directed hemodynamics. In: Lough, editor. Hemodynamic moni-
toring: evolving technologies and clinical practice. Missouri: Elsevier; 2016. p. 713–26.
8. Mahjoub Y, et al. The passive leg-raising maneuver cannot accurately predict fluid respon-
siveness in patients with intra-abdominal hypertension. Crit Care Med. 2010;38(9):1824–9.
doi:10.1097/CCM.0b013e3181eb3c21.
9. Lehman LH, Saeed M, Talmor D, Mark R, Malhotra A. Methods of blood pressure measure-
ment in the ICU. Crit Care Med. 2013;41(1):34–40.
10. Malbrain M, De Laet I, DeWaele J. IAH/ACS: the rationale for surveilance. World J Surg.
2009;33(6):1110–5.
11. Abdominal Compartment Syndrome: medical management algorithm. http://www.wsacs.org/
images/algorithms/IAH_ACS_medical_management_2014.pdf. Accessed 1 September 2016.
12. Metheny N. AACN practice alert: initial and ongoing verification of feeding tube placement in
adults. Crit Care Nurse. 2016;36(2):e8–e13. 10.4037/ccn2016141.
13. Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the provision and assessment
of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care
Med. 2016;44(2):390–438. doi:10.1097/CCM.0000000000001525.
14. MacLeod JBA, Lefton J, Houghton D, Roland C, et al. Prospective randomized control trial
of intermittent versus continuous gastric feeds for critically ill trauma patients. J Trauma.
2007;63:57–61.
Take-Home Messages
• Patients with an open abdomen are still at risk for IAH and need their IAP
measured regularly.
• Basic nursing interventions can assist in minimizing IAH.
• Obtain goals to manage hemodynamics with fluids and vasopressors.
• Dynamic volume indicators are better than static hemodynamic parameters
to assess fluid responsiveness.
• Maintain adequacy of enteral nutrition by using evidence based
principles.
• Mobility is an important recovery intervention and begins with proper
positioning.
• The patient should be screened for depression and PTSD risk.
R.K. Lee
213
15. Marik PE (2016) Chapter 32 nutrition in the ICU: it’s whey cool. In: Marik (auth) Evidence
based critical care 3. Springer, Heidelberg.
16. Vollman KM. Hemodynamic instability: is it really a barrier to turning critically ill patients?
Crit Care Nurse. 2012;32(1):70–5.
17. Malbrain M, DeWaele J. Principles of IAP management. In: Vuylsteke, editor. Intra-abdominal
hypertension: core critical care. Cambridge: Cambridge University Press; 2013. p. 25–33.
18. Society of Critical Care Medicine: ICU Liberation http://www.iculiberation.org . Accessed on
15 August 2016.
19. Curtis K, Judson K. Management of fistulae in patients with an open abdomen. Nurs Stand.
2014;28(25):56–64.
20. Zarzaur BL, 2011, DiCocco JM, Shahan CP et al Quality of life after abdominal wall recon-
struction following open abdomen. J Trauma. 70(2) p 285–291.
21. Clark JM, Cheatham ML, Safcsak K, Alban RF. Effects of race and insurance on outcomes of
the open abdomen. Am Surg. 2013;79(9):928–32.
16 The Nursing Management of Open Abdomen Patients
215
© 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_17
A. Tarasconi (*)
Emergency Surgery Department, Maggiore Hospital of Parma, University of Parma, Parma,
Italy
e-mail: atarasconi@gmail.com
O. Chiara • S. Cimbanassi
Niguarda Hospital Trauma Center, Milan, Italy
A. Birindelli • R. Cirocchi • G. Tugnoli
Emergency Surgery and Trauma Surgery Unit, Maggiore Hospital Regional Emergency
Surgery and Trauma Center – Bologna Local Health District, AUSL, Bologna, Italy
S. Di Saverio
Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust,
Addenbrooke’s Hospital, Cambridge, UK
17
Open Abdomen Complications:
Prevention and Management
Antonio Tarasconi, Osvaldo Chiara, Stefania Cimbanassi,
Arianna Birindelli, Roberto Cirocchi, Gregorio Tugnoli,
and Salomone Di Saverio
Highlights
• The advantages of open abdomen are not disputable, but the exposure of
the abdominal viscera to the outer environment brings itself a great burden
of dreadful complications.
• Open abdomen could be double-edged sword: prevention is still the best
way to treat open abdomen complications.
• Open abdomen complications could be divided in medical and surgical.
• A multidisciplinary team formed by surgeons, anesthetists and ICU-
attending personnel, nutritionist, psychologist, and specialized nurses with
a specific expertise in open abdomen management is mandatory.
• Every attempt should be made to close the abdomen as soon as reasonably
possible: a primary fascial closure within the first week of open abdomen
seems to be the best way to reduce the complication rate.
216
17.1 Introduction
The idea that leaving the abdomen open after an emergent laparotomy could be
beneficial for patient survival dates back to the first years of the twentieth century,
when Pringle originally described the term open abdomen (OA) [1] and in 1940
Ogilvie provided the first description of a temporary abdominal closure system for
OA management [2]. Unfortunately, these techniques were associated with tremen-
dous infective and hemorrhagic complications and were not routinely used until the
1990s, when the huge advancements in intensive care medicine and antibiotic ther-
apy set the base for the development of the so-called damage control surgery (DCS).
In fact, in 1983 Stone et al. [3] described the use of an abbreviated laparotomy in
case of major coagulopathy, and in 1993 Rotondo et al. [4] borrowed the term dam-
age control from the US Army to describe the abbreviated laparotomy as the only
way to stop the lethal triad of hypothermia, coagulopathy, and acidosis. Furthermore,
the increasing comprehension of the pathophysiology of trauma and abdominal
compartment syndrome (ACS) made the open abdomen (OA) a cornerstone step of
damage control surgery (DCS) [5].
Nowadays the advantages of OA in trauma patients are not disputable, but the
exposure of the abdominal viscera to the outer environment brings itself a great
burden of dreadful complications, such as malnutrition and starvation, because
of the massive fluid and protein losses, fascial retraction and subsequent loss of
abdominal domain, and the development of huge ventral hernia. The most feared
and devastating complication is the formation of an enteroatmospheric fistula,
which is associated with significant morbidity and mortality and characterized
by extremely challenging critical care and nutritional management issues. EAF
requires a multidisciplinary management and, despite the continuous progresses
in OA management, EAF’s mortality can nowadays still be as high as up to 40%
[6, 7].
For all these reasons, surgeons must be aware that OA could be double-edged
sword: prevention is still the best way to treat open abdomen complications.
17.2 Open Abdomen: Definition, Indications, and Temporary
Abdominal Closure
The term open abdomen (OA) means not closing the abdominal fascia after a lapa-
rotomy and temporarily closing the abdomen with a temporary abdominal closure
(TAC) technique. Currently accepted indications for OA [8–10] are: as part of DCS
for trauma, intra-abdominal hypertension or abdominal compartmental syndrome
(ACS) not responsive to medical therapy, acute mesenteric ischemia necessitating a
second look, and impossibility to safely close the abdomen, either because of mas-
sive visceral edema and retroperitoneal swelling or because of the loss of abdominal
wall (traumatic or after necrotizing fascitis). Further indications are infected pancre-
atic necrosis and abdominal sepsis, even if OA in these settings is still a matter of
debate and comparative or randomized studies are lacking.
A. Tarasconi et al.
217
The role of the TAC is crucial, and some of the OA complications depend directly
from the TAC method; theoretically, the ideal TAC technique is the one that:
– Acts like a barrier, thus completely isolating the abdomen content from the outer
atmosphere
– Is not traumatic on the abdominal viscera and prevents the formation of adhesions
– Allows abdominal fluid collection and quantification
– Is quick and easy to apply, allowing easy access to the peritoneal cavity for fur-
ther re-explorations
– Easily allows nursing maneuvers
– Prevents fascial retraction and protects the fascia for an eventual primary closure
– Is cost-effective
Surgical techniques for management of OA have evolved tremendously in the
past three decades [11, 12], and currently the use of negative pressure wound ther-
apy (NPWT) is the best management option [10, 13], especially in the setting of a
septic open abdomen, and can be associated to different kinds of fascial traction
systems [14–16].
17.3 Open Abdomen Complications
OA complications could be artificially divided in medical and surgical, where medi-
cal complications derive from the pathophysiology of a massive open abdominal
wound and surgical complications arise from surgical maneuvers performed into the
open abdomen.
Medical complications are:
– Dehydration, electrolyte imbalance, and acid–base disturbances
– Malnutrition and starvation
Surgical complications are:
– Bleeding
– Enteroatmospheric fistula
– Frozen abdomen
– Huge ventral hernia due to fascial retraction with loss of abdominal domain
17.3.1 Dehydration, Electrolyte Imbalance, and Acid–Base
Disturbances
The presence of an open peritoneal cavity leads to massive fluid losses, both from
direct secretion and from augmented evaporation. Furthermore, the patient with an
open abdomen is usually a critically ill patient, where any imbalance of the
17 Open Abdomen Complications: Prevention and Management
218
physiological status can be detrimental and where the presence of an organ dysfunc-
tion is extremely common. In this setting, it is mandatory to limit and to promptly
correct any fluid loss.
Prevention In the beginning of the open abdomen era, the Bogota bag and the skin-
only closure were the most used TAC [17, 18]; these techniques had the main drawback
of fluid collection, because they did not allow the quantification of fluid losses and let
most of the peritoneal fluid pooling into the OA. The best way to prevent dehydration
and electrolyte imbalance is the utilization of a negative pressure TAC that allows a
correct quantification of fluid losses and completely isolates the open abdomen, signifi-
cantly reducing the excessive evaporation across the open wound [19].
Management Prompt fluid replacement should be meticulously balanced on the
base of patient’s fluid balance; volume status monitoring must be meticulous
throughout the entire length of hospital stay; electrolyte and acid–base imbalance
should be punctually corrected.
17.3.2 Malnutrition and Starvation
The importance of a correct nutrition in critically ill patients is well known since
1964, when Chapman et al. [20] noted that malnutrition was the leading cause of
death in patients with enterocutaneous fistula and mortality was considerably
reduced with a daily intake of at least 1500 Kcal. Patients with OA are continuously
in a hypercatabolic state, due to the high amount of nitrogen losses from abdominal
fluid and to the continuous activation of an exaggerated systemic inflammatory
response, promoted by the secretion of pro-inflammatory cytokines in the open
abdominal wound and by the eventual ongoing peritonitis. At the same time, the
endless healing process consumes calories and proteins. This particular combina-
tion of factors explains the high risk of malnourishment and starvation typical of
this population of patients; furthermore, in the unlucky event of EAF formation, the
fluid and nutrient losses increase dramatically as well as the pro-inflammatory stim-
ulus [21–23].
Prevention The creation of a personalized nutritional plan is of critical importance
and is based on a correct nutritional assessment at the beginning of the OA treat-
ment and the continuous monitoring of the nutritional status. Different empiric
nutritional estimators are currently available (e.g., the Harris–Benedict equation)
for a preliminary evaluation of the basal energy expenditure; subsequently correc-
tions should be made in accordance to the specific characteristics of the single
patient.
Management The first critical step is the establishment of a safe and effective
feeding access, which could be either enteral or parenteral. An effective total par-
enteral nutrition (TPN) usually necessitates of a central venous access that carries
A. Tarasconi et al.