Bryan R. Collier

The management of the open abdomen in trauma and emergency general surgery: part 1-damage control.

BACKGROUND The open abdomen technique, after both military and civilian trauma, emergency general or vascular surgery, has been used in some form for the past 30 years. There have been several hundred citations on the indications and the management of the open abdomen. Eastern Association for the Surgery of Trauma practice management committee convened a study group to organize the worlds literature for the management of the open abdomen. This effort was divided into two parts: damage control and the management of the open abdomen. Only damage control is presented in this study. Part 1 is divided into indications for the open abdomen, temporary abdominal closure, staged abdominal repair, and nutrition support of the open abdomen. METHODS A literature review was performed for more than 30 years. Prospective and retrospective studies were included. The reviews and case reports were excluded. Of 1,200 articles, 95 were selected. Seventeen surgeons reviewed the articles with four defined criteria. The Eastern Association for the Surgery of Trauma primer was used to grade the evidence. RESULTS There was only one level I recommendation. A patient with documented abdominal compartment syndrome should undergo decompressive laparotomy. CONCLUSION The open abdomen technique remains a heroic maneuver in the care of the critically ill trauma or surgical patient. For the best outcomes, a protocol for the indications, temporary abdominal closure, staged abdominal reconstruction, and nutrition support should be in place.

Guidelines for Management of Small Bowel Obstruction

STATEMENT OF THE PROBLEMThe description of patients presenting with small bowel obstruction (SBO) dates back to the third or fourth century, when early surgeons created enterocutaneous fistulas to relieve a bowel obstruction. Despite this success with operative therapy, the nonoperative management o

Feeding the Open Abdomen

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

The impact of a normoglycemic management protocol on clinical outcomes in the trauma intensive care unit.

50,000. CONCLUSIONS EEN in the OA was associated with (1) earlier primary abdominal closure, (2) lower fistula rate, (3) lower hospital charges.

Eastern Association for the Surgery of Trauma: A Review of the Management of the Open Abdomen-Part 2 "Management of the Open Abdomen"

BACKGROUND The purpose of this study was to determine if protocol-driven normoglycemic management in trauma patients affected glucose control, ventilator-associated pneumonia, surgical-site infection, and inpatient mortality. METHODS A prospective, consecutive-series, historically controlled study design evaluated protocol-driven normoglycemic management among trauma patients at Vanderbilt University Medical Center. Those mechanically ventilated > or =24 hours and > or =15 years of age were included. A glycemic-control protocol required insulin infusion therapy for glucose >110 mg/dL. Control patients included those who met criteria, were admitted the year preceding protocol implementation, and had hyperglycemia treated at the physicians discretion. RESULTS Eight hundred eighteen patients met study criteria; 383 were managed without protocol; 435 underwent protocol. The protocol group had lower glucose levels 7 of 14 days measured. After admission, both groups had mean daily glucose levels <150 mg/dL. No difference in pneumonia (31.6% vs 34.5%; p = .413), surgical infection (5.0% vs 5.7%; p = .645) or mortality (12.3% vs 13.1%; p = .722) occurred between groups. If one episode of blood glucose level was > or =150 mg/dL (n = 638; 78.0%), outcomes were worse: higher daily glucose levels for 14 days after admission (p < .001), pneumonia rates (35.9% vs 23.3%; p = .002), and mortality (14.6% vs 6.1%; p = .002). One or more days of glucose > or =150 mg/dL had a 2- to 3-fold increase in the odds of death. Protocol use in these patients was not associated with outcome improvement. CONCLUSIONS Protocol-driven management decreased glucose levels 7 of 14 days after admission without outcome change. One or more glucose levels > or =150 mg/dL were associated with worse outcome.

Colon Anastomosis After Damage Control Laparotomy: Recommendations From 174 Trauma Colectomies

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 “Damage Control” have been published.1 During the development of the open abdomen part II “Management of the Open Abdomen,” the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 “Management of the Open Abdomen” and provides clinical direction regarding the following specific topics.

Morbid Obesity is Not a Risk Factor for Mortality in Critically Ill Trauma Patients

BACKGROUND Primary colonic anastomosis in trauma patients has been demonstrated to be safe. However, few studies have investigated this in the setting of damage control laparotomy. We hypothesized that colonic anastomosis for trauma patients requiring an open abdomen (OA) would have a higher anastomotic leak (AL) rate when compared with patients having an immediate abdominal closure following trauma laparotomy. METHODS We performed a cohort comparison study of all trauma patients who underwent colectomy, between the years 2004 and 2009. Exclusion criteria were mortality within 24 hours of admission or colectomy for indications unrelated to injury. Data collected included age, gender, injury severity score, mechanism, length of stay, and mortality. Multivariable logistic regression was performed to assess the relationship of OA to our primary outcome measure, AL. RESULTS Totally, 174 patients met study criteria. Fecal diversion was performed in 58 patients, and colonic anastomosis was performed in the remaining 116 patients. Patients with OA had a clinically significant increase in AL rate compared with immediate abdominal closure (6% vs. 27%, p=0.002). Logistic regression demonstrated that OA was independently associated with AL, with OA patients having more than a sixfold increase in odds of AL compared with those who were closed (odds ratio=6.37, p=0.002, area under the receiver operator curve=0.72). Transfusion requirement and left-sided anastomosis were risk factors for leak. CONCLUSIONS Patients with a colonic anastomosis and an OA have an unacceptably high leak rate compared with those who undergo reconstruction with immediate closure. Given the significant risk of AL, colonic anastomosis should not be routinely performed in patients with OA.

Does regionalization of acute care surgery decrease mortality

BACKGROUND Age, Injury severity score (ISS), hyperglycemia (HGL) at admission, and morbid obesity are known risk factors of poor outcome in trauma patients. Our aim was to which risk factors had the highest risk of death in the critically ill trauma patient. METHODS A Trauma Registry of the American College of Surgeons database retrospective study was performed at our Level I trauma center from January 2000 to October 2004. Inclusion criteria were age >15 years and >or=3 days hospital stay. Data collected included age, gender, and ISS. Groups were divided into nonobese and morbidly obese (MO) (body mass index, BMI >or=40 kg/m2) and into HGL (mean >or=150 mg/dL on initial hospital day) and non-HGL. Primary outcome was 30-day mortality. Differences in mortality and demographic variables between groups were compared using Fishers exact and Wilcoxons rank sum tests. Univariate and multivariate logistic regression was used to assess the relationship of HGL, morbid obesity, age, and injury severity to risk of death. Relationships were assessed using odds ratios (OR) and area under the receiver operator characteristic curve (AUC). RESULTS A total of 1,334 patients met study criteria and 70.5% were male. Demographic means were age 40.3, ISS 25.7, length of stay 13.4, and BMI 27.5. The most common mechanism of injury was motor vehicle collision 55.1%. Overall mortality was 4.7%. Mortality was higher in HGL versus non-HGL (8.7% vs. 3.5%; p < 0.001). Mortality was higher in MO versus nonobese, but not significantly (7.8 vs. 4.6%; not significant [NS] p = 0.222). Univariate logistic regression relationships of death to age OR: 1.031, p < 0.001, AUC +/- SE: 0.639 +/- 0.042; ISS OR: 1.044, p < 0.001, AUC +/- SE: 0.649 +/- 0.039; HGL OR: 2.765, p < 0.001; MO: OR: NS, p = NS, AUC +/- SE: NS. Relationships were similar in a combined multivariate model. CONCLUSION HGL >150 mg/dL on the day of admission is associated with twofold increase in mortality, and an outcome measure should be followed. Morbid obesity (BMI >or=40) is not an independent risk factor for mortality in the critically ill trauma patient.

Efficacy and Safety of Glutamine-supplemented Parenteral Nutrition in Surgical ICU Patients: An American Multicenter Randomized Controlled Trial.

BACKGROUND During the initial development of an Emergency General Surgery (EGS) service, severity of illness (SOI) can be expected to be high and should decrease as the service matures. We hypothesize that a matured regional EGS service would show decreasing mortality and length of stay (LOS) over time. METHODS We performed a retrospective study of a prospectively collected EGS registry data from 2004 to 2009. Patients were included if they had been discharged from the EGS service and were stratified by year of discharge. Systemic inflammatory response syndrome, sepsis, shock, peritonitis, perforation, and acute renal failure were used as markers of SOI. Patients were defined as high acuity if they had one or more of these SOI markers. Differences in mortality, LOS, intensive care unit admissions, SOI, charges, and distance were compared across and between years using nonparametric statistical tests (Fishers exact, Wilcoxon rank-sum, and Kruskal-Wallis tests). RESULTS A total of 3,439 patients met study criteria. The mean age was 47 years ± 17.5 years. The majority of the patients were female (1,813, 47.3%). The overall LOS was 6.4 days ± 9.4 days (median, 4 days). In all, 2,331 (67.8%) of the patients underwent operation. Over the course of the study period, the SOI indicators stabilized at between 13% and 17% of the patient population with at least one indicator. During that time period, mortality steadily decreased from 4.9% to 1.3% (p < 0.5). CONCLUSION Despite consistently high SOI, a dedicated and matured EGS service demonstrated a decrease in mortality and LOS.

The Place for Glycemic Control in the Surgical Patient

Objective:To determine whether glutamine (GLN)-supplemented parenteral nutrition (PN) improves clinical outcomes in surgical intensive care unit (SICU) patients. Summary Background Data:GLN requirements may increase with critical illness. GLN-supplemented PN may improve clinical outcomes in SICU patients. Methods:A parallel-group, multicenter, double-blind, randomized, controlled clinical trial in 150 adults after gastrointestinal, vascular, or cardiac surgery requiring PN and SICU care. Patients were without significant renal or hepatic failure or shock at entry. All received isonitrogenous, isocaloric PN [1.5 g/kg/d amino acids (AAs) and energy at 1.3× estimated basal energy expenditure]. Controls (n = 75) received standard GLN-free PN (STD-PN); the GLN group (n = 75) received PN containing alanyl-GLN dipeptide (0.5 g/kg/d), proportionally replacing AA in PN (GLN-PN). Enteral nutrition (EN) was advanced and PN weaned as indicated. Hospital mortality and infections were primary endpoints. Results:Baseline characteristics, days on study PN and daily macronutrient intakes via PN and EN, were similar between groups. There were 11 hospital deaths (14.7%) in the GLN-PN group and 13 deaths in the STD-PN group (17.3%; difference, −2.6%; 95% confidence interval, −14.6% to 9.3%; P = 0.66). The 6-month cumulative mortality was 31.4% in the GLN-PN group and 29.7% in the STD-PN group (P = 0.88). Incident bloodstream infection rate was 9.6 and 8.4 per 1000 hospital days in the GLN-PN and STD-PN groups, respectively (P = 0.73). Other clinical outcomes and adverse events were similar. Conclusions:PN supplemented with GLN dipeptide was safe, but did not alter clinical outcomes among SICU patients.