Open abdomen in the trauma ICU patient: who? when? why? and what are the outcome results?

Abstract

Purpose
Temporary abdominal closure is a component of damage control surgery and may decrease mortality rates. The ultimate aim in managing an open abdomen is to achieve definitive fascial closure. The aim of this study is to assess the previously known predictors for failure to achieve definitive fascial closure and identify new predictors in order to achieve a better outcome.

Methods
An 11-year retrospective chart review included open abdomen cases at Inkosi Albert Luthuli Hospital Trauma ICU in KZN (Ethics Approval BCA207-09). The evaluated outcomes were definitive fascial closure, open abdomen and mortality. Variables included age, co-morbidities, albumin levels, renal failure, multiple blood transfusions, type of blood products given, entero-atmospheric fistulas, TAC, anastomosis, intra-abdominal abscess, type of nutrition, ACS, number of re-laparotomies, deep site infections (peritonitis), systemic infections (bloodstream), ventilator acquired pneumonia, head injury, and type of fluids given.

Results
This study reviewed 188 cases, 46.8% (88) arrived from elsewhere with an open abdomen while 53.2% (100) did not; 46.8% suffered blunt trauma, 45.2% suffered gunshots, while 8.0% were stabbed. Ninety deaths (47.9%) occurred during the index admission with 57 (30.3%) within the first 30 days. For both death within 30 days and death as final outcome, the majority were blunt abdominal trauma, 51.1 and 52.6%, respectively. Out of 188 patients, 27.1% had definitive fascial closure and 26.6% remained with an open abdomen. The relevant variables related to failure to achieve fascial closure were hypoalbuminemia (p = 0.002, p = 0.036), anastomotic leak (p < 0.05), VAP (p = 0.007), age (p = 0.002), intra-abdominal abscesses (p = 0.006), ACS (p = 0.005), multiple re-laparotomies (p = 0,028), deep surgical site infection (p < 0.05) and multi-organ failure (p = 0.003).

Conclusion
This study identified the predictors of failed fascial closure and mortality. While not directly modifiable, hypoalbuminaemia, anastomotic leak and sepsis, leading to multiple re-laparotomy, preclude early closure and portend high mortality.

Full text

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European Journal of Trauma and Emergency Surgery (2022) 48:953–961
https://doi.org/10.1007/s00068-020-01543-6
ORIGINAL ARTICLE
Open abdomen inthetrauma ICU patient: who? when? why? andwhat
are theoutcome results?
KurtNirishanBoolaky1 · AliHassanTariq2 · TimothyCraigHardcastle3,4
Received: 1 August 2020 / Accepted: 31 October 2020 / Published online: 17 November 2020
© Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract
Purpose Temporary abdominal closure is a component of damage control surgery and may decrease mortality rates. The
ultimate aim in managing an open abdomen is to achieve definitive fascial closure. The aim of this study is to assess the
previously known predictors for failure to achieve definitive fascial closure and identify new predictors in order to achieve
a better outcome.
Methods An 11-year retrospective chart review included open abdomen cases at Inkosi Albert Luthuli Hospital Trauma
ICU in KZN (Ethics Approval BCA207-09). The evaluated outcomes were definitive fascial closure, open abdomen and
mortality. Variables included age, co-morbidities, albumin levels, renal failure, multiple blood transfusions, type of blood
products given, entero-atmospheric fistulas, TAC, anastomosis, intra-abdominal abscess, type of nutrition, ACS, number of
re-laparotomies, deep site infections (peritonitis), systemic infections (bloodstream), ventilator acquired pneumonia, head
injury, and type of fluids given.
Results This study reviewed 188 cases, 46.8% (88) arrived from elsewhere with an open abdomen while 53.2% (100) did
not; 46.8% suffered blunt trauma, 45.2% suffered gunshots, while 8.0% were stabbed. Ninety deaths (47.9%) occurred dur-
ing the index admission with 57 (30.3%) within the first 30days. For both death within 30days and death as final outcome,
the majority were blunt abdominal trauma, 51.1 and 52.6%, respectively. Out of 188 patients, 27.1% had definitive fascial
closure and 26.6% remained with an open abdomen. The relevant variables related to failure to achieve fascial closure were
hypoalbuminemia (p = 0.002, p = 0.036), anastomotic leak (p < 0.05), VAP (p = 0.007), age (p = 0.002), intra-abdominal
abscesses (p = 0.006), ACS (p = 0.005), multiple re-laparotomies (p = 0,028), deep surgical site infection (p < 0.05) and
multi-organ failure (p = 0.003).
Conclusion This study identified the predictors of failed fascial closure and mortality. While not directly modifiable,
hypoalbuminaemia, anastomotic leak and sepsis, leading to multiple re-laparotomy, preclude early closure and portend
high mortality.
Keywords Open abdomen· Definitive closure· Risk factors· Trauma ICU
Introduction
An open abdomen (OA) has been variably defined in litera-
ture but results in not approximating the abdominal rectus
sheath after considering assessment of physiology, identi-
fied injuries and need for abdominal re-exploration. This
decision is usually made either pre-operatively or intra-
operatively [1].
Damage control surgery (DCS) is the most common pro-
cedure resulting in the OA [2]. As per the WSES guidelines
for trauma, the predictors with level 2A evidence to leave an
open abdomen are persistent hypotension (SBP < 90mmHg),
acidosis (pH < 7.2), base deficit > 8, hypothermia (T < 34°C)
This work has not been published or presented elsewhere.
* Timothy Craig Hardcastle
hardcastle@ukzn.ac.za
1 Department ofSurgery, University ofKwaZulu-Natal,
Durban, SouthAfrica
2 General Surgery, Prince Mshiyeni Memorial Hospital,
Umlazi, SouthAfrica
3 Trauma Unit, Inkosi Albert Luthuli Central Hospital,
Department ofSurgery, University ofKwaZulu-Natal,
Durban, SouthAfrica
4 IALCH Trauma Service, 800 Vusi Mzimela Rd, Mayville,
Durban4055, SouthAfrica
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