Abdominal V.A.C. Therapy in Trauma

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1 Abdominal V.A.C. Therapy in Trauma Stefaan Nijs, M.D., Ph.D. Mathieu D Hondt, M.D. Dept Abdominal Surgery UZ Leuven 1 2 Damage control = naval technique Damage Control in Trauma 3 USS Nevada 4 In extremis Stabilized Transient responders Unstable Stable QuickTime en een -decompressor zijn vereist om deze afbeelding weer te geven. USS Cole 5 6 1

2 In extremis Stabilized Damage Control Transient responders Unstable Stable Early total trauma care 7 In extremis Haemostatic intervention Stabilized Transient responders Unstable Stable No haemostatic intervention Damage control Is a total concept not a bail out procedure! 9 10 Prolonged surgery Abdominal packing Coagulopathy Hypothermia Abdomen Retroperitoneum Pelvis Acidosis

sense when the source of bleeding cannot easily be removed or ligated.

Damage control Abdominal packs Oedema due to ligation and compression Increased

syndrome ACS is defined as a sustained IAP > 20mmHg (with or without an APP <

The most common organ dysfunction / failure(s) are: Metabolic acidosis despite

$Hypercarbia refractory to increased ventilation Hypoxemia refractory to oxygen$

3 Why packing? Why packing? Compression ± Haemostatic fleece Compression ± Haemostatic fleece Only makes sense when the source of bleeding cannot easily be removed or ligated. Haemostasis 13 Haemostasis 14 What can I ligate? Damage control Abdominal packs Oedema due to ligation and compression Increased abdominal pressure Fluid shift to the 3th space Abdominal compartment syndrome ACS is defined as a sustained IAP > 20mmHg (with or without an APP < 60mmHg) that is associated with new organ dysfunction/ failure. The most common organ dysfunction / failure(s) are: Metabolic acidosis despite resuscitation Oliguria despite volume repletion Elevated peak airway pressures Hypercarbia refractory to increased ventilation Hypoxemia refractory to oxygen and PEEP Intracranial hypertension Abdominal perfusion pressure (APP) = mean arterial pressure (MAP) 17 minus intra-abdominal pressure (IAP) = MAP - IAP. Damage control laparotomy Leave the abdomen open 1 3

4 Temporary closure Towel clip closure Abdominal zipper Bogota bag Abdominal velcro Abdominal VAC Dressing Abdominal VAC Dressing PU-foam Adhesive drape Placement: Step 1: The polyethylene sheeth is tucked under the fascial edges Perforated Polyethylene sheet PU-foam Abdominal VAC Dressing Abdominal VAC Dressing Placement: Step 2: Placement of polyurethane sponges Placement: Step 3: Appliance of the adhesive dressing and T.R.A.C.-pad connector Step 4: -125 mm Hg, continuous suction 4

5 Benefits Control of leaking 3rd space fluid Minimizes dressing changes (/3-5d) Maintains low bacterial counts Stimulates wound healing and granulation Decreases abdominal wall tension Facilitates closure of the abdominal wall (fascial closure rates:6-92% (2), (3)) (2)Suliburk et al. J Trauma 2003 (3) Garner et al. Am J Surg VAC Assisted Fascial Closure (VAFC) VAC Assisted Fascial Closure (VAFC) Open abdomen VAC Pack Reoperation close the abdomen? % FASCIAL CLOSURE Yes No Repeat every 3 5 days until closure 35 cm Close fascia VAFC Reoperation (4) Miller er al. J Trauma 2002 (5) Miller et al. Ann Surg 2004 Cases Patient 1: female 39 years old * Concussion * Rib fracture * Grade 4 liver lesion

$44 years old * Pelvic fracture *$ Deglovement left leg * Secondary

$Pelvic fracture * Flail chest *$ Ruptured diaphragm * Bilateral

$Open pelvic fracture * Rib$ $fractures * Grade 4 liver lesion *$

6 Patient 1: female 39 years old * ISS = 29 * RTS= 5,1 * TRISS probability of survival blunt = 7% Outcome = Survival Patient 2: male 44 years old * Pelvic fracture * Proximal humerus fracture * Deglovement left leg * Secondary abdominal compartment syndrome Abdominal closure at relook Pedestrian hit by truck Patient 2: male 44 years old * ISS = 36 * RTS= 6, * TRISS probability of survival blunt = % Outcome = Survival Abdominal closure VAFC Patient 3: male 46 years old * Concussion * Pelvic fracture * Flail chest * Ruptured diaphragm * Bilateral pneumothorax * Grade 2 liver lesion * Perforated colon Biker rolled over by car Patient 3: male 44 years old * ISS = 57 * RTS= 5,1 * TRISS probability of survival blunt = 26% Outcome = Survival Abdominal closure VAFC Patient 4: female 22 years old * Cerebral contusion * Open pelvic fracture * Rib fractures * Grade 4 liver lesion * Perforated ileum * Deglovement trunk + both lower extremities * Distal humerus fracture Biker rolled over by truck 6

$pelvic fracture *$ $Rib fractures *$ * Perforated ileum *

$humerus fracture$

7 Patient 4: female 22 years old * Cerebral contusion * Open pelvic fracture * Rib fractures * Grade 4 liver lesion * Perforated ileum * Deglovement trunk + both lower extremities * Distal humerus fracture Biker rolled over by truck

Patient 4: female 22 years old * ISS = 66 * RTS= 5,1 * TRISS

the Emerging technology: AB Thera These results suggest that the

andthe lowest mortality rates. 45 46 Abdominal V.A.C.

8 Patient 4: female 22 years old * ISS = 66 * RTS= 5,1 * TRISS probability of survival blunt = 14% Outcome = Survival What is the evidence? Abdominal closure Laparostomy + graft Still in preparation 44 What is the evidence? Emerging technology: AB Thera These results suggest that the artificial burrand the VAC are associated with the highest FC rates andthe lowest mortality rates Abdominal V.A.C. Therapy in Trauma: lowers mortality rate in damage control patients has a high primary fascial closure rate makes the nursing of open abdomen patients more easy 47

Bogota-VAC A Newly Modified Temporary Abdominal Closure Technique

Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2008 Bogota-VAC A Newly Modified Temporary Abdominal Closure Technique von