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
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 11 12 2
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 15 16 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
Temporary closure Towel clip closure Abdominal zipper Bogota bag Abdominal velcro 19 20 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
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 2001 26 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 29 7 5
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
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 3 39 40 41 42 7
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. 45 46 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