Open Abdomen in Critical 1

Cover
Open Abdomen in
Trauma and Critical Care
Eleanor R. Fitzpatrick, RN, MSN, ACNP, CCRN
The open abdomen technique and temporary abdominal closure after damage control surgery is fast
becoming the standard of care for managing intra-abdominal bleeding and infectious or ischemic pro-
cesses in critically ill patients. Expansion of this technique has evolved from damage control surgery in
severely injured trauma patients to use in patients with abdominal compartment syndrome due to acute
pancreatitis and other disorders. Subsequent therapies after use of the open abdomen technique and
temporary abdominal closure are resuscitation in the intensive care unit and planned reoperation to
manage the underlying cause of bleeding, infection, or ischemia. Determining the need for this poten-
tially lifesaving intervention and managing the wound after the open abdomen has been created are all
within the realm of critical care nurses. Case studies illustrate the implementation of the open abdomen
technique and patient management strategies. (Critical Care Nurse. 2017;37[5]:22-45)
he open abdomen is a technique with recently expanded implementation in managing com-
T plex problems in critically ill patients. First used in trauma care in the 1990s, the technique is
now a management strategy for many other illnesses and conditions in critically ill adults. The
mainstay of treatment for intra-abdominal infections, intra-abdominal bleeding, and abdominal com-
partment syndrome (ACS), whatever the cause, is the intentional creation of an open abdomen, which
is a laparotomy wound that allows a damaged or edematous viscera to expand, reducing intra-abdominal
pressure (IAP) and related complications.1 The technique of the open abdomen is defined as intention-
ally leaving the fascial edges of the abdomen unapproximated (laparostomy) through a surgically created
entrance into the cavity. As a result, the abdominal contents are exposed but are protected by a temporary
CE 1.0 hour, CERP A
This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:
1. Analyze the risks in varied patient populations for the onset of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).
2. Explore the indications for using the open abdomen technique in trauma, medical, and surgical conditions that can yield IAH and ACS.
3. Describe the open abdomen intervention and temporary abdominal closure in the management of IAH, ACS, and trauma.
To complete evaluation for CE contact hour(s) for activity C1751, visit www.ccnonline.org and click the “CE Articles” button. No CE fee for AACN members.
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Table 1 Indications for the open abdomen
Indication Conditions
Damage control surgery Damage control surgery in patients in unstable condition with hypothermia, acidosis,
coagulopathy, and unstable hemodynamic status
Prevention of hypothermia and acidosis
Abbreviated operation needed in trauma and nontrauma conditions including
Penetrating and nonpenetrating trauma
Emergent vascular surgery
Orthotopic liver transplantation
Uncontrolled venous bleeding in pancreatic surgery
Abdominal compartment syndrome Abdominal compartment syndrome due to any cause including
or inability to achieve abdominal Necrotizing, infected pancreatitis
closure because of excess fluid or Intra-abdominal sepsis
edematous abdominal contents Massive fluid replacement
Retroperitoneal swelling
Bowel obstruction
Toxic megacolon
Tense ascites
Requirement for second-look sur- Intra-abdominal sepsis
gery to assess bowel viability or Bowel obstruction
to evaluate and treat continued Intestinal ischemia due to acute mesenteric ischemia or other entity
intra-abdominal contamination Necrotizing, infectious acute pancreatitis
Gastrointestinal perforation with peritonitis
covering placed at the end of the surgical procedure.2 open abdomen, the medical and nursing management
All types of critical care units will have patients with an strategies involved, and the complications inherent in
open abdomen because the indications for this proce- the application of this procedure. I also review nutri-
dure have increased dramatically and now include both tional considerations.
medical and surgical diagnoses (Table 1). Use of the open
abdomen and temporary abdominal closure (TAC) after Indications for the Open Abdomen
creation of the open incision has become a common and The most common indication for the open abdomen
valuable tool in critical care.3-5 is damage control surgery for abdominal trauma.3 Dam-
Creation of an open abdomen is a considerable chal- age control consists of abbreviated surgical interventions
lenge for critical care nurses, requiring astute assessment in critically ill patients who are too ill to continue with a
before, during, and after its implementation. Use of the laparotomy that is being performed. Conversion to the
open abdomen comes about as the technological advances abbreviated laparotomy (damage control) is defined as
of trauma care and management of infection and abdomi- the initial control of surgical bleeding by simple opera-
nal emergencies have expanded exponentially. Manage- tive techniques such as packing for a lifesaving purpose
ment of severe illnesses with the open abdomen has and returning the patient to the critical care unit for cor-
improved survival and overall patient outcomes after rection of acidosis, hypothermia, and coagulopathy and
severe trauma and major vascular surgery, and the effec- for continued resuscitation.2,6 Other indications for an
tiveness of the open abdomen in other conditions is being open abdomen are life-threatening intra-abdominal
explored.5 In this article, I describe the creation of the bleeding (related to trauma or vascular disruption),
Author
Eleanor R. Fitzpatrick is a clinical nurse specialist for surgical critical care at the Thomas Jefferson University Hospital, Philadelphia,
Pennsylvania.
Corresponding author: Eleanor R. Fitzpatrick, RN, MSN, ACNP, CCRN, Thomas Jefferson University Hospital, 111 S 11th St, Philadelphia, PA, 19107 (email: eleanor.fitzpatrick
@jefferson.edu).
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or
(949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.
www.ccnonline.org CriticalCareNurse Vol 37, No. 5, OCTOBER 2017 23

prevention or treatment of intra-abdominal hyperten- which, if unchecked, will ultimately lead to visceral
sion (IAH), and management of severe intra-abdominal hypoperfusion and multiple organ failure in trauma and
sepsis.3 As use of the procedure has evolved, it is also in other disease processes.4,7
indicated for treatment of severe abdominal conditions The systemic inflammatory response syndrome,
such as mesenteric ischemia, intra-abdominal infection, increased vascular permeability, bleeding, and aggres-
and intra-abdominal hemorrhage. All of the indications sive crystalloid replacement predispose patients to fluid
for the open abdomen are marked by the development sequestration with formation of excess peritoneal fluid.2
of extreme swelling or edema or both of intra-abdominal In patients with severe sepsis, shock bowel, a mechanism
structures or collection of large amounts of fluid (blood, for increasing bowel edema, also develops. These patho-
leaking intraluminal contents) in the intra-abdominal physiological changes and instances in which the
space or retroperitoneum or both. Emergency general abdominal wall is closed after surgery may result in
abdominal surgery, vascular catastrophes, and acute increasing IAP ultimately leading to IAH.2 Elevated IAP
pancreatitis are all entities that may be managed by causes both regional and global hypoperfusion that pro-
using the open abdomen technique.7 gresses to marked organ dysfunction and failure.2
Increased abdominal pressure and the decreased venous
Abdominal Compartment Syndrome and return and increasing intrathoracic pressure that ensue
the Open Abdomen also adversely affect organ function. The progression of
Abdominal compartment syndrome due to trauma, IAH to ACS occurs when the persistently elevated IAP
serious vascular disruption, or from any of the causes results in multiple organ dysfunction.2 The point at which
noted in Table 1 is a condition that may respond to multiple organ dysfunction occurs is variable and depends
decompressive laparotomy and open abdomen.7 ACS is on many patient factors, including severity of illness or
defined as sustained intra-abdominal pressure (IAP) injury and the presence of any preexisting conditions.
greater than 20 mm Hg (with or without an abdominal IAH has 4 grades: I, IAP 12 to 15 mm Hg; II, IAP 16 to
perfusion pressure [APP] <60 mm Hg) that occurs in 20 mm Hg; III, IAP 21 to 25 mm Hg; and IV, IAP greater
association with new organ dysfunction or failure.5 APP than 25 mm Hg.5 As pressures increase within the intra-
is defined as the mean arterial pressure minus the IAP.5 abdominal space and severity of IAH worsens, more adverse
APP should be maintained between 50 and 60 mm Hg physiological sequelae occur. The earliest or potentially
for patients most effective means of treating ACS in high-risk patients
Within the abdominal cavity, there are being moni- is recognition of the condition and prompt intervention.2
potential sources of sepsis, bleeding, tored.8 IAP is Two types of ACS exist. The first is primary ACS, a
ischemia, and other conditions that the steady- condition associated with injury or disease in the abdomi-
can yield IAH and ACS. state pressure nopelvic region that often requires early surgical or inter-
contained ventional treatment. Secondary ACS refers to conditions
within the abdominal cavity. Normal IAP is approxi- that do not originate from the abdominopelvic region but
mately 5 to 7 mm Hg in critically ill adults.9-11 The abnor- the end results are increasing edema and pressure within
mal elevation in IAP is known as IAH. Elevated IAP is a the cavity.3,4,12 ACS is a potentially lethal complication
continuum from IAH to ACS. IAH is a sustained or characterized by effects on splanchnic, cardiovascular,
repeated pathological elevation in IAP greater than 12 pulmonary, renal, and central nervous system circulation.
mm Hg.9,10 This process occurs in trauma, vessel disrup- Ventricular filling is reduced because of decreased venous
tion with bleeding, fluid resuscitation, and any other return caused by the compression of the inferior vena cava
condition that increases the contents and pressure or portal vein by the IAP. The result is seriously compro-
within the abdominal cavity. The pathophysiological fac- mised blood flow to the heart, lungs, kidneys, and brain.2
tors that can result in IAH include diminished abdomi-
nal wall compliance, increase in abdominal contents, and Damage Control Surgery
capillary leak or massive fluid replacement or both.6 Use Starting in the late 1990s, damage control surgery
of the open abdomen and damage control surgical inter- has become the standard of care in the treatment of
ventions can interrupt the progression of this IAH, injured patients with severe physiological compromise

who require surgical intervention to prevent further control surgery is performed in severely injured trauma
worsening in clinical status.4 Damage control surgery patients and other patients with critical illness.10,12,16,17
involves an expeditious, immediate laparotomy to man- The use of damage control surgery, versus the use of
age life-threatening abdominal trauma or bleeding, IAH, more traditional surgical interventions in traumatically
and ACS. Damage control is accomplished by using injured patients, has resulted in improved survival statis-
intra-abdominal packing, rapid control of bleeding vessels tics, and the use of this type of surgery in other critically
via shunting or ligation,13 removal of infectious and necrotic ill patients is being studied for its effects, although the
tissue, and drain placement.3,7 The damage control tech- exact incidence of use of the damage control technique is
nique should be considered and implemented early before not known. Results of retrospective reviews and prospec-
a patient’s situation is further compromised, reaching the tive, observational trials have indicated improved out-
extremis stage (defined as coagulopathy, hypothermia comes, such as decreased occurrence of multiple organ
[<35°C], severe acidosis with base deficit >15 mmol/L, failure, and acceptance of the damage control technique
or transfusion of ≥10 units of packed red blood cells).3,4,7,14 has been widespread.4,5,7,18,19
Many experts3,4 advise that damage control surgery be
considered early on for any patient who requires an Temporary Abdominal Closure
urgent or emergent laparotomy for any cause. Some of At the completion of the damage control procedure,
the conditions that may result in the need for this type the abdomen cannot be closed and the fascia cannot be
of laparotomy are listed in Table 1. approximated because of visceral edema, bleeding, or
The initial goals of damage control are to achieve infection; therefore, the wound requires a dressing or
hemostasis in a patient who is hemorrhaging, to control TAC.18 TAC provides reentry into the abdominal cavity
leakage of intraluminal intestinal contents, and to for multiple operations and eventual completion of the
achieve control quickly by using abbreviated strategies definitive surgical course of treatment.19,20 The ideal TAC
to shorten the time the patient is in the operating room.2 should be easily applied; allow room for abdominal con-
Shortening the intraoperative time in damage control is tents to expand; limit contamination; decrease bowel
of advantage in preventing the adverse outcomes of edema; protect the viscera, fascia, and skin; allow for
emergency open laparotomy, such as coagulopathy and evacuation of fluids; prevent adhesions; limit dressing
acidosis. Once the injuries are treated temporarily, the changes; minimize loss of domain (ie, 50% of the abdom-
patient is transferred from the operating room to the inal viscera
intensive care unit (ICU). During the second phase of outside the Nurses in most critical care units can
damage control, physiological parameters are normal- abdominal expect to see patients with an open
ized with transfusion of blood and blood products, inva- cavity); and be abdomen because the indications span
sive monitoring, rewarming, and metabolic support.14-16 cost-effective. both medical and surgical diagnoses.
The final phase of damage control is definitive repair, The open
performed in the operating room once the patient’s abdomen and the TAC should also prevent the develop-
physiological status is normalized.14-16 ment (or recurrence) of ACS, support a high rate of clo-
Over the past 10 to 20 years, damage control tech- sure, and limit complications (especially enterocutaneous
niques have been used in both trauma and nontrauma fistulas), and mortality.18
situations. Although the prevalence of use of the damage Temporary abdominal closure can be accomplished
control technique is not well defined, potential benefits with a variety of techniques (Table 2), including bridged
are thought to be mitigation of the risk for ACS and biological or synthetic systems such as the Wittman patch
facilitation of abbreviated surgical procedures in physio- (Figure 1), Bogota bag (Figure 2), or negative-pressure
logically unstable patients. In patients with sepsis and wound therapy (NPWT) between the fascial edges
septic shock due to an abdominal source, outcomes are (Figure 3). These techniques may prevent ACS and are
improved when control of the infection source is extremely effective in preserving the fascia for eventual
achieved quickly through the damage control method.2,16 closure of the abdominal wall.8 Table 2 describes the
Studies have indicated decreased mortality and fewer varied techniques for TAC and the advantages and
immediate postoperative complications when damage disadvantages of each technique.

Table 2 Options for temporary abdominal closurea
Option Uses Disadvantage Other information
Bogota bag or silo: Uses a sterile Equipment readily available Prone to leaking, no Generally not appropriate for use
plastic fluid bag, which is sutured Able to visualize condition of peritoneal fluid in the United States because
to the fascia, allowing inspection structures through device removed, skin damage, superior options available
of abdominal contents and loss of domain, Cannot apply a suction source
assessment for ischemia recurrence of ACS
NPWT: Includes the Barker vac- Prevents lateral retraction System and dressing Most extensively used
uum pack technique and VAC of fascia and removes must be changed Suction applied for removal of
and Abthera dressing; nonad- contaminated fluid several times weekly toxic fluid and enhanced wound
herent sheets are used to cover Facilitates reoperation and and as needed healing
and protect the exposed viscera; improves wound Requires intensive VAC provides more uniform
sheets are covered with a granulation nursing care suction across entire dressing
sponge (VAC) or moist towel Quantifies fluid losses compared with the Barker
(Barker vacuum pack), and suc- Sutureless Barker vacuum vacuum pack, which has less
tion is applied to the entire pack is the more cost- equally distributed suction3,4
apparatus via separate catheters effective option but lacks High rate of fascial and abdomi-
in the Barker technique and with the more sophisticated nal wall closure
a prepackaged drainage tube dressing sponges, drains, When used with mesh-mediated
connected to a special suction and suction fascial retraction can result in
pump in the VAC dressing; trac- less formation of ventral hernia
tion and counter-traction are and enteroatmospheric fistula
applied to the abdominal wall in (P = .001)21
both types of NPWT
Wittman Patch: Consists of Facilitates reoperation No peritoneal fluid Suction source can be applied
sheets of nonadherent polypro- Prevents lateral retraction, removal unless suction
pylene, loops and hooks that recovers and maintains fas- applied, damage to the
bind together and approximate cial domain fascia occurs
as visceral edema and adverse
conditions resolve; 2 opposing
Velcro sheets are sutured to
fascial edges and overlap, allow-
ing gradual reapproximation of
abdominal wall
Skin closure over fascial defect Not commonly used because Unable to collect or Promotes IAH
with towel clips or a running more sophisticated options contain drainage Intra-abdominal contents not
suture: Not used in the United available Fluids are damaging to protected or isolated
States skin
Synthetic meshes Encourage granulation tissue Does not prevent IAH or High incidence of complications
ACS
No drainage of abdominal
fluid
Cannot be used in patients
with abdominal sepsis
Abbreviations: ACS, abdominal compartment syndrome; IAH, intra-abdominal hypertension; NPWT, negative pressure wound therapy; VAC, vacuum-assisted closure.
a
Based on data from Demetriades and Salim4 and Quyn et al.22
The Bogota bag, an early version of TAC, has largely commonly used today in the United States.17 The VAC-
been abandoned for more sophisticated techniques. pack (Figure 5) is a type of NPWT that uses 3 layers
NPWT systems are effective in removing and quantify- with a vacuum seal. The first layer is a polypropylene
ing abdominal fluids, some of which may be infectious, sheet that covers the abdominal viscera under the perito-
and in preventing lateral retraction, potentially an aid neum of the abdominal wall with a moist surgical towel
in eventual closure of the fascia.3,4,23 These systems, overlaying the sheet. Two drains are placed over the
including the VAC abdominal dressing (KCI; Figure 3) towel and tunneled under the skin. All of these contents
and the ABThera system (KCI; Figure 4), are most are covered with an adhesive polyester sheet, and suction

A
Figure 1 Velcro-type (Wittman patch) or zipper-type tem-

porary abdominal wall closure. Use of this technique pre-
serves the abdominal wall domain and facilitates fascial
closure. It should not be used in patients with sepsis. It
may be combined with a negative-pressure dressing.
Reprinted from Demetriades and Salim,4 with permission. Copyright Elsevier
2014.
Figure 3 A and B, Abdominal VAC device.

2014.
Figure 2 Bogota bag for temporary abdominal wall clo- these systems may increase the rate of healing by stimu-
sure after damage control surgery for multiple gunshot lating the formation of granulation tissue and also may
wounds. The Bogota bag has limited or no role in the man-
agement of the open abdomen, especially in patients with
prevent the loss of domain that occurs when the fascia
sepsis. It does not allow effective drainage of intra-abdominal retracts unopposed, preventing delayed primary closure
toxin-rich fluid, does not reduce bowel edema, and does and yielding a giant hernia.4,7,24 The continuous medial
not preserve the wall domain.
traction provided by the negative pressure thwarts this
2014. loss of domain. The negative pressure has the additional
benefit of removing fluids thought to be extremely toxic,
containing bacteria, cytokines, and other inflammatory
is applied to the drains to achieve negative pressure and mediators and a likely source of continued infection, sep-
closure of the abdominal wall.20,23 sis, and multiorgan dysfunction.25,26 The Wittman patch
Many NPWT products are now available with a interposes a graft material between the fascial edges. The
polyurethane sponge in place of the moist towel layer.4 patch is gradually refastened over multiple procedures,
Commercially available products are prevalent in the pulling the fascia together. This multiple refastening
management of the open abdomen and provide easy optimizes the wound condition, thus enhancing defini-
access for reoperation, placement without sutures, and tive delayed closure of the fascia.18,23
isolation and protection of the abdominal viscera from The beneficial outcomes associated with the open
contamination.4 The negative pressure associated with abdomen may be related, in part, to the removal of the

A D
B
E
Figure 4 Application of the ABThera system. A, Polyurethane foam with 6 strut arms is embedded between 2 fenestrated
nonadherent sheets. B, The device is placed directly over the bowel and tucked under the peritoneum. C, Perforated foam cut
into size and shape is placed over the protective foam. D, The foam is covered by a semiocclusive adhesive drape. E, A small
piece of the adhesive drape and underlying sponge is excised, and an interface pad with a tubing system is applied over this
opening and connected to a negative-pressure system.
Reprinted from Demetriades and Salim,4 with permission. Copyright Elsevier 2014.
toxic fluid associated with IAH. This fluid, some of which 28% to 78% in the varied series reviewed. The use of
is produced in the lymphatics, is thought to contribute these techniques is also associated with the lowest mor-
to the onset of organ dysfunction associated with IAH. tality and the lowest complication rates.22 In a comparison
Removal of the fluid by decompressive laparotomy and of the 2 NPWT methods, ABThera dressing and Barker
open abdomen management may foster improved patient vacuum packing, active NPWT was associated with fewer
outcomes.2 In a meta-analysis22 of the techniques for TAC days to primary fascial closure (P = .12) and lower 30-day
described here, the Wittman patch and NPWT have the all-cause mortality (P = .01). In addition, patients treated
highest overall success for fascial closure, with rates of with NPWT were more likely to survive (odds ratio, 3.17;

Clinical Priorities of Care and Their
A Management
Patients who have undergone surgery for trauma,
bleeding, ACS, or intra-abdominal infection have many
priorities of care. Astute and ongoing assessment and
treatment in the ICU is required. Table 3 describes the
clinical priorities after damage control and open abdo-
men and the multidisciplinary management needed.
Nurses and other members of the interprofessional
team must assess, interpret patients’ responses, and
adjust varied therapies.
B Unstable Physiologic Status

After emergent laparotomy (with or without the
damage control technique), open abdomen, and TAC,
patients need resuscitation focused on the correction of
physiological derangements, acidosis, oxygen debt, and
hypothermia.34 The interprofessional team ensures
achievement of the goals of restored stable physiological
status and homeostasis as evidenced by normovolemia,
normothermia, and absence of coagulopathies in prepa-
ration for a return to the operating room for definitive
C management of temporarily treated injuries.
Hypothermia, Coagulopathy, and Acidosis

Along with management of volume replacement,
other priorities addressed by the interprofessional team
include correcting the coagulopathy that occurs because
of hypothermic effects on the coagulation cascade in the
intraoperative and postoperative periods. In addition,
hypoperfusion causes a shift from aerobic to anaerobic
metabolism at the cellular level, with subsequent lactic
Figure 5 VAC-pack technique. A, A fenestrated, nonadher- acidosis, a reflection of the effectiveness of the fluid
ent sheet is placed over the bowel and underneath the peri-
toneum. B, Moist surgical gauze and 2 drains are placed
replacement.
over the sheet. C, A transparent adhesive dressing is used
to cover the gauze and drains. The drains are connected to Pain Management and Sedation
continuous wall suction (100-150 mm Hg).
Improving comfort and decreasing anxiety and agita-
2014. tion are crucial elements of the care of patients with an
open abdomen. Continuous infusions of narcotic agents
are often prescribed to manage postoperative and inci-
95% CI, 1.22-8.26; P = .02) after adjustments for age, sional pain. Some evidence indicates that use of neuro-
severity of illness, and total fluid administration.27 A recent muscular blocking agents may prevent retraction of the
meta-analysis28 revealed that the use of NPWT (compared fascial edge and provide improved abdominal wall com-
with other methods) for temporary wound closure resulted pliance, a situation that may facilitate eventual primary
in improved primary fascial closure, decreased length of fascial closure because the abdominal compartment can
stay in the critical care unit, and a lower 30-day complication more readily expand, allowing more room for increasing
rate, including bleeding, fistula, or abscess formation. abdominal contents.19 However, the evidence on the use

Table 3 Management priorities for patients with an open abdomen
Management priority Medical interventions
Hemodynamic stabilization altered due to Address problem immediately by prescribing volume replacement with blood products
increased pressure on the inferior vena cava, and crystalloids18
intra-abdominal circulation, and perfusion, Monitor hemoglobin level or hematocrit or both
impaired venous return6 Vasopressor medications may also be required but before administration, fluid replace-
Hemodynamic consequences may also be ment should be guided by the assessment of hemodynamic parameters
associated with the shock state due to hypo- Use of hypertonic fluids may be effective in achieving replacement goals while avoiding
volemia caused by blood and fluid losses excessive third-spacing and peripheral and visceral edema18
from trauma or organ and tissue injury
Optimum fluid management, achieving normo-
volemia and avoiding over- or underresuscita-
tion may decrease the recurrence of ACS
and promote early fascial closure after the
creation of an open abdomen
Supporting, stabilizing respiratory function Order arterial blood gas values, interpret and adjust interventions accordingly, such as venti-
altered because of increased IAP forcing dia- lator settings, patient positioning
phragm up, decreasing intrathoracic space,
restricting ventilation; if uncorrected will result
in decreased lung compliance and hypoxia6
Prevention of infection, possible due to intra- Assess patient for signs of infection
abdominal sepsis, wound open to the atmo- Order laboratory tests such as white blood counts and cultures as needed
sphere, and invasive catheters and tubes Administer empiric antibiotics preoperatively when possible, especially in patients with
expected or confirmed intra-abdominal contamination or traumatic injury
Inadequate broad-spectrum antibiotic regimen is associated with poorer outcomes in criti-
cally ill patients2
Subsequent modification (deescalation) of the initial antibiotics is made later when culture
results become available
Identifying infections caused by Candida species is of great importance because these
infections are associated with a poor prognosis2,18
Management of pain and anxiety due to open Assess level of pain and anxiety
abdominal wound, intra-abdominal infection, Prescribe analgesics and sedatives as needed
trauma
Monitoring for continuing or recurrent ACS due Monitor for hypotension, decreased cardiac output, decreased urine output, increased
to ongoing IAH; IAH and ACS develop and can peak inspiratory pressures, hypercarbia, and hypoxia
recur when excess fluid is present within the Determine ongoing changes in bladder pressure
abdominal cavity, and/or the abdominal con-
tents expand in excess of the capacity of the
abdominal cavity
Wound assessment and management Placement of the NPWT system and assessment
Hypothermia and coagulopathy due to heat In order to correct hypothermia and the concomitant coagulopathy, patients require
loss from the open abdominal procedure, rewarming via fluid warmers, warming the circuit of the ventilator, or use of a temper-
inducing changes ranging from mild platelet ature management system designed for core temperature control or forced air warm-
dysfunction and sometimes a mild decrease ing system.
in platelet count to reduced synthesis and Order laboratory tests and monitor results
kinetics of clotting enzymes and plasminogen
activator inhibitor34; acidosis due to fluid and
blood losses with resultant hypoperfusion
Nutrition Consult nutritionist or nutrition support team; order early enteral nutritional feedings if not
contraindicated
Order and monitor nutrition-related laboratory tests and adjust nutrition orders as necessary
Ensure starting point in nutritional support of 1.5-2.5 g/kg per day of protein to achieve a posi-
tive nitrogen balance, and follow ongoing measurements of nutritional parameters.35
Include provision of vitamins and minerals, including zinc and vitamin C, administered at
twice the normal recommended daily allowance.14
Abbreviations: ACS, abdominal compartment syndrome; IAH, intra-abdominal hypertension; IAP, intra-abdominal pressure.

Nursing interventions
Administer fluid and blood as ordered
Obtain samples for laboratory tests as ordered and follow results
Monitor intake and output
Monitor for indications and endpoints of adequate volume replacement such as stroke volume variation, pulse pressure variation, central
venous pressure, and central venous oxygen saturation
Hourly and cumulative intake and output provide valuable data for quantifying patient’s volume state
All of these data aid in decision-making on continued fluid administration14
Obtain arterial blood gas results, interpret results, and implement interventions such as adapting ventilator settings, position changes, and
suctioning
Assess patient for signs of infection

Monitor temperature
Obtain laboratory tests as ordered and monitor results
Monitor wound for signs of inflammation and infection
Administer antibiotic therapy and monitor for side effects
Use of antibiotics should be reassessed daily and adjusted as needed
Assess for adequate pain control, level of pain and anxiety

Various anxiolytic medications can be administered either via continuous infusion or intermittent dosing to provide sedation and increase
patient comfort
Administer analgesics and sedatives as needed and adjust infusion rates of continuous medications to keep the patient as comfortable as
possible
Assess effectiveness of analgesics and sedatives and report insufficient analgesia or sedation
Daily assessment of the continued use of sedatives may be useful in reducing oversedation and its effects
Deep sedation may be of some benefit in achieving early delayed primary closure by decreasing the force of abdominal muscle retraction12
Communicate with the patient about pain and anxiety and their effect and the plan to manage them
Assess for findings indicative of this trend, including decreased cardiac output and blood pressure, decreased urine output, increased peak
inspiratory pressures, hypercarbia,29-32 and hypoxia9,11
Measurement of bladder pressure via an indwelling urinary bladder catheter is considered the standard of care for the measurement of IAP.
Obtain bladder pressure values, follow trends, and report results
Repeat measurements every 2-4 hours in patients with IAP ≥12 mm Hg so that trends may be established and increases in pressure and
potentially dangerous increases in IAP, IAH, and ACS are detected10,11,33; commercial monitors are available for this purpose, and the pres-
sures can also be measured with the connection of a basic pressure monitoring system to the sample port of the Foley catheter (Figure 6)
with the transducer at the anatomic location of the iliac crest in the midaxillary line (Figure 7)
Ongoing monitoring of the wound for signs of healing or complications
The NPWT system is maintained and assessed by the nurse for its integrity, effluent drainage, vascular supply to the wound, and any areas
of new intestinal fluid leakage6
Set up, maintain, and troubleshoot warming devices as needed
Continually or frequently monitor core temperature
Closely scrutinize laboratory values, especially values for acidosis, a common phenomenon after damage control that is due to decreased
tissue perfusion and hypoxia6
Blood gases and lactate levels will be markers of metabolic acidosis resulting from blood and fluid losses with hypoperfusion and subse-
quent oxygen debt to tissues
Ensure early involvement of nutritionist

Provide and monitor enteral nutrition, which is recommended to be started early after damage control surgery and the establishment of the
open abdomen18
Monitor patient’s weight and nutritional parameters, such as levels of prealbumin, albumin, C-reactive protein and weekly 24-hour urine
urea nitrogen level and adjust nutritional plan accordingly15

infection should follow critical care standards and
institutional guidelines as well as the consensus state-
ment of the Surviving Sepsis Campaign.37 Concurrent
with these interventions is the aggressive treatment of
Bag of NSS
fluid, electrolyte, and acid-base imbalances that occur
with the open abdomen.18 Major volume depletion and
electrolyte abnormalities with resultant extreme alter-
25-mL syringe Calibration port ations in homeostasis may result if close attention is
Connect Luer-Lok Pigtail not given to these imbalances.38
tubing to catheter
sample port Monitor
Transducer
connection Monitoring for Complications
Needleless
catheter Monitoring for continuing or recurrent ACS is para-
sample port mount in the postoperative management of patients
with an open abdomen. The adverse effects of ACS can
Figure 6 Bladder pressure monitoring setup. A total of 25 compromise abdominal organ perfusion with resultant
mL of fluid is inserted into the urinary catheter through this multiorgan dysfunction or failure and increased associ-
system and the tubing is clamped. The transducer is zeroed
and calibrated at the level of the iliac crest in the midaxillary ated mortality.9-11,29-33 Members of the interprofessional
line (see Figure 7). After approximately 1 minute to allow team monitor patients for clinical indications of increas-
for relaxation of the detrusor muscle, bladder pressure is
obtained. The value should also be measured at the point of ing IAP, IAH, and progression to ACS. The closed cavity
end-expiration. of the abdomen is sensitive to increased contents and
Abbreviation: NSS, normal saline solution. pressure, situations that can compromise perfusion to
Reprinted from Gallagher,29 with permission. Illustration by John J. Galla- the visceral organs.19,32,33 The bladder functions as a
gher. Copyright Elsevier Saunders 2011.
passive reservoir for a small amount (25 mL) of fluid,
which is injected. The pressure within the abdominal
space is transmitted through the passive reservoir to
45°
the transducer, which is attached to an indwelling
catheter. This pressure recording is an accurate reflec-
20°
Transducer location tion of the IAP (Figure 6).9,29,32,33 Serial monitoring of
bladder pressures is useful in detecting the onset of
IAH and the progression to or recurrence of the more
0° severe condition of ACS. Normal bladder pressure is 0
mm Hg or may be subatmospheric.
Monitoring for the advent of bleeding is also extremely
Figure 7 Correct transducer position at the iliac crest in important. If surgery was performed for a major intra-
the midaxillary line for patients in the supine position with abdominal vascular injury or disruption, marked life-
the head of the bed elevated. threatening bleeding can ensue. Gastrointestinal organs
Reprinted from Gallagher,29 with permission. Copyright Elsevier Saunders
2011.
also have extensive vasculature. If the emergent proce-
dure involved these organs, complete disruption or per-
sistent, major oozing can occur postoperatively.
of neuromuscular blocking agents compared with sim-
ple sedation is equivocal, and therefore the blocking Nutritional and Metabolic Support
agents are not currently implemented universally.12,36 Nutritional and metabolic support may not seem a
critical intervention in patients with the life-threatening
Infection Control phenomenon of intra-abdominal catastrophe and the
Aggressive treatment of infection must be under- open abdomen. However, providing nutritional support
taken quickly in patients with an open abdomen. can contribute to decreased complications and improved
Interprofessional interventions to treat and prevent patient outcomes.14,38 Early enteral feeding has been

associated with fewer complications such as pneumonia, the delay in abdominal closure, the greater is the likeli-
local and systemic infections, delayed fascial closure, and hood of complications.2,18 If the abdomen cannot be
fistula formation, possibly due to the enhanced muco- closed at the end of the second reoperation when
sal integrity and immunological protection afforded by injuries, bleeding, and infection are fully under control
early enteral nutrition.35,38-40 In a study by Dissanaike et (no further operations are necessary), definitive closure
al,41 rates of ventilator-associated pneumonia were sig- is the eventual goal. Certain factors must be present
nificantly lower in the enterally fed group (43.8%) than before definitive fascial closure can be accomplished.
in the nonfed group (72.1%), but ICU length of stay, hos- Bowel edema must be essentially resolved, and IAP must
pital length of stay, and wound or bloodstream infec- be consistently less than 25 to 30 mm Hg. The fascial
tions did not differ significantly between the 2 groups. closure must be performed without excess tension or
Collier et al39 found no statistical significance in rates of increasing IAP, because ACS may develop or recur. The
bloodstream, wound, or urinary infections and length of patient should be afebrile and infection free. 23 Once
ICU or hospital stays between patients who received these goals are achieved, definitive closure can be planned
early enteral feedings and patients who did not. as either a delayed primary closure (the wound can be
Morbidity and mortality rates have been compared sutured closed days after the initial surgery when the
in groups receiving early enteral feedings with groups who adverse conditions have resolved) or closure with bio-
did not. In the study by Dissanaike et al,41 the mortality logical or synthetic mesh grafting material that can
rate was lower for the enteral feeding group (12.5%) than for then be covered with a skin graft if the wound edges
the group not given enteral feedings (23.5%), but the dif- cannot be approximated.44
ference was not statistically significant. The results of the Early fascial closure has been associated with improved
study by Collier et al39 also revealed no significant mor- outcomes for patients with the open abdomen. A meta-
tality benefit for enteral feeding. However, hospital costs analysis45 revealed lower mortality (P < .001) and fewer
in the early enteral feeding group were significantly lower. complications (P < .001) in patients in whom early fas-
Nutritional support is a critical intervention that cial closure was achieved within 4 to 7 days of the initial
must begin early in the phase of damage control surgery laparotomy. IAP is monitored closely during and after
and open abdomen management to promote positive the closure procedure. During the attempted abdomi-
nitrogen balance and healing. Contraindications that nal closure, peak airway pressures for mechanical ven-
preclude use of enteral feeding are intestinal discontinu- tilation should also be assessed for increases compared
ity, insufficient bowel length, inability to obtain access with the pressures when the abdomen was open to deter-
for the administration of the feedings, and inability to mine if exces-
tolerate enteral feedings as indicated by nausea, vomit- sive tension Use of the open abdomen and
ing, or high gastric residual volumes.35 Providing nutri- on the fascia damage control surgery can thwart
tional support is an essential element in the early phases is increasing the progression of IAH, which can
of open abdomen but also continues well beyond this IAP. Elevated lead to multiple organ failure.
phase and throughout hospitalization. peak inspira-
Table 4 describes potential complications associated tory pressure is due to the IAP compressing the thoracic
with damage control surgery and the open abdomen as cavity, forcing the diaphragm up, decreasing intrathoracic
described here and reviews the prevention, recognition, space, and restricting ventilation.6 The increased IAP thus
and management strategies for the interprofessional prevents complete thoracic expansion.6,23
team. These strategies are key in preventing the develop- No irrefutable evidence or expert consensus exists
ment of the complications and in providing meticulous about the time frame within which the open abdomen
care to enhance patients’ survivability and quality of life. should undergo closure. Fascial closure may be impossi-
ble because of ongoing intra-abdominal infection, visceral
Closure of the Open Abdomen edema, or fistula formation.46 The abdominal viscera will
Definitive closure of the open abdomen, if achievable, is become immobilized and cocoon like within 14 to 21
highly associated with patients’ original pathophysiological days. Attempting to reopen this frozen abdomen and
state and their ongoing condition. In general, the longer free the viscera away from the abdominal wall is a

Table 4 Complications associated with the open abdomen technique
Complication Prevention Recognition
Impaired nutrition in a Recognize that all patients with an open abdomen have major nutritional Abnormal weight
catabolic state needs Early involvement of nutritionist
Identify patients at increased risk due to preexisting nutritional deficits Abnormal levels of acute-phase
Ensure early involvement of nutritionist proteins
Start enteral nutrition early after damage-control surgery and the open
abdomen18
Place a feeding tube (nasogastric, postpyloric, nasojejunal) during the
early intraoperative period, and ensure that nutritional needs are estab-
lished and met
Ensure starting point in nutritional support of 1.5-2.5 g/kg per day of
protein to achieve a positive nitrogen balance and monitor ongoing
measurements of nutritional parameters35
Increased ICU and Assess daily for critical care needs Monitor number of ICU and hos-
hospital LOS Use ongoing assessment for signs of complications of the open abdo- pital days and identify causes for
Inability to achieve defin- men and intervene as needed any prolonged stay
itive primary wound Do daily assessment for ICU-related complications such as delirium,
closure CLABSI, GI bleeding, and CAUTI; intervene with nonpharmacological
This condition is associ- interventions (nurse implemented) and pharmacological treatment as
ated with longer ICU needed (physician directed) for delirium; have team discussion about
and hospital LOS criteria to remove central and urinary catheters; institute prophylaxis
(P < .001)14 against GI bleeding, and ongoing assessment by nurses and physicians
for signs such as GI bleeding
Provide early definitive primary fascial closure; patients in whom defini-
tive primary closure cannot be performed are more likely to experience
CLABSI (P < .001) and, to a lesser extent, CAUTI (P < .037)13
Replace fluids to achieve the goal of abdominal wall closure as indicated
by results of monitoring hemodynamic parameters such as SVV, PPV,
or ScvO2, which indicate fluid responsiveness and are markers of the
endpoints of resuscitation3,4,6,18
According to the Surviving Sepsis guidelines, fluid replacement should
be based on achieving a mean arterial pressure of ≥65 mm Hg, CVP
8-12 mm Hg in combination with ScvO2 >70%, and urine output >0.5
mL/kg per hour during the initial 6 hours of replacement³7; these goals
can be reached by transfusing blood products earlier in the replace-
ment phase, minimizing crystalloid infusions, and considering use of
hypertonic saline, which may result in less tissue edema18
Increased duration (days) Once the patien’s hemodynamic status is stable, begin daily SATs and Monitor number of days of
of mechanical SBTs mechanical ventilation and iden-
ventilation Extubate patient once the results of the trials are acceptable and patient tify cause for this prolonged
Inability to achieve defini- meets institutional criteria for extubation intervention
tive primary wound clo- Recognize that failure to achieve definitive primary wound closure is
sure is associated with associated with greater number of days of mechanical ventilation
longer ICU and hospital (P < .001)14
LOS (P < .001)14
Bleeding related to major Use NPWT cautiously in patients with ongoing, active bleeding Drainage of blood occurs via the
intra-abdominal vascu- In patients treated with NPWT and in whom inadequate hemostasis is a wound or in the suction collec-
lar injury or disruption concern, application of high negative pressures (-125 mm Hg) to the tion device
or due to emergent sur- wound via the NPWT system may aggravate the bleeding. In order to
gery on vascular organs avoid aggravating bleeding, NPWT should not be used near or in con-
tact with vessels. Commercial devices are available to disperse negative
pressure across the entire dressing or sponge to minimize the risk of
bleeding and maximize fluid removal.
An initial low negative pressure of -25 to -50 mm Hg is recommended in
these cases.4

Management
Implement early involvement of nutritionist, who will use a predictive equation such as Swinamer, Ireton-Jones, Brandi, Faisy and
Penn State or indirect calorimetry with a metabolic cart to establish calorie and protein needs in catabolic states15
Use early enteral nutrition if tolerated and no contraindications to use such as an ongoing shock state, which may be revealed by
elevated serum lactate levels and an ongoing requirement for a vasopressor
Ensure that enteral feedings meet nutritional requirements and include provision of vitamins and minerals, including zinc and vitamin
C, and administered at twice the normal recommended daily allowance15
Ensure starting point in nutritional support of 1.5-2.5 g/kg per day of protein to achieve a positive nitrogen balance and monitor ongo-
ing measurements of nutritional parameters35
If contraindications to enteral nutrition exist, start parenteral nutritional feedings within 48 hours of the initial damage control procedure
Monitor nutritional parameters such as levels of prealbumin, albumin, and C-reactive protein and weekly 24-hour urine urea nitrogen level
to determine caloric requirements; assess protein balance and adjust nutritional plan accordingly15,38
Monitor and replace sodium, potassium, chloride, and bicarbonate to achieve normal levels to restore stable metabolic status
Assess for indicators of effectiveness of nutritional support such as wound granulation15
Weigh patient daily and address losses with the management team42
Consider refeeding fistulous output through the fistula in patients with EAF to reduce fluid and electrolyte disturbances, consult wound/
ostomy/continence nurse to assist in this activity15
Implement strategies given in this table for prevention of complications
Follow institutional guidelines for ICU and hospital admission and discharge criteria
Achieve early definitive primary fascial closure
Adjust plan of care to address variances in length of stay data relative to diagnoses
As stated in Prevention column

If unable to extubate early in course, begin alternative ventilator weaning modes
If a patient begins to bleed, rapid action is in order

Discontinue any suction source connected to the TAC, assess the patient for hemodynamic compromise associated with the bleeding,
and contact the physician or APN
Consider a lower suction setting until the cause of the bleeding is corrected, eg, until a coagulopathy is reversed4
Continued

Table 4 Continued
Infectious complica- MOD is the most common cause of mortality in patients with an open Signs of hemodynamic, cardiovascular,
tions and MOD abdomen. The condition may be due to the primary injury or secondary respiratory, renal, or other system
(sepsis) complications such as fistula formation, other intestinal leaks, intra- dysfunction or failure
abdominal abscess or other infection, systemic infections, or infection Indicators of abscess: persistent fever,
at another site.22 leukocytosis, and abdominal pain
Early intervention for adverse hemodynamic conditions and signs of Signs of inflammation or infection
inflammation and infection such as fever, tachycardia, hypotension, and Leukocytosis
elevated WBC Computed tomography of the
Assess wound to monitor for signs of infection such as drainage, inflam- abdomen
mation. Surgical site infections are a frequent complication of an open
abdomen.37
Monitor SVV, PPV, CVP, ScvO2, cardiac output, urine output
Achieve early definitive primary fascial closure; patients in whom defini-
tive primary closure cannot be performed are more likely to experience
sepsis (P < .001)14
Acute kidney injury Monitor intake and output hourly and cumulatively Decreasing urine output
Assess for signs of optimum and complete volume replacement (SVV, Rising creatinine and urea nitrogen
PPV, CVP, ScvO2, urine output) levels
Monitor creatinine and urea nitrogen levels
Achieve early definitive primary fascial closure; patients in whom definitive
primary closure cannot be performed are more likely to experience AKI
(P < .001)14
Acute respiratory Identify risk factors such as multiple blood transfusions, traumatic injury Refractory hypoxemia as evident on
distress syndrome Assess respiratory status for signs of distress such as tachypnea and ABG analysis or by decreasing SpO2
increased work of breathing
Obtain samples and monitor results of ABG analysis for changes
Assess for changes in chest radiograph indicative of noncardiogenic
pulmonary edema
Use continuous pulse oximetry
Enteroatmospheric Achieve early fascial closure within 5-7 days; patients in whom definitive Drainage of intestinal fluid (succus)
fistula primary closure cannot be performed are more likely to experience EAF from a hole or holes in the bowel,
(P < .001)14 that is exposed in the open abdomen
Place biologic material (omentum if present) during first and subsequent
laparotomies over exposed viscera and use nonadherent dressings to
protect organs; avoid visceral contact with gauze dressings or adherent
negative-pressure dressings15
Minimize fistula output with nasogastric drainage
Implement acid suppression with proton pump inhibitor or histamine
receptor antagonists to decrease the amount and the acidity of GI
secretions; use of octreotide, a somatostatin analog, administered sub-
cutaneously, inhibits GI and pancreatic exocrine secretion15
Fascial retraction with Use NPWT Frozen fascial appearance with inabil-
loss of abdominal Achieve early fascial closure within 5-7 days ity to bring wound edges together
domain with NPWT or Wittman patch, etc
Large incisional hernia Use NPWT Frozen fascial appearance with inabil-
Achieve early fascial closure within 5-7 days ity to bring wound edges together
with NPWT or Wittman patch, etc
Protruding abdominal contents and
patient discomfort
difficult, if not impossible, and dangerous task.24 Some TAC should be discontinued and other interventions
experts18 have recommended that 5 to 7 days after com- should be planned, such as doing a bridge repair of the
pletion of damage control surgery and creation of an fascia with mesh, performing an acute abdominal wall
open abdomen, no advantage exists in continuing TAC. reconstruction, or creating a ventral hernia.18,24,44 If the

Management
Administer broad-spectrum antibiotics
Narrow antibiotic therapy according to cultures of intraoperative samples and other cultures
Implement surgical or interventional (catheter drainage) control of source to eradicate the origin of the abdominal sepsis due to
abscess2
Apply aggressive management of infections by using other strategies such as NPWT
Implement interventions to manage organ-specific dysfunction
Establish early definitive primary fascial closure
Replace fluids until patient can attain and maintain normal values of parameters listed in Prevention
Avoid overreplacement and achievement of super-normal values13
Establish definitive primary closure as soon as feasible
Use ventilatory strategies to improve oxygenation

Use alveolar recruitment strategies, including positioning (eg, prone position)
Start early enteral feedings

Control drainage as described in Table 5
Assess for closure of fistula while controlling drainage
If no spontaneous healing occurs, do surgical repair with skin grafting over the site or use synthetic or biologic mesh, often in concert
with NPWT. This surgical intervention is recommended 6-12 months after initial laparotomy.
Monitor and record the amount and characteristics of fistula output. A draining fistula results in marked losses of sodium, potassium,
chloride, and bicarbonate.43
Monitor for and correct the electrolyte disturbances
Seal small areas of fistula leakage when first recognized, protecting adjacent viscera with biologic dressings and controlling effluent
with NPWT3,4,44
Apply ostomy appliances and other strategies for local EAF drainage control as described in Table 5
Avoid efforts to create a controlled fistula by intubating the fistula with a urinary catheter because intubation may result in increasing
the size of the fistula3,4,44
Use methods of delayed primary closure with skin grafting or use synthetic or biologic mesh, often in concert with NPWT
Use methods of delayed primary closure with skin grafting or use synthetic or biologic mesh, often in concert with NPWT
Continued
viscera are bulging, a Vicryl mesh closure may be used performed. After the 5- to 7-day mark, the likelihood of
to cover the defect. In patients with nonbulging vis- abdominal wall closure is decreased and the risk for
cera, a biological mesh closure may be implemented.6,18 complications is increased.13,18 Experienced surgeons
The skin is closed when possible, or skin grafting is may recommend a shorter time limitation within which

Table 4 Continued
Loss of bowel function Early enteral feedings Decrease or loss of bowel sounds
Early and progressive mobility Lack of flatus and stool
Fluid, electrolyte, and Monitor electrolyte levels and ABG levels at least daily, more frequently Presence of edema and evidence of
protein losses in the most seriously ill third spacing into tissue
Tissue losses in the Replete electrolytes as needed according to findings Cumulative output greater than intake
open abdomen can Assess and quantify fluid losses as monitored with frequent intake
cause large amounts Choose fluids for resuscitation and replacement of ongoing losses on the and output determinations
of insensible fluid basis of serum sodium and systemic volume status15 Signs of abnormal electrolyte levels
losses42; loss of Weigh patient daily to identify potential fluid loss or overresuscitation42 due to GI losses such as dysrhyth-
hypotonic fluid Use NPWT mias due to abnormal calcium or
from the large, potassium level or neurological
open wound and changes due to abnormal sodium
abdominal cavity levels
can cause a hypo- Results of frequent laboratory deter-
volemic hyponatre- minations of electrolyte levels
mia; protein is lost Signs of acid-base abnormalities,
via the same mech- which may be due to GI losses of
anism and results in bicarbonate and chloride (acidosis
changes in oncotic results), which may include tachy-
pressure at the pnea, respiratory distress, dysrhyth-
capillary level, with mias, neurological changes
increasing losses
into the interstitial
spaces
NPWT that covers the
abdominal viscera
can reduce some of
the losses of fluid,
electrolyes, and
protein and quanti-
fies losses so that
they can be
replaced15
Abbreviations: ABG, arterial blood gas; AKI, acute kidney injury; APN, advanced practice nurse; CAUTI, catheter-associated urinary tract infection; CLABSI, central catheter–associated
bloodstream infection; CVP, central venous pressure; EAF, enteroatmospheric fistula; GI, gastrointestinal; ICU, intensive care unit; LOS, length of stay; MOD, multisystem organ
dysfunction; NPWT, negative pressure wound therapy; PPV, pulse pressure variation; SAT, spontaneous awakening trial; SBT, spontaneous breathing trial; ScvO2, central venous
oxygen saturation; SpO2, oxygen saturation according to pulse oximetry; SVV, stroke volume variation; TAC, temporary abdominal closure; WBC, white blood cell count.
an open abdomen should be closed, but no definitive patients who require definitive fascial closure.3,4,6,13,18 In
data support this recommendation.3,4,7,20 one study,13 achieving definitive primary closure of the
abdominal wall resulted in significantly reduced mortal-
Complications of the Open Abdomen ity rates (P < .001).
Several complications are associated with the cre- Once a patient who has undergone damage control
ation of an open abdomen. The impact of these compli- surgery and the open abdomen is in stable condition,
cations is great and can result in increased morbidity the goal should be early and definitive closure of the
and mortality.6,13,18 The most effective method to reduce abdomen. Closing the abdominal fascia may be possible
the rate of complications is closure of the abdominal wall in some patients within days of the initial surgical proce-
(also known as definitive primary closure) as quickly as dure, but in others, bowel edema and intra-abdominal
possible.13 This goal can be achieved by a combination of infection may preclude this option.4 A modern strategy
3 strategies: avoidance of excessive fluid replacement, for reducing the complications associated with an open
marked by third spacing of fluid, worsening of bowel abdomen is a more restrictive fluid replacement than
edema, and supranormal hemodynamic parameters; use previously recommended.13 Overaggressive administra-
of NPWT for TAC; and use of biological materials in tion of fluid to achieve supranormal parameters can

Management
Nasogastric suction
Early mobility
Recognize and closely monitor patients at greatest risk for these losses
Replace electrolytes according to laboratory results. In hypovolemic patients, use isotonic fluids. Once a patient’s status is stabilized and
has with normalized markers of end-organ perfusion, as described in Recognition section, use hypotonic replacement fluids.15
Consider fluid replacement with albumin15
Use NPWT
Consider refeeding fistulous output through the fistula in EAF to reduce fluid and electrolyte disturbances15
have an adverse impact on cardiopulmonary function had definitive primary closure also had fewer repeat
and cause increased bowel edema. Bowel edema can be surgical procedures (P < .001) and significantly lower
reduced by using a more conservative approach to fluid peak airway pressures (P < .001).13 Diuretics have been
replacement, thus increasing the potential for early used in some instances to reduce edema and promote
definitive abdominal wall closure. the achievement of definitive primary closure, but this
In patients with intra-abdominal sepsis, aggressive intervention requires study.
hemodynamic support can limit tissue damage and
prevent overstimulation of endothelial activity. How- Fistula Formation
ever, overreplacement of fluid losses has the undesired Enteroatmospheric fistula (EAF) is the most devastat-
sequelae of impaired cardiopulmonary function and ing complication of the open abdomen that occurs when
the development of bowel edema. In one study,13 delayed abdominal closure cannot be performed within
definitive primary closure was statistically more likely the 5- to 7-day period recommended, although data are
(P < .001) in patients whose mean rates of 24-hour fluid limited.3,4 An EAF is an abnormal opening or hole directly
intake were lower than the mean rates of the patients from the bowel into an open abdomen caused by intesti-
in whom the closure was not definitive. Patients who nal damage from anastomotic leakage or traumatized or

Table 5 Management strategies for draining enteroatmospheric fistulas (EAFs)
Intervention Rationale
Suture the fistula Should not be attempted unless the repair is covered by patient’s skin or a skin graft
Use skin barriers and protectants Provide additional barrier on the skin to prevent erosion by drainage
Place an ostomy or fistula appliance Adherent, protective device covers the fistula opening and is placed close to the skin;
over the opening (fistula) contains drainage and prevents its contact with the skin
Location of a fistula within an open abdomen and surrounded by bowel may preclude the
use of standard appliance or stoma bags
Place a skin graft over granulation Provides an intact skin anchor for an appliance
tissue that has formed around the
fistula to facilitate placement of
an appliance2
Place nonstandard ostomy or fistula A piece of NPWT sponge is cut into a ring shape and placed over the fistula, and a stoma
appliance: “ring technique” appliance is affixed over the ring after NPWT is initiated2 (Figure 8)
Place nonstandard ostomy or fistula A nipple of latex or silicone is placed over the fistula and a hole is cut in the top of the nip-
appliance: “nipple technique” ple through which a catheter is threaded and suction applied without direct contact with
the bowel; the remainder of the bowel is covered with nonadherent gauze2 (Figure 9)
Use negative-pressure wound therapy Contains and measures drainage, prevents skin breakdown due to intestinal fluid drain-
(NPWT) age (Figure 10)
Catheterize or intubate draining This intervention is contraindicated in an open fistula because it may cause the fistula
fistula to enlarge and may support nonhealing.2
Provide intensive nutritional support The goal is to achieve positive nitrogen balance and optimum wound and fistula healing;
the recommended starting point for meeting nutritional needs is 20-30 kcal/kg per day
of nonprotein calories and 1.5-2.5 g/kg per day of protein17
Use equations for initial calculation of basal energy expenditure, and use correction fac-
tors for stress
Indirect calorimetry can also be used
Follow ongoing measurements of nutritional parameters and make appropriate adjustments
Trace minerals and vitamins are recommended, including zinc and vitamin C at twice the
recommended daily allowance17
Use surgical intervention and repair If a small, low-output EAF remains drained and the patient receives adequate nutrition, a
fistula may heal and self-repair; a persistent fistula may require surgical intervention and
repair. More than 50% will require surgery for infection or repair.2,23
ruptured bowel.44 The exposed bowel is at risk for fistu-

A
lization when synthetic meshes are used or when a patient
has intra-abdominal infection.3,4 Intestinal fluid (succus)
can leak through this abnormal opening, contaminating
the abdominal cavity and causing bile peritonitis, pro-
longed inflammation, and formation of multiple fistulas.3,4
The incidence of EAF is 5% to 19% in patients who B
have undergone damage control laparotomy and survive
long enough for complications to develop.43 EAF results
in overall mortality ranging from 10% to 20% due to
infection and to damage to adjacent viscera.43 A single
EAF may occur or a patient may have multiple openings
in the bowel communicating with the atmosphere.
Exposed viscera in the open abdomen are at great risk
for formation of fistula due to trauma, exposure, or
dressing changes, and are an unwanted but generally Figure 8 A and B, The fistula ring technique may be useful
unpreventable complication. An EAF is a challenge for in difficult enteroatmospheric fistulas, including those with
thick contents.
Reprinted from Demetriades and Salim,4 with permission. Copyright Elsevier 2014.
40 CriticalCareNurse Vol 37, No. 5, OCTOBER 2017

A
Figure 10 Local control of enteroatmospheric fistula with

liquid contents via the VAC technique.
2014.
of compensatory mechanisms. Administration of sodium

chloride to correct the reduced volume of extracellular
fluid and administration of potassium to replace urinary
losses are recommended.35
Control and collection of effluent from an EAF are
Figure 9 A and B, The nipple technique may be useful in
some patients with enteroatmospheric fistulae with liquid necessary components of management of this compli-
contents. cation. The general principles of management include
Reprinted from Demetriades and Salim,4 with permission. Copyright Elsevier ensuring that fluids are effectively drained to prevent
2014.
contact of intestinal material with the skin.4,5,20,23 The
high enzyme content and low pH of this fluid creates
the critical care team and for the patient and the a caustic environment when in contact with skin, caus-
patient’s family. ing the area to become denuded and even bleed and,
Fluid and electrolytes are lost in great quantities via most devastating to patients, be extremely painful. Pro-
an EAF. Members of the critical care team prevent compli- tection of the skin, effluent control, and pain management
cations associated with these losses by monitoring and are necessary elements of the plan of care for patients
replacing commonly lost electrolytes. Patients with high- with an EAF. In addition to the soiling and malodor
output fistulas may be severely volume depleted and have created by an uncontrolled draining fistula, having an
marked electrolyte abnormalities and severe contraction EAF is a difficult and distressing situation for patients
alkalosis, which occurs because of the significant losses of and creates a major alteration in body image that may
gastrointestinal fluids and electrolytes, particularly chlo- be ongoing as clinicians collaborate to address the com-
ride.35 Management of this imbalance is necessary to plication.3,4 Management of an EAF, especially control
prevent worsening alkalosis and the development of of the fistula effluent, is challenging for all members of
marked and dangerous hypokalemia caused by stimulation the interprofessional team, but is possible with the use

of a great deal of knowledge and creativity. Some of these
methods are described in Table 5.
Intra-abdominal Abscess or Sepsis

Intra-abdominal sepsis is one indication for an open
abdomen, but because the abdominal space remains
open to the atmosphere, infection can occur after the
open abdomen has been created. Risk factors for intra-
abdominal sepsis include preexisting abdominal infec-
tion, retained blood or debris that becomes secondarily
infected, and prolonged period of open abdomen with
ongoing inability to close the fascia. Other patients who
are at risk for continued or new intra-abdominal infec-
tion are those with persistent organ failure during the
early postoperative period.2 Intra-abdominal abscess or
sepsis is significantly more likely to occur in patients in Figure 11 Absorbable mesh for temporary abdominal wall
whom definitive primary closure of the fascia is unattain- closure. Subsequently, skin grafts may be applied for
able (33% of patients in 1 study, P < .001) than in patients wound cover, but grafting results in an incisional hernia.
in whom closure is possible.14 Identification, prevention, 2014.
and management of intra-abdominal abscess or sepsis
are described in Table 4.
wound can be elevated and the ends approximated to a
Hernia Formation skin-only closure. This type of closure has a potential
In patients in whom a fascial defect cannot be for ischemia, infarction, and loss of the integrity of the
closed with progressive closure techniques after TAC, a skin closure, especially if an underlying intra-abdominal
ventral hernia will ultimately develop, because the intra- infection has not been controlled or the surgical tech-
abdominal contents cannot be contained. Support is nique is flawed.4
lacking because of the completely retracted fascia associ- In patients with giant ventral hernias, which require
ated with the open abdomen. In this situation, the abdo- prosthetic bridging for fascial closure, synthetic mesh or
men protrudes, a situation that can result in discomfort biological material may be used, such as a cellular der-
and altered body image, and the protruding abdomen may mal matrix, which can be used in contaminated fields.
be associated The mesh or biological material should be taut. Skin
with difficulty edges can then be mobilized and closed, or a nonadher-
Of premier importance for any surgical
in normal ent dressing can be placed and covered by NPWT
intervention is that the patient’s
activities of until the wound heals.18
condition be optimized, especially in
daily living
regards to nutrition.
and in social Planning for Surgery to Manage Wound
situations. Complications
A ventral hernia can be managed only with a complex Before any surgical correction or abdominal wall
abdominal reconstructive procedure. In this intervention, reconstruction can be attempted, most patients require
once the viscera are fixed and the base of the open wound 6 to 12 months or more of physiological and nutritional
granulates, the fascial defect should be covered with rehabilitation.46 The patient should be fully recovered
split-thickness skin grafts to cover the abdominal vis- and able to withstand the rigors of another major
cera18 (Figure 11). Because of the risk of infection, any operation.18 Of premier importance for any surgical
synthetic grafting material used previously should be intervention is that the patient’s condition be optimized,
removed before skin grafting is undertaken.18 If the fas- especially in regards to nutrition. Malnutrition and sep-
cial defect is not large, skin flaps on either side of the sis remain the most common causes of morbidity and

mortality in patients with an EAF.35 Repair may not be decision was made to truncate the procedure with dam-
performed for months to even years while aggressive age control methods, create an open abdomen, and take
management is used to achieve an infection-free, adequately EJ to the ICU for resuscitation and warming. A TAC
nourished patient before surgery is undertaken. Surgical was created with a negative-pressure dressing. EJ’s con-
strategies include fistula resection or takedown and com- dition became stable during the next 12 hours, and he
plex abdominal wall reconstruction via suture repair was given 6 L of additional fluid and blood products.
techniques with absorbable or nonabsorbable mesh.23,44,47 His serum level of lactate decreased from 6 mmol/L
Even in patients in the most optimized condition, defini- to 3 mmol/L during those hours, and his temperature
tive reconstructive surgery may include several proce- was brought into the normal range by use of a forced-air
dures completed in stages. These procedures are often warming system. He was brought back to the operating
fraught with complications, including refistulization, room once his status was stable, and he underwent a
sepsis, ischemia, and various wound complications.20,47 small-bowel
resection Determining the need for the open
Implications for Nurses and cauteri- abdomen, a potentially lifesaving
A patient with an open abdomen is critically ill and zation of intervention, and managing the wound
requires implementation of many aggressive manage- detected after the procedure are all within the
ment techniques. Once a patient’s physiological condi- bleeding ves- realm of critical care nurses.
tion is stable after the initial injury and multiple acute sels. An open
interventions, the patient begins to experience some of abdomen with TAC was maintained after this procedure.
the myriad complications and adversities that accom- During the next 2 days, EJ returned to the operating
pany the underlying condition and its treatment. The room several times and had reexploration of the abdo-
patient and the patient’s family members may no longer men, repair of a diaphragmatic defect, omental packing
be focused on survival from life-threatening illness but of the liver laceration, additional small-bowel anasto-
on recovery and restoration of a “new normal.” Members moses, and removal of a foreign body and then a TAC.
of the critical care team, particularly the critical care Because of extreme visceral edema, EJ’s abdomen could
nurse, are in a unique position to provide the emotional not be surgically closed, and the TAC was in place for
support and guidance so necessary in this situation. The 23 days with use of NPWT. His wound granulated
patient and the patient’s family will need education about well, and he had a split-thickness skin graft applied
many of the treatments the patient undergoes and about over the defect. A small low-output enterocutaneous
how they can be involved in discharge planning and fistula developed later at the distal part of the abdomi-
resource use. All of these elements come under the pur- nal wound. EJ had been provided with early nutritional
view of critical care nurses to facilitate and coordinate support with enteral feedings via a nasojejunal feeding
as a patient’s condition slowly improves. tube beginning on the third day after the injury (once
the bowel discontinuity was corrected with anatomoses)
Case Studies and reached the goal rate by day 4 after the injury, allow-
Case Study 1 ing him to maintain adequate caloric intake during the
EJ, a 24-year-old man involved in an altercation, was critical and rehabilitative phases of his hospital stay.
shot multiple times in the abdomen. He was rushed to The enterocutaneous fistula healed well during the ensu-
the trauma center. In the emergency department he was ing 2 months and closed without surgical intervention.
in extremis, and an urgent laparotomy was performed.
A liver laceration was partially repaired and packed with Case Study 2
gauze dressings, and multiple small-bowel enterotomies TS, a 65-year-old woman, arrived at the emergency
were detected and sutured. During the procedures EJ department with a ruptured abdominal aortic aneurysm
continued to bleed from multiple areas, and additional with massive retroperitoneal hemorrhage. She was hos-
small-bowel injuries and bowel discontinuity were a con- pitalized and had aggressive volume replacement with
cern. His temperature was decreasing, and the decrease blood products and crystalloids. She was experiencing
was thought to be contributing to the bleeding. The marked IAH and ACS. She had decreased cardiac output,

decreased urine output, and elevated peak inspiratory physicians, respiratory therapists, nutritionists, and
pressures on mechanical ventilation. The decision was wound, ostomy, and continence nurses are key partici-
made to take her to the operating room and perform a pants in the care of patients after damage control surgery
laparotomy. Because of the intraoperative findings of and creation of an open abdomen. Astute surveillance
severe intra-abdominal bleeding, the surgeons decided by the team for the onset of intra-abdominal sequelae
to create an open abdomen with temporary abdominal and management of the open abdomen and its compli-
closure via the VAC method, and TS returned to the ICU cations are vital to growth of the scientific knowledge
to receive further fluid replacement, correction of coagu- of this phenomenon. CCN
lopathy and hypothermia, and ongoing abdominal Financial Disclosures
assessment. The TAC allowed the surgeon to reexplore None reported.
the abdomen on a daily or every-other-day basis to

assess for continued compromise, bleeding, or other Now that you’ve read the article, create or contribute to an online discussion about
abnormality. Reexploration of the abdomen occurred once this topic using eLetters. Just visit www.ccnonline.org and select the article you want
to comment on. In the full-text or PDF view of the article, click “Responses” in the
homeostasis was achieved and TS’s physiological condi- middle column and then “Submit a response.”
tion was stabilized in the ICU. During the next week,
the wound edges were brought closer to reapproxima- See also
tion with each dressing change. Early enteral feeding was To learn more about trauma patients, read “Association of Injury
Factors, Not Body Mass Index, With Hospital Resource Usage in
attempted once the lactate level normalized and TS no Trauma Patients” by Lee et al in the American Journal of Critical Care,
longer required vasopressors to manage septic shock. A July 2016;25:327-334. Available at www.ajcconline.org.
postpyloric feeding tube was placed during one of the References
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Open Abdomen in Trauma and Critical Care
Eleanor R. Fitzpatrick
Crit Care Nurse 2017;37 22-45 10.4037/ccn2017294
©2017 American Association of Critical-Care Nurses
Published online http://ccn.aacnjournals.org/
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he open abdomen is a technique with recently expanded implementation in managing com-

CE 1.0 hour, CERP A

©2017 American Association of Critical-Care Nurses doi: https://doi.org/10.4037/ccn2017294

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Figure 1 Velcro-type (Wittman patch) or zipper-type tem-

Figure 3 A and B, Abdominal VAC device.

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B Unstable Physiologic Status

Hypothermia, Coagulopathy, and Acidosis

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Assess patient for signs of infection

Assess for adequate pain control, level of pain and anxiety

Ensure early involvement of nutritionist

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As stated in Prevention column

If a patient begins to bleed, rapid action is in order

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Use ventilatory strategies to improve oxygenation

Start early enteral feedings

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ruptured bowel.44 The exposed bowel is at risk for ﬁstu-

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Figure 10 Local control of enteroatmospheric ﬁstula with

of compensatory mechanisms. Administration of sodium

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Intra-abdominal Abscess or Sepsis

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the abdomen on a daily or every-other-day basis to

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