Management Principles

Abdominal Compliance:

Pain control

NM blockade

Space decompression:

Proper positioning (supine position)

NG tube decompression

Enteral via rectal tube/ neostigmine if colonic dilatation or Ogilvie’s

*early use of pressors

*no good data on diuretic use

                - biphasic approach?

Drainage procedures:

-          Ie in chronic ascites patients

-          Prevented ex lap in 81% of patients IF drained at least 1L + decreased pressure by 9mmHg

Hemodynamic and Vent Support:

Effect on intra-abdominal pressure-volume curve is exponential- that is that removing small volumes may significantly help

-          Drain (ascites)

-          Linea alba fasciotomy (ie in pancreatiis)                                           

-          Midline laparotomy is the definitive treatment: does NOT need to extend from xiphoid to pubis

* contain viscera, while allowing for ascitic fluid to drain

                - can use wound vac systems, iobans, bogota bags

Considerations in the management of a patient with an open abdomen:

-          Fluid resuscitation, manage acidosis, hypothermia

-          JP drains

-          Nutritional support (enteral if possible)

Closure of the open abdomen:

-          If can not close at takeback: sequential closure

-          Constant fascial tension towards midline, wound vac, diligent return to OR

-          Bridging devices

-          Denver technique (white sponge stapled) + PDS sutures