Curativo à vácuo para cobertura temporária de peritoneostomia / Vacuum dressing technique to temporary cover of laparostomy

INTRODUÇÃO: O avanço nos cuidados com pacientes traumatizados ou com infecções intra-abdominais graves, trouxe importante ganho na sobrevida com o aumento de peritoneostomias. O manejo dos pacientes apresentou um problema de difícil solução: o fechamento primário sem tensão da cavidade abdominal. OBJETIVO: Apresentar proposta para cobertura temporária das peritoneostomias em pacientes submetidos à laparotomias de controle de danos ou laparotomias descompressivas por síndrome compartimental abdominal. TÉCNICA: Realiza-se isolamento das alças intestinais das bordas da parede que são envolvidas por um filme de polietileno estéril multiperfurado com tesoura ou lâmina de bisturi, para impedir contato direto com a espuma. É colocado abaixo das bordas do defeito, entre o peritônio visceral e o parietal, e sobre ele uma espuma de poliuretano estéril fixada às bordas deixando o defeito livre de tensão quando o vácuo for aplicado. Ela é recoberta com um plástico adesivo de poliéster impregnado por iodo colado à pele e adicionada drenagem aspirativa contínua. O curativo é trocado entre três e cinco dias. Foi utilizado com sucesso em quatro pacientes onde foi possível o fechamento primário da cavidade abdominal após sete a 21dias. Destes, três tinham ficado com o abdome aberto após laparotomia por trauma (dois para controle de danos e um por impossibilidade de fechamento primário); o quarto tinha sido submetido à laparotomia descompressiva por síndrome compartimental abdominal. CONCLUSÃO: O curativo a vácuo mostrou ser boa opção para cobertura temporária de peritoneostomias permitindo fechamento mais rápido da ferida abdominal, reduzindo o número de reoperações e promovendo proteção das alças contra contaminação bacteriana.

BACKGROUND: The advances in patient care with trauma or severe intra-abdominal infections, brought important gains in survival with the use of peritoneostomies. But the management of patients brought a difficult problem: the primary closure without tension of the abdominal cavity. AIM: To present a proposal for temporary coverage of peritoneostomies in patients undergoing damage control laparotomy or decompressive laparotomy for abdominal compartment syndrome. TECHNIC: Isolation of the small intestine loops from abdominal internal; coverage of the intestinal surface with a polyethylene film multiperforated with sterile scissors or scalpel blade, to prevent direct contact with the foam. It is placed below the edges of the defect between the parietal and visceral peritoneum. Over it, a polyurethane sterile foam is fixed to the edges, leaving the defect tension free to the vacuum be applied. Another coverage with a plastic adhesive polyester impregnated with iodine stuck to skin is done, and, at the end, is added a drainage continuous aspiration system. The dressing is changed between three and five days. It was used successfully in four patients with primary closure of the abdominal cavity after seven to 21 days. Of these, three had open abdomen after laparotomy for trauma (two due to damage control and one for lack of primary closure); the fourth had been previously submitted to decompressive laparotomy for abdominal compartment syndrome. CONCLUSION: The vacuum dressing proved to be good choice for temporary coverage of peritoneostomies allowing faster closure of the abdominal wound, reducing the number of reoperations and providing protection against bacterial contamination of the intestinal loops.

[Comparison of intra-abdominal pressure measurement and physical exam for diagnosis of surgery indication in patients with abdominal compartment syndrome due to blunt trauma]

Increase in abdominal pressure can lead to the so-called intra-abdominal compartment syndrome [ACS] that is often observed during the first 24 hours after sever abdominal trauma and surgery. Measurement of the intra abdominal pressure through the bladder as a non-invasive measurement can provide a quick and accurate assessment of abdominal pressure changes. This study was performed to compare the diagnostic value of intra-abdominal pressure measurement through the bladder with that of physical exam in the diagnosis of surgery indication. This descriptive-analytical study was performed on patients with intra-abdominal compartment syndrome due to blunt abdominal trauma referred to Nemazee hospital, Shiraz, Iran. Tools for data collection included a check list consisting demographic information, and intra-abdominal pressure measurement instruments. Data analysis was done through SPSS software. Of 100 patients with abdominal trauma whose abdominal pressures were measured, 28 ones had abdominal compartment syndrome of whom, 21 ones [75 percent] were referred to the operation room by physician. Among all patients who were sent to the surgery room, 5 patients [23.80%] were survived and all those who were not sent to the surgery room died. Mean diagnosis time of measuring abdominal pressure for detection of operation indication was significantly lower than that of physical exam [P<0.01]. Age, sex, type of trauma and type of injury to internal organ had no significant relationship with the rate of abdominal compartment syndrome. Also, there was no significant difference between the two methods in finding surgery indication. Implementing education on methods of early diagnosis of intra-abdominal pressure increase for medical team especially nurses is one of the treatment priorities