Open Abdomen in Trauma and Critical Care.

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 processes 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 potentially 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.

Fistula Isolation and the Use of Negative Pressure to Promote Wound Healing: A Case Study.

BACKGROUND: A 54-year-old morbidly obese woman with a small bowel obstruction and large ventral hernia was admitted to hospital. She underwent an exploratory laparotomy, lysis of adhesions, and ventral hernia repair with mesh placement. She subsequently developed an enteroatmospheric fistula; several months of hospital care was required to effectively manage the wound and contain effluent from the fistula. METHODS: Several approaches were used to manage output from the fistula during her hospital course. She was initially discharged to a skilled nursing facility where a fistula management pouch was used for several months to encompass the wound and contain effluent, but this method ultimately proved ineffective. The fistula was then isolated using a collapsible enteroatmospheric fistula isolation device and an ostomy appliance to contain effluent. CONCLUSION: The application of the collapsible enteroatmospheric fistula isolation and effluent containment devices in conjunction with negative-pressure wound therapy produced positive patient outcomes; it improved patient satisfaction with fistula management, promoted wound healing, and diminished cost.

Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient.

BACKGROUND: Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs. METHODS: All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients' records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs. RESULTS: A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4-66.4) minutes and in the OR 98.2 (94.6-101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844). CONCLUSIONS: VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.

Impacto económico del uso de un nuevo apósito postoperatorio en la herida incisional abdominal / Economic impact of the use of new post-surgical dressing in incisional abdominal wounds

OBJETIVO: conocer el coste de las curas quirúrgicas de laparotomías cerradas por primera intención y estimar el impacto económico del uso de un apósito que no precise curas diarias en el postoperatorio de cirugía abdominal. MATERIAL Y MÉTODOS: estudio prospectivo observacional en 30pacientes sometidos a una laparotomía divididos en dos grupos, Ay B, dependiendo de si la cura se realizó con un apósito convencional o con el apósito Mepilex Border Post-Op®, respectivamente. RESULTADOS: calculado el coste de una cura hospitalaria con el material habitualmente utilizado, se estima en 4,92 € (apósito no incluido). El coste del tiempo de trabajo de Enfermería sin complementos en euros/minuto fue de 0,14 €/min. El coste total (apósito+ coste de la cura + coste de Enfermería) fue mayor en el grupo A que en el grupo B, siendo de 402,70 € y de 233,61 € respectivamente, ahorrándose un total de 169,09 €. El coste de Enfermería representó el 11% del total del gasto de la cura en el grupo A yel 2% en el grupo B. El coste medio cura/paciente fue de 26,85 € (grupo A) y 15,57 € (grupo B) con un ahorro de 11,31 € por paciente. CONCLUSIONES: un apósito que no precise cambios diarios y permita revisar la herida quirúrgica garantiza un buen control de la evolución de la herida, siendo más económico en el coste total que sise realizan curas convencionales

OBJECTIVE: to ascertain the cost of surgical wound dressing in primary intention closed la parotomies and to estimate the economic impact of a dressing that does not required daily wound treatment in the post-surgical phase of abdominal surgery MATERIAL AND METHODS: prospective observational study of 30patients undergoing a laparotomy divided into 2 groups -A and B- according to whether wound treatment was performed using conventional dressing or using the Mepilex Border Post-Op®dressing respectively. RESULTS: having calculated the cost of a hospital wound treatment using the material normally used, the cost is estimated at €4.92(dressing not included). The cost of working time of a nurse without overtime in euros/minute was of €0.14 /min. The total cost(dressing + cost of wound care + cost of nurse) was higher in group A than in group B, being of €402.70 and €233.61 respectively, with total savings of €169.09. The cost of nursing accounted for 11% of the overall cost of the wound care in group A and 2% in group B. The average cost wound care/patient was of €26.85 (group A) and of€15.57 (group B) with a savings of €11.31 per patient. CONCLUSIONS: a dressing which does not require daily changes and allows for inspection of the surgical wound guarantees good control of the evolution of the wound, being more economical in terms of overall cost than using conventional post-surgical wound care

Dehiscencia de una herida abdominal tras una cesárea tratada con terapia de cierre al vacío en el domicilio / Vacuum assisted closure therapy in dehiscence of abdominal wound after cesarean section treated in a hospital-at-home

Resumen La hospitalización a domicilio es una asistencia de rango hospitalario que se proporciona a los pacientes en su propio domicilio de manera que paciente y familia se hacen partícipes activamente del proceso. La cesárea es una intervención quirúrgica que requiere una corta estancia hospitalaria. Sin embargo, si aparecen complicaciones en dicho proceso, como es el caso de la dehiscencia de la herida quirúrgica, el ingreso se prolonga en el tiempo impidiendo la unión materno-infantil que es de suma importancia para el desarrollo del bebé. Los cuidados de enfermería en el cierre de las heridas por segunda intención son prioritarios para su curación. La terapia VAC ayuda a una pronta recuperación, requiriendo curas de ámbito hospitalario y vigilancia activa, así como un adiestramiento por parte del personal de enfermería para su manejo en el domicilio. Describimos el caso de una dehiscencia quirúrgica y la evolución en las curas con la terapia VAC no solo por el interés intrínseco de una cura complicada, sino por los factores asociados de la realización de este procedimiento en su domicilio ya que consideramos la hospitalización a domicilio como la mejor alternativa asistencial en este caso (AU)

Abstract The Hospital at Home is a range of hospital care provided to patients in the comfort of their own homes, so patient and family can actively participate in the process. Cesarean section is a surgical procedure that requires a short hospital stay. However if complications arise during the process, such as a dehiscence of surgical wound, the hospital stay is prolonged, delaying mother-child bonding, which is very important for the growth of the child. Nursing care in wound healing by secondary intention is a priority for the patient's recovery. VAC therapy (vacuum assisted closure) promotes a rapid recovery, although it requires dressings and active medical surveillance, as well as training by the nursing staff for carrying it out at home. We describe the outcome and the process of the healing of a surgical wound after caesarean section, not only because of a complex wound, but the previously mentioned factors that make us consider the Hospital at Home as the best alternative care (AU)