Trauma and emergency general surgery patients should be extubated with an open abdomen

Abstract

BACKGROUND Open abdomen (OA) and temporary abdominal closure (TAC) are common techniques to manage several surgical problems in trauma and emergency general surgery (EGS). Patients with an OA are subjected to prolonged mechanical ventilation. This can lead to increased rates of ventilator-associated pneumonia (VAP). We hypothesized that patients who were extubated with an OA would have a decrease in ventilator hours and as a result would have a lower rate of VAP without an increase in extubation failures. METHODS A retrospective review was performed of all trauma and EGS patients managed at our institution with OA and TAC from January 2014 to February 2016. Patients were divided into cohorts consisting of those who were successfully extubated with an OA and those who were not. The number of extubation events and ventilator-free hours were calculated for each patient. Adverse events such as the need for reintubation with an OA and VAP were collected. RESULTS Fifty-two patients (20 trauma, 32 EGS) were managed with an OA and TAC during the study period. Twenty-five patients (6 trauma, 19 EGS) had at least one extubation event with an OA. Median extubation events per patient was 3 (interquartile range, 1–5). The median ventilator-free hours for patients who were extubated was 101 hours (interquartile range, 39.42–260.46). Patients that were never extubated with an OA had higher rates of VAP (30.8% vs. 3.8%, p = 0.01). CONCLUSION This study provides much needed data regarding the feasibility of extubation in trauma and EGS patients managed with an OA and TAC. Benefits of early extubation may include lower VAP rates in this population. Plans for reexploration hinder the decision to extubate in these patients. LEVEL OF EVIDENCE Therapeutic study, level IV.

More medications, more problems: results from the Sedation Level after Emergent Exlap with Packing for TRAUMA (SLEEP-TRAUMA) study

“…This demonstrates disparate sedation strategies among practicing surgeons, in the face of growing evidence that minimizing sedation can prevent delirium and improve outcomes [26]. Additionally, there is increasing trauma literature supporting extubation prior to DFC, a practice we have adopted in two SE and four LE patients in our series [25].…”

“…Daily spontaneous awakening and breathing trials were performed daily for patients on continuous intravenous sedation [16,18,28]. At our institution, an open abdomen is not considered a contraindication to extubation [25,29]. During the time period covered by this study, we did not have an established early mobilization pathway for patients with damage control laparotomy.…”

“…There is a paucity of data exploring the specific impacts of sedation and delirium after trauma DCL. Currently, no practice consensus exists regarding sedation strategies in this patient population, and in some centers patients may even be extubated before DFC [25].…”

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

“…However, prolonged mechanical ventilation beyond 48 h increases the risk of ventilator‐associated pneumonia in surgical patients by approximately 10%–20% and at least doubles the mortality risk [ 583 ]. Retrospective studies of OA patients have demonstrated that extubation prior to definitive closure of the abdomen is feasible and is associated with a significantly lower incidence of ventilator‐associated pneumonia [ 583 , 584 ]. Early extubation, a joint decision between surgical and intensive care teams, should therefore be considered in patients with an OA.…”

Management of the patient with the open abdomen

“…Extubation prior to abdominal closure was associated with a reduced risk of respiratory complications and no increased risk of abdominal complications. Similarly, Taveras et al [29] analysed 52 trauma and general surgical patients who were managed with an open abdomen. Of these, 25 were extubated prior to abdominal closure.…”