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Nursing care for raised intra-abdominal pressure and abdominal decompression in the critically ill
Original article
Nursing care for raised intraabdominal pressure and abdominal decompression in the critically ill Sidney J. Cuthbertson Abdominal assessment is one of a number of continuous assessments that critical care nurses undertake. Since 1988 in the Department of Critical Care Medicine (DCCM), the technique of abdominal decompression has become another therapy for severe critical illness. The critical care nurse requires to have an understanding of raised intra-abdominal pressure assessment, pressure measurement and the care of abdominal polypropylene mesh insertion in the critical care setting. Our experience has been that the use of polypropylene mesh insertion halved since 1993. A retrospective study (Torrie et al. 1996) of 68 occasions (64 patients) of polypropylene mesh insertion, showed that seven patients developed fistulas and 32 patients died. There was no dehiscence of the mesh from the fascia. Forty-two wounds had primary fascial closure (28 with primary skin closure, 3 with secondary skin closure, 11 left to granulate) and 3 of them later dehisced. At follow-up (27 patients, median 7.5 months), 6 had stitch sinuses, and 5 had incisional hernias. Care of patients with polypropylene mesh inserted requires vigilant nursing practice but decompression of raised intra-abdominal pressure can be life-saving and complications are manageable. © 2000 Harcourt Publishers Ltd
Introduction Sidney J. Cuthbertson RGON, DipATE, Clinical Nurse Consultant, Department of Critical Care Medicine, Private Bag 92024, Auckland Hospital, Auckland, New Zealand. Tel: + 64 9 3797440, ext.7460; Fax: + 64 9 3074927; E-mail: [email protected] (Requests for offprints to SJC) Manuscript accepted 11/02/00
Raised intra-abdominal pressure can present as a pathophysiological condition where the pressure in the abdomen may rise to a point where it causes change in function to thoracic and abdominal organs (Burch et al. 1996). In the Department of Critical Care Medicine, Auckland Hospital, we have been measuring and treating raised intra-abdominal pressure since 1988 (Torrie et al. 1996). Initially, the patients that were treated for this condition were infrequent and in the first year only two patients were selected for release of raised abdominal pressure. However, as the benefits of this technique became apparent, the decompression rate increased to 20 a year (out of approximately 1000 admissions a year). In more recent years, the rate has fallen to about 10 a year as shown in Table 1.
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure is uncommon in critical care illness, but when it is diagnosed it commonly presents in pelvic trauma, from crush injury to tissue and the associated swelling; with retro-peritoneal haemorrhage, with the bulk of the haematoma exerting pressure as seen in some aortic aneurysm repairs; peritonitis with ascites, or bowel oedema and distension causing rise in the abdominal pressure (Torrie et al. 1996).
Pathophysiology Burch et al. (1996) describe the physiological changes that occur with raised intra-abdominal pressure which leads to the reduction in thoracic compliance. Here, the diaphragm becomes splinted from the pressure of the abdominal contents and this reduction in the volume of the thoracic cavity impairs gas exchange due to
Intensive and Critical Care Nursing ( 2 0 0 0 )
16, 175–180
175
Intensive and Critical Care Nursing
Table 1
Yearly trend of mesh insertion and mortality
Year No. of patients No. of deaths
1988–1993
1994
1995
1996
1997
1998
1999
64 32
25 10
0 4
14 5
11 7
13 8
9 3
atelectasis and the subsequent shunting. This pressure is detected with climbing peak airway pressures when the patient ventilation mode is ‘volume control’. In ‘pressure support’ mode, a decrease in tidal volume is seen (Sussman et al. 1991). The increased pressure reduces the visceral blood flow to the abdominal organs and consequently compromises the function of the kidneys and gut. As blood flow is impeded in the abdomen, the healing of any abdominal wound is also impaired (Diebel et al. 1992). The abdominal pressure that is exerted within the thoracic cavity can cause distortion to cardiac geometry (Burch et al. 1996) which diminishes the filling capacity of the ventricles, leading to a reduction in cardiac output. Patients who have had abdominal decompression in the period 1988–1999 primarily have come from three distinct patient classification groups. Trauma, sepsis and cardiovascular (in particular abdominal aortic aneurysms). This latter group has had a poor success rate and polypropylene mesh insertion is now very selective in this group of patients
Abdominal pressure assessment Raised intra-abdominal pressure is detected initially by observing the expanding girth of the patient, and when the abdomen is palpated there is an increase in the tension of the skin. Rising airway pressures in the ventilated patient are present or a reduced tidal volume, depending on the ventilation mode the patient is receiving. The reduced blood flow to the renal bed leads to oliguria and the reduced filling capacity of the ventricle produces a compensatory tachycardia. Prior to 1988, an expanding girth was measured with a measuring tape. This captured the abdominal expansion but did not convey the pressure that was being exerted within the abdominal cavity. Since 1988 we have used bladder pressure measurements to quantify the pressure build up within the abdomen. Sugne et al. 1994 and Collee et al. 1993 studied the
176
Intensive and Critical Care Nursing
(2000) 16, 175–180
effectiveness of an indwelling nasogastric tube for measuring intra-abdominal pressure with mixed results. However, Farouck et al. (1995) undertook a randomized controlled trial to determine the reliability of abdominal pressure measurement via the rectum, stomach and bladder and showed that the bladder was the most reliable viscus from which to measure abdominal pressure.
Bladder pressure measurement To measure abdominal pressure via the bladder, the bladder is drained by a standard urinary catheter. Intravenous infusion of 0.9% saline set up with a standard giving set and fluid column (as used in central venous pressure monitoring). The urinary drainage tube is clamped distal to the sampling port and 50 ml of saline is infused into the bladder via the urinary drainage sampling port. The column is zeroed to the midthoracic point and the bladder pressure is then read in centimetres of water. Our practice is to use intermittent monitoring of the abdominal pressure rather than continuous transduced pressure monitoring. Abdominal decompression is considered when the abdominal pressure reading is greater than 25 cm of water, along with deterioration in respiratory parameters, heart rate, pulmonary wedge pressure and hourly urine flow.
Abdominal decompression Schein et al. (1986, 2 papers) described his technique of surgical abdominal decompression for major intra-abdominal sepsis and, since 1988, we have used a modified Schein’s technique primarily for raised intra-abdominal pressure as described previously. A polypropylene mesh is inserted into the wound by suturing the mesh to the divided abdominal fascia and leaving the remaining abdominal layers open. The common surgical approach is a midline incision but transverse
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure and abdominal decompression in the critically ill
subphrenic incisions have been used, particularly in patients with pancreatitis. If the mesh is to remain in place for more than 7 days, a plastic film is laid over the viscera first to prevent the mesh adhering to the bowel. Two large bore drains are then placed on top of the mesh, on either side of the wound, at the edge of the mesh and fascia, and are sutured in place. The drains are tunnelled under the skin and exit the skin about 10 cm from the wound edge. The skin is painted with tincture of benzoin to aid drape adhesion, and the entire open wound is covered and sealed with the adhesive drape. For the best effect when applying the drape, the middle of the drape is applied to the middle of the wound, and with a circular hand action move out over the drape to the wound edge and on to the skin margin. The drains are connected to 100 mmHg suction to remove blood serum and peritoneal fluid before it pools on top of the mesh. Large polypropylene meshes can be used and have been left insitu for up to 40 days (see Fig. 1). The study by Torrie et al. (1996) showed a median of 10 days for mesh insertions.
Specific nursing intervention Nursing management of these wounds requires vigilant assessment of the patency of the drains, abdominal fluid loss, wound colour and the integrity of the drape. It is essential that the suction is maintained through the drains at all times. If disconnection from suction is necessary (for example when organizing a patient for
Fig. 1 This is an example of a large polypropylene mesh that has been inserted to decompress the abdomen. Note the placement of the drains and the tunnelled exit points.
© 2000 Harcourt Publishers Ltd
transportation), the drain should first be clamped, and unclamped when suction is reapplied. Clamping should take place for the shortest period of time possible, as peritoneal fluid will steadily accumulate. If the drains are not clamped, on breaking the suction the peritoneal fluid in the drains and suction tubing will disappear back into the abdomen, causing an infection risk. Fluid loss requires close monitoring to ensure that the patient receives adequate fluid replacement – 8 hourly volume totals assist in monitoring this loss. Observing the colour of the wound allows soft tissue viability (and any signs of infection) to be monitored. If the mesh inserted is too small, abdominal pressure will keep rising and the patient will need to return to the Operating Room for reinsertion of a larger mesh. Small leaks in the drape can be patched using a small transparent dressing but if the leak is large and the drains are blocked the entire drape requires to be replaced. A small persistent bleeder can be controlled by injecting adrenaline 1:1000 directly through the drape topically onto the vessel. Large bleeds may need diathermy which can be undertaken in the intensive care unit. If the drains block with blood clot, additional blood loss will form a clot underneath the drape, but on top of the mesh. When this occurs the drape should be replaced. This can be undertaken at the bedside under sterile conditions and requires two additional nurses to assist with the application of the drape (Cuthbertson 1998). The drape is peeled off exposing the clot, which is duly removed. The wound is cleaned with saline, the drains irrigated to re-establish patency and the wound is cleansed of any blood clot. At this point the drape is reapplied as described above. In some patients, staged closure of the abdomen and reduction of the mesh size are undertaken to facilitate complete abdominal closure. The polypropylene mesh is removed completely when the critical period of raised intra-abdominal pressure is over. The abdominal fascia is usually closed at this point. In some instances when the mesh has been in for a long period of time, the edges of the divided abdominal fascia adhere to the gut, and after removal of the mesh, the wound is left to granulate until epithelialization is achieved.
Intensive and Critical Care Nursing
(2000) 16, 175–180
177
Intensive and Critical Care Nursing
178
Fig. 2 This wound is after mesh removal and abdominal fascia closure. Healing is by granulation.
Fig. 4 Granulation tissue has developed over the bowel after 48 hours.
Fig. 3 This is an abdomen immediately after mesh removal. You can see how the loops of the bowel are covered with a fibrinous extudate.
Fig. 5 Granulation tissue that has developed over the bowel after 96 hours.
The skin and subcutaneous tissue may be left to heal by secondary intention from the abdominal fascia to the skin. This provides greater strength in the wound (Fig. 2). These wounds granulate well and achieve epithelialization over a period of 6–8 weeks. Figure 3 shows an abdomen immediately after mesh removal and a fibrinous extudate over the bowel can been seen. Figure 4 shows the granulation tissue that has developed within 48 hours after mesh removal. We have found that using a foam dressing for the first 24–48 hours allows for absorption of the peritoneal fluid without adhesion to the gut wall. After 48 hours, granulation has always covered the abdominal contents. For reasons of costeffectiveness, our practice is then to change to saline-soaked alginate. These wounds are redressed 12 or 24 hourly. It can take between 4 and 6 months for complete healing from intestine to skin to be achieved. Figure 6 is the same pa– tient as shown in Figures 3, 4 and 5, four months
later. Such patients are left with a large abdominal hernia. Between 6 and 12 months after abdominal healing, the scar tissue from this wound contracts and is able to be lifted off the abdomen with the fingers (see Fig. 7). At this point, the patient is ready to undergo abdominal fascia closure and scar revision. Typically, these wounds heal well after mesh removal, with or without abdominal fascial closure. Figure 7 shows the patient in Figure 1, who had abdominal fascia closure and scar revision a year after abdominal healing was achieved. Due to the severity of the patients’ illness at the time they have a mesh inserted for abdominal decompression, they are either neuromuscularly blocked or heavily sedated and have no awareness of the seriousness of their condition. At this point, it is the family who require support and teaching through this procedure. As the patients recover, they may have had their abdomen closed prior to their achieving awareness, or their abdomen may be open but
Intensive and Critical Care Nursing
(2000) 16, 175–180
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure and abdominal decompression in the critically ill
Fig. 6 This is the same patient as shown in Figure 3 and 4, four months later.
Fig. 7 When the scar tissue can be lifted off the abdomen, surgical scar revision can be successfully undertaken.
with soft tissue granulation. At this point the patients’ altered body image needs to be discussed with each patient and explanation provided about why the treatment was necessary, outcomes and that complete closure will be undertaken in the future. It is our experience that these patients manage this situation very well, knowing that they will have their abdomen repaired in due course.
Outcomes Between June 1988 and December 1998, 147 patients had a polypropylene mesh inserted for raised intra-abdominal pressure. Table 1, column 2 shows the period from June 1988 to December 1993. Here, 64 patients had mesh inserted and 32 died. The rest of the table logs the annual number of patients who had mesh inserted and the mortality rate. There was a steady decline in the use of this technique, which can partly be © 2000 Harcourt Publishers Ltd
Fig. 8 This abdomen is the same abdomen as show in Figure 1, after abdominal fascia closure and scar revision.
explained by a change in our trauma casemix. However, experience with this technique over the years has made our medical staff more discerning and selective in the use of this technique and polypropylene mesh is not inserted into patients who have had abdominal aortic aneurysm repair. Of the 147 patients from 1988 to 1998, 62 have died in the department and 4 have died later in hospital, giving a hospital mortality rate of 45%. Follow-up data of the whole group are not available, but the retrospective follow-up study by Torrie et al. (1996) of 68 cases of polypropylene mesh insertion showed that in 64 patients, 32 patients died (26 prior to mesh removal), and seven developed a fistula. There was no dehiscence of the mesh from the edge of the fascia. Forty-two wounds had primary fascial repair and definitive closure, three of these had abdominal dehiscence, 28 had primary skin closure, 3 were secondarily closed at 2, 3, and 15 days respectively, and 11 were left to granulate.
Conclusion Polypropylene mesh insertion in DCCM is confined to 1% of the most severely ill patient population. Vigilant nursing assessment and care allows for effective decompression of the abdomen. The complications that occur are manageable and this technique may allow recovery from a critical surgical illness. References Burch JM, Moore E, Moore FA, Franciose R 1996 The abdominal compartment syndrome. Surgical Clinics of North America 76 (4): 833–842 Collee GG, Lomax DM, Ferguson C, Hanson GC 1993 Bedside measurement of intra abdominal pressure (IAP)
Intensive and Critical Care Nursing
(2000) 16, 175–180
179
Intensive and Critical Care Nursing
via an indwelling naso-gastric tube: clinical validation of the technique Intensive Care Medicine 19: 478–480 Cuthbertson S 1998 Wound management in staged abdominal repair. Journal of Wound Care 7(4) 168–170 Diebel L, Saxe J, Dulchavsky S 1992 Effect of intraabdominal pressure on abdominal wall blood flow. The American Surgeon 58: 573–576 Farouck O, Guslits B, Buck J 1995 Increases in intrapulmonary compliance. Archives of Surgery 130: 544–548 Sugue M, Buist MD, Lee A, Sanche DJ, Hillman KM 1994 Intra abdominal pressure measurement using a modified naso-gastric tube: description and validation of a new technique. Intensive Care Medicine 20: 588–590
180
Intensive and Critical Care Nursing
(2000) 16, 175–180
Sussman AM, Boyd CR, Williams JS, Dibenedetto RJ, 1991 Effect of positive end-expiratory pressure on intraabdominal pressure. Southern Medical Journal 84: (6) 697–700 Torrie J, Hill A, Streat S 1996 Staged abdominal repair in critical illness. Anaesthesia and Intensive Care 24: 368–374 Schein M, Saadia R, Jamieson JR, Decker GAG 1986 The ‘sandwich technique’ in the management of the open abdomen. British Journal of Surgery 73: 369–370 Schein M, Saadia R, Decker GGA 1986 The open management of the septic abdomen. Surgery for Gynaecology and Obstetrics 163: 587–592
© 2000 Harcourt Publishers Ltd
Nursing care for raised intraabdominal pressure and abdominal decompression in the critically ill Sidney J. Cuthbertson Abdominal assessment is one of a number of continuous assessments that critical care nurses undertake. Since 1988 in the Department of Critical Care Medicine (DCCM), the technique of abdominal decompression has become another therapy for severe critical illness. The critical care nurse requires to have an understanding of raised intra-abdominal pressure assessment, pressure measurement and the care of abdominal polypropylene mesh insertion in the critical care setting. Our experience has been that the use of polypropylene mesh insertion halved since 1993. A retrospective study (Torrie et al. 1996) of 68 occasions (64 patients) of polypropylene mesh insertion, showed that seven patients developed fistulas and 32 patients died. There was no dehiscence of the mesh from the fascia. Forty-two wounds had primary fascial closure (28 with primary skin closure, 3 with secondary skin closure, 11 left to granulate) and 3 of them later dehisced. At follow-up (27 patients, median 7.5 months), 6 had stitch sinuses, and 5 had incisional hernias. Care of patients with polypropylene mesh inserted requires vigilant nursing practice but decompression of raised intra-abdominal pressure can be life-saving and complications are manageable. © 2000 Harcourt Publishers Ltd
Introduction Sidney J. Cuthbertson RGON, DipATE, Clinical Nurse Consultant, Department of Critical Care Medicine, Private Bag 92024, Auckland Hospital, Auckland, New Zealand. Tel: + 64 9 3797440, ext.7460; Fax: + 64 9 3074927; E-mail: [email protected] (Requests for offprints to SJC) Manuscript accepted 11/02/00
Raised intra-abdominal pressure can present as a pathophysiological condition where the pressure in the abdomen may rise to a point where it causes change in function to thoracic and abdominal organs (Burch et al. 1996). In the Department of Critical Care Medicine, Auckland Hospital, we have been measuring and treating raised intra-abdominal pressure since 1988 (Torrie et al. 1996). Initially, the patients that were treated for this condition were infrequent and in the first year only two patients were selected for release of raised abdominal pressure. However, as the benefits of this technique became apparent, the decompression rate increased to 20 a year (out of approximately 1000 admissions a year). In more recent years, the rate has fallen to about 10 a year as shown in Table 1.
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure is uncommon in critical care illness, but when it is diagnosed it commonly presents in pelvic trauma, from crush injury to tissue and the associated swelling; with retro-peritoneal haemorrhage, with the bulk of the haematoma exerting pressure as seen in some aortic aneurysm repairs; peritonitis with ascites, or bowel oedema and distension causing rise in the abdominal pressure (Torrie et al. 1996).
Pathophysiology Burch et al. (1996) describe the physiological changes that occur with raised intra-abdominal pressure which leads to the reduction in thoracic compliance. Here, the diaphragm becomes splinted from the pressure of the abdominal contents and this reduction in the volume of the thoracic cavity impairs gas exchange due to
Intensive and Critical Care Nursing ( 2 0 0 0 )
16, 175–180
175
Intensive and Critical Care Nursing
Table 1
Yearly trend of mesh insertion and mortality
Year No. of patients No. of deaths
1988–1993
1994
1995
1996
1997
1998
1999
64 32
25 10
0 4
14 5
11 7
13 8
9 3
atelectasis and the subsequent shunting. This pressure is detected with climbing peak airway pressures when the patient ventilation mode is ‘volume control’. In ‘pressure support’ mode, a decrease in tidal volume is seen (Sussman et al. 1991). The increased pressure reduces the visceral blood flow to the abdominal organs and consequently compromises the function of the kidneys and gut. As blood flow is impeded in the abdomen, the healing of any abdominal wound is also impaired (Diebel et al. 1992). The abdominal pressure that is exerted within the thoracic cavity can cause distortion to cardiac geometry (Burch et al. 1996) which diminishes the filling capacity of the ventricles, leading to a reduction in cardiac output. Patients who have had abdominal decompression in the period 1988–1999 primarily have come from three distinct patient classification groups. Trauma, sepsis and cardiovascular (in particular abdominal aortic aneurysms). This latter group has had a poor success rate and polypropylene mesh insertion is now very selective in this group of patients
Abdominal pressure assessment Raised intra-abdominal pressure is detected initially by observing the expanding girth of the patient, and when the abdomen is palpated there is an increase in the tension of the skin. Rising airway pressures in the ventilated patient are present or a reduced tidal volume, depending on the ventilation mode the patient is receiving. The reduced blood flow to the renal bed leads to oliguria and the reduced filling capacity of the ventricle produces a compensatory tachycardia. Prior to 1988, an expanding girth was measured with a measuring tape. This captured the abdominal expansion but did not convey the pressure that was being exerted within the abdominal cavity. Since 1988 we have used bladder pressure measurements to quantify the pressure build up within the abdomen. Sugne et al. 1994 and Collee et al. 1993 studied the
176
Intensive and Critical Care Nursing
(2000) 16, 175–180
effectiveness of an indwelling nasogastric tube for measuring intra-abdominal pressure with mixed results. However, Farouck et al. (1995) undertook a randomized controlled trial to determine the reliability of abdominal pressure measurement via the rectum, stomach and bladder and showed that the bladder was the most reliable viscus from which to measure abdominal pressure.
Bladder pressure measurement To measure abdominal pressure via the bladder, the bladder is drained by a standard urinary catheter. Intravenous infusion of 0.9% saline set up with a standard giving set and fluid column (as used in central venous pressure monitoring). The urinary drainage tube is clamped distal to the sampling port and 50 ml of saline is infused into the bladder via the urinary drainage sampling port. The column is zeroed to the midthoracic point and the bladder pressure is then read in centimetres of water. Our practice is to use intermittent monitoring of the abdominal pressure rather than continuous transduced pressure monitoring. Abdominal decompression is considered when the abdominal pressure reading is greater than 25 cm of water, along with deterioration in respiratory parameters, heart rate, pulmonary wedge pressure and hourly urine flow.
Abdominal decompression Schein et al. (1986, 2 papers) described his technique of surgical abdominal decompression for major intra-abdominal sepsis and, since 1988, we have used a modified Schein’s technique primarily for raised intra-abdominal pressure as described previously. A polypropylene mesh is inserted into the wound by suturing the mesh to the divided abdominal fascia and leaving the remaining abdominal layers open. The common surgical approach is a midline incision but transverse
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure and abdominal decompression in the critically ill
subphrenic incisions have been used, particularly in patients with pancreatitis. If the mesh is to remain in place for more than 7 days, a plastic film is laid over the viscera first to prevent the mesh adhering to the bowel. Two large bore drains are then placed on top of the mesh, on either side of the wound, at the edge of the mesh and fascia, and are sutured in place. The drains are tunnelled under the skin and exit the skin about 10 cm from the wound edge. The skin is painted with tincture of benzoin to aid drape adhesion, and the entire open wound is covered and sealed with the adhesive drape. For the best effect when applying the drape, the middle of the drape is applied to the middle of the wound, and with a circular hand action move out over the drape to the wound edge and on to the skin margin. The drains are connected to 100 mmHg suction to remove blood serum and peritoneal fluid before it pools on top of the mesh. Large polypropylene meshes can be used and have been left insitu for up to 40 days (see Fig. 1). The study by Torrie et al. (1996) showed a median of 10 days for mesh insertions.
Specific nursing intervention Nursing management of these wounds requires vigilant assessment of the patency of the drains, abdominal fluid loss, wound colour and the integrity of the drape. It is essential that the suction is maintained through the drains at all times. If disconnection from suction is necessary (for example when organizing a patient for
Fig. 1 This is an example of a large polypropylene mesh that has been inserted to decompress the abdomen. Note the placement of the drains and the tunnelled exit points.
© 2000 Harcourt Publishers Ltd
transportation), the drain should first be clamped, and unclamped when suction is reapplied. Clamping should take place for the shortest period of time possible, as peritoneal fluid will steadily accumulate. If the drains are not clamped, on breaking the suction the peritoneal fluid in the drains and suction tubing will disappear back into the abdomen, causing an infection risk. Fluid loss requires close monitoring to ensure that the patient receives adequate fluid replacement – 8 hourly volume totals assist in monitoring this loss. Observing the colour of the wound allows soft tissue viability (and any signs of infection) to be monitored. If the mesh inserted is too small, abdominal pressure will keep rising and the patient will need to return to the Operating Room for reinsertion of a larger mesh. Small leaks in the drape can be patched using a small transparent dressing but if the leak is large and the drains are blocked the entire drape requires to be replaced. A small persistent bleeder can be controlled by injecting adrenaline 1:1000 directly through the drape topically onto the vessel. Large bleeds may need diathermy which can be undertaken in the intensive care unit. If the drains block with blood clot, additional blood loss will form a clot underneath the drape, but on top of the mesh. When this occurs the drape should be replaced. This can be undertaken at the bedside under sterile conditions and requires two additional nurses to assist with the application of the drape (Cuthbertson 1998). The drape is peeled off exposing the clot, which is duly removed. The wound is cleaned with saline, the drains irrigated to re-establish patency and the wound is cleansed of any blood clot. At this point the drape is reapplied as described above. In some patients, staged closure of the abdomen and reduction of the mesh size are undertaken to facilitate complete abdominal closure. The polypropylene mesh is removed completely when the critical period of raised intra-abdominal pressure is over. The abdominal fascia is usually closed at this point. In some instances when the mesh has been in for a long period of time, the edges of the divided abdominal fascia adhere to the gut, and after removal of the mesh, the wound is left to granulate until epithelialization is achieved.
Intensive and Critical Care Nursing
(2000) 16, 175–180
177
Intensive and Critical Care Nursing
178
Fig. 2 This wound is after mesh removal and abdominal fascia closure. Healing is by granulation.
Fig. 4 Granulation tissue has developed over the bowel after 48 hours.
Fig. 3 This is an abdomen immediately after mesh removal. You can see how the loops of the bowel are covered with a fibrinous extudate.
Fig. 5 Granulation tissue that has developed over the bowel after 96 hours.
The skin and subcutaneous tissue may be left to heal by secondary intention from the abdominal fascia to the skin. This provides greater strength in the wound (Fig. 2). These wounds granulate well and achieve epithelialization over a period of 6–8 weeks. Figure 3 shows an abdomen immediately after mesh removal and a fibrinous extudate over the bowel can been seen. Figure 4 shows the granulation tissue that has developed within 48 hours after mesh removal. We have found that using a foam dressing for the first 24–48 hours allows for absorption of the peritoneal fluid without adhesion to the gut wall. After 48 hours, granulation has always covered the abdominal contents. For reasons of costeffectiveness, our practice is then to change to saline-soaked alginate. These wounds are redressed 12 or 24 hourly. It can take between 4 and 6 months for complete healing from intestine to skin to be achieved. Figure 6 is the same pa– tient as shown in Figures 3, 4 and 5, four months
later. Such patients are left with a large abdominal hernia. Between 6 and 12 months after abdominal healing, the scar tissue from this wound contracts and is able to be lifted off the abdomen with the fingers (see Fig. 7). At this point, the patient is ready to undergo abdominal fascia closure and scar revision. Typically, these wounds heal well after mesh removal, with or without abdominal fascial closure. Figure 7 shows the patient in Figure 1, who had abdominal fascia closure and scar revision a year after abdominal healing was achieved. Due to the severity of the patients’ illness at the time they have a mesh inserted for abdominal decompression, they are either neuromuscularly blocked or heavily sedated and have no awareness of the seriousness of their condition. At this point, it is the family who require support and teaching through this procedure. As the patients recover, they may have had their abdomen closed prior to their achieving awareness, or their abdomen may be open but
Intensive and Critical Care Nursing
(2000) 16, 175–180
© 2000 Harcourt Publishers Ltd
Raised intra-abdominal pressure and abdominal decompression in the critically ill
Fig. 6 This is the same patient as shown in Figure 3 and 4, four months later.
Fig. 7 When the scar tissue can be lifted off the abdomen, surgical scar revision can be successfully undertaken.
with soft tissue granulation. At this point the patients’ altered body image needs to be discussed with each patient and explanation provided about why the treatment was necessary, outcomes and that complete closure will be undertaken in the future. It is our experience that these patients manage this situation very well, knowing that they will have their abdomen repaired in due course.
Outcomes Between June 1988 and December 1998, 147 patients had a polypropylene mesh inserted for raised intra-abdominal pressure. Table 1, column 2 shows the period from June 1988 to December 1993. Here, 64 patients had mesh inserted and 32 died. The rest of the table logs the annual number of patients who had mesh inserted and the mortality rate. There was a steady decline in the use of this technique, which can partly be © 2000 Harcourt Publishers Ltd
Fig. 8 This abdomen is the same abdomen as show in Figure 1, after abdominal fascia closure and scar revision.
explained by a change in our trauma casemix. However, experience with this technique over the years has made our medical staff more discerning and selective in the use of this technique and polypropylene mesh is not inserted into patients who have had abdominal aortic aneurysm repair. Of the 147 patients from 1988 to 1998, 62 have died in the department and 4 have died later in hospital, giving a hospital mortality rate of 45%. Follow-up data of the whole group are not available, but the retrospective follow-up study by Torrie et al. (1996) of 68 cases of polypropylene mesh insertion showed that in 64 patients, 32 patients died (26 prior to mesh removal), and seven developed a fistula. There was no dehiscence of the mesh from the edge of the fascia. Forty-two wounds had primary fascial repair and definitive closure, three of these had abdominal dehiscence, 28 had primary skin closure, 3 were secondarily closed at 2, 3, and 15 days respectively, and 11 were left to granulate.
Conclusion Polypropylene mesh insertion in DCCM is confined to 1% of the most severely ill patient population. Vigilant nursing assessment and care allows for effective decompression of the abdomen. The complications that occur are manageable and this technique may allow recovery from a critical surgical illness. References Burch JM, Moore E, Moore FA, Franciose R 1996 The abdominal compartment syndrome. Surgical Clinics of North America 76 (4): 833–842 Collee GG, Lomax DM, Ferguson C, Hanson GC 1993 Bedside measurement of intra abdominal pressure (IAP)
Intensive and Critical Care Nursing
(2000) 16, 175–180
179
Intensive and Critical Care Nursing
via an indwelling naso-gastric tube: clinical validation of the technique Intensive Care Medicine 19: 478–480 Cuthbertson S 1998 Wound management in staged abdominal repair. Journal of Wound Care 7(4) 168–170 Diebel L, Saxe J, Dulchavsky S 1992 Effect of intraabdominal pressure on abdominal wall blood flow. The American Surgeon 58: 573–576 Farouck O, Guslits B, Buck J 1995 Increases in intrapulmonary compliance. Archives of Surgery 130: 544–548 Sugue M, Buist MD, Lee A, Sanche DJ, Hillman KM 1994 Intra abdominal pressure measurement using a modified naso-gastric tube: description and validation of a new technique. Intensive Care Medicine 20: 588–590
180
Intensive and Critical Care Nursing
(2000) 16, 175–180
Sussman AM, Boyd CR, Williams JS, Dibenedetto RJ, 1991 Effect of positive end-expiratory pressure on intraabdominal pressure. Southern Medical Journal 84: (6) 697–700 Torrie J, Hill A, Streat S 1996 Staged abdominal repair in critical illness. Anaesthesia and Intensive Care 24: 368–374 Schein M, Saadia R, Jamieson JR, Decker GAG 1986 The ‘sandwich technique’ in the management of the open abdomen. British Journal of Surgery 73: 369–370 Schein M, Saadia R, Decker GGA 1986 The open management of the septic abdomen. Surgery for Gynaecology and Obstetrics 163: 587–592
© 2000 Harcourt Publishers Ltd