CV
available VAC system (vacuum-assisted closure, KCI, San
Antonio, Tex).
Advantages of the commercially available system include a
standardized method of placing the system, ability to adjust
the negative pressure applied, and having portable systems
available. However, the VAC system is more expensive in
the short term than the previously described surgeon-created system with similar rates of complications [34].
Trips back to the operating room for “washouts” and examination of abdominal contents are kept to a minimum. It is
the senior author’s preference that the integrity of the occlusive dressing be vigorously maintained and that returns
for laparotomy be limited, when possible, to a single trip for
definitive fascial closure.
Achievement of negative fluid balance, normal peak inspiratory pressures, absence of transfusion requirement, and
a pliable abdomen guide the timing of operative returns for
definitive closure.
Bjorck et al. [35] have devised a classification scheme
(Table 4) designed to aid in the description of the patient’s
course, as well as to improve reporting of OA management
and standardize some of the clinical guidelines for treatment of this heterogeneous patient population.
This scheme, while providing a clear system for classification and broad guidelines for management of the patient
with an open abdomen, has yet to be examined in prospectively randomized studies.
Use of the open abdomen is an essential component of
damage control surgery as practiced by modern trauma and
acute care surgery teams. Smith and colleagues [36] have
reported use of directed peritoneal resuscitation with 2.5%
glucose-based peritoneal dialysis solution (Delflex, Fresenius, USA) at a rate of 1.5 mL/kg/hour in a negative pressure dressing until closure.
Using this protocol, they achieved earlier definitive fascial
closure as compared to standard management, that is, 4.35
± 1.6 versus 7.05 ± 3.31 days, P < 0.003, respectively. The
same team has presented data from animal models demonstrating favorable modulation of the inflammatory cascade
by this technique [37].
The utility and risk associated with this management technique in the setting of rAAA has yet to be defined but holds
promise.
9. Conclusions
Bozeman, Ross
Management of patients with intra-abdominal catastrophic
vascular events such as rAAA and complicated mesenteric
revascularization for ischemic bowel will continue to challenge vascular surgical and critical care teams even in the
endovascular era.
IAH and ACS are predictable complications which must
be promptly recognized and managed to prevent excessive
morbidity and mortality. Correct identification of patients
CV DIRECTIONS VOL. 2, NO. 2
at risk, standardized monitoring of IAP, prompt recognition of the disease in patients with closed abdomens, and
selective use of prophylactic delayed abdominal closure can
optimize outcomes.
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