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Surgical CC Therapy Exam Solution guide. Indications for an Open Abdomen – - abdominal compartment syndrome - damage control laparotomy - intra-abdominal sepsis - multiple injuries +/- multipl... e body cavities - prohibitive operative time >90min - massive transfusion - hemodynamic instability - acidosis (pH < 7.2) - hypothernia (35 C) - coagulopathy - elevated Lactate Techniques for temporary abdominal closure (TAC) – - bogata bag - towel-clip closure - barker vac pac - wittmann patch - skin closure - negative pressure wound therapy Data supports which TAC is associated with better outcomes compared to other closure techniques? - negative pressure wound therapy. ex: abthera Advantages to negative pressure wound therapy? - - covers wound - protects visera - reduces tissue edema - decreases loss of abdominal wall domain - decreases evaporative losses - measures fluids accurately TAC dressings should be changed in the operating room or in the intensive care unit every ____ days. - 2-3 Does a patient with a TAC require antibiotics? - If the patient is not on antibiotics for other reasons, they are not indicated when using these devices. Resuscitation of the Open Abdomen - Resuscitation is guided by reestablishing end-organ perfusion as indicated by adequate urine output, restitution of vital signs, and clearance of lactic acidosis. Other resuscitation targets include an *oxygen delivery index >600 mL/min/m2*, *oxygen consumption index >150 mL/min/m2*, and lactate <2.5 mmol/L within 12 h Oxygen Extraction Ratio (O2ER) - O2ER = VO2 (oxygen consumption) / DO2 ( oxygen delivery) = (SaO2 -SvO2) / SaO2o How does hypothermia affect coagulopathy? - Hypothermia impairs thrombin generation (Hypothermia primarily inhibits the initiation phase of thrombin generation - triggered by the release of tissue factor into the bloodstream) and contributes to PLT dysfunction. Correcting hypothermia and rewarming the patient assists in the resuscitative process by allowing cofactors in the clotting cascade to work, thereby decreasing blood loss and correcting acidosis. Ventilator Strategies in patients with open adbomen - - low stretch protocol (tidal volume <6ml/kg) -> AVOID VOLUME AND BAROTRAUMA - high PEEP. -> MAINTAIN OXYGENATION - reduced I:E -> MAINTAIN OXYGENATION - sedation/analgesia -> VENTILATOR SYNCHRONY - prone position -> DECREASE V/Q MISMATCH - HFOV, APRV -> TREAT. REFRACTORY HYPOXIA Anastomotic leak rates are significantly higher in the _____ colon compared to other side - left What is the single best approach to reduce the rate of GI fistula formation? - early fascial closure. There is some evidence that suggests _______ increases the likelihood of fistula closure as well as reduces the time to fistula closure - octreotide Adjuncts used to decrease high fistula output ? - high fistula output include antimotility agents such as loperamide, diphenoxylate, and tincture of opium and antisecretory agents such as proton pump inhibitors. The most common late complication of an open abdomen is - a ventral hernia. 10% of people who undergo definitive abdominal closure develop a ventral hernia by 21 months PA Catheter ports: distal and proximal - - proximal: opens roughly in RA and allows measurement of RA pressures and or CVP, sampling of blood (ScvO2), and delivery of meds or fluid for CO measurement. - distal: opens at the catheter tip. Allows for measurement of PA pressure (wedge) and sampling of blood for Svo2 (mixed gas) - note there are many other ports not just "two" [Show More]

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