Health & Medical intensive care

Vacuum-Assisted Closure Device Enhances Recovery

´╗┐Vacuum-Assisted Closure Device Enhances Recovery

Abstract and Introduction

Abstract


Introduction Critically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control.
Methods This prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring.
Results The Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups.
Conclusions Patients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and earlier discharge from the ICU as compared to similar patients treated with the Bogota bag.

Introduction


Intra-abdominal hypertension (IAH) is defined as a sustained pathological elevation in intra-abdominal pressure (IAP) above 12 mmHg. The effect of persistent elevation of IAP beyond 20 mmHg is commonly referred to as abdominal compartment syndrome (ACS) resulting in depressed renal function, cardiac output, respiratory mechanics, and mesenteric perfusion. Capillary leakage following the evolution of systemic inflammatory response syndrome in septic and trauma patients contributes to diminished abdominal wall compliance, as well as the need for mechanical ventilation and high positive end-expiratory pressures. The altered compliance of the abdominal wall is made worse by the increase in the intraabdominal volume (ileum, gastroparesis, capillary leakage, interstitial fluid loading), which frequently occurs in intensive care unit (ICU) patients as a consequence of major trauma, opioid infusions and/or parenteral nutrition. The incidence of IAH has been reported to be as high as 40% in post-surgical and severely injured patients, and 30% in a population of medical and surgical ICU patients. In particular, major trauma patients are at risk for increasing IAP and subsequently developing ACS.

The importance of IAP monitoring to prevent ACS in critically ill patients has been widely emphasized in the literature, even if routine IAP monitoring has yet to be made standard in many ICUs internationally.

The management of IAH includes both medical and surgical interventions. The medical approach consists primarily of reducing intra-abdominal volume (nasogastric/colonic decompression, prokinetic drugs) or increasing compliance of the abdominal wall through neuromuscular blockade. Although non-surgical treatments must be attempted as the first step in the treatment of IAH, worsening IAP and/or deteriorating organ dysfunction requires surgical decompression with a temporary abdominal closure (TAC) system.

The aim of the present investigation was to evaluate the efficacy of two different TAC systems (Bogota bag and vacuum-assisted closure (VAC) device) in ICU patients requiring emergency open abdomen treatment.

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