PubMed · 14834035
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R J FLORES BELAUNDE. 1951-02-23. [Non-traumatic instruments for bladder surgery].. https://pubmed.ncbi.nlm.nih.gov/14834035/
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OBJECTIVE: The abdominal compartment syndrome is a potentially life-threatening condition with frequent renal involvement. There are few if any means of inferring subclinical effects before organ dysfunction. Because intrarenal pressure correlates with renal sonographic indices in other renal diseases, the purpose of this study was to determine the relationship between increasing intraabdominal hypertension and renal vascular flow velocities in a porcine model using renal Doppler ultrasound. DESIGN: Animal study. SETTING: University research laboratory. SUBJECTS: Eight anesthetized, mechanically ventilated, well-hydrated, 30-kg female Yorkshire pigs. INTERVENTIONS: Intraabdominal hypertension was induced by instillation of warmed intraperitoneal saline through a midline laparoscopic port. Intraabdominal pressure (IAP) was continuously monitored directly from the peritoneum and indirectly from the bladder. IAP was varied from 0 to 50 mm Hg in increments of 5 mm Hg. At each IAP level, gray-scale, color, and spectral Doppler renal arcuate artery ultrasound was obtained and resistive index (RI) and peak airway pressure calculated. MEASUREMENTS AND MAIN RESULTS: Excellent agreement between direct and indirect IAP was found (bias, 0.032 mm Hg; 95% limits, -5.5 to 5.6 mm Hg). A linear relationship between RI and indirect IAP was observed and was defined by the regression equation: RI = 0.553 + 0.0104 x bladder pressure. There was a trend toward different RIs between left and right kidneys (p = .052) at the same IAP. RI varied in a linear fashion at low peak airway pressure and demonstrated an inflection point with steeper subsequent slope after peak airway pressure of 30 cm H2O. RI values rapidly returned to near baseline after abdominal decompression. CONCLUSIONS: In this model, the renal artery RI correlated strongly and linearly with the severity of intraabdominal hypertension, making renal Doppler ultrasound a potential noninvasive screening tool for the renal effects of intraabdominal hypertension. Further studies are warranted.
OBJECTIVE: Goal-directed nutritional support is essential to improving morbidity and mortality. Open abdominal decompression is similarly crucial to the successful treatment of intra-abdominal hypertension and abdominal compartment syndrome. The open abdomen, however, places the patient at risk for potentially significant fluid, electrolyte, and presumably protein losses from the exposed viscera. Although nutritional protein assessments are frequently utilized to measure urinary nitrogen, these calculations do not consider the loss of protein from the open abdomen. We hypothesize that accurate assessment of nitrogen balance in the patient requiring an open abdomen must include either a measurement or estimation of abdominal fluid nitrogen loss. DESIGN: Prospective, observational cohort study. SETTING: Adult surgical/trauma intensive care unit of a level I trauma center. PATIENTS: Surgical/trauma patients requiring laparotomy. INTERVENTIONS: Serial 24-hr collections of urine and abdominal fluid protein were performed to characterize abdominal fluid protein loss and evaluate the clinical effect of accounting for abdominal fluid nitrogen as part of nitrogen balance calculations. MEASUREMENTS AND MAIN RESULTS: Nitrogen intake correlates with urinary nitrogen loss but not with abdominal fluid nitrogen loss. Abdominal fluid nitrogen loss is significant and remains relatively stable in the early postoperative period. Nutritional calculations that fail to account for abdominal fluid nitrogen loss significantly overestimate actual nitrogen balance by an average of 3.5 g/24 hrs. CONCLUSIONS: The open abdomen represents a significant source of protein/nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a direct effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.
BACKGROUND: The timely diagnosis of perforations or dead gut can be extremely difficult in micropremmies with necrotizing enterocolitis. A negative laparotomy is just as detrimental as failure to recognize early perforation in this group of patients. We have been exploring the role of microlaparoscopy using a needlescope to determine if this modality is feasible and useful in the surgical management of these patients. We report our technique and initial experience with needlescopic diagnosis. METHODS: Four patients (weight >500 to <1000 g) with abdominal distension and clinical sepsis not responsive to aggressive medical treatment were included in this study. None had radiologic evidence of pneumatosis or perforation. There was no absolute surgical indication for laparotomy except for strong suspicion of a surgical cause. Needlescopic diagnosis was performed in all these patients. RESULTS: There was no evidence of perforation or bile in the abdominal cavity in one patient. This patient improved on medical management, avoiding a laparotomy. The rest had bile or fibrin in the abdominal fluid with a localized perforation, and in each case we performed a microlaparotomy directly over the site of perforation to create a stoma. CONCLUSIONS: Needlescopic diagnosis is feasible and appears to be safe, even in critically ill micropremmies less than 1000 g. The technique can provide useful information for surgical decision-making and allows for precise placement of a microlaparotomy incision over the site of perforation, thus minimizing the trauma from open surgery in this special group of patients. We are currently expanding its role in patients with overt perforations to determine if we can limit the extent of surgical exploration without compromising the adequacy of surgical management.