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Episode 030 Rationale for consensus on clinical guidelines. Classification, an important step to improve the management of patients with an open abdomen
Rationale for consensus on clinical guidelines. Classification, an important step to improve the management of patients with an open abdomen.
�
The patient may reach the situation of needing to be treated with an open abdomen (OA)
through different clinical pathways:
1) The septic contaminated abdomen that cannot be closed for infectious reasons and/or
where a second-look laparotomy is mandatory;
2) The patient with a tense abdomen after massive resuscitation or a prolonged major
surgical procedure, who is at risk of developing ACS;
3) A ?damage control? situation where the patient remains inadequately resuscitated and
who needs a period of intensive care therapy prior to a definitive surgical procedure;
4) The patient with primary or secondary ACS, who needs a life-saving decompressive
laparotomy.
A consensus group with experts in the field of treating patients with OA met twice in
Amsterdam, 2007 and 2009. We concluded that a classification system for patients with OA
could be an important step forward allowing:
1) A description of the patient?s clinical course;
2) Standardised clinical guidelines improving OA management; 3) Improved reporting of OA
status, facilitating comparisons between studies and heterogeneous patient populations. The
following grading is suggested:
Grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of
the abdominal wall (lateralisation); Grade 1B, contaminated OA without adherence/fixity;
Grade 2A, clean OA developing adherence/fixity; Grade 2B, contaminated OA developing
adherence/fixity; Grade 3, OA complicated by fistula formation; Grade 4, frozen OA with
adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this
classification system will facilitate communication, clarify OA management, and potentially
improve patient care.
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Rationale for consensus on clinical guidelines. Classification, an important step to improve the management of patients with an open abdomen.
�
The patient may reach the situation of needing to be treated with an open abdomen (OA)
through different clinical pathways:
1) The septic contaminated abdomen that cannot be closed for infectious reasons and/or
where a second-look laparotomy is mandatory;
2) The patient with a tense abdomen after massive resuscitation or a prolonged major
surgical procedure, who is at risk of developing ACS;
3) A ?damage control? situation where the patient remains inadequately resuscitated and
who needs a period of intensive care therapy prior to a definitive surgical procedure;
4) The patient with primary or secondary ACS, who needs a life-saving decompressive
laparotomy.
A consensus group with experts in the field of treating patients with OA met twice in
Amsterdam, 2007 and 2009. We concluded that a classification system for patients with OA
could be an important step forward allowing:
1) A description of the patient?s clinical course;
2) Standardised clinical guidelines improving OA management; 3) Improved reporting of OA
status, facilitating comparisons between studies and heterogeneous patient populations. The
following grading is suggested:
Grade 1A, clean OA without adherence between bowel and abdominal wall or fixity of
the abdominal wall (lateralisation); Grade 1B, contaminated OA without adherence/fixity;
Grade 2A, clean OA developing adherence/fixity; Grade 2B, contaminated OA developing
adherence/fixity; Grade 3, OA complicated by fistula formation; Grade 4, frozen OA with
adherent/fixed bowel, unable to close surgically, with or without fistula. We propose that this
classification system will facilitate communication, clarify OA management, and potentially
improve patient care.