Early Escharotomy as a Measure to Reduce Intraabdominal Hypertension in Full‐Thickness Burns of the Thoracic and Abdominal Area

Abstract

Intraabdominal hypertension (IAH) can occur in critically ill patients who have undergone surgery, who have required fluid resuscitation after intraabdominal operations, or whose abdominal surgical wound closure was under tension. If IAH remains unrelieved, it can lead to development of the abdominal compartment syndrome (ACS). The latter presents with severe cardiorespiratory and urinary symptoms such as hypotension, hypoventilation, and oliguria, and it can become fatal if it is not diagnosed early and treated properly. Moreover, IAH has been documented in the context of major burns, complicating the initial resuscitation of these patients. This study was set up to investigate the role of full-thickness burns of the thoracic and abdominal areas in IAH during the early resuscitation period, to determine whether escharotomy could influence its levels. During the past 2 years 10 burn patients were enrolled in this study, as they fulfilled the necessary criteria: >35% total body surface area (TBSA) full-thickness burn affecting the anterior, lateral, and most of the posterior surface of the thorax and abdomen (torso), no respiratory mechanical support at admission, and initial evaluation at another facility and transfer to our burn center 2-6 h postburn. Upon admission, the following parameters (indicative of intraabdominal hypertension, IAH) were measured: bladder pressure and gastric pressure. Also, we monitored inferior vena cava pressure, and as a routine, central venous pressure, systolic blood pressure, and arterial blood gases. Elevated intraabdominal pressure to hazardous levels was documented in all patients included in our study. The same escharotomy pattern was performed in every case, and 5-10 min after the procedure all measurements were repeated. Immediate improvement of all the parameters measured was recorded, and the alterations were found statistically significant. These results were indicative of significant relief of the elevated intraabdominal pressure in all patients after escharotomy, as well as the efficacy of the procedure. It is thus demonstrated that full-thickness burns of the thoracic and abdominal areas can cause a significant early increase in intraabdominal pressure that, if left untreated, can lead to the development of ACS. However, the application of simple decompression techniques can offer remarkable, immediate, and often lifesaving results and is absolutely indicated for this reason, as well as for its well-known beneficial effects on respiratory function.

The role of abdominal compliance, the neglected parameter in critically ill patients — a consensus review of 16. Part 2: measurement techniques and management recommendations

“…• Umbilical hernia repair [145,146] • Muscle contractions (pain) [93] • Body builders (six-pack) [115] • Interstitial and anasarc oedema (skin, abdominal wall) • Abdominal burn eschars (circular) [97,98,147] • Thoracic burn eschars (circular) • Tight closure after abdominal surgery • Abdominal Velcro belt or adhesive drapes [148] • Prone positioning [103] • HOB > 45° [102] • Pneumoperitoneum • Pneumatic anti-shock garments • Abdominal wall bleeding • Rectus sheath haematoma [149] • Correction of large hernias • Gastroschisis • Omphalocoele • Mechanical ventilation (positive pressure) [65] • Fighting with the ventilator • Use of accessory muscles • Use of positive end expiratory pressure (PEEP) [66] • Presence of auto-PEEP (tension pneumothorax) • COPD emphysema (diaphragm flattening)…”

Acute lung injury secondary to intra-abdominal hypertension and abdominal decompression in a burn patient

“…Regarding ACS in burn patients, several case reports, 3,4,8,17 as well as reported of changes of physiologic parameters before and after decompression, 13,16 and a correlation between IAP and total fluid volume, 7,14 have been published. Deterioration of the ventilation status due to IAH was examined in both primary 2 and secondary ACS, 10 in which PIP, 5 PaO 2 , 16 PaCO 2 , 3 PaO 2 /F I O 2 ratio and pulmonary compliance 2 were evaluated.…”

The Neglected Role of Abdominal Compliance in Organ-Organ Interactions

“…Likewise, escharotomies (abdominal but also thoracic) will increase C ab while sternotomy will increase not only thoracic wall compliance but also C ab [42][43][44]. Placing a chest tube in case of a tension pneumothorax or pleural effusion will also increase C ab .…”