25 September 2022: Articles
Use of a Modified ABTHERA ADVANCE™ Open Abdomen Dressing with Intrathoracic Negative-Pressure Therapy for Temporary Chest Closure After Damage Control Thoracotomy
Unusual clinical course, Management of emergency care, Educational Purpose (only if useful for a systematic review or synthesis)Luis G. Fernandez1ABCDEF*, Scott H. Norwood1ACDEF, Carolina Orsi2ABEF, Marvin Heck2ABF, Katherine Gonzalez 3ABEF, Natalie Williams1AB, Marc R. Matthews4ACDEF, Thomas M. Scalea5ACDE, Rebecca Swindall6EF
Am J Case Rep 2022; 23:e937207
BACKGROUND: Damage control surgery (DCS) is an established emergency operative concept, initially described and most often utilized in abdominal trauma. DCS prioritizes managing acute hemorrhage and contamination, leaving the abdominal wall fascia open and covering the existing wound with a temporary abdominal wall closure, most commonly negative-pressure wound therapy (NPWT). The patient undergoes aggressive resuscitation to optimize physiology. Once achieved, the patient is returned to the operating room for definitive surgical intervention. There is limited evidence suggesting that using damage control thoracotomy within the chest cavity improves mortality and morbidity rates. Our review failed to find a case in which NPWT using ABTHERA ADVANCE™ Open Abdomen Dressing has been successfully used in the setting of thoracic trauma.
CASE REPORT: This case series describes 2 examples of NPWT as a form of temporary chest closure in penetrating and blunt thoracic injury. The first case was a penetrating self-inflicted stab wound to the chest. The NPWT was applied as a form of temporary thoracotomy, closure at the index surgery. The second case was a blunt injury to the chest of a polytrauma patient following a motor vehicle accident. The patient sustained rib fractures on his left side and had a bilateral pneumothorax. An emergent thoracotomy was performed due to delayed intrathoracic bleeding noted on hospital day 11, and NPWT was applied as described above, in the first case.
CONCLUSIONS: These cases suggest that damage control thoracotomy with intrathoracic placement of a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system may be an effective and life-saving technique with the potential for positive outcomes in these high-risk patients.
Keywords: Negative-Pressure Wound Therapy, Thoracic Injuries, Trauma Centers
MODIFIED ABTHERA ADVANCE TEMPORARY THORACIC CLOSURE TECHNIQUE (AA-TTC):
In both cases presented, an ABTHERA ADVANCE™ Open Abdomen Dressing was used to achieve TTC. A step-by-step description of the technique is provided below and the correct procedural sequence was found to perform a successful AA-TTC.
Technical Steps: All surgical bleeding must be quickly and effectively controlled. Apply large sheets of oxidized cellulose over the controlled bleeding areas or areas of generalized oozing, as needed (eg, SURGICEL® NU-KNIT Absorbable Hemostat or another non-exothermic agent). The ABTHERA ADVANCE™ Fenestrated Visceral Protective Layer (VPL) is cut to fit and applied within the chest cavity, being careful to cover the area of injury and all adjacent organs. This is placed over the oxidized cellulose layer. A 32-French right-angle pericardial tube and 32-French thoracostomy tube is placed within the thoracic cavity as needed. Sterile laparotomy packs are added as needed. ABTHERA ADVANCE™ Perforated Foam is applied over the sterile laparotomy packs. The polyvinyl adhesive sheets, provided in the ABTHERA ADVANCE™ Open Abdomen Dressing kit, are applied to seal the AA-TTC dressing. A 2- to 3-cm perforation is made in the polyvinyl adhesive sheet and the SENSAT.R.A.C.™ pressure delivery system is applied and adhered over the perforation. The SENSAT.R.A.C.™ pressure delivery system is attached to a compatible V.A.C.® Therapy Unit and set to an initial negative pressure (NP) of 35 mmHg. The NP settings may be adjusted as needed based on observed blood/fluid output.
All surgical bleeding must be quickly and effectively controlled.
Apply large sheets of oxidized cellulose over the controlled bleeding areas or areas of generalized oozing, as needed (eg, SURGICEL® NU-KNIT Absorbable Hemostat or another non-exothermic agent).
The ABTHERA ADVANCE™ Fenestrated Visceral Protective Layer (VPL) is cut to fit and applied within the chest cavity, being careful to cover the area of injury and all adjacent organs. This is placed over the oxidized cellulose layer.
A 32-French right-angle pericardial tube and 32-French thoracostomy tube is placed within the thoracic cavity as needed.
Sterile laparotomy packs are added as needed.
ABTHERA ADVANCE™ Perforated Foam is applied over the sterile laparotomy packs.
The polyvinyl adhesive sheets, provided in the ABTHERA ADVANCE™ Open Abdomen Dressing kit, are applied to seal the AA-TTC dressing.
A 2- to 3-cm perforation is made in the polyvinyl adhesive sheet and the SENSAT.R.A.C.™ pressure delivery system is applied and adhered over the perforation.
The SENSAT.R.A.C.™ pressure delivery system is attached to a compatible V.A.C.® Therapy Unit and set to an initial negative pressure (NP) of 35 mmHg. The NP settings may be adjusted as needed based on observed blood/fluid output.
The patient was a 33-year-old man who presented to the Emergency Department after multiple self-inflicted stab wounds to the chest. The patient was combative and confused at the scene, with a knife through the left side of his chest, just lateral to his sternum (Figure 2A–2C). The patient was tachypneic, hypotensive (87/70 mmHg), tachycardiac (126 beats/min), with distended neck veins, muffled heart tones (Becks’ triad), with absent breath sounds to auscultation to the left chest. The patient had an Injury Severity Score and an Abbreviated Injury Score of 25 and 5, respectively. He was intubated upon arrival and taken to the operating room for an emergent thoracotomy.
A left lateral thoracotomy at the fifth intercostal space was performed. Six lacerations to the apex of the right and left ventricle were found. There was also a contusion to the left lower lobe of the lung. A longitudinal pericardiotomy was performed to release the cardiac tamponade. The cardiac lacerations on the right and left ventricular apex were repaired with 3-O pledged proline sutures (see Figure 3A–3C). The left hemithorax and heart were irrigated with 3 liters of hypochlorous acid solution. The heart was wrapped in SURGICEL NU-KNIT® Absorbable Hemostat to mitigate continued oozing from the cardiac repair (Figure 4).
The DCT was complete. At this time, we decided to use the modified TTC-NPWT technique to keep the left anterolateral thoracotomy incision open. A 32-French right-angle pericardial tube was placed within the anterior mediastinum and a standard 32-French thoracostomy tube was placed in the left thoracic cavity. The ABTHERA ADVANCE™ Fenestrated VPL was cut to fit and applied to the heart and lungs. Three sterile laparotomy packs were added and ABTHERA ADVANCE™ Perforated Foam was applied to negative 35 mmHg pressure (Figure 5A, 5B).
During the operation, 21 units of packed red blood cells (PRBC), 2 units of platelets, 4 units of cryoprecipitate, 16 units of fresh frozen platelets, 1 liter of 0.9 normal saline, and 250 cc of sodium bicarbonate were administered intravenously. The patient received a total of 23 units of PRBC, 2 units of platelets, and 18 units of fresh frozen plasma in the first 24 h.
The patient became febrile (39°C) and hypotensive during the first night after the DCT. He was given an additional 2 units of fresh frozen plasma and a chest X-ray was performed, which showed left lower-lobe consolidation. A computed tomography (CT) scan of the chest with intravenous contrast showed no active cardiac bleeding and transesophageal echo demonstrated no cardiac structural anomalies. The patient had an estimated ejection fraction of 65%. On post-operative day (POD) 2, a second-look thoracotomy was performed. The right and left ventricular apex laceration repairs were intact and the left hemidiaphragm and lung parenchyma had no further injuries noted. Primary closure of left lateral thoracotomy incision was completed along with the placement of a 3M™ Prevena™ Peel and Place Dressing negative-pressure system over the incision (Figure 6A–6D).
Complications after the second-look thoracotomy included thrombocytopenia, anemia due to blood loss, and continued difficulty with moving the right upper extremity. On POD 7 the patient was weaned from the ventilator, extubated, and the pericardial tube was removed. The left thoracostomy tube was left in place on water seal. The patient was transferred in stable condition to the University of Texas Medical Branch in Galveston for his remaining recovery on POD 9. His thoracostomy tube was removed on POD 13 (Figure 7) and his neurologic examination continued to improve. The patient had no further complications reported, the thoracotomy incision was healing well, and he was subsequently discharged to a rehabilitation facility.
A 51-year-old man with past medical history of substance abuse, yet negative for other comorbidities, was transferred from an outside hospital after suffering polytrauma from a motor vehicle accident. His injuries included left rib fractures and bilateral pneumothorax, which were managed with bilateral tube thoracostomies. On hospital day (HD) 11, the left tube thoracostomy had increased bloody output and the patient clinically decompensated, rapidly becoming tachycardic and severely hypotensive (systolic blood pressure of 40 mmHg). The patient was taken to the operating room for an emergent left thoracotomy.
A left lateral thoracotomy was performed through the fifth intercostal space. Upon entry into the chest, approximately 2 liters of clotted blood was encountered (Figure 8A). The chest was packed starting at the apex. Additional laparotomy packs were then placed laterally, posteriorly, and medially. The rib fracture sites were identified but there was no active bleeding. The chest was irrigated with hypochlorous acid solution and the laparotomy packs were systematically removed starting at the apex, then laterally, medially, and posteriorly. A search was made for a suspected intercostal artery as the source of the hemorrhage and the entire contents of the left hemithorax, heart, and mediastinum were inspected, but no obvious injury or active source of bleeding could be found.
The decision was made to use the modified TTC-NPWT technique to temporarily close the chest to return for re-exploration after further resuscitation. Two 32-French chest tubes were positioned posteriorly and anteriorly. A modified ABTHERA vacuum-assisted wound closure device was positioned over the entire left lung. Four laparotomy packs were placed over the device and ABTHERA ADVANCE™ Perforated Foam was applied to negative 35 mmHg pressure (Figure 8B).
The patient was resuscitated in the ICU over 48 h. He received 4 units of PRBC peri-operatively and the chest tube output and output through the TTC-NPWT/DCT was negligible. The patient remained hemodynamically stable. A post-operative CT angio-gram of the chest was performed 24 h after the TTC-NPWT/DCT, which revealed no active arterial extravasation (Figure 9). The patient was then taken back to the operating room 48 h after the index thoracotomy. The vacuum-assisted closure device was removed and the left thoracic cavity was irrigated and inspected. An intercostal artery at a left fourth rib fracture was noted to have active bleeding. This was ligated and packed with oxidized cellulose (Figure 10), and definitive closure of the left lateral thoracotomy was done. The patient returned to the ICU intubated. He underwent percutaneous tracheostomy placement, was weaned from the ventilator, transferred to the floor, and subsequently discharged to rehabilitation.
Case 1 demonstrates a successful use of DCT principles to emergently treat cardiac tamponade, perform cardiac massage, repair complex penetrating cardiac injuries, and use a modified vacuum-assisted temporary thoracic closure to stabilize the patient before definitive surgical closure of the chest. Case 2 illustrates the successful treatment of a massive, delayed hemothorax in a patient with severe polytrauma that was treated with evacuation of the hemothorax, DCT and temporary chest wall closure with NPWT, followed by effective resuscitation, elective definitive washout, control of bleeding, and closure of the thoracic cavity. The temporary chest wall closure with NPWT did not lead to physiologic cardiopulmonary compromise in either of these patients and afforded the opportunity to evaluate the underlying traumatic injuries to provide definitive repair in a more physiologically favorable setting. No patient required re-exploration for bleeding and there was no clinically significant difference in mean airway pressure following the index operation and chest definitive closure.
DCT is a life-saving measure, with infrequent opportunities for its application; therefore, there is limited clinical experience in its use [5,6]. Retrospective reports about the procedure are scarce [5–9]. Therefore, there remains controversy surrounding the procedure as to patient selection, surgical technique, and optimal application. Consequently, no consensus exists regarding the most effective temporary closure technique for the open thoracic cavity. Although a wide variety of packing and closure methods have been used, these 2 cases provide a clear example of how delayed closure with a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system can be successfully used as a form of TTC after DCT.
A review of 130 DCT procedures found a survival rate of 67%, ranging from 42% to 77% [5–9]. In these studies, optimal packing technique has not been established. Unlike damage control in abdominal laparotomies, careful consideration is required when deciding on the location and type of packing to ensure normal respiratory and cardiac physiology in the chest during temporary closure. In a review of their surgical experiences, O’Connor, DuBose, and Scalea demonstrated that peak airway pressures were lower in patients undergoing temporary closure with an institutionally developed modified NPWT system compared to those who underwent traditional bony thoracic closure .
Negative-pressure therapy has been used for deep sternal wounds [11,13,14]. When negative pressure is used for sternal wounds, it allows arteriolar dilatation to promote granulation tissue formation and decreases edema and bacterial colonization of the wound . NPWT has also been used effectively as a form of TAC in abdominal DCS [1–4,16]. Negative-pressure therapy can provide an optimal physiologic environment for healing [11–16].
Our report supports the use of NPWT temporary closure techniques as a safe and effective TTC after DCT. It is our opinion that the experience gained in the management of the open abdomen with TAC-NPWT may be translational to application in the thoracic cavity in appropriately selected patients. We believe that this report will contribute to the scant existing clinical experience in the use of modified NPWT in the setting of DCT. We have shown that intrathoracic placement of a modified NPWT system for TTC can be successfully applied in penetrating and blunt thoracic injuries and may be a viable alternative for TTC. We hope that this experience will lead to further scientific study of the effects of NPWT in the thoracic setting, developing a fuller understanding of DCT, its indications, techniques, and available options for the treating surgeon.
These cases suggest that DCT with intrathoracic placement of a modified ABTHERA ADVANCE™ Open Abdomen Dressing negative-pressure system may be an effective and life-saving technique with the potential for positive outcomes in these high-risk patients.
FiguresFigure 1.. ABTHERA ADVANCE™ Open Abdomen Dressing, negative-pressure wound therapy system. Figure 2.. (A, B) Penetrating self-inflicted, stab wound to the chest with cardiac laceration (circle), (A, C) improvised “shank” (arrow). Figure 3.. (A) Left ventricular apex laceration (arrow), (B, C) operative repair of left and right ventricle lacerations (circle). Figure 4.. The heart wrapped with SURGICEL NU-KNIT® Absorbable Hemostat dressing (circle). Figure 5.. (A) Placement of the modified ABTHERA ADVANCE™ Open Abdomen Dressing, (B) left thoracostomy tubes for temporary chest closure. Figure 6.. Second-look thoracotomy. (A) Laparotomy packs (arrow), (B) Visceral Protective Layer (arrow), (C) intact cardiac repair (circle), (D) 3M™ Prevena™ Peel and Place Dressing (arrow). Figure 7.. Post-operative left thoracotomy incision. Figure 8.. (A) Upon entry into the chest approximately 2 liters of clotted blood was encountered. (B) Modified ABTHERA ADVANCE™ Open Abdomen Dressing and left thoracostomy tubes placed for temporary chest closure. Figure 9.. Post-operative CT angiogram of the chest was performed 24 hours after negative-pressure wound therapy and damage control therapy revealed no active arterial extravasation. Figure 10.. An intercostal artery at the left fourth rib fracture was noted to have active bleeding. This was ligated and packed with oxidized cellulose (circle).
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