|Year : 2017 | Volume
| Issue : 1 | Page : 5-10
Factors predicting the risk of intra-abdominal sepsis and burst abdomen in patients with abdominal trauma undergoing laparotomy
Bhupinder Singla1, Karnail Singh2, Inderjit Chawla2
1 Department of General Surgery, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of General Surgery, Government Medical College, Rajindra Hospital, Patiala, Punjab, India
|Date of Web Publication||15-Feb-2017|
Dayanand Medical College and Hospital, Ludhiana, Punjab
Source of Support: None, Conflict of Interest: None
AIM: This study aims to study the factors which predict the risk of intra-abdominal sepsis (IAS) and burst abdomen in patients with abdominal trauma undergoing laparotomy.
MATERIALS AND METHODS: Seventy-five patients with abdominal trauma undergoing laparotomy were evaluated in pre-, intra-, post-operative period for factors such as injury severity score (ISS), abdominal trauma index (ATI), operative severity score (OSS), and intra-abdominal pressure (IAP). The correlation was found among these factors and risk of IAS and burst abdomen following laparotomy.
RESULTS: Mean ATI, ISS, and OSS in IAS present and absent group were (35 ± 10 and 21 ± 7), (47 ± 16 and 22 ± 9), and (30 ± 6 and 18 ± 6), respectively. Mean ATI, ISS, and OSS in burst abdomen present and absent group were (35 ± 10 and 22 ± 8), (43 ± 14 and 23 ± 12), and (30 ± 6 and 19 ± 6) respectively. Mean IAP on D0, D1, and D2 in IAS present and absent group were (23 ± 7 mmHg and 16 ± 3 mmHg), (14 ± 4 mmHg and 7 ± 3 mmHg), and (11 ± 5 mmHg and 5 ± 2 mmHg), respectively. Mean IAP on D0, D1, and D2 in burst abdomen present and absent group were (23 ± 7 mmHg and 16 ± 3 mmHg), (13 ± 4 mmHg and 7 ± 4 mmHg), and (11 ± 5 mmHg and 5 ± 2 mmHg), respectively. Out of the 15 patients who had IAS, 13 also had burst abdomen. Significant correlation was found between ATI, ISS, and OSS with IAS and burst abdomen, and between IAS and burst abdomen.
CONCLUSIONS: Higher scores of ATI, ISS, OSS, and IAP are associated with higher chance of developing IAS and burst abdomen in the postoperative period. The presence of one complication in the postoperative period increases the risk for the other. Therefore, we can have risk-based approach in managing the patients having above-mentioned risk factors.
Keywords: Abdominal trauma, burst abdomen, factors, intra-abdominal sepsis, laparotomy
|How to cite this article:|
Singla B, Singh K, Chawla I. Factors predicting the risk of intra-abdominal sepsis and burst abdomen in patients with abdominal trauma undergoing laparotomy. Int J Health Allied Sci 2017;6:5-10
|How to cite this URL:|
Singla B, Singh K, Chawla I. Factors predicting the risk of intra-abdominal sepsis and burst abdomen in patients with abdominal trauma undergoing laparotomy. Int J Health Allied Sci [serial online] 2017 [cited 2019 Sep 20];6:5-10. Available from: http://www.ijhas.in/text.asp?2017/6/1/5/200198
Intra-abdominal sepsis (IAS) and burst abdomen are two most notorious and frequent complications in patients of blunt abdominal trauma who undergo emergency laparotomy. They have an incidence of 20% and jeopardize the outcome considerably. IAS is a forerunner of acute respiratory distress syndrome, multiple organ failure, abdominal wall defect and repetitive admissions to Intensive Care Units (ICUs), and carries a high mortality which may go up to over 50% if its diagnosis is delayed.,,
The extent and severity of the injury within the abdominal cavity, the rise in intra-abdominal pressure (IAP) in pre, intra-, and peri-operative phase, and the operative severity score (OSS) are some of the factors responsible for these complications. If the injury is severe or widespread and carries a high injury severity score (ISS), the risk of IAS and burst abdomen escalates. The reason being generalized hypoperfusion, tissue hypoxia, and immunosuppression. Being a precursor of abdominal compartment syndrome; raised IAP diminishes the mesenteric, renal, cardiovascular, and pulmonary circulation. As the intestinal mucosal blood flow drops, translocation of bacteria through gut wall is also liable to occur. The operative score, a part of Physiologic and OSS for the Enumeration of Mortality and Morbidity (POSSUM) variable, captures several variables which have a major influence in the occurrence of IAS in abdominal trauma. The score takes into account the need of a preoperative transfusion; the time elapsed between trauma and surgical intervention; the total operative time; the type of surgical procedure performed; and the number of contaminated abdominal quadrants found during the surgery.
The present study was done to demonstrate the role of these variables utilizing simple clinical measures the ISS and abdominal trauma index (ATI) to assess the role of severity of injury, IAP in pre-, intra-, and peri-operative phase and the OSS-to determine how each of them influence the development of IAS and burst abdomen. Depending on the results of the study, we may possibly be able to predict the risk of these complications, and propose a risk-based approach for the use of a primary temporary abdominal closure (TAC), an early infection search and a planned re-exploration following the first laparotomy.
| Materials and Methods|| |
This was a prospective study conducted on 75 patients of abdominal trauma admitted in the Department of Surgery of our institute between July 2010 and July 2012, who underwent laparotomy alone. Immunocompromised patients, or with age <12 years or having damage control surgery were excluded. Informed consent was taken from the patient, or their relatives and data were recorded. Ethical clearance was taken from Institutional Review Board.
All patients of abdominal trauma, with or without polytrauma, in need of laparotomy, were evaluated in the preoperative phase. The records were made regarding mechanism of injury, ATI, ISS, and IAP.
The surgical exploration was done by means of midline abdominal incision. During the operation, the OSS (part of POSSUM) was recorded.
During the postoperative period, IAP was measured on days 1 and 2; a close watch was kept on each patient to look for any signs indicative of intra-abdominal infection. The patient was duly investigated if he develops fever, tachycardia, hypotension, abdominal pain, persistent abdominal distension, oliguria, and leukocytosis. In that case, evaluation was done with ultrasonography and/or computed tomography to assess for the presence of a fluid collection. Guided aspiration and culture was done where indicated.
Abdominal sepsis comprised infected collections, intra-abdominal abscesses, and/or diffuse suppurative peritonitis. Fascial wound dehiscence was diagnosed if there was a serosanguinous discharge from the wound site with the absence of palpable bridge along the whole or part of suture line or if the bowel becomes visible when skin sutures also gave way or were removed due to infection.
IAP was first assessed clinically and was graded as the normal, moderate, or markedly tense abdomen. Thereafter, the IAP was measured indirectly by employing the saline fluid column manometry technique. Sixty milliliter of saline was instilled into the urinary bladder through the indwelling catheter. Zero-reference point was taken at pubic symphysis keeping Y of the Foley's at the symphysis. Then, Foley's was connected with graduated transparent tubing.
Operative severity score
The POSSUM  developed at the Broad Green Hospital in Liverpool, England, is a scoring system which allows for evaluation of surgical or postoperative care. This can allow comparison of care between different providers and/or institutions. The parameters used are operative severity, number of procedures done, total blood loss, peritoneal soiling, presence of malignancy, and mode of surgery.
Operative score = sum of points for all six parameters.
Injury severity score
ISS ,,, can be used to assess patients involved in traffic accidents. It makes use of the abbreviated injury scale and its value correlates with the risk of mortality. Injuries are assigned to five body regions (general, head and neck, chest, abdominal, extremities, and pelvis), and each type of injury encountered is assigned a value from 1 to 6.
The highest score, indicating the most severe injury for each region is selected. These are then ranked from the highest to the lowest value. The three highest values are then used to calculate the ISS.
ISS = (Highest region score)2 + (Second highest region score)2 + (Third highest region score) 2
The minimum score: 0 and maximum score is 75. The mortality rate increases with score and age.
Abdominal trauma index
The penetrating ATI , can be used to assess the severity of injury in patients with knife, gunshot, or other penetrating wounds to the abdomen. The index can be used to compare the performance of different emergency care settings. Fourteen organs are examined. The risk associated with injury to each organ is graded from 1 to 5.
Organ score = (Risk factor) × (Injury estimate)
ATI = SUM (all injured organs)
The minimum ATI: 0 and maximum ATI: 200.
The risk of postoperative complications is low if the ATI is ≤25, and increases sharply if the ATI >25.
Frequency distribution tables were used to demonstrate mean scores of ATI, ISS, OSS, IAP, and number of patients with IAP and burst abdomen. Means were compared using independent t-test. Chi-square test was used to correlate IAS and burst abdomen with ATI, ISS, OSS, and IAP.
| Results|| |
The male-female ratio in our study was 3:1, with a preponderance of males (n = 56) compared to females (n = 19). The cause of injury was blunt trauma in 77% patients (n = 55), whereas it was penetrating injury in 23% patients (n = 20).
Abdominal trauma index, injury severity score, operative severity score, intra-abdominal pressure
[Table 1] presents the ATI, ISS, and OSS for the 75 patients. [Table 2] presents the IAP for the 75 patients.
|Table 1: Abdominal trauma index, injury severity score, operative severity score|
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Twenty percent of the patients (n = 15) developed sepsis and 80% (n = 60) did not in the first 8 days.
17.3% of the patients (n = 13) developed burst abdomen and 82.7% (n = 62) did not in first 8 days.
Correlation between intra-abdominal sepsis and abdominal trauma index, injury severity score, operative severity score
[Table 3] represents the mean scores of ATI, ISS, OSS in relation to IAS present or not. Furthermore, these means have been compared using independent t-test. The correlation between IAS and ATI, ISS, OSS had a P - 0.000 which meant highly significant correlation.
|Table 3: Correlation between intra-abdominal sepsis and abdominal trauma index, injury severity score, and operative severity score|
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Correlation between burst abdomen and abdominal trauma index, injury severity score, operative severity score
[Table 4] represents the mean scores of ATI, ISS, OSS in relation to burst abdomen present or not. Furthermore, these means have been compared using independent t-test. The correlation between burst abdomen and ATI, ISS, OSS had a P - 0.000 which meant highly significant correlation.
|Table 4: Correlation between burst abdomen and abdominal trauma index, injury severity score and operative severity score|
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Correlation between intra-abdominal sepsis and intra-abdominal pressure on day 0, 1, 2
[Table 5] represents the mean scores of IAP on day 0, 1, 2 in relation to IAS present or not. In addition, these means have been compared using independent t-test. The correlation between IAS and IAP on day 0, 1, 2 had a P - 0.000 which meant highly significant correlation.
|Table 5: Correlation between intra-abdominal sepsis and intra-abdominal pressure on day 0, 1, 2|
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Correlation between burst abdomen and intra-abdominal pressure on day 0, 1, 2
[Table 6] represents the mean scores of IAP on day 0, 1, 2 in relation to burst abdomen present or not. The patients who had burst abdomen, later on, had a higher mean value on all 3 days readings.
|Table 6: Correlation between burst abdomen and intra-abdominal pressure on day 0, 1, 2|
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In addition, these means have been compared using independent t-test. The correlation between burst abdomen and IAP on day 0, 1, 2 had a P - 0.000 which meant highly significant correlation.
Correlation between intra-abdominal sepsis and burst abdomen
[Table 7] shows that out of the 15 patients who had IAS, 13 had burst abdomen too (87.2%). Out of the 13 patients who had burst abdomen, all had IAS (100%). In Chi-square tests, very high level of correlation was found between the presence of burst abdomen and IAS, as all the possible tests showed a P < 0.001.
| Discussion|| |
To summarize, the present study has been undertaken in two parts. In the first part of the study, 75 patients above the age of 12 years of age who were admitted to General Surgery Department of our institute and later on operated in view of their abdominal trauma were selected. The severity of their injury was calculated by ISS, ATI, and OSS. The epidemiological factors were identified. The IAP was taken on D0, D1, and D2. The occurrence of postoperative complications such as IAS and burst abdomen were identified through regular follow-ups and keeping high index of suspicion which was helped by different relevant investigations in the postoperative period. In the second part of the study, these scores were correlated with the incidence of IAS and burst abdomen in these patients.
Of total 75 patients evaluated; 55 had blunt abdominal trauma, and 20 had penetrating abdominal trauma. Male to female ratio was 3:1. The mean ATI value and ISS value were 24 ± 9 and 27 ± 15. The mean values of OSS were 20 ± 7. The mean values of IAP on D0, D1, and D2 were 17 ± 5 mmHg, 8 ± 4 mmHg, and 6 ± 4 mmHg. IAS rate were 20%, and burst abdomen rate were 17.3% [Table 1] and [Table 2].
In a study by Croce et al., a total of 926 patients were evaluated; 592 following blunt abdominal trauma and 334 following penetrating abdominal trauma. Male to female ratio was 8:1 for penetrating group and 2:1 in blunt group. The mean ATI value and ISS value were 16 ± 12 and 16 ± 10 for penetrating trauma group and 14 ± 9 and 29 ± 14 for blunt trauma group, respectively.
In comparison with the results of other reports; the 20% incidence of intra-abdominal infection found in our series was more than other similar studies. Fraser et al. reported an incidence of 10.6% in 926 patients they had included in their study. The mean ATI in the IAS present group in our study was 35 ± 10 and the absent group it was 21 ± 7. It was found to be statistically significant by t-test with a P - 0.000 [Table 3].
Borlase et al. stated that the risk of IAS increased with increasing score with half of the patients with IAS having score >35. It is noteworthy that the risk of IAS increased exponentially with scores >25. Hence, our study matches well with the above-mentioned study.
Croce et al. stated that in most of the cases, IAS occurred in the groups with higher ATI values: The incidence being 16% in patients with an ATI value >25. In this study, the mean value of ISS in IAS present and absent group was 47 ± 16 and 22 ± 9. There was a significant correlation between ISS and IAS (P- 0.000).
McDonald et al. stated that a low ISS correlated with a lower incidence of abdominal septic complications (ASCs) and an elevated ISS correlated with higher incidence of ASCs. The mean ISS value for patients with ASCs was 23 ± 9, and 16 ± 10 for those without ASCs (P < 0.001). In our study also, we found a higher value of ISS in patients with IAS than those who did not have IAS [Table 3].
OSS which as such has not been correlated with IAS in trauma patients is considered to be one of the few risk factors which have been studied previously and is found to be associated with the development of IAS. OSS also showed a significant correlation in our study with the occurrence of these complications. The mean value of OSS for patients with IAS was 30 ± 6, and 18 ± 6 for those without ASCs (P < 0.001) [Table 3].
Ertel et al. stated that ASC does not represent a rare clinical entity but a critical complication in the very early period trauma in certain subgroups, mostly in multiply injured patients with abdominal and/or pelvic trauma. The amount of third-space fluids correlates with duration and severity of hypovolemic shock. This state of hypoperfusion and hypoxia is possible explanation for the high incidence of infection. Further investigations are required to define the incidence of intra-abdominal hypertension in IAS and the prognostic impact of this setting and finally the potential specific treatment.
The above-mentioned studies formed the basis of including IAP as one of the variables to correlate with IAS in our study. The mean value of IAP on D0, D1, and D2 in IAS present and absent group were (23 ± 7 mmHg and 16 ± 3 mmHg), (14 ± 4 mmHg and 7 ± 3 mmHg), and (11 ± 5 mmHg and 5 ± 2 mmHg), respectively [Table 5]. In t-test, a significant correlation was found between IAP on D0 (P - 0.000), D1 (P - 0.000), D2 (P - 0.000) and development of IAS. Hence, it can be stated from our study that patients who had developed IAS, later on, had higher IAP on these days and those who did not develop IAS had lower IAP on these respective days.
We, in our study, also tried to find out if there is any significant correlation between these trauma scores and development of burst abdomen.
In our study of 75 patients, 17.3% of patients developed Burst abdomen. The mean ATI in patients with burst abdomen were 35 ± 10 and the mean ATI in patients without burst abdomen were 22 ± 8. Statistically significant correlation was found between ATI (P - 0.000) and burst abdomen when calculated by Student's t-test [Table 4].
Swaroop et al. stated that patients undergoing repeat laparotomy after trauma are at increased risk for wound dehiscence. This risk appears to be associated with intra-abdominal abscess and ISS. The mean ISS in our study were 43 ± 14 and 23 ± 12 in burst abdomen present and absent group, respectively. The correlation was statistically significant (P - 0.000). The mean OSS in these patients was 30 ± 6 and 19 ± 6 in burst abdomen present and absent group, respectively. There was statistical correlation found between burst abdomen and OSS (P - 0.000) [Table 4].
This rise in IAP has been frequently cited in retrospective reviews as the instigator factor if not the actual source of wound dehiscence. We, in our prospective study, correlated serial IAP measurements on D0, D1, and D2 with burst abdomen. In t-test, a significant correlation was found between IAP on D0 (P - 0.000), D1 (P - 0.000), and D2 (P - 0.000) with burst abdomen [Table 6].
In our study, involving 75 patients, 15 patients had IAS, out of them 13 had burst abdomen, and out of these 13 patients, all had developed IAS. In Chi-square tests, high amount of correlation was found (P < 0.001). Hence, it can be concluded that presence of either IAS or burst abdomen indicates a high possibility of the presence of the other [Table 7].
The limitation of this study lies in small patient number, which makes it difficult to generalize the results on population as a whole. Still the results of the study give the basic foundation to establish the need of risk-based approach in managing the patients with abdominal trauma having above-mentioned risk factors. Future research directed toward defining parameters and scores for the risk factors can help better predict the complication rate and take appropriate steps to avoid them.
| Conclusions|| |
It can be concluded from our study that high ISS, ATI, and OSS are associated with increased risk of IAS and burst abdomen. The presence of one complication in the postoperative period increases the risk for the other. Therefore, it can be stated we can have risk-based approach in managing the patients having above-mentioned risk factors. TAC had long been followed as a method of choice in patients with high risk of such postoperative complications as it prevents abdominal compartment syndrome, multiple organ dysfunction, and acute respiratory distress. Hence, our study is helpful in identifying those patients who can be benefited by TAC, for example, vacuum-assisted closure.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]