Hypertonic Saline to Facilitate Early Fascial Closure after Damage Control Laparotomy

Original Date: 02/2012 | Last Review Date: 05/2024
Purpose: To describe the use of 3% sodium chloride in trauma patients with an open abdomen.

Indications:

  1. Patients who arrive to the STICU with an open abdomen after initial DCL for trauma
  2. Patients who arrive to the STICU with an open abdomen after initial DCL for emergency general surgical procedure at the operating surgeon’s discretion.

Contraindications:

  1. Serum sodium >160 mEq/L

Dosing:

  1. 3% NaCl solution is infused at a rate of 30 cc/hr by central venous catheter.1 If unavailable, may be administered for up to 48 hours via a peripheral IV (20G or larger) that is proximal to the wrist, has good blood return, and is dedicated to only 3% saline infusion. If phlebitis should occur, the infusion should be stopped, and access to a larger peripheral vein or a central vein should be obtained. If these are unavailable, 2% NaCl solution may be given until adequate venous access is achieved.
  2. This is the patient’s maintenance intravenous fluids and should not be titrated.
  3. Resuscitation with crystalloid, colloid, or blood products should continue as dictated by the patient’s clinical picture.
  4. HTS is discontinued as maintenance fluid replacement once the fascia is closed or 72 hours, whichever comes first.

Background:
The use of damage control laparotomy (DCL) in severely injured trauma patients to attenuate or avoid the “lethal triad” of acidosis, coagulopathy, and hypothermia has been associated with improved survival. 2,3,4,5,6,7,8 Unfortunately, failure to achieve fascial closure after DCL is not uncommon and carries a tremendous economic and morbidity burden. Failure to achieve early fascial closure (within the first 7 days) may result from intestinal and/or retroperitoneal edema, recurrent abdominal compartment syndrome, and continued coagulopathy, acidosis, or hypothermia. 9,10 The open abdomen has multiple physiologic implications, including increased insensible losses, protein losses, and nutritional demands. 11,12 The open abdomen also may result in significant morbidity, including, but not limited to incisional hernias, gastrointestinal fistulae, intra-abdominal infections, anastomotic leakage, and sepsis/infections 13,14,15,16.

Extensive research from UTH has demonstrated that hypertonic saline (HTS) prevents and reverses resuscitation induced intestinal edema in rat models 17,18,19 HTS has also been shown to mitigate the systemic inflammatory response secondary to intestinal ischemia-reperfusion injury in rat models. 20,21,22

In the clinical setting, we have shown that replacing standard maintenance intravenous fluids (LR or NS @ 125-150 mL/hr) with HTS (3% NaCl @ 30 mL/hr) in patients undergoing damage control laparotomy for trauma limits intestinal edema, assists in diuresis, and results in early fascial closure. 23

References:

  1. Stone HH, Strom PR, Mullins RJ. Management of the Major Coagulopathy with Onset during Laparotomy. Ann Surg. May 1983;197(5):532-35.
  2. Use of Pedicled Omentum as an Autogenous Pack for Control of Hemorrhage in Major Injuries to the Liver. Surg Gynecol Obstet. 1975;141:92-94.
  3. Feliciano DV, Mattox KL, Jordan GL. Intra-abdominal Packing for Control of Hepatic Hemorrhage: a Reappraisal. Apr 1981;21(4):285-90.
  4. Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan GL Jr. Abbreviated Laparotomy and Planned Reoperation for Critically Injured Patients. May 1992:215(5):476-83.
  5. Morris JA, Eddy VA, Blinman TA, Rutherford EJ, Sharpe KW. Stage Celiotomy for Trauma. Ann Surg. May 1993;217(5):576-84.
  6. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. ‘Damage Control’: An Approach for Improved Survival in Exsanguinating Penetrating Abdominal Injury. J Trauma. Sept 1993;35(3):375-383.
  7. Moore EE. Staged Laparotomy for the Hypothermia, Acidosis, and Coagulopathy Syndrome. Am J Surg. Nov 1996:172(5):405-10.Stone HH, Lamb JM.
  8. Asensio  JA, McDuffie L, Petrone P, et al. Reliable Variables in the Exsanguinated Patient which Indicate Damage Control and Predict Outcome. Am J Surg. 2001;182:743-51.
  9. Shah SK, et al. Resuscitation-Induced Intestinal Edema and Related Dysfunction: State of the Science. J of Surg Res.  May 2011; 166(1): 120-30.
  10. Hatch QM, Osterhout LM, Ashraf A, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Current Use of Damage-Control Laparotomy, Closure Rates, and Predictors of Early Fascial Closure at the First Take-Back. J Trauma. Jun 2011;70(6):1429-36.
  11. Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen Balance, Protein Loss, and the Open Abdomen. Crit Care Med. 2007;35(1):127-31.
  12. Hourigan LA, Linfoot JA, Chung KK, Dubick MA, Rivera RL, Jones JA, Salinas RD, Mann EA, Wade CE, Wolf SE, Baskin TW. Loss of Protein, Immunoglobulins, and Electrolytes in Exudates from Negative Pressure Wound Therapy.  Nutr Clin Pract. Oct 2010;25(5):510-16.
  13. Hatch QM, Osterhout LM, Podbielski J, Kozar RA, Wade CE, Holcomb JB, Cotton BA. Impact of Closure at the First Take Back: Complication Burden and Potential Overutilization of Damage Control Laparotomy. J Trauma. Dec 2011;71(6):1503-11.
  14. Cheatham ML, Safcsak K, Llerena LE, Morrow CE Jr, Block EF. Long-term Physical, Mental, and Functional Consequences of Abdominal Decompression. J Trauma. Feb 2004;56(2):237-41.
  15. Montalvo JA, Acosta JA, Rodriguez P, Alegandro K, Sẚrraga A. Surgical Complications and Causes of Death in Trauma Patients that Require Temporary Abdominal Closure. Am Surg. Mar 2005;71(3):219-24.
  16. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage Control: Collective Review. J Trauma. Nov 2000;49(5):969-78.
  17. Radhakrishnan RS, Xue H, Moore-Olufemi SD, Weisbrodt NW, Moore FA, Allen SJ, Laine GA, Cox CS Jr. Hypertonic Saline Resuscitation Prevents Hydrostatically Induced Intestinal Edema and Ileus. Crit Care med. Jun 2005;34(6):1713-18.
  18. Radhakrishnan RS, Radhakrishnan HR, Xue H, Moore-Olufemi SD, Mathur AB, Weisbrodt NW, Moore FA, Allen SJ, Laine GA, Cox CS Jr. Hypertonic Saline Reverses Stiffness in a Sprague-Dawley Rat Model of Acute Intestinal Edema, Leading to Improved Intestinal Function. Crit Care Med. Feb 2007;35(2):538-43.
  19. Cox CS Jr, Radhakrishnan R, Villarrubia L, Xue H, Uray K, Gill BS, Stewart RH, Laine GA. Hypertonic Saline Modulation of Intestinal Tissue Stress and Fluid Balance. Shock. May 2008;29(5):598-602.
  20. Attuwaybi BO, Kozar RA, Moore-Olufemi SD, Sato N, Hassoun HT, Weisbrodt NW, Moore FA. Heme Oxygenase-1 Induction by Hemin Protects Against Gut Ischemia/Reperfusion Injury. J Surg Res. May 2004;118(1):53-7.
  21. Attuwaybi B, Kozar RA, Gates KS, Moore-Olufemi S, Sato N, Weisbrodt NW, Moore FA. Hypertonic Saline Prevents Inflammation, Injury, and Impaired Intestinal Transit after Gut Ischemia/Reperfusion by Inducing Heme Oxygenase-1 Enzyme. J Trauma. Apr 2004;56(4):749-58.
  22. Gonzalez EA, Kozar RA, Suliburk JW, Weisbrodt NW, Mercer DW, Moore FA. Conventional Dose Hypertonic Saline Provides Optimal Gut Protection and Limits Remote Organ Injury after Gut Ischemia Reperfusion. J Trauma. Jul 2006;61(1):66-73.
  23. Harvin JA, Mims M, Duchesne J, Wade CE, Holcomb JB, Cox Jr CS, Cotton BA. Chasing 100%: the Use of Hypertonic Saline to Improve Early Fascial Closure Rates following Damage Control Laparotomy. J Trauma Acute Care Surg. J Trauma Acute Care Surg. Feb 2013;74(2):426-32.