Open Abdomen pp 187-204 | Cite as

Nutritional Support in Patients with an Open Abdomen

  • Patricia Marie Byers
  • Andrew B. PeitzmanEmail author
Part of the Hot Topics in Acute Care Surgery and Trauma book series (HTACST)


Nutritional support has evolved over the last 50 years with improvements in line care, enteral access, enteral formulas, and intestinal rehabilitation, which has occurred in conjunction with major advances in critical care and operative management of surgical emergencies. The utilization of the open abdomen in cases of damage control surgery and for treatment of abdominal compartment syndrome has been a paradigm shift. Although the open abdomen was initially popularized in trauma patients, it is now commonly applied in burn patients and patients with catastrophic operative emergencies. Nutritional support of these patients is extremely challenging, and a standardized approach remains elusive. Several retrospective and prospective studies have demonstrated that early enteral feedings benefit this population, but there is no consensus on how to proceed if this therapy fails (Burlew et al., J Trauma Acute Care Surg 73:1380–1387, 2012; Moore and Burlew, Nutr Clin Pract 31:9–13, 2016; Collier et al., J Parenter Enter Nutr 31:410–415, 2007; Dissanaike et al., J Am Coll Surg 31:410–415, 2008; Byrnes et al., Am J Surg 199:359–362, 2010). Recent publications on nutritional support in ICU patients have reported increased mortality and complications in patients treated with aggressive nutritional support, while others have reported these same adverse events in patients who developed progressive caloric and protein deficits (Weijs et al., J Parenter Enter Nutr 36:60–68, 2012; Singer et al., Intensive Care Med 37:601–609, 2011; Caesar et al., N Engl J Med 365:506–517, 2011; Heiddegger et al., Lancet 381:385–393, 2013).

To develop an effective clinical approach in this patient population, this conflicting literature must be placed in perspective. Older studies and those across mixed intensive care units, age groups, and disease processes must be interpreted carefully. This most challenging patient population requires a customized approach due to the variability that has been noted in these patients (Burlew et al., J Trauma Acute Care Surg 73:1380–1387, 2012). Nutrition support must be managed and titrated, similar to other critical interventions, such as pressor support and ventilator therapy.


  1. 1.
    Burlew CC, Moore EE, Cuschieri J, et al. Who should we feed? A Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury. J Trauma Acute Care Surg. 2012;73(6):1380–7.CrossRefPubMedGoogle Scholar
  2. 2.
    Moore SM, Burlew CC. Nutrition support in the open abdomen. Nutr Clin Pract. 2016;31(1):9–13.CrossRefPubMedGoogle Scholar
  3. 3.
    Collier B, Guillamondequi O, Cotton B, et al. Feeding the open abdomen. J Parenter Enter Nutr. 2007;31:410–5.CrossRefGoogle Scholar
  4. 4.
    Dissanaike S, Pham T, Shalhub S, et al. Effect of immediate enteral feeding on trauma patients with an open abdomen: protection from nosocomial infections. J Am Coll Surg. 2008;31:410–5.Google Scholar
  5. 5.
    Byrnes MC, Reicks P, Irwin E. Early enteral nutrition can be successfully implemented in trauma patient with an “open abdomen”. Am J Surg. 2010;199(3):359–62.CrossRefPubMedGoogle Scholar
  6. 6.
    Weijs PJM, Stapel SN, de Groot SDW, et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. J Parenter Enter Nutr. 2012;36:60–8.CrossRefGoogle Scholar
  7. 7.
    Singer P, Anbar R, Cohen J, et al. The tight calorie control study (TICACOS): a prospective randomized, controlled pilot study of the nutritional support in critically ill patients. Intensive Care Med. 2011;37:601–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Caesar MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365:506–17.CrossRefGoogle Scholar
  9. 9.
    Heiddegger CP, Berger MM, Graf S, et al. Optimization of energy provision with supplemental parenteral nutrition in critically ill patients: a randomized, controlled clinical trial. Lancet. 2013;381:385–93.CrossRefGoogle Scholar
  10. 10.
    Cuthbertson DP. Post shock metabolic response. Lancet. 1942;239:433–7.CrossRefGoogle Scholar
  11. 11.
    Stahel PF, Flieri MA, Moore EE. “Metabolic staging” after major trauma – a guide for clinical decision making? Scand J Trauma Resusc Emerg Med. 2010;18:34.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Powell NJ, Collier B. Nutrition and the open abdomen. Nutr Clin Pract. 2012;27(4):499–506.CrossRefPubMedGoogle Scholar
  13. 13.
    Weijs PJM, Cynober L, DeLegge M, et al. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. Crit Care. 2014;18:591.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Herridge MS, Tansey CM, Matte A, (Canadian Critical Care Trials Group), et al. Functional disability 5 years after acute respiratory distress syndrome. N Engl J Med, 2011;364:1203–1304.CrossRefGoogle Scholar
  15. 15.
    Hirose T, Shimizu K, Ogura H, et al. Altered balance of the aminogram in patients with sepsis – the relation to mortality. Clin Nutr. 2014;33(1):179–82.CrossRefPubMedGoogle Scholar
  16. 16.
    Gentile LF, Cuenca AG, Efron PA, et al. Persistent inflammation and immunosuppression: a common syndrome and new horizon for surgical intensive care. J Trauma Acute Care Surg. 2012;72(6):1491–501.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society of Parenteral and Enteral Nutrition (A.S.P.E.N). J Parenter Enter Nutr. 2016;40(2):159–211.CrossRefGoogle Scholar
  18. 18.
    Kondrup J, Allison SP, Elia M, et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22(4):415–21.CrossRefPubMedGoogle Scholar
  19. 19.
    Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutritional therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R268.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Hourigan LA, Omaye ST, Keen CL. Vitamin and trace element loss from negative-pressure wound therapy. Adv Skin Wound Care. 2016;29(1):20–5.CrossRefPubMedGoogle Scholar
  21. 21.
    Charles EJ, Petroze RT, Metzger R, et al. Hypocaloric compared with eucaloric nutritional support and its effect of infection rates in a surgical intensive care unit: a randomized controlled trial. Am J Clin Nutr. 2014;100(5):1337–43.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Cheatham ML, Safcsak K, Brzezinksi S, et al. Nitrogen balance, protein loss, and the open abdomen. Crit Care Med. 2007;35(1):127–31.CrossRefPubMedGoogle Scholar
  23. 23.
    Polk TM, Schwab CW. Metabolic and nutritional support of the enterocutaneous fistula patient: a 3-phase approach. World J Surg. 2012;36:524–33.CrossRefPubMedGoogle Scholar
  24. 24.
    Beebe ML, Crowley N. Can hypocaloric high-protein nutrition support be used in complicated bariatric patients to promote weight loss? Nutr Clin Pract. 2015;30(4):522–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Wells DL. Provision of enteral nutrition during vasopressor therapy for hemodynamic instability– an evidence-based review. Nutr Clin Pract. 2012;27(4):521–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Martindale RG, Warren M. Should enteral nutrition be started in the first week of critical Cuthillness? Curr Opin Clin Nutr Metab Care. 2015;18(2):202–6.CrossRefPubMedGoogle Scholar
  27. 27.
    Tan SJ, Yu C, Yu Z, et al. High-fat enteral nutrition reduces intestinal mucosal barrier damage after peritoneal air exposure. J Surg Res. 2016;202(1):77–86.CrossRefPubMedGoogle Scholar
  28. 28.
    Zaloga GP, Black KW, Prielipp R. Effect of rate of enteral nutrient supply on gut mass. J Parenter Enter Nutr. 1992;16:39–42.CrossRefGoogle Scholar
  29. 29.
    Kozar RA, Hu S, Hassoun HT, et al. Specific intraluminal nutrients alter mucosal blood flow during gut ischemia/reperfusion. J Parenter Enter Nutr. 2002;26:226–9.CrossRefGoogle Scholar
  30. 30.
    Arabi YM, Aldawood AS, Haddad SH, et al. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med. 2015;372(25):2398–40.CrossRefPubMedGoogle Scholar
  31. 31.
    Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contra-indications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309:2130–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Heyland DK, MacDonald S, Keefe L, et al. Total parenteral nutrition in the critically ill patient: a meta-analysis. JAMA. 1998;280(23):2013–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Braunschweig CL, Levy P, Sheean PM, et al. Enteral compared with parenteral nutrition: a meta-analysis. Am J Clin Nutr. 2001;74(4):534–42.CrossRefPubMedGoogle Scholar
  34. 34.
    Peev MP, Yeh DD, Quraishi SA, et al. Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. J Parenter Enter Nutr. 2015;39(1):21–7.CrossRefGoogle Scholar
  35. 35.
    Wei X, Day AG, Ouellette-Kuntz H, Heyland DK. The association between nutritional adequacy and long-term outcomes in critically ill patients requiring prolonged mechanical ventilation: a multicenter cohort study. Crit Care Med. 2015;43(8):1569–79.CrossRefPubMedGoogle Scholar
  36. 36.
    Calder PC, Jensen GL, Koletzko BV, et al. Lipid emulsions in parenteral nutrition of intensive care patients: current thinking and future directions. Intensive Care Med. 2010;36:735–49.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Howard L, Ashley C, Lyon D, Shenkin A. Autopsy tissue trace elements in 8 long-term parenteral nutrition patients who received the current US FDA formulation. J Parenter Enter Nutr. 2007;31:388–96.CrossRefGoogle Scholar
  38. 38.
    Van Zanten AR. Glutamine and antioxidants: status of their use in critical illness. Curr Opin Clin Nutr Metab Care. 2015;18(2):179–86.CrossRefPubMedGoogle Scholar
  39. 39.
    Furst P, Stehle P. Are intravenous amino acid solutions unbalanced? New Horiz. 1994;2:215–23.PubMedGoogle Scholar
  40. 40.
    Grintescu IM, Luca Vasiliu I, Cucereanu Badica I, et al. The influence of parenteral glutamine supplementation on glucose homeostasis in critically ill polytrauma patients – a randomized controlled clinical study. Clin Nutr. 2015;34(3):377–82.CrossRefPubMedGoogle Scholar
  41. 41.
    Van Zanten AR, Sztark F, Kaisers UX, et al. High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU: a randomized clinical trial. JAMA. 2014;312(5):514–24.CrossRefPubMedGoogle Scholar
  42. 42.
    Ziegler TR, May AK, Hebbar G, et al. Efficacy and safety of glutamine-supplemented parenteral nutrition in surgical ICU patients: an American multicenter randomized clinical trial. Ann Surg. 2016;263(4):646–55.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Heyland D, Muscedere J, Wischmeyer PE, Canadian Critical Care Trials Group, et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med. 2013;368(16):1489–97.CrossRefPubMedGoogle Scholar
  44. 44.
    Bansal V, Coimbra R. Nutritional support in patients following damage control laparotomy with an open abdomen. Eur J Emerg Surg. 2013;39:243–8.CrossRefGoogle Scholar
  45. 45.
    Taylor B, Brody R, Denmark R, et al. Improving enteral delivery through the adoption of the “feed early enteral diet adequately for maximum effect (FEED ME)” protocol in a surgical trauma ICU: a quality improvement review. Nutr Clin Pract. 2014;29(5):639–48.CrossRefPubMedGoogle Scholar
  46. 46.
    Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015;8:CD008875.Google Scholar
  47. 47.
    Fei JF, DeMuro JP. Percutaneous endoscopic gastrostomy in the open abdomen patient. J Parenter Enter Nutr. 2013;37(5):695–6.CrossRefGoogle Scholar
  48. 48.
    Li J, Zhu W, et al. Management of enterocutaneous fistulas: a 30-year clinical experience. Chin Med J. 2003;116(2):171–5.PubMedGoogle Scholar
  49. 49.
    Carlson GL, Dark P. Acute intestinal failure. Curr Opin Crit Care. 2010;16(4):347–52.CrossRefPubMedGoogle Scholar
  50. 50.
    Yuan Y, Ren J, Gu G, et al. Early enteral nutrition improves outcomes of open abdomen in gastrointestinal fistula patients complicated with severe sepsis. Nutr Clin Pract. 2011;26(6):688–94.CrossRefPubMedGoogle Scholar
  51. 51.
    Willcutts K, Mercer D, Ziegler J. Fistuloclysis: an interprofessional approach to nourishing the fistula patient. J Wound Ostomy Cont Nurs. 2015;42(5):549–53.CrossRefGoogle Scholar
  52. 52.
    Cooper AM, Braatvedt GD, Brown H, et al. Fasting and post-prandial splanchnic blood flow is reduced by a somatostatin analogue (octreotide) in man. Clin Sci (Lond). 1991;81(2):169–75.CrossRefGoogle Scholar
  53. 53.
    Peake SL, Davies AR, Deane AM, et al. Use of a concentrated enteral nutrition solution to increase calorie delivery to critically ill patients: a randomized, double-blind, clinical trial. Am J Clin Nutr. 2014;100(2):616–25.CrossRefPubMedGoogle Scholar
  54. 54.
    Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009;35:1728–37.CrossRefPubMedGoogle Scholar
  55. 55.
    Leppaniemi A, Kimball EJ, Delaet I, et al. Management of abdominal sepsis-a paradigm shift? Anesthesiol Intensive Ther. 2015;47(4):400–8.CrossRefGoogle Scholar
  56. 56.
    Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–97.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Dewitt Daughtry Department of SurgeryUniversity of Miami Miller School of MedicineMiamiUSA
  2. 2.Department of SurgeryUniversity of Pittsburgh School of MedicinePittsburghUSA

Personalised recommendations