Intraabdominal Lavage of Hypochlorous Acid

A New Paradigm for the Septic and Open Abdomen

Luis G Fernández, MD, KHS, KCOEG, FACS, FASAS, FCCP, FCCM, FICS; Marc R. Matthews, MD, FACS; Lawton Seal, MS, PhD

Disclosures

Wounds. 2020;32(4):107-114. 

In This Article

Results

The initial experience, as demonstrated by this case series, suggests instillation of HOCl through the tubing set in conjunction with the TAC device is safe and easy to use. This technique allowed for the use of a timed, pre-programmed, and repeated instillation of a defined quantity of topical solution in the surgical intensive care unit (SICU). This decreased the need for more frequent OA lavages in the OR after the index procedure, as well as the associated concomitant risks of transporting patients who are critically ill between the SICU and OR. No acute complications related to the TAC device with HOCl were noted.

Case 1

A 59-year-old man with diabetes presented to the emergency department (ED) with generalized abdominal pain and lactic acidosis, coupled with multisystem organ failure, including acute respiratory failure (ARF), acute kidney injury (AKI), hepatic encephalopathy, and septic shock. The patient was emergently intubated; an emergent abdominal/pelvis computerized tomography (CT) with oral contrast showed a thickened small bowel and sigmoid colon (Figure 1A). The patient underwent a lower gastrointestinal endoscopy for colonic decompression and was diagnosed with ischemic colitis.

Figure 1.

(A) Abdominal and pelvis computerized tomography scan showing edema of the sigmoid colon and small bowel (blue arrows); (B) gangrenous colon (blue arrow) during exploratory laparotomy; (C) gangrenous colon during subsequent intrabdominal lavage with hyphochlorous acid solution after colonic resection; (D) subtotal colectomy, partial omentum, and gallbladder; and (E) temporary abdominal closure utilizing the temporary abdominal closure device with the negative pressure wound therapy and tube set for instillation and suction.

Despite initial stabilization with intravenous (IV) resuscitation and a trial of nonoperative management, the patient developed abdominal compartment syndrome within 72 hours of SICU admission. The patient underwent an emergent exploratory laparotomy at 72 hours post admission. A gangrenous, toxic megacolon and gangrenous cholecystitis were noted (Figure 1B-1D). The patient required small bowel adhesiolysis, subtotal colectomy, open cholecystectomy, and 1 L of HOCl abdominal washout followed by placement of sodium hyaluronate and carboxymethylcellulose bioresorbable membrane (Seprafilm Adhesion Barrier; Sanofi-Aventis US LLC, A Sanofi Company, Bridgewater, NJ) (Figure 1C). Damage control surgery (DCS) devices were applied to the OA (Figure 1E) for TAC for subsequent 3-L lavage of normal saline with a 10-minute dwell time using the aforementioned protocol.

The patient returned to the SICU for continued resuscitation. On postoperative day (POD) 5, the patient underwent an end ileostomy with an abdominal washout. Pink, healthy small bowel and distal sigmoid stumps were noted, and no intraperitoneal abscesses or fibrin depositions were found. The abdominal cavity was closed by primary fascial closure. The skin was left open, and a sterile dressing was applied. The patient was subsequently weaned from the ventilator and was discharged on hospital day (HD) 36 to a skilled nursing facility where, upon follow-up, he continues to remain stable with no wound complications.

Case 2

A 62-year-old woman with diabetes, an insulin dependency, chronic kidney failure, and congestive heart failure (CHF) with an ejection fraction of 25%, presented to the ED with abdominal pain and altered mental status. She was on antiplatelet therapy, including clopidogrel bisulfate (PLAVIX; Bristol-Myers Squibb, New York, NY) and chronic steroids for a noted meningeal mass. Abdominal/pelvic CT scans revealed pneumoperitoneum and small bowel thickening (Figure 2A). Her resuscitation included IV fluids, antibiotics, stress-dose steroids, platelet transfusion, and desmopressin acetate (DDAVP; Ferring Pharmaceuticals Inc, Parsippany, NJ).

Figure 2.

(A) Thoracoabdominal CT scan revealing pneumoperitoneum (blue arrow); (B) exploratory laparotomy revealing feculent peritonitis/purulence consistent with a Hinchey classification type IV; (C) exploratory laparotomy revealing fibrin biofilm deposition (blue arrow) and (D) sigmoid perforation (blue arrow); (E) temporary abdominal closure utilizing the temporary abdominal closure device sealed with an occlusive dressing as well as the application of negative pressure wound therapy with tube set and dressing for instillation of hypochlorous acid solution as per protocol; and (F, G) postoperative day 12, follow-up exploratory laparotomy showing clearance of all fibrinous exudates, no anastomotic leakage, and no evidence of abscess or bowel/organ injury.

An emergent, exploratory laparotomy, done immediately upon presentation, revealed a mid-sigmoid colon perforation with feculent peritonitis and multiple intraabdominal and pelvic abscesses with fibrinous exudate, coupled with a necrotic dome of the urinary bladder (Figure 2B-2D). An extensive adhesiolysis, partial sigmoid, and bladder resection with primary repair of the urinary bladder dome were performed, followed by a lavage of the purulent abdomen utilizing 3 L of Bacitracin (Pfizer Inc, New York, NY) solution, followed by 1 L of HOCl with a 5-minute dwell time before suction removal. Sodium hyaluronate and carboxymethylcellulose bioresorbable membrane were placed within the abdomen, followed by the TAC device for intermittent intraperitoneal instillation, as per the authors' protocol, initiated in the OR (Figure 2E). The patient was admitted to the SICU postoperatively for further resuscitation. After 48 hours, the patient underwent a second abdominal washout with saline and HOCl, during which a small area of necrotic bladder was resected and repaired. A subsequent TAC was placed over the OA utilizing the same TAC system, as previously described in the protocol.

By POD 5, the patient underwent a third exploratory laparotomy, which showed minimal bowel wall edema and no purulence. Therefore, the descending colon and sigmoid remnants were mobilized for a functional, end-to-end stapled anastomosis, which was wrapped/reinforced with the abdominal omentum.

Following abdominal lavage, another TAC placement over the OA was used with the same TAC system configuration for the utilization of the instillation protocol. On POD 12, intraoperative assessment revealed no anastomotic leakage, with clearance of all fibrinous exudates (Figure 2F, 2G). The abdominal incision was closed utilizing existing native fascia, and an incision management system (PREVENA Incision Management System; KCI) was applied to the stapled skin incision. The patient showed no further signs of sepsis, was successfully weaned from the ventilator, tolerated an enteral diet, and progressed to normal bowel movements. On HD 14, she was discharged to a long-term acute care facility.

Unfortunately, 4 days following discharge, the patient developed ARF, believed to be secondary to her CHF, and possible subclinical aspiration, which required intubation. A chest CT scan revealed multiple areas of pneumonitis and atelectasis, while the abdominal/pelvic CT scans did not reveal any intraabdominal pathology or anastomotic leak. The patient's condition continued to require ventilator management for which the family requested palliative care; comfort care was instituted, and the patient subsequently died on POD 20 following initial surgery upon presentation.

Case 3

A 76-year-old woman with dementia presented with severe sepsis, AKI, and worsening encephalopathy. She had generalized abdominal pain; an abdominal/pelvic CT without contrast showed extensive free intraperitoneal air (Figure 3A-3C). The patient underwent an emergent laparotomy, which revealed diffuse peritonitis from a perforated appendix, accompanied with a large pelvic abscess, multiple interloop abscesses, and diffuse, intraabdominal fibrinous exudates (Figure 3D, 3E). An appendectomy, small and large bowel resection adhesiolysis, and an open cholecystectomy for an ischemic appearing gallbladder were performed. Drainage of the pelvic/interloop abscesses also was done. Intraabdominal lavage was performed, which included 2 L of HOCl for a 10-minute dwell, followed by suction removal and then placement of sodium hyaluronate and carboxymethylcellulose bioresorbable membrane and the TAC device, with the previously described instillation protocol (Figure 3F).

Figure 3.

(A) Abdominal computerized tomography (CT) scan revealing evidence of pneumoperitoneum throughout the abdomen (blue arrow); (B, C) abdominal/pelvis CT scans revealing multiple areas of peritoneal fluid consistent with a hollow viscus perforation (blue arrow); (D, E) multiple areas of fibrin biofilm deposition across the small bowel (noted by surgeon's hand); and (F) temporary abdominal closure over the open abdomen with irrigation port (blue arrow) at superior aspect of the incision.

On POD 3, the patient returned to the OR for another abdominal exploration, peritoneal washout, and primary closure of the abdomen. There was no evidence of intraperitoneal abscesses or fibrin deposition. The patient was weaned from the ventilator and began tolerating a regular diet. She was discharged on POD 17 to a skilled nursing facility. The patient continues to improve and remains stable upon clinical follow-up.

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