Nutrition support for the patient with an open abdomen after major abdominal trauma

Nutrition support in the severely injured trauma patient is crucial to minimize the hypermetabolic stress response. Even though enteral nutrition is the preferred method of feeding, it is not always feasible after multiple trauma. We present a complex nutritional case in a patient who sustained severe abdominal trauma with a severe liver injury, rib fractures, and pulmonary contusion. The patient required several repeat laparotomies, abdominal packing, and temporary abdominal closure. The clinical course was complicated by hypotension requiring multiple vasopressors; coagulopathy requiring more than 35 U of packed red cells, more than 50 U of fresh frozen plasma, and more than 80 U of platelets; acute renal failure requiring dialysis; and pneumonia and acute respiratory distress syndrome requiring intricate ventilator management. Nutrition intervention began on post-trauma day 4 with total parenteral nutrition due to hypotension, resuscitation, and massive bowel edema; by post-trauma day 8. the patient was receiving goal nutrients. On post-trauma day 27, bowel edema was significantly less, and a nasoenteric feeding tube was placed and enteral feeding initiated. By post-trauma day 31, full enteral feeds were tolerated, and total parenteral nutrition was stopped. Nutrient provision was adjusted daily to account for organ and metabolic changes including hepatic, pulmonary, and renal dysfunction. The patient did well and was eventually extubated and eating a regular diet. With careful monitoring and adjusting of the nutritional plan, a hypermetabolic complex trauma patient with an open abdomen can be fed optimally, safely, and successfully despite increased bowel edema and multiple organ dysfunction.