How to manage a patient with bilateral wound infection, ACS, AKI, and acute respiratory failure?

Management of Bilateral Wound Infection with ACS, AKI, and Acute Respiratory Failure

This critically ill patient requires immediate ICU admission with a multidisciplinary approach prioritizing surgical decompression for ACS, mechanical ventilation for respiratory failure, source control of infection, and renal replacement therapy for AKI—all managed simultaneously as these conditions create a lethal synergistic effect on mortality.

Immediate Triage and Stabilization

Transfer this patient immediately to an ICU with surgical capabilities, as the combination of ACS, AKI, and respiratory failure carries mortality exceeding 80%. 1, 2

Respiratory Management

• Intubate early and electively if not already done, as patients with impending respiratory failure should undergo planned intubation rather than emergent procedures 1
• Implement low tidal volume ventilation (6 mL/kg predicted body weight) immediately after intubation 1
• Target PaO2 70-90 mmHg or SaO2 92-97% with appropriate PEEP selection based on gas exchange, hemodynamic status, and lung recruitability 1
• Avoid non-invasive ventilation (CPAP/NIV) in this critically ill patient with multiple organ failures, as it has high failure rates in severe illness 1
• Consider prone positioning if PaO2/FiO2 < 150 mmHg despite optimal ventilation 1
• Use neuromuscular blockers if PaO2/FiO2 < 150 mmHg to improve ventilator synchrony 1

Abdominal Compartment Syndrome Management

Surgical decompression must not be delayed if ACS is confirmed, as it is the definitive and life-saving treatment 1

• Measure intra-abdominal pressure every 4-6 hours once ACS is suspected or organ failure develops 1
• Attempt non-surgical measures first only if time permits: nasogastric decompression, rectal decompression, neuromuscular blockade, and cautious fluid management 1
• Proceed immediately to laparotomy with open abdomen (OA) technique if non-surgical measures fail or patient deteriorates 1
• Plan for damage control surgery principles: leave abdomen open, use temporary abdominal closure with negative pressure wound therapy 1
• Avoid prolonged open abdomen as it increases risk of enteroatmospheric fistula and frozen abdomen; plan for early definitive closure when physiology permits 1

Acute Kidney Injury Management

The combination of AKI with ARDS creates kidney-lung crosstalk that dramatically worsens outcomes through inflammatory cytokines and neutrophil activation. 3, 2

• Initiate continuous renal replacement therapy (CRRT) early rather than waiting for absolute indications, as this allows better fluid management in the setting of respiratory failure 4, 2
• Target neutral to negative fluid balance once hemodynamically stable, as conservative fluid management improves outcomes in ARDS but must be balanced against renal perfusion 4
• Monitor for volume overload contributing to pulmonary edema, recognizing that AKI causes both cardiogenic and non-cardiogenic pulmonary edema 2
• Adjust ventilator settings to minimize ventilator-induced kidney injury by avoiding excessive PEEP that reduces renal blood flow 4

Wound Infection Source Control

Aggressive surgical debridement of bilateral wound infections is mandatory and should occur simultaneously with or immediately after ACS decompression. 1

• Perform urgent surgical exploration and debridement of all infected wounds 1
• Obtain intraoperative cultures before antibiotic administration if not already started 1
• Apply negative pressure wound therapy to both wound sites and the open abdomen 1
• Plan for serial debridements every 24-48 hours until all necrotic tissue is removed 1

Hemodynamic and Resuscitation Strategy

Implement damage control resuscitation principles immediately, as this is fundamental to OA management and influences outcome. 1

• Tailor vasopressor and inotrope use to the patient's condition and surgical interventions performed 1
• Avoid over-resuscitation with crystalloids, as this worsens IAH/ACS and pulmonary edema 1, 4
• Target mean arterial pressure ≥ 65 mmHg with norepinephrine as first-line vasopressor 1
• Maintain core body temperature > 36°C, as hypothermia worsens the lethal triad of acidosis, coagulopathy, and hypothermia 1
• Correct coagulopathy aggressively with blood products as needed 1

ICU Monitoring Requirements

Continuous monitoring of all organ systems is essential given the high mortality risk. 1

• Intra-abdominal pressure measurement every 4-6 hours 1
• Continuous cardiac output monitoring to guide fluid and vasopressor therapy 1
• Hourly urine output without routine urinary catheterization unless needed for monitoring 1
• Serial lactate measurements to assess tissue perfusion 1
• Daily assessment for readiness to close abdomen: resolution of edema, negative fluid balance, IAP < 15 mmHg 1

Critical Pitfalls to Avoid

• Do not delay surgical decompression for ACS while attempting prolonged medical management—mortality increases with delay 1
• Do not use high tidal volumes (> 6 mL/kg) even if initial oxygenation is poor, as this causes ventilator-induced lung injury 1
• Do not aggressively fluid resuscitate once initial resuscitation is complete, as this worsens both ACS and ARDS 1, 4
• Do not attempt NIV or high-flow nasal cannula in this severely ill patient with multiple organ failures 1
• Do not leave the abdomen open longer than necessary—plan for definitive closure within 5-7 days if possible 1
• Recognize that clinical examination is inaccurate for diagnosing IAH/ACS—always measure bladder pressure 1

Antibiotic Therapy

• Start broad-spectrum antibiotics immediately after obtaining cultures, covering gram-positive, gram-negative, and anaerobic organisms 1
• Consider anti-pseudomonal coverage if risk factors present (prolonged hospitalization, prior antibiotics, structural lung disease) 1
• De-escalate based on culture results once available 1

Prognosis and Family Communication

The combination of ACS, bilateral wound infections, AKI requiring dialysis, and respiratory failure requiring mechanical ventilation carries mortality exceeding 80%. 2 Early, honest communication with family about the grave prognosis is essential while pursuing aggressive life-saving interventions.