2025 PACUPrep BCCCP Preparatory Course Enterocutaneous and Enteroatmospheric Fistulas Management Strategies for Enterocutaneous and Enteroatmospheric Fistulas in Critical Care
Supportive Care and Monitoring to Mitigate Complications in Fistula Management

Supportive Care and Monitoring to Mitigate Complications in Fistula Management

Objectives Icon A checkmark inside a circle, symbolizing achieved goals.

Learning Objective

Recommend appropriate supportive care and monitoring to manage complications associated with enterocutaneous and enteroatmospheric fistulas and their treatment.

1. Supportive Wound and Skin Management

Effective containment of enteric effluent and protection of peristomal skin are vital to reduce local inflammation, prevent excoriation, and promote granulation in enteroatmospheric and high‐output enterocutaneous fistulas.

Negative Pressure Wound Therapy (NPWT)

Indications:

  • Open abdomen with Enteroatmospheric Fistula (EAF)
  • High‐output Enterocutaneous Fistula (ECF) when primary closure is delayed or impossible

Devices & Settings:

  • Commercial VAC systems or improvised foam
  • Pressures: −50 to −125 mmHg (continuous vs intermittent)

Application:

  • Place non‐adherent visceral protective layer
  • Position foam/gauze around fistula opening
  • Secure airtight drape
  • Change dressings every 48–72 hours

Monitoring:

  • Bleeding
  • Foam adherence to bowel
  • Loss of seal
  • Increased fistula output
  • Signs of infection
Controversy Icon A chat bubble with a question mark, indicating a point of controversy or debate. Controversy: NPWT Pressure Regimen

Optimal pressure regimen and duration remain individualized based on tissue response.

Skin Protection Measures

  • Barrier creams (zinc oxide, dimethicone) and polymer films: Reapply with each dressing change.
  • Customized ostomy wafers and convex appliances: Seal irregular wound edges, channel effluent.
  • Advanced stents (3D‐printed) or fibrin sealants: Under investigation for reducing effluent and protecting skin.
  • Interdisciplinary input: Early consultation with wound, ostomy, continence (WOC) nurses.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl: NPWT and Bowel Protection

Always place a non‐adherent layer over exposed bowel before NPWT dressing to prevent secondary fistula formation.

Vignette Icon A clipboard or document, indicating a case vignette. Case Vignette: EAF Management

A 62-year-old trauma patient on day 5 post‐laparotomy develops a 700 mL/day EAF. NPWT at −75 mmHg intermittent with silicone contact layer isolates effluent and promotes granulation.

2. Prevention of ICU-Related Complications

Critically ill fistula patients require tailored prophylaxis against VTE, stress-related mucosal bleeding, and catheter‐related infections, balancing efficacy against bleeding and infection risks.

A. Venous Thromboembolism (VTE) Prophylaxis

Risk stratification: Padua Score (medical), Caprini Score (surgical).

Pharmacologic Prophylaxis

Pharmacologic VTE Prophylaxis Options
Agent Type Drug & Dosage Considerations
LMWH Enoxaparin 40 mg SC daily Adjust to 30 mg SC q12h if CrCl <30 mL/min or weight <50 kg
UFH Heparin 5,000 U SC q8–12h Preferred for severe renal impairment
Monitoring Anti-Xa levels Consider in extremes of weight, renal dysfunction, or recurrent VTE events

Mechanical Prophylaxis

Intermittent pneumatic compression devices and graduated compression stockings should be used when anticoagulation is contraindicated.

Pitfall Icon A warning triangle, indicating a clinical pitfall. Pitfall: VTE Prophylaxis Timing

Delay pharmacologic prophylaxis in cases of uncontrolled bleeding. Resume once hemostasis is achieved.

B. Stress-Related Mucosal Bleeding (SRMB) Prophylaxis

Indications:

  • Mechanical ventilation >48 hours
  • Coagulopathy (platelets <50,000/mm³, INR >1.5)
  • Persistent shock

Agents for SRMB Prophylaxis

Agents for SRMB Prophylaxis
Agent Class Drug & Dosage Key Characteristics
PPI Pantoprazole 40 mg IV daily Potent acid suppression; potential risk of C. difficile infection
H2RA Famotidine 20 mg IV q12h Less potent acid suppression; potentially lower infection risk compared to PPIs
Controversy Icon A chat bubble with a question mark, indicating a point of controversy or debate. Controversy: PPI vs. H2RA

The choice between PPIs and H2RAs should be based on an individual patient’s risk profile for infection versus bleeding.

Monitoring for SRMB:

  • Check for melena/hematemesis
  • Perform stool occult blood tests
  • Test for C. difficile if diarrhea develops

C. Catheter-Related Infection Prevention

  • Insertion bundles: Utilize maximal sterile barriers, chlorhexidine skin preparation, and follow best practice checklists.
  • Dressings & caps: Employ chlorhexidine-impregnated dressings and antimicrobial needleless connectors.
  • Antimicrobial lock therapy: Consider ethanol or antibiotic locks for tunneled catheters with recurrent infections.
  • Maintenance: Conduct daily assessments of line necessity and ensure early removal of unnecessary catheters.
Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl: Reducing CRBSI Rates

Implement daily line-review rounds and maximal barrier precautions to achieve the largest reduction in catheter-related bloodstream infection (CRBSI) rates.

3. Management of Iatrogenic Complications

Frequent laboratory monitoring and prompt replacement of electrolytes, along with vigilance for organ dysfunction, are essential to prevent treatment-related morbidity.

A. Drug-Induced Electrolyte Disturbances

Management of Common Drug-Induced Electrolyte Disturbances
Disturbance Threshold Treatment Monitoring
Hypokalemia <3.5 mmol/L IV KCl 20–40 mEq per dose; max peripheral rate 10 mEq/h, central up to 20 mEq/h Serum K every 4–6 h; continuous ECG for high‐rate infusions
Hypomagnesemia <1.5 mg/dL MgSO₄ 1–2 g IV over 1–2 h; repeat dosing for refractory cases Deep tendon reflexes (DTRs) and serum Mg before and after
Hypophosphatemia <2.5 mg/dL Potassium phosphate 15–30 mmol IV over 2–6 h Serum Ca and phosphate

Laboratory Monitoring: Daily Basic Metabolic Panel (BMP) or more frequent checks during active repletion protocols.

Pearl Icon A shield with an exclamation mark, indicating a clinical pearl. Clinical Pearl: Electrolyte Repletion Sequence

Always correct magnesium depletion before aggressive potassium repletion to prevent refractory hypokalemia.

B. Monitoring for Organ Dysfunction

  • Renal: Adjust dosing of renally cleared drugs (e.g., LMWH, aminoglycosides); avoid nephrotoxins (e.g., NSAIDs, contrast media) and monitor CrCl daily.
  • Hepatic: Check LFTs in patients on PPIs and antifungals; adjust hepatically metabolized drug dosages as needed.
  • Volume status: Use daily weights, strict intake and output records, physical examination, and, if available, hemodynamic monitors to avoid under- or over-resuscitation.

4. Multidisciplinary Goals of Care Conversations

Early and iterative discussions with patients, families, and the care team ensure that high-morbidity interventions align with patient values and clinical prognosis.

  • Identify patients with persistent sepsis, refractory organ failure, or poor nutritional reserve as candidates for goals of care review.
  • Engage ethics consultants, palliative care, surgery, nutrition, nursing, and pharmacy in structured meetings.
  • Use shared decision-making frameworks (e.g., SPIKES, SHARE) to clarify wishes, document code status, and outline acceptable treatments.
  • Reassess and document goals regularly as clinical status evolves.
Key Points Icon A star, symbolizing key takeaways or important points.

Key Points: Goals of Care

  • Proactive goals of care discussions reduce non-beneficial interventions and improve patient-centered outcomes.
  • Critical care pharmacists play a pivotal role in medication optimization and symptom management during these conversations.

References

  1. Bobkiewicz A, Walczak D, Smolinski S, et al. Management of enteroatmospheric fistula with negative pressure wound therapy in open abdomen treatment: A multicentre observational study. Int Wound J. 2017;14(2):255–264.
  2. Bruhin A, Ferreira F, Chariker M, et al. Systematic review and evidence based recommendations for the use of negative pressure wound therapy in the open abdomen. Int J Surg. 2014;12(11):1105–1114.
  3. Di Saverio S, Tarasconi A, Inaba K, et al. Open abdomen with concomitant enteroatmospheric fistula: Attempt to rationalize the approach to a surgical nightmare and proposal of a clinical algorithm. J Am Coll Surg. 2015;220(1):e23–e33.
  4. Ghimire P. Management of Enterocutaneous Fistula: A Review. J Nepal Med Assoc. 2022;60(245):93–100.
  5. Gribovskaja-Rupp I, Melton GB. Enterocutaneous Fistula: Proven Strategies and Updates. Clin Colon Rectal Surg. 2016;29(2):130–137.
  6. Hoedema RE, Suryadevara S. Enterostomal therapy and wound care of the enterocutaneous fistula patient. Clin Colon Rectal Surg. 2010;23(3):161–168.
  7. Huang JJ, Ren JA, Wang GF, et al. 3D-printed “fistula stent” designed for management of enterocutaneous fistula: An advanced strategy. World J Gastroenterol. 2017;23(41):7489–7494.
  8. Klek S, Forbes A, Gabe S, et al. Management of acute intestinal failure: A position paper from the ESPEN Special Interest Group. Clin Nutr. 2016;35(6):1209–1218.
  9. Lloyd DA, Gabe SM, Windsor AC. Nutrition and management of enterocutaneous fistula. Br J Surg. 2006;93(9):1045–1055.
  10. Paradiso FV, Nanni L, Merli L, et al. Vacuum assisted closure for the treatment of complex wounds and enterocutaneous fistulas in full term and premature neonates: a case report. Ital J Pediatr. 2016;42:2.
  11. Pepe G, Chiarello MM, Bianchi V, et al. Entero-Cutaneous and Entero-Atmospheric Fistulas: Insights into Management Using Negative Pressure Wound Therapy. J Clin Med. 2024;13(5):1279.
  12. Roberts DJ, Leppaniemi A, Tolonen M, et al. The open abdomen in trauma, acute care, and vascular and endovascular surgery: Comprehensive, expert, narrative review. BJS Open. 2023;7(1):zrad084.
  13. Terzi C, Egeli T, Canda AE, et al. Management of enteroatmospheric fistulae. Int Wound J. 2014;11(Suppl 1):17–21.
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