Abstract
BackgroundAlthough damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).MethodsWe searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.ResultsAmong 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.ConclusionsFew indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
Highlights
Damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated
Most included studies attempted to validate indications for use of damage control (DC) surgery by assessing if they were associated with poor outcomes; few studies subsequently sought to determine if DC improves survival in these situations and nearly one quarter of these studies included patients who only underwent DC
This systematic review identified a large number of indications for use of DC surgery in civilian trauma patients
Summary
Damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. In patients requiring operative intervention after major trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure [1, 2]. Widely assumed to reduce mortality in critically injured patients [5], survivors of DC surgery have been reported to have a high risk of complications (e.g., intra-abdominal sepsis, enteric fistulae, and complex ventral herniae) and often suffer long lengths of ICU and hospital stay [2, 4, 6,7,8,9,10,11]. The benefit/risk profile of using DC surgery in different clinical situations has not been comprehensively evaluated, and several authors have recently reported data suggesting that substantial variation in use of DC surgery exists across trauma centers or that it may be overused [12,13,14,15]
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