Patients Undergoing Damage Control Laparotomy Research Articles

The impact of hypertonic saline on damage control laparotomy after penetrating abdominal trauma.

The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements. We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey's comparison, and student's t, and Fischer's exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution. Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37h ± 14.21 vs 59.05h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72h, peak sodium (Na) concentration (146.2mEq/L ± 2.94 vs 142.8mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days. HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm. Level III.

Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients.

Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Indications, mortality, and long-term outcomes of 50 consecutive patients undergoing damage control laparotomy for abdominal gunshot wounds

Indications, mortality, and long-term outcomes of 50 consecutive patients undergoing damage control laparotomy for abdominal gunshot wounds

Failure to Rescue: A Quality Improvement Imperative in Achieving Zero Death in Damage Control Laparotomy Patients

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.

Evolution of Fascial Closure Optimization in Damage Control Laparotomy

Management of patients undergoing damage control laparotomy (DCL) involves many surgical, medical, and logistical factors. Ideal patient management optimizing fascial closure with regard to timing and closure techniques remains unclear. A retrospective review of patients undergoing DCL from 2000 to 2012 at an urban Level I trauma center was undertaken. Mortality of DCL decreased over the study period from 62.5 to 34.6 per cent, whereas enterocutaneous fistula rate decreased from 12.5 to 3.8 per cent. Delayed primary fascial closure rate improved from 22.2 to 88.2 per cent. Time to closure (P < 0.001), time to first attempted closure (P < 0.001), and number of explorations (P < 0.001) were associated with ability to achieve delayed primary fascial closure. In subgroup analysis, achievement of delayed primary fascial closure was decreased with time to closure after one week (91.7% vs 52.0%, P = 0.002) and time to first attempted closure after two days (86.5% vs 70.0%, P = 0.042). In multivariate analysis, time to closure (odds ratio: 0.13, 95% confidence interval: 0.04-0.39; P < 0.001) and time to first attempted closure (odds ratio: 0.61, 95% confidence interval: 0.37-0.99; P = 0.046) were the only factors associated with achieving delayed primary fascial closure. Timing of attempted closure plays a significant role in attaining delayed primary fascial closure, highlighting the importance of early re-exploration.

Delayed interventions and mortality in trauma damage control laparotomy

In damage control laparotomy, operative principles include hemorrhage and contamination control. However, required components of initial damage control laparotomy are unknown, and nonemergency injury repair is sometimes delayed for resuscitation, angiography, or nonabdominal operations. The frequency and effects of delayed interventions are unknown. A retrospective review of patients undergoing damage control laparotomy at a single, urban trauma center was performed. Interventions initially performed at the second laparotomy were considered delayed interventions. In the study, 330 damage control laparotomy patients survived to reoperation. Of all interventions, 13.9% were first performed at the second laparotomy, including 11.9% of visceral interventions and 27.2% of vascular interventions. Overall, 29.7% of patients underwent an unplanned re-exploration, and 21.8% of patients underwent re-exploration for hemorrhage control. There was no significant increase in mortality (33.3% vs 23.9%, P=.09), intra-abdominal infection (37.9% vs 28.0%; P=.10), anastomotic leak (8.0% vs 5.8%, P=.45), or enterocutaneous fistula formation (9.2% vs 9.1%, P=1.00) with delayed interventions overall. However, mortality was increased in patients undergoing delayed vascular interventions (59.1% vs 22.8%, P=.003), unplanned re-exploration (45.9% vs 18.1%, P<.001) and re-exploration for hemorrhage control (50.0% vs 19.8%, P<.001). Delayed interventions are common in damage control laparotomy, with abdominal interventions often spread over multiple explorations. Mortality is increased in patients undergoing emergent re-exploration and with delayed repair of major vascular injuries. Ideal treatment of damage control laparotomy patients may include addressing injuries more completely at the first laparotomy instead of deferring care for other priorities.

Time to first take-back operation predicts successful primary fascial closure in patients undergoing damage control laparotomy

Failure to achieve primary fascial closure (PFC) after damage control laparotomy is costly and carries great morbidity. We hypothesized that time from the initial laparotomy to the first take-back operation would be predictive of successful PFC. Trauma patients managed with open abdominal techniques after damage control laparotomy were prospectively followed at 14 Level 1 trauma centers during a 2-year period. Time to the first take-back was evaluated as a predictor of PFC using hierarchical multivariate logistic regression analysis. A total of 499 patients underwent damage control laparotomy and were included in this analysis. PFC was achieved in 327 (65.5%) patients. Median time to the first take-back operation was 36 hours (interquartile range 24-48). After we adjusted for patient demographics, resuscitation volumes, and operative characteristics, increasing time to the first take-back was associated with a decreased likelihood of PFC. Specifically, each hour delay in return to the operating room (24 hours after initial laparotomy) was associated with a 1.1% decrease in the odds of PFC (odds ratio 0.989; 95% confidence interval 0.978-0.999; P = .045). In addition, there was a trend towards increased intra-abdominal complications in patients returning after 48 hours (odds ratio 1.80; 95% confidence interval 1.00-3.25; P = .05). Data from this prospective, multicenter study demonstrate that delays in returning to the operating room after damage control laparotomy are associated with reductions in PFC. These findings suggest that emphasis should be placed on returning to the operating room within 24 hours after the initial laparotomy if possible (and no later than 48 hours).

Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy

Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. Fourteen level I trauma centers. A total of 517 patients with an open abdomen following damage control laparotomy. Complication of ECF, EAF, or IAS. More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

Curativo à vácuo para cobertura temporária de peritoneostomia

The advances in patient care with trauma or severe intra-abdominal infections, brought important gains in survival with the use of peritoneostomies. But the management of patients brought a difficult problem: the primary closure without tension of the abdominal cavity. To present a proposal for temporary coverage of peritoneostomies in patients undergoing damage control laparotomy or decompressive laparotomy for abdominal compartment syndrome. Isolation of the small intestine loops from abdominal internal; coverage of the intestinal surface with a polyethylene film multiperforated with sterile scissors or scalpel blade, to prevent direct contact with the foam. It is placed below the edges of the defect between the parietal and visceral peritoneum. Over it, a polyurethane sterile foam is fixed to the edges, leaving the defect tension free to the vacuum be applied. Another coverage with a plastic adhesive polyester impregnated with iodine stuck to skin is done, and, at the end, is added a drainage continuous aspiration system. The dressing is changed between three and five days. It was used successfully in four patients with primary closure of the abdominal cavity after seven to 21 days. Of these, three had open abdomen after laparotomy for trauma (two due to damage control and one for lack of primary closure); the fourth had been previously submitted to decompressive laparotomy for abdominal compartment syndrome. The vacuum dressing proved to be good choice for temporary coverage of peritoneostomies allowing faster closure of the abdominal wound, reducing the number of reoperations and providing protection against bacterial contamination of the intestinal loops.

Primary fascial closure after damage control laparotomy: Sepsis vs haemorrhage

ObjectiveTo compare the outcomes of patients undergoing damage control laparotomy (DCL) for intra-abdominal sepsis vs intra abdominal haemorrhage. We hypothesize that patients undergoing DCL for sepsis will have a higher rate of septic complications and a lower rate of primary fascial closure. Settings and patientsRetrospective study of patients undergoing DCL from December 2006 to November 2009. Data are presented as medians and percentages where appropriate. Results111 patients were identified (55 men), 79 with sepsis and 32 with haemorrhage. There was no difference in age (63 vs 62 years), body mass index (BMI, 27 vs 28), diabetes mellitus (13% vs 9%), or duration of initial operation (125 vs 117min). Patients with sepsis presented with a lower serum lactate (2.2 vs 4.7mmol/L, p<0.01), base deficit (4.0 vs 8.0, p≤0.01) and ASA score (3.0 vs 4.0, p<0.01). There was no statistical difference in overall morbidity (81% vs 66), mortality (19% vs 22%), intra-abdominal abscess (18% vs 16%), deep wound infection (9% vs 9%), enterocutaneous fistula (ECF) (8% vs 6%) and primary fascial closure (58% vs 59%). Multivariable analysis demonstrated that intra-abdominal abscess (OR 4.26, 95% CI 1.06–19.32), higher base deficit (OR 1.14, 95% CI 1.00–1.31) and more abdominal explorations (OR 1.54, 95% CI 1.23–2.07) were associated with lack of primary fascial closure, but BMI (OR 1.00, 95% CI 0.94–1.07), ECF (OR 2.02, 95% CI 0.23–19.98), wound infection (OR 0.93, 95% CI 0.15–5.27), amount of crystalloids infused within the first 24h (OR 1.00, 95% CI 0.99–1.00) and intra-abdominal sepsis (OR 1.14, 95% CI 0.35–3.80) were not. ConclusionsThere was an equivalent rate of septic complications and primary fascial closure rates regardless of cause for DCL. Intra-abdominal abscess, worse base deficit and higher number of abdominal explorations were independently associated with the lack of primary fascial closure.

Damage Control Resuscitation Is Associated With a Reduction in Resuscitation Volumes and Improvement in Survival in 390 Damage Control Laparotomy Patients

To determine whether implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival. DCR aims at preventing coagulopathy through permissive hypotension, limiting crystalloids and delivering higher ratios of plasma and platelets. Previous work has focused only on the impact of delivering higher ratios (1:1:1). A retrospective cohort study was performed on all DCL patients admitted between January 2004 and August 2010. Patients were divided into pre-DCR implementation and DCR groups and were excluded if they died before completion of the initial laparotomy. The lethal triad was defined as immediate postoperative temperature less than 95°F, international normalized ratio more than 1.5, or a pH less than 7.30. A total of 390 patients underwent DCL. Of these, 282 were pre-DCR and 108 were DCR. Groups were similar in demographics, injury severity, admission vitals, and laboratory values. DCR patients received less crystalloids (median: 14 L vs 5 L), red blood cells (13 U vs 7 U), plasma (11 U vs 8 U), and platelets (6 U vs 0 U) in 24 hours, all P < 0.05. DCR patients had less evidence of the lethal triad upon intensive care unit arrival (80% vs 46%, P < 0.001). 24-hour and 30-day survival was higher with DCR (88% vs 97%, P = 0.006 and 76% vs 86%, P = 0.03). Multivariate analysis controlling for age, injury severity, and emergency department variables, demonstrated DCR was associated with a significant increase in 30-day survival (OR: 2.5, 95% CI: 1.10-5.58, P = 0.028). In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration. More importantly, DCR is associated with an improvement in 30-day survival.

Management of ongoing arterial haemorrhage after damage control laparotomy: Optimal timing and efficacy of transarterial embolisation

Introduction Patients undergoing damage control laparotomy need intensive and aggressive resuscitation, and may also require adjunctive transarterial embolisation (TAE) for ongoing arterial haemorrhage. We evaluated the effectiveness and timing of TAE in these patients as well as their final outcome. Materials and methods From January 1998 to December 2006, the case records of 16 patients with ongoing arterial haemorrhages (hepatic haemorrhage = 7, extra-hepatic haemorrhage = 9) who underwent TAE after damage control laparotomy were reviewed. Fourteen patients had blunt injuries and two had penetrating injuries. Results There were 13 men and three women. Their ages ranged from 3 to 85 years (mean, 36 years). Of seven hepatic angiograms, contrast extravasation at the right hepatic artery and left hepatic artery was found in three patients each. Bilateral hepatic artery injuries were found in one patient. Of nine extra-hepatic angiograms, the internal iliac artery was the most commonly injured artery ( n = 6). After TAE, 14 of 16 ongoing arterial haemorrhages could be controlled and eight patients survived; however, two patients with uncontrolled haemorrhages eventually died (hepatic artery injury = 1, lumbar artery injury = 1). Of 16 patients overall, profound haemorrhagic shock ( n = 4) and multiple organ failure ( n = 4) resulted in eight deaths (hepatic injury = 4, extra-hepatic injury = 4), and accounted for a mortality rate of 50%. Of 16 patients, nine were taken directly from the operating room to the angiography suite and the mortality rate was 33.3%. The other seven patients were taken to the angiography suite from the intensive care unit and the mortality rate was 71.4%. Of three survivors who underwent hepatic TAE, the operative time ranged from 30 min to 72 min (mean, 48 min). However, of four nonsurvivors who underwent hepatic TAE, the operative time ranged from 58 min to 180 min (mean, 119 min). Conclusions TAE is an effective tool in the management of ongoing arterial haemorrhage after damage control laparotomy and eight (50%) patients with ongoing arterial haemorrhages survived from this multidisciplinary treatment. To achieve a good outcome, the operative time of damage control laparotomy should be as short as possible and TAE should be performed without delay. Interventional radiology colleagues should be informed in advance during laparotomy and resuscitation continued in the angiography suite.

Infections following damage control laparotomy with abdominal packing

Our objective was to describe postoperative infections for patients undergoing damage control laparotomy (DCL) with abdominal packing. We retrospectively reviewed data on packing patients in Jinling hospital (China) during a 5-y period. Of 26 patients, 15 (57.7%) had postoperative infections. Pneumonia/lower respiratory tract infection (57.7%), bacteraemia (50%), and urinary tract infection (15.4%) were the 3 prominent types of infections. The most frequently isolated bacteria were Pseudomonas aeruginosa (20.7%), staphylococcal species (15.6%), Acinetobacter baumannii (13.9%), and Klebsiella species (11.1%). Antibiotic resistance was common both for the Gram-positive and Gram-negative isolates. No statistical correlation was demonstrated between positive packs and postoperative infection (p=0.10) or death (p=1.00). Multivariate regression analysis revealed pre-existing abdominal infection (OR=22.4, p=0.02) and increased number of surgical procedures (OR=3.69, p=0.05) to be independent risk factors for postoperative de novo infection. We conclude that patients undergoing DCL with packing carry a high incidence of postoperative infections. Causative pathogens are typical for ICU acquired infections and are often associated with low levels of susceptibility to multiple antimicrobial agents. Pre-existing abdominal infection and increased number of surgical procedures are the independent risk factors for postoperative de novo infection in these patients.