Damage control laparotomy utilization rates are highly variable among Level I trauma centers

Abstract

Background Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, INR, temperature and major intra-abdominal vascular injury (MVI) would not adequately capture all patients. Methods Trauma patients at 12 level 1 North American trauma centers were randomized based on transfusion ratios as described in the PROPPR trial. We analyzed outcomes following emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management (DSM) with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results 329 patients underwent emergent laparotomy: 213 DCL (65%) and 116 DSM (35%). DCL rates varied between institutions (33%-83%), (p=0.002). Median ISS was higher in the DCL group, 29 (IQR: 13,34) versus 21 (IQR: 22,41) (p<0.001). 24-hour mortality was 19% with DCL versus 4% (p<0.001); 30-day mortality was 28% with DCL versus 19% (p<0.001). In a mixed-effects model, ISS and MVI were correlates of DCL (OR: 1.05, 95% CI: 1.02-1.07 and 2.7, 95% CI: 1.4-5.2). DCL was not associated with 30-day mortality OR 2.33 (CI 0.97-5.60). Correlates included ISS (OR: 1.06, 95% CI: 1.02, 1.09), PRBCs in 24hrs (OR: 1.10, 95% CI: 1.03, 1.18), and age (1.04, 95% CI: 1.01, 1.06). No significant mortality difference was detected between institutions (p=0.63). Sepsis and VAP occurred more frequently with DCL (p<0.05). 80% (135/213) of DCL patients met standard criteria. Conclusions Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications.

Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization

“…A major asset in the treatment of a trauma patient is knowledge of damage control concepts. Damage control surgery (DCS) can be performed in severely injured patients as part of the resuscitation process [12]. In DCS, the goal is to reduce operating time as much as possible, preferably within 1-1.5 h, in which hemorrhage and contamination is controlled, while additional damage is prevented [13].…”

Evidence for Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients: A Systematic Review

“…Collectively, the above data suggest that there exists little evidence to support the high DC surgery utilization rates reported by many level 1 trauma centers. In a recently reported post-hoc analysis of the PROPPR randomized trial, DC was used among 33-83% of patients requiring urgent laparotomy across 12 of the participating institutions [15]. Interestingly, although there was no signi cant adjusted mortality difference between these centers, the unadjusted risk of sepsis and ventilator-associated pneumonia was higher among those treated with DC laparotomy, suggesting that decreasing use of DC among individual trauma centers may not in uence mortality, but may decrease associated morbidity [15].…”

“…It is therefore important to ensure that DC surgery is only performed on patients in which the expected survival bene t of the procedure outweighs its expected risk of negative consequences [1]. Despite this, the bene t/risk pro le 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].…”

Damage control surgery Concept

“…In sum, the DCS approach should be applied in the presence of the previously described prognosis factors, and the surgical management strategy must be based on the dynamic response to resuscitation rather than the patient physiology indicators or injury characteristic at the presentation. Due to the absence of high-level evidence data regarding the appropriate indications, a recent report (2017) highlighted the inconsistent use of the DCS approach with signifi cant variation across tertiary trauma centres [46]. However, the damage control strategy remains primordial in the management of shocked patients or those not responding to intensive resuscitation.…”