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

Abstract

Background: Although 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).Methods: We 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. Results: Among 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) 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.Conclusions: Few 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.

Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

“…Another systematic review conducted by our group in 2018 identified two cohort studies [22,23] that evaluated outcomes associated with implementation or utilization of indications for DC surgery [24]. Rice et al reported that, when compared with minor deviations, moderate or major deviations from a protocol that suggested using DC surgery for patients with a temperature <35°C, lactate >4 mmol/L (or greater than twice the upper limit of normal), or corrected pH <7.3 were independently associated with a significantly reduced survival at 90 days [22,24].…”

“…Another systematic review conducted by our group in 2018 identified two cohort studies [22,23] that evaluated outcomes associated with implementation or utilization of indications for DC surgery [24]. Rice et al reported that, when compared with minor deviations, moderate or major deviations from a protocol that suggested using DC surgery for patients with a temperature <35°C, lactate >4 mmol/L (or greater than twice the upper limit of normal), or corrected pH <7.3 were independently associated with a significantly reduced survival at 90 days [22,24]. Asensio et al developed a guideline that suggested use of DC surgery in patients who received more than 4 L of packed red blood cells (PRBCs), more than 5 L of PRBCs and whole blood combined, or a total operating room fluid (PRBCs and whole blood, other blood products, and crystalloid) volume replacement of more than 12 L; had a temperature <34°C, serum [HCO3-] ≤15 mEq/L, or arterial pH ≤7.2 during operation; were found to have a thoracic or abdominal vascular injury or complex hepatic injury requiring packing; required emergency department or operating room thoracotomy; or developed intraoperative coagulopathy or dysrhythmias [23,24].…”

“…Rice et al reported that, when compared with minor deviations, moderate or major deviations from a protocol that suggested using DC surgery for patients with a temperature <35°C, lactate >4 mmol/L (or greater than twice the upper limit of normal), or corrected pH <7.3 were independently associated with a significantly reduced survival at 90 days [22,24]. Asensio et al developed a guideline that suggested use of DC surgery in patients who received more than 4 L of packed red blood cells (PRBCs), more than 5 L of PRBCs and whole blood combined, or a total operating room fluid (PRBCs and whole blood, other blood products, and crystalloid) volume replacement of more than 12 L; had a temperature <34°C, serum [HCO3-] ≤15 mEq/L, or arterial pH ≤7.2 during operation; were found to have a thoracic or abdominal vascular injury or complex hepatic injury requiring packing; required emergency department or operating room thoracotomy; or developed intraoperative coagulopathy or dysrhythmias [23,24]. In this study, use of this guideline was associated with a significantly decreased unadjusted odds of intra-abdominal abscesses, extra-abdominal infections, and abdominal fistulae; a significantly increased unadjusted odds of abdominal closure; and significantly reduced unadjusted lengths of ICU and hospital stay [23,24].…”

“…We also identified 14 other cohort studies [18,19,[25][26][27][28][29][30][31][32][33][34][35][36]] that compared outcomes of patients treated with DC versus definitive laparotomy in different clinical situations [24]. Stone et al, Rotondo et al, and Chinnery et al reported a significant improvement in unadjusted survival with use of DC or staged laparotomy instead of definitive laparotomy for those that developed a coagulopathy during operation, received more than 10 U PRBCs and had one or more major abdominal vascular and two or more abdominal visceral injuries, or had combined abdominal vascular and pancreas gunshot injuries, respectively [25][26][27].…”

“…Therefore, some have suggested that decreasing use of DC among individual trauma centers may not necessarily influence injured patient mortality but may decrease their morbidity [38]. Variation in use of DC across trauma centers could relate to increasing use of the procedure for indications other than those previously suggested to be appropriate or validated in the literature [1,6,24]. In support of this, one retrospective cohort study by Hatch et al reported that one in five patients who received DC laparotomy at a level-1 trauma center between 2004 and 2008 failed to have at least one traditional indication for use of the procedure [1,6,39].…”