The conjoint effect of reduced crystalloid administration and decreased damage-control laparotomy use in the development of abdominal compartment syndrome.
ABSTRACT Anticipation of abdominal compartment syndrome (ACS) is a factor for performing damage-control laparotomy (DCL). Recent years have seen changes in resuscitation patterns and a decline in the use of DCL. We hypothesized that reductions in both crystalloid resuscitation and the use of DCL is associated with a reduced rate of ACS in trauma patients.
We reviewed the records of all patients who underwent trauma laparotomies at our Level 1 trauma center over a 6-year period (2006-2011). We defined DCL as a trauma laparotomy in which the fascia was not closed at the initial operation. We defined ACS by elevated intravesical pressures and end-organ dysfunction. Our primary outcome measure was a development of ACS.
A total of 799 patients were included. We noted a significant decrease in the DCL rate (39% in 2006 vs. 8% in 2011, p < 0.001), the crystalloid volume per patient (mean [SD], 12.8 [7.8] L in 2006 vs. 6.6 [4.2] L in 2011; p < 0.001), rate of ACS (7.4% in 2006 vs. 0% in 2011, p < 0.001), and mortality rate (22.8% in 2006 vs. 10.6% in 2011, p < 0.001). However, we noted no significant changes in the mean Injury Severity Score (ISS) (p = 0.09), in the mean abdominal Abbreviated Injury Scale (AIS) score (p = 0.17), and in the mean blood product volume per patient (p = 0.67). On multivariate regression analysis, crystalloid resuscitation (p = 0.01) was the only significant factor associated with the development of ACS.
Minimizing the use of crystalloids and DCL was associated with better outcomes and virtual elimination of ACS in trauma patients. With the adaption of new resuscitation strategies, goals for a trauma laparotomy should be definitive surgical care with abdominal closure. ACS is a rare complication in the era of damage-control resuscitation and may have been iatrogenic.
Therapeutic, retrospective study, level III.
SourceAvailable from: Viraj Pandit[Show abstract] [Hide abstract]
ABSTRACT: The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone. We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy. A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28 %; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone. PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.World Journal of Surgery 05/2014; DOI:10.1007/s00268-014-2631-y · 2.35 Impact Factor
Transfusion Medicine 06/2014; 24(3). DOI:10.1111/tme.12127 · 1.31 Impact Factor
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ABSTRACT: Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies.Journal of Surgical Research 01/2014; 190(2). DOI:10.1016/j.jss.2014.01.029 · 2.12 Impact Factor