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

Department of Surgery, The University of Texas Health Science Center, Houston, TX, USA.
Annals of surgery (Impact Factor: 8.33). 09/2011; 254(4):598-605. DOI: 10.1097/SLA.0b013e318230089e
Source: PubMed


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.

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    • "After the DCL, the clinicians then return patients to relatively stable conditions, so the patients can undergo definitive surgical treatment at the next stage. Even with the development of new strategies to manage and resuscitate patients with severe trauma [8,9] and the lack of high level supporting evidence [10], DCL still plays an important role in trauma care, even though some clinicians have reflected on its futility [11,12]. "
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    ABSTRACT: In this study, we explored the possible causes of death and risk factors in patients who overcame the initial critical circumstance when undergoing a damage control laparotomy for abdominal trauma and succumbed later to their clinical course. This was a retrospective study. We selected patients who fulfilled our study criteria from 2002 to 2012. The medical and surgical data of these patients were then reviewed. Fifty patients (survival vs. late death, 39 vs. 11) were enrolled for further analysis. In a univariable analysis, most of the significant factors were noted in the initial emergency department (ED) stage and early intensive care unit (ICU) stage, while an analysis of perioperative factors revealed a minimal impact on survival. Initial hypoperfusion (pH, BE, and GCS level) and initial poor physiological conditions (body temperature, RTS, and CPCR at ED) may contribute to the patient's final outcome. An analysis and summary of the causes of death were also performed. According to our study, the risk factors for late death in patients undergoing DCL may include both the initial trauma-related status and clinical conditions after DCL. In our series, the cause of death for patients with late mortality included the initial brain insult and later infectious complications.
    World Journal of Emergency Surgery 01/2014; 9(1):1. DOI:10.1186/1749-7922-9-1 · 1.47 Impact Factor
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    • "The importance of fluid resuscitation to maintain tissue perfusion in hemorrhagic shock has been well established, but the optimal blood pressure capable of providing adequate organ perfusion without augmenting hemorrhage is currently a topic for research [3-9]. Recent clinical studies on permissive hypotension and damage control resuscitation aiming at delivering higher ratios of blood products and decreasing crystalloid infusion have led to fewer complications associated with excessive fluids, less coagulopathy and ultimately increased survival [6,7]. "
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    ABSTRACT: The objective of this study was to investigate regional organ perfusion acutely following uncontrolled hemorrhage in an animal model that simulates a penetrating vascular injury and accounts for prehospital times in urban trauma. We set forth to determine if hypotensive resuscitation (permissive hypotension) would result in equivalent organ perfusion compared to normotensive resuscitation. Twenty four (n=24) male rats randomized to 4 groups: Sham, No Fluid (NF), Permissive Hypotension (PH) (60% of baseline mean arterial pressure - MAP), Normotensive Resuscitation (NBP). Uncontrolled hemorrhage caused by a standardised injury to the abdominal aorta; MAP was monitored continuously and lactated Ringer's was infused. Fluorimeter readings of regional blood flow of the brain, heart, lung, kidney, liver, and bowel were obtained at baseline and 85 minutes after hemorrhage, as well as, cardiac output, lactic acid, and laboratory tests; intra-abdominal blood loss was assessed. Analysis of variance was used for comparison. Intra-abdominal blood loss was higher in NBP group, as well as, lower hematocrit and hemoglobin levels. No statistical differences in perfusion of any organ between PH and NBP groups. No statistical difference in cardiac output between PH and NBP groups, as well as, in lactic acid levels between PH and NBP. NF group had significantly higher lactic acidosis and had significantly lower organ perfusion. Hypotensive resuscitation causes less intra-abdominal bleeding than normotensive resuscitation and concurrently maintains equivalent organ perfusion. No fluid resuscitation reduces intra-abdominal bleeding but also significantly reduces organ perfusion.
    World Journal of Emergency Surgery 08/2012; 7 Suppl 1(Suppl 1):S9. DOI:10.1186/1749-7922-7-S1-S9 · 1.47 Impact Factor
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    ABSTRACT: Damage control laparotomy (DCL) is a lifesaving technique initially employed to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. Recently, it has been recognized that DCL itself carries significant morbidity and may be overutilized. The purpose of this study was to determine (1) whether early fascial closure is associated with a reduction in postoperative complications and (2) whether patients at our institution met traditional DCL indications (acidosis, hypothermia, and coagulopathy). This is a retrospective review of all patients undergoing immediate laparotomy at a Level I trauma center between 2004 and 2008. DCL was defined as temporary abdominal closure at the initial surgery. Early closure was defined as primary fascial closure at initial take back laparotomy. Patients were excluded if they died before first take back. Acidosis (pH <7.30), hypothermia (temperature <95.0°F), and coagulopathy (international normalized ratio >1.5) were measured on intensive care unit (ICU) arrival. Totally, 925 patients were eligible. Thirty percent had DCL employed. Of these, 86 subjects (34%) were closed at first take back while 161 (66%) were not. Both groups were similar in demographics, injury severity score, resuscitation volumes, blood products, and prehospital, emergency department, and operating room vital signs. Univariate analyses noted that intra-abdominal abscesses (8.4% vs. 21.3%), respiratory failure (14.4% vs. 37.1%), sepsis (8.4% vs. 25.1%), and renal failure (3.6% vs. 25.1%) were lower in patients closed at first take back (all <0.05). Controlling for age, gender, injury severity score, and transfusions, logistic regression analysis noted that closure at the first take back was associated with a reduction in infectious (odds ratio, 0.28; 95% confidence interval [CI], 0.12-0.66; p = 0.004) and noninfectious abdominal complications (odds ratio, 0.23; 95% CI, 0.09-0.56; p = 0.001) as well as wound (odds ratio, 0.31; 95% CI, 0.13-0.72; p = 0.007) and pulmonary complications (odds ratio, 0.35; CI, 0.20-0.62; p < 0.001). Of patients closed at the initial take back, 78% were acidotic (35%), coagulopathic (49%), or hypothermic (44%) on initial ICU admission. Early fascial closure is an independent predictor of reduced complications in DCL patients. One in five patients closed at initial take back did not meet any of the traditional indications for DCL upon initial ICU admission. This may represent an overutilization of this valuable technique, exposing patients to increased complications. Further efforts should be directed at achieving both early facial closure as well as redefining the appropriate indications for DCL.
    The Journal of trauma 12/2011; 71(6):1503-11. DOI:10.1097/TA.0b013e31823cd78d · 2.96 Impact Factor
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