Publications (2)4.96 Total impact
-
Article: Impact of closure at the first take back: complication burden and potential overutilization of damage control laparotomy.
[show abstract] [hide abstract]
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. · 2.48 Impact Factor -
Article: Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back.
[show abstract] [hide abstract]
ABSTRACT: Damage-control laparotomy (DCL) is a lifesaving technique but carries significant morbidity. If DCL is over used and the factors that predict early fascial closure have not been fully evaluated. The purpose of the current study was to determine (1) the current rate of DCL, (2) the percentage of DCLs that are closed at first take-back, and (3) possible physiologic and resuscitative parameters predicting early fascial closure. A retrospective review of all trauma laparotomies from a Level I trauma center between January 2004 and December 2008 was performed. Patients were excluded if they died before first take-back. Univariate and multivariate analyses were performed. Nine hundred thirty patients were eligible, 278 (30%) underwent DCL, 36 excluded for death before first take-back. Of the remaining 242 DCL patients, 83 (34%) were closed at first take-back and 159 (66%) were not closed at first take-back. These two groups were similar in injury severity, demographics, and prehospital and emergency department fluids and vitals. Median emergency department international normalized ratio (INR; 1.13 vs. 1.29, p = 0.010), post-op INR (1.4 vs. 1.5, p = 0.028), 24-hour fluids (11.9 L vs. 15.5 L, p = 0.006), peak post-op intra-abdominal pressure (IAP; 15 vs. 18, p < 0.001), and mortality (1.2% vs. 8.2%, p = 0.027) were different between groups. Multivariate analysis noted vacuum-assisted closure at initial laparotomy (Odds ratio, 3.1; 95% confidence interval [CI], 1.42-6.63; p = 0.004) was an independent predictor of closure at first take-back. However, post-op INR (Odds ratio, 0.18; 95% CI, 0.03-0.97; p = 0.04) and post-op peak IAP (Odds ratio, 0.85; 95% CI, 0.76-0.95; p = 0.005) predicted failure to close fascia at first take-back. In similarly injured DCL patients, increased post-op INR and IAP predicted inability to achieve primary fascial closure on first take-back, while use of the vacuum-assisted closure was associated with increased likelihood of early fascial closure. At a busy academic Level I trauma center, the current rate of DCL among those undergoing emergent laparotomy is 30%. Whether this represents optimal use or overutilization of this technique still needs to be determined.The Journal of trauma 06/2011; 70(6):1429-36. · 2.48 Impact Factor
