Damage control resuscitation in combination with damage control laparotomy: a survival advantage.
BACKGROUND
Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE).


METHODS
This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression.


RESULTS
One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005).


CONCLUSIONS
This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.
Duchesne
Juan C
JC
Section of Trauma and Critical Care Surgery, Department of Surgery, Emergency Medicine and Anesthesia, Tulane University Health Science Center, New Orleans, Louisiana 70112-2699, USA. jduchesn@tulane.edu
Kimonis
Katerina
K
Marr
Alan B
AB
Rennie
Kelly V
KV
Wahl
Georgia
G
Wells
Joel E
JE
Islam
Tareq M
TM
Meade
Peter
P
Stuke
Lance
L
Barbeau
James M
JM
Hunt
John P
JP
Baker
Christopher C
CC
McSwain
Norman E
NE
D000328:Adult; D001803:Blood Transfusion; D005260:Female; D006470:Hemorrhage / Q000401:mortality / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000379:methods / Q000401:mortality*; D008297:Male; D015999:Multivariate Analysis; D012044:Regression Analysis; D015532:Rehydration Solutions / Q000627:therapeutic use; D012151:Resuscitation / Q000379:methods / Q000401:mortality*; D012189:Retrospective Studies; D016019:Survival Analysis; D014947:Wounds and Injuries / Q000401:mortality / Q000601:surgery*; D014949:Wounds, Nonpenetrating / Q000401:mortality / Q000601:surgery*; D014950:Wounds, Penetrating / Q000401:mortality / Q000601:surgery
D015532:Rehydration Solutions