title: The 1-2-3 approach to abdominal packing.
abstract: BACKGROUND
  Abdominal packing (AP) in damage-control laparotomy (DCL) is a lifesaving technique that controls coagulopathic hemorrhage in severely injured trauma patients. However, the impact of the duration of AP on the incidence of re-bleeding and on intra-abdominal infections in penetrating abdominal trauma is not clear. The objective of the present study was to evaluate the complications related to the duration of AP and to determine the optimal time for AP removal.
  
  
  METHODS
  Prospectively collected/retrospectively analyzed data at an urban level I trauma center from January 2003 to December 2010 were used as the basis for this study. Inclusion criteria were adults (≥18 years old) with penetrating abdominal trauma, who had survived both the initial DCL procedure and their first re-laparotomy. All initial DCL patients included in the study underwent abdominal packing for coagulopathic hemorrhage control. The outcome measures of this study were re-bleeding after packing removal, intra-abdominal infection, and 30-day cumulative mortality. We considered time after packing as an independent variable. This was defined as the total amount of time (in days) that the packs were left in the patient's abdomen. Patients were grouped according to the duration in days of their AP in <1, 1-2, 2-3, and >3 days.
  
  
  RESULTS
  Of 503 patients with penetrating abdominal trauma, 121 underwent DCL and AP. The mean age was 30.1± 11.5 years, and the male to female ratio was 9:1. The mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 17.6±7.2. The mean Injury Severity Score (ISS) score was 24.9±9.1. The right upper quadrant was packed in 39 (32.2%) patients, retroperitoneum in 70 (57.8%), pelvis in 13 (10.7%), and left upper quadrant in 9 (7.4%). Fifty-one patients (42.1%) had associated colon injuries and 58 (47.9%) had small bowel injuries. Twenty-six patients (21.5%) had AP<1 day, 42 patients (34.7%) had AP between 1 and 2 days, 35 patients (28.9%) had AP between 2 and 3 days, and 18 patients (14.8%) had AP>3 days. The re-bleeding rate in patients packed for 1-2 days compared to those packed for <1 day was a third lower, 14.3%, (95% confidence interval [95% CI]: 8.06, 20.5) versus 38.5% (95% CI: 25.4, 51.5). Conversely, an increasing trend toward intra-abdominal infection occurred as time after packing increased. The infection rate tripled from 16.7% (95% CI: 6.6, 26.7) to 44.4% (95% CI: 31.03, 57.7) when comparing 1-2 days versus >3 days. Overall mortality was 16.5%. Of these deaths, 8.26% were attributable to re-bleeding, and 13.2% to intra-abdominal infection. Deaths secondary to re-bleeding seemed to decrease with time of AP, whereas intra-abdominal infection deaths increased with time of AP (Chi square for trend p value=0.04).
  
  
  CONCLUSIONS
  The present study suggests that AP used in the setting of DCL for coagulopathic hemorrhage control should not be removed prior to the first postoperative day because of the increased risk of re-bleeding. The ideal length of AP is 2-3 days, and AP left in longer than 3 days is associated with a significantly increased risk of infectious complications.
authors.affiliation: Departamento de Cirugía, Fundación Valle del Lili, Avenida Simón Bolivar, Carrera 98 Número 18-49, Cali, Colombia. ordonezcarlosa@gmail.com
authors.forename: Carlos
authors.initials: C
authors.lastname: Ordoñez
authors.forename: Luis
authors.initials: L
authors.lastname: Pino
authors.forename: Marisol
authors.initials: M
authors.lastname: Badiel
authors.forename: Alvaro
authors.initials: A
authors.lastname: Sanchez
authors.forename: Jhon
authors.initials: J
authors.lastname: Loaiza
authors.forename: Oscar
authors.initials: O
authors.lastname: Ramirez
authors.forename: Fernando
authors.initials: F
authors.lastname: Rosso
authors.forename: Alberto
authors.initials: A
authors.lastname: García
authors.forename: Marcela
authors.initials: M
authors.lastname: Granados
authors.forename: Gustavo
authors.initials: G
authors.lastname: Ospina
authors.forename: Andrew
authors.initials: A
authors.lastname: Peitzman
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Puyana
authors.forename: Michael W
authors.initials: MW
authors.lastname: Parra
mesh_terms: D000007:Abdominal Injuries / Q000150:complications / Q000401:mortality / Q000601:surgery*; D000328:Adult; D004638:Emergency Treatment / Q000379:methods*; D058450:Endotamponade / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006470:Hemorrhage / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D006801:Humans; D015601:Injury Severity Score; D059413:Intraabdominal Infections / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D007813:Laparotomy; D008297:Male; D012008:Recurrence; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000150:complications / Q000401:mortality / Q000601:surgery*