title: Intra-abdominal packing with laparotomy pads and QuikClot™ during damage control laparotomy: A safety analysis.
abstract: BACKGROUND
  Intra-abdominal packing with laparotomy pads (LP) is a common and rapid method for hemorrhage control in critically injured patients. Combat Gauze™ and Trauma Pads™ ([QC] Z-Medica QuikClot®) are kaolin impregnated hemostatic agents, that in addition to LP, may improve hemorrhage control. While QC packing has been effective in a swine liver injury model, QC remains unstudied for human intra-abdominal use. We hypothesized QC packing during damage control laparotomy (DCL) better controls hemorrhage than standard packing and is safe for intracorporeal use.
  
  
  METHODS
  A retrospective review (2011-2014) at a Level-I Trauma Center reviewed all patients who underwent DCL with intentionally retained packing. Clinical characteristics, intraoperative and postoperative parameters, and outcomes were compared with respect to packing (LP vs. LP+QC). All complications occurring within the patients' hospital stays were reviewed. A p≤0.05 was considered significant.
  
  
  RESULTS
  68 patients underwent DCL with packing; (LP n=40; LP+QC n=28). No difference in age, BMI, injury mechanism, ISS, or GCS was detected (Table 1, all p>0.05). LP+QC patients had a lower systolic blood pressure upon ED presentation and greater blood loss during index laparotomy than LP patients. LP+QC patients received more packed red blood cell and fresh frozen plasma resuscitation during index laparotomy (both p<0.05). Despite greater physiologic derangement in the LP+QC group, there was no difference in total blood products required after index laparotomy until abdominal closure (LP vs LP+QC; p>0.05). After a median of 2days until abdominal closure in both groups, no difference in complications rates attributable to intra-abdominal packing (LP vs LP+QC) was detected.
  
  
  CONCLUSIONS
  While the addition of QC to LP packing did not confer additional benefit to standard packing, there was no additional morbidity identified with its use. The surgeons at our institution now select augmented packing with QC for sicker patients, as we believe this may have additional advantage over standard LP packing. A randomized controlled trial is warranted to further evaluate the intra-abdominal use of advanced hemostatic agents, like QC, for both hemostasis and associated morbidity.
authors.affiliation: Department of Surgery, Cooper University Hospital, Camden, NJ, United States. Electronic address: choron-rachel@cooperhealth.edu.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Choron
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: Hazelton-Joshua@cooperhealth.edu.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Hazelton
authors.affiliation: Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States. Electronic address: Hunter-Krystal@cooperhealth.edu.
authors.forename: Krystal
authors.initials: K
authors.lastname: Hunter
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: Capano-Wehrle-Lisa@cooperhealth.edu.
authors.forename: Lisa
authors.initials: L
authors.lastname: Capano-Wehrle
authors.affiliation: Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States. Electronic address: Gaughan-John@cooperhealth.edu.
authors.forename: John
authors.initials: J
authors.lastname: Gaughan
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: Chovanes-John@cooperhealth.edu.
authors.forename: John
authors.initials: J
authors.lastname: Chovanes
authors.affiliation: Division of Trauma, Hospital of the University of Pennsylvania, Philadelphia, PA, United States. Electronic address: Mark.Seamon@uphs.upenn.edu.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Seamon
mesh_terms: D034841:Abdominal Cavity / Q000098:blood supply / Q000473:pathology*; D000007:Abdominal Injuries / Q000150:complications / Q000601:surgery*; D000328:Adult; D058450:Endotamponade / Q000379:methods; D005260:Female; D006470:Hemorrhage / Q000517:prevention & control*; D006801:Humans; D015601:Injury Severity Score; D007813:Laparotomy / Q000009:adverse effects / Q000379:methods*; D008297:Male; D061214:Patient Safety; D012189:Retrospective Studies; D015996:Survival Rate; D014193:Trauma Centers; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult
keywords: Combat gauze™; Damage control laparotomy; Hemorrhage control; Hemostasis; Hemostatic agent; Intra-abdominal hemorrhage; Intra-abdominal packing; Kaolin; QuikClot; Trauma pad™