Predicting mortality in damage control surgery for major abdominal trauma.
Background. Damage control surgery (DCS) has become well
established in the past decade as the surgical strategy to be employed
in the unstable trauma patient. The aim of this study was to determine
which factors played a predictive role in determining mortality in
patients undergoing a damage control laparotomy.
Materials and methods. A retrospective review of all patients undergoing a laparotomy and DCS in a level 1 trauma centre over a 3-year period was performed. Twenty-nine potentially predictive variables for mortality were analysed.
Results. Of a total of 1 274 patients undergoing a laparotomy for trauma, 74 (6%) required a damage control procedure. The mean age was 28 years (range 14 - 53 years). The mechanism of injury was gunshot wounds in 57 cases (77%), blunt trauma in 14 (19%) and stabs in 3 (4%). Twenty patients died, giving an overall mortality rate of 27%. Factors significantly associated with increased mortality were increasing age (p=0.001), low base excess (p=0.002), pH (p<0.001), core temperature (p=0.002), and high blood transfusion requirement over 24 hours (p=0.002).
Conclusion. The overall survival of patients after damage control procedures for abdominal trauma was excellent (73%). The main factors that are useful in deciding when to initiate DCS are age, base excess, pH and the core temperature.
|Article Type:||Clinical report|
Mortality (Risk factors)
Mortality (South Africa)
Abdomen (Risk factors)
Abdomen (Care and treatment)
Abdomen (Health aspects)
|Publication:||Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 South African Medical Association ISSN: 0038-2361|
|Issue:||Date: Feb, 2010 Source Volume: 48 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
Over the past two decades, damage control surgery (DCS) rather than
definitive repair of all injuries has become established as the
appropriate surgical strategy in the severely injured patient needing
operative intervention. This change has increased the survival rate
after major trauma to over 50%. (1-6)
The term 'damage control' was defined by Rotondo et al. (4) in 1993 as 'initial control of hemorrhage and contamination followed by intra-peritoneal packing and rapid closure, resuscitation to normal physiology in the intensive care unit (ICU) and subsequent definitive re-exploration'. Two further stages have been added to the three traditional stages of operation, restoration of physiology and definitive surgery. These comprise the first stage, namely the decision as to when to perform DCS, and the final stage of abdominal wall closure. (7) However, little appears to have been documented on factors predicting mortality in this setting.
The aim of this study was to determine factors that may predict mortality in patients undergoing a damage control laparotomy.
Patients and methods
Seventy-four patients who underwent DCS for abdominal injury were retrospectively reviewed. All were admitted to the Groote Schuur Hospital Trauma Centre between January 2002 and December 2004. DCS was defined as an abbreviated laparotomy performed either because of poor physiological status or the extent of the injury, with definitive surgery to be performed 48 hours later after resuscitation in the ICU. The indications for DCS were major multiple and complex injuries, evidence of disseminated intravascular coagulation (DIC), a base excess greater than 10, a core temperature less than 35[degrees]c, and transfusion of more than 10 units of blood.
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) for Windows, version 12.0 (SAS Systems International, Cary, NC, USA). The collected variables consisted of two different types of parameters: continuous and categorical. The chi-square test was used for the categorical variables, and the independent-samples t-test for the continuous variables.
The significant variables of both the chi-square test and the independent-samples t-test were used as input for the logistic regression to determine significance of sets of variables in relation to mortality. In all tests, a p-value <0.05 was considered statistically significant.
Over the duration of this 3-year study, 1 274 patients underwent a laparotomy following trauma. Seventy-four (6%) of these patients required DCS. The mean age of these patients was 28 years (range 14 - 53 years). There were 64 males and 10 females. There were 133 organ injuries in these 74 patients, distributed as set out in Table I. The mechanism of injury was gunshot wounds in 57 cases (77%), blunt trauma in 14 (19%; 11 patients had been involved in motor vehicle accidents and 3 in train accidents) and stabs in 3 (4%).
Twenty patients died, giving an overall mortality rate of 27%. The mortality rates for gunshot wounds, blunt trauma and stab wounds were 28.0%, 28.5% and 0%, respectively.
Nine patients died in the ICU within 24 hours after the initial damage control laparotomy. An emergency re-look was necessary in 12 patients after a mean of 12 hours because of bleeding in 7 patients, abdominal compartment syndrome in 4 and bowel leakage in 1. Of these patients, 5 died within the next 2 weeks. Forty-nine patients (66%) underwent a planned re-look after a mean of 40.8 hours, and 3 (6%) of these patients died. Three patients died within 1 week after their initial DCS procedure, 1 from cardiac failure and 2 from head injuries.
The mean age of the patients who survived was 26 years, compared with 34 years in the non-survivor group. Increasing age was found to be a statistically significant factor predicting mortality, with a p-value of 0.001. The other pre-operative factors predictive of mortality are set out in Table II. These include low base excess (p=0.002), pH (p<0.001) and core temperature (p<0.001).
The postoperative factors that were predictive of mortality were the total number of blood transfusions required over 24 hours, the INR and the total platelet count (Table III). The factors that were not predictive of mortality are listed in Table IV.
In total, there were 147 complications. Forty patients developed DIC, 38 required inotropes, 21 were diagnosed with systemic inflammatory response syndrome (SIRS), 17 developed abdominal compartment syndrome, 14 were treated for nosocomial pneumonia, and 8 were treated for septic shock. The development of DIC (p<0.001), the need for inotropes (p<0.001) and the presence of septic shock (p=0.017) were found to be significant predictors of mortality.
Logistic regression analysis was undertaken to find out whether any of the parameters tested were independently predictive of mortality. In both the pre-operative and postoperative groups, only pH (p=0.001), age (p=0.006) and INR (p=0.046) were independent predictors of mortality.
The main factors influencing outcome in trauma surgery are hypothermia, acidosis and coagulopathy. These three factors, also called the 'triad of death', can create a situation in which the physiological state of the patient will deteriorate very rapidly, leading to death. Hypothermia causes deterioration of coagulopathy and increases acidosis. A decreased temperature results in cold haemoglobin that cannot release its oxygen in tissues as readily as normothermic haemoglobin. In hypothermia, enzymatic function is decreased as well, resulting in a decrease in the rate of the cascade reaction and a decrease in the production of clotting factors. The adverse links between hypothermia and coagulopathy have been extensively reviewed. (9,10)
DCS is used in patients who would not survive regular surgery because of their physiological state. However, some patients do not survive DCS. Hypothermia, acidosis and coagulopathy have already been proven to be related mortality. (2,11-14)
Sharp and Locicero (12) showed that packing the abdominal cavity to prevent the development of acidosis, hypothermia and coagulopathy can be done safely. In their search for predictive factors for mortality, they found that a pH <7.18, temperature <33[degrees]C, PTT >50 and transfusion of 10 units or more of blood are highly predictive of outcome. Their study population consisted of 39 patients of whom the majority had been involved in traffic accidents; only 6 injuries were gunshot wounds.
Aoki and colleagues (11) performed a retrospective study to identify risk factors associated with mortality in 68 patients who underwent DCS. They found an overall mortality rate of 66% and concluded that inability to correct pH and PTT at the conclusion of initial damage control laparotomy may be predictive of death.
The incidence of DCS as a component of definitive surgery varies in the literature from between 8.9% to 18%. (15-17) In our study, 6% of laparotomies for trauma were DCS. Mortality rates for DCS have been reported to range from 26% to 67%. (11,12,14,16,17) In our series, the mortality rate was 27%. The mortality rates for gunshot wounds, blunt trauma and stabs were 28.0%, 28.5% and 0%, respectively.
DCS is becoming an increasingly accepted form of surgery in the severely injured patient. (18) One of the most important key points is when to initiate DCS. (1) Many studies have been undertaken to determine the correct timing. Morris et al. (16) proposed early use of damage-control laparotomy in patients with temperatures of <35[degrees]C, base deficit worse than 14, and coagulopathy. Cosgriff et al. (19) stressed the importance of the damage control approach if coagulopathy is present. The conditions that predict its onset are hypotension, pH <7.10, temperature <34[degrees]C, and an ISS [greater than or equal to]25. Johnson et al. (15) proposed that a pH <7.30, transfusion requirement of 10 or more units of packed red cells with an estimated blood loss of >4 litres, and temperature [less than or equal to]35[degrees]C in combination were trigger points to initiate DCS. Another study, which focuses solely on core temperature measurement intra-operatively using a dynamic computer simulation, showed that there is a window of opportunity of 60 - 90 minutes to salvage a patient before the temperature drops below 32[degrees]C. (20) Beyond this point, mortality is as high as 100%, as Jurkovich et al. described. (21) All the above studies agree that DCS is indicated when there is derangement of temperature, pH and coagulation but differ in respect of the specific values at which it should be initiated. It could therefore be proposed that DCS should be initiated according to severity of injury and early recognition of changes in core temperature, acidosis and coagulation.
Rutherford et al. (24) identified base deficit after logistic regression analysis as a parameter predicting mortality. In our study, pH remained a significant predictor for mortality after logistic regression. Base deficit, on the other hand, was only significant when the independent-samples t-test was used.
DCS is an effective method of managing the critically injured trauma patient. To prevent death, it is of crucial importance that the need for a damage control procedure is recognised as early as possible.
This study found that age, base excess, pH and core temperature were significant pre-operative predictors of mortality. DCS should be performed when the pH falls below 7.20, the base excess is under 10.5 or the core temperature is less than 35[degrees]C.
There were no sources of financial support.
(1.) Garrison JR, Richardson JD, Hilakos AS, et al. Predicting the need to pack early for severe intra-abdominal hemorrhage. J Trauma 1996; 40: 923-929.
(2.) Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995; 222: 3-8.
(3.) Kouraklis G, Spirakos S, Glinavou A. Damage control surgery: an alternative approach for the management of critically injured patients. Surg Today 2002; 32: 195-202.
(4.) Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35: 375-383.
(5.) Carrillo C, Fogler RJ, Shaftan GW. Delayed gastrointestinal reconstruction following massive abdominal trauma. J Trauma 1993; 34: 233-235.
(6.) Hirshberg A, Wall MJ Jr, Mattox KL. Planned reoperation for trauma: a two year experience with 124 consecutive patients. J Trauma 1994; 37: 365369.
(7.) Loveland JA, Boffard KD. Damage control in the abdomen and beyond. Br J Surg 2004; 91: 1095-1101.
(8.) American College of Surgeon's Committee on Trauma. Advanced Trauma Life Support Manual. Chicago: ACS, 1997: 11-242.
(9.) Reed RL, Bracey AW, Hudson JD, et al. Hypothermia and blood coagulation: dissociation between enzyme activity and clotting factor levels. Circ Shock 1990; 32: 141-152.
(10.) Patt A, McCroskey BL, Moore EE. Hypothermia-induced coagulopathies in trauma. Surg Clin North Am 1988; 68: 775-785.
(11.) Aoki N, Wall MJ, Demsar J, et al. Predictive model for survival at the conclusion of a damage control laparotomy. Am J Surg 2000; 180: 540-545.
(12.) Sharp KW, Locicero RJ. Abdominal packing for surgically uncontrollable hemorrhage. Ann Surg 1992; 215: 467-475.
(13.) Arthurs Z, Cuadrado D, Beekley A, et al. The impact of hypothermia on trauma care at the 31st combat support hospital. Am J Surg 2006; 191: 610614.
(14.) Burch JM, Ortiz VB, Richardson RJ, et al. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg 1992; 215: 476484.
(15.) Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 2001; 51: 261-271.
(16.) Morris JA, Eddy VA, Blinman TA, et al. The staged celiotomy for trauma. Issues in unpacking and reconstruction. Ann Surg 1993; 217: 576-586.
(17.) Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the management of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 2003; 55: 1095-1110.
(18.) Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg 1983; 197: 532-535.
(19.) Cosgriff N, Moore EE, Sauaia A. Predicting life-threatening coagulopathy in the massively transfused trauma patient: hypothermia and acidoses revisited. J Trauma 1997; 42: 857-862.
(20.) Hirshberg A, Sheffer N, Barnea O. Computer simulation of hypothermia during 'damage control' laparotomy. World J Surg 1999; 23: 960-965.
(21.) Jurkovich GJ, Greiser WB, Luterman A, Curreri PW. Hypothermia in trauma victims: an ominous predictor of survival. J Trauma 1987; 27: 10191024.
(22.) Asensio JA, McDuffie L, Petrone P, et al. Reliable variables in the exsanguinated patient which indicate damage control and predict outcome. Am J Surg 2001; 182: 743-751.
(23.) Falcone RE, Santanello SA, Schulz MA, et al. Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool. World J Surg 1993; 17: 575-579.
(24.) Rutherford EJ, Morris JA Jr, Reed GW, Hall KS. Base deficit stratifies mortality and determines therapy. J Trauma 1992; 33: 417-423.
JOEP TIMMERMANS, Department of Surgery, Atrium Medical Centre, University of Maastricht, Holland
ANDREW NICOL, F.C.S. (S.A.)
Kairinos, Nick, M.B. CH.B.
Trauma Centre, Groote Schuur Hospital and University of Cape Town
JOEP TEIJINK, M.D.
MARTIN PRINS, M.D.
Department of Surgery, Atrium Medical Centre, University of Maastricht
PRADEEP NAVSARIA, M.MED. (SURG.), F.C.S. (S.A.)
Trauma Centre, Groote Schuur Hospital and University of Cape Town
Table I. ORGAN INJURIES IN 4 PATIENTS Organ injured Frequency Inferior vena cava 18 Small bowel 18 large bowel 16 liver 15 Kidney 14 Spleen 12 Duodenum 8 Iliac vessels 8 Diaphragm 7 bladder and ureter 7 Stomach 6 Pancreas 4 TABLE II. PRE-OPERATIVE FACTORS PREDICTIVE OF MORTALITY Non- Survivor survivor Factor (mean) (mean) p-value age (yrs) 26 34 0.001 base excess -10.5 -16.3 0.002 pH 7.20 7.03 <0.001 Temperature ([degrees]C) 35.0 33.5 <0.001 TABLE III. POSTOPERATIVE FACTORS PREDICTIVE OF MORTALITY Non- Survivor survivor Factor (mean) (mean) p-value Platelets 148.1 60.4 0.03 InR 1.8 2.5 0.02 blood units/24 h 11.8 18.7 0.002 TABLE IV. FACTORS NOT PREDICTIVE OF MORTALITY Factor Survivors Non-survivors p-value Glasgow coma Score (median) 14 13 0.25 Penetrating abdominal Trauma Index (median) 35 40 0.09 Revised Trauma Score (mean) 7.4 6.8 0.11 Injury Severity Score (median) 25 34 0.07 Total operations (mean) 3.4 2.7 0.24 Hb (g/dl) (mean) 9.3 9.2 0.90 mean ICU stay (d) 10.4 9.2 0.72
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