K. M. Ibraheem1, P. Rhee1, A. A. Haider1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, R. Latifi1, G. Vercruysse1, L. Gries1, R. Friese1, B. Joseph1 1University Of Arizona,Trauma Surgery,Tucson, AZ, USA
Introduction: Major hepatic trauma (AAST grade ≥4) classically has been associated with mortality as high as 80%. With improvements in resuscitation, increased utilization of angioembolization, and non-operative management, morality associated with these injuries is expected to change. The aim of this study was to assess our experience with the management of major hepatic injuries, to determine if there is a difference in mortality with the use of different techniques for hemorrhage control, and to determine factors associated with mortality.
Methods: We performed a 4 year (2009-2012) retrospective analysis of all patients with major hepatic injuries (AAST grade ≥4) who presented to our trauma center and abstracted information regarding patient injuries, physiological parameters, resuscitation details, radiological findings, and operative details. Our outcome measures were mortality. Multivariate regression and ROC curve analysis were performed.
Results: A total of 98 (Grade 4, 73; Grade 5, 25) patients with a mean age of 30.6 ±19.1 years and mean ISS of 26 [18 – 34] were included. 27.6% (n=27) had other solid organ injuries and 12.2% (n=12) had juxtahepatic vascular injuries. 26.5% (n=26) patients required massive transfusion; and mean pRBC and FFP packs transfused were 8±11 and 5±8 units respectively. 66.3% (n=65) patients required operative intervention and mean estimated blood loss was 2500 mL. The most common hemorrhage control techniques performed were packing (36.7%, n=36) and hepatorraphy (34.7%, n=34) followed by Pringle’s (18.4%, n=18), hepatotomy (8.2%, n=8), non-anatomical resection (4.1%, n=4), omental packing (3.1%, n=3), total hepatic isolation (3.1%, n=3), atriocaval shunt (1.0%, n=1), and lobectomy (1.0%, n=1). Angioembolization was performed in (8.2%, n=8) patients. Overall mortality rate was 28.6% (n=28). Mortality rate with packing (70.6%) was significantly higher as compared to hepatorraphy (18.8%) and angioembolization (0.0%; p<0.001). The strongest predictor of mortality was 24hours pRBC transfusion (OR [CI]: 1.8 [1.3-2.6]; p=001). ROC curve analysis revealed >4.5units of pRBC transfusion as the most sensitive cutoff associated with mortality.
Conclusion: The use of angioembolization and hepatorraphy for hemorrhage control are associated with significantly lower mortality compared to packing after major hepatic trauma. Greater than 4.5 units of pRBC requirement is the most sensitive cutoff associated with mortality in these patients.