K. Asi1, M. George1, M. D. Swartz1, M. McNutt1, L. Moore1, C. Wade1, B. Cotton1, J. Holcomb1, J. Harvin1 1University Of Texas Health Science Center At Houston,Department Of Surgery, Division Of Acute Care Surgery,Houston, TX, USA
Introduction: Damage control laparotomy (DCL) in severely injured patients is associated with improved survival in the setting of acidosis, coagulopathy and hypothermia. The decision to leave a patient’s abdomen open after the initial laparotomy is multifactorial and can depend on resources and assistance available, which varies based on time of day even at major trauma centers. We hypothesized that fewer immediately available resources on nights, weekends and holidays would increase the rate of DCL.
Methods: All trauma patients from 2011-2015 who underwent emergent laparotomy were included. Emergent laparotomy in this patient population was defined as admission from the emergency department (ED) directly to the operating room (OR). Intraoperative deaths were excluded from analysis. Patients were grouped by the time of ED arrival: 1) Monday through Friday 7:00 AM to 5:00 PM and 2) Monday through Friday 5:00 PM to 7:00 AM, weekends, and institutional holidays. The groups were compared in a univariate fashion to determine differences in baseline characteristics. A purposeful multivariate logistic regression model was constructed using variables selected a priori (mechanism, Injury Severity Score [ISS], ED and OR transfusions) as well as those found to be both statistically and clinically significant on univariate analysis. Continuous variables are presented as: median with 25th and 75th inter-quartile ranges [IQR].
Results: From 1/1/2011-12/31/2015 there were 23,410 trauma admissions. 1,058 underwent emergent laparotomy – 687 (65%) definitive laparotomy, 325 (31%) DCLs, and 46 intraoperative deaths (4%). On weekdays 203 (19%) emergent laparotomies were performed, with 121 (60%) being definitive, 72 (35%) DCL, and 10 intraoperative deaths (5%). On nights, weekends and holidays, 855 (81%) emergent laparotomies were performed, with 566 (66%) being definitive, 253 (30%) DCL, and 36 (4%) intraoperative deaths. The table summarizes characteristics of patients surviving the initial emergent laparotomy. Controlling for age, injury mechanism, and arrival physiology, multivariate analysis demonstrated that Injury Severity Score (OR 1.04, 95% CI 1.02-1.06, p<0.001) and ED and OR blood transfusions (OR 1.23, 95% CI 1.17-1.28, p<0.001) were associated with an increased odds of DCL. Weeknight, weekend, and holiday laparotomy were not associated with DCL (OR 1.30, 95% CI 0.81-2.09, p=0.0.284).
Conclusions: Patients undergoing emergent trauma laparotomy on weeknights, weekends, and holidays are not more likely to be managed with DCL than those patients cared for during the weekdays. Weeknight, weekend, and holiday resources appear sufficient to not factor into the decision to perform damage control.
