A. R. Yang1, H. Hosseinpour1, A. Nelson1, Q. Alizai1, C. Colosimo1, O. Hejazi1, A. L. Spencer1, L. Castanon1, L. J. Magnotti1, B. Joseph1 1University Of Arizona, Division Of Trauma, Critical Care, Burns, And Emergency Surgery, Department Of Surgery, Tucson, AZ, USA
Introduction: Damage control surgery is successfully used for severe abdominal trauma. Although the principles are applicable to thoracic trauma, there is a lack of data on the outcomes of thoracic damage control surgery (TDCS). The aim of this study was to describe the characteristics and outcomes of patients undergoing TDCS on a national scale.
Methods: This is a retrospective analysis of the ACS-TQIP database over 5 years (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (Pediatric [<18 yrs], Adults [18-64 yrs], Older adults [≥65yrs]). Our primary outcome measures included 6-hr, 24-hr, and in-hospital mortality. Secondary outcomes were major complications, including cardiac arrest, deep and superficial surgical site infections, sepsis, deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, unplanned intubation, unplanned return to OR, unplanned ICU admission, acute kidney injuries, ventilator-associated pneumonia, and acute respiratory distress syndrome. Descriptive statistics were performed.
Results: Over 5 years, we identified 14,192 thoracotomies, out of which 213 (0.01%) underwent TDCS (Pediatric [n=17], Adults [n=175], Older adults [n=21]). The mean (SD) age was 37 (18) and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] GCS of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median ISS and chest-AIS of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%), followed by heart (16.9%) and vessels (9.9%) being the most injured intra-thoracic structures. The median 4-hour PRBC, FFP, and platelet requirements were 14, 11, and 4 units, respectively. The median time to TDCS was 35 [16-79] minutes and 72 (33.8%) had their procedure started in ED with a median time of 13 [4-30] minutes. Moreover, the median time to first take-back operation among survivors of index surgery was 30 [12-42] hours, with 12.7% having definitive repair within their first take-back operation. Overall, the rates of 6-hr, 24-hr, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. When comparing different age groups, there was no significant difference in terms of in-hospital mortality (p=0.800) and major complications (0.416) among pediatrics, adults, and older adults (Figure).
Conclusion: One in three patients undergoing TDCS die within the first 24-hr and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. TDCS must be reserved for selected patients and future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.
