S. Ahmad4, L. O’Meara3, E. Klyushnenkova2, T. M. Scalea2,3, J. Diaz2,3, B. R. Bruns2,3 2University Of Maryland School Of Medicine,Surgery,Baltimore, MD, USA 3R. Adams Cowley Shock Trauma Center,Surgery,Baltimore, MD, USA 4University Of Maryland,Department Of Surgery,Baltimore, MD, USA
Introduction: Abbreviated laparotomy and open abdomen have shown acceptable mortality rates for non-trauma, acute care surgery (ACS) patients with abdominal catastrophe. However, these studies are retrospective and limited in size. In prospective fashion, we aimed to identify demographic and hospital course variables that were associated with in-hospital mortality.
Methods: All adult ACS patients managed with open abdomen from June 2013 until December 2013 were prospectively enrolled into an IRB-approved study at a single university medical center. Variables examined include demographics, Charlson Comorbidity Index (CCI), operative interventions, laboratory data, and outcomes. Wilcoxon rank sum, Fisher’s exact, and paired t tests were used to determine differences between survivors and non-survivors.
Results: 58 patients (32 male, 26 female) were managed with open abdomen over a 6-month period with 25 in-hospital mortalities (43%). There was an association between age and mortality. Patients who died were older than those who survived (median 66 vs. 62 years, p=0.012). Mortality was not associated with gender, BMI (median 33.8), CCI, type of initial surgery, hospital or ICU length of stay (median 24.5 and 18 days, respectively), or time from initial surgery to death (median 16 days). The most common indication for laparotomy was mesenteric ischemia (n=12), followed closely by perforated viscus or pneumoperitoneum (n=11). No single indication for surgery was associated with increased mortality. The most common indication for open abdomen was need for damage control (n=30, 52%); however, presence of contamination or clinical indications for damage control (acidosis, coagulopathy, or hypothermia) had no association with mortality. Ventilator associated pneumonia was associated with increased mortality (p=0.003). Lower preoperative platelet level (p=0.003) and hemoglobin level (p=0.046) were associated with increased mortality, but white blood cell count, INR, lactate, pH, and base deficit were not.
Conclusion: This effort represents a large, single-institution, prospective cohort of ACS patients managed with open abdomen. Age, development of ventilator-associated pneumonia, platelet level, and to a lesser degree, hemoglobin level were associated with mortality. Contrary to previous studies, presence of intra-abdominal sepsis and damage control indicators at time of operation were not associated with increased mortality. ACS patients managed with open abdomen, in contrast to trauma, represent an older population with significant medical co-morbidities and a high likelihood of mortality.
