J. N. Steward1, B. A. Cotton1, J. B. Holcomb1, J. A. Harvin1 1University Of Texas Health Science Center At Houston,Houston, TX, USA
Introduction: Damage control laparotomy (DCL) is a technique initially described in the 1980’s to address multi-trauma patients with penetrating torso injury and worsening coagulopathy. However, it application increased dramatically over the next three decades and only recently has its use been called into question with data demonstrating potential morbidity and overutilization. DCL has also been shown to delay definitive repair of orthopedic injuries (especially femur fixation), with an increase in pulmonary complications. The purpose of this study was to compare pulmonary complications and delays in definitive femur fixation among patients undergoing emergent laparotomy managed by either definitive laparotomy (DEF) of DCL.
Methods: Following IRB approval, our trauma registry was queried for (1) all adult patients >17 years of age, (2) undergoing emergent laparotomy (directly to the operating room within 1-hour of arrival), and sustaining femur fracture. Patients were then divided into DEF group: patients with primary fascial closure at the end of emergent laparotomy and DCL: those whose fascia was left open at the end of the initial case. The co-primary outcomes of interest were pulmonary complications and time to femur fixation (both initial and/or definitive, internal). Univariate analysis was followed by purposeful linear and logistic regression.
Results: 106 patients met study criteria; 65 in the DCL cohort and 41 in teh DEF group. There were no differences in demographics or pre-hospital vitals between the groups, with teh exception of lower systolic blood pressurein the DCL patients (median 96 vs. 119; p=0.001). The DCL group had higher Injury severity scores (median 34 vs. 26; p<0.001), more hypotension (median 87 vs. 120; p<0.001) and shock (median -8 vs. -4; p=0.002) on arrival. While initial labs and vitals demonstarted worse physiology and coagulaopthy, the temperature (96.8 vs. 96.1), systolic (124 vs, 133), base value (-4 vs. -6) and prothrombin time (16.3 vs. 16.2) were similar. Time to definitive internal fixation was longer in the DCL group (71 vs. 32 hours; p=0.010). Multivariate modeling confirmed increased risk of pulmonary (odds ratio 1.90; p=0.039) and septic complications (odds ratio 1.86, p=0.048).
Conclusion: Employment of DCL in teh setting of emergent laparotomy delays definitive femur fixation and is associated with increased likelihood of pulmonary and septic complications.