E. A. Taub1, B. Shrestha1, B. Tsang1, B. A. Cotton1, C. E. Wade1, J. B. Holcomb1 1University Of Texas Health Science Center At Houston,Houston, TX, USA
Introduction: Increasing data has shown that Damage Control Resuscitation (DCR), employing low-volume, balanced resuscitation, is associated with improved survival in severely injured patients. However, little attention has been paid to outcomes by specific organ injury. We wanted to determine if implementation of DCR has improved survival among patients with severe blunt splenic injury.
Methods: Following IRB approval, a retrospective study was performed on all adult trauma patients with severe, blunt splenic injury admitted to our center between 01/2005-12/2012. Severe splenic injury was defined as AAST grade IV or V. Our center adopted and employed DCR principles in 2009. Therefore, patients were stratified into two groups: pre-DCR (2005-2008) and DCR (2009-2012). Patients who died before leaving the emergency department (ED) were excluded. Outcomes (resuscitation products used and survival) were then compared by univariate analysis. A purposeful regression model was then constructed to identify independent predictors of mortality.
Results: Between 2005-2012 there were 29,801 trauma admissions, with 224 patients 18 years of age or older who sustained blunt AAST grade IV or V splenic injuries. Of these, 206 patients survived to leave the ED and made up the study group; 83 pre-DCR and 123 DCR patients. The groups were similar in demographics, prehospital and ED vital signs. However, DCR patients had a higher abdominal AIS scores (median 4 vs. 4; p=0.050). While arrival physiology and base deficit were similar, DCR patients had higher aPTT (median 28.2 vs. 26.4; p=0.017) and lower initial platelet count (median 223 vs. 246; p=0.019). DCR patients received more plasma (median 2 vs. 0 U; p<0.001) and less crystalloid (median 0.1 vs. 1.0 L; <0.001) while in the ED. Splenectomy rates were higher, but not statistically significant, in DCR patients (58 vs. 47%; p=0.103). DCR patients received less RBC (median 2 vs. 6 U), plasma (median 2 vs. 4 U), platelets (median 0 vs. 0) and crystalloid (median 1.0 vs. 3.1 L) in the operating room; all p<0.05. While there were no differences in ICU complications, mortality was lower, but not statistically significant, in the DCR group (10 vs. 19%; p=0.106). Multiple logistic regression demonstrated that DCR was an independent predictor of decreased mortality (odds ratio 0.05, 95% C.I. 0.006-0.341; p=0.003). In addition, this same model (controlling for age, abdominal AIS, admission platelet count) found that DCR was not associated with increased likelihood of splenectomy (odds ratio 1.29, 95% C.I. 0.693-2.431, p=0.419).
Conclusion: In patients with severe splenic injury, implementation of DCR has been associated with a 95% reduction in mortality at our facillity.