Damage control laparotomy utilization rates are highly variable among Level I trauma centers: Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings

Justin Jeremiah Joseph Watson, Jamison Nielsen, Kyle Hart, Priya Srikanth, John D. Yonge, Christopher R. Connelly, Phillip M. Kemp Bohan, Hillary Sosnovske, Barbara C. Tilley, Gerald Van Belle, Bryan A. Cotton, Terence OKeeffe, Eileen M. Bulger, Karen J. Brasel, John B. Holcomb, Martin A. Schreiber

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

Background: Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma-induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, international normalized ratio, temperature and major intra-abdominal vascular injury would not adequately capture all patients. Methods: Trauma patients at 12 Level 1 North American trauma centers were randomized based on transfusion ratios as described in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. We analyzed outcomes after emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results: Three hundred twenty-nine patients underwent emergent laparotomy: 213 (65%) DCL and 116 (35%) definitive surgical management. DCL rates varied between institutions (33-83%), (p = 0.002). Median Injury Severity Score (ISS) was higher in the DCL group, 29 (interquartile range, 13-34) versus 21 (interquartile range, 22-41) (p < 0.001). Twenty-four-hour mortality was 19% with DCL versus 4% (p < 0.001); 30-day mortality was 28% with DCL versus 19% (p < 0.001). In a mixed-effects model, ISS and major intra-abdominal vascular injury were correlates of DCL (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.07 and OR, 2.7; 95% CI, 1.4-5.2). DCL was not associated with 30-day mortality (OR, 2.33; 95% CI, 0.97-5.60). Correlates included ISS (OR, 1.06; 95% CI, 1.02-1.09), PRBCs in 24 hours (OR, 1.10; 95% CI, 1.03-1.18), and age (OR, 1.04; 95% CI, 1.01-1.06). No significant mortality difference was detected between institutions (p = 0.63). Sepsis and VAP occurred more frequently with DCL (p < 0.05). Eighty percent (135/213) of DCL patients met standard criteria. Conclusion: Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications. Level of Evidence: Therapeutic study, level III.

Original languageEnglish (US)
Pages (from-to)481-488
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Volume82
Issue number3
DOIs
StatePublished - Mar 1 2017
Externally publishedYes

Fingerprint

Trauma Centers
Laparotomy
Blood Platelets
Mortality
Odds Ratio
Confidence Intervals
Injury Severity Score
Abdominal Injuries
Vascular System Injuries
Sepsis
International Normalized Ratio
Wounds and Injuries

Keywords

  • Variability
  • control
  • damage
  • laparotomy
  • trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Damage control laparotomy utilization rates are highly variable among Level I trauma centers : Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings. / Watson, Justin Jeremiah Joseph; Nielsen, Jamison; Hart, Kyle; Srikanth, Priya; Yonge, John D.; Connelly, Christopher R.; Kemp Bohan, Phillip M.; Sosnovske, Hillary; Tilley, Barbara C.; Van Belle, Gerald; Cotton, Bryan A.; OKeeffe, Terence; Bulger, Eileen M.; Brasel, Karen J.; Holcomb, John B.; Schreiber, Martin A.

In: Journal of Trauma and Acute Care Surgery, Vol. 82, No. 3, 01.03.2017, p. 481-488.

Research output: Contribution to journalArticle

Watson, JJJ, Nielsen, J, Hart, K, Srikanth, P, Yonge, JD, Connelly, CR, Kemp Bohan, PM, Sosnovske, H, Tilley, BC, Van Belle, G, Cotton, BA, OKeeffe, T, Bulger, EM, Brasel, KJ, Holcomb, JB & Schreiber, MA 2017, 'Damage control laparotomy utilization rates are highly variable among Level I trauma centers: Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings', Journal of Trauma and Acute Care Surgery, vol. 82, no. 3, pp. 481-488. https://doi.org/10.1097/TA.0000000000001357
Watson, Justin Jeremiah Joseph ; Nielsen, Jamison ; Hart, Kyle ; Srikanth, Priya ; Yonge, John D. ; Connelly, Christopher R. ; Kemp Bohan, Phillip M. ; Sosnovske, Hillary ; Tilley, Barbara C. ; Van Belle, Gerald ; Cotton, Bryan A. ; OKeeffe, Terence ; Bulger, Eileen M. ; Brasel, Karen J. ; Holcomb, John B. ; Schreiber, Martin A. / Damage control laparotomy utilization rates are highly variable among Level I trauma centers : Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings. In: Journal of Trauma and Acute Care Surgery. 2017 ; Vol. 82, No. 3. pp. 481-488.
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abstract = "Background: Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma-induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, international normalized ratio, temperature and major intra-abdominal vascular injury would not adequately capture all patients. Methods: Trauma patients at 12 Level 1 North American trauma centers were randomized based on transfusion ratios as described in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. We analyzed outcomes after emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results: Three hundred twenty-nine patients underwent emergent laparotomy: 213 (65{\%}) DCL and 116 (35{\%}) definitive surgical management. DCL rates varied between institutions (33-83{\%}), (p = 0.002). Median Injury Severity Score (ISS) was higher in the DCL group, 29 (interquartile range, 13-34) versus 21 (interquartile range, 22-41) (p < 0.001). Twenty-four-hour mortality was 19{\%} with DCL versus 4{\%} (p < 0.001); 30-day mortality was 28{\%} with DCL versus 19{\%} (p < 0.001). In a mixed-effects model, ISS and major intra-abdominal vascular injury were correlates of DCL (odds ratio [OR], 1.05; 95{\%} confidence interval [CI], 1.02-1.07 and OR, 2.7; 95{\%} CI, 1.4-5.2). DCL was not associated with 30-day mortality (OR, 2.33; 95{\%} CI, 0.97-5.60). Correlates included ISS (OR, 1.06; 95{\%} CI, 1.02-1.09), PRBCs in 24 hours (OR, 1.10; 95{\%} CI, 1.03-1.18), and age (OR, 1.04; 95{\%} CI, 1.01-1.06). No significant mortality difference was detected between institutions (p = 0.63). Sepsis and VAP occurred more frequently with DCL (p < 0.05). Eighty percent (135/213) of DCL patients met standard criteria. Conclusion: Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications. Level of Evidence: Therapeutic study, level III.",
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author = "Watson, {Justin Jeremiah Joseph} and Jamison Nielsen and Kyle Hart and Priya Srikanth and Yonge, {John D.} and Connelly, {Christopher R.} and {Kemp Bohan}, {Phillip M.} and Hillary Sosnovske and Tilley, {Barbara C.} and {Van Belle}, Gerald and Cotton, {Bryan A.} and Terence OKeeffe and Bulger, {Eileen M.} and Brasel, {Karen J.} and Holcomb, {John B.} and Schreiber, {Martin A.}",
year = "2017",
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TY - JOUR

T1 - Damage control laparotomy utilization rates are highly variable among Level I trauma centers

T2 - Pragmatic, Randomized Optimal Platelet and Plasma Ratios findings

AU - Watson, Justin Jeremiah Joseph

AU - Nielsen, Jamison

AU - Hart, Kyle

AU - Srikanth, Priya

AU - Yonge, John D.

AU - Connelly, Christopher R.

AU - Kemp Bohan, Phillip M.

AU - Sosnovske, Hillary

AU - Tilley, Barbara C.

AU - Van Belle, Gerald

AU - Cotton, Bryan A.

AU - OKeeffe, Terence

AU - Bulger, Eileen M.

AU - Brasel, Karen J.

AU - Holcomb, John B.

AU - Schreiber, Martin A.

PY - 2017/3/1

Y1 - 2017/3/1

N2 - Background: Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma-induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, international normalized ratio, temperature and major intra-abdominal vascular injury would not adequately capture all patients. Methods: Trauma patients at 12 Level 1 North American trauma centers were randomized based on transfusion ratios as described in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. We analyzed outcomes after emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results: Three hundred twenty-nine patients underwent emergent laparotomy: 213 (65%) DCL and 116 (35%) definitive surgical management. DCL rates varied between institutions (33-83%), (p = 0.002). Median Injury Severity Score (ISS) was higher in the DCL group, 29 (interquartile range, 13-34) versus 21 (interquartile range, 22-41) (p < 0.001). Twenty-four-hour mortality was 19% with DCL versus 4% (p < 0.001); 30-day mortality was 28% with DCL versus 19% (p < 0.001). In a mixed-effects model, ISS and major intra-abdominal vascular injury were correlates of DCL (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.07 and OR, 2.7; 95% CI, 1.4-5.2). DCL was not associated with 30-day mortality (OR, 2.33; 95% CI, 0.97-5.60). Correlates included ISS (OR, 1.06; 95% CI, 1.02-1.09), PRBCs in 24 hours (OR, 1.10; 95% CI, 1.03-1.18), and age (OR, 1.04; 95% CI, 1.01-1.06). No significant mortality difference was detected between institutions (p = 0.63). Sepsis and VAP occurred more frequently with DCL (p < 0.05). Eighty percent (135/213) of DCL patients met standard criteria. Conclusion: Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications. Level of Evidence: Therapeutic study, level III.

AB - Background: Damage control laparotomy (DCL) is intended to limit deleterious effects from trauma-induced coagulopathy. DCL has been associated with mortality reduction, but may increase complications including sepsis, abscess, respiratory failure, hernia, and gastrointestinal fistula. We hypothesized that (1) DCL incidence would vary between institutions; (2) mortality rates would vary with DCL rates; (3) standard DCL criteria of pH, international normalized ratio, temperature and major intra-abdominal vascular injury would not adequately capture all patients. Methods: Trauma patients at 12 Level 1 North American trauma centers were randomized based on transfusion ratios as described in the Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial. We analyzed outcomes after emergent laparotomy using a mixed-effects logistic model comparing DCL versus definitive surgical management with random effect for study site. Primary outcomes were 24-hour and 30-day mortality. Results: Three hundred twenty-nine patients underwent emergent laparotomy: 213 (65%) DCL and 116 (35%) definitive surgical management. DCL rates varied between institutions (33-83%), (p = 0.002). Median Injury Severity Score (ISS) was higher in the DCL group, 29 (interquartile range, 13-34) versus 21 (interquartile range, 22-41) (p < 0.001). Twenty-four-hour mortality was 19% with DCL versus 4% (p < 0.001); 30-day mortality was 28% with DCL versus 19% (p < 0.001). In a mixed-effects model, ISS and major intra-abdominal vascular injury were correlates of DCL (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.07 and OR, 2.7; 95% CI, 1.4-5.2). DCL was not associated with 30-day mortality (OR, 2.33; 95% CI, 0.97-5.60). Correlates included ISS (OR, 1.06; 95% CI, 1.02-1.09), PRBCs in 24 hours (OR, 1.10; 95% CI, 1.03-1.18), and age (OR, 1.04; 95% CI, 1.01-1.06). No significant mortality difference was detected between institutions (p = 0.63). Sepsis and VAP occurred more frequently with DCL (p < 0.05). Eighty percent (135/213) of DCL patients met standard criteria. Conclusion: Although DCL utilization varied significantly between institutions, there was no significant mortality difference between centers. This finding suggests tempering DCL use may not decrease mortality, but could decrease related complications. Level of Evidence: Therapeutic study, level III.

KW - Variability

KW - control

KW - damage

KW - laparotomy

KW - trauma

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