Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

Abstract Background Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). Methods We searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. Conclusions Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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Evidence for Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients: A Systematic Review

10.21203/rs.3.rs-126134/v1 ◽

2020 ◽

Author(s):

Derek J. Roberts ◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Andrew W. Kirkpatrick ◽

Chad G. Ball ◽

...

Keyword(s):

Systematic Review ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Clinical Scenario ◽

Cross Sectional ◽

Iliac Vessel ◽

Civilian Trauma ◽

Definitive Surgery

Abstract Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring >10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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Opinions of Practicing Surgeons on the Appropriateness of Published Indications for Use of Damage Control Surgery in Trauma Patients: An International Cross-Sectional Survey

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2016.06.002 ◽

2016 ◽

Vol 223 (3) ◽

pp. 515-529 ◽

Cited By ~ 20

Author(s):

Derek J. Roberts ◽

David A. Zygun ◽

Peter D. Faris ◽

Chad G. Ball ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Damage Control ◽

Damage Control Surgery ◽

Trauma Patients ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Indications For Use

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A protocol for a scoping and qualitative study to identify and evaluate indications for damage control surgery and damage control interventions in civilian trauma patients

BMJ Open ◽

10.1136/bmjopen-2014-005634 ◽

2014 ◽

Vol 4 (7) ◽

pp. e005634-e005634 ◽

Cited By ~ 11

Author(s):

D. J. Roberts ◽

D. A. Zygun ◽

A. W. Kirkpatrick ◽

C. G. Ball ◽

P. D. Faris ◽

...

Keyword(s):

Qualitative Study ◽

Damage Control ◽

Damage Control Surgery ◽

Trauma Patients ◽

Civilian Trauma

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Damage control in penetrating duodenal trauma: less is better

Colombia Medica ◽

10.25100/cm.v52i2.4509 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4104509

Author(s):

Carlos Alberto Ordoñez ◽

Michael Parra ◽

Mauricio Millan ◽

Yaset Caicedo ◽

Natalia Padilla ◽

...

Keyword(s):

Surgical Management ◽

Primary Repair ◽

Damage Control ◽

Treatment Algorithm ◽

Surgical Techniques ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Severe Injuries ◽

Duodenal Injuries

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma which are commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and consequential increase in the rates of mortality. The aim of this article is to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery which sticks to the philosophy of “Less is Better”. Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability and/or significant associated injuries then the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

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Epidemiological evaluation of hepatic trauma victims undergoing surgery

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-69912016001006 ◽

2016 ◽

Vol 43 (1) ◽

pp. 22-27 ◽

Cited By ~ 5

Author(s):

Mitre Kalil ◽

Isaac Massaud Amim Amaral

Keyword(s):

Blunt Trauma ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Liver Trauma ◽

Metropolitan Region ◽

Trauma Patients ◽

Hepatic Trauma ◽

Female Ratio ◽

Packed Red Blood Cells

Objective : to evaluate the epidemiological variables and diagnostic and therapeutic modalities related to hepatic trauma patients undergoing laparotomy in a public referral hospital in the metropolitan region of Vitória-ES. Methods : we conducted a retrospective study, reviewing charts of trauma patients with liver injuries, whether isolated or in association with other organs, who underwent exploratory laparotomy, from January 2011 to December 2013. Results : We studied 392 patients, 107 of these with liver injury. The male: female ratio was 6.6 : 1 and the mean age was 30.12 years. Penetrating liver trauma occurred in 78.5% of patients, mostly with firearms. Associated injuries occurred in 86% of cases and intra-abdominal injuries were more common in penetrating trauma (p <0.01). The most commonly used operative technique was hepatorrhaphy and damage control surgery was applied in 6.5% of patients. The average amounts of blood products used were 6.07 units of packed red blood cells and 3.01 units of fresh frozen plasma. The incidence of postoperative complications was 29.9%, the most frequent being infectious, including pneumonia, peritonitis and intra-abdominal abscess. The survival rate of patients suffering from blunt trauma was 60%, and penetrating trauma, 87.5% (p <0.05). Conclusion : despite technological advances in diagnosis and treatment, mortality rates in liver trauma remain high, especially in patients suffering from blunt trauma in relation to penetrating one.

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Indications for Use of Damage Control Surgery in Civilian Trauma Patients

Annals of Surgery ◽

10.1097/sla.0000000000001347 ◽

2016 ◽

Vol 263 (5) ◽

pp. 1018-1027 ◽

Cited By ~ 44

Author(s):

Derek J. Roberts ◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Chad G. Ball ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Damage Control ◽

Damage Control Surgery ◽

Trauma Patients ◽

Civilian Trauma ◽

Indications For Use

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Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

Journal of Endovascular Resuscitation and Trauma Management ◽

10.26676/jevtm.v5i1.168 ◽

2021 ◽

Vol 5 (1) ◽

Author(s):

Derek Jason Roberts ◽

Juan Duchesne ◽

Megan L. Brenner ◽

Bruno Pereira ◽

Bryan A. Cotton ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Damage Control ◽

Damage Control Surgery ◽

Healthcare Resource Utilization ◽

Trauma Patients ◽

Appropriate Use ◽

Initial Surgery ◽

Civilian Trauma ◽

Planned Reoperation

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit patients more likely to succumb from the “vicious cycle” of hypothermia, acidosis, and coagulopathy and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete organ repairs. However, there currently exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long lengths of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are expected to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to guide medical and surgical education, quality improvement, and surgical practice.

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Not All Abdomens Are the Same: A Comparison of Damage Control Surgery for Intra-abdominal Sepsis versus Trauma

The American Surgeon ◽

10.1177/000313481608200518 ◽

2016 ◽

Vol 82 (5) ◽

pp. 427-432 ◽

Cited By ~ 3

Author(s):

Jason W. Smith ◽

Nick Nash ◽

Levi Procter ◽

Matthew Benns ◽

Glen A. Franklin ◽

...

Keyword(s):

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Abdominal Sepsis ◽

Fascial Closure ◽

Trauma Patients ◽

Complication Rates ◽

Emergency General Surgery ◽

Risk Of Death ◽

Abdominal Complication

Damage control surgery (DCS) was developed to manage exsanguinating trauma patients, but is increasingly applied to the management of peritoneal sepsis and abdominal catastrophes. Few manuscripts compare the outcomes of these surgeries on disparate patient populations. A multi-institutional three group propensity score matched case cohort study comparing penetrating trauma (PT-DCS), blunt trauma (BT-DCS), and intraperitoneal sepsis (IPS-DCS) was performed comparing patients treated with DSC between 2008 and 2013. Propensity scoring was performed using demographic and presenting physiologic data. Four hundred and twelve patients were treated with DCS across two institutions. Propensity matching for age, gender, and initial Acute Physiology and Chronic Health Evaluation II score 80 identified 80 patients per group for comparison. Rate of primary fascial closure was lowest in the IPS-DCS group, and highest in the penetrating trauma DCS group. Intra-abdominal complication rates were highest in the IPS-DCS group. IPS-DCS had increased time to definitive closure compared with the other two groups (RR 1.8; 1.3–2.2; P < 0.03). Mortality at 90 days was highest in the IPS-DCS group and patients whose definitive closure was delayed >eight days were more than twice the risk of death at 90 days across all groups. (RR 2.15; 1.2–3.5; P < 0.002). Expected outcomes after the use of DCS for trauma and emergency general surgery are quite different. Despite this difference, prompt abdominal closure at the earliest possible opportunity afforded the best outcome in patients managed via DCS.

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Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2018-000235 ◽

2019 ◽

Vol 4 (1) ◽

pp. e000235 ◽

Cited By ~ 1

Author(s):

Ross Weale ◽

Victor Kong ◽

Johan Buitendag ◽

Abraham Ras ◽

Joanna Blodgett ◽

...

Keyword(s):

South Africa ◽

Abdominal Trauma ◽

Injury Severity ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Organ Injury ◽

Trauma Patients ◽

Abbreviated Injury Scale ◽

Trauma Service

BackgroundThis study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS.MethodsAll patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest.ResultsA total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS.ConclusionDCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.Levels of evidenceLevel III.

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