Damage-control resuscitation

increases successful non-operative

management rates and survival after

severe blunt liver injury

Binod Shrestha, MD, John B. Holcomb, MD,

Elizabeth A. Camp, PhD et al, Houstan, Texas

The Journal of Trauma and Acute care surgery

Volume 78, Number 2

Background

The liver is the most common solid organ in adult

abdominal trauma

The management of blunt liver injury had changed to

non-operative management in lower grade since

1980s.

In high grade has still required operative management.

In high grade [IV,V,VI]patients always use massive

amount of fluid during initial resuscitation and didnt

have a good result due to multiple injury.

Patients who survive develop more complications, and

non-operative management tends to fail more than in

lower-grade injuries.

Background

Damage control Resuscitation

Crystalloid-based Blood product based and

permission hypotension enabling perfusion to vital

organ

Dilutional coagulopathy & cellular dysfunction

In OR, abdominal compartment syndrome, organ

failure, blood product use, hospital charges, fascial

closure time.

Background

Patients and Method

Study setting :

- Memorial Hermann Hospital

- UTHealths affliiated teaching hospital

Patient population :

- Trauma patients who sustained a blunt liver injury from

January 2005 December 2011

- Patient with a blunt liver injury of AAST-OIS Grade IV or

higher

- Severe or high grade liver injury -> AAST-OIS Grade IV, V, VI

- Exclusion -> Patients younger than 16 years who were

transferred from another institution, or who died in

emergency department (ED)

Study setting :

In-hospital mortality

Data collection :

- Standard demographic data

- Liver injury grading -> surgeons operative note or

radiologists report from abdominal CT scan

- Damaged control resuscitation (DCR)

Patients and Method

Pre-DCR

(2005-2008)

DCR

(2009-2011)

Management in OR/IR

Management in

non-operative group

Management in OR/IR

Management in

non-operative group

Patients and Method

PATIENTS AND METHODS

Definitions :

- Patients went to the OR -> liver procedure

- Patients went to the IR suite -> therapeutic angioembolization of

hepatic vessels

- Patients in non-operative group :

1) Didnt go to the OR or IR.

2) Went to the OR but not for a hepatic procedure.

3) Went to the IR suite for a diagnostic procedure, but not for

angioembolization of hepatic vessels.

- Mortality -> death within the initial hospital stay of any cause

PATIENTS AND METHODS

Definitions (continue) :

- Morbidity :

1) Infectious complications (pneumonia, intra-abdominal abscess

and sepsis)

2) Liver-related complications (hepatic rebleeding, liver failure and

biliary complication)

3) Other complications (bleeding from other sites other than liver,

ACS, DVT, PE)

- Abdominal compartment syndrome (ACS) -> abdominal hypertension

with organ dysfunction necessitating operative intervention and

documentation by the trauma attending physician

PATIENTS AND METHODS

Definitions (continue) :

- Hepatic rebleeding -> Any bleeding from the liver, occurring after

initial management, necessitating unplanned surgical or radiological

intervention

- Biliary complications -> bile leakage, bile peritonitis, biloma, biliary

fistula and any gall bladder-related events requiring endoscopic or

surgical intervention documented by the trauma attending physician

- PE and DVT -> documented after confirmation by CT chest and limb

U/S

PATIENTS AND METHODS

Definitions (continue) :

- Systemic inflammatory response syndrome (SIRS) :

1) T > 38oC or < 36oC

2) HR > 90 bpm

3) RR > 20 /min or PaCO2 < 32 mmHg

4) WBC count > 12,000/mL or < 4,000/mL or band form > 10%

- Infectious complications -> SIRS + clinical + culture positive

- Intra-abdominal abscess -> hepatic abscess and abscess from a

nonhepatic source after confirmation from radiologic or surgical

evidence

PATIENTS AND METHODS

Definitions (continue) :

- Ventilator free days

= days alive and free from the ventilator

= 30 total ventilator days

- For those who died before 30 days and had no days free of

ventilator, this was recorded as 0.

- ICU free days

= days alive and not admitted to the ICU

= 30 total ICU days

- Hospital free days

= days alive and not admitted to the hospital

= 30 hospital days

Statistical analysis :

- Retrospective study

- Outcomes were compared by univariate and

multivariate analysis.

Patients and Method

Patients and Method

The full implementation of DCR in 2009, a substantial decrease in the volumes of

crystalloid and blood products administered during the first 24 hours of hospital

admission to patients with severe liver injuries was observed.

- There was no significant difference in the volume of crystalloid administered in

patients who did not receive blood products.

- In patients who received blood products, the patients in the pre-DCR group

received significantly more blood products and crystalloid volume than the

patients in the DCR group during the first 24 hours of hospital admission

When evaluating only the patients who did not receive blood products, there

was no difference in survival between pre-DCR

and DCR groups. The impact on survival seemed to be only among those patients

who received blood products

- There was significant improvement in ventilator-free days and ICU-free days in

the DCR group.

- There was no significant difference in the number of patients experiencing

complications between groups.

- Forward stepwise regression was used and generated the core variables for

analysis (ISS, 24-hour RBC, 24-hour plasma, and 24-hour crystalloid volumes

and ED GCS). The model demonstrated an R-squared of 0.6842 and adjusted R-

squared of 0.6404.

- A multiple logistic regression model was generated using these five variables

and adding DCR and non-operative

management.

1.The DCR cohort had an increase in successful nonoperative

management (from 54% to 74%, p < 0.01)

2.The DCR cohort had a reduction in initial 24-hour packed red

blood cell (median, from 13 U to 6.5 U; p < 0.01), plasma

(median, from 13 U to 8 U; p < 0.01), and crystalloid (median, from

5,800 mL to 4,100 mL; p < 0.01) administration

3.The DCR treatment was associated with improved survival, from

73% to 94% (p < 0.01).

Conclusion

DCR Pre-DCR

- increased survival rate in patient

received any blood products

- successful non-operative

management rate

- decreased blood product and

crystalloid use

- decreased intra-abdominal sepsis

rate

- decreased day in ICU

- Increased ventilator-free days

- No difference in hepatic-related, infectious, or thromboembolic

complications

Conclusion

The largest single-center series to date examining

severe blunt liver injuries

DCR

- increased survival rate in patient received any blood

products

- successful non-operative management rate

- decreased blood product and crystalloid use

- decreased intra-abdominal sepsis rate

- decreased day in ICU

- Increased ventilator-free days

Conclusion