Skip to main content

Table 3 Content validity (surgeons would performed damage control in that clinical scenario or the indication predicts use of damage control in practice) of reported indications for use of damage control surgery or damage control interventions in civilian trauma patients

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

Indication (variable included in statistical analyses) Confounding factors adjusted for Outcome Content validity
Surgeon opinions on the content validity of indications for use of TAC/open abdominal management after laparotomy in cross-sectional studies
Prep for a second look [69] NA Percentage of respondents who would leave the abdomen open 6%
Abdominal organ distention [69] 22%
Inability to close the fascia [69] 20%
Physically unable to close the fascia [70] NA Percentage of respondents supporting relevance of indications for leaving the abdomen open after trauma laparotomy 87%
Planned reoperation [70] 80%
Intra-abdominal packing [70] 59%
Magnitude of injury/gestalt [70] 43%
Airway pressure measurements [70] 41%
Bladder pressure measurements [70] 39%
Visual edema of the bowel [70] 33%
Young previously healthy male; grade IV spleen injury identified at laparotomy; massive hemoperitoneum (20% blood volume loss); no other intra- or extra-abdominal injuries; 45 min laparotomy; given 4 L crystalloid and 4 U PRBCs; intraoperative temperature 36.2 °C, pH 7.34; INR 1.3; and [71] NA Percentage of respondents who would perform TACa  
 Fascial closure possible without excessive tension 1%
 Fascial closure extremely tight 45%
 Fascial closure physically not possible but skin closure is 51%
 Neither fascial nor skin closure is possible 73%
Same as the above scenario except a splenectomy was performed; intraoperative temperature 34 °C, pH 7.16, and INR 2.0; and [71]  
 Fascial closure possible without excessive tension 9%
 Fascial closure extremely tight 61%
 Fascial closure physically not possible but skin closure is 50%
 Neither fascial nor skin closure is possible 75%
Young previously healthy male; presented with severe hemorrhagic shock (40% blood volume loss); bleeding grade III stellate liver rupture with devitalization of 30% of the right hepatic lobe, grade IV spleen injury which is no longer bleeding, 6 cm diaphragmatic tear, devascularization of a 6 cm segment of small bowel, and a one-third thickness circumferential tear of the distal descending colon; after packing of liver and spleen and repair of the diaphragm, major bleeding appears controlled, but there is diffuse oozing from cut surfaces; BP is 80/40 mmHg with vasopressors and after infusion of 8 L of crystalloid and 16 U PRBCs; intraoperative temperature 34 °C, pH 7.16, and INR 2.0; and fascial closure without tension is possible [71] 75%
Subjectively tight closure [72] NA Percentage of respondents who were much less or less willing to close the abdomen after trauma laparotomy 77%
Massive bowel edema [72] 89%
Multiple intra-abdominal injuries [72] 21%
Intra-abdominal packing [72] 71%
Fecal contamination/peritonitis [72] 12%
Massive transfusion [72] 19%
Hypothermia [72] 21%
Acidosis (pH < 7.3) [72] 22%
Coagulopathy [72] 31%
Planned reoperation [72] 76%
Pulmonary deterioration on closure [72] 94%
Hemodynamic instability with closure [72] 91%
Association between indications and use of DC in practice [as predicted by cohort studies estimating the association (e.g., OR or HR for conducting DC) between certain clinical scenarios and the decision to conduct DC in practice]
Preoperative indications
High ISS [15] Study site, penetrating mechanism, major abdominal vascular injury Use of DCL OR per ISS ↑, 1.05 (95% CI, 1.02–1.07)
Systolic BP < 90 mmHg on admission and grade III–V liver injury [46] None Use of DCL Not associated with use of DCL
An artificial neural network including variables for bullet wound location (right or left chest or upper or lower abdominal quadrant) and trajectory pattern [horizontal shift (e.g., one that traversed the abdomen from RUQ to LUQ) or entry wound in back] and lowest ED systolic BP predicted that DC laparotomy would be used in patients with a horizontal shift upper abdominal trajectory pattern and a systolic BP < 105 mmHg or a RUQ wound with a bullet retained in the same quadrant and a systolic BP < 90 mmHg [55] Bullet wound location and trajectory pattern, lowest ED systolic BP Use of DCL Model Se, 83%; model Sp, 93%
Intraoperative indications
Major abdominal vascular injury [15] Study site, ISS, penetrating mechanism Use of DCL OR, 2.70 (95% CI, 1.42-5.16)
Combined AAST grade III–V liver and IV–V spleen injury [46] None Use of DCL All patients with this injury pattern underwent DCL while 42% of those without it did not (p = 0.02)
AAST grade V liver injury [46] NR Use of DCL Not associated with ↑ use of DCL when compared to patients with grade III-IV injury
Pre- or intraoperative indications (or indications for which the setting was unclear or not specified)
Multiple trauma and AAST grade III-V liver injury [46] NR Use of DCL Not associated with use of DCL
Transfusion > 10 U PRBCs and AAST grade III-V liver injury [46] NR Use of DCL Not associated with use of DCL
Transfusion of a large volume of PRBCs [41] FFP and fluids administered, BD, lactate Use of DCL OR per PRBC U ↑, 1.05 (95% CI, 0.85–1.29)
Transfusion of a large volume of FFP [41] PRBCs and fluids administered, BD, lactate Use of DCL OR per FFP U ↑, 0.95 (95% CI, 0.77–1.18)
Administration of a large volume of fluids [41] PRBCs and FFP administered, BD, lactate Use of DCL OR per L of fluids ↑, 1.13 (95% CI, 0.92–1.37)
A PRBC transfusion volume that exceeds the CAT [39] Admission systolic BP, MOI, NISS Use of DCL HR, 2.72 (95% CI, 1.26–5.91)
The number of times the PRBC transfusion volume exceeds the CAT [39] Admission systolic BP, MOI, NISS Use of DCL HR per CAT multiple, 1.27 (95% CI, 1.11–1.47) (survival was 89.3%, 66.7%, 64.3%, and 75% in CAT0, CAT1, CAT2, and CAT3 pts, respectively )[39]
Elevated BD (max BD) [41] PRBCs, FFP, and fluids transfused, lactate Use of DCL OR per max BD ↑, 1.25 (95% CI, 0.97–1.61)
Elevated lactate (max lactate) [41] PRBCs, FFP, and fluids transfused, BD Use of DCL OR per max lactate ↑, 0.94 (95% CI, 0.73–1.22)
  1. Where AAST indicates American Association for the Surgery of Trauma; BD, base deficit; BP, blood pressure; CAT, critical administration threshold (≥ 3 units of packed red blood cells administered in 1 h of the first 24 h of injury); DC, damage control; DCL, damage control laparotomy; ED, Emergency Department; GSW, gunshot wound; ISS, Injury Severity Scale score; INR, international normalized ratio; LUQ, left upper quadrant; pts, patients; NA, not applicable; PPV, positive predictive value; PRBCs, packed red blood cells; RUQ, right upper quadrant; Se, sensitivity; Sp, specificity; and TAC, temporary abdominal closure
  2. aThe definition of TAC in this study did not include mesh fascial closures