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Table 4 Construct validity (how well one indication or a combination of indications and demographic variables predicted patient outcomes in patients not treated with damage control) of reported indications for use of damage control surgery 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) % DC pts in the study Confounding factors adjusted for Outcome Predictive validity
Preoperative indications
Overall injury burden
High ISS 0 BD, temperature Survival BD, temperature OR per ISS ↑, 1.12 (95% CI, 1.03 to 1.23) [57]
100 None Survival ↑ mean ISS in non-survivors vs. survivors (38 vs. 29, p < 0.05) [61]
Volume and/or type of resuscitation provided
Transfusion of a large volume of PRBCs 100 None Survival ↑ mean U PRBCs transfused in non-survivors vs. survivors (20 vs. 14, p < 0.01) [61]
Degree of physiologic insult
Prolonged duration of hypotension 100 None Survival ↑ mean duration of preoperative hypotension in non-survivors vs. survivors (90 vs. 50 min., p < 0.05) [61]
Hypothermia (min temperature) 0 BD, ISS Survival OR per min temperature ↓ in °C, 0.32 (95% CI, 0.15 to 0.64) [57]
Temperature < 35 °C 100 Age, BD, pH Survival ↓ temperature not independently associated with survival [47]
Elevated BD (max BD) 0 ISS, temperature Survival OR per max BD ↑, 0.66 (95% CI, 0.56 to 0.78) [57]
BD > 10.5 mEq/L 100 Age, pH, temperature Survival ↑ BD not independently associated with survival [47]
Decreased pH 100 None Survival ↓ mean pH in non-survivors vs. survivors (7.1 vs. 7.3, p < 0.05) [61]
pH < 7.20 100 Age, BD, temperature Survival ↑ pH independently associated with ↓ survival (p = 0.001) [47]
Decreased platelet count 100 None Survival ↓ mean platelet count in non-survivors vs. survivors (179,000 vs. 229,000 mm3) [61]
Laboratory-confirmed coagulopathy 100 None Survival ↑ mean PT (22 vs. 14 s) and PTT (69 vs. 42 s) in non-survivors vs. survivors (p < 0.05 for both) [61]
PT ≥ 16 s 100 None Survival OR, 0.11 (p < 0.05) [63]
PTT ≥ 50 s 100 None Survival OR, 0 (survival, 0% vs. 71% with PTT <50 sec; p < 0.05) [63]
A model included highest ED BD, lowest ED temperature, and ISS 0 BD, lowest ED temperature, ISS Survival Model Se, 83%; model Sp, 93% [57]
A model predicting that survival was possible only when the equation 0.012(age) - 0.707(lowest preoperative pH) - 0.032(lowest preoperative temperature in °C) + 6.002 = < 0.5 100 None Survival Model Se, 25%; model PPV, 100% [49]
Intraoperative indications
Injury pattern identified during operation
Combined abdominal vascular and pancreas gunshot injuries 20 12 variablesa Survival OR, 0.12 (95% CI, 0.041–0.36) [44]
20 11 variablesa Complications OR, 3.59 (95% CI, 1.10–11.68) [44]
Iliac vessel injury and prolonged duration of hypotension 22 None Survival ↑ mean duration of hypotension in non-survivors vs. survivors who underwent definitive (95 vs. 65 min, p value NR) and DC (40 vs. 85 min, p < 0.05) laparotomy [58]
Iliac vessel injury and initial temperature < 34 °C 17 None Survival OR, 0.27 (95% CI, 0.072-1.0) [59]
Iliac vessel injury and final temperature < 35 °C 17 None Survival OR, 0.025 (95% CI, 0.0028-0.23) [59]
Iliac vessel injury and initial BD > 15 mEq/L 17 None Survival OR, 0.037 (95% CI, 0.0072-0.19) [59]
Iliac vessel injury and final BD > 6 mEq/L 17 None Survival OR, 0.091 (95% CI, 0.019–0.45) [59]
Iliac vessel injury and initial pH < 7.1 17 None Survival OR, 0.032 (95% CI, 0.0055–0.19) [59]
Iliac vessel injury and final pH < 7.3 17 None Survival OR, 0.069 (95% CI, 0.014–0.36) [59]
Penetrating iliac vessel injury and final pH < 7.2 22 None Survival ↓ mean final pH in non-survivors vs. survivors who underwent definitive (7.11 vs. 7.29, p value NR) and DC (7.20 vs. 7.32, p value < 0.05) [58]
Penetrating iliac vessel injury and final PT > 20 s 22 None Survival ↑ final PT in non-survivors vs. survivors who underwent definitive (25.2 vs. 17.8 sec, p value NR) and DC (20.2 vs. 15.9 s, p < 0.05) laparotomy [58]
Penetrating iliac vessel injury and final PTT >70 s 22 None Survival ↑ final PTT in non-survivors vs. survivors who underwent definitive (86.1 vs. 59.2 s, p value NR) and DC (66.2 vs. 47.8 s, p < 0.05) laparotomy [58]
Iliac vessel injury and shock, hypothermia, acidosis, or coagulopathy (timing of measurement not specified) 18 ≤ 14 variablesb Survival Shock, hypothermia, acidosis, and coagulopathy not independently associated with survival [54]
Volume and/or type of resuscitation provided
Transfusion > 4 L PRBCs 100 23 variablesb Survival Independently associated with ↓ survival [56]
Transfusion > 5 L PRBCs and whole blood 100 None Survival ↑ mean volume of PRBCs and whole blood in non-survivors vs. survivors (8.2 vs. 5.6 L, p < 0.001) [56]
Administration > 12 L PRBCs and/or whole blood, other blood products, and crystalloids 100 None Survival ↑ mean volume of these fluids in non-survivors vs. survivors (15.0 vs. 12.4 L, p < 0.001) [56]
Degree of physiologic insult
Temperature ≤ 34 °C 100 None Survival ↓ mean min temperature in non-survivors vs. survivors (33.9 vs. 35.0, p < 0.001) [56]
Serum [HCO3-] ≤ 15 mEq/L 100 None Survival Serum [HCO3-] ≤ 15 mEq/L associated with ↓ survival [56]
pH < 7.2 100 None Survival ↓ mean initial (7.1 vs. 7.4), max (7.2 vs. 7.4), and min (7.0 vs. 7.2) pH in non-survivors vs. survivors (p < 0.001 for all) [56]
Elevated ACT 23 Unclear for logistic regression Clinical coagulo-pathyc The mean of 2 ACT measurements (taken within the first 10 min of beginning surgery and repeated ~ 15 min later) was 180 s in patients with coagulopathy versus 118 s in those without (p < 0.001) [53] The 1st, 2nd, and mean ACT values were independently associated with coagulopathy using logistic regression (p value NR) [53]
Systolic BP < 90 mmHg, BD > 7.5 mEq/L, and/or temperature < 35.5 °C at the start of surgery 100 None Survival OR for survival was 0.13 (95% CI, 0.021-0.77) among patients who presented with all 3 vs. < 3 variables. There was also a stepwise ↓ in survival as the no. of variables present ↑ [48]
A model predicted that survival was only possible when patients lie below and to the right of a diagonal discriminant line given by the equation PRBC transfusion rate (U/h) = 35.7(arterial pH) - 242 (for an arterial pH = 7.2, transfusion rate = 15 U/h) 100 PRBC transfusion rate, pH 48 h survival Model Se, 77% [65]
Pre- or intraoperative indications (or indications for which the setting was unclear or not specified)
Volume and/or type of resuscitation provided
Transfusion > 15 U PRBCs 100 None Coagulopathyd OR, 6.0 (95% CI, 0.67–75.61) [66]
Transfusion > 10 U PRBCs in the first 24 h and an ISS > 25 31 PRBCs transfused in 24 h, lowest systolic BP < 70 mmHg, pH < 7.1, and temperature < 34 °C PT & PTT > 2acontrol OR, 7.7 (95% CI, 1.5–38.8) [60]e
Transfusion > 10 U PRBCs in the first 6 h and an ISS >25 NR 9 variablesf INR > 1.5 at 6 h OR, 4.14 (95% CI, 0.57–3.18) [50]
Transfusion > 10 U PRBCs in the first 24 h and the lowest systolic BP < 70 mmHg 31 ISS > 25, PRBCs transfused in 24 h, pH < 7.1, and temperature < 34 °C PT & PTT > 2acontrol OR, 5.8 (95% CI, 1.2–28.2) [60]e
Transfusion > 10 U PRBCs in the first 6 h and ED systolic BP < 70 mmHg NR 9 variablesf INR > 1.5 at 6 h OR, 0.48 (95% CI, 0.10–2.23) [50]
Transfusion > 10 U PRBCs in the first 24 h and lowest temperature < 34 °C 31 ISS > 25, PRBCs transfused in 24 h, lowest systolic BP <70 mmHg, and pH <7.1 PT & PTT > 2acontrol OR, 8.7 (95% CI, 1.8–41.8) [60]e
Transfusion > 10 U PRBCs in the first 6 h and ED temperature < 34 °C NR 9 variablesf INR > 1.5 at 6 h OR, 6.10 (95% CI, 1.54–24.19) [50]
Transfusion > 10 U PRBCs in the first 24 h and lowest pH < 7.1 31 ISS > 25, PRBCs transfused in 24 h, lowest systolic BP < 70 mmHg, and temperature < 34 °C PT & PTT > 2acontrol OR, 12.3 (95% CI, 2.4–64.0) [60]e
Transfusion > 10 U PRBCs in the first 6 h and ED pH < 7.1 NR 9 variablesf INR > 1.5 at 6 h OR, 1.69 (95% CI, 0.56–5.08) [50]
Degree of physiologic insult
Min temperature ≤ 33 °C 100 None Survival OR, 0.20 (p-value reported as NS) [63]
Elevated max BD in the first 24 h in blunt trauma patients without TBI NR Age ≥ 55 yr Mortality OR per max BD ↑, 1.39 (95% CI, 1.35 to 1.41) [64]
Elevated max BD in the first 24 h in penetrating trauma patients without TBI NR Age ≥ 55 yr Mortality OR per max BD ↑, 1.58 (95% CI, 1.44 to 1.75) [64]
Elevated max BD in the first 24 h in blunt trauma patients with TBI NR Age ≥ 55 yr Mortality OR per max BD ↑, 1.25 (95% CI, 1.14 to 1.38) [64]
Min pH ≤ 7.18 100 None Survival OR, 0.17 (p < 0.05) [63]
Miscellaneous
Transfusion ≥ 10 U PRBCs, lowest ED or intraoperative temperature ≤ 33 °C, pH ≤ 7.18, ED PT ≥ 16 s, or ED PTT ≥ 50 s 100 None Survival ↓ survival when 4–5 (0% vs. 82%; p < 0.04) or 2–3 (17% vs. 82%; p < 0.003) vs. 0–1 of these indications were present [63]
A model including BD, penetrating MOI, TBI, age ≥ 55 yr, and an interaction between BD and penetrating MOI and BD and TBI. This model predicted that the BD for which the probability of survival was 75% was 15 mmol/L for young patients without TBI versus 8 mmol/L for patients aged < 55 yr with a TBI and older patients aged ≥ 55 yr NR BD, penetrating MOI, TBI, age ≥ 55 yr 75% survival Model Se, 71%; model Sp, 89% [64]
  1. Where ACT, activated coagulation time; BD, base deficit; BP, blood pressure; CI, confidence interval; DC, damage control; ED, Emergency Department; FFP, fresh frozen plasma; h, hours; HD, hemodynamic; INR, international normalized ratio; ISS, Injury Severity Scale score; max, maximum; min, minimum; MOI, mechanism of injury; NISS, New Injury Severity Scale score; NR, not reported; NS, not significant; OR, operating room; PPV, positive predictive value; PRBCs, packed red blood cells; PT, prothrombin time; PTT, partial thromboplastin time; pts, patients; U, unit(s); Se, sensitivity; Sp, specificity; ULN, upper limit of normal; and yr, years
  2. aVariables reported to be entered into the logistic regression model for mortality included age; Revised Trauma Score; systolic BP < 90 mmHg on admission; need for a major transfusion and volume transfused; need for DC surgery; AAST grade III-V pancreas injury and proximal pancreas injury; associated colonic, duodenal, and vascular injuries; postoperative complications; ICU admission; and length of ICU stay. Variables reported to be entered into the logistic regression model for complications included age; Revised Trauma Score; systolic BP < 90 mmHg on admission; need for transfusion and volume of blood transfused; need for DC surgery; grade of pancreas injury; repeat laparotomy; second pancreatic surgery; associated duodenal or vascular injury; intensive care unit (ICU) admission; and length of ICU stay
  3. bVariables reported to be entered into the regression model included those associated with mortality (p < 0.20) that did not have > 10% missing data. These may have included, at a minimum, systolic BP and respiratory rate in the ED; Glasgow Coma Scale score, ISS, and Revised Trauma Scale score; preoperative hematocrit; crystalloids and blood given in the ED; estimated intraoperative blood loss; crystalloids and blood given in the OR; total fluids; and length of stay in the surgical intensive care unit and hospital
  4. bVariables reported to be entered into the logistic regression model included those associated with survival in bivariate analysis (p < 0.20). These appeared to at least include ISS > 20; RTS > 0; GCS ≤ 3 or < 9; MOI; absence of spontaneous ventilation, a palpable carotid pulse, or extremity movement; non-sinus rhythm on the electrocardiogram; systolic BP and respiratory rate as a 3-level or 2-level categorical variable; a pulmonary artery and vein, thorax, thoracic or abdominal vascular, or liver injury; thoracotomy or laparotomy in the OR; coagulopathy; dysrhythmia; and type of dysrhythmia
  5. cDefined by the authors as the perceived need to initiate DC maneuvers by a surgical attending, which was reported to be subjective, but usually occurred in the setting of major blood loss, hypothermia, acidosis, and the presence of multiple injuries [53]
  6. dDefined by the authors as diffuse bleeding from all wounds without discrete bleeding vessels, absence of observable clots, prolonged PT and PTT along with decreased platelet count, or decreased platelet count alone [66]
  7. eIn this study, the probability of developing coagulopathy (defined as a PT and PTT > 2 times that of normal laboratory control) in patients who had received a transfusion of > 10 Us PRBCs in the first 24 h was 10% for those with an ISS > 25; 39% for those with an ISS > 25 and lowest systolic BP < 70 mmHg; 58% for those with an ISS > 25 and lowest pH < 7.1; 49% for those with an ISS > 25 and lowest temperature < 34 °C; 85% for those with an ISS > 25 and lowest systolic BP < 70 mmHg and temperature < 34 °C; and 98% for those with an ISS > 25 and lowest systolic BP < 70 mmHg, pH < 7.1, and temperature < 34 °C.
  8. fVariables entered into the logistic regression model included FFP:PRBC ratio at 6 h; age > 55 years; ISS > 25; PRBC, FFP, and platelet U transfused at 6 h; crystalloids in 24 h; and ED systolic BP < 70 mmHg, temperature < 34 °C, and pH < 7.1