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Table 5 Criterion validity (extent to which the utilization or conduct of damage control instead of definitive surgery for one or more indications was associated with patient outcomes) of reported indications for use of damage control surgery or damage control interventions

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

Source Treatment or exposure group (n) Comparison group (n) Confounding factors adjusted for Outcome(s)
Harvin et al. 2016 [38] DC laparotomy (n = 144) for intra-abdominal packing (68%), a second-look laparotomy (6%), hemodynamic instability (15%), to expedite postoperative care or intervention (8%), abdominal compartment syndrome prophylaxis (1%), contamination (1%), or for other/unclear reasons (1%) Definitive laparotomy (n = 78) Propensity scores created using 17 different variablesa The adjusted incidence of ileus was 13% (95% CI, 6–26%) higher in the DC versus definitive laparotomy group
The adjusted incidence of suture line failure was 7% (95% CI, 0–14%) higher in the DC versus definitive laparotomy group
The adjusted incidence of GI bleed was 4% (95% CI, 0–7%) higher in the DC versus definitive laparotomy group
The adjusted incidence of abdominal fascial dehiscence was 11% (95% CI, 2–19%) higher in the DC versus definitive laparotomy group
The adjusted incidence of superficial SSI was 19% (95% CI, 10–28%) higher in the DC versus definitive laparotomy group
The adjusted incidence of death was 18% (95% CI, 11–26%) higher in the DC versus definitive laparotomy group
Ordoñez et al. 2014 [40] DC laparotomy with primary duodenal repair (n = 14) for complex penetrating AAST grade II–IV duodenal injuries Definitive laparotomy with primary duodenal repair for complex penetrating AAST grade II-IV duodenal injuries (n = 7) None Survival was 92.9% in the DC versus 100% in the definitive laparotomy group (p > 0.99)
Thompson et al. 2013 [42] DC surgery with or without the first stage of a Whipple procedure for patients with severe pancreaticoduodenal trauma (n = 12) A complete Whipple procedure (including reconstruction) at the index operation for patients with severe pancreaticoduodenal trauma (n = 3) None for all comparisons Survival was 83.3% in the DC versus 100% in the complete Whipple group (p > 0.99)
Sepsis occurred in 16.7% of the DC versus 100% of the complete Whipple group (p = 0.01)
Enterocutaneous/enteroatmospheric fistulae occurred in 8.3% of the DC versus 66.7% of the complete Whipple group (p = 0.04)
Rice et al. 2012 [43] Those who had moderate or major deviations from a protocol that suggested use of DC surgery when any of the following were present: temperature < 35 °C, lactate > 4 mmol/L (or more than twice the ULN), or corrected pH < 7.3 (n = 92)a Those who had no or minor deviations from the DC surgery protocol (n = 358)b 13 variablesc Survival at 90 d: adjusted OR, 0.50 (95% CI, 0.27–0.92)
Martin et al. 2012 [14] DC laparotomy for patients with an arrival systolic BP > 90 mmHg, no severe TBI (head AIS score < 3), and no combined abdominal injuries (n = 62) Therapeutic definitive laparotomy in patients with an abdomen AIS score > 2 10 variablesd Major postoperative complication: adjusted OR, 2.96 (95% CI, 1.25–6.99)
The adjusted length of hospital stay was 9.69 d longer in patients who underwent DC instead of definitive laparotomy (p < 0.001)
Chinnery et al. 2012 [44] DC surgery for unstable patients with pancreatic and major associated organ and visceral vascular injuries (n = 43) Before use of DC surgery for patients with this indication (n = 32) None for both comparisons Survival: OR, 0.082 (95% CI, 0.014–0.34)
Postoperative complications (systemic, pancreatic, and intra-abdominal): OR, 8.02 (95% CI, 1.44–80.24)
Mayberry et al. 2011 [45] DC laparotomy for patients with full-thickness duodenal lacerations (n = 25) Definitive surgery for patients with this indication (n = 16) None Duodenal-related complications: OR, 0.38 (95% CI, 0.029-3.83)
Liu et al. 2011 [24] DC laparotomy for patients with a preoperative temperature < 35 °C, PT > 16 s, PTT > 50 s, or pH < 7.3 or who received > 10 U PRBCs (n = 46) Definitive laparotomy for patients with these indications (n = 58) None for both comparisons Survival: OR, 3.51 (95% CI, 1.18–11.73)
Complications (pneumonia, peritonitis, intra-abdominal abscess, biliary or pancreatic fistula, bowel obstruction): OR, 0.29 (95% CI, 0.12–0.69)
Yu et al. 2009 [25] DC surgery for patients with the following: preoperative temperature < 35 °C, pH < 7.25, PT > 16 s, aPTT > 50 s, or systolic BP < 70 mmHg; transfusion >10 U PRBCs; inability to close the abdomen because of visceral edema; or a predicted surgical duration > 90 min (n = 45) Definitive surgery for patients with these indications (n = 45) None for all comparisons Survival: OR, 3.03 (95% CI, 0.66–18.79)
Complications (abscesses, ARDS, multiple organ failure): OR, 0.29 (95% CI, 0.099–0.80)
Mean ICU LOS: 10 vs. 8 d (p = 0.02)
Mean hospital LOS: 27 vs. 21 d (p = 0.01)
MacKenzie et al. 2004 [51] Laparotomy with early therapeutic perihepatic packing followed by angioembolization for patients with AAST grade IV-V liver injuries (n = 7)e Definitive laparotomy for patients with AAST grade IV–V liver injuries (n = 30)e None for all comparisons Survival was 100% in the early packing versus 63.3% in the definitive laparotomy group (p = 0.08)
Complications in the early packing vs. definitive laparotomy group included liver necrosis (OR, 4.88; 95% CI, 0.49–41.81), sepsis (OR, 1.75; 95% CI, 0.21–12.67), abscesses (OR, 6.75; 95% CI, 0.62–66.67), and bile leak (OR, 4.38; 95% CI, 0.56–35.95)
Median hospital LOS: 30 vs. 10.5 d (p value NR)
Median ICU LOS: 7 vs. 2 d (p value NR)
Asensio et al. 2004 [52] After implementation of a guideline that suggested use of DC surgery for patients with the following: transfusion > 4 L PRBCs or > 5 L PRBCs and whole blood combined; total OR fluid (PRBCs and whole blood, other blood products, and crystalloid) replacement > 12 L; operating room patient temperature ≤ 34 °C, serum [HCO3-] ≤ 15 mEq/L, or arterial pH ≤ 7.2; a thoracic or abdominal vascular injury or complex hepatic injury requiring packing; those requiring ED or operating room thoracotomy; or patients that develop intraoperative coagulopathy or dysrhythmias (n = 53) Before implementation of the DC surgery guideline (n = 86) None for all comparisons Survival: OR, 0.99 (95% CI, 0.42 to 2.42)
Intra-abdominal abscesses: OR, 0.29 (95% CI, 0.067 to 0.95)
Abdominal fistula(e): 0.34 (95% CI, 0.059 to 1.32)
Extra-abdominal infection: OR, 0.34 (95% CI, 0.15 to 0.77)
Abdominal wall closure: OR, 44.93 (95% CI, 11.17 to 248.12)
Mean SICU LOS: 14.1 vs. 22.4 d (p = 0.02)
Mean hospital LOS: 22.9 vs. 36.8 d (p = 0.08)
Apartsin et al. 2002 [23] DC laparotomy for liver and retroperitoneal injuries (n = 62) or major small bowel injuries (n = 15) Definitive laparotomy for liver and retroperitoneal (n = 59) and major small bowel injuries (n = 14) None for both comparisons Survival for liver and retroperitoneal injuries: OR, 2.73 (95% CI, 1.15 to 6.60)
Survival for patients with major small bowel injuries: OR, 10.08 (95% CI, 1.44 to 80.87)
Carrillo et al. 1998 [58] DC laparotomy for patients with penetrating injuries to the iliac vessels (n = 14) (11 had combined arteriovenous injuries to the common and external iliac vessels) Definitive laparotomy for patients with this indication (n = 50) (13 had combined arteriovenous injuries) None for both comparisons Survival overall: OR, 0.71 (95% CI, 0.16–3.70)
Survival for patients with combined injuries: OR, 6.25 (95% CI, 0.50–324.50)
Rotondo et al. 1993 [62] DC laparotomy for penetrating trauma patients requiring transfusion of > 10 U PRBCs before completion or termination of laparotomy with ≥ 1 major abdominal vascular injury and ≥ 2 abdominal visceral injuries (n = 13) Definitive laparotomy for penetrating trauma patients with this indication (n = 9) None Survival: OR, 26.67 (95% CI, 1.84–1296.95)
Carmona et al. 1984 [67] Therapeutic liver packing for patients with intraoperative hemodynamic instability after more conventional techniques of hemorrhage control (e.g., direct, Pringle maneuver, hepatic artery ligation) had failed (n = 17) Definitive surgery for patients with this indication who were similarly matched on age, mechanism of injury, and associated injuries (n = 14) None for both comparisons Survival: OR, 2.05 (95% CI, 0.19–27.79)
Infection: OR, 0.75 (95% CI, 0.13–4.43)
Stone et al. 1983 [68] DC laparotomy followed by closure of the abdomen under tension for patients who develop coagulopathy during operation (n = 17) Definitive laparotomy for patients who develop coagulopathy during operation (n = 14) None for all comparisons Survival: OR, 23.83 (95% CI, 2.22–1102.13)
All survivors (including n = 12 managed with DC and closure of the abdomen under tension and n = 1 managed with definitive laparotomy) developed complications, including wound infections (100% of those managed with DC), intra-abdominal abscesses (69.2% of the 13), and intestinal fistulae (15.4% of the 13)
  1. Where AIS indicates Abbreviated Injury Scale; BD, base deficit; BP, blood pressure; CI, confidence interval; d, days; DC, damage control; ED, Emergency Department; GI, gastrointestinal; LOS, length of stay; MOI, mechanism of injury; NR, not reported; OR, odds ratio; PRBC, packed red blood cells; SICU, surgical intensive care unit; SSI, surgical site infection; and TBI, traumatic brain injury
  2. aVariables reported to be used to generate propensity scores for matching between the groups included ISS; age; gender; mechanism of injury; ED systolic BP; ED Glasgow Coma Scale score; ED BD; ED activated clotting time; ED percent lysis at 30 min; ED PRBC transfusion; time in ED; final operating room temperature; final OR systolic BP; total operating room PRBCs; final operating room pH; final operating room BD; and final operating room lactic acid
  3. bWhere minor deviations included departures deemed not clinically significant; moderate deviations included care, which although departures were present, mostly followed protocol; and major deviations included those that did not meet the standards outlined in the protocol.
  4. cVariables reported to be entered into the logistic regression model included age; gender; injury type; time from injury to hospitalization; PRBCs transfused before hospitalization; ISS; Glasgow Coma Scale score; shock; baseline hemoglobin, creatinine and activated PTT; country; and patients who did not require DC for both outcome comparisons
  5. dVariables reported to be entered into logistic and linear regression models included age; gender; mechanism of injury; head injury; major extremity injury; combined abdominal injury; ISS; presenting vitals; BD; and need for colon resection
  6. eIn this study, 15 of the patients in the definitive laparotomy group were reported to ultimately need abdominal packing after conventional hepatic injury repair techniques. Moreover, 1 patient in the early therapeutic packing group received angiography before laparotomy