Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project

Abstract

Background: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multi-center quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. Methods: In 2016, six US Level 1 trauma centers performed a year-long, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. DCL cases were adjudicated based upon majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for two years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions.

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

“…In this study, only 33% of the patients who underwent DC laparotomy were acidotic, 43% hypothermic, and 48% coagulopathic on arrival at the ICU after operation [1,6,24,39]. Although the ideal rate of use of DC during emergent laparotomy is presently unknown, it was estimated in one cohort study to range between 19% and 27% across six American, level-1 trauma centers [40]. Some evidence suggests that overuse of DC laparotomy may be associated with increased morbidity and mortality [3,4,18,19,39,41].…”

Damage control laparotomy in trauma: a pilot randomized controlled trial. The DCL trial

“…These same indications may be appropriate for a larger, multicenter randomized trial DCL. 3 Second, social media allowed for efficient community consultation and public notification (both required to obtain an EFIC) in order to obtain greater reach at lesser cost than methods used in prior RCTs at our institution. 12 18-20 Lastly, we augmented our statistical approach with Bayesian analyses to avoid the pervasive misinterpretation of frequentist analyses.…”

“… 1 2 As comfort with the open abdomen has increased, indications for DCL have gradually broadened and its use has reached upward of 40% of all trauma laparotomies at some centers. 3 4 However, when used liberally, DCL may result in more risks than benefits, as several studies from trauma centers across the country have reported increased complications associated with the open abdomen resulting from DCL. 5–7 …”

Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry)

“…DCL has gradually become an accepted strategy for non-trauma abdominal emergencies such as acute mesenteric ischemia and bowel perforation [7][8][9][10][11][12][13][14][15][16][17][18]. DCL has been associated with increased hospital length of stay (LOS)and resource utilization, although these findings may actually represent survival or selection bias as there are no randomized controlled trials in this area [19,20]. In the trauma population, DCL-associated complications include wound infections, enterocutaneous or entero-atmospheric fistula (ECF/EAF), intra-abdominal sepsis (IAS), and mortality [18,19,21].…”

“…DCL has been associated with increased hospital length of stay (LOS)and resource utilization, although these findings may actually represent survival or selection bias as there are no randomized controlled trials in this area [19,20]. In the trauma population, DCL-associated complications include wound infections, enterocutaneous or entero-atmospheric fistula (ECF/EAF), intra-abdominal sepsis (IAS), and mortality [18,19,21]. ECF are associated with increased morbidity and mortality, as they can lead to many complications, including fluid loss, electrolyte abnormalities, complex wound care issues, malnutrition, and increased ICU and hospital LOS [22].…”