Indications for use of damage control surgery in civilian trauma patients. A content analysis and expert appropriateness rating study
Roberts DJ., Bobrovitz N., Zygun DA., Ball CG., Kirkpatrick AW., Faris PD., Brohi K., D'Amours S., Fabian TC., Inaba K., Leppäniemi AK., Moore EE., Navsaria PH., Nicol AJ., Parry N., Stelfox HT.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Objectives: To characterize and evaluate indications for use of damage control (DC) surgery in civilian trauma patients. Background: Although DC surgery may improve survival in select, severely injured patients, the procedure is associated with significant morbidity, suggesting that it should be used only when appropriately indicated. Methods: Two investigators used an abbreviated grounded theory method to synthesize indications for DC surgery reported in peer-reviewed articles between 1983 and 2014 into a reduced number of named, content-characteristic codes representing unique indications. An international panel of trauma surgery experts (n = 9) then rated the appropriateness (expected benefit-to-harm ratio) of the coded indications for use in surgical practice. Results: The 1107 indications identified in the literature were synthesized into 123 unique pre- (n = 36) and intraoperative (n = 87) indications. The panel assessed 101 (82.1%) of these indications to be appropriate. The indications most commonly reported and assessed to be appropriate included pre- and intraoperative hypothermia (median temperature < 34°C), acidosis (median pH < 7.2), and/or coagulopathy. Others included 5 different injury patterns, inability to control bleeding by conventional methods, administration of a large volume of packed red blood cells (median > 10 units), inability to close the abdominal wall without tension, development of abdominal compartment syndrome during attempted abdominal wall closure, and need to reassess extent of bowel viability. Conclusions: This study identified a comprehensive list of candidate indications for use of DC surgery. These indications provide a practical foundation to guide surgical practice while studies are conducted to evaluate their impact on patient care and outcomes.