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Multicenter Study
. 2019 Jul;87(1):27-34.
doi: 10.1097/TA.0000000000002288.

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

John A Harvin  1 , John P Sharpe, Martin A Croce, Michael D Goodman, Timothy A Pritts, Elizabeth D Dauer, Benjamin J Moran, Rachel D Rodriguez, Ben L Zarzaur, Laura A Kreiner, Jeffrey A Claridge, John B Holcomb
Affiliations
Multicenter Study

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

John A Harvin et al. J Trauma Acute Care Surg. 2019 Jul.

Abstract

Background: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists.

Methods: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 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.

Results: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate).

Conclusion: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury.

Level of evidence: Epidemiological study with one negative criterion, level III.

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Figures

Figure 1.
Figure 1.. Monthly DCL Rates
Time series analyses of monthly damage control laparotomy (DCL) rates at each institution. Accounting for secular trends in DCL, only Site 4 had a significant change in the rate of DCL. The initial reduction in DCL observed at Site 4, however, did not last for the entire study period. * p<0.05; m1 = first month of year
See this image and copyright information in PMC

References

    1. Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, Latenser BA, Angood PA. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–82. - PubMed
    1. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy. Ann Surg. 1983;197(5):532–5. - PMC - PubMed
    1. Harvin JA, Maxim T, Inaba K, Martinez-Aguilar MA, King DR, Choudhry AJ, Zielinski MD, Akinyeye S, Todd SR, Griffin RL, et al. Mortality after emergent trauma laparotomy: A multicenter, retrospective study. J Trauma Acute Care Surg. 2017;83(3):464–8. - PMC - PubMed
    1. Harvin JA, Wray CJ, Steward J, Lawless RA, McNutt MK, Love JD, Moore LJ, Wade CE, Cotton BA, Holcomb JB. Control the damage: morbidity and mortality after emergent trauma laparotomy. Am J Surg. 2016;212(1):34–9. - PubMed
    1. George MJ, Adams SD, McNutt MK, Love JD, Albarado R, Moore LJ, Wade CE, Cotton BA, Holcomb JB, Harvin JA. The effect of damage control laparotomy on major abdominal complications: A matched analysis. Am J Surg. 2018;216(1):56–59. - PMC - PubMed

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