More than three out of four older adults who undergo damage-control laparotomy for abdominal trauma do not survive to hospital discharge, according to a retrospective study.
Damage-control laparotomy (DCL), which aims to control hemorrhage and abdominal contamination after abdominal trauma, improves outcomes in younger patients. But it remains unclear whether older patients have the physiologic reserve to tolerate the coagulopathy, academia, and hypothermia that often accompany this approach, researchers note in The American Journal of Surgery, online November 14.
Dr. Andrew H. Stephen and colleagues from Alpert Medical School of Brown University, in Providence, Rhode Island, undertook a retrospective trauma registry and a medical record review of all 31 patients greater than 65 years of age (mean age, 75.2 years) who underwent DCL at their Level 1 trauma center between 2010 and 2017.
Most patients undergoing DCL (24/31, 77.4%) died, and all seven remaining survivors were discharged to a rehabilitation center/nursing home. Multisystem organ failure was the most common cause of death (62.5%), followed by cardiac arrest (20.5%). There were no significant differences between survivors and non-survivors in ICU length of stay, number of total operations, or infection of any kind.
Initial INR was significantly higher among non-survivors than among survivors. But the groups did not differ significantly in lactic acid concentrations on presentation or on the second draw, nor did they differ in the change in lactate concentration. "Presenting vital signs and laboratory markers may not be useful in older patients to predict mortality," the researchers note.
Dr. John A. Harvin of The University of Texas Medical School at Houston, who has studied DCL, told Reuters Health by email, "A mortality rate of 77% is quite surprising," said Harvin.
"There is some inherent selection bias that can account for this i.e., patients who need damage-control surgery have injuries that are more severe than those who do not but that is still a large proportion of patients undergoing this procedure who die. It is much larger than any other reported mortality rate that I have seen," said Harvin.
"I think the 'damage control' part of the study is somewhat of a red herring," said Dr. Harvin, who was not involved in the research. "They had severely injured elderly patients who underwent damage-control laparotomy and had an average number of operating room trips of two."
'Which means they had the first operation and they were closed at the second. Then, an average of 12 days later, they died of multiple-organ failure. This may be an example of how the injury can throw the equilibrium of multiple aged organ systems off in elderly patients leading to death," said Dr. Harvin.
"If you have an elderly patient for whom damage-control surgery is necessary, this study gives us some information to inform their family that death is possible," Dr. Harvin said.
"In most series, patients who undergo damage-control surgery die from hemorrhage or brain injury. In this one, they died mostly from multiple-organ failure at an average of two weeks after their hospital stay. So, even if they survive the initial first few days, they have delayed complications that can still lead to death in the weeks after," Dr. Harvin said.
Dr. Parker Hu of the University of Alabama at Birmingham, who also was not involved in the study, recently evaluated the impact of initial temporary abdominal closure in damage-control surgery.
He told Reuters Health by email, "This report highlights the surprisingly poor survival rates among patients over 65 managed with damage control laparotomy. Of further interest, the only significant difference in clinical or laboratory values between survivors and non-survivors was the presence of coagulopathy in non-survivors."
"Injury necessitating damage-control laparotomy in this population is associated with increased risk of mortality and poor functional outcomes," he concluded. "Therefore, surgeons should be proactive and aggressive in the limitation of ongoing hemorrhage and correction of coagulopathy."