-Original-

A New Look at Criteria for Damage Control Surgery

Hisashi Matsumoto^1,2, Kunihiro Mashiko^1,2, Yuichiro Sakamoto^1,2, Noriyoshi Kutsukata^1,2, Yoshiaki Hara^1,2 and Hiroyuki Yokota¹

¹Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Nippon Medical School
²Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital

Background: Several reports have validated the criteria for damage control surgery (DCS). However, although metabolic acidosis and body temperature can be measured quickly, tests for predicting the severity of coagulopathy require special laboratory equipment and take 15 to 30 minutes. Such delays could be life-threatening for patients requiring DCS. The aim of this study was to establish simplified and practical criteria to enable rapid decision-making regarding the need for DCS.
Methods: Thirty-four consecutive patients with unstable hemodynamics after initial fluid resuscitation who had undergone DCS for severe abdominal or pelvic injuries were retrospectively analyzed. The patients' characteristics, clinical courses, laboratory data, and outcomes were reviewed using the data contained in their medical records.
Results: The overall survival rate was 55.9% (survivors group: n=19; nonsurvivors group: n=15), which was similar to the calculated mean probability of survival (Ps=0.5671). At the start of surgery, the systolic blood pressure (SBP) was less than 90 mm Hg in all cases in which surgery failed, and the mean SBP in the nonsurvivors group (69.6 ± 14.8 mm Hg) was significantly lower than that in the survivors group (93.2 ± 22.9 mm Hg, p=0.006). Except in two cases, the value of the base excess in the nonsurvivors group was less than -7.5 mmol/L, and the mean base excess (-11.5 ± 5.3 mmol/L) in the nonsurvivors group was significantly less than that in the survivors group (-5.5 ± 4.9 mmol/L, p=0.008) at the start of surgery. The core temperature at the start of surgery was less than 35.5°C in all cases in the nonsurvivors group. On the basis of these results, three indicators (SBP less than 90 mm Hg, base excess less than -7.5 mmol/L, and core temperature less than 35.5°C at the start of surgery) were identified. The success rate of DCS in patients who possessed all three indicators (28.6% ) was significantly lower than that in patients who did not possess all three indicators (75.0%; p=0.014).
Conclusion: Our results indicate that surgeons should decide to perform DCS when only one or two criteria defined in this study are met and should not wait for all three criteria. Although our proposed criteria are not strict and may broaden the indications for DCS, leading to an increase in the number of DCS procedures, saving the lives of patients who have sustained severe torso trauma must be the priority; 'over-triage' may be acceptable in situations where an appropriate decision-making protocol has been followed.

J Nippon Med Sch 2010; 77: 13-20

Keywords
trauma, damage control surgery, coagulopathy, hypothermia, acidosis

Correspondence to
Hisashi Matsumoto, MD, PhD, Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital, 1715 Kamakari, Inba-mura, Inba-gun, Chiba 270-1964, Japan
hmatsu@nms.ac.jp

Received, June 2, 2009
Accepted, August 26, 2009