Thoracic damage control: association of complications and mortality
Matthew Vasquez, Patrick Walker, David V Feliciano, Thomas M Scalea, James V O’ConnorBackground
Thoracic damage control (TDC) is an operative strategy for physiologically depleted patients with severe thoracic injuries. The relationship of TDC complications and mortality has not been comprehensively examined. This study analyzed the association of complications and mortality following TDC.
Methods
A retrospective registry review at a Level 1 trauma center identified patients ≥16 years undergoing TDC. Demographics, physiological data, injuries, operations, complications, and mortality were abstracted. Univariate and multivariate analyses for mortality risk factors were performed.
Results
A total of 98 patients met the inclusion criteria. The median age was 31 (23-44) years, 52% male, and 69% had penetrating trauma. The median Injury Severity Score (ISS) was 32 (26-41), chest Abbreviated Injury Scale 4 (4–5), admission systolic blood pressure 112 (77-138), pH 7.16 (6.99–7.25), base deficit −11 (−17 to −7), and lactate 8.1 (5.7–11.3). The operative procedures performed included pulmonary 63.5%, cardiac 29.6%, great vessels 16.2%, and 66.3% had a concomitant damage control laparotomy. Of the entire cohort, 72 (73.5%) patients developed at least one complication, including bacteremia 35%, renal failure requiring continuous renal replacement therapy (CRRT) 23%, pneumonia 18%, and empyema 12%. Mortality was 25.5% (25/98), with 72% (18/25) occurring prior to chest closure. Univariate analysis demonstrated that blunt trauma (p<0.001), male sex (p=0.006), lower pH (p=0.007), higher ISS (p<0.001), and CRRT (p=0.031) were statistically significant risk factors for mortality. On multivariate analysis, only blunt trauma (OR 3.82, 95% CI 1.1 to 13.3, p=0.035) and admission pH <7.1 (OR 3.13, 95% CI 1.03 to 9.5, p=0.044) were independently associated with mortality.
Conclusion
TDC is an essential operative strategy in patients with severe thoracic injuries presenting in advanced shock. Both blunt trauma and degree of shock are independent risk factors for mortality, which are present on admission. Although complications are frequent and severe, they do not predict mortality.
Level of evidence
IV, diagnostic test/criteria.