Highlights from EAST - Direct peritoneal resuscitation

An interesting concept using peritoneal dialysis solution to minimize bowel edema in patients with damage control and vac closure

DIRECT PERITONEAL RESUSCITATION MAY ATTENUATE LIVER INJURY AFTER HEMORRHAGIC SHOCK

Authors
Jason Smith , MD , Matthew Benns , MD , Glen A. Franklin , MD , Brian G. Harbrecht , MD , Paul J Matheson , PhD , R Neal Garrison , MD , University of Louisville

Objective
Hemorrhage due to trauma is a leading cause of death in people under 35 years of age. Despite adequate restoration of central hemodynamics, end organ perfusion often continues to be compromised leading to end organ failure and late death. Direct Peritoneal Resuscitation (DPR) has been shown to improve visceral blood flow. Our objective of this study is to translate these innovative laboratory findings into clinical practice in damage control surgery (DCS) patients.

Methods
Forty-two (42) DCS patients were enrolled over a 4 year (2008-2011) period to undergo DPR in addition to standard resuscitation as part of a prospective case-control study. DPR consisted of peritoneal lavage with 2.5% Deflex solution (a commercially available peritoneal dialysis solution) at a predetermined rate while the abdomen was temporarily closed. Patients were matched against 42 case controls for ISS, type of injury, age, gender and AIS of head and abdominal injury. Univariate and Multivariate analysis was performed.

Results
Patients undergoing DPR had a more rapid normalization of liver enzymes after hemorrhagic shock (Table 1). Also, DPR patients had a lower total transfusion requirement at 48 hours compared to controls. (31 ±14 vs. 39 ±15, p =0.021). Transfusion ratios (RBC:FFP) in the first 24 hours were no different between the two groups (1.76 vs 1.57, p=0.52). DPR patients had a shorter time to abdominal closure (3.6 ±2.1 vs. 5.7 ±3.2, p=0.003) and fewer abdominal complications compared to controls. Mortality between the groups showed a lower overall mortality at 30 days for the DPR group compared to conventional resuscitation (10% vs 14%, p=0.17). Multivariate Analysis showed that DPR was associated with more rapid correction of liver enzymes as well as a more rapid abdominal closure rate.

Conclusion
DPR may attenuate liver injury after hemorrhagic shock. This may lead to less overall transfusion requirements, faster abdominal closure, fewer complications and better outcomes for patients.

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