DAMAGE CONTROL THORACIC SURGERY: MANAGEMENT AND OUTCOMES
James O'Connor MD, Joseph DuBose* MD, Thomas Scalea* MD, R Adams Cowley Shock Trauma Center
Introduction: Damage control surgery (DCS) is successfully employed for severe abdominal trauma. Although the DCS principles of early hemorrhage control, subsequent resuscitation and delayed planned definitive surgery are applicable to thoracic trauma, there is a dearth of data on damage control thoracic surgery (DCTS).
Methods: An IRB approved retrospective trauma registry and chart review from January 2002 to December 2012 for thoracic injuries requiring emergency thoracotomy or sternotomy, and temporary closure. Demographics, physiologic and laboratory data, operative procedures and outcomes were abstracted. Data are presents as mean and standard deviation; Student t-test was used with p <0.05 conferring statistically significance.
Results: 44 patients were identified. Mean age 34, 86% were male. ISS 33.2±14.7, 89% had ISS ≥ 15 and severe chest injury was common (chest AIS ≥ 3 = 93%; ≥ 4 = 61%, ≥ 5 = 32%) with gunshot (48%) and stab wounds (21%) the most common mechanisms. Admission temperature, pH, base deficit and INR were 36±1 C, 7.07±0.13, -11.1±6.5, and 1.7 respectively. Operative approaches included unilateral thoracotomy 50%, clamshell 32% and sternotomy 23%. 52% required pulmonary resection (pneumonectomy 3, lobectomy 11, non-anatomic resection 9), 20% had cardiorraphy; the remainder had a variety of vascular injuries. 43% required intra-operative CPR, and 41% left the OR on vasoactives. Mean intra-operative blood requirement was 13 units pRBC’s. 42(95%) patients had packing with vacuum assisted closure; the only thoracic compartment syndrome occurred in one to the two who had packing and skin closure. The decision to close the bony thorax was based on normalized physiology, with the time to closure of 3±1 days. At chest closure, echocardiography (TEE) was utilized for patients on vasoactives to assess evidence of tamponade physiology precluding closure. Comparing the physiologic parameters during the initial operation and prior to chest closure; temperature C (34.4±1.3 vs. 37.4±0.8), pH (7.13±0.14 vs.7.38±0.6) and INR (1.8±0.9 vs. 1.2±0.3), were all statistically significantly (p < 0.001). Complications were common, including sepsis (36%), local wound infection (30%), acute renal failure requiring CRRT (30%), ARDS 25% and empyema (23%). Adjunctive salvage ECMO was utilized in 4 patients with 1 survivor. Mean ventilator days, ICU length of stay and hospital length of stay were 19, 20 and 30 days respectively. Overall mortality was 23%. Excluding the 3 ECMO deaths, in-hospital mortality was 16%. Follow-up was available for 73% with a mean duration of 34 months, with all survivors neurologically intact and dialysis free.
Conclusions: Patients with severe chest trauma and marked physiologic derangement can benefit from DCTS. Thoracic packing and temporary vacuum closure avoids thoracic compartment syndrome. Timing of thoracic closure is based on physiology, and TEE is a useful adjunct when closing the thorax of those on vasoactives. While complication were common, mortality is acceptable in this group of these severely injured, metabolically depleted, challenging patients.
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