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Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies

Villalobos, Miguel A. MD; Hazelton, Joshua P. DO; Choron, Rachel L. MD; Capano-Wehrle, Lisa; Hunter, Krystal MBA; Gaughan, John P. PhD; Ross, Steven E. MD; Seamon, Mark J. MD

Journal of Trauma and Acute Care Surgery: May 2017 - Volume 82 - Issue 5 - p 901–909
doi: 10.1097/TA.0000000000001412
Original Articles

BACKGROUND: Injury is the leading cause of death in children under 18 years. Damage control principles have been extensively studied in adults but remain relatively unstudied in children. Our primary study objective was to evaluate the use of damage control laparotomy (DCL) in critically injured children.

METHODS: An American College of Surgeons–verified Level 1 trauma center review (1996–2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age older than 18 years, laparotomy for abdominal compartment syndrome or delayed longer than 2 hours after admission. Demographics, mechanism, resuscitation variables, injuries, need for DCL, and outcomes were evaluated. Independent t test, Mann–Whitney U test, Fisher's exact test, and single-factor analysis of variance assessed statistical significance. Study endpoints were hospital survival and DCL complications.

RESULTS: Of 371 children who underwent trauma laparotomy, the median age (IQR; LQ-UQ) age was 16 (5; 11–17) years. Most (73%) were male injured by blunt mechanism (65%). Fifty-six (15%) children (Injury Severity Score [ISS], 33 (25; 17–42), pediatric trauma score 5 (6; 2–8), penetrating abdominal trauma index score [PATI] 29 (32; 12–44)) underwent DCL after major solid organ (63%), vascular (36%), thoracic (38%) and pelvic (36%) injury. DCL patients were older (16.5 (4; 14–18) vs. 16 (7; 10–17)) and were more severely injured (ISS, 33 [25; 17–42] vs. 16 [16; 9–25]), requiring greater intraoperative packed red blood cell transfusion (8 [13; 3.5–16.5] vs. 1 (0; [0–1] units) than definitive laparotomy counterparts. Nonsurvivors arrived in severe physiologic compromise (base deficit, 17 [17; 8–25] vs. 7 [4; 4–8]), requiring more frequent preoperative blood product transfusion (67% vs. 10%) after comparable injury (ISS survivors, 36 [23; 18–41] vs. nonsurvivors 26 (7; 25–32), p = 0.8880). Fifty-five percent of DCL patients survived (length of stay, 26 [21; 18–39] days) requiring 3 (2; 2–4) laparotomies during 4 (6; 2–8) days until closure (fascial, 90%; vicryl/split thickness skin grafting, 10%). DCL complications (surgical site infection, 18%; dehiscence, 2%; enterocutaneous fistula, 2%) were analyzed. When stratified by age (<15 years vs. 15–18 years) and period (1996–2006 vs. 2007–2013), no differences were found in injury severity or DCL outcomes (p > 0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (odds ratio, 1.10 [95% confidence interval, 1.01 – 1.19], p = 0.0218) and arrival systolic blood pressure (odds ratio, 0.96 [95% confidence interval, 0.93–0.99], p = 0.0254) predicted mortality after severe injury.

CONCLUSION: DCL is a proven, lifesaving surgical technique in adults. This report is the first to analyze the use of DCL in children with critical abdominal injuries. With similar survival and morbidity rates as critically injured adults, DCL merits careful consideration in children with critical abdominal injuries.

LEVEL OF EVIDENCE: Therapeutic study, level IV.

From the Department of Surgery (M.A.V., R.L.C.), Division of Trauma (J.P.H., L.C.-W., S.E.R.), Cooper Research Institute (K.H., J.P.G.), Cooper University Hospital, Camden, New Jersey; and Division of Trauma (M.J.S.), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Submitted: September 9, 2015, Revised: January 5, 2017, Accepted: January 24, 2017, Published online: March 15, 2017.

This work was accepted for a “Quick Shot” podium presentation at the American Association for the Surgery of Trauma Annual Meeting, September, 2015.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com).

Address for reprints: Miguel A. Villalobos, MD, 3 Cooper Plaza, Suite 411 Camden, NJ 08103; email: Villalobos-Miguel@cooperhealth.edu.

© 2017 Lippincott Williams & Wilkins, Inc.