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Chasing 100%: The use of hypertonic saline to improve early, primary fascial closure after damage control laparotomy

Harvin, John A. MD; Mims, Mark M. BS; Duchesne, Juan C. MD; Cox, Charles S. Jr MD; Wade, Charles E. PhD; Holcomb, John B. MD; Cotton, Bryan A. MD, MPH

Journal of Trauma and Acute Care Surgery: February 2013 - Volume 74 - Issue 2 - p 426–432
doi: 10.1097/TA.0b013e31827e2a96
AAST 2012 PLENARY PAPER
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BACKGROUND Failure to achieve fascial closure after damage control laparotomy (DCL) is associated with increased morbidity and long-term disability. In addition, early closure is associated with reduces infectious, wound, and pulmonary complications. We hypothesized that hypertonic saline (HTS), which attenuates resuscitation-induced intestinal edema in animals, would improve early primary fascial closure (EPFC) rates.

METHODS This is a retrospective study of trauma patients undergoing DCL, from January 2010 to July 2011. Patients in the HTS group had 30 mL/h of 3% sodium chloride as maintenance fluids while the fascia was open. Patients in the cohort group had isotonic fluids (125 mL/h). The primary outcome, EPFC, was defined as primary fascial closure by postinjury day 7.

RESULTS Seventy-seven patients underwent DCL (23 received HTS and 54 received isotonic fluids). There were no differences in demographics, injury severity, or pre–intensive care unit vitals, laboratories, fluids, or transfusions. Median fluids in the first 24 hours were lower in the HTS group (3.9 vs. 7.8 L, p < 0.001). Times to fascial closure were shorter in those receiving HTS (34 vs. 49 hours, p < 0.001), as were the rates of closure at first take back (78% vs. 53%, p = 0.036). The primary outcome of EPFC was higher in the HTS group compared with standard fluids (100% vs. 76%, p = 0.010). At discharge, the HTS group had a 96% primary fascial closure rate compared with 80% with standard fluids.

CONCLUSION The use of 3% HTS as maintenance fluids after DCL was associated with 100% EPFC. HTS may be used as an adjunct to facilitate fascial closure in patients undergoing DCL.

LEVEL OF EVIDENCE Diagnostic study, level III.

From the Department of Surgery (J.A.H, M.M.M, C.E.W, J.B.H, B.A.C.), Center for Translational Injury Research (C.E.W., J.B.H., B.A.C.), Department of Pediatric Surgery (C.S.C.), University of Texas Medical School at Houston, Houston, Texas; and Department of Surgery and Anesthesia (J.C.D.), Tulane University School of Medicine, New Orleans, Louisiana.

Submitted: July 31, 2012; Revised: November 6, 2012; Accepted: November 8, 2012.

This study was presented at the 71st Annual Meeting of the American Association for the Surgery of Trauma, September 12–15, 2012, Kauai,

Address for reprints: Bryan A Cotton, MD, MPH, UTHSCH-CeTIR, 6410 Fannin St, 1100.20 UPB, Houston, TX 77030; email: bryan.a.cotton@uth.tmc.edu.

© 2013 Lippincott Williams & Wilkins, Inc.
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