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Risk factors for hepatic morbidity following nonoperative management: multicenter study
Rosemary A Kozar1, Frederick A Moore, C Clay Cothren
1University of Texas, Houston 77030, USA. rosemary.a.kozar@uth.tmc.edu
Hypothesis:
Early risk factors for hepatic-related morbidity in patients undergoing initial nonoperative management of complex blunt hepatic injuries can be accurately identified.
Design:
Multicenter historical cohort.
Setting:
Seven urban level I trauma centers.
Patients:
Patients from January 2000 through May 2003 with complex (grades 3-5) blunt hepatic injuries not requiring laparotomy in the first 24 hours.
Intervention:
Nonoperative treatment of complex blunt hepatic injuries.
Main Outcome Measures:
Complications and treatment strategies.
Results:
Of 699 patients with complex blunt hepatic injuries, 453 (65%) were treated nonoperatively. Overall, 61 patients (13%) developed 87 hepatic complications including bleeding (38), biliary (bile peritonitis, 7; bile leak, 9; biloma, 11; biliary-venous fistula, 1; and bile duct injury, 1), abdominal compartment syndrome (5), and infections (abscess, 7; necrosis, 2; and suspected abdominal sepsis, 6), which required 86 multimodality treatments (angioembolization, 32; endoscopic retrograde cholangiopancreatography and stenting, 9; interventional radiology drainage, 16; paracentesis, 1; laparotomy, 24; and laparoscopy, 4). Hepatic complications developed in 5% (13 of 264) of patients with grade 3 injuries, 22% (36 of 166) of patients with grade 4 injuries, and 52% (12 of 23) of patients with grade 5 injuries. Univariate analysis revealed 24-hour crystalloid, total and first 24-hour packed red blood cells, fresh frozen plasma, platelet, and cryoprecipitate requirements and liver injury grade to be significant but only liver injury grade (grade 4 odds ratio, 4.439; grade 5 odds ratio, 12.001) and 24-hour transfusion requirement (odds ratio, 6.446) predicted complications by multivariable analysis.
Conclusions:
Nonoperative management of high-grade liver injuries is associated with significant morbidity and correlates with grade of liver injury. Screening patients with transfusion requirements and high-grade injuries may result in earlier diagnosis and treatment of hepatic-related complications.
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