Caring for critically injured children: An analysis of 56 pediatric damage control laparotomies
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Published on: April 19, 2022
Miguel A Villalobos1, Joshua P Hazelton, Rachel L Choron
1From 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.
Insights
Damage control laparotomy (DCL) is a life-saving procedure for critically injured children, showing similar survival and complication rates to adults. This study highlights DCL as a viable option for pediatric trauma patients requiring urgent abdominal surgery.
Area of Science:
- Pediatric Surgery
- Trauma Management
- Surgical Critical Care
Background:
- Injury remains a leading cause of death in children.
- Damage control principles are well-established in adults but understudied in pediatric populations.
- This study addresses the gap in understanding damage control laparotomy (DCL) for critically injured children.
Purpose of the Study:
- To evaluate the application and outcomes of damage control laparotomy (DCL) in critically injured pediatric patients.
- To compare DCL outcomes in children with those reported for adult trauma patients.
- To identify factors influencing mortality in pediatric patients undergoing DCL.
Main Methods:
- Retrospective review of pediatric trauma laparotomies (1996-2013) at a Level 1 trauma center.
- Inclusion criteria focused on critically injured children undergoing laparotomy within 2 hours of admission.
- Statistical analysis included t tests, Mann-Whitney U, Fisher's exact, and ANOVA to assess survival and DCL complications.
Main Results:
- Of 371 pediatric trauma laparotomies, 56 (15%) underwent DCL, primarily due to blunt trauma and severe solid organ/vascular/thoracic/pelvic injuries.
- DCL patients were older, more severely injured (ISS 33 vs. 16), and required more blood transfusions than those undergoing definitive laparotomy.
- Fifty-five percent of DCL patients survived, with outcomes and complications comparable to adult data; Injury Severity Score (ISS) and systolic blood pressure predicted mortality.
Conclusions:
- Damage control laparotomy (DCL) is a feasible and life-saving intervention for critically injured children.
- Pediatric DCL demonstrates comparable survival and morbidity rates to those observed in adult trauma populations.
- DCL should be carefully considered for pediatric patients with severe abdominal injuries.
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.
