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

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 ACS verified Level I trauma center review (1996-2013) of pediatric trauma laparotomies was undertaken. Exclusion criteria included: age >18, laparotomy or for compartment syndrome or >2hrs 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 (ISS 33 (25; 17-42), Pediatric Trauma Score 5 (6; 2-8), 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 DL counterparts. Non-survivors 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 non-survivors 26 (7; 25-32), p = 0.8880). Fifty-five percent of DCL patients survived (LOS 26 (21; 18-39) days) requiring 3 (2; 2-4) laparotomies during 4 (6;2-8) days until closure (fascial 90%, vicryl/STSG 10%). DCL complications (SSI 18%, dehiscence 2%, ECF 2%) were analyzed. When stratified by age (0.05). After controlling for DCL, age, and gender, multivariate analysis indicated only ISS (OR 1.10 [95% CI 1.01 - 1.19], p = 0.0218) and arrival SBP (OR 0.96 [95% CI 0.93 - 0.99], p = 0.0254) predicted mortality after severe injury. Conclusions: DCL is a proven, life-saving 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/care management study, level IV. (C) 2017 Lippincott Williams & Wilkins, Inc.

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