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Early severe-injury DCL fascial closure more likely with postop hypertonic saline

Key clinical point: Order 30 cc/hour of 3% sodium chloride after bleeding DCL if you want to close patients in about a day.

Major finding: The median time for fascial closure was 29 hours in the hypertonic saline. group but 38 hours in the traditional fluid maintenance group (P = .035).

Data source: Review of 95 DCL patients.

Disclosures: The investigators had no disclosures.

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Volume might be the issue

We all agree that fascial closure should be a goal. Many people have many ideas on how best to achieve delayed primary fascial closure. Diuretics decrease visceral edema. The Whitman patch prevents fascial retraction. Patients who return earlier to the operating room are more likely to be closed.

This study describes an institutional effort to improve rates of delayed primary fascial closure which should be commended. Despite patients presenting more critically ill, the rate of closure at first take-back was improved with hypertonic saline. Maybe it is not the hypertonic saline per se but the fact that they gave it instead of all the fluid we used to give.

Dr. Margaret Lauerman is an assistant professor of shock trauma at the University of Maryland Medical Center in Baltimore. She has no disclosures.


 

AT THE EAST SCIENTIFIC ASSEMBLY

References

SAN ANTONIO – In massively transfused patients undergoing damage control laparotomy, postop hypertonic saline improves primary fascial closure rates at first take-back, according to investigators from the University of Texas Health Science Center at Houston.

After controlling for age, injury severity, and resuscitation volumes, primary fascial closure (PFC) at first take-back was almost four times as likely in patients who received hypertonic saline (HTS) after bleeding damage control laparotomy (DCL) instead of traditional isotonic maintenance fluids (odds ratio, 3.82; 95% confidence interval, 1.02-14.31; P = .047).

Dr. Lindley Folkerson

Dr. Lindley Folkerson

“In a group of seriously injured bleeding trauma patients undergoing DCL, the use of HTS was associated with a lower fluid balance and a higher rate of PFC at the first take-back,” the investigators concluded.

It’s unclear if the results are because of the hypertonic saline drawing off more edema fluid and making early PFC more likely, or because HTS patients in the study received less fluid than their standard maintenance peers – 30 cc/hr of 3% sodium chloride versus 125 cc/hr of traditional isotonic fluids post op.

PFC at first take-back is known to reduce complications. Previous studies have shown that HTS improves PFC rates, but they included moderately injured patients who would have been closed early no matter what postop fluids they received. The investigators wanted to see how well HTS worked in more severely injured patients.

The study compared 54 adult DCL patients from 2010 to 2011 who received traditional isotonic postop maintenance with 41 from 2013 to 2014 on HTS, both for 72 hours or until fascial closure, whichever came first. The university switched to HTS around 2012 based on earlier studies, allowing for the comparison. Patients in both groups received at least three RBC units during surgery, according to investigator Dr. Lindley Folkerson, a surgery resident at the university.

Twenty-seven HTS patients (66%) were closed at first take-back, versus 33 (61%) in the traditional maintenance group. The median time for closure was 29 hours in the HTS group but 38 hours in traditional maintenance patients (P = .035).

There were no between-group demographic or injury severity differences, but because the university has become more conservative with DCL in recent years, the HTS patients were more hypotensive and had greater baseline fluid deficits at emergency department arrival, and received more blood in the operating room. Even so, HTS patients had significantly lower fluid balances at 24 and 48 hours.

The university hasn’t noticed increased kidney injuries with lower-volume HTS, but that might prove to be a problem in a larger study, Dr. Folkerson said at the annual scientific assembly of the Eastern Association for the Surgery of Trauma.

A limitation of the study is that patients were resuscitated as their physicians saw fit, so some in the HTS group likely got isotonic fluids. “We did not restrict fluids because they were on the HTS protocol. Crystalloid, colloid, and blood products were given as deemed necessary by the bedside physician,” she said.

The investigators had no disclosures.

aotto@frontlinemedcom.com

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