SCOTTSDALE, ARIZ. – Direct peritoneal resuscitation with 2.5% Delflex solution significantly reduced abdominal closure time and operative complications in patients with hemorrhagic shock undergoing damage control surgery, a prospective case-control study showed.
The time to definitive wound closure fell from 5.7 days with standard resuscitation to 3.6 days with the addition of direct peritoneal resuscitation (DPR) with 2.5% Delflex solution (P = .006).
In addition, the control group was 3.2 times more likely to develop an intra-abdominal complication than was the DPR group (odds ratio, 3.2; P = .03), Dr. Jason W. Smith reported at the annual scientific assembly of the Eastern Association for the Surgery of Trauma..
"DPR is a safe, simple, and inexpensive method of managing an open abdomen following damage control surgery," he said. "DPR may attenuate persistent hepatic injury following hemorrhagic shock."
Dr. Smith and his colleagues at the University of Louisville (Ky.) have been strong proponents of the technique, and previously reported that DPR with Delflex shortened abdominal closure by 2.7 days in a retrospective proof-of-concept study in 19 trauma patients (J. Am. Coll. Surg. 2010;210:658-67).
Vasodilators and heparin can be used to augment microvascular circulation and prevent blood clots, but in patients with hemorrhagic shock, this generally leads to bad results. Activated drotrecogin alfa (Xigris), which was pulled from the market in October 2011, was initially used, but the sepsis drug treats only the symptoms, Dr. Smith explained.
"We selected Delflex because of its ability to have an effect on microvascular permeability as well as microvascular blood flow," he said. "So really this is a new take on what is a very old medicine."
Between 2008 and 2011, the investigators prospectively enrolled 42 patients who underwent damage control surgery and conventional resuscitation plus DPR consisting of peritoneal lavage with an 800-mL bolus of 2.5% Delflex for the first hour and a 400-mL/hr infusion thereafter. A 19 Fr drain was placed along the root of the mesentery into the pelvis, and suction dressing was applied to drain fluid. The infusion was stopped when the abdomen was closed definitively either by primary closure or by the use of an absorbable or a biologic mesh.
The patients (average age, 30.6 years) were propensity matched against 42 case controls (average age, 29.1 years) who had undergone conventional resuscitation at the discretion of the treating surgeon after damage control surgery. All patients underwent blood product resuscitation in the first 24-48 hours of treatment.
The average Injury Severity Score was 19 among patients and 21 among controls. The hepatic Abbreviated Injury Scale (AIS) score was 3.4 in both groups, and roughly 40% of patients underwent a liver operation.
Control patients had significantly elevated alanine transaminase levels at 48 (731 vs. 507 U/L) and 72 hours (791 vs. 501 U/L) post resuscitation, compared with DPR patients, and this difference continued up to 14 days after the initial injury (all P less than .01), Dr. Smith said.
International normalized ratio (INR) levels were persistently higher in the control group, reaching statistical significance at 72 hours (1.3 vs. 1.8; P = .03). Time to INR normalization was no different whether the red blood cell to fresh frozen plasma (FFP) ratio was 1:1 or 1:2, he said.
Controls achieved a slightly better transfusion ratio (1.57 vs. 1.76; P = .52), although DPR patients had significantly lower FFP requirements after 48 hours (P = .04), and received significantly fewer transfusions at 72 hours post admission (31 vs. 41; P = .007).
As observed in the pilot study, the primary fascial closure rate was significantly higher with DPR than conventional resuscitation alone (88% vs. 66%; P = .01), and mortality was similar (10% vs. 17%; P = .25), Dr. Smith said. There were no complications with DPR administration.
In a multivariate analysis, the two strongest predictors of persistent hepatic injury following hemorrhagic shock were hepatic AIS greater than 3 (OR, 3.18), followed by nonutilization of DPR (OR, 0.63).
Invited discussant Dr. Greta Piper of Yale University, New Haven, Conn., asked whether the results would have been even better with a higher infusion rate or concentration of Delflex since one effect of the infusion is continuous dialysis, with a potential reduction in total body salt and water content.
Dr. Smith replied that they have tried DPR with other agents such as mannitol and Delflex 1.5% and 4.25%, but said the 2.5% concentration "is kind of a Goldilocks dose," as 1.5% is too weak to do anything and 4.25% desiccates the intravascular space.