Resuscitation at a cost: Excessive perioperative crystalloid administration is associated with increased fascial complications following damage control laparotomy for trauma.

Introduction: Over the past two decades, damage control laparotomy and resuscitation (DCL and DCR, respectively) have become the dominant paradigms for the management of exsanguinating trauma. Fascial complications are common after DCL. Minimizing crystalloid administration is a key component of DCR, but there is little direct evidence that it reduces fascial complications. This study was designed to test the hypothesis that lower crystalloid administration volume during the perioperative period for DCL is associated with an increase in fascial closure rates and a decreased rate of fascial dehiscence.

Methods: This was a retrospective observational study at a single urban trauma center. Adult trauma patients who underwent emergent DCL between March 2019 - December 2022 were included. Patients who died within 7 days of definitive closure or underwent additional intracavitary operations (e.g., thoracotomy) before or concurrent with laparotomy were excluded. Risk factors for fascial dehiscence and planned ventral hernia (PVH) were evaluated using univariate and multiple logistic regression analysis.

Results: Among 287 included patients, median age was 32 (IQR 23-44), median injury severity score (ISS) 25 (17-34), median base deficit 6 (2-9), and 56.1 % had penetrating mechanism. The median crystalloid intravenous fluid (IVF) received from prehospital period to 48 h after index operation was 16.3 L (13.0-20.1 L). ISS, base deficit, and vital signs (systolic blood pressure, heart rate, and respiratory rate) did not differ between patients discharged with PVH or primary fascial closure, nor between patients who experienced a documented dehiscence event versus those who did not. Crystalloid volume was statistically different across both comparisons (primary fascial closure vs PVH at discharge: 15.6 vs 20.5 L, p < 0.001; no dehiscence vs any dehiscence 15.0 vs 18.1 L, p < 0.001). By multiple logistic regression, early IVF administration was associated with both PVH at discharge (odds ratio (OR) 1.14, 95 %CI 1.07-1.23) and fascial dehiscence (OR 1.17, 95 %CI 1.04-1.20).

Conclusion: Increased volume of perioperative crystalloid is associated with higher risk of fascial complications among patients requiring DCL for trauma. The DCR paradigm may reduce surgical complications as well as mortality among patients with severe trauma requiring laparotomy.