Loftus Tyler J, Jordan Janeen R, Croft Chasen A, Smith R Stephen, Efron Philip A, Moore Frederick A, Mohr Alicia M, Brakenridge Scott C
From the Department of Surgery and Sepsis and Critical Illness Research Center, University of Florida Health, Gainesville, Florida.
J Trauma Acute Care Surg. 2017 Oct;83(4):650-656. doi: 10.1097/TA.0000000000001553.
The purpose of this study was to characterize associations among serum proteins, negative-pressure wound therapy (NPWT) fluid loss, and primary fascial closure (PFC) following emergent laparotomy and temporary abdominal closure (TAC). We hypothesized that high levels of C-reactive protein (CRP) and NPWT output would be associated with hypoalbuminemia and failure to achieve PFC.
We performed a retrospective analysis of 233 patients managed with NPWT TAC. Serum proteins and resuscitation indices were assessed on admission, initial laparotomy, and then at 48 hours, 96 hours, 7 days, and discharge. Correlations were assessed by Pearson coefficient. Multivariable regression was performed to identify predictors of PFC with cutoff values for continuous variables determined by Youden index.
Patients who failed to achieve PFC (n = 55) had significantly higher CRP at admission (249 vs. 148 mg/L, p = 0.003), initial laparotomy (237 vs. 154, p = 0.002), and discharge (124 vs. 72, p = 0.003), as well as significantly lower serum albumin at 7 days (2.3 vs. 2.5 g/dL, p = 0.028) and discharge (2.5 vs. 2.8, p = 0.004). Prealbumin (in milligrams per deciliter) was similar between groups at each time point. There was an inverse correlation between nadir serum albumin and total milliliters of NPWT output (r = -0.33, p < 0.001). Exogenous albumin administration (in grams per day) correlated with higher serum albumin levels at each time point: 48 hours: r = 0.26 (p = 0.002), 96 hours: r = 0.29 (p = 0.002), 7 days: r = 0.40 (p < 0.001). Albumin of less than 2.6 g/dL was an independent predictor of failure to achieve PFC (odds ratio, 2.59; 95% confidence interval, 1.02-6.61) in a multivariate model including abdominal sepsis, body mass index of greater than 40 kg/m, and CRP of greater than 250 mg/L.
Early and persistent systemic inflammation and high NPWT output were associated with hypoalbuminemia, which was an independent predictor of failure to achieve PFC. The utility of exogenous albumin following TAC requires further study.
Prognostic study, level III; Therapeutic study, level IV.
本研究的目的是描述急诊剖腹手术和临时腹部关闭（TAC）后血清蛋白、负压伤口治疗（NPWT）液体丢失与一期筋膜缝合（PFC）之间的关联。我们假设高浓度的C反应蛋白（CRP）和NPWT引流量与低白蛋白血症及无法实现PFC相关。
我们对233例行NPWT TAC治疗的患者进行了回顾性分析。在入院时、初次剖腹手术时，然后在48小时、96小时、7天和出院时评估血清蛋白和复苏指标。通过Pearson系数评估相关性。进行多变量回归以确定PFC的预测因素，并通过约登指数确定连续变量的截断值。
未实现PFC的患者（n = 55）在入院时（249 vs. 148 mg/L，p = 0.003）、初次剖腹手术时（237 vs. 154，p = 0.002）和出院时（124 vs. 72，p = 0.003）的CRP显著更高，以及在7天时（2.3 vs. 2.5 g/dL，p = 0.028）和出院时（2.5 vs. 2.8，p = 0.004）的血清白蛋白显著更低。各时间点两组间的前白蛋白（毫克/分升）相似。最低血清白蛋白与NPWT总引流量毫升数呈负相关（r = -0.33，p < 0.001）。外源性白蛋白给药（克/天）与各时间点更高的血清白蛋白水平相关：48小时：r = 0.26（p = 0.002），96小时：r = 0.29（p = 0.002），7天：r = 0.40（p < 0.001）。在包括腹部脓毒症、体重指数大于40 kg/m²和CRP大于250 mg/L的多变量模型中，白蛋白低于2.6 g/dL是无法实现PFC的独立预测因素（比值比，2.59；95%置信区间，1.02 - 6.61）。
早期和持续的全身炎症以及高NPWT引流量与低白蛋白血症相关，低白蛋白血症是无法实现PFC的独立预测因素。TAC后外源性白蛋白的效用需要进一步研究。
预后研究，III级；治疗研究，IV级。
