创伤与非创伤损伤控制性剖腹术：区别在于意识障碍（来自东部创伤外科学会 SLEEP-TIME 多中心试验的数据）。
Trauma and nontrauma damage-control laparotomy: The difference is delirium (data from the Eastern Association for the Surgery of Trauma SLEEP-TIME multicenter trial).
机构信息
From the Division of Acute Care Surgery (K. McArthur), Loma Linda University School of Medicine, Loma Linda, California; Division of Acute Care Surgery (C.K., E.K., X.L.-O., M.C.-Y., S.B., D.T., K. Mukherjee), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma, Burns, Critical Care, and Acute Care Surgery (L.S., C.K., A.G., J. Nahmias), UC Irvine Medical Center, Irvine, California; Division of Trauma and Critical Care (A.B., A.G.), LAC+USC Medical Center, Los Angeles, California; Grant Medical Center Trauma Services (A.L., M.K.), Ohio Health Grant Medical Center, Columbus, Ohio; Division of Trauma/Surgical Critical Care (M.N.F., N.G.), Rutgers-New Jersey Medical School, Newark, New Jersey; Division of Trauma (S.T., E.L.), Cedars-Sinai Medical Center, Los Angeles, California; Division of Trauma and Surgical Critical Care (S.R.L., O.D.G.), Vanderbilt University Medical Center, Nashville, Tennessey; Division of Trauma/Acute Care Surgery/Critical Care (J.M.B., C.D.), West Virginia University, Morgantown, West Virginia; Division of Trauma (S.M.W., K.L.), Cooper University Health System, Camden, New Jersey; Section of Acute Care Surgery (N.T.D., J. Nunez), University of Utah Medical Center, Salt Lake City, Utah; Division of Trauma and Critical Care Surgery (S.M., J.P.), Northwestern Memorial Hospital, Chicago, Illinois; Division of Trauma, Emergency Surgery and Surgical Critical Care (L.N., H. Kaafarani), Massachusetts General Hospital, Boston, Massachusetts; Trauma Center (H. Kemmer, M.J.L.), Research Medical Center-Kansas City Hospital, Kansas City, Missouri; Mount Sinai Hospital-Chicago (A.D., G.C.), Chicago, Illinois; and Trauma and Acute Care Center (Z.N.), Morristown Medical Center, Morristown, New Jersey.
出版信息
J Trauma Acute Care Surg. 2021 Jul 1;91(1):100-107. doi: 10.1097/TA.0000000000003210.
BACKGROUND
Damage-control laparotomy (DCL) has been used for traumatic and nontraumatic indications. We studied factors associated with delirium and outcome in this population.
METHODS
We reviewed DCL patients at 15 centers for 2 years, including demographics, Charlson Comorbidity Index (CCI), diagnosis, operations, and outcomes. We compared 30-day mortality; renal failure requiring dialysis; number of takebacks; hospital, ventilator, and intensive care unit (ICU) days; and delirium-free and coma-free proportion of the first 30 ICU days (DF/CF-ICU-30) between trauma (T) and nontrauma (NT) patients. We performed linear regression for DF/CF-ICU-30, including age, sex, CCI, achievement of primary fascial closure (PFC), small and large bowel resection, bowel discontinuity, abdominal vascular procedures, and trauma as covariates. We performed one-way analysis of variance for DF/CF-ICU-30 against traumatic brain injury severity as measured by Abbreviated Injury Scale for the head.
RESULTS
Among 554 DCL patients (25.8% NT), NT patients were older (58.9 ± 15.8 vs. 39.7 ± 17.0 years, p < 0.001), more female (45.5% vs. 22.1%, p < 0.001), and had higher CCI (4.7 ± 3.3 vs. 1.1 ± 2.2, p < 0.001). The number of takebacks (1.7 ± 2.6 vs. 1.5 ± 1.2), time to first takeback (32.0 hours), duration of bowel discontinuity (47.0 hours), and time to PFC were similar (63.2 hours, achieved in 73.5%). Nontrauma and T patients had similar ventilator, ICU, and hospital days and mortality (31.0% NT, 29.8% T). Nontrauma patients had higher rates of renal failure requiring dialysis (36.6% vs. 14.1%, p < 0.001) and postoperative abdominal sepsis (40.1% vs. 17.1%, p < 0.001). Trauma and NT patients had similar number of hours of sedative (89.9 vs. 65.5 hours, p = 0.064) and opioid infusions (106.9 vs. 96.7 hours, p = 0.514), but T had lower DF/CF-ICU-30 (51.1% vs. 73.7%, p = 0.029), indicating more delirium. Linear regression analysis indicated that T was associated with a 32.1% decrease (95% CI, 14.6%-49.5%; p < 0.001) in DF/CF-ICU-30, while achieving PFC was associated with a 25.1% increase (95% CI, 10.2%-40.1%; p = 0.001) in DF/CFICU-30. Increasing Abbreviated Injury Scale for the head was associated with decreased DF/CF-ICU-30 by analysis of variance (p < 0.001).
CONCLUSION
Nontrauma patients had higher incidence of postoperative abdominal sepsis and need for dialysis, while T was independently associated with increased delirium, perhaps because of traumatic brain injury.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
背景
损伤控制性剖腹术（DCL）已被用于创伤和非创伤性适应证。我们研究了该人群中与谵妄和结局相关的因素。
方法
我们在 15 个中心回顾性分析了 DCL 患者，包括人口统计学特征、Charlson 合并症指数（CCI）、诊断、手术和结局。我们比较了创伤（T）和非创伤（NT）患者的 30 天死亡率；需要透析的肾衰竭；再次剖腹的次数；住院、呼吸机和重症监护病房（ICU）天数；以及 ICU 前 30 天无昏迷和无谵妄的比例（DF/CF-ICU-30）。我们进行了线性回归分析，包括年龄、性别、CCI、实现主要筋膜闭合（PFC）、小肠和大肠切除术、肠中断、腹部血管手术以及创伤作为协变量。我们使用单因素方差分析了 DF/CF-ICU-30 与创伤性脑损伤严重程度的关系，采用头部损伤严重程度评分（Abbreviated Injury Scale for the head）进行评估。
结果
在 554 例 DCL 患者（25.8%为 NT）中，NT 患者年龄更大（58.9 ± 15.8 岁 vs. 39.7 ± 17.0 岁，p < 0.001），女性更多（45.5% vs. 22.1%，p < 0.001），CCI 更高（4.7 ± 3.3 vs. 1.1 ± 2.2，p < 0.001）。再次剖腹的次数（1.7 ± 2.6 次 vs. 1.5 ± 1.2 次）、首次再次剖腹的时间（32.0 小时）、肠中断的持续时间（47.0 小时）和实现 PFC 的时间（63.2 小时，73.5%的患者实现）相似。NT 和 T 患者的呼吸机、ICU 和住院天数和死亡率相似（31.0% NT，29.8% T）。NT 患者肾衰竭需要透析的发生率（36.6% vs. 14.1%，p < 0.001）和术后腹部脓毒症的发生率（40.1% vs. 17.1%，p < 0.001）更高。T 和 NT 患者的镇静剂（89.9 小时 vs. 65.5 小时，p = 0.064）和阿片类药物输注（106.9 小时 vs. 96.7 小时，p = 0.514）的时间相似，但 T 的 DF/CF-ICU-30 较低（51.1% vs. 73.7%，p = 0.029），表明谵妄更多。线性回归分析表明，T 与 DF/CF-ICU-30 降低 32.1%（95%CI，14.6%-49.5%；p < 0.001）相关，而实现 PFC 与 DF/CF-ICU-30 增加 25.1%（95%CI，10.2%-40.1%；p = 0.001）相关。头部损伤严重程度评分的增加与 DF/CF-ICU-30 的减少通过方差分析相关（p < 0.001）。
结论
NT 患者术后腹部脓毒症和需要透析的发生率更高，而 T 与谵妄发生率增加独立相关，这可能是由于创伤性脑损伤。
证据水平
治疗性研究，IV 级。
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