Damage-control thoracic surgery: Management and outcomes


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Abstract

BACKGROUNDDamage-control surgery is successfully used for severe abdominal trauma. Although the damage-control surgery principles are applicable to thoracic trauma, there is a dearth of data on damage-control thoracic surgery.METHODSThis is an institutional review board–approved, retrospective trauma registry study, from January 2002 to December 2012, for thoracic injuries requiring emergency thoracotomy or sternotomy, with temporary closure. Demographics, physiologic and laboratory data, operative procedures, and outcomes were abstracted. Data are presented as mean and SD; Student’s t test was used with p < 0.05 conferring statistically significance.RESULTSForty-four patients were identified, with a median age of 34 years and 86% males. Mean (SD) Injury Severity Score (ISS) was 33.2 (14.7), with 93% having a chest Abbreviated Injury Scale (AIS) score of 3 or greater, 61% having a chest AIS score of 4 or greater, and 32% having a chest AIS score of 5 or greater. Of the patients, 48% had gunshot wounds and 21% had stab wounds. Admission temperature, pH, base deficit, and international normalized ratio were 36°C (1°C), 7.07 (0.13), 11.1 (6.5), and 1.7, respectively. Incisions included anterolateral thoracotomy in 69% and sternotomy in 25%; 73% required pulmonary resection, 20% required cardiorraphy, and 9% had major vascular injuries; multiple procedures were common. Mean intraoperative transfusion was 13 U of packed red blood cells. Forty-two patients (95%) had thoracic packing with vacuum-assisted closure. The thorax was closed when physiology normalized, on a mean (SD) of 3 (1) days. When comparing physiologic parameters at initial operation and chest closure, temperature was 34.4°C (1.3°C) versus 37.4°C (0.8°C), pH was 7.13 (0.14) versus 7.38 (0.6), and international normalized ratio was 1.8 (0.9) versus 1.2 (0.3), respectively, all statistically significantly (p < 0.001). Complications included sepsis (36%), renal failure requiring continuous renal replacement therapy (30%), adult respiratory distress syndrome (25%), and empyema (23%). Six required salvage extracorporeal membrane oxygenation with one survivor. Mortality was 23%. Predictors included higher ISS, renal failure, continuous renal replacement therapy, and extracorporeal membrane oxygenation. All survivors were neurologically intact and dialysis free.CONCLUSIONPatients with severe chest trauma and marked physiologic derangement can benefit from damage-control thoracic surgery. Thoracic packing and temporary vacuum closure avoids thoracic compartment syndrome. Timing of thoracic closure is based on physiology. While complications were common, mortality is acceptable in this group of severely injured, metabolically depleted, challenging patients.LEVEL OF EVIDENCETherapeutic study, level V.

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