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Invited Critique
February 1, 2004

Has Evolution in Awareness of Guidelines for Institution of Damage Control Improved Outcome in the Management of the Posttraumatic Open Abdomen?—Invited Critique

Arch Surg. 2004;139(2):215. doi:10.1001/archsurg.139.2.215

Asensio and the group from USC have nicely documented the efficacy of damage control as it applies to the treatment of severely injured patients resulting in an open abdomen. Although they have used institutional historical controls for this purpose, this does not detract from their conclusions emphasizing early damage control in select high-risk patients. It is interesting to note that the mortality rate of 24%, laudable in this group of trauma patients, did not change over the decade of observation, but various parameters of morbidity were clearly improved. There was likely a "halo effect" due to faculty/resident awareness, but this often changes behavior prior to its documentation. It is pleasing to see that this clinical standard of care started off with Harlan Stone, MD, who has pioneered so many in the care of the trauma patient. In fact, many of us began to pack the abdomen shortly after the appearance of his report, only to see sound validation of this concept years later. Asencio has provided the best statistically valid evidence to date; yet it is not so-called "Class I data" for evidence-based medicine. We know it would be ethically wrong to require a prospective, randomized clinical trial in this area and it must be strongly emphasized that such a method used in this report is often the most efficacious and safe way to advance clinical care. This is an extremely ill group of complex trauma patients in which senior clinical judgment is valued and which usually pushes the residents to pack earlier than they would otherwise. As the authors rightly note, many of the so-called objective parameters are inappropriate, inaccurate, or difficult to obtain in the "heat of battle," and thus not clinically useful at the time when most needed. Thus there is no substitute for accrued clinical acumen in the care of these patients, coupled with the awareness of such clinical guidelines as provided by the authors, to minimize patient morbidity. What the study does not address is timing of the take-back, which is an issue of resuscitation completeness vs risk of subsequent infection. It seems from evolution of the literature over this same time period that re-laparotomy should be earlier as well, because damage control has essentially shortened the resuscitation period.