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"Тrauma" Том 16, №4, 2015

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Selection of phase individual differential surgical treatment strategy «DAMAGE CONTROL» in victims with close combined abdominal injury.

Authors: Kryliuk V.(1),(2), Roschin G. G.(1),(2), Kuzmin V.(1), Novikov F. M.(2), Ivanov V.(2), Dorosh V.(3)
(1) — National Medical Academy of Postgraduate Education named after P. L. Shupyk, Kyiv, Ukraine
(2) —GI «Ukrainian Scientific and Practical Center of Emergency and Disaster Medicine of Health Ministry of Ukraine», Kyiv, Ukraine
(3) — Kyiv City Hospital of Emergency Medicine, Kyiv, Ukraine

Categories: Traumatology and orthopedics

Sections: Clinical researches

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Keywords

closed combined abdominal injury, prognostic scale TRISS end MODS-II

Background.

To improve therapeutic and diagnostic activities at the hospital stage, conducted multivariate analysis of treatment of 167 patients with combined closed  abdominal injury . On the basis of standardized scales assessing the severity of the injury and status of the victim, substantiates the choice of stage differential surgical treatment «Damage control». By anatomical and functional assessment of severity combined closed abdominal injury  on a scale TRISS introduced haemoperitoneum volume indicator - as predictor of complications of traumatic process at an early hospital period. Indices of abdominal perfusion pressure - as a predictor of functional complications in the traumatic process that realized in the modification of the scale MODS-II.

Methods.

The analysis mortality of   patients with severe combined abdominal trauma (n = 48) who died in the postoperative period (during  shock period). Anatomical damage assessment was carried out using the integral index prediction of survival and scale TRISS. A power factor (b) calculated by the experimental formula №1, which introduced the product value of the coefficient b4, the volume haemoperitoneum is calculated in scores:

b=b0+b1×(TS)+b2×(ISS)+b3×(A)+b4×(hem.)   (1),

where b0-b4 values of regression coefficients: b0 = (-1,6465), b1 = (0,5175), b2 = (-0,0734), b3 = (-1,9261), and we calculated the coefficient b4 = (-0,0060), TS –  functional scale score for TS, ISS - the sum of squares of anatomical points on a scale AIS-90, A – the age of the victim in scores, hem. – the volume indicator haemoperitoneum presented us scores scale to: 500 ml – 1 score, from 500 to 1500 ml –  2 scores, from 1500 to 2500 ml –  3 scores, more than 2500 ml –  4 scores.
The randomized simultaneous retrospective study of results obtained following the treatment of 119 victims with closed abdominal polytrauma has determined the value of abdominal perfusion pressure index as a functionally signifi cant predictor clarifying the beginning of the organic dysfunction development in victims. Qualimetric evaluation of victim condition severity using the MODS-ІІ scale and the index of abdominal perfusion pressure permits to determine the terms of probable deaths already during the early hospitalization period. 
The authors have analyzed the consequences of treatment for 119 victims with closed abdominal polytraumas. The patients were divided into two groups, the first group including the cured (n=62) and the second one – the deceased persons (n=57). All the victims were operated and providing the urgent health care in the Polytrauma Department of the Kyiv City Clinical Hospital  
The qualimetric evaluation of victims' condition was carried out using the MODS-ІІ scale, the index of abdominal perfusion pressure (APP) having been included to this scale in our studies. 
It was determined as the difference between the average value of arterial pressure (APAV ) and intraabdominal pressure (IAP). To evaluate the IAP degree, the classifi cation of D. Meldrum et al. (1997) was used; according to this classifi cation, the fi rst, second, third, and forth IAP degrees correspond to 10–15, 15–25, 25–35, and > 35 mm Hg, respectively [19]. The IAP measurement was carried out by the bladder catheterization [20].
To improve the current MODS-ІІ scale taking into consideration the APP index, we have elaborated its gradation from 0 to 3 points. These calculations were carried out based on the confiidence interval for minimal APP index values (CI95% min is 37) and IAP levels (CI95% min is 17) corresponding to the 2-nd victim condition severity taking into consideration the value of kidney perfusion pressure. So, 0 point, 1 point, 2 points, and 3 points correspond to APP indices ≤ 81, 66−80, 35−65, and ≤ 34 mm Hg, respectively.
To determine the calculating capacities of different scales, regression analysis was carried out based on calculations of binary logistic regression models (AUROC analysis); in such a way receiver operator curves (ROC) were modeled and the areas under the curves (AUC) were estimated (AUCMODS -indices, AUC ± SE, where SE is the standard error).The data obtained were verifi ed using the software package STATISTICA 8.0 (StatSoft Inc.,USA, 2007).

Results.

Based on the experimental model for the integrated scale - TRISS(N), with a prognostic standpoint, found a high degree of correlation (rP=0,81) indicator prediction of survival (CI95% 21,4-41,4, in %) in terms of mortality (CI95% 12,1-24,2%, in hours). Moreover, the volume haemoperitoneum more than 682 ml (CI95% 682-1198 ml) should be considered as a private to one day predictor of mortality in victims.
Respectively of the received data, the severity of the victim and predicting the likely death rate is estimated in the range of probability of survival in an experimental scale TRISS(N) (which already takes into account the volume haemoperitoneum), namely from 100 to 80% - the first degree of severity and favorable prognosis for life. in the range of 80 to 60% - the second severity of doubtful prognosis for life. in the range of 60 to 40% - the third severity of poor prognosis for life and death over the shock period, from 40 to 20% - the fourth severity of the probable death of the first day or during the hospitalization period and possibility of survival less than 20%  - trauma incompatible with life. 
To clarify the prognostic value of the  experimental scale TRISS (N) conducted regression AUROC-analysis: predictive value of the area under the ROC-curve was 76,3% (AUC=0,763±0,087; p=0.0027).
The following qualimetric estimation of victim's condition severity degree was carried out depending on point quantity obtained using the experimental MODS-N scale being a sum of points determined with the MODS-ІІ and the APP index. Taking into account the point quantity according to the experimental MODS-N scale (see the fiirst column of the Table 2), the severity degree of the victim condition, prognosis for life and refinement of hospital death risk (%) may be made (see Table 2).
According to the pilot scale MODS (N), there is a strong positive correlation with the index patient day in predicting the duration of the treatment in the group of survivors (rР=0.89) and in the group of deaths (rР= -0.69). Using the MODS-II scale, the prognostic value of the ROC-curve obtained reaches 71.8 % (AUCMODS-ІІ 0.718±0.047; р=0.021) comparing to its value found with the experimental scale MODS-II(N) whose prognostic value is significantly higher – 76.3 % (AUCMODS-II(N) 0.763±0.044; р=0.001). 
Further developed scale TRISS(N) and MODS-II(N) were used in the  algorithm staged tactics «damage control»  of surgical treatment . The essence of the proposed algorithm is as follows: during the surgical operation is determined  prognosis of the affected  according to the scale TRISS(N): at least 20% of the index is done directly in the operating room, namely stop bleeding and stabilize the general condition; 20 to 80% – implemented the first phase of «DC» and directed the victim in intensive care to stabilize the general condition; index at 80% – allows you to perform in one stage removal of existing damage. In the postoperative period while stabilizing the condition the victim conducted by the dynamic scale MODS-II(N) and based on that,  decision to conduct the next stages of surgical treatment. Thus, when the index of 25 or more scores – spend stabilization of the victim; 21 to 13 scores, along with the stabilization of general condition, necessary identify and eliminate the causes that lead to the deterioration of general condition, such as abdominal compression syndrome; by 12 scores or less should be the next stage of surgery – the ultimate elimination of existing damage, laparostomy closure.

Conclusions.

1. In patients with severe combined abdominal trauma in the hospital stage, intraoperative and during the first phase of individual differential surgical treatment «Damage control» should be using the anatomical and functional assessment of injury severity on a scale TRISS(N).
2. In assessing the severity of injuries on a scale TRISS, take account of the volume indicator hemoperitoneum – as predictor of complications during hospital  period for traumatic process, enables to predict the timing of the death for shock period.
3. The prognostication of probable lethality terms based on the use of the MODS-ІІ scale and the index of abdominal perfusion pressure in victims is necessary for grounding of differential surgical tactics of «damage control».
4. The use of experimental MODS-N scale is possible in clinical practice to carry out the dynamic evaluation of organ dysfunction for victims with closed abdominal polytrauma being treated in the DRIC.
5. The decrease of the abdominal perfusion pressure below 65 mm Hg indicates the development of abdominal hypertension syndrome accompanied by the damage of kidney perfusion pressure; these phenomena correspond to the 2-nd condition severity degree of the victim according to the experimental MODS-N scale.

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