Abstract：
OBJECTIVE: The inability to achieve primary fascial closure (PFC) after emergency laparotomy increases the rates of adverse outcomes including fistula formation, incisional hernia, and intraabdominal infection. Hypertonic saline (HTS) infusion improves early PFC rates and decreases time to PFC in patients undergoing damage control laparotomy (DCL) after injury. We hypothesized that in patients undergoing DCL after penetrating abdominal injury, HTS infusion would decrease the time to fascial closure as well as the volume of crystalloid required for resuscitation without inducing clinically relevant acute kidney injury (AKI) or electrolyte derangements.
METHODS: We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30 mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72 h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey\'s comparison, and student\'s t, and Fischer\'s exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution.
RESULTS: Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37 h ± 14.21 vs 59.05 h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24 h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48 h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72 h, peak sodium (Na) concentration (146.2 mEq/L ± 2.94 vs 142.8 mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1 mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days.
CONCLUSIONS: HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm.
METHODS: Level III.
METHODS: We retrospectively analyzed all penetrating abdominal injury patients undergoing DCL within the University of Pennsylvania Health System (January 2015-December 2018). We compared patients who received 3% HTS at 30 mL/h (HTS) to those receiving isotonic fluid (ISO) for resuscitation while the abdominal fascia remained open. Primary outcomes were the rate of early PFC (PFC within 72 h) and time to PFC; secondary outcomes included acute kidney injury, sodium derangement, ventilator-free days, hospital length of stay (LOS), and ICU LOS. Intergroup comparisons occurred by ANOVA and Tukey\'s comparison, and student\'s t, and Fischer\'s exact tests, as appropriate. A Shapiro-Wilk test was performed to determine normality of distribution.
RESULTS: Fifty-seven patients underwent DCL after penetrating abdominal injury (ISO n = 41, HTS n = 16). There were no significant intergroup differences in baseline characteristics or injury severity score. Mean time to fascial closure was significantly shorter in HTS (36.37 h ± 14.21 vs 59.05 h ± 50.75, p = 0.02), and the PFC rate was significantly higher in HTS (100% vs 73%, p = 0.01). Mean 24-h fluid and 48-h fluid totals were significantly less in HTS versus ISO (24 h: 5.2L ± 1.7 vs 8.6L ± 2.2, p = 0.01; 48 h: 1.3L ± 1.1 vs 2.6L ± 2.2, p = 0.008). During the first 72 h, peak sodium (Na) concentration (146.2 mEq/L ± 2.94 vs 142.8 mEq/L ± 3.67, p = 0.0017) as well as change in Na from ICU admission (5.1 mEq/L vs 2.3, p = 0.016) were significantly higher in HTS compared to ISO. Patients in the HTS group received significantly more blood in the trauma bay compared to ISO. There were no intergroup differences in intraoperative blood transfusion volume, AKI incidence, change in chloride concentration (△Cl) from ICU admit, Na to Cl gradient (Na:Cl), initial serum creatinine (Cr), peak post-operative Cr, change in creatinine concentration (△Cr) from ICU admission, creatinine clearance (CrCl), initial serum potassium (K), peak ICU K, change in K from ICU admission, initial pH, highest or lowest post-operative pH, mean hospital LOS, ICU LOS, and ventilator-free days.
CONCLUSIONS: HTS infusion in patients undergoing DCL after penetrating abdominal injury decreases the time to fascial closure and led to 100% early PFC. HTS infusion also decreased resuscitative fluid volume without causing significant AKI or electrolyte derangement. HTS appears to offer a safe and effective fluid management approach in patients who sustain penetrating abdominal injury and DCL to support early PFC without inducing measurable harm.
METHODS: Level III.
摘要：
目的：急诊剖腹手术后无法实现原发性筋膜闭合（PFC）会增加包括瘘管形成在内的不良结局的发生率，切口疝,和腹腔内感染。高渗盐水（HTS）输注可提高受伤后进行损伤控制剖腹手术（DCL）的患者的早期PFC率并减少PFC时间。我们假设在腹部穿透性损伤后接受DCL的患者中，HTS输注将减少筋膜闭合的时间以及复苏所需的晶体体积，而不会引起临床相关的急性肾损伤（AKI）或电解质紊乱。
方法：我们回顾性分析了在宾夕法尼亚大学卫生系统（2015年1月至2018年12月）内接受DCL的所有穿透性腹部损伤患者。我们比较了在30mL/h（HTS）下接受3％HTS的患者与在腹部筋膜保持开放的情况下接受等渗液体（ISO）进行复苏的患者。主要结局是早期PFC（72h内PFC）和PFC时间；次要结局包括急性肾损伤，钠紊乱，无呼吸机日，住院时间（LOS），ICULOS通过方差分析和Tukey's比较进行组间比较，和学生的t，和Fischer的精确测试,视情况而定。进行Shapiro-Wilk检验以确定分布的正常性。
结果：57例患者在腹部穿透性损伤后接受了DCL（ISOn=41，HTSn=16）。基线特征或损伤严重程度评分无显著组间差异。HTS的平均筋膜闭合时间明显缩短（36.37h±14.21vs59.05h±50.75，p=0.02），并且在HTS中PFC率明显更高(100%比73%，p=0.01)。HTS与ISO相比，平均24小时液体和48小时液体总数显着降低（24小时：5.2L±1.7vs8.6L±2.2，p=0.01；48小时：1.3L±1.1vs2.6L±2.2，p=0.008）。在最初的72小时内，钠（Na）的峰值浓度（146.2mEq/L±2.94vs142.8mEq/L±3.67，p=0.0017）以及ICU入院时Na的变化（5.1mEq/Lvs2.3，p=0.016）在HTS中明显高于ISO。与ISO相比，HTS组的患者在创伤湾中接受了更多的血液。术中输血量无组间差异,AKI发生率,ICU入院时氯化物浓度(△Cl)的变化，Na至Cl梯度(Na:Cl),初始血清肌酐（Cr），术后Cr峰值,ICU入院时肌酐浓度（△Cr）的变化，肌酐清除率（CrCl），初始血清钾（K），ICUK峰值,ICU入院时K的变化，初始pH值,术后最高或最低pH值，平均医院LOS，ICULOS,和无呼吸机的日子。
结论：在腹部穿透性损伤后接受DCL的患者中输注HTS减少了筋膜闭合的时间，并导致100%早期PFC。HTS输注还减少了复苏液的体积，而不会引起明显的AKI或电解质紊乱。HTS似乎为患有穿透性腹部损伤和DCL的患者提供了安全有效的液体管理方法，以支持早期PFC，而不会引起可测量的伤害。
方法：三级。
方法：我们回顾性分析了在宾夕法尼亚大学卫生系统（2015年1月至2018年12月）内接受DCL的所有穿透性腹部损伤患者。我们比较了在30mL/h（HTS）下接受3％HTS的患者与在腹部筋膜保持开放的情况下接受等渗液体（ISO）进行复苏的患者。主要结局是早期PFC（72h内PFC）和PFC时间；次要结局包括急性肾损伤，钠紊乱，无呼吸机日，住院时间（LOS），ICULOS通过方差分析和Tukey's比较进行组间比较，和学生的t，和Fischer的精确测试,视情况而定。进行Shapiro-Wilk检验以确定分布的正常性。
结果：57例患者在腹部穿透性损伤后接受了DCL（ISOn=41，HTSn=16）。基线特征或损伤严重程度评分无显著组间差异。HTS的平均筋膜闭合时间明显缩短（36.37h±14.21vs59.05h±50.75，p=0.02），并且在HTS中PFC率明显更高(100%比73%，p=0.01)。HTS与ISO相比，平均24小时液体和48小时液体总数显着降低（24小时：5.2L±1.7vs8.6L±2.2，p=0.01；48小时：1.3L±1.1vs2.6L±2.2，p=0.008）。在最初的72小时内，钠（Na）的峰值浓度（146.2mEq/L±2.94vs142.8mEq/L±3.67，p=0.0017）以及ICU入院时Na的变化（5.1mEq/Lvs2.3，p=0.016）在HTS中明显高于ISO。与ISO相比，HTS组的患者在创伤湾中接受了更多的血液。术中输血量无组间差异,AKI发生率,ICU入院时氯化物浓度(△Cl)的变化，Na至Cl梯度(Na:Cl),初始血清肌酐（Cr），术后Cr峰值,ICU入院时肌酐浓度（△Cr）的变化，肌酐清除率（CrCl），初始血清钾（K），ICUK峰值,ICU入院时K的变化，初始pH值,术后最高或最低pH值，平均医院LOS，ICULOS,和无呼吸机的日子。
结论：在腹部穿透性损伤后接受DCL的患者中输注HTS减少了筋膜闭合的时间，并导致100%早期PFC。HTS输注还减少了复苏液的体积，而不会引起明显的AKI或电解质紊乱。HTS似乎为患有穿透性腹部损伤和DCL的患者提供了安全有效的液体管理方法，以支持早期PFC，而不会引起可测量的伤害。
方法：三级。
