The conjoint effect of reduced crystalloid administration and decreased damage-control laparotomy use in the development of abdominal compartment syndrome Bellal Joseph, MD, Bardiya Zangbar, MD, Viraj Pandit, MD, Gary Vercruysse, MD, Hassan Aziz, MD, Narong Kulvatunyou, MD, Julie Wynne, MD, Terence O’Keeffe, MB, ChB, Andrew Tang, MD, Randall S. Friese, MD, and Peter Rhee, MSD, Tucson, Arizona BACKGROUND: Anticipation of abdominal compartment syndrome (ACS) is a factor for performing damage-control laparotomy (DCL). Recent years have seen changes in resuscitation patterns and a decline in the use of DCL. We hypothesized that reductions in both crystalloid resuscitation and the use of DCL is associated with a reduced rate of ACS in trauma patients. METHODS: We reviewed the records of all patients who underwent trauma laparotomies at our Level 1 trauma center over a 6-year period (2006Y2011). We defined DCL as a trauma laparotomy in which the fascia was not closed at the initial operation. We defined ACS by elevated intravesical pressures and end-organ dysfunction. Our primary outcome measure was a development of ACS. RESULTS: A total of 799 patients were included. We noted a significant decrease in the DCL rate (39% in 2006 vs. 8% in 2011, p G 0.001), the crystalloid volume per patient (mean [SD], 12.8 [7.8] L in 2006 vs. 6.6 [4.2] L in 2011; p G 0.001), rate of ACS (7.4% in 2006 vs. 0% in 2011, p G 0.001), and mortality rate (22.8% in 2006 vs. 10.6% in 2011, p G 0.001). However, we noted no significant changes in the mean Injury Severity Score (ISS) ( p = 0.09), in the mean abdominal Abbreviated Injury Scale (AIS) score ( p = 0.17), and in the mean blood product volume per patient ( p = 0.67). On multivariate regression analysis, crystalloid resuscitation ( p = 0.01) was the only significant factor associated with the development of ACS. CONCLUSION: Minimizing the use of crystalloids and DCL was associated with better outcomes and virtual elimination of ACS in trauma patients. With the adaption of new resuscitation strategies, goals for a trauma laparotomy should be definitive surgical care with abdominal closure. ACS is a rare complication in the era of damage-control resuscitation and may have been iatrogenic. (J Trauma Acute Care Surg. 2014;76: 00Y00. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic, retrospective study, level III. KEY WORDS: Damage-control laparotomy; abdominal compartment syndrome; crystalloid resuscitation; trauma laparotomy; damage- control resuscitation. A bdominal compartment syndrome (ACS) is a potential com- plication after major trauma, especially in critically ill pa- tients undergoing aggressive resuscitation protocols. 1 Despite a decrease in mortality caused by this complication during the past decade, the mortality rate in patients with ACS remains as high as 37%. 2 Several risk factors have been identified in the literature for the development of ACS, including trauma lapa- rotomies and massive fluid transfusions. 3Y5 The changing patterns of resuscitation in the past decade have resulted in an increase in the survival rate in patients un- dergoing trauma laparotomy. 1,6,7 Evidence is growing that avoid- ing massive crystalloid transfusions is associated with survival benefits and decrease in incidence of both primary and secondary ACS in trauma patients. 1,6 However, there have been limited studies investigating the relationship of reducing both crystalloid use and the use of damage-control laparotomy (DCL) in development of ACS. 8 DCL is not always beneficial and can give rise to mul- tiple complications itself. 9Y11 A decrease in the use of DCL has shown to have survival benefits. 12 However, other studies have promoted a modification in the use of emergency trauma lapa- rotomy in favor of DCL. 13Y15 It has been suggested to leave the abdomen open, in the belief that doing so can potentially decrease the incidence of ACS and improve outcomes. 13 The aim of this study was to describe the relationship of reducing both crystalloid resuscitation and DCL with de- velopment of ACS. We hypothesized that reductions in both crystalloid resuscitation and the use of DCL are associated with a reduced rate of ACS in trauma patients. PATIENTS AND METHODS This is a 6-year (2006Y2011) retrospective cohort anal- ysis of all trauma patients who underwent laparotomies at our Level 1 trauma center. Patients with intra-abdominal injuries who underwent emergent laparotomies were included. Patients who died before the completion of the initial emergent ORIGINAL ARTICLE J Trauma Acute Care Surg Volume 76, Number 2 1 Submitted: August 2, 2013, Revised: August 19, 2013, Accepted: August 21, 2013. From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of Arizona, Tucson, Arizona. This study was presented as a poster at the 36th Annual Conference on Shock, June 2013, in San Diego, California. Address for reprints: Bellal Joseph, MD, University of Arizona, Department of Surgery, Division of Trauma, Critical Care, Emergency Surgery, and Burns, 1501 N Campbell Ave, Room.5411, PO Box 245063, Tucson, AZ 85724; email: bjoseph@surgery.arizona.edu. DOI: 10.1097/TA.0b013e3182a9ea44 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.