Adult respiratory distress syndrome risk factors for injured patients undergoing damage-control laparotomy: AAST multicenter post hoc analysis

BACKGROUND: Severely injured patients undergoing damage-control laparotomy (DCL) have multiple risk factors for adult respiratory distress syndrome (ARDS), making it challenging to differentiate the contributions of individual causative factors. We aimed to determine the relative contributions of ARDS risk factors. METHODS: Analysis of the prospectively collected American Association for the Surgery of Trauma Multi-institutional Open Abdomen Database was performed. Inclusion criteria were any patient, 18 years or older, undergoing DCL at 1 of 14 participating Level I trauma centers. Univariable and multivariable Cox regression analyses were performed to determine the association of variables with the development of ARDS during hospitalization. RESULTS: A total of 563 patients (78% men; mean [SD] age, 40 [18] years) were identified, of whom 77 developed ARDS (14%). Overall mortality was 23%, with a 39% mortality rate for ARDS patients. Univariable analysis demonstrated that Injury Severity Score (ISS, 1.03; 95% confidence interval [CI], 1.02-1.05), intraoperative (IO) estimated blood loss (hazard ratio [HR], 1.09; 95% CI, 1.04-1.13), IO plasma transfusion (HR, 1.17; 95% CI, 1.10-1.25), 24-hour colloid volume (HR, 1.07; 95% CI, 1.04-1.10), and 24-hour crystalloid volume (HR, 1.01; 95% CI, 1.00-1.01) were associated with the development of ARDS. Cox multivariable analysis demonstrated that ISS, IO plasma transfusions, and total fluid balance through 23 hours all increased the risk of ARDS development. CONCLUSION: Severity of injury, plasma transfusions, and greater fluid administration by 24 hours were independently associated with ARDS development. Judicious use of plasma and other fluids may reduce rates of ARDS in this critically injured population. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.