Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored

Dominik A Jakob; Panagiotis Liasidis; Morgan Schellenberg; Kazuhide Matsushima; Lydia Lam; Demetrios Demetriades; Kenji Inaba

doi:10.1007/s00268-020-05906-3

Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored

World J Surg. 2021 Apr;45(4):1014-1020. doi: 10.1007/s00268-020-05906-3. Epub 2021 Jan 16.

Authors

Dominik A Jakob¹, Panagiotis Liasidis¹, Morgan Schellenberg¹, Kazuhide Matsushima¹, Lydia Lam¹, Demetrios Demetriades¹, Kenji Inaba²

Affiliations

¹ Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA.
² Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, 2051 Marengo Street, Inpatient Tower (C), 5th Floor, C5L100, Los Angeles, CA, 90033, USA. Kenji.Inaba@med.usc.edu.

PMID: 33454792
DOI: 10.1007/s00268-020-05906-3

Abstract

Background: Routine four-quadrant packing (4QP) for hemorrhage control immediately upon opening is a standard practice for acute trauma laparotomy. The aim of this study was to evaluate the utility of 4QP for bleeding control in acutely injured patients undergoing trauma laparotomy.

Methods: Retrospective single-center study (01/2015-07/2019), including adult patients who underwent trauma laparotomy within 4 h of admission. Only patients with active intra-abdominal hemorrhage, defined as bleeding within the peritoneal cavity or expanding retroperitoneal hematoma, were considered for analysis. Bleeding sources were categorized anatomically: liver/retrohepatic inferior vena cava (RIVC), spleen, retroperitoneal zones 1, 2 and 3, mesentery and others. Hemorrhage was further categorized as originating from a single bleeding site (SBS) or from multiple bleeding sites (MBS). The effectiveness of directed versus 4QP was evaluated for bleeding from the liver/RIVC, spleen and retroperitoneal zone 3, areas that are potentially compressible. Directed packing was defined as indicated if the bleeding was restricted to one of the anatomic sites suitable for packing, 4QP was defined as indicated if ≥ 2 of the anatomic sites suitable for packing were bleeding.

Results: During the study time frame, 924 patients underwent trauma laparotomy, of which 148 (16%) had active intra-abdominal hemorrhage. Of these, 47% had a SBS and 53% had MBS. The liver/RIVC was the most common bleeding source in both patients with SBS (42%) and in patients with MBS (54%). According to our predefined indications, 22 of 148 patients (15%) would have benefitted from initial 4QP, 90 of 148 patients (61%) from directed packing and 36 of 148 patients (24%) packing would not have been of any value.

Conclusion: Routine four-quadrant packing is frequently practiced. However, this is only required in a small proportion of patients undergoing trauma laparotomy. Directed packing can be equally effective, saves time and decreases the risk of iatrogenic injury from unnecessary packing.

MeSH terms

Abdominal Injuries* / complications
Abdominal Injuries* / surgery
Adult
Hemorrhage / etiology
Hemorrhage / prevention & control
Humans
Laparotomy
Retrospective Studies
Wounds, Nonpenetrating* / surgery