Early fluid overload and mortality in damage control laparotomy

Abstract Background Optimal fluid resuscitation strategies in critically ill surgical patients remain unclear, particularly in emergency general surgery (EGS) patients undergoing damage control laparotomy (DCL). This study aimed to evaluate the association between the magnitude, rate, and dose of early fluid accumulation and mortality in patients undergoing DCL. We propose the peak fluid index (PFI), defined as the highest-volume net fluid balance during a hospitalization. Methods This retrospective cohort study included adult patients undergoing emergent exploratory laparotomy with DCL for nontraumatic indications at a single academic institution from January 2013 to December 2023. Patients younger than 18 years, pregnant patients, prisoners, trauma cases, mortality within 24 h postoperatively, and those with missing data were excluded. The primary outcome was in-hospital mortality. Secondary outcomes included time to fascial closure and major complications. Key exposure variables included PFI, fluid volume administered within the first 24 h, and rate of fluid accumulation to the first fluid peak. Results Among 416 patients (mean age, 63.0 years; 52% male), 111 (27%) died during hospitalization. On multivariable analysis, rate of fluid accumulation (OR 1.35 per L/day; 95% CI 1.12–1.60, p < 0.001) was independently associated with mortality, whereas PFI and first 24-hour fluid volume were not. In a Cox proportional hazards model, rate of fluid accumulation remained significant (HR 1.28; 95% CI 1.20–1.37, p < 0.001). Conclusion Early fluid resuscitation patterns, particularly the rate of accumulation, are strongly associated with mortality in patients undergoing DCL. These results suggest that a controlled fluid resuscitation might be more beneficial to patients, and that the tempo of resuscitation may matter more than cumulative volumes received.