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

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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.

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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Authors and 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

    Dominik A. Jakob, Panagiotis Liasidis, Morgan Schellenberg, Kazuhide Matsushima, Lydia Lam, Demetrios Demetriades & Kenji Inaba

Authors
  1. Dominik A. Jakob
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  2. Panagiotis Liasidis
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  3. Morgan Schellenberg
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  4. Kazuhide Matsushima
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  5. Lydia Lam
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  6. Demetrios Demetriades
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  7. Kenji Inaba
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Contributions

DAJ, KI designed the study. DAJ and PL collected the data. DAJ analyzed data. DAJ and KI wrote the first draft of the manuscript. All authors contributed to the interpretation of the data and writing of the manuscript and approved the final version of the manuscript. KI supervised all aspects of study design, data acquisition, analyses and manuscript writing. The study was approved by the Institutional Review Board of the University of Southern California.

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Correspondence to Kenji Inaba.

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Jakob, D.A., Liasidis, P., Schellenberg, M. et al. Intra-Abdominal Hemorrhage Control: The Need for Routine Four-Quadrant Packing Explored. World J Surg 45, 1014–1020 (2021). https://doi.org/10.1007/s00268-020-05906-3

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  • DOI: https://doi.org/10.1007/s00268-020-05906-3

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