Intraoperative factors associated with unplanned return to the operating room after emergent hemorrhage control surgery

BACKGROUND Unplanned return to the operating room (uROR) is associated with worse outcomes and increased mortality. Little is known regarding intraoperative factors associated with uROR after emergent surgery in trauma patients. The objective of this study was to identify intraoperative factors associated with uROR after emergent hemorrhage control procedures in bleeding trauma patients. METHODS We used anesthetic record of intraoperative management to perform a retrospective study (2017–2022) of bleeding trauma patients who were taken for an emergent hemorrhage control operation. RESULTS A total of 225 patients met the inclusion criteria, 46 (20%) had uROR, and 181 (80%) did not. While there was no difference in demographics, mechanism, admission physiology, or time from emergency department to operating room, the uROR patients had a higher Injury Severity Score (30 vs. 25, p = 0.007). While there was no difference in volume of crystalloid infused (3,552 ± 2,279 mL vs. 2,977 ± 2,817 mL, p = 0.20), whole blood (2.2 ± 0.9 vs. 2.0 ± 0.5, p = 0.20), or platelets (11.6 ± 8.6 vs. 9.2 ± 9.0, p = 0.14), the uROR group received more packed red blood cells (11.5 ± 10.6 vs. 7.8 ± 7.5, p = 0.006) and plasma (9.6 ± 8.3 vs. 6.5 ± 6.6, p = 0.01), and more uROR patients received ≥10 U of packed red blood cells (48% vs. 27%, p = 0.006). Damage-control surgery (DCS) was more common in uROR patients (78% vs. 45%, p < 0.0001). After logistic regression, ≥10 U of packed cells in the operating room (4.3 [1.5–12.8], p = 0.009), crystalloid (1.0 [1.0–1.001], p = 0.009), International Normalized Ratio (INR) (7.6 [1.3–45.7], p = 0.03), and DCS (5.7 [1.7–19.1], p = 0.005) were independently associated with uROR. CONCLUSION Massive transfusion, crystalloid resuscitation, persistent coagulopathy, and DCS are the most significant risk factors for uROR. During hemorrhage control surgery in bleeding trauma patients who receive ≥10 U of blood, providers must maintain a keen focus on minimizing crystalloid and ongoing balanced resuscitation, particularly during damage-control procedures. LEVEL OF EVIDENCE Retrospective/Descriptive; Level IV.