Prognostic factors in patients with inferior vena cava injuries

Inferior vena cava (IVC) injuries are potentially devastating insults that continue to be associated with high mortality despite advances in prehospit al and in-hospital critical care. Between 1987 and 1996, 37 patients (32 ma les and 5 females; average age, 30 years) were identified from the trauma r egistry as having sustained IVC trauma. Overall mortality was 51 per tent ( n = 19), with 13 intraoperative deaths and five patients dying within the f irst 48 hours. Blunt IVC injuries (n = 8) had a higher associated mortality than penetrating wounds (63% versus 48%). Of the 29 patients with penetrat ing IVC trauma, the wounding agent influenced mortality (shotgun-100% versu s gunshot-43% versus stab-0%). Anatomical location of injury was also predi ctive of death [suprahepatic (n = 3)-100% versus retrohepatic (n = 9)-78% v ersus suprarenal (n = 6)-33% versus juxtarenal (n = 2)-50% versus infrarena l (n = 15)-33%]. A direct relationship existed between outcome and the numb er of associated injuries: nonsurvivors averaged four and survivors average d three. Eighty per cent of patients sustaining four or more associated inj uries died, by contrast to a 33 per cent mortality in those suffering less than four injuries. Physiological factors were also predictive of outcome. Patients in shock (systolic blood pressure <80) on arrival had a higher mor tality than those who were hemodynamically stable (76% versus 30%). Preoper ative lactate levels were of prognostic value for death (greater than or eq ual to 4.0-59% versus <4.0-0%), as was base deficit (<4-22%, greater than o r equal to 4, and <10-36%, greater than or equal to 10-73%). Interestingly, neither time from injury to hospital arrival (47.4 minutes versus 33.0 min utes) nor time in the emergency department before surgery (45.6 minutes ver sus 42.6 minutes) differed between survivors and fatalities. Mortality rema ined high in the 34 patients who had operative control of their IVC injurie s [lateral repair (n = 27)-44% versus ligation (n = 6)-66% versus Gortex gr aft (n = 1)-0%]. As wounding agent, anatomical location, associated injurie s, and physiological status seem to most directly impact mortality, future efforts must focus both on establishing prevention programs directed at red ucing the incidence of this injury, as well as on advancing the management of those who do survive to hospitalization, if we are to improve on the out come of these devastating injuries.