Damage Control Surgery Principles

Dr. Josip Janković

Dr. Boris Hrečkovski

Department of surgery

General hospital Slavonski Brod

„The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation“

Lord Moynihan

Standard surgical practice (early total care): the best operation for a patient is one,

definitive procedure the first chance of any surgical intervention

is the best chance for any definitive repair or reconstruction

ER→OR→ICU

BUT!!!

Multiple trauma patients (ISS ≥35) are more likely to die from their intra-operative metabolic failure that from a failure to complete operative repairs

The death triad: - Hypothermia- Acidosis- Coagulopathy

One of the major advances in surgical technique in the past 20 years.

The most technically demanding and challenging surgery a trauma surgeon can perform.

approach method

ER→OR→ICU→OR→ICU

Hypothermia: Clinically important if less than 37*C for

more than 4 h Can lead to cardiac arrhythmias,

decreased cardiac output, increassed systemic vascular resistance

Can induce and exacerbate coagulopathy by inhibition of clotting cascade reaction

Acidosis: Uncorrected haemorrhagic shock leads

into inadequate cellular perfusion, anaerobic metabolism and the production of lactatic acid

Interferes with blood clotting mechanisms and promotes coagulopathy and blood loss

Coagulopathy: Hypothermia, acidosis and the

consequences of massive blood transfusion all lead to the development of a coagulopathy

Platelet dysfunction at low temperature Activation of the fibrinolytic system Haemodilution following massive

resuscitation

Parameters as a guideline for instituting damage control: pH less then or equal to 7.2 serum bicarbonate level less than or equal to 15 mEq/L core temperature less than or equal to 34*C transfusion volume of packed RBCs more than or equal to 4000 ml total blood replacement more than or equal to 5000 ml total fluid replacement more than or equal to 12 000 ml

If all - deathIf one - DCS

The principles of damage control surgery are:

Control haemorrhage

Prevention contamination

Avoid further injury

Prehospital and emergency department times should be minimized

BTLS NO unnecessary and superfluous investigations Rapid transport to the operating room without

repeated attempts to restrore cisculating volume- they require operative control of haemorrhage and simultaneous vigorous resuscitation

Stage 1 DCS (abdomen)

initial laparotomy identify the main source of bleeding perihepatic packing (superior and inferior) small gastotomies and enterotomies can be

rapidly closed resect non-viable bowel and close the ends minor pancreatic injuries not involving duct- no

treatment distal injury including the panceratic duct- distal

pancreatectomy NO pancreaticoduodenectomy (drainage) abdominal closure is rapid and temporary- if

there is any doubt about abdominal compartment syndrome, left it open (silo-bag, vacuum-pack technique)

Stage 1 DCS (skeletal)

Stable patient – osteosynthesis Polytrauma patient- FE Do not insist on anatomical reposition, but

on fracture stabilisation Open fracture-debridman Timing is individual considering clinical

state Secundary brain damage?

Stage 2 DCS

Begins in ICU The next 24 to 48 hours are crucial Correction of metabolic disorder Core rewarming Correction of coagulopathy Complete ventilatory support Correction of acidosis Identification of occult injury

Stage 3 DCS – planned reoperation

Window of opportunity is 24-48 hours after the trauma- between the correction of metabolic disorder and the onset of SIRS and MOF

Removal of the abdominal packs (48-72 h) Primary repair with end-to-end anastomosis undertaken Copious washout should be performed and the abdomen

closed The patient sometimes needs early unplanned

reoperation-ongoing haemorrhage, abdominal compartment syndrome or peritontis

Window of opportunity for definitive osteosynthesis is 5-10 days after trauma

Complications of DCS

Abdominal compartment syndrome

General copmlications: wound sepsis wound dehiscence fistula formation ICU-related infections skin complications

DCS is a treathement method DCS is one of the major advances in surgical

technique in the past 20 years DCS is recognized all over the world for

treathing polytraumatized patients (ISS≥35) DCS is used in our hospital in the last 10 years Patients who had death rate according to

ISS≥90%, survived How much surgery polytrauma patient can

tolerate?