Transcript Damage Control Surgery Principles

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!!!
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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.
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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:
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pH less then or equal to 7.2
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serum bicarbonate level less than or equal to
15 mEq/L
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core temperature less than or equal to 34*C
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transfusion volume of packed RBCs more than
or equal to 4000 ml
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total blood replacement more than or equal to
5000 ml
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total fluid replacement more than or equal to
12 000 ml
If all - death
If one - DCS
The principles of damage control surgery
are:
 Control haemorrhage
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Prevention contamination
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Avoid further injury
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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)
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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?
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Stage 2 DCS
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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
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Window of opportunity is 24-48 hours after the traumabetween 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 510 days after trauma
Complications of DCS
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Abdominal compartment syndrome
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General copmlications:
wound sepsis
wound dehiscence
fistula formation
ICU-related infections
skin complications
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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?