Damage control surgery and resuscitation

DAMAGE CONTROL SURGERYAND

RESUSCITATION

by

Phongthorn Tuntivararut, MD, R.Ph.

Surgical Residency

Police General Hospital, Thailand

“The modern operation is safe for the

patient. The modern surgeon must make the

patient safe for the modern operation.”

- Lord Moynihan -

DAMAGE CONTROL SURGERY

• Damage control surgery is one of the major advances in

surgical technique in the past 20 years, including

• Minimizing time at the scene of trauma and in the emergency

department (ED)

• Minimizing admission laboratory testing

• Initiating resuscitation in the operating room for patients with

severe hypotension, cardiac arrest, or external hemorrhage

• Early operative control of hemorrhage

DAMAGE CONTROL SURGERY

• Damage control surgery are performed in injured patients with

profound hemorrhagic shock and preoperative or

intraoperative metabolic unstable that are known to adversely

affect survival

WHO NEEDS DCS??

• Thoracic Trauma

• Penetrating thoracic wound and systolic blood pressure <90

mmHg

• Pericardial fluid on surgeon-performed ultrasound after blunt or

penetrating thoracic trauma

• S/p emergency department thoracotomy for penetrating thoracic

wound

• Trauma to an Extremity

• Shotgun wound to femoral triangle of thigh

Mattox. Trauma 6th Edition

WHO NEEDS DCS??

• Abdominal or Pelvic Trauma

• Penetrating abdominal wound and systolic blood pressure <90

mmHg

• Blunt abdominal trauma, systolic blood pressure <90 mmHg, and

peritoneal fluid on surgeon-performed ultrasound or gross blood

on diagnostic peritoneal tap

• Closed pelvic fracture, systolic blood pressure <90 mmHg, and

peritoneal fluid on surgeon-performed ultrasound or gross blood

on diagnostic peritoneal tap

• Open pelvic fracture


Why we need Damage Control Surgery ??

ER OR ICU

ER OR Death

OR

“Multiple trauma patients are more likely to

die from their intra-operative metabolic failure

that from a failure to complete operative

repairs”

www.trauma.org

LETHAL TRIADS

• Hypothermia

• Severe hypothermia despite warming maneuvers initiated in the

ED and continuing in the operating room

• Acidosis

• Persistent acidemia despite vigorous resuscitation and control of

hemorrhage

• Coagulopathy

HYPOTHERMIA

• Hypovolemic shock in the preoperative period adversely

affects oxygen delivery and leads to decreases in oxygen

consumption and production of heat

• Hypothermia is the gateway to the triad because almost all

clotting mechanisms are temperature dependent

• Cold inhibits the clotting cascade, leading to coagulopathy

• Platelet dysfunction at low temperature

• Clinically important if less than 37˚C for more than 4 hr

Class I II III IV

Blood loss (ml) <750 750-1,500 1,500-2,000 ≥2,000

%Blood volume lost <15% 15-30% 30-40% ≥40%

Pulse rate <100 >100 >120 >140

Blood pressure Normal Normal Decreased Decreased

Pulse pressure Normal or increased Decreased Decreased Decreased

Capillary refill Normal Delayed Delayed Delayed

Respiratory rate 14-20 20-30 30-40 >35

Urine output(ml/hr) >30 20-30 5-15 Negligible

Mental status Slightly anxious Mildly anxiousAnxious,

confused

Confused,

lethargic

Recommended fluid

replacement0.9%saline, 3:1 0.9%saline, 3:1

0.9%saline+

red cells

0.9%saline+

red cells

ATLS program for physician, student and instructor manual, American College of Surgeons, 1993

COAGULOPATHY

• Unchecked hemorrhage, in turn, decreases blood pressure and

the amount of available oxygen, causing cells to convert to

anaerobic metabolism

• Hypothermia, acidosis and the consequences of massive blood

transfusion all lead to the development of a coagulopathy

• Haemodilution following massive resuscitation

HEMODILUTION

• Aggressive crystalloid, colloid resuscitation in absence of

plasma increases likelihood of coagulopathy

Maegele, Injury, 2007

Volume fluids (ml) % Coagulopathy

500 10

2000 40

3000 50

4000 80

ACIDOSIS

• Interferes with blood clotting mechanisms and promotes

coagulopathy and blood loss

• Can lead to cardiac arrhythmias, decreased cardiac output,

increassed systemic vascular resistance

ER OR ICU OR ICU

Limited operation

Resuscitation

Reoperation

Trauma patients

withMetabolic failure


LIMITED OPERATION

• Control of hemorrhage from the heart or lung

• Conservative management of injuries to solid organs

• Resection of major injuries to the gastrointestinal tract without

reanastomosis

• Control of hemorrhage from major arteries and veins in the

neck, trunk, or extremities

• Packing of organs or spaces to control the inevitable

coagulopathy

RESUSCITATION

• Vigorous rewarming of the hypothermic patient

• Restoration of a normal cardiovascular state by the infusion of

fluids and blood and the use of inotropic and related drugs

• Correction of residual coagulopathy after hypothermia is

reversed

• Supportive care for stunned lungs and kidneys

REWARMING

• Bair Hugger

• Warming light, fluid and

blood product

• Gentilello

• Continuous arteriovenous

rewarming device

COAGULATION MANAGEMENT

• Plasma and platelet transfusion

• The ratio of 2:1:1 or 3:1:1

• Serial coagulation parameters should be monitored

• The administration of recombinant activated factor VII

(Novoseven) may also play a role in the management of a life-

threatening coagulopathy

• Administration of rFVIIa to coagulopathic trauma patients

significantly reduces the need for blood and blood-product

transfusion

• Three intravenous injections of rFVIIa (200, 100, and 100

μg/kg) at 8th unit of PRC, 1 and 3 hr after

Critical Care 2006, 10:R178

Critical Care 2006, 10:R178

ENDPOINT OF RESUSCITATION

• Permissive Hypotensive Resuscitation

• The optimal MAP is one which would provide a sufficient flow of

blood to delicately balance hemostasis

• The minimal MAP for the functioning of the vital organs is about

50 - 70 mmHg

• The goal blood pressure for these patients is a MAP of 40-50

mmHg or a SBP ≤ 80 mmHg


• Contraindication of Permissive hypotension

• Preexisting hypertension

• Preexisting cardiovascular disease

• Traumatic brain injury

• Pregnancy

• Underlying disease of cerebrovascular disease, carotid artery

stenosis, and compromised renal function

• Controlled resuscitation can effectively

• ↓ Additional blood loss

• avoid excessive hemodilution and coagulopathy

• Improve the early survival rate, and

• ↓ Apoptosis of visceral organs

J Trauma 2007; 63(4): 798-804

• In uncontrolled hemorrhage shock (UCHS) fluid treatment is

aimed at

• Restoration of radial pulse

• Obtaining a SBP of 80 mmHg By titration of 250 ml of isotonic

solution (Control resuscitation)

• High blood pressure (SBP>100 mmHg, MAP>70 mmHg) in

head-injured and in pregnant patients

World J Emerg Surg 2006; 31(4): 339-44


• Simple restoration of normal vital signs is not adequate as a

patient may simply be in “compensated” shock while

continuing to have occult hypoperfusion and ongoing tissue

damage

• Endpoint of resuscitation can be divided to :

• Global endpoint

• Regional endpoint

• Cardiac output, Cardiac index

• Oxygen delivery

• Mixed venous oxygenation

• Right ventricular end-diastolic volume

• Left-ventricular stroke work index

• Left-ventricular power output

• Base excess

• Lactate level

Global Endpoint

• Gastric tonometry

• Intramucosal pH (pHi)

• The gap between intramucosaland arterial pCO2

• Esophageal CO2, pH

• Sublingual CO2, pH

• Intramuscular pH

• Intramuscular pCO2

• Tissue O2 and CO2

Regional Endpoint

2003 Eastern Association for the surgery of Trauma

REOPERATION

• Completion of definitive repairs

• Search for missed injuries

• Formal closure of the incision



THANK YOU FOR YOUR ATTENTION

Damage control surgery and resuscitation

Health & Medicine