Surgery

DR ASHIRWAD KARIGOUDARPG IIIRD YEARDR C K DURGA UNIT

Definition.

Etymology.

Indications.

Damage control protocols.

Conclusion.

Definition

Damage control surgery(DCS) is a concept of abbreviated laparotomy,

designed to prioritize short-term physiological recovery over anatomical

reconstruction in the seriously injured and compromised patient.

Damage control resuscitation (DCR) : A systematic approach to major

trauma combining the ABC paradigm with a series of clinical techniques

from point of wounding to definitive treatment in order to minimize blood

loss, maximize tissue oxygenation, and optimize outcome.

Etymology

Stone and colleagues: Technique of ‘truncated laparotomy’ in 1983.

Rotondo and colleagues: DCS as a 3 phase technique in 1993.

Johnson and schwab: 4 phase technique ( pre-theatre phase).

Indications for DCS: Physiological Factors

1. Hypotension<90mmHg systolic pressure.

2. Hypothermia (temperature < 35° C).

3. Acidosis (pH < 7.2 or base deficit > 8).

4. Coagulopathy (increase in PT and/or PTT, thrombocytopenia,

hypo-fibrinogenemia).

5. Prohibitive operative time needed for definitive repair (> 90

minutes).

6. Massive blood requires > 10 units PRBC or body volume

replacement.

Injury severity

1. Inability to establish haemostasis.

2. High energy blunt abdominal/chest trauma.

3. Multiple penetrating abdominal/chest injuries.

4. Combined visceral injury with major vascular trauma.

5. Major intra-abdominal vascular injury.

6. Pelvic fracture with associated abdominal/vascular life-threatening

injury.

7. Massive abdominal contamination.

8. Life-threatening extra-abdominal injuries.

9. Abdominal wall reconstruction failure (IAH, ACS).

Complications of DCS : intra- abdominal infection, fistula formation,

abdominal wall hernias.

Phases

PART I ( DC 0)

PART II ( DC 1)

PART III ( DC 2)

PART IV ( DC 3)

Phase 0

Pre – hospital setting and in emergency room. Scoop and run, rather than stay and play. DCR includes:

-ABC resuscitation

-Permissive hypotension

-Limitation of crystalloid with early use of blood and blood products

-Early use of TXA

-DCS (DC I)

Massive transfusion protocols:

DO NOT WAIT for results to before transfusing ,use ROTEM results as a guide if available .Send repeat samples & check ABG, K+, Ca++

Patient still bleeding? Send for Pack 3 .

Collect haemorrhage Pack 3 and transfuse accordingly.

Patient still bleeding? Discuss with consultant haematologist Further component require authorization from consultant to haematologist

Transfusion targets Hb 70–90 g litre–1 Platelets >75×109 litre–1 PT/PTT <1.5×normal Fibrinogen >1.5–2.0 g litre–1

Imaging studies :

- USG FAST

- X- rays

- CT scans.

Phase I

Primary objectives include:

-Haemorrhage control.

-Limit contamination.

-Temporary abdominal closure. Aims to restore physiology at the expense of anatomical

reconstruction. On- going DCR.

Phase I addresses the following things expeditiously :

Preparation. Incision. Haemorrhage control. Contamination limitation. Abdominal closure. Interventional radiology (???). Monitoring & transfer of patient to ICU.

Phase II

The first several hours in the ICU are extremely labour intensive Require collaborative efforts of multiple critical care physicians,

nurses, and ancillary staff. The goal of DC II is to reverse the sequelae of hypotension related

metabolic failure. Physiological and biochemical restoration.

Phase II consists of:

Adequate oxygen delivery to body tissues Intensive monitoring Immediate and aggressive core rewarming Aggressive approach to correction of coagulopathy Complete physical examination or ‘tertiary survey’. This may only require 12 h while many more will require 24–36 h

Phase II unplanned re-exploration:

These include:

-Patients who have ongoing transfusion requirements or persistent

acidosis despite normalized clotting and core temperature.

-The second group requiring unplanned return to the operating

theatre have developed ACS.

Phase III

Timing is critical. Ensure that adequate resuscitation and physiological optimization

has been achieved. With focused, critical care management and resuscitation one may

obtain this physiological state within 24–36 hours. Addresses the definitive repair and tension free abdominal closure.

TAKE HOME MESSAGE !!!

DCS and resuscitation have been associated with improvements in survival .

Reduced incidence of complications in major trauma patients.

DCR - may reduce the requirement of DCS.

THANK YOU