Damage control and its importance the lect.ppt
- 1. DAMAGE CONTROL DAMAGE CONTROL HAMED RASHAD Professor of Surgery -Egypt Professor of Surgery -Egypt
- 2. Damage control Damage control US navy defines it as the capacity of the US navy defines it as the capacity of the ship to absorb damage and maintain its ship to absorb damage and maintain its mission integrity mission integrity
- 5. Evolution of damage control in Evolution of damage control in surgical patients surgical patients 1908 Pringle: 1908 Pringle: Compression and hepatic packing for Compression and hepatic packing for portal venous hemorrhage. Ann Surg 1908;48:541 portal venous hemorrhage. Ann Surg 1908;48:541
- 6. Evolution of damage control in Evolution of damage control in surgical patients surgical patients 1983 Stone et al. : 1983 Stone et al. : Coagulopathy contributed to poor Coagulopathy contributed to poor outcomes. Proposed truncation of laparotomy, reversal of outcomes. Proposed truncation of laparotomy, reversal of coagulopathy and then return to OR for definite surgical coagulopathy and then return to OR for definite surgical repair. Ann Surg : 1983 May; 1979(5) : 532 repair. Ann Surg : 1983 May; 1979(5) : 532
- 7. Evolution of damage control in Evolution of damage control in surgical patients surgical patients 1990S 1990S
- 8. Evolution of damage control in Evolution of damage control in surgical patients surgical patients Burch, et al 1992 Ann Surg : 1992 May; Burch, et al 1992 Ann Surg : 1992 May; 215 (5) :476 215 (5) :476
- 9. Evolution of damage control in Evolution of damage control in surgical patients surgical patients 1993 Rotondo et al coined “ Damage Control 1993 Rotondo et al coined “ Damage Control Laparotomy “ Laparotomy “ 20 year review : 52% mortality – 40% morbidity 20 year review : 52% mortality – 40% morbidity
- 10. The lethal triad The lethal triad Hypothermia Hypothermia Acidosis Acidosis Coagulopathy Coagulopathy
- 11. The lethal triad The lethal triad Bleeding Bleeding coagulopathy coagulopathy Acidosis Acidosis hypothermia hypothermia
- 12. Effects of hypothermia Effects of hypothermia 100% mortality if core temp < 32C 100% mortality if core temp < 32C Diminished cardiac function Diminished cardiac function Coagulopathy: clotting cascade is a temp. Coagulopathy: clotting cascade is a temp. dependent reaction, fibrinolysis, platelet dependent reaction, fibrinolysis, platelet dysfunction/sequestration dysfunction/sequestration
- 13. Acidosis Acidosis Lactate production from anaerobic Lactate production from anaerobic metabolism metabolism Failure to normalize lactate concentration Failure to normalize lactate concentration by 48 hours, mortality between 86 to 100% by 48 hours, mortality between 86 to 100% Systemic effects: decreased contractility, Systemic effects: decreased contractility, impaired response to catecholamines and impaired response to catecholamines and ventricular arrhythmias ventricular arrhythmias Coagulopathy worsened Coagulopathy worsened
- 14. Coagulopathy Coagulopathy Dilution worsens coagulopathy Dilution worsens coagulopathy Dilution and hypothermia additive Dilution and hypothermia additive Acidosis worsens coagulopathy Acidosis worsens coagulopathy
- 15. Control or not? Control or not? Damage control surgery: an alternative approach Damage control surgery: an alternative approach for the management of critically injured patients for the management of critically injured patients Kouraklis G, Spirakos S, Glinavou A Surg Today. Kouraklis G, Spirakos S, Glinavou A Surg Today. 2002;32(3):195-202 2002;32(3):195-202 … …These observations have led to the development These observations have led to the development of a new surgical strategy that sacrifices the of a new surgical strategy that sacrifices the completeness of immediate repair in order to completeness of immediate repair in order to adequately address the combined physiological adequately address the combined physiological impact of trauma and surgery impact of trauma and surgery
- 16. Control or not? Control or not? Coagulopathy, hypothermia and acidosis in trauma Coagulopathy, hypothermia and acidosis in trauma patients: the rationale for damage control surgery patients: the rationale for damage control surgery De Waele JJ, Vermassen FE. Acta Chir Belg. 2002 De Waele JJ, Vermassen FE. Acta Chir Belg. 2002 Oct;102(5):313-6 Oct;102(5):313-6. . Over the past 20 years, it has gradually become Over the past 20 years, it has gradually become apparent that the results of prolonged and apparent that the results of prolonged and extensive surgical procedures performed on extensive surgical procedures performed on critically injured patients are often poor, even in critically injured patients are often poor, even in experienced hands… experienced hands…
- 17. Damage control Damage control Definite surgery is time-consuming and may be Definite surgery is time-consuming and may be not executed not executed Surgical insult may waste functional reserve Surgical insult may waste functional reserve Aims: Aims: – Damage control operation Damage control operation – Resuscitation in SICU Resuscitation in SICU – Planned reoperation in 24-48 hours Planned reoperation in 24-48 hours
- 18. Damage control in surgical Damage control in surgical patients : Who needs it ? patients : Who needs it ? Bleeding caused by coagulopathy Bleeding caused by coagulopathy Severe metabolic acidosis (pH <7.3) Severe metabolic acidosis (pH <7.3) Hypothermia during operation (T° <34°) Hypothermia during operation (T° <34°) Shock Shock Massive transfusion : >10 units PRBCs Massive transfusion : >10 units PRBCs
- 19. Damage control in surgical Damage control in surgical patients : Who needs it ? patients : Who needs it ? Surgeon gestalt : --High energy blunt torso trauma Surgeon gestalt : --High energy blunt torso trauma –Multiple visceral injuries – Multiple torso –Multiple visceral injuries – Multiple torso penetrating injuries – Multi regeonal injuries penetrating injuries – Multi regeonal injuries Inability to control the hemorrhage (hepatic, Inability to control the hemorrhage (hepatic, retroperitoneal, pelvic, thoracic or cervical) retroperitoneal, pelvic, thoracic or cervical) Inability to formally close the abdomen because of Inability to formally close the abdomen because of intestinal edema intestinal edema
- 24. Technique of damage control Technique of damage control :Components :Components A- Abbreviated surgery A- Abbreviated surgery for rapid control of for rapid control of hemorrhage and contamination hemorrhage and contamination B- Resuscitation in ICU B- Resuscitation in ICU with correction of with correction of physiological abnormalities physiological abnormalities C- Subsequent definitive repair C- Subsequent definitive repair and and abdominal wall closure abdominal wall closure
- 25. Damage Control Surgery Damage Control Surgery Phase I Phase I – Rapid termination of operative procedure Rapid termination of operative procedure – Arrest of bleeding Arrest of bleeding – Removal of contamination Removal of contamination Phase II Phase II – Correction of physiologic abnormalities Correction of physiologic abnormalities – Acidosis, hypothermia, coagulopathy Acidosis, hypothermia, coagulopathy Phase III Phase III – Definitive surgery Definitive surgery
- 26. What is different? What is different? Surgical dogma: complete the operation Surgical dogma: complete the operation – 1908: Pringle packing of liver injury 1908: Pringle packing of liver injury – Fell out of favour, not used in Vietnam war Fell out of favour, not used in Vietnam war – 1981: Feliciano 90% survival by packing in severe liver 1981: Feliciano 90% survival by packing in severe liver injury injury – 1983: Stone abbreviated laparotomy, 11/17 survivors 1983: Stone abbreviated laparotomy, 11/17 survivors Rotundo: damage control surgery, 1990s Rotundo: damage control surgery, 1990s
- 27. Damage control : Technique Damage control : Technique A-Abbreviated resuscitative surgery A-Abbreviated resuscitative surgery : : -- Do only necessary procedures -- Do only necessary procedures 1-- Control bleeding : 1-- Control bleeding : 0- Ligation 0- Ligation 0- Shunting 0- Shunting 0- Packing 0- Packing 2--Excision/Stapling of bowel to prevent further 2--Excision/Stapling of bowel to prevent further contamination contamination 3-- Temporary closure of abdominal wall defect 3-- Temporary closure of abdominal wall defect --Limit heat loss --Limit heat loss
- 28. Abdomen Abdomen Liver packing Liver packing Ligation of blood vessels Ligation of blood vessels Placement of intraluminal shunts Placement of intraluminal shunts Chest tubes in to aorta or IVC Chest tubes in to aorta or IVC Inflatable balloon catheters Inflatable balloon catheters
- 29. Abdomen II Abdomen II Resect hollow viscus with a stapler Resect hollow viscus with a stapler Biliopancreatic injuries by closed suction drainage Biliopancreatic injuries by closed suction drainage Ligation of ureter or tube ureterostomy Ligation of ureter or tube ureterostomy Formal closure Formal closure – Abdominal compartment syndrome Abdominal compartment syndrome – ARDS ARDS – MOF MOF Closure of skin, mesh Closure of skin, mesh
- 30. Damage Control Surgery •Prep surgical field from neck to knees and from flank to flank •Longitudinal incision form xiphoid to pubis •Cell saver to reinfuse autologous blood if possible •Urgent exploration with packing of all four quadrants of abdomen •Serial controlled examination of each quadrant and organ •Pack liver injuries and splenic injuries •Control vascular injuries •Close off perforated gastrointestinal tract •Examine retroperitoneal structures
- 31. DAMAGE CONTROL SURGERY •Avoid hypotension, hypothermia, acidosis leading to coagulopathy •Repair or ligate vascular injuries •Splenectomy if injured •Repair or resect intestines •Pack liver hemorrhage •Pack and leave open abdomen if necessary
- 35. Damage control in surgical Damage control in surgical patients patients 1- Control of bleeding : 1- Control of bleeding : * * Temporary stenting Temporary stenting * Packing/ Tamponade * Packing/ Tamponade * Angio-embolization * Angio-embolization * Recombinant FactorVIIa * Recombinant FactorVIIa * Ligation of vessels rather than repair * Ligation of vessels rather than repair
- 36. Contrast “blush” on CT Contrast “blush” on CT
- 37. Lap pad packing Lap pad packing
- 38. Lap pad packing Lap pad packing
- 39. Lap pad packing Lap pad packing
- 40. Solid organ Solid organ tract tract haemorrhage: haemorrhage: Balloon tamponade Balloon tamponade
- 44. Extraperitoneal pelvic packing Extraperitoneal pelvic packing
- 45. Damage control: Damage control: Control of bleeding Control of bleeding Recombinant Factor VIIa : Recombinant Factor VIIa : --Dilutional coagulopathy --Dilutional coagulopathy --Stored blood product --Stored blood product --Clot promotion; activates factor Xa --Clot promotion; activates factor Xa --Throbo-embolic risk ? --Throbo-embolic risk ?
- 46. Damage control : Damage control : Contamination control Contamination control 2- Contamination control 2- Contamination control – Hollow viscus ligation instead of repair Hollow viscus ligation instead of repair – External tube drainage of biliary and pancreatic External tube drainage of biliary and pancreatic injury instead of pancreatoduodenectomy injury instead of pancreatoduodenectomy – ERCP for diagnosis and treatment ERCP for diagnosis and treatment – Avoidance of formal colostomy Avoidance of formal colostomy
- 47. Temporary bowel closure Temporary bowel closure
- 48. Duodenal injury Duodenal injury Pyloric exclusion Pyloric exclusion
- 50. Biliary Leak Biliary Leak Diagnosis and treatment by ERCP Diagnosis and treatment by ERCP
- 51. Damage control : Closure Damage control : Closure 3- Temporary closure of abdominal 3- Temporary closure of abdominal wall defect wall defect
- 52. Temporary abdominal closure Temporary abdominal closure Towel clips Towel clips
- 53. Temporary abdominal closure Temporary abdominal closure Cystoscopy irrigation bag or IV bag Cystoscopy irrigation bag or IV bag
- 54. Temporary abdominal closure Temporary abdominal closure Silastic sheeting Silastic sheeting
- 55. Temporary abdominal closure Temporary abdominal closure Gore-Tex or Vicryl Mesh Gore-Tex or Vicryl Mesh
- 56. Temporary abdominal closure Temporary abdominal closure VAC pack VAC pack
- 57. B-ICU Resuscitation B-ICU Resuscitation Warm the patient Warm the patient Correct the acidosis Correct the acidosis Correct the coagulopathy Correct the coagulopathy
- 58. Resuscitation Resuscitation End points of resuscitation End points of resuscitation Adequate urinary output Adequate urinary output Haematocrit >20% Haematocrit >20% Restoration of vital signs Restoration of vital signs - - Normal mixed venous O2 Normal mixed venous O2 - Normal or high cardiac output - Normal or high cardiac output Clearance of lactic acidosis/base deficit Clearance of lactic acidosis/base deficit Normalize pH preferably without NaHCO3 Normalize pH preferably without NaHCO3
- 59. Resuscitation Resuscitation IV volume restoration best accomplished IV volume restoration best accomplished using FFP in 1:1 ratio with PRBCs using FFP in 1:1 ratio with PRBCs Crystalloid use is more limited Crystalloid use is more limited
- 60. Metabolic acidosis Metabolic acidosis Usually correct on its own once the patient Usually correct on its own once the patient is warm and volume resuscitated is warm and volume resuscitated O2 debt repaid O2 debt repaid Anaerobic Aerobic metabolism Anaerobic Aerobic metabolism Need for NaHCO3 is rare – but Need for NaHCO3 is rare – but If cadiotonic agents are needed, keep pH>7.2 If cadiotonic agents are needed, keep pH>7.2
- 61. Pitfalls Pitfalls Continued hemorrhage: Continued hemorrhage: Especially in a warm non-coagulopathic patient Especially in a warm non-coagulopathic patient Vessels that were constricted and NOT ligated at the time of Vessels that were constricted and NOT ligated at the time of operation may begin bleeding as the patient is warmed and operation may begin bleeding as the patient is warmed and resuscitated resuscitated Return to the OR Return to the OR
- 62. Pitfalls Pitfalls Continued shock : Continued shock : --Missed injury --Missed injury --Failed repair with leakage --Failed repair with leakage Return to the OR Return to the OR
- 63. C- Definitive repair C- Definitive repair When to return to the OR ? When to return to the OR ? -- When patient is warm and acidosis and -- When patient is warm and acidosis and coagulopathy has been corrected coagulopathy has been corrected -- 36-72 hours had reduced risk of -- 36-72 hours had reduced risk of rebleeding for patients with perihepatic rebleeding for patients with perihepatic packing packing
- 64. C- Definitive repair C- Definitive repair Bowel injuries Bowel injuries -- Colostomy or anastomosis ? -- Colostomy or anastomosis ? * Delayed anastomosis as safe as colostomy * Delayed anastomosis as safe as colostomy -- Stapled or hand sewn anastomosis -- Stapled or hand sewn anastomosis * * Controversial Controversial * Surgeon comfort with the technique * Surgeon comfort with the technique * Presence of bowel oedema * Presence of bowel oedema Oedematous bowel is more prone to anastomotic leak Oedematous bowel is more prone to anastomotic leak Wait for oedema to resolve to do anastomosis Wait for oedema to resolve to do anastomosis
- 65. C- Definitive repair : Closure C- Definitive repair : Closure Velcro patch Velcro patch
- 66. C- Definitive repair : Closure C- Definitive repair : Closure Vaccuom closure Vaccuom closure 92% of patients closed in 9.9 _+ 1.9 days 92% of patients closed in 9.9 _+ 1.9 days Garner et al, Garner et al, Am J Surg Am J Surg 2001; 132 : 630 2001; 132 : 630
- 67. Closure Closure When the abdomen can not be closed When the abdomen can not be closed Bowel becomes “stuck” Bowel becomes “stuck” Multiple solutions : Multiple solutions : * Permanent mesh * Permanent mesh * Absorbable mesh * Absorbable mesh * Prosthetic patches * Prosthetic patches * Bioprosthetic patches * Bioprosthetic patches * STSG directly on granulated bowel * STSG directly on granulated bowel * Component separation * Component separation
- 68. Summary Summary Organ injury patterns and survival from Organ injury patterns and survival from penetrating abdominal injury have remained penetrating abdominal injury have remained similar over the last decade similar over the last decade Death from refractory hemorrhage in the Death from refractory hemorrhage in the first 24 hours remain the common cause of first 24 hours remain the common cause of mortality. mortality.
- 69. Summary Summary DCS and use of open abdomen are being used more frequently with DCS and use of open abdomen are being used more frequently with imporved survival, but result in more morbidity. imporved survival, but result in more morbidity. Evidence-based analysis will be the ultimate guideline to determine Evidence-based analysis will be the ultimate guideline to determine the optimal management. the optimal management.
- 70. THANK YOU THANK YOU for your attention! for your attention!