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