Damage control resuscitation. history theory and technique
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Damage control resuscitation (DCR) evolved from the concept of damage control surgery. It involves early blood product transfusions using a 1:1:1 ratio of red blood cells, plasma, and platelets to address trauma-induced coagulopathy. It also focuses on immediately arresting hemorrhage, restoring blood volume, and correcting physiological abnormalities like hypothermia and acidosis. DCR can be applied anywhere to critically injured patients. Massive transfusion protocols that guide DCR have been shown to improve survival rates in patients with severe injuries and hemorrhage. While DCR leaves surgical repairs incomplete initially, it buys time to stabilize patients sufficiently to allow for definitive care later.
![Can J Surg, Vol. 57, No. 1, February 2014 59
REVIEW
immediately after progressive increases in tension at the
midline during repeat laparotomy and attempted closure.
This typically abates over the subsequent few hours and is
considered acceptable in the absence of end organ ischemia
(decreased urine output, increased airway pressures). As a
result, it is considered fundamentally different from the
acute phase of ACS. If the intra-abdominal pressure does
not normalize, however, the abdomen must be reopened to
prevent recurrent ACS.
In summary, an individual patient with an open ab-
domen will either continue to improve, mobilize fluid and
allow gradual abdominal closure via repeat laparotomies,
or continue to be challenged with sepsis and multiorgan
failure, will not mobilize fluid, and will eventually require
skin graft coverage. Enteroatmospheric fistulae must also
be prevented at all costs. This morbidity not only compli-
cates short-term management, but also eventual abdominal
wall reconstruction (component separation, modified com-
ponent separation). If present, these fistulae are best intu-
bated by soft rubber catheters placed within the sponge
material of negative pressure suction dressing.64
Over time,
this will allow the clinician to develop a granulation plate
around the fistulae appropriate for a skin graft (i.e., conver-
sion into a stoma).
A detailed discussion of the tiered algorithm for abdom-
inal wall reconstruction, as well as the indications for occa-
sional use of biologic materials, is beyond the goals of this
review. The appropriate timing of reconstruction (8–
12 mo) is crucial to the success of the repair (adhesions v.
rectus muscle lateral retraction). Extensive experience in
reconstructive techniques is crucial to ensure acceptable
outcomes. These principles include but are not limited to
timing, sequencing (stoma reversal, fistula closure), ensur-
ing adequate skin coverage, sparing of periumbilical per-
forators, minimally invasive lateral releases and manage-
ment of wound complications.
HYBRID CARE SUITES
Given that DCR is dedicated to our most critically injured
patients, it is not surprising that the development of a sin-
gle location (i.e., resuscitation with angiography, percu-
taneous techniques, and operative repair [RAPTOR]
suites) where percutaneous therapies, operative interven-
tions, cross-sectional imaging and critical care can all be
delivered holds substantial promise.65
This concept modi-
fies care from a location-based approach to a truly disease
and urgency-based algorithm. The best example is a
patient with ongoing hemorrhage from an unstable pelvic
fracture in the context of additional associated injuries
that may or may not require emergent operative inter-
vention. The concerns associated with this technology are
the tremendous cost of building hybrid suites and the
clinician training paradigm required for safely performing
hybrid procedures.65
CONCLUSION
Damage control resuscitation currently includes early
blood product transfusion, immediate arrest and/or tem-
porization (i.e., TIVS and balloon tamponade) of ongoing
hemorrhage, and restoration of blood volume and
physiologic/hematologic stability. As a result, DCR
addresses the early coagulopathy of trauma, avoids massive
crystalloid resuscitation and leaves the peritoneal cavity
open when a patient approaches physiologic exhaustion
without improvement. Future evolution of the DCR con-
cept will include further elucidation of personalized resus-
citations (individual blood product ratios based on point
of care testing) as well as introduction of hybrid angiog-
raphy operating suites in centres with resource availability.
Competing interests: None declared.
References
1. Warfare Manual. Department of the Navy. The Department: Wash-
ington (DC);1996.
2. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control:
an approach for improved survival in exsanguinating penetrating
abdominal injury. J Trauma 1993;35:375-82.
3. Lucas CE, Ledgerwood AM. Prospective evaluation of hemostatic
techniques for liver injuries. J Trauma 1976;16:442-51.
4. Calne RY, McMaster P, Pentlow BD. The treatment of major liver
trauma by primary packing with transfer of the patient for definitive
treatment. Br J Surg 1979;66:338-9.
5. Feliciano DV, Mattox KL, Jordan GL Jr. Intra-abdominal packing for
control of hepatic hemorrhage: a reappraisal. J Trauma 1981;21:285-90.
6. Stone HH, Strom PR, Mullins RJ. Management of the major coagu-
lopathy with onset during laparotomy. Ann Surg 1983;197:532-5.
7. Firoozmand E, Velmahos GC. Extending damage control principles
to the neck. J Trauma 2000;48:541-3.
8. Granchi T, Schmittling Z, Vascuez J, et al. Prolonged use of intralu-
minal arterial shunts without systemic antigoagulation. Am J Surg
2000;180:493-6.
9. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge
to nailing for patients with multiple injuries and with femur fractures:
damage control orthopedics. J Trauma 2000;48:613-21.
10. Vargo DJ, Battistella FD. Abbreviated thoracotomy and temporary
chest closure: an application of damage control after thoracic trauma.
Arch Surg 2001;136:21-4.
11. Holcomb JB, Helling TS, Hirshber A. Military, civilian and rural
application of the damage control philosophy. Mil Med 2001;166:
490-3.
12. Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the man-
agement of penetrating abdominal trauma: the more things change,
the more they stay the same. J Trauma 2003;55:1095-108.
13. Lier H, Krep H, Schroeder S, et al. The influence of acidosis,
hypocalcemia, anemia, and hypothermia on functional hemostasis in
trauma. J Trauma 2008;65:951-60.
14. Wyrzykowski AD, Feliciano DV. Trauma damage control. In:
Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New
York: McGraw-Hill Medical; 2008. p. 851-70.
15. Cushman JG, Feliciano DV, Renz BM, et al. Iliac vessel injury: opera-
tive physiology related to outcome. J Trauma 1997;42:1033-40.
16. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation:
directly addressing the early coagulopathy of trauma. J Trauma 2007;
62:307-10.](https://image.slidesharecdn.com/damage-control-resuscitation-history-theory-and-technique-160218201025/85/Damage-control-resuscitation-history-theory-and-technique-5-320.jpg)
Damage control resuscitation. history theory and technique
- 1. © 2014 Canadian Medical Association Can J Surg, Vol. 57, No. 1, February 2014 55 REVIEW • REVUE Damage control resuscitation: history, theory and technique Damage control resuscitation (DCR) represents the natural evolution of the initial concept of damage control surgery. It currently includes early blood product transfu- sion, immediate arrest and/or temporization of ongoing hemorrhage (i.e., temporary intravascular shunts and/or balloon tamponade) as well as restoration of blood volume and physiologic/hematologic stability. As a result, DCR addresses the early coagulo- pathy of trauma, avoids massive crystalloid resuscitation and leaves the peritoneal cavity open when a patient approaches physiologic exhaustion without improvement. This concept also applies to severe injuries within anatomical transition zones as well as extremities. This review will discuss each of these concepts in detail. La réanimation salvatrice et conservatrice découle naturellement du concept initial de chirurgie salvatrice et conservatrice. Ce concept repose actuellement sur l’administra- tion rapide de transfusions sanguines, l’arrêt et(ou) la temporisation immédiats de l’hémorragie active (c.-à-d., dérivations intravasculaires temporaires et(ou) tampon- nade par ballonnet), de même que le rétablissement du volume sanguin et la stabilisa- tion de l’état physiologique et hématologique. Ainsi, la réanimation salvatrice et con- servatrice corrige rapidement la coagulopathie post-traumatique, permet d’éviter les mesures de réanimation par cristalloïdes et laisse la cavité péritonéale ouverte lorsqu’un patient atteint l’épuisement physiologique sans amélioration. Le concept s’applique aussi au blessures graves affectant des zones anatomiques de transition ou les membres. Cette analyse abordera chacun des éléments du concept plus en détail. D amage control is a Navy term defined as “the capacity of a ship to absorb damage and maintain mission integrity.”1 When applied to surgery and critically ill patients, damage control surgery (DCS) incorporates fundamental tenets: arresting surgical hemorrhage, containing gastrointestinal spillage, inserting surgical sponges and applying a temporary abdominal closure. This sequence is followed by immediate transfer to the intensive care unit (ICU) with subsequent rewarming, correction of coagu- lopathy and hemodynamic stabilization. Return to the operating theatre is then pursued 6–48 hours later for a planned re-exploration that includes definitive repair and primary fascial closure if possible. In essence, a typical operative sequence is interrupted by completing only the most crucial aspects during the first phase. Although the adaption of the term “damage control” to the field of trau- matology can be credited to Schwab and colleagues2 in 1993, its dominant principles are more accurately rooted in the 1976 address by Lucas and Ledgerwood3 to the American Association for the Surgery of Trauma. More specifically, they described a small series of patients who underwent sponge- based packing of major liver injuries.3 This concept was reiterated shortly thereafter by Calne and colleagues4 and by Feliciano and colleagues5 in 1979 and 1981, respectively. Despite these small series outlining the success of per- ihepatic packing, the visionary extrapolation of this principle to patients with multiple, concurrent life-threatening injuries and major coagulopathy was not published until 1983.6 Stone and colleagues6 retrospectively described 31 patients in whom major bleeding diatheses developed. Of these, Chad G. Ball, MD, MSc From the University of Calgary and Foothills Medical Centre, Calgary, Alta. Accepted for publication Feb. 4, 2013 Correspondence to: C.G. Ball University of Calgary Foothills Medical Centre 1403–29 St. NW Calgary AB T2N 2T9 ball.chad@gmail.com DOI: 10.1503/cjs.020312
- 2. 56 J can chir, Vol. 57, No 1, février 2014 REVUE 17 patients underwent the modern damage control princi- ples of arresting surgical hemorrhage and abbreviating the operative intervention. This led to the survival of 11 pa- tients who were predicted to have a lethal coagulopathy. Once DCS was established, it was quickly marketed into other disciplines, including but not limited to neck,7 vascu- lar,8 orthopedic,9 thoracic10 and military injuries.11 Although each discipline uses DCS in a slightly different manner, it is clear that the DCS approach leads to improved survival in patients with either blunt or penetrating injures who are approaching physiologic exhaustion.12 The widespread propagation of DCS throughout the trauma community has led to an overuse of this tech- nique. More specifically, patients with multiple injuries who are not approaching physiologic exhaustion are often exposed to the potential risks associated with an open abdomen and the DCS process. As a result, the pertinent question is that of who truly requires DCS. The succinct response is patients who are more likely to die from an uncorrected state of shock than from failure to complete organ repairs. Depending on the centre, these patients with severe metabolic compromise encompass 3%–8% of all severely injured patients (penetrating v. blunt; military v. civilian). In essence, they continue to experience the sequelae of tissue shock that manifests as persistent hypothermia, persistent metabolic acidosis and nonme- chanical (i.e., nonsurgical) bleeding. Damage control surgery triggers, therefore, include core temperature less than 35°C, pH less than 7.2, base deficit greater than –15 and/or significant coagulopathy.13–16 It must be empha- sized, however, that not all patients with initial physio- logic deficits require DCS. With rapid arrest of hemor- rhage, as well as ongoing resuscitation, some patients will show dramatic improvement in all parameters on repeated intraoperative blood gases. It should also be stated that patients with multiple intra-abdominal injuries do not always experience metabolic failure. The natural extension and development of DCS has been damage control resuscitation (DCR). This concept includes DCS, but also the early initiation of blood prod- uct transfusions, reduced crystalloid fluid administration, permissive hypotension in selected populations and im- mediate hemorrhage control (operative or angiographic). In summary, DCR is a structured, mobile intervention that can be delivered to a critically ill patient in any location (emergency department, interventional radiology suite, operating theatre and/or ICU). Basic principles include arresting hemorrhage; restoring blood volume; and cor- recting coagulopathy, acidosis and hypothermia. MASSIVE TRANSFUSION Although the traditional definition of a massive transfu- sion is 10 units or more of red blood cells (RBC) within a 24-hour period, this term has been modified to better reflect true coagulation biochemistry with regards to both the amount of blood product and the associated time interval.16,17 The 3% and 8% of civilian and military patients, respectively, who require a massive transfusion have injuries that are predictably associated with high mortality (27%–51%).17 Furthermore, the early coagu- lopathy of trauma is a well-recognized entity that is pre- sent at the time of admission in more than 25% of injured patients with a base deficit greater than 6.18 Equally interesting, although coagulopathy was historic- ally viewed as a byproduct of resuscitation, hemodilution and hypothermia, the bloody vicious cycle is now under- stood to be substantially more complex.19 Tissue trauma, shock, hemodilution, hypothermia, acidemia and inflam- mation all play key trigger roles in the acute coagulo- pathy of trauma in patients with shock.19 The improved understanding of inter-relationships and recognition of these 6 key initiators of coagulopathy supports the mod- ern use of massive transfusion protocols (MTPs). In brief, a modern MTP aims to approximate delivery of 1:1:1 ratio of RBC:fresh frozen plasma:platelets.19 By address- ing the early coagulopathy of trauma, MTPs have been shown to improve mortality in patients with multiple injuries.20,21 While the specific structure of MTPs varies slightly from centre to centre,21 they are all approxima- tions of the fresh whole blood resuscitation principles reported by Sheldon and colleagues22 in 1975. It should also be noted that reasonable scientific concern remains with regard to the apparent improvement in survival associated with MTPs.23 The possibility of a strong sur- vival bias (i.e., surviving long enough to receive the most RBC units) is significant.23 Additional benefits of a formal MTP include earlier administration of blood products during resuscitations, improved blood banking efficiency, decreased total blood product use during a hospital stay and significant economic savings.24 Another major benefit surrounds the avoidance of excess crystalloid fluid administration.25 This reduction in crystalloid volume during resuscitation minimizes sev- eral associated side effects, including reperfusion injury, increased leukocyte adhesion and inflammation, associated acidosis and resulting acute respiratory distress syndrome, systemic inflammatory response syndrome and multiorgan failure.25–28 Excess crystalloid administration also remains an obstacle to obtaining early definitive fascial closure sec- ondary to both visceral and abdominal wall edema. In summary, if the initiation of an MTP is accurately based on rapid recognition of physiologic exhaustion sec- ondary to persistent hemorrhage, then it also typically acts as a trigger for the entire damage control process. It must be re-emphasized, however, that some severely injured patients will improve dramatically with an MTP and reverse their physiologic derangements to an extent that allows the surgeon to complete their operative intervention (i.e., rather than leaving the abdomen open).
- 3. Can J Surg, Vol. 57, No. 1, February 2014 57 REVIEW VASCULAR DAMAGE CONTROL TECHNIQUES Although it is clear that arresting ongoing hemorrhage is the most crucial of damage control tenets, vascular damage control has been traditionally limited to vessel ligation. More recently, however, balloon catheter tamponade and temporary intravascular shunts (TIVS) have increased in popularity. The impressive utility of balloon catheters for tamponade of exsanguinating hemorrhage has a long hist- ory, dating back more than 50 years.29 Although this tech- nique was originally described for esophageal varices,30 it was quickly extended to patients with traumatic vascular and solid organ injuries.31 Since the initial treatment of an iliac arteriovenous lesion in 1960,3 balloon catheters have also been used for cardiac,32 aortic,33 pelvic,34 neck (carotid, vertebral and jugular),35,36 abdominal vascular,37 hepatic,38 subclavian,39 vertebral29 and facial trauma.40 While this tech- nique was originally intended as an intraoperative endo- vascular tool,29 it has since been used as an emergency department manoeuvre, with the balloon being placed out- side of the lumen of the injured vessel.41,42 Modern indications for this damage control technique are limited, primarily because routine methods for control- ling hemorrhage, such as direct pressure, are typically suc- cessful. As a result, indications for catheter tamponade include inaccessible (or difficult to access) major vascular injuries, large cardiac injuries and deep solid organ paren- chymal hemorrhage (liver and lung).29,42 Of interest, the type of balloon catheter (Foley, Fogarty, Blakemore or Penrose with red rubber Robinson) as well as the duration of indwelling can vary substantially. In summary, balloon catheter tamponade is a valuable tool for damage control of exsanguinating hemorrhage when direct pressure fails or when tourniquets are not applicable. The technique can be used in several anatomic regions and for variable patterns of injury. Prolonged catheter placement for maintenance of hemostasis is par- ticularly useful for central hepatic gunshot injuries.42 Temporary intravascular shunts (TIVS) are intraluminal synthetic conduits that offer nonpermanent maintenance of arterial inflow and/or venous outflow.43 As a result, they are frequently life- and limb-saving when patient physiol- ogy is hostile. By bridging a damaged vessel and maintain- ing blood flow, they address both acute hemorrhage and critical warm ischemia of distal organs and limbs. Although Eger and colleagues44 are commonly credited for pioneering the use of TIVS in modern vascular trauma, this technique was initially used by Carrel in animal experi- ments.45 The first documented use in humans occurred in 1915 when Tuffier46 used paraffin-coated silver tubes to bridge injured arteries. This technique evolved from glass to plastic conduits in World War II,47 and continues to vary both in structure and material among today’s surgeons.48 Modern indications for TIVS include replantation, open extremity fractures with concurrent extensive soft tissue loss and arterial injury (Gustilo IIIC), peripheral vascular dam- age control, truncal vascular damage control and temporary stabilization before transport.43,49 Although the understand- ing of TIVS use for military and civilian settings is increas- ing,48 the optimal shunt material, dwell time and anticoagu- lation requirements remain poorly studied. It can be noted, however, that TIVS are remarkably durable and rarely clot unless they are too small (diameter), kink because of inap- propriate length and/or are placed in an extremity without appropriate (or shunted) venous outflow (venous hyperten- sion leads to arterial thrombosis).49 Although the literature is peppered with case series and reports on practical experi- ence using TIVS, the most dramatic example of their utility surrounds the near-complete disappearance of limb loss fol- lowing ligation of the common and/or external iliac arter- ies.49 More specifically, despite similar injury and patient characteristics, the improvement in amputation rate from 47% to 0% in 22 patients with penetrating trauma after the introduction of TIVS at a high-volume trauma centre is remarkable.49 Further advantages included an observed reduction in fasciotomies (from 93% to 43%) and extra- anatomic bypasses (from 6 to 0).49 Despite the penetrating mechanism dogma associated with TIVS over the past 40 years, the majority (64%) of TIVS in a large national database (National Trauma Data Bank; NTDB) were used in patients injured via a blunt mechanism.50 Although the kinetic force of a motor vehicle collision (MVC) or MVC–pedestrian collision can be tremendous, TIVS is often discussed in the context of extremity damage control for gunshot wounds in patients with hostile physiology.50 This NTDB analysis, however, indicated that most extremity TIVS were actually placed for blunt vascular trauma associated with extensive orthopedic and/or soft tissue injuries (74%). They were also most often used as a temporizing manoeuvre to provide distal flow to a limb while orthopedic injuries are assessed and fixated. The use of TIVS for this scenario is well recognized and docu- mented to significantly reduce the rate of amputation. In the patients who did not receive TIVS for fractures and soft tissue defects, it appears that shunting was used as an extremity damage control technique in those who presented with hemodynamic instability and severe base deficits (26%).50 These patients displayed a much lower level of subsequent amputation than patients with blunt trauma with concurrent fractures and soft tissue trauma. In addition to using TIVS in patients with blunt injuries, the NTDB also indicates that this technique is being performed relatively uncommonly across a wide range of hospitals.50 Of 111 trauma centres using TIVS, only 6 used 5 or more shunts throughout the study period. In addition, only 3 centres used more than 10 shunts. In summary, TIVS appear to be useful in any scenario with a major vascular injury and concurrent hostile patient physiology. This includes cases of blunt MVC trauma with concurrent severe extremity fractures and/or
- 4. 58 J can chir, Vol. 57, No 1, février 2014 REVUE soft tissue injuries. Despite their simplicity, however, TIVS are underused. ABDOMINAL COMPARTMENT SYNDROME Many of the dominant risk factors for abdominal com- partment syndrome (ACS) mirror variables that have been proposed as physiologic triggers for DCS/DCR.51,52 When taken as a whole, these indicators (pH, base deficit, core temperature) clearly reflect the extreme biochemical and physiologic stress that characterizes many of our most critically ill patients. Closing abdomens in patients mani- festing physiologic extremis often leads to ACS, as first demonstrated by Morris and colleagues53 in 1993. With fascial closure, the authors described severe abdominal distension in concert with raised peak airway pressures, CO2 retention and oliguria.53 The 63% mortality associ- ated with subsequent reperfusion injury (i.e., after remov- ing sponges from the intraperitoneal cavity during the second operation) that they observed was dramatic and also emphasized the importance of preventing “recurrent” or “tertiary” ACS.54 In summary, these publications indi- cate that maintaining an open abdomen via a temporary abdominal closure, and therefore planning a delayed fas- cial closure, is not only a vital component of DCR, but is also a clear method for preventing ACS. Despite the increased understanding surrounding this anatomic and physiologic complication, however, it is clear that clin- icians require more education with regard to preventing, monitoring and treating all forms of ACS.55 More specif- ically, while the incidence of primary ACS (i.e., injury to the torso) has decreased dramatically over the past decade,51 continued vigilance is crucial to guard against secondary (i.e., resuscitation-induced ACS) and recurrent ACS (i.e., creating an inadequate fascial opening and/or closing the fascia too early in repeat operations). OPEN ABDOMINAL MANAGEMENT The concept of delaying abdominal wall closure is cred- ited to Stone and colleagues56 at Grady Memorial Hospital in 1981. Among 167 patients, mortality approximated 85% in those whose abdomens were closed under tension, compared with only 22% who underwent delayed fascial closure. This truly remarkable report altered the DCS landscape dramatically. Unfortunately, the open abdomen is also responsible for significant short-term (fluid and protein loss, sepsis, intestinal fistulae, nursing care chal- lenges, economic costs) and long-term (chronic physical discomfort, physique embarrassment, delayed return to work, poor quality of life) morbidity.57–60 Several techniques for covering the open abdomen at the index operation are available (Box 1). Because no single technique has been shown to be superior to others, a given trauma centre should use a single consistent option that ensures familiarity among all surgeons, house staff and nurses. This allows accurate assessment of fluid losses as well as intermittent troubleshooting. A simple and cost effective choice is a large sterile radiograph cassette drape with 2 closed suction drains and a covering plastic adhesive drape. Avoiding commercial negative suction devices dur- ing the initial critical phase also prevents any concern for generating recurrent ACS.61 It is clear that as the patient is exposed to multiple sub- sequent operative interventions, intestinal coverage (via endogenous abdominal wall or skin or split-thickness skin graft) must be achieved as soon as possible to limit the development of fistulae. It is also evident that regardless of technique, severely injured patients more commonly achieve fascial closure during their initial hospital stay than their nontrauma, acute care surgery counterparts. If closed too early, ACS, fascial dehiscence, necrotizing fasciitis and ventilation challenges are notable complications. Despite the poor methodology inherent in the open abdomen liter- ature (i.e., mixed patient cohorts, lack of complete inclu- sion, ignorance of nonsurvivors, variable individual sur- geon effort and interest), it is evident that the application of negative suction dressings at subsequent operations has improved closure rates and reduced complications, such as intestinal fistulae. Whether “homegrown”62 or commer- cially derived,63 these technologies have become common- place. The 2 dominant principles when using negative suction therapy remain: maintenance of the peritoneal/ abdominal domain and continuous and progressive tension on the midline abdominal wall. These goals are achieved by insertion of a plastic barrier deep into the paracolic gut- ters (maximally lateral to prevent adhesions between the colon and abdominal wall) and by generation of midline abdominal wall tension using nonfascial retention sutures or commercial systems. It should also be noted that intra- abdominal pressures often exceed “normal” (> 20 mm Hg) Box 1. Open abdomen coverage techniques • Skin only • Towel clip • Silastic sheet • Bogota bag • 3 L genitourinary bag • Steri-drape/x-ray cassette • Zippers • Slide fasterners • Velcro analogue/Wittmann • Polypropylene mesh • Polyglycolic/polyglactic acid mesh • Polytetrafluoro-thylene mesh • Parachute silk • Hydrogel/aquacel • Loban • Vacuum pack • Abdominal wound vacuum-assisted closure • Bioprosthetics
- 5. Can J Surg, Vol. 57, No. 1, February 2014 59 REVIEW immediately after progressive increases in tension at the midline during repeat laparotomy and attempted closure. This typically abates over the subsequent few hours and is considered acceptable in the absence of end organ ischemia (decreased urine output, increased airway pressures). As a result, it is considered fundamentally different from the acute phase of ACS. If the intra-abdominal pressure does not normalize, however, the abdomen must be reopened to prevent recurrent ACS. In summary, an individual patient with an open ab- domen will either continue to improve, mobilize fluid and allow gradual abdominal closure via repeat laparotomies, or continue to be challenged with sepsis and multiorgan failure, will not mobilize fluid, and will eventually require skin graft coverage. Enteroatmospheric fistulae must also be prevented at all costs. This morbidity not only compli- cates short-term management, but also eventual abdominal wall reconstruction (component separation, modified com- ponent separation). If present, these fistulae are best intu- bated by soft rubber catheters placed within the sponge material of negative pressure suction dressing.64 Over time, this will allow the clinician to develop a granulation plate around the fistulae appropriate for a skin graft (i.e., conver- sion into a stoma). A detailed discussion of the tiered algorithm for abdom- inal wall reconstruction, as well as the indications for occa- sional use of biologic materials, is beyond the goals of this review. The appropriate timing of reconstruction (8– 12 mo) is crucial to the success of the repair (adhesions v. rectus muscle lateral retraction). Extensive experience in reconstructive techniques is crucial to ensure acceptable outcomes. These principles include but are not limited to timing, sequencing (stoma reversal, fistula closure), ensur- ing adequate skin coverage, sparing of periumbilical per- forators, minimally invasive lateral releases and manage- ment of wound complications. HYBRID CARE SUITES Given that DCR is dedicated to our most critically injured patients, it is not surprising that the development of a sin- gle location (i.e., resuscitation with angiography, percu- taneous techniques, and operative repair [RAPTOR] suites) where percutaneous therapies, operative interven- tions, cross-sectional imaging and critical care can all be delivered holds substantial promise.65 This concept modi- fies care from a location-based approach to a truly disease and urgency-based algorithm. The best example is a patient with ongoing hemorrhage from an unstable pelvic fracture in the context of additional associated injuries that may or may not require emergent operative inter- vention. The concerns associated with this technology are the tremendous cost of building hybrid suites and the clinician training paradigm required for safely performing hybrid procedures.65 CONCLUSION Damage control resuscitation currently includes early blood product transfusion, immediate arrest and/or tem- porization (i.e., TIVS and balloon tamponade) of ongoing hemorrhage, and restoration of blood volume and physiologic/hematologic stability. As a result, DCR addresses the early coagulopathy of trauma, avoids massive crystalloid resuscitation and leaves the peritoneal cavity open when a patient approaches physiologic exhaustion without improvement. Future evolution of the DCR con- cept will include further elucidation of personalized resus- citations (individual blood product ratios based on point of care testing) as well as introduction of hybrid angiog- raphy operating suites in centres with resource availability. Competing interests: None declared. References 1. Warfare Manual. Department of the Navy. The Department: Wash- ington (DC);1996. 2. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375-82. 3. Lucas CE, Ledgerwood AM. Prospective evaluation of hemostatic techniques for liver injuries. J Trauma 1976;16:442-51. 4. Calne RY, McMaster P, Pentlow BD. The treatment of major liver trauma by primary packing with transfer of the patient for definitive treatment. Br J Surg 1979;66:338-9. 5. Feliciano DV, Mattox KL, Jordan GL Jr. Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma 1981;21:285-90. 6. Stone HH, Strom PR, Mullins RJ. Management of the major coagu- lopathy with onset during laparotomy. Ann Surg 1983;197:532-5. 7. Firoozmand E, Velmahos GC. Extending damage control principles to the neck. J Trauma 2000;48:541-3. 8. Granchi T, Schmittling Z, Vascuez J, et al. Prolonged use of intralu- minal arterial shunts without systemic antigoagulation. Am J Surg 2000;180:493-6. 9. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma 2000;48:613-21. 10. Vargo DJ, Battistella FD. Abbreviated thoracotomy and temporary chest closure: an application of damage control after thoracic trauma. Arch Surg 2001;136:21-4. 11. Holcomb JB, Helling TS, Hirshber A. Military, civilian and rural application of the damage control philosophy. Mil Med 2001;166: 490-3. 12. Nicholas JM, Rix EP, Easley KA, et al. Changing patterns in the man- agement of penetrating abdominal trauma: the more things change, the more they stay the same. J Trauma 2003;55:1095-108. 13. Lier H, Krep H, Schroeder S, et al. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 2008;65:951-60. 14. Wyrzykowski AD, Feliciano DV. Trauma damage control. In: Feliciano DV, Mattox KL, Moore EE, editors. Trauma. 6th ed. New York: McGraw-Hill Medical; 2008. p. 851-70. 15. Cushman JG, Feliciano DV, Renz BM, et al. Iliac vessel injury: opera- tive physiology related to outcome. J Trauma 1997;42:1033-40. 16. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62:307-10.
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