Damage Control Surgery Principles Dr. Josip JankoviDr. Boris HrekovskiDepartment of surgeryGeneral hospital Slavonski Brod

The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation Lord Moynihan

Standard surgical practice (early total care):the best operation for a patient is one, definitive procedurethe first chance of any surgical intervention is the best chance for any definitive repair or reconstruction

ERORICU

BUT!!!

Multiple trauma patients (ISS 35) are more likely to die from their intra-operative metabolic failure that from a failure to complete operative repairs

The death triad: HypothermiaAcidosisCoagulopathy

One of the major advances in surgical technique in the past 20 years.The most technically demanding and challenging surgery a trauma surgeon can perform.

approach method

ERORICUORICU

Hypothermia:Clinically important if less than 37*C for more than 4 hCan lead to cardiac arrhythmias, decreased cardiac output, increassed systemic vascular resistanceCan induce and exacerbate coagulopathy by inhibition of clotting cascade reaction

Acidosis:Uncorrected haemorrhagic shock leads into inadequate cellular perfusion, anaerobic metabolism and the production of lactatic acid Interferes with blood clotting mechanisms and promotes coagulopathy and blood loss

Coagulopathy:Hypothermia, acidosis and the consequences of massive blood transfusion all lead to the development of a coagulopathyPlatelet dysfunction at low temperatureActivation of the fibrinolytic system Haemodilution following massive resuscitation

Parameters as a guideline for instituting damage control: pH less then or equal to 7.2 serum bicarbonate level less than or equal to 15 mEq/L core temperature less than or equal to 34*C transfusion volume of packed RBCs more than or equal to 4000 ml total blood replacement more than or equal to 5000 ml total fluid replacement more than or equal to 12 000 mlIf all - deathIf one - DCS

The principles of damage control surgery are:Control haemorrhage

Prevention contamination

Avoid further injury

Prehospital and emergency department times should be minimizedBTLSNO unnecessary and superfluous investigationsRapid transport to the operating room without repeated attempts to restrore cisculating volume- they require operative control of haemorrhage and simultaneous vigorous resuscitation

Stage 1 DCS (abdomen)

initial laparotomyidentify the main source of bleeding perihepatic packing (superior and inferior)small gastotomies and enterotomies can be rapidly closedresect non-viable bowel and close the endsminor pancreatic injuries not involving duct- no treatmentdistal injury including the panceratic duct- distal pancreatectomyNO pancreaticoduodenectomy (drainage)abdominal closure is rapid and temporary- if there is any doubt about abdominal compartment syndrome, left it open (silo-bag, vacuum-pack technique)

Stage 1 DCS (skeletal)

Stable patient osteosynthesisPolytrauma patient- FEDo not insist on anatomical reposition, but on fracture stabilisationOpen fracture-debridmanTiming is individual considering clinical stateSecundary brain damage?

Stage 2 DCSBegins in ICUThe next 24 to 48 hours are crucial Correction of metabolic disorderCore rewarmingCorrection of coagulopathyComplete ventilatory supportCorrection of acidosisIdentification of occult injury

Stage 3 DCS planned reoperation

Window of opportunity is 24-48 hours after the trauma- between the correction of metabolic disorder and the onset of SIRS and MOFRemoval of the abdominal packs (48-72 h)Primary repair with end-to-end anastomosis undertakenCopious washout should be performed and the abdomen closed The patient sometimes needs early unplanned reoperation-ongoing haemorrhage, abdominal compartment syndrome or peritontisWindow of opportunity for definitive osteosynthesis is 5-10 days after trauma

Complications of DCS Abdominal compartment syndrome

General copmlications: wound sepsis wound dehiscence fistula formation ICU-related infections skin complications

DCS is a treathement methodDCS is one of the major advances in surgical technique in the past 20 yearsDCS is recognized all over the world for treathing polytraumatized patients (ISS35)DCS is used in our hospital in the last 10 yearsPatients who had death rate according to ISS90%, survived How much surgery polytrauma patient can tolerate?