Jurnal Reading

Damage Control Surgery

In The Era Of Damage
Control Resucitation
C. M. Lamb, P. MacGoey, A. P. Navarro and A. J. Brooks

Dio Resna Oktavinanda

 Introduction
 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.
 In last 10 years a new addition to the damage control paradigm has emerged,
referred to as damage control resuscitation (DCR).
 DCR focuses on initial hypotensive resuscitation and early use of blood
products to prevent the lethal triad of acidosis, coagulopathy, and
hypothermia.
 The use of DCR and DCS have been associated with improved outcomes for
the severely injured
 DCR may allow borderline patients, who would previously have required DCS,
to undergo early definitive surgery as their physiological derangement is
corrected earlier.
LETHAL TRIAD OF DEATH
Purpose

 This study aims to present the evidence behind DCR and

its current application, and also to present a strategy of
overall damage control to include DCR and DCS in
conjunction.
 Damage Control

 Management of injured patients with multiple body cavities, massive haemorrhage,

and near exhausted physiological reserve has changed significantly in the last
decade with the emergence of a new paradigm termed damage control.
 A combination of acidosis, hypothermia, and coagulopathy may preclude definitive
surgical repair of all injuries in one sitting and in this subset of patients that ‘damage
control surgery’ (DCS) is should be done.
 DCS is a treatment strategy of temporization; prioritizing physiological recovery over
anatomical repair.
 Damage control resuscitation (DCR) is a newer describes novel resuscitation
development within the damage control paradigm, and strategies aimed to limit the
physiological derangement of trauma patients
 History of Damage Control

 The
first phisician (military surgeon) who reported was doing the abdominal
packing and this has been the basement for the damage control surgery.
 Stoneet al. were the first to describe a technique of ‘truncated laparotomy’ for
patients with clinically evident coagulopathy and retrospectively reviewed its
efficacy in 1983.
 10years later, Rotondo et al. popularized the term ‘damage control
laparotomy’ or ‘damage control surgery’ as three-phase technique.
 Johnson and Schwab have recently coined and added the Ground 0 pre
hospital phase of damage control.
 Damage Control Phase
In modern trauma practice, it is not capable that DCS should be practiced
separately from DCR;
 DC 0: emphasizes on injury pattern recognition and abbreviated DCR by the
emergency department. Rapid-sequence induction (RSI) of anaesthesia and
intubation, early rewarming, and expedient transport to the operating room
(OR).
 DC I: the patient has arrived in OR and consists of immediate exploratory
laparotomy with rapid control of bleeding and contamination, abdominal
packing, and temporary wound closure.
 DC II: ICU resuscitative phase where physiological and biochemical
stabilization is expected to be achieved and a thorough tertiary examination is
performed to identify all injuries.
 DC III: Once physiology has normalized and consists of re-exploration in OR to
perform definitive repair of all injuries.
 Indications for damage control

 There are published data to guide patient selection but no single ‘physiological
threshold’ has been defined.
 Indications to damage control strategy are primarily those of
 physiological derangement
 significant bleeding requiring massive transfusion (>10 units PRBC)
 severe metabolic acidosis (pH<7.30)
 hypothermia (temperature <35 C)
 operative time >90 min
 coagulopathy either on laboratory results or seen as ‘non-surgical’ bleeding
 lactate >5 mmol/litre
 Damage control part zero (DC 0)

 Occurs
in the pre-hospital setting and continues into the emergency
department.
 The emphasis is on injury pattern recognition (to identify patients likely to
benefit from damage control), followed by DCR and rapid transfer to theatre
of identified patients.
 Once in hospital, emergency department DCR and rapid assessment of the
trauma patient is the goal. Gaining large-bore i.v. access, RSI, chest drainage if
indicated, prevention of hypothermia, DCR, and expedient transport to the
operating theatre are the keys of DC 0. Broad-spectrum i.v. antibiotics and
tetanus prophylaxis should be administered and OR should be placed on
standby and preparation of appropriate instrument trays.
 Rapid patient transfer to OR if required.
 Damage control part zero (DC 0):
Damage Control Resuscitation

The recognition of an endogenous coagulopathy in a large proportion of severely

injured trauma patients on arrival in hospital is associated with poor outcomes. Its
discovery promoted interest in resuscitation strategies that directly target coagulopathy
therefore the modern resuscitation contain permissive hypotension and early treatment
of anticipated coagulopathy with blood products.
The main elements of DCR are:
 <C>ABC resuscitation
 Permissive hypotension
 Limitation of crystalloid with early use of blood and blood products
 Early use of Tranexamic Acid
 DCS (DC I)
 Damage control part zero (DC 0):
Early use of blood and blood products

It is important to give more attention to the ratio of blood components that are
used in transfusion, to directly target coagulopathy. A higher ratio of fresh frozen
plasma (FFP) to PRBC has been associated with survival benefit in trauma
patients even though the optimal ratio of blood, FFP, platelets, and other
products have not yet been defined.
Damage control part zero (DC 0):
Massive transfusion protocols

 Major trauma centres should have a massive transfusion

protocol in place, designed to prevent delays.
 All
should have available an initial pack of non-cross-
matched blood for immediate use in the unstable patient.
 Once bloods have been cross-matched, further group
specific or fully matched components are provided
designed to prevent clotting factor depletion and
coagulopathy during early massive transfusion.
 Damage control part zero (DC 0):
Imaging
 Rapid work-up of trauma in the unstable patient, minimal diagnostic X-rays are
required. A chest X-ray after intubation might be considered to confirm tube
placement and identify haemo-, pneumothorax, or both that might compromise the
patient during transport to OR.
 Plain films may also be useful to confirm the presence or absence of residual foreign
bodies.
 In blunt trauma, spinal precautions are observed throughout resuscitation, rule out the
need for immediate spinal imaging.
 Similarly, in the shocked patient early empirical pelvic stabilization with a pelvic binder
(or equivalent) may provide pelvic X-rays unnecessary initially.
 Majority of trauma patients can be stabilized sufficiently in the emergency department
to survive their trip through the CT scanner.
 Timely contrast enhanced CT is without doubt an extremely useful diagnostic adjunct
to the primary and secondary surveys, particularly in multiple injuries.
 In the unstable patient, however, any delay to the operating theatre may be
detrimental and CT may have to be bypassed.
Damage control part one (DC I)

 The
primary objectives of the initial laparotomy are
haemorrhage control, limitation of contamination and
temporary abdominal wall closure.
 Aims
to restore physiology at the expense of anatomical
reconstruction.
 DCRshould be on-going throughout DC 0 and DC I and is
indeed an integral part of the damage control strategy.
 Damage control part one (DC I):
Preparation
 Cell salvage suction equipment, instrument trays consisting of a standard laparotomy
set, vascular, and chest instruments (including a sternal saw) should all be immediately
available. A large supply of laparotomy pads must also be available for the initial
packing.
 The patient is placed in a ‘cruciform’ position on the table.
 Positioning of the electrocardiogram leads and monitoring equipment must not limit
the options for surgical exposure.
 In anticipation of the need for a median sternotomy, resuscitative left thoracotomy, or
bilateral tube thoracostomy, no leads or tubing should be present on the anterior or
lateral chest wall.
 The patient is prepped from chin to mid thighs, extending down to the table laterally
should thoracotomy be necessary. A urinary catheter and nasogastric/orogastric tube
are inserted at this stage if not done already.
 Surgery should not be delayed for the insertion of arterial or central venous lines in the
unstable patient.
 Damage control part one (DC I):
Incision

 The best incision for abdominal exploration is the vertical midline extending
from the xiphoid process to the pubic symphysis.
 Inaddition to giving good abdominopelvic exposure, a midline incision has the
advantage that it can be easily extended superiorly, laterally, or both to give
exposure to the chest
 Inthe setting of a suspected severe pelvic fracture, the inferior limit of this
incision initially might be curtailed to just below the umbilicus, allowing for
continued tamponade of a potential large pelvic haematoma.
 Damage control part one (DC I):
Haemorrhage control
 Once the peritoneum is entered, the first step is haemorrhage control.
 Large clots should be removed manually and then a large hand-held retractor
is used sequentially around the periphery of the abdomen to provide space for
the packing of all four quadrants.
 Adequate packing should provide a good degree of haemorrhage control for
most venous or solid organ bleeding.
 If
the patient remains profoundly hypotensive after packing, a significant
arterial source of haemorrhage is likely and control of aortic inflow should be
obtained. Manual occlusion of the aorta at the diaphragmatic hiatus can be
performed quickly to control abdominal exsanguination and give the
anaesthetic team some time to catch up with volume replacement.
 Thismanoeuvre also has been shown to augment cerebral and myocardial
perfusion
 Damage control part one (DC I):
Haemorrhage control

 Between occlusion of the aorta and intra-abdominal packing, the majority of

significant bleeding should be controlled.
 Iflimb circulation has been compromised for a significant period of time,
fasciotomy is necessary once haemorrhage is controlled.
 Splenic, renal, and pancreatic tail injuries are managed best with total or
partial resection
 Bleeding from liver lacerations after blunt trauma can be torrential and diffi-
cult to manage but in the damage control situation is dealt with primarily by
packing. On-going bleeding from deep hepatic parenchymal injury may need
to be controlled by the Pringle manoeuvre (temporary hepatic vascular inflow
occlusion by compression of the porta hepatis within the lateral edge of the
gastrohepatic ligament).
Damage control part one (DC I):
Haemorrhage control

 Other strategies can be used to deal with larger, actively

bleeding liver parenchymal disruptions; placement of
topical haemostatic agents (such as microfibrillarcollagen,
TachosilTM, or fibrin glue) on the liver injury itself may
provide additional haemostatic support. Where available,
angio-embolization can be a useful technique for the
treatment of bleeding vessels deep within the liver
parenchyma.
 Definitive
reconstruction of complex arterial injuries should
be avoided in unstable patients as these procedures can
be lengthy.
 Damage control part one (DC I):
Contamination control

 Thesecond priority in a damage control laparotomy is to control the spillage of

intestinal contents or urine from hollow viscus injuries.
 Urinary contamination of the abdominal cavity is less serious than that caused
by bile, pancreatic juice, or bowel content but injuries to the urinary tract may
still be encountered.
 Once all vascular and viscus injuries have been controlled, intra-abdominal
packing is performed. Packing should be suffi- cient to provide adequate
tamponade without impeding venous return or arterial blood supply.
 Damage control part one (DC I):
Abdominal Closure

 Abdominal closure is the final step before transfer to the ICU

 In all damage control cases, fascial closure is not recommended at the initial
laparotomy
 Reperfusion injury and on-going capillary leakage during resuscitation will cause
intestinal andabdominal wall oedema to develop and potentially cause intra-
abdominal hypertension (IAH) and abdominal compartment syndrome (ACS).
 In this situation, a number of different methods often temporary abdominal closure
have been described, from the simple home-made solutions (e.g. the Bogota bag,
OpsiteTM sandwich) to custom made commercial devices, mostly using some form of
topical negative pressure therapy (e.g. AbtheraTM). All rely on the same basic
principles of preventing visceral adherence to the abdominal wall while attempting to
allow drainage of the oedema and maintaining some tension between the skin and
fascial edges to prevent retraction and allow secondary closure at a later date.
 Damage control part one (DC I):
Further Procedures

 Damage control part I cannot be considered complete until all surgical

bleeding is arrested
 Patients
will sometimes require an interventional radiological procedure to
achieve haemostasis.
 Uncontrolled surgical bleeding may not respond to packing alone and
interventional radiology (IR) techniques are useful to halt bleeding in complex
hepatic, retroperitoneal, pelvic, or deep muscle injuries that, because of
location, are not amenable to surgical control or would require lengthy surgical
exploration in the setting of coagulopathy.
 Damage control part two (DC II)

 The goal of DC II is to reverse the sequelae of hypotension related metabolic

failure and support physiological and biochemical restoration.
 Oneof the keys to physiological restoration is the establishment of adequate
oxygen delivery to body tissues.
 Abramson et al, show that serum lactate clearance correlates well with patient
survival and that the ability to clear lactate to normal levels within 24 h was
paramount to ensuing patient survival.
 Immediate and aggressive core rewarming not only improves perfusion, but
also helps reverse coagulopathy.
 Gentilello showed that failure to correct a patient’s hypothermia after a
damage control operation is a marker of inadequate resuscitation or
irreversible shock.
 Damage control part two (DC II)

 Standard therapy to correct coagulopathy includes reversal of hypothermia

and administration of FFP, which is rich in Factors V and VIII. Repletion of
clotting factors with FFP continues until laboratory measurements of
coagulation are normal. (All blood product should be warmed before infusion)
 During DC II, a complete physical examination or ‘tertiary survey’ of the patient
should occur.
 The goal is to resuscitate the patient to within normal physiological parameters;
for some patients, this may only require 12 h while many more will require 24–36
h.
 Ifa patient does not normalize haemodynamically or lactic acid or base deficit
fail to improve, the patient should be taken back to the operating theatre
earlier for re-exploration.
 Two subgroups of patients are seen in DC II
who require ‘unplanned’ re-operation
 Thefirst is the group of patients who have ongoing transfusion requirements or
persistent acidosis despite normalized clotting and core temperature. Usually a
missed visceral injury that was not treated adequately during the initial
damage control operation and have a very high mortality rate
 The
second group requiring unplanned return to the operating theatre have
developed ACS. ACS is the endpoint of a disease spectrum of IAH, defined as
a pathological, sustained increase in intra-abdominal pressure .12 mm Hg
 Surgical
treatment consists of opening the patient’s abdomen to relieve the
pressure.
 the best treatment of ACS is prevention.
 Colloid
rather than crystalloid resuscitation to decrease gut oedema,
nasogastric drainage, or bowel purgation or increase abdominal wall
compliance. Optimal analgesia and sedation including complete
neuromuscular block if necessary can ameliorate the consequences of IAH.
Damage control part three (DC III)

 Timing
of DC III is critical as it will likely have the most
impact on achieving traditional measures of ‘successful
outcomes’
 Patients
should be normothermic, have normal
coagulation studies and also a normal pH and lactate.
With focused, critical care management and resuscitation
one may obtain this physiological state within 24–36 h.
 Damage control part three (DC III)
Operative game plan

 Detailed ‘hand-over’ should occur before DC III if the restorative surgeon did
not perform the original DC I laparotomy.
 All packs are irrigated copiously and removed carefully to avoid clot disruption
or further visceral damage
 When repeated attempts to control the bleeding using local haemostatic
measures fail, immediate repacking is the safest course of action to prevent
massive blood loss and recurrent physiological deterioration.
 Aftersuccessful pack removal, a complete re-examination of the abdominal
contents should occur, with particular attention paid to any previous repairs
made during DC I.
 Additional sites of bleeding are controlled, vascular repairs are performed, and
intestinal continuity is restored.
 Damage control part three (DC III)
Abdominal Closure

 Once all of the repairs are completed, formal abdominal closure without
tension is the challenging final step in the planned re-operation sequence
 Ifgentle adduction allows the fascial edges to approximate, a standard fascial
closure should be possible.
 However,persistent oedema within the retroperitoneum, bowel wall, and
abdominal wall often renders primary closure impossible.
 Inthis case, the patient is returned to the ICU where aggressive diuresis should
be considered in an attempt to decrease bowel and body wall oedema as
haemodynamically tolerated.
 The majority of damage controlled open abdomens can be closed primarily
within 1 week, especially if there is no sign of intra-abdominal infection.
 Conclusions

DCS and resuscitation have been associated with improvements in survival

for the severely injured trauma patient. An abbreviated operation to attain
control of haemorrhage and enteral contamination and also aggressive
resuscitation allows one to improve the patients’ physiology, albeit at the
expense of anatomical repair in the short term. DCR used during the initial phases
of damage control has further been associated with improved mortality rates
and reduced incidence of complications in major trauma patients. It may
reduce the requirement for DCS as patients’ better physiological condition after
DCR allow them to better withstand early definitive surgery.
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