Question 21

College Answer

Key feature. Damage Control Surgery involves a 4 phase approach to major emergency abdominal injuries:

•    recognition of at risk patient
•    Limited, focused surgery for control of haemorrhage and address contamination with temporary abdominal closure,

•    restoration of near normal physiology – cardiovascular resuscitation, rewarming (usually active) if hypothermic, correction of coagulopathy (blood products and aFVII) and acidosis.  – with optimization of ventilation and
•    re laparotomy at 24 – 36 hours with removal of packs, definitive surgery and formal abdominal closure, where possible.

Important complications

New onset or uncontrolled surgical bleeding
Abdominal compartment syndrome (ACS),
inability to wake and wean (open abdomen / planned return to theatre)
missed injuries in the multiply injured patient (need for full examination on admission)

Discussion

An excellent article on this is available from 2004 (Critical Care Clinics). The topic of damage control surgery is also discussed briefly in the answer to Question 20 from the first paper of 2011. To simplify revision, that answer is replicated below:

Definition:

• Rapid termination of an operation after control of life-threatening bleeding and contamination followed by correction of physiologic abnormalities and definitive management.

Rationale:

• Hypothermia, acidosis, and coagulopathy render attempts at definitive surgical repair less likely to succeed.
• The surgical control of immediately lifethreatening injuries and the establishment of haemostasis must be achieved early, but definitive management can be delayed in most cases.
• Definitive management can take place safely once the physiological abnormalities are corrected.

Key principles:

• Control of haemorrhage
• Control of contamination
• Use of temporary shunts to bypass ligated vascular injuries
• Delay of abdominal closure, or temporary wound closure

Complications upon returning to the ICU:

Remember that the patient was not being definitively managed in theatre; if you are lucky they are bleeding slightly less than they were before they went to theatre, but in general the resuscitation is only half-complete. Not only that, but they were probably rushed through the ED, and a secondary survey (or trauma CT) may not have been performed.

Thus, one can anticipate the following:

• Old, uncontrolled traumatic bleeding
• New, uncontrolled surgical bleeding
• Uncontrolled coagulopathy, hypothermia and acidosis
• An open abdomen (thus, high sedation and analgesia requirements)
• Abdominal compartment syndrome (if they decided to close it)
• Missed injuries

Morrison, C. Anne, et al. "Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial." Journal of Trauma and Acute Care Surgery 70.3 (2011): 652-663.

Kaafarani, H. M. A., and G. C. Velmahos. "Damage Control Resuscitation In Trauma." Scandinavian Journal of Surgery (2014): 1457496914524388.

Jaunoo, S. S., and D. P. Harji. "Damage control surgery." International Journal of Surgery 7.2 (2009): 110-113.

Schreiber, Martin A. "Damage control surgery." Critical care clinics 20.1 (2004): 101-118.