Damage control surgery

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Question 20 from the first paper of 2011 and Question 21 from the second paper of 2008 discuss the principles of damage control surgery in trauma, the practice of repairing lifethreatening injuries quickly, and leaving the definitive management until physiological normality is restored.

The LITFL page on damage control surgery is an excellent introduction to the subject. Godat et al (2013) cover the topic with satisfactory detail, which is perhaps excessive when it comes to last minute cramming; it was the major source for this summary chapter. A good article on this is also vailable from 2004 (Critical Care Clinics). For a complete bibliography on this subject, one is directed to trauma.org.

Basic principles of damage control surgery

Definition of damage control surgery

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

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
• Staged definitive procedure

Rationale for damage control surgery and delay of definitive management

Historically, much of the mortality and morbidity from trauma was associated with the early attempt at repair. Attempts were made to complete the definitive management early, in the first operation. The repair attempts turned into prolonged procedure,s lasting many hours. Frequently such rescues were attempted by teams composed of mainly junior staff, and out of normal working hours. Attempts to subject unstable trauma patients to these "classical" long laparotomies were frustrated by failure. This is because hypothermia, acidosis, and coagulopathy render attempts at definitive surgical repair less likely to succeed. Thus, the rationale for damage control surgery is early surgical control of immediately lifethreatening injuries and the establishment of haemostasis.  Definitive management can be delayed in most cases; the patient can spend some time in ICU getting their physiology un-deranged. Definitive management can take place safely (and is more likely to succeed) once the physiological abnormalities are corrected. The timing can be negotiated with the surgical teams, so that the optimum level of expertise can be present.

This has had a marked effect on mortality. The first publication on this topic (Stone et al, 1983) offers a nightmarish glimpse of the bloodied hell-scape that was early trauma surgery. Thirty one patients who developed lethal coagulopathy in theatre were enrolled. Of the "traditional" surgical approach, the mortality rate was 98%. The others were quickly clamped and packed, and taken to ICU with their abdomens open. Their return to theatre was dictated by the resolution of their coagulopthy. The abdominal packs were left in for an average of about 27 hours; then definitive management took place.
The mortality rate from this was 35%.

Practical  aspects of damage control surgery

Indications for damage control surgery

I was able to find this list of indications in Godat's 2013 position paper. It, in turn, draws on Rotondo and Zonies' "The damage control sequence and underlying logic" (1997). In trauma patients, the pre-operative indications include the following:

• Specific injury patterns which favour DCL:
  • Penetrating injury
  • Gun shot wound
  • High-energy blunt torso trauma
  • Major abdominal vascular injury
  • Multicavitary exsanguination
• Systolic blood pressure (SBP) <90 mmHg.
• Need for re-suscitative thoracotomy.
• Hypothermia (≤33°C)
• inappropriate bradycardia
• pH of <7.2
• Transfusion of more than 10units of PRBCs
• Total fluid replacement >12 L
• Estimated blood losses of ≥ 5 L

Temporary abdominal closure (TAC) methods:

• From Godot, "The ideal TAC should be easily and quickly applied, allow room for expansion, limit contamination, decrease bowel edema, protect the viscera, fascia and skin from damage, evacuate fluids, prevent adhesions, minimize loss of domain and be cost-effective".
• First TAC experiments ghad patients with intra-abdominal packs termporarily half-closed with towel clips or runing sutures. Abdominal compartment sydnrome was the cvonsequence. This practice has since been abandoned.
• Later, some sort of erzats water-impermeable barrier was used (eg. a disembowelled IV bag or stoma bag). But, it was sutured directly to the skin. Again, abdominal compartment syndrome developed in up to 33% of patients because the abdomen was technically still "closed".
• Vacuum-assicted closure devices are used most frequently today. They consist of packing sponged and an occlusive surface dressing. There is much less abdominal compartment pressure problems with these. But, there are occasional issues with enterocutaneous fistula. The rates of this complication vary from 1.5 to 15% in the literature.

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

Principles of ICU management between stages of surgical repair

While recovering from one horrendoplasty and while waiting for the next one, the ICU team has several jobs to do. The emphasis for rescuing the patient has shifted from ED procedures (who now merely triage the trauma) and from the surgical team (who do a quick clamp-and-burn). Now, the ICU is in charge of the bulk of the resuscitation, which - some might argue - is how it should be.

An excellent 2006 article by Sagraves et al ("Damage control surgery—the intensivist's role") does this topic justice with the appropriate amount of detail.  The domains of ICU management can be discussed in a familiar sequence, starting with the airway.

1. Keep them intubated. There is no rush to get the tube out.
2. Ventilate with lung-protective strategy.
   The compliance will be poor for a number of reasons (eg. fluid excess, lung contusion, massive distended abdoimen, and so forth).
3. Correct hypovolemia; use lactate to determine the effectiveness of resuscitation.
   Vasopressors will not be helpful (the SVRI is already very high due to the endogenous catecholamine surge)
4. Sedate and paralyse. No coughing is permitted. This improves the integrity of the open abdomen dressing, improves chest wall compliance and protects you from abdominal compartment syndrome.
5. Electrolytes may be deranged; specifically, one ought to obsess over the calcium, which is a necessary cofactor in clotting.
   Rewarming and correction of acidosis are essential part of resuscitation.
6. One must remember to measure the CK. In a major trauma, as attention ends up focused on the abdomen, everybody forgets about the compartment syndrome of a compromised limb, and rhabdomyolysis ensues.
7. It would not be wise to start either TPN or NG diet at this stage, particularly if the bowel has been left disconnected. One may wait until after the definitive surgery.
8. Correct the coagulopathy. One may consider using Factor VII off-label for this.
9. Antibiotics are indicated; the wounds are usually contaminated.