Damage Control Surgery: when should it be an option?

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Damage Control Surgery. ▫ A firmly established concept in the management of abdominal trauma. ▫ Temporizing measure to salvage otherwise moribund trauma.
Damage Control Surgery: when should it be an option?

Rodrigo C. Leão Edelmuth, MD Yuri dos Santos Buscariolli. MD Marcelo A. Fontenelle Ribeiro Jr, MD, PhD, TCBC, TCBCD, FACS

§ No conflict of interest § São Paulo City University - UNICID § Santo Amaro University - UNISA

Damage Control Surgery §  A firmly established concept in the management of abdominal trauma §  Temporizing measure to salvage otherwise moribund trauma patients §  Severely injured patients undergoing prolonged operations often die from metabolic failure rather than the inability to complete organ repairs - LETHAL TRIAD

Damage Control Surgery §  Several clinical findings and laboratory data suggest which patients would benefit from DCS. §  However, there is no consensus, based on objective data, on when to perform this approach. §  AIM: §  To establish objective criteria regarding the best moment to perform DCS

METHODS §  PubMed/Medline literature review §  Search limits: §  “Damage Control” on the title §  Articles published in the last 10 year §  English or Portuguese §  “Only Humans”

RESULTS §  A= Garrison et al., 1996, prospective, n=70; §  B= Cushmann et al., 1997, retrospective, n=53; §  C= Cosgriff et al., 1997, prospective, n=58; §  D= Rotondo et al., 1997, review; §  E= Krishna et al., 1998, retrospective, n=40; §  F= Parreira et al., 2002, prospective, n=74; §  G= Stalhschmidtet al.; 2006, review; §  H= Germanos et al., 2008, review; §  I= Matsumoto et al., 2010, retrospective, n=34

Criteria §  Hypothermia à Temperature §  Acidosis à Base excess, pH, §  Coagulopathy à Hematologic parameters §  Hypotension à Blood pressure

Temperature A= Garrison et al., 1996, prospective, n=70

--

B= Cushmann et al., 1997, retrospective, n=53

< 35°C

C= Cosgriff et al., 1997, prospective, n=58

< 34°C

D= Rotondo et al., 1997, review

< 35°C

E= Krishna et al., 1998, retrospective, n=40

< 33°C

F= Parreira et al., 2002, prospective, n=74

--

G= Stalhschmidtet al.; 2006, review

< 34°C

H= Germanos et al., 2008, review

< 34°C

I= Matsumoto et al., 2010, retrospective, n=34

< 35,5°C

Study

Base excess

pH

A= Garrison et al., 1996, prospective, n=70

--

< 7,2

< -6 mEq/L

< 7,3

C= Cosgriff et al., 1997, prospective, n=58

--

< 7,1

D= Rotondo et al., 1997, review

--

< 7,3

E= Krishna et al., 1998, retrospective, n=40

< -12 mEq/L

severe acidosis

F= Parreira et al., 2002, prospective, n=74

≤ -10 mEq/L

7,25

G= Stalhschmidtet al.; 2006, review

--

< 7,2

H= Germanos et al., 2008, review

--

< 7,2

< 7,5 mmol/L.

--

B= Cushmann et al., 1997, retrospective, n=53

I= Matsumoto et al., 2010, retrospective, n=34

Blood pressure A= Garrison et al., 1996, prospective, n=70 B= Cushmann et al., 1997, retrospective, n=53

Blood Pressure

C= Cosgriff et al., 1997, prospective, n=58 D= Rotondo et al., 1997, review

prolonged hypotension (>70 min) -systolic blood pressure < 70 mmHg; --

E= Krishna et al., 1998, retrospective, n=40

< 80 mmHg;

F= Parreira et al., 2002, prospective, n=74

SBP < 110 mmHg at the start of the surgery

G= Stalhschmidtet al.; 2006, review

--

H= Germanos et al., 2008, review

SBP < 70 mmHg

I= Matsumoto et al., 2010, retrospective, n=34

SBP < 90 mmHg

Hematologic

Transfusion

Coagulopathy

A= Garrison et al., 1996, prospective, n=70

> 15 PRBCs,

--

B= Cushmann et al., 1997, retrospective, n=53

--

--

C= Cosgriff et al., 1997, prospective, n=58

--

coagulopathy, aPTT or PT > 2x baseline parameters

≥ 10 PRBCs, > 4L of blood loss

coagulopathy

E= Krishna et al., 1998, retrospective, n=40

> 4L of blood loss*

INR > 2,2*

F= Parreira et al., 2002, prospective, n=74

PRBCs > 1200ml or persistent shock

--

G= Stalhschmidtet al.; 2006, review

hypovolemic shock > 70 min

coagulopathy

≥ 10 PRBCs

aPTT > 19s, PT > 19s or hemodynamic instability

--

--

Hematologic

D= Rotondo et al., 1997, review

H= Germanos et al., 2008, review

I= Matsumoto et al., 2010, retrospective, n=34

Operation time § > 90 min §  H= Germanos et al., 2008, review §  D= Rotondo et al., 1997, review

Mechanics of Trauma § Mechanics of Trauma §  High-energy, blunt torso trauma §  Multiple torso penetration §  Complexes of injuries §  Major abdominal vascular, §  Complex hepatic §  Major thoracic vascular injuries §  Need for intraoperative thoracotomy

Conclusion §  Polytraumatized patients with multiple visceral lesions, important vascular injuries, severe hepatic trauma or multiple thoracic penetration. §  Hemodynamic instability (SBP < 70-80 mmHg; < 110mmHg) §  Massive transfusion §  Hypothermia (T < 33-35°C) §  Acidosis (pH < 7,1 – 7,3; BE < -6 mEq/L) §  Coagulopathy (> 10 PRBCs, altered aPTT/TP) §  For more than 90 minutes

Conclusion § Surgeons: §  Experience §  Adaptability §  Training §  Creativity

Thank you

Rodrigo Edelmuth, MD [email protected]