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]