Damage control surgery: it’s evolution over the last …

1 314 Rev. Col. Bras. Cir. 2012; 39(4): 314-321 WaibelWaibelWaibelWaibelWaibelDamage control surgery : it s evolution over the last 20 yearsRevis oRevis oRevis oRevis oRevis oDamage control surgery : it s evolution over the last 20 yearsDamage control surgery : it s evolution over the last 20 yearsDamage control surgery : it s evolution over the last 20 yearsDamage control surgery : it s evolution over the last 20 yearsDamage control surgery : it s evolution over the last 20 yearsCirurgia para o controle de danos: sua evolu o durante os ltimos 20 anosCirurgia para o controle de danos: sua evolu o durante os ltimos 20 anosCirurgia para o controle de danos: sua evolu o durante os ltimos 20 anosCirurgia para o controle de danos: sua evolu o durante os ltimos 20 anosCirurgia para o controle de danos: sua evolu o durante os ltimos 20 anosBRETT H WAIBEL, MD FACS1; MICHAEL MF ROTONDO, MD FACS1 ABSTRACTABSTRACTABSTRACTABSTRACTABSTRACT In less than twenty years, what began as a concept for the treatment of exsanguinating truncal trauma patients has become theprimary treatment model for numerous emergent, life threatening surgical conditions incapable of tolerating traditional methods.

2 Itscore concepts are relative straightforward and simple in nature: first, proper identification of the patient who is in need of followingthis paradigm; second, truncation of the initial surgical procedure to the minimal necessary operation; third, aggressive, focusedresuscitation in the intensive care unit; fourth, definitive care only once the patient is optimized to tolerate the procedure. Thesesimple underlying principles can be molded to a variety of emergencies, from its original application in combined major vascular andvisceral trauma to the septic abdomen and orthopedics. A host of new resuscitation strategies and technologies have beendeveloped over the past two decades, from permissive hypotension and Damage control resuscitation to advanced ventilators andhemostatic agents, which have allowed for a more focused resuscitation, allowing some of the morbidity of this model to be combination of the simple, malleable paradigm along with better understanding of resuscitation has proven to be a potentblend.

3 As such, what was once an almost lethal injury (combined vascular and visceral injury) has become a survivable words: Key words: Key words: Key words: Key words: Patients. Wounds and injuries. Therapeutics. Surgical procedures, operative. Brody School of Medicine East Carolina University Greenville, North Department of surgery Division of Trauma and Surgical Critical term Damage control surgery has yet to reachtwenty years of use, but the simple concepts at its corehave radically changed the way critically ill patients areapproached for surgery , and not just in trauma. Itsbeginnings were in the treatment of patients withexsanguinating abdominal injuries. The traditional approachwas the same as with an elective surgery patient; definitiverepair of injuries and abdominal closure in a single operativesetting. The innovative change with Damage control wasrecognition that those patients with exsanguinating injurieswere not capable of such a challenge.

4 They required anabbreviated initial laparotomy to control bleeding andcontamination, followed by recovery of physiologic reservein the intensive care unit (ICU) before definitive repair andabdominal closure at a subsequent laparotomy(ies).While some discussions of using an abbreviatedlaparotomy can be found back to the American Civil Warand World Wars, it was generally dismissed as poor surgicalcare. It was not until the 1980 s, with H Harlan Stonedemonstrating improved survival with abdominal packingfor coagulopathic bleeding and Burch with hepatic injuries,that a more rigorous evaluation of this approach wasbegun1,2. Damage control surgery was coined in 1993, withRotondo and Schwab s landmark paper showing a seven-fold improvement (11% to 77%) in mortality in patientswith combined visceral and major vascular injury using thedamage control Most larger series havedemonstrated approximately a 60% overall survival ratewith using Damage control surgery techniques, though somehave higher survival rates when low energy mechanisms(stabbings) improvement in survival for these patientscomes with understanding that fundamental differences existbetween the elective surgery patient and the exsanguinatingtrauma patient for both physiology and anatomy.

5 The multi-system trauma patient can have injuries in multiple locationsacross different body cavities with loss of physiology reserveat presentation due to ongoing bleeding and contamination,which is profoundly different from the elective surgery patientwho usually has a single issue without uncontrolledhemorrhage or contamination during their procedure. Theexsanguinating trauma patient does not have time foroptimization of medical problems, and often is unable toeven give a medical history. These essential differences inpresentation lead to an overall poor physiologic reserveincapable of sustaining a prolonged surgical to provide a single definitive procedure in thesepatients leads to ongoing bleeding from coagulopathy, anunresuscitatable shock state, or multiple organ 1993, Rotondo and Schwab coined the term Damage control surgery , demonstrated the survival benefitwith it, and provided a model for its application.

6 Over theWaibelWaibelWaibelWaibelWaibelDamage control surgery : it s evolution over the last 20 years315 Rev. Col. Bras. Cir. 2012; 39(4): 314-321following decades, refinements were made to the basicsteps to produce the current model in use today 7-10. At itscore is the identification of patients unable to tolerate atraditional approach due to present or impending shockstate, use of an abbreviate laparotomy focused only oncontrol of bleeding and contamination to limit surgical insultand allow for aggressive resuscitation in an ICU to regainphysiologic reserve. Only after correction of acidosis,hypothermia and shock are definitive repairs of the abdominal wound has further been separatedin the sequence; a change brought about by an emergingunderstanding of abdominal compartment syndrome. Whilethe particular employment of Damage control surgery mayvary from patient to patient, the simple core concepts haveallowed Damage control surgery to be modified to otherareas than trauma.

7 Most notably, these include vascularsurgery, orthopedics, and the septic abdomen , modern military care of injured soldiers hasbecome aligned with this model in some countries, withforward surgical teams dealing with ongoing bleeding andcontamination control with definitive repair being delayedto later, rear echelon teams for Damage control SurgeryIndications for Damage control SurgeryIndications for Damage control SurgeryIndications for Damage control SurgeryIndications for Damage control SurgeryThe underlying goal is to abbreviate the initiallaparotomy in those patients who would develophypothermia, acidosis, and an acquired coagulopathy andthe associated complications they bring using a moretraditional approach. Therefore, the primary determinantin the need for Damage control surgery should be thepatient s own physiology (Table 1).The complex interactions of multiple variablesprevent absolute determinants of when Damage controlsurgery should be performed.

8 Critical physiological factors,such as the development of acidosis, acquired coagulopathy,hypothermia, profound hypotension/hypoperfusion, are thepredominately-discussed indications for Damage controlsurgery. Prolonged operative times (greater than 90minutes) are also discouraged due to the high incidence ofprogression to physiological injury patterns, such as high energyblunt torso, multiple penetrating injuries, injuries acrossmultiple compartments, or combined vascular/visceralinjuries, also lend themselves to Damage control approach,especially when injuries have competing priority fortreatment. These injury complexes lend themselves toongoing or recurrent hemorrhage from sites not visualizedby the operative team, which can hasten the progress tophysiologic exhaustion. control of hemorrhage should betreated as a continuum across body cavities and regionswith the surgeon starting at the perceived most compellingsource of hemorrhage and expeditiously move to others asthe situation evolves, keeping in mind the next area maynot be in the current surgical , some injuries may be better treated withadjuncts, such as angiographic embolization of hepatic orpelvic injuries.

9 Additionally, variation in physiological reserveexists across patient populations. The elderly and thosewith multiple medical comorbidities tend to have lesstolerance for surgical procedures due to poor preexistingreserve. The young and athletic may hide the progressionto physiologic exhaustion until hemodynamic collapse. Asthe surgery progresses, the need for Damage control surgeryshould be reevaluated based upon changes in physiologybalanced against the operative/treatment needs of adaption of Damage control surgery for trau-ma to other areas generally resolves around identifyingthose patients who would develop a similar loss ofphysiologic reserve with intolerance to the shock 1 -Table 1 -Table 1 -Table 1 -Table 1 -Indications for Damage control surgery Physiological Factorsi)Hypothermia- temperature < 35 Cii)Acidosis- pH < or base deficit > 8iii)Coagulopathy- nonmechanical bleeding, increase in prothrombin (PT) and/or partial thromboplastin time (PTT),thrombocytopenia, hypofibrinoginemia, or massive transfusion requires (> 10 units packed red blood cells [pRBC] orbody volume replacement)iv)Prohibitive operative time needed for definitive repair (> 90 minutes)v)

10 Hemodynamic instability or profound Complexes Associated with Loss of Physiologic Reservei)High energy blunt torso traumaii)Multiple penetrating torso injuriesiii)Combined visceral injury with major vascular traumaiv)Injuries across body cavities, especially those with competing treatment priorities, such as closed head injury, majorvascular injury and pelvic Considerations in Trauma Patientsi)Injuries better treated with nonsurgical adjunct, such as angiographic embolization of hepatic or pelvic injuriesii)Variation in physiologic reserve (elderly, multiple comorbidities, young, athletes)316 Rev. Col. Bras. Cir. 2012; 39(4): 314-321 WaibelWaibelWaibelWaibelWaibelDamage control surgery : it s evolution over the last 20 yearsThis is generally driven by a systemic inflammatoryresponse from either an infectious source (septic abdomen)or second hit phenomenon stimulating an already primedimmune state ( Damage control orthopedics).