Damage Control Surgery


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1 : Dr. AHMED KANDIL, MD.PhD. Consultant Surgeon Head of surgery Dep. Shifa Hosp. Gaza, PNA. DAMAGE CONTROL SURGERY
2 : Damage Control Surgery (DCS) 1 During past two decade, a new surgical strategy developed to avoid high mortality in severe trauma patients, during operation or resuscitation. DCS is the most common term to describe staged surgery or staged abdominal re-operation for abdominal trauma (STAR).
3 : DCS 2 In severe trauma patients a triad of hypothermia, metabolic acidosis, and coagulopathy rapidly established. Once it is established a vicious circle form, which may be impossible to overcome.
4 : DCS 3 Hypothermia In severe trauma hypothermia occurs due to: Inadequate protection of the patients. Blood loss ? shock ? worsening of hypothermia. I.V. fluid & blood transfusion. Hypothermia has dramatic effects on body functions, exacerbate coagulopathy and interfere with blood homeostatic mechanisms.
5 : DCS 4 Acidosis Uncorrected hemorrhagic shock will lead to production of lactic acid. This leads to profound metabolic acidosis which interfere with clotting mechanisms causing more blood loss.
6 : DCS 5 Coagulopathy Hypothermia, acidosis, massive blood transfusions all leads to coagulopathy. Patient continue to bleed even when mechanical control of bleeding achieved. This worsen hemorrhagic shock and so worsening of hypothermia and acidosis; producing a vicious circle.
7 : DCS 6 The Goals of DCS are:- Identify injuries. Control hemorrhage. Control of intestinal spillage. So that the operation end as soon as possible before establishment of the triad.
8 : DCS 7 Damage Control Surgery consist of 3 phases: Initial laparotomy in OR. Resuscitation phase in ICU. Definitive operation in OR.
9 : DCS 8 Part I - OR Control of hemorrhage Control of contamination Intraabdominal packing Temporary closure Part II - ICU Core Rewarming Correct coagulopathy Maintained hemodynamic Ventilatory support Injury identification Part III - OR Pack removal Definitive repair
10 : DCS 8 1- Initial laparotomy:- Decision for DCS should ideally made within the first 15 minutes of the operation. Indications for DCS :- Exanguinating patient with hypothermia and coagulopathy who is hemodynamically unstable. Inability to control bleeding by direct hemostasis. Inability to close abdomen without tension. Expected long time operation.
11 : DCS 9 Initial laparotomy: steps Big arteries and veins are repaired or ligated Abdominal packing in form of pads or rolled mesh gauze are used to control slow venous bleeding. The packs are placed above and below the injury, achieving compression in both sides.
12 : DCS – Initial laparotomySevere liver lacerations
13 : DCSextensive liver laceration from GSWA-packing
14 : DCS – Packing of big hole in pelvis
15 : DCS 10 Initial laparotomy:- Multiple holes in the bowel closed by stappling or ligation to prevent further spillage of contents. The abdomen closed without tension by using towel clips, Bogota bag or other mrthods. Bogota bag is transparent allows inspection of intestine, hemorrhage ,leaks and gangrene.
16 : DCS Alternative method of abdominal closure Bogota bag
17 : DCSAlternative methods of abdominal closure
18 : DCS 11 2- Resuscitation phase:- Done in ICU for prevention or correction of trauma triad of death; hypothermia, acidosis and coagulopathy. This achieved by: Rewarming. Correction of coagulopathy Correction of acidosis. Optimizing pulmonary functions.
19 : DCS 12 Resuscitation: Rewarming Heat loss during major trauma patient may be as high as 4.5 ºC per hour. Hypothermia is correcting by increase room temperature, avoid unnecessary skin exposure, use of blood and fluid warmer, etc.
20 : DCS 13 Resuscitation: Reversing coagulopathy Thrombocytopenia results from massive blood transfusion ? coagulopathy; corrected by platelets transfusion. Large volumes of crystalloids and packed RBCs ? diluting coagulating proteins corrected by clotting factors and fibrinogen.
21 : DCS 14 Resuscitation: Reversing acidosis Metabolic acidosis induced by Lactic acid accumulation that produced by shock. Aggressive treatment of shock by fluids, blood, fresh frozen plasma, inotropic agents are needed. Use of i.v. sodium bicarbonate and follow the PH estimation.
22 : DCS 15 Optimizing pulmonary functions:- Following DCS patients are intubated in ICU and maintained on mechanical ventilation. Goal are to achieve oxygen saturation more than 92%. Those patients usually require deep sedation and pain medication.
23 : DCS 16 3- Definitive operation or planned re-operation: Re-operation done within 24 – 72 hours. Principals of re-operation: Removal of clots and abdominal packs. Complete inspection of abdomen to detect missed injuries. Restoration of intestinal integrity. Abdominal wound closure.
24 : DCS 17 Unplanned re-operation: Indications: Continued bleeding despite normalization of coagulation functions. Intra abdominal pressure greater than 25 cm water with complication of abdominal compartment syndrome.
25 : DCS 18 Complications of DCS:- Abdominal compartment syndrome (ACS). Multiple organ failure. Intraabdominal abscess (between 12% - 67%). Other septic complications in chest and abdomen.
26 : Abdominal compartment syndrome (ACS)1 ACS is the result of acute increase in intra-abdominal pressure after major surgery or DCS. Causes:- Perihepatic packing. Bowel edema and congestion in major trauma. Accumulation of blood in the mesentery and/or retro-peritoneal space Persistent intraabdominal bleeding.
27 : ACS 2 ACS has bad effect on almost all body system, ultimately causing multiple organ system failure. 1- Cardio vascular effect: A rise in the intraabdominal pressure lead to compression on IVC ? reduction in venous return ? fall in cardiac output.
28 : ACS 3 2- Respiratory: Raised intraabdominal pressure will compress the diaphragm and ? rise in peak air way pressure and intra-thoracic pressure ? reduced venous return to the heart. The increase in airway pressure contribute to the development of ARDS.
29 : ACS 4 3- Gastrointestinal: Gut is extremely sensitive to increases in intraabdominal pressure. Mesenteric blood flow decreases. Increase of visceral edema secondary to resuscitation and compression of thoracic duct. Ischemia and gangrene of the gut.
30 : ACS 5 Renal: An acute increase in intraabdominal pressure ? oliguria and anuria due to compression of renal veins and renal parenchyma. Renal blood flow, glomerular filtration are decreased with corresponding increase in renal vascular resistance.
31 : ACS 6 Cerebral: The rise in intraabdominal pressure and intra-thoracic pressure ? rise in central venous pressure which prevent adequate venous drainage from the brain ? rise in intracranial pressure and worsening of intra-cerebral oedema.
32 : ACS 7 Diagnosis of ACS: ACS suspected in any multiple trauma patient. Fall in urine output. Elevated central venous pressure. Confirmed by measurement of intraabdominal pressure, through Foley catheter in the bladder. Normal intraabdominal pressure is zero; a pressure > 25 cm water is diagnostic of ACS
33 : ACS 8 Management of ACS: Anticipate development of ACS and use an alternate technique of wound closure. Management is entirely surgical decompression. Before surgical decompression; maximize intravascular volume status. Maximize O2 delivery, correct hypothermia and coagulation defect.
34 : ACS 9 Management of ACS: 5. Administration of crystalloid solution containing bicarbonate and mannitol to avoid side effect of releasing the product of anaerobic metabolism. 6. Return of normal hemodynamic and pulmonary parameters occurs immediately, including return of renal function. 7. Be aware of good preparation because sudden decompression can cause hypotension or rarely asystole and death.
35 : Thank You

 

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