Damage control surgery
Surgical damage control (DCS) is a life-saving series of steps in the critically ill polytrauma patient.
History [edit | edit source]
- in the past there was a trend towards a„traditional approach “ - i.e. do everything at once (access, revision, resection, reconstruction) regardless of the patient's condition, but this procedure showedhigh lethality
- 1983 Stone et al. - principles of DCS
- 1992 Burch et al. - described the triad of death
- 1993 Rotondo and Schwab - term DCS
- 2001 Assensio et al. - intraoperative parameters and indications for starting the DCS protocol
DCS Targets [edit | edit source]
- restoration of physiological parameters before anatomical adjustment
- facilitate control of bleeding and contamination (1. stabilization of fatal problems, 2. resuscitation, 3. definitive treatment)
Triad of Death[edit | edit source]
1. Hypothermia - consequence of bleeding and resuscitation
Clinical manifestations: ↓ 36°C (if lasting >4h), arrhythmia, suppression of the immune system, systemic vascular resistance
2. Coagulopathy - massive volume resuscitation worsens it with dilution
Clinical manifestations: disorder and inhibition of coagulation factors, platelet dysfunction
Laboratory results are not indicative of hypothermia, only clinical diagnosis (bleeding from wounds, serous surfaces, skin edges)
3. Metabolic acidosis - long-term hypoperfusion → anaerobic metabolism and lactic acidosis
Clinical manifestations: ↓ myocardial contractility, ↓ ejection volume
Indications for DCS[edit | edit source]
Preoperative parameters
- high energy injury
- blunt trauma to the trunk
- multiple torso injuries
- hemodynamic instability, coagulopathy and hypothermia on admission
Intraoperative parameters
- ↓ 34°C
- pH <7,2
- HCO3- <15 mEq/l
- administration of >5,000 ml transfusions
- intraoperative replacement > 12,000 ml
- clinical evidence of intraoperative coagulopathy
Surgical damage control in abdominal injuries[edit | edit source]
It consists of three successive phases:
1. Phase - abbreviated laparotomy
- bleeding control and hemostasis (ligatures, clamps, shunts, balloon catheters...)
- reconstruction is not carried
- FR abdominal lavage, open abdominal fascia, subcutaneous vacuum drainage
2. Phase - resuscitation in the ICU (modification of the triad of death)
- hypothermia - warm infusion solutions, thermal insulation blankets
- coagulopathy - ERY meat, Tr concentrate and fresh frozen plasma
- MAC - adjusts itself by warming the patient
3. Phase - definitive surgical treatment
- reoperation after 36-48h (vascular reconstruction, GIT continuity)
- enteral nutrition
Links[edit | edit source]
Related Articles[edit | edit source]
References[edit | edit source]
- HUŤAN, Martin, et al. Základy všeobecnej a špeciálnej chirurgie. prvé vydání. Bratislava : Univerzita Komenského v Bratislave, 2012. 198 s. ISBN 978-80-223-3214-9.
