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DAMAGE CONTROL

Rochelle A. Dicker, MD

Associate Professor of

Surgery and Anesthesia

University of California, San Francisco

No Disclosures

Definition

Term used in the Merchant Marines and in

Navies for the emergency control of

situations that may hazard the sinking of a

ship

Outline

Human Injury/Damage

Compartment syndrome

Guidelines for Damage Control

Algorithm for Damage Control

Highlighting ICU Care

The Open Abdomen and Complications

Enteroatmospheric fistulae

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Consequences of Major

Injury or Disease

anatomic defect

physiologic defect

iatrogenic defect

… a lethal cascade of events ...

Anatomic Defects

Anatomic Derangement of the Airway

Holes in blood vessels

Holes in solid organs causing hemorrhage

Holes in hollow viscera causing leakage of intestinal contents and urine

Contusions of the lung and heart causing organ dysfunction

Disruption of the skeleton

Intercranial Injury

Physiologic Consequences of

Prolonged Shock

Hypoperfusion

Vasoconstriction

Metabolic Acidosis

Massive Release of catecholamines,

glucocorticoids, ADH, Aldosterone,

Cytokines

Consequences of Prolonged

Shock

Loss of integrity of cellular membranes

Leakage of fluid into interstitium

Leakage of sodium into cells

Result: Requirement for Massive

Fluid Infusion to restore intravascular

volume and tissue perfusion

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The Lethal Triad

metabolic acidosis

hypothermia

coagulopathy

Iatrogenic Consequences of

Resuscitation

Massive Edema

Increased intra-abdominal, intra-thoracic,

intracranial and subfascial pressures: i.e.

Compartment Syndrome

Definition of the World Congress on

Abdominal Compartment

Syndrome

Persistent bladder pressure of >20mm

mercury with new onset organ dysfunction

Risk Factors for Compartment

Syndrome

Post-traumatic hemorrhage

Intraperitoneal bleeding

Retroperitoneal bleeding

Any vigorous fluid resuscitation

Post-resuscitative visceral edema

Lethal triad

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Splanchnic

hypoperfusion

Abdominal

compartment syndrome

Abdominal bleeding

Coagulopathy

Hypothermia Acidosis

Hepatic ischemia

Free radicals

organ damage

Gut edema

Intra-abdominal

hypertension

A cycle of ischemia producing intra-abdominal hypertension and

the abdominal compartment syndrome ( from Michael Rotondo, MD).

Physiologic Consequences of the

Abdominal Compartment Syndrome

Cardiovascular

Decreased VR

Increased SVR

Hypotension

Splanchnic Circulation

Decreased splanchnic flow

Decreased pHi

Decreased hepatic artery

and portal vein flow

Decreased Renal blood flow,

GFR and Urine Output

Pulmonary

Decreased

Compliance

Increased PIP

Increased PA pressure

Increased Vd/Vt

Increased Qs/Qt

Cerebral Circulation

Increased ICP

Decreased CPP

Damage Control

In Surgical Care

Stone in 1983- Abbreviated celiotomy and

packing

Damage Control in the Trauma setting

coined by Rotondo and Schwab in 1993

Guidelines for Initiating Damage

Control Maneuvers

Acidosis

pH < 7.2

Base Deficit ≥ -8

Lactate ≥ 4

Hypothermia

< 35° celcius

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More Guidelines for Damage

Control

Ongoing Resuscitation

Persistent shock with systolic BP <90

> 10 litres crystalloid

>10 units packed red blood cells

Operative Time

> 60-90 minutes with abdominal cavity open

More Damage Control Guidelines

Coagulopathy

PTT > 60

INR >1.6

Host Factors Defining Reserve

Age

Underlying disease

Physiologic reserve: TIME

Malperfusion and ISS

Indications for the Open

Abdomen Damage Control for Trauma

Abdominal Compartment Syndrome

Massive Resuscitation

Burn

Pancreatitis

Severe Abdominal Infection

Acute Mesenteric Ischemia

Necrotizing Infection of the Abdominal Wall

Goals of Damage Control

Laparotomy Control of Hemorrhage

Rapid Control of Intestinal Spillage

Rapid Temporary Abdominal Closure

Rapid Transfer to the ICU for continued resuscitation and restoration of physiologic homeostasis

Delay of intestinal reconstruction until repeat laparotomy 24-48 hours later

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Algorithm for Damage Control

Step One

Initial ED assessment

Resuscitation

Recognition and operative decisions

Algorithm for Damage Control

Step Two

Initial trauma laparotomy

Hemorrhage control

Contamination control

Intra-abdominal packing

Temporary dressing

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Algorithm for Damage Control

Step Three

ICU 2° resuscitation

Warming

Correct coagulopathy

Individualized ventilatory support

Secondary survey and planning

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ICU Resuscitation

Rewarming/Correct hypothermia

CENTRAL LINE

Infusion of warm fluids

Bair hugger

Prevent insensible losses

PRN humidifier on vent set at 40°

ICU Resuscitation

Correct coagulopathy, acidosis, electrolyte

imbalance

Measure CBC, coags, fibrinogen

Correct K+, Mg+, Ca+ deficiencies

Measure and use base deficit as guideline

Consider effect of Normal Saline on base deficit

ICU Resuscitation

Utilize central venous pressures to assist

in guiding resuscitation

KNOW the pitfalls of interpretation

ICU Resuscitation

If PA Catheter is necessary

CI > 3L/min

End diastolic volume index 120-140ml

SaO2 >95%

SVO2 >65%

Consider ECHO

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ICU Care

Medications

Peptic ulcer prophylaxis

H2 blockers or proton pump inhibitors

DVT prophylaxis

Low molecular weight heparin is superior

Insulin drip

Maintain blood glucose 80-110 mg/dl

Drips for analgesia and sedation

Antibiotic therapy with open abdomen

ICU Care-Best Practices

Head of Bed at 30°

Frequent suctioning and oral hygiene

Functioning nasogastric tube

Functioning wound vac

Hourly urine output

Bladder pressure checks (if applicable)

Pad pressure points

Algorithm for Damage Control

Step Four

Reoperation: Typically 12-36 hours

Pack removal

Definitive repairs

Decisions on closure

Revolution in the Management

of the Open Abdomen

Preservation of the Peritoneal Space

Progressive abdominal closure (prevention

of lateral fascial retraction)

Vacuum-assisted wound management

Use of biologic dressings

Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen: A quiet

Revolution. Scand J Surg2005;94:9-14.

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Options for Biologic Dressing of

Exposed Viscera

Skin Flaps

Homologous split thickness skin

Autologous split thickness skin

Acellular dermal matrix

Musculofascial advancement flaps

Rotation skin and muscle flaps

Free flaps

Complications of the

Open Abdomen

Abdominal

Wound infection

Dehiscence

Fasciitis/necrosis

Intra-abdominal abscess

Enteroatmospheric fistula

Risks increase with multiple operations and

multiple Surgeons

Problem of “Entero-

atmospheric” Fistula Absence of overlying soft tissue with good

blood supply precludes spontaneous

healing

Exposed abdominal viscera predisposes

to development of additional holes in the

GI tract

Complex Wound difficult to manage

Principles of Management

Specific for “Entero-

atmospheric” Fistula

PREVENTION Protect exposed

abdominal viscera during open abdomen management

Limit access to the wound to one or two SENIOR people

Attempt to seal leak when first recognized

Protect adjacent viscera with biologic dressings to avoid additional holes

Control fistula effluent

Rotate flaps with good blood supply to cover fistula in selected cases

Resect well established “entero-atmospheric” fistula only when patient fit and infection free

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Principle 4

Control Fistula Effluent

Fixed Visceral Block

Vacuum Assisted Wound Management

System

Wound Drainage Bags

Requires expert enthusiastic nursing

assistance

Creativity 1.Hyon SH, Martinez-Garbino JA, Benati ML, et al. Management of a high-output postoperative

Enterocutaneous fistual with a vacuum sealing method and continuous enteral nutrition. ASAIO J.

2000;46:511-4.

2.Erdmann D, Drye C, Heller L et al. Abdominal wall defect and enterocutaneous fistula treatment

With Vacuum –Assisted closure (V.A.C.) system. Plast Reconstr Surg 2001;108:2066-8

3.Alvarez AA, Maxwell GL, Rodriguez GC. Vacuum-assisted closure for cutaneous gastrointestinal

Fistula management. Gynecol Oncol 2001;80:413-6.

4. Cro C, George KJ, Donnelly J, et al. Vacuum assisted closure in the management of enterocutaneous

Fistulae. Postgrad Med J. 2002;78:364-5.

Principle 4

Control Fistula Effluent

DO NOT INTUBATE A FISTULA in the

middle of a fixed visceral block open

abdomen

You won’t control the drainage

You will make the hole bigger

Risk of additional holes

Complications of the

Open Abdomen

Extra-Abdominal

Ventilator-associated pneumonia

Aspiration pneumonitis

ARDS

Bloodstream infections

Deep venous thrombosis/Pulmonary embolus

Pressure ulcers

Multiple organ dysfunction syndrome

Clinical Signs:

Veering off Trajectory

Systemic Inflammatory Response

Tachycardia

Tachypnea

Elevated WBC

Fever

Increased pain and aggitation

Mental status changes

Decreased urine output

Worsening base deficit

Each observation is relative to the last

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Damage Control Long-Term

Mortality Impact Now indisputable:

Early studies from 53% survival to 90% survival

Morbidity 76% readmission rate

Sutton et al from Maryland Shock/Trauma

Infection, hernia management and fistula management were reasons for readmission

Survival of readmitted patients 100%

Average ISS 33