DAMAGE CONTROL Rochelle A. Dicker, MD Associate Professor of - - PDF document

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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

• rgan 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

5/29/2014 5 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

• f the Open Abdomen

 Preservation of the Peritoneal Space  Progressive abdominal closure (prevention

• f 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

• nly 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