Damage Control Surgery...modulated through the protein C pathway? » Brohi K et al. Ann Surg. 2007...
Transcript of Damage Control Surgery...modulated through the protein C pathway? » Brohi K et al. Ann Surg. 2007...
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Damage Control Surgery
Patrick Limoges, m.dAnesthésiologiste
Hôpital du Sacré-Coeur de Montréal
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Présentation de cas:
»♂69 ans, Trauma piéton-camion (~18h)» Hématome cervical D» Hémopneumothorax D» FAST +» Open-book
» Réanimation initiale à l’urgence, puis en radiologie pour embolisation
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(suite)
En salle d’op (~21h30):A- intubé, trachée déviée a GB- Hémopneumothorax mal drainéC- Instable, TA 80 syst, Pouls 110 FAD- CGS 15 initial, actuellement sédation E- Temp. 30,8°C
Gaz: 7,01 /56 /-18 /14 /287 /115
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Plan: • 1. Quoi?• 2. Pourquoi?• 3. Qui?• 4. Quand?• 5. Comment?• 6. Comp. abdom.
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1. Quoi?
l 1908: Pringlel 1913: Halsted
l 1983: Stone et al. / Rotondo et al.l Paquetage abdominal et fermeture temporaire
rapide
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Principes de base:
l 1- Contrôler hémorragiel 2- Prévenir contaminationl 3- Limiter sepsisl 4- Protéger vs autres lésions
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• « …keeping afloat a badly damaged ship by procedures to limit flooding, stabilize the vessel, isolate fires and explosions and avoid their spreading… »
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2. Pourquoi?
• “a fully repaired but dead patient.”
• Éviter ou corriger la triade léthale
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Triade léthale:
Hypothermie
Acidose
Coagulopathie
HYPOVOLÉMIE
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2.1.Hypothermiel Cardio: ¯D.C.,RVS, Arythmiesl Rénal: ¯TFG, diurèse au froidl Acidose métaboliquel Shift à gauche courbe HbO2l Coagulopathie: dysfct plaquettaire
dysfct voies de coagfibrinolyse
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Hypothermie
• < 35oC
• Mortalité avec ¯ To
– < 34oC Þ mortalité 40%– < 33oC Þ mortalité 69%– < 32oC Þ mortalité 100%
• Jurkovich et al, J Trauma 1987;27:1019-24
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2.2. Acidose
l Acidose métabolique 2aire métabolisme anaérobique
l Acidose hyperchlorémiquel Cardio: ¯contractilité, ¯réponse inotropesl Neuro: PICl Coagulopathie: PTT, ¯activité facteur V
CIVD, Coag. trauma
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Acidose: lactates
• Normalisation des lactates:– < 24h Þ 100% de survie– 24 - 48h Þ 78%– > 48 h Þ 14%
» Abramson et al, J Trauma 1993;35:4
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2.3. Coagulopathiel Facteurs contribuants:l Dilution, perte continuel Hypothermiel Acidosel Thrombocytopénie, dysfct plql Hypocalcémiel ¯synthèse facteurs 2aire insulte hépatiquel Fibrinolyse
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Acute Traumatic Coagulopathy
l Brohi et al, J of Trauma 54:1127-30, 2003l HEMS Londresl 1088 patients, temps moyen 72min.l À arrivée à urgence:
l 28% PT aN l 8% PTT aN
l Coagulation normale: 10,9% mortalitél Coagulopathes: 46% mortalité
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Coagulopathie: PT,PTT
• PT initial = risque décès 35%
• PTT initial = risque décès 325%
MacLeod et al. J Trauma 2003;55:39-44
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Acute Traumatic Coaguloathy
COAGULOPATHIE
Inflammation Fibrinolyse
TRAUMA
HypoT Acidose
CHOC
ATCHÉMORRAGIE
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« Thrombin switch »
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Acute Traumatic Coagulopathy1) « Increased mortality associated with the early coagulopathy
of trauma in combat casualties » Niles SE et al.J Trauma. 2008 Jun;64(6):1459-63; discussion 1463-5
2) « Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? » Brohi K et al.Ann Surg. 2007 May;245(5):812-8
3) « Hemostatic resuscitation during surgery improves survival in patients with traumatic-induced coagulopathy. » Duchesne JC et al.J Trauma. 2009 Jul;67(1):33-7; discussion 37-9.
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3. Qui?• Pts avec exsanguination:
– Instabilité hémodynamique– Pertes de sang initiales > 40%– Saignement actif important– Lésions propices à exsanguination
• Lésions sévères techniquement difficiles• Chirurgies extensives
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Qui?l Multiples traumatisés (mass casualties)l Lésions abdominales majeures et
l Lésions multisystémiquesl Fracture bassin ouvertel Amputation traumatique
l Lésions vasculaires majeures (thorax ou abdo.)l Nécessité de thoracotomiel HypoTA (<90mmHg) prolongée (>60min)l Angioembolisation nécesairel Lésions hépatiques complexes
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4. Quand?
• Paramètres physiologiques prédictifs:– To < 34oC– pH < 7.2– HCO3- < 15mEq/L– > 4000mL sang ou – > 5000mL produits sanguins– > 12 000mL intraop– Évidence clinique de coagulopathie
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Quand?
l Avant épuisement physiologique
l Facteurs pronostiques à l’arrivée aux SI:l pH < 7.2l PTT > 78 secl (To < 32oC)
= 100% mortalitéAoki et al, American Jounal of Surgery, 2000; 180
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l Donc:l Emphase TÔT sur damage control
l Basé srt sur blessures et physiologie
l Indicateurs pê tardifs dans le processus
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5. Comment?Étape 1: Salle d’op
Contrôle hémorragie, contaminationPrévenir hypothermie
Fermeture abdominale temporaire
Étape 2: Soins intensifsCorrection acidose, hypothermie, coagulopathie
Oxygénation, ventilation, perfusionPression intra-abdominale
Étape 3:Chirurgie définitive
Fermeture abdominaleLorsque physiologie N sauf exceptions
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Comment?l 3 Exceptions:l Saignements persistantsl Contamination manquéel Syndrome du compartiment abdominal
l « Timing » du retour en salle d’op:l < 72 heures
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Syndrome du compartiment abdominal
• 1984: Kron et al.• 2004: World Society of the Abdominal
Compartment Syndrome (WSACS)
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Synd. Comp. Abdo. (suite)
l PIA = < 5mmHgl PIA = 5 - 10mmHg aux SI
l HIA ≥ 12mmHgl Grade 1 PIA 12-15 mmHgl Grade 2 PIA 16-20 mmHgl Grade 3 PIA 21-25 mmHgl Grade 4 PIA ≥ 25 mmHg
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Synd. Comp. Abdo. (suite)
l SCA: PIA > 20mmHgET
Dysfct d’organe(s)
l Classification:l Primaire: lié à conditions abdominopelv.l Secondaire: ailleurs que abdominopelv.l Récurrent: suite à Tx pour primaire ou 2aire
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Primaire ou secondaire???
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Synd. Comp. Abdo. (suite)
l Facteurs de risque:l Acidose, Hypothermiel Hemorragie intra abdo / rétropéritonéalel Coagulopathies / Polytransfusionsl Chirurgie abdominalel Péritonite (pancréatite), Iléusl Dysfct Pulm. / Rénale / Hépatique pré-exist.l Résuscitation liquidienne massive (>5L / 24h)
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Synd. Comp. Abdo. (suite)
l Maintenir APP > 60mmHgl Atteinte des organes-cibles:l Rénalel Cardiovasculairel Pulmonairel Viscéralel Cérébralel Humorale
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Synd. Comp. Abdo. (suite)l Examen physique insensiblel Options de Tx:l Sédation/Analgésie/BNMl Positionnementl Décompression gastrique/colonl Diurétiques/Hémofiltrationl Décompression percutanéel Décompression chirurgicale
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Damage Control STRATEGY
Implique Communication / Coordination:• Pré-hospitalier • Urgence• Salle d’opération• Soins Intensifs• Banque de sang, pharmacie, Radiologie
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Protocole de transfusion massive (HSCM)
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