No Disclosures DAMAGE CONTROL - UCSF CME · Damage Control In Surgical Care Stone in 1983-...
Transcript of No Disclosures DAMAGE CONTROL - UCSF CME · Damage Control In Surgical Care Stone in 1983-...
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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