1. Damage Control Surgery Principles Dr. Josip Janković Dr. Boris Hrečkovski Department of surgery General hospital Slavonski Brod

2. „The modern operation is safe for the patient. The modern surgeon must make the patient safe for the modern operation“ Lord Moynihan

3. Standard surgical practice (early total care): the best operation for a patient is one, definitive procedure the first chance of any surgical intervention is the best chance for any definitive repair or reconstruction ER→OR→ICU

4. BUT!!! Multiple trauma patients (ISS ≥35) are more likely to die from their intra-operative metabolic failure that from a failure to complete operative repairs The death triad: - Hypothermia - Acidosis - Coagulopathy

5. One of the major advances in surgical technique in the past 20 years. The most technically demanding and challenging surgery a trauma surgeon can perform. approach method

6. ER→OR→ICU→OR→ICU

7. Hypothermia: Clinically important if less than 37*C for more than 4 h Can lead to cardiac arrhythmias, decreased cardiac output, increassed systemic vascular resistance Can induce and exacerbate coagulopathy by inhibition of clotting cascade reaction

8. Acidosis: Uncorrected haemorrhagic shock leads into inadequate cellular perfusion, anaerobic metabolism and the production of lactatic acid Interferes with blood clotting mechanisms and promotes coagulopathy and blood loss

9. Coagulopathy: Hypothermia, acidosis and the consequences of massive blood transfusion all lead to the development of a coagulopathy Platelet dysfunction at low temperature Activation of the fibrinolytic system Haemodilution following massive resuscitation

10. Parameters as a guideline for instituting damage control: pH less then or equal to 7.2 serum bicarbonate level less than or equal to 15 mEq/L core temperature less than or equal to 34*C transfusion volume of packed RBCs more than or equal to 4000 ml total blood replacement more than or equal to 5000 ml total fluid replacement more than or equal to 12 000 ml If all - death If one - DCS

11. The principles of damage control surgery are: Control haemorrhage Prevention contamination Avoid further injury

12. Prehospital and emergency department times should be minimized BTLS NO unnecessary and superfluous investigations Rapid transport to the operating room without repeated attempts to restrore cisculating volume- they require operative control of haemorrhage and simultaneous vigorous resuscitation

13. Stage 1 DCS (abdomen)

14. initial laparotomy identify the main source of bleeding perihepatic packing (superior and inferior) small gastotomies and enterotomies can be rapidly closed resect non-viable bowel and close the ends minor pancreatic injuries not involving duct- no treatment distal injury including the panceratic duct- distal pancreatectomy NO pancreaticoduodenectomy (drainage) abdominal closure is rapid and temporary- if there is any doubt about abdominal compartment syndrome, left it open (silo-bag, vacuum-pack technique)

16. Stage 1 DCS (skeletal)

17. Stable patient – osteosynthesis Polytrauma patient- FE Do not insist on anatomical reposition, but on fracture stabilisation Open fracture-debridman Timing is individual considering clinical state Secundary brain damage?

18. Stage 2 DCS Begins in ICU The next 24 to 48 hours are crucial Correction of metabolic disorder Core rewarming Correction of coagulopathy Complete ventilatory support Correction of acidosis Identification of occult injury

19. Stage 3 DCS – planned reoperation Window of opportunity is 24-48 hours after the trauma- between the correction of metabolic disorder and the onset of SIRS and MOF Removal of the abdominal packs (48-72 h) Primary repair with end-to-end anastomosis undertaken Copious washout should be performed and the abdomen closed The patient sometimes needs early unplanned reoperation-ongoing haemorrhage, abdominal compartment syndrome or peritontis Window of opportunity for definitive osteosynthesis is 5- 10 days after trauma

20. Complications of DCS Abdominal compartment syndrome General copmlications: wound sepsis wound dehiscence fistula formation ICU-related infections skin complications

21. DCS is a treathement method DCS is one of the major advances in surgical technique in the past 20 years DCS is recognized all over the world for treathing polytraumatized patients (ISS≥35) DCS is used in our hospital in the last 10 years Patients who had death rate according to ISS≥90%, survived How much surgery polytrauma patient can tolerate?