Recent Updates:

Damage Control
Resuscitaion and
Damage Control
Surgery
Division
Kiki Lukman
of Digestive Surgery
Department of Surgery,
Medical Faculty of UNPAD/ Dr Hasan Sadikin
Bandung
 Objectives :

Discuss the current concept of

Damage Control Resuscitation
(DCR)
Discuss the recent updates on
Damage Control Surgery (DCS)
Discuss the strategy in
implementing DCR and DCS
 Backgrounds

Most preventable in-hospital deaths from trauma are

due to uncontrolled hemorrhage and resultant
coagulopathy

Evans JA, van Wessem KJ, McDougall D et al: World J Surg 2010; 34(1) :158-163

To increase the chances of survival:

surgically control hemorrhage,

successfully resuscitate the bleeding patient,
adequately correct traumatic coagulopathy
 Problems in Hemorrhagic Shock

Coagulopathy

Acidosis

Severe trauma Bleeding Tissue

hypoxia

Hypothermia

Colloid and Dilution of

Crystalloid infusion Coagulation factors
And platelets

Massive RBC
transfusion

Moore EE : Am J Surg 172: 405-410 1996

 Traumatic Coagulopathy

Mc Leod, JBA, Arch Surg 143, Aug.2008

The Trauma Team: How to implement?
 Combination DCS + DCR

improve 30-day patient survival

Five pillars of DCR:

(1) body rewarming,

(2) correction of acidosis,
(3) permissive hypotension,
(4) restrictive fluid administration, and
(5) hemostatic resuscitation.
DAMAGE CONTROL
RESUSCITATION
 Current Definition of
Damage Control Resuscitation:

a systematic approach to the management

of the trauma patient with severe injuries that
starts in the emergency room and continues
through the operating room and the
intensive care unit (ICU).

It is designed, along with damage control

surgery, to promptly and aggressively
reverse the lethal trauma triad of
coagulopathy, acidosis, and hypothermia.
 Damage Control
Resuscitation and Surgery
Algorithm

H.M. A. Kaafarani, G. C. Velmahos

Scandinavian Journal of Surgery 0: 18,
2014
 Pre hospital Care

Scoop and Run

Injury
Minimize Fluid Resuscitation

Prevent Hypothermia

GOAL:
Pre Hospital
Get the patient to the trauma Care
center Less than 20
minutes
 Resuscitation

Allow permissive hypotension

Administer blood and blood

products early

Minimize fluid resuscitation

Start Tranexamic Acid

Start massive transfusion protocol

Emergency
GOAL:
Room
Mobilize promptly to OR/IR Less than 30
Suite minutes
 Operating Theater

Allow permissive hypotension

Aim for 1:1:1 PRBC/FFP/Platelets

ratio

Administer cryoprecipitate

Abdominal packing

Temporary abdominal closure

Abbreviated
GOAL: surgical
Procedure
Control surgical bleeding
Control contamination Less than 90
minutes
 Intensive Care (1)

Reverse hypothermia

Reverse coagulopathy

Reverse acidosis

Support hemodynamics

GOAL:
Intensive Care
Resuscitate Unit
Reverse Triads of death 12 36 hours
 Operating Theater

Remove packing

Definitive Surgical Repair

Serial primary abdominal

closure

Definitive surgical
GOAL: procedure
(2 8 days)
Definitive Surgical Repair
 Intensive Care (2)

Diuresis

GOAL:

Decrease fluid overload to

allow:
1.Definitive abdominal
closure
Intensive Care
2.Postoperative liberation
Unit Stay
from ventilator
(2 8 days)
 Reversing Hypothermia

Body Rewarming:

(1) passive external rewarming (e.g.

removal of wet clothing, warm
blankets, raising the ambient
temperature of room),
(2) active external rewarming (e.g.
forced air-warming devices),
(3) active internal core rewarming
 Reversing Acidosis

It is better achieved through:

aggressive blood and blood product resuscitation
vasopressor support until surgical control of
hemorrhage is achieved, shock is reversed, and
end-organ perfusion is restored.

End-points of resuscitation:
Vital signs alone are poor indicators of end-organ
perfusion.
Base deficit and lactate levels are reliable perfusion
indices (markers of the adequacy of resuscitation);
 Permissive Hypotension

Definition:

A strategic decision to delay the initiation

of fluid resuscitation and limit the volume of
resuscitation fluids/blood products
administered to the bleeding trauma patient
by targeting a lower than normal blood
pressure, usually a SBP of 8090 mmHg or
MAP of 50 mmHg.
 The Advantages

Rationales:

(1)decreasing the incidence and severity of

dilutional coagulopathy

(2)avoiding the hypothetical pop the clot

effect,

(3)to
the amelioration of the inflammatory
cascade, which is exacerbated in response to
exogenous fluids administration.
 Restrictive Fluid Administration

intravenous fluids should be minimized.

Aggressive fluid resuscitation results:

in worse coagulopathy,
an exaggerated trauma-related systemic
inflammatory response syndrome (SIRS),
an increased incidence of adult respiratory
distress syndrome (ARDS), pulmonary edema,
compartment syndrome, anemia,
thrombocytopenia, pneumonia, electrolyte
disturbances, and overall worse survival
 Hemostatic Resuscitation

One of the main pillars of DCR is early

and aggressive transfusion of blood
products aiming for a ratio of PRBCs,
FFP, and platelets that approximates
1:1:1

Massive transfusion is typically defined

as a transfusion of 10 or more units of
PRBCs within the first 24 h of injury
 Role of Hemostatic Adjuncts

These agents may:

decrease mortality,
transfusion requirements,
rates of transfusion-related organ
failure among certain trauma
patients.

BUT, increase thromboembolic events

 Hemostatic Adjuncts

Tranexamic acid:
Prevent fibrinolysis
Useful within 3 hours of injury
Recombinant human factor VIIa:
Does not decrease mortality
thrombo-embolic complications
Prothrombin complex, which contains
factors II, VII, IX, X, C,and S:
mortality, transfusion
requirements, complications, &
lengths of stay
 Hemostatic Adjuncts

Anti-fibrinolytic agents
Early administration of tranexamic acid
(TXA), an anti-fibrinolytic agent, (slightly
decrease the risk of death from bleeding)

Factor-concentrates
recombinant factor VIIa or prothrombin
complex concentrates (PCCs) (lack of
evidence)
Resuscitation Goals and Monitoring

Coagulation test is inappropiate opiate

PRBCs should be given to target a hemoglobin
>7 g/dL,
FFPs to target an international normalized
ratio (INR) <2,
Platelets to target a count >50,000,
Cryoprecipitate to target a fibrinogen level
>100 mg/dL.
The use of thrombo-elastography-based
protocols (promising results)
DAMAGE CONTROL SURGERY
FOR ABDOMINAL TRAUMA

Laura Godat, Leslie Kobayashi, Todd

Costantini and Raul Coimbra
World Journal of Emergency Surgery
2013, 8:53
 The Indications: Pre operative

The decision should be made early (pre

operative):
Systolic blood pressure (SBP) <90 mmHg with
penetrating torso,
Blunt abdominal, or severe pelvic trauma,
The need for resuscitative thoracotomy
Other Emergency Department (ED) variables :
include SBP <60 mmHg,
hypothermia,
inappropriate bradycardia,
pH of <7.2
 The Indications: Intra-operative

non-surgical bleeding,
pH 7.18,
temperature 33C,
transfusion of 10 units of blood,
total fluid replacement >12 L,
estimated blood losses of 5 L
Platelet count, PT, aPTT, fibrinogen
levels and thrombo-elastography
findings
 The Indications: Intra-operative

Patients at high risk for ACS should be left

open prophylactically at the time of
laparotomy:

Patients requiring large volume

resuscitation (>15 L or 10 Units of
PRBCs),
Those with evidence of visceral edema,
peak inspiratory pressures >40,
intra-abdominal pressure (IAP) >21 during
attempted closure [12-16].
 The perioperative Critical Care

sedation,
paralysis,
nutrition,started early
fluid management strategies may
improve closure rates and recovery.
Prophylactic antibiotics no more than
24 hours.
Reconstructive strategies that may be
used in the acute and chronic phases
of abdominal closure (6 -12 months).
Temporary Abdominal Closure Devices

Negativepressure dressing such as the

vacuum pack method or its
commercially available alternative.

After 5-7 days if the abdomen cannot

be closed convert to the use of a
bridging device which progressively
brings the fascia together such as the
Wittman patch or modified V.A.C..
VACUUM OPEN ABDOMEN
MANAGEMENT
 VACUUM OPEN
ABDOMEN
MANAGEMENT

Fabian TC Surg. Clin N Am, 87 (2007) 73-93

1. Non-occlusive dressing;layer
2. Dressing and drainage catheter;layer
3. Retention suture; layer
4. Dressing; layer
5. Bowel bag ; and layer
6. omentum
Comparison the results of various
techniques
 SUMMARY

The successful resuscitation of the massively

bleeding and unstable trauma patient will depend
on:

effective trauma team leadership,

identification of early trauma-related
coagulopathy,
sound decision-making in the emergency and
operating rooms
Prompt implementation of a DCR and a damage
control operative approach.
 SUMMARY

Damage Control Resuscitation

includes:

permissive hypotension,
body rewarming,
minimization of fluid resuscitation,
early balanced administration of
blood and blood products.