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

5/29/2014 No Disclosures DAMAGE CONTROL Rochelle A. Dicker, MD Associate Professor of Surgery and Anesthesia University of California, San Francisco Definition Outline Term used in the Merchant Marines and in  Human Injury/Damage Navies for the emergency control of  Compartment syndrome situations that may hazard the sinking of a  Guidelines for Damage Control ship  Algorithm for Damage Control  Highlighting ICU Care  The Open Abdomen and Complications  Enteroatmospheric fistulae 1

5/29/2014 Consequences of Major Anatomic Defects Injury or Disease  Anatomic Derangement of the Airway  Holes in blood vessels  Holes in solid organs causing hemorrhage  anatomic defect  Holes in hollow viscera causing leakage of  physiologic defect intestinal contents and urine  iatrogenic defect  Contusions of the lung and heart causing organ dysfunction  Disruption of the skeleton … a lethal cascade of events ...  Intercranial Injury Physiologic Consequences of Consequences of Prolonged Prolonged Shock Shock  Hypoperfusion  Loss of integrity of cellular membranes  Vasoconstriction  Leakage of fluid into interstitium  Metabolic Acidosis  Leakage of sodium into cells  Massive Release of catecholamines,  Result: Requirement for Massive glucocorticoids, ADH, Aldosterone, Fluid Infusion to restore intravascular Cytokines volume and tissue perfusion 2

5/29/2014 Iatrogenic Consequences of Resuscitation The Lethal Triad  Massive Edema  metabolic acidosis  Increased intra-abdominal, intra-thoracic,  hypothermia intracranial and subfascial pressures: i.e.  coagulopathy Compartment Syndrome Definition of the World Congress on Risk Factors for Compartment Abdominal Compartment Syndrome Syndrome  Post-traumatic hemorrhage Persistent bladder pressure of >20mm  Intraperitoneal bleeding mercury with new onset organ dysfunction  Retroperitoneal bleeding  Any vigorous fluid resuscitation  Post-resuscitative visceral edema  Lethal triad 3

5/29/2014 Physiologic Consequences of the Splanchnic hypoperfusion Abdominal Compartment Syndrome  Pulmonary Hepatic ischemia Gut edema  Cardiovascular  Decreased  Decreased VR Intra-abdominal Compliance hypertension  Increased SVR Coagulopathy Free radicals  Increased PIP Hypothermia organ damage  Hypotension Acidosis  Increased PA pressure  Splanchnic Circulation  Increased Vd/Vt  Decreased splanchnic flow  Increased Qs/Qt  Decreased pHi Abdominal Abdominal bleeding compartment  Decreased hepatic artery  Cerebral Circulation syndrome and portal vein flow  Increased ICP  Decreased Renal blood flow,  Decreased CPP GFR and Urine Output A cycle of ischemia producing intra-abdominal hypertension and the abdominal compartment syndrome ( from Michael Rotondo, MD) . Damage Control Guidelines for Initiating Damage In Surgical Care Control Maneuvers  Stone in 1983- Abbreviated celiotomy and  Acidosis packing  pH < 7.2  Base Deficit ≥ -8  Lactate ≥ 4  Damage Control in the Trauma setting  Hypothermia coined by Rotondo and Schwab in 1993  < 35 ° celcius 4

5/29/2014 More Guidelines for Damage More Damage Control Guidelines Control  Ongoing Resuscitation  Coagulopathy  Persistent shock with systolic BP <90  PTT > 60  > 10 litres crystalloid  INR >1.6  >10 units packed red blood cells  Host Factors Defining Reserve  Operative Time  Age  > 60-90 minutes with abdominal cavity open  Underlying disease  Physiologic reserve: TIME  Malperfusion and ISS Indications for the Open Goals of Damage Control Abdomen Laparotomy  Control of Hemorrhage  Damage Control for Trauma  Abdominal Compartment Syndrome  Rapid Control of Intestinal Spillage  Massive Resuscitation  Rapid Temporary Abdominal Closure  Burn  Rapid Transfer to the ICU for continued  Pancreatitis resuscitation and restoration of physiologic  Severe Abdominal Infection homeostasis  Acute Mesenteric Ischemia  Delay of intestinal reconstruction until  Necrotizing Infection of the Abdominal Wall repeat laparotomy 24-48 hours later 5

5/29/2014 Algorithm for Damage Control Algorithm for Damage Control Step One Step Two  Initial ED assessment  Initial trauma laparotomy  Resuscitation  Hemorrhage control  Recognition and operative decisions  Contamination control  Intra-abdominal packing  Temporary dressing 6

5/29/2014 Algorithm for Damage Control Step Three  ICU 2 ° resuscitation  Warming  Correct coagulopathy  Individualized ventilatory support  Secondary survey and planning 7

5/29/2014 ICU Resuscitation ICU Resuscitation  Rewarming/Correct hypothermia  Correct coagulopathy, acidosis, electrolyte imbalance  CENTRAL LINE  Measure CBC, coags, fibrinogen  Infusion of warm fluids  Bair hugger  Correct K+, Mg+, Ca+ deficiencies  Measure and use base deficit as guideline  Prevent insensible losses  PRN humidifier on vent set at 40 °  Consider effect of Normal Saline on base deficit ICU Resuscitation ICU Resuscitation  Utilize central venous pressures to assist  If PA Catheter is necessary in guiding resuscitation  CI > 3L/min  KNOW the pitfalls of interpretation  End diastolic volume index 120-140ml  SaO2 >95%  SVO2 >65%  Consider ECHO 8

5/29/2014 ICU Care ICU Care-Best Practices  Head of Bed at 30 °  Medications  Peptic ulcer prophylaxis  Frequent suctioning and oral hygiene  H2 blockers or proton pump inhibitors  Functioning nasogastric tube  DVT prophylaxis  Functioning wound vac  Low molecular weight heparin is superior  Hourly urine output  Insulin drip  Maintain blood glucose 80-110 mg/dl  Bladder pressure checks (if applicable)  Drips for analgesia and sedation  Pad pressure points  Antibiotic therapy with open abdomen Revolution in the Management Algorithm for Damage Control of the Open Abdomen Step Four  Preservation of the Peritoneal Space  Reoperation: Typically 12-36 hours  Progressive abdominal closure (prevention of lateral fascial retraction)  Pack removal  Vacuum-assisted wound management  Definitive repairs  Use of biologic dressings  Decisions on closure Scott BG, Feanny MA, Hirshberg A. Early definitive closure of the open abdomen: A quiet Revolution. Scand J Surg2005;94:9-14. 9

5/29/2014 Options for Biologic Dressing of Complications of the Exposed Viscera Open Abdomen  Skin Flaps  Abdominal  Wound infection  Homologous split thickness skin  Dehiscence  Autologous split thickness skin  Fasciitis/necrosis  Acellular dermal matrix  Intra-abdominal abscess  Musculofascial advancement flaps  Enteroatmospheric fistula  Rotation skin and muscle flaps  Risks increase with multiple operations and  Free flaps multiple Surgeons Principles of Management Problem of “ Entero- Specific for “ Entero- atmospheric ” Fistula atmospheric ” Fistula  Absence of overlying soft tissue with good blood supply precludes spontaneous  PREVENTION  Control fistula healing  Protect exposed effluent abdominal viscera  Exposed abdominal viscera predisposes  Rotate flaps with during open abdomen management good blood supply to development of additional holes in the  Limit access to the to cover fistula in wound to one or two GI tract selected cases SENIOR people  Complex Wound difficult to manage  Attempt to seal leak  Resect well when first recognized established “ entero-  Protect adjacent viscera atmospheric ” fistula with biologic dressings only when patient fit to avoid additional holes and infection free 10

5/29/2014 Principle 4 Principle 4 Control Fistula Effluent Control Fistula Effluent  DO NOT INTUBATE A FISTULA in the  Fixed Visceral Block middle of a fixed visceral block open  Vacuum Assisted Wound Management abdomen System  You won ’ t control the drainage  Wound Drainage Bags  You will make the hole bigger  Requires expert enthusiastic nursing assistance  Risk of additional holes  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. Clinical Signs: Complications of the Veering off Trajectory Open Abdomen  Systemic Inflammatory Response  Extra-Abdominal  Tachycardia  Ventilator-associated pneumonia  Tachypnea  Aspiration pneumonitis  Elevated WBC  ARDS  Fever  Increased pain and aggitation  Bloodstream infections  Deep venous thrombosis/Pulmonary embolus  Mental status changes  Pressure ulcers  Decreased urine output  Multiple organ dysfunction syndrome  Worsening base deficit Each observation is relative to the last 11