Elsevier

Critical Care Clinics

Volume 20, Issue 1, January 2004, Pages 101-118
Critical Care Clinics

Damage control surgery

https://doi.org/10.1016/S0749-0704(03)00095-2Get rights and content

Section snippets

Historical perspective

Traditional surgical dogma dictates that an operation should be completed definitively regardless of the physiologic condition of the patient. This means that complex reconstructions may be performed in severely compromised patients, resulting ultimately in death. Strategies designed to avoid this inevitable outcome are not new to surgery. Battlefield victims with exsanguinating extremity injuries have undergone rapid amputation for thousands of years. Pringle described compression of liver

The lethal triad

The philosophy of damage control is to abbreviate surgical interventions before the development of irreversible physiologic endpoints. Uncontrolled hemorrhage and iatrogenic interventions ultimately result in the development of hypothermia, coagulopathy, and acidosis. Each of these life-threatening abnormalities exacerbates the others, contributing to a spiraling cycle that rapidly results in death unless hemorrhage is stopped, and the abnormalities reversed. This bloody vicious cycle is

Initial management

The initial management of trauma patients is based on principles described in the Advanced Trauma Life Support course. A systematic evaluation of the patient is performed focusing on treating life-threatening injuries. Patients with life-threatening injuries who require operative intervention are transported to the operating room rapidly. Efforts designed to avoid the lethal triad are implemented throughout this process. The operating room temperature is elevated, and resuscitation fluids are

Complications

Complications following damage control procedures may be related to the site of original injury or to the systemic complications of injury, hemorrhage, massive resuscitation, and infection. Examples of local complications include abscess, fistula formation, intestinal necrosis, and pancreatic pseudocyst. Systemic complications include ARDS and MOF. Massive resuscitation associated with ischemia and reperfusion also results in acute visceral swelling and decreased abdominal compliance,

Summary

Damage control is a staged approach to severely injured patients predicated on treatment priorities. Initially, life-threatening injuries are addressed expediently, and procedures are truncated. Normal physiology is restored in the ICU, and patients subsequently are returned to the operating room for definitive management. This strategy breaks the bloody vicious cycle and results in improved outcomes. Novel technologies like CAVR and rFVIIa contribute to the effectiveness of damage control.

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      Standardizing the role of DCL therefore has the potential to limit unnecessary use without adversely affecting mortality, thus minimizing complications and optimizing resource use. There is no doubt that DCL is valuable in severely injured, unstable, trauma patients.3,4,20,21 However, less evidence speaks to the precise indications for its use.

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      However, as early as 1992, Burch and colleagues19 in a retrospective study of 200 bleeding trauma patients reported more than half the patients died within the first 2 hours of resuscitation after abbreviated laparotomy (damage control surgery), suggesting simple correction of the source of bleeding did not halt exsanguination. Schreiber10 conducted a similar study of damage control surgery to mitigate the effects of the lethal triad and found mortality rates decreased. However, the study concluded two important points.

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