Damage control surgery

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Surgical damage control (DCS) is a life-saving series of steps in the critically ill polytrauma patient.

History [edit | edit source]

  • in the past there was a trend towards a„traditional approach “ - i.e. do everything at once (access, revision, resection, reconstruction) regardless of the patient's condition, but this procedure showedhigh lethality
  • 1983 Stone et al. - principles of DCS
  • 1992 Burch et al. - described the triad of death
  • 1993 Rotondo and Schwab - term DCS
  • 2001 Assensio et al. - intraoperative parameters and indications for starting the DCS protocol


DCS Targets [edit | edit source]

  1. restoration of physiological parameters before anatomical adjustment
  2. facilitate control of bleeding and contamination (1. stabilization of fatal problems, 2. resuscitation, 3. definitive treatment)


Triad of Death[edit | edit source]

1. Hypothermia - consequence of bleeding and resuscitation

Clinical manifestations: ↓ 36°C (if lasting >4h), arrhythmia, suppression of the immune system, systemic vascular resistance


2. Coagulopathy - massive volume resuscitation worsens it with dilution

Clinical manifestations: disorder and inhibition of coagulation factors, platelet dysfunction            

Laboratory results are not indicative of hypothermia, only clinical diagnosis (bleeding from wounds, serous surfaces, skin edges)


3. Metabolic acidosis - long-term hypoperfusion → anaerobic metabolism and lactic acidosis

Clinical manifestations: ↓ myocardial contractility, ↓ ejection volume

Indications for DCS[edit | edit source]

Preoperative parameters

  1. high energy injury
  2. blunt trauma to the trunk
  3. multiple torso injuries
  4. hemodynamic instability, coagulopathy and hypothermia on admission


Intraoperative parameters

  1. ↓ 34°C  
  2. pH <7,2
  3. HCO3-  <15 mEq/l
  4. administration of >5,000 ml transfusions
  5. intraoperative replacement > 12,000 ml
  6. clinical evidence of intraoperative coagulopathy


Surgical damage control in abdominal injuries[edit | edit source]

It consists of three successive phases:

1. Phase - abbreviated laparotomy

  • bleeding control and hemostasis (ligatures, clamps, shunts, balloon catheters...)
  • reconstruction is not carried
  • FR abdominal lavage, open abdominal fascia, subcutaneous vacuum drainage


2. Phase - resuscitation in the ICU (modification of the triad of death)

  • hypothermia - warm infusion solutions, thermal insulation blankets  
  • coagulopathy - ERY meat, Tr concentrate and fresh frozen plasma
  • MAC - adjusts itself by warming the patient


3. Phase - definitive surgical treatment

  • reoperation after 36-48h (vascular reconstruction, GIT continuity)
  • enteral nutrition



Links[edit | edit source]

Related Articles[edit | edit source]

References[edit | edit source]

  • HUŤAN, Martin, et al. Základy všeobecnej a špeciálnej chirurgie. prvé vydání. Bratislava : Univerzita Komenského v Bratislave, 2012. 198 s. ISBN 978-80-223-3214-9.