Indications for the Appropriate Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients

In patients undergoing emergent operation for trauma, surgeons must decide whether to perform a definitive or damage control (DC) procedure. DC surgery (abbreviated initial surgery followed by planned reoperation after a period of resuscitation in the intensive care unit) has been suggested to most benefit patients more likely to succumb from the “vicious cycle” of hypothermia, acidosis, and coagulopathy and/or postoperative abdominal compartment syndrome (ACS) than the failure to complete organ repairs. However, there currently exists no unbiased evidence to support that DC surgery benefits injured patients. Further, the procedure is associated with substantial morbidity, long lengths of intensive care unit and hospital stay, increased healthcare resource utilization, and possibly a reduced quality of life among survivors. Therefore, it is important to ensure that DC laparotomy is only utilized in situations where the expected procedural benefits are expected to outweigh the expected procedural harms. In this manuscript, we review the comparative effectiveness and safety of DC surgery when used for different procedural indications. We also review recent studies suggesting variation in use of DC surgery between trauma centers and the potential harms associated with overuse of the procedure. We also review published consensus indications for the appropriate use of DC surgery and specific abdominal, pelvic, and vascular DC interventions in civilian trauma patients. We conclude by providing recommendations as to how the above list of published appropriateness indications may be used to guide medical and surgical education, quality improvement, and surgical practice.

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Damage control in the intensive care unit: what should the intensive care physician know and do?

Colombia Medica ◽

10.25100/cm.v52i2.4810 ◽

2021 ◽

Vol 52 (2) ◽

pp. e4174810

Author(s):

Monica Vargas ◽

Alberto Garcia ◽

Yaset Caicedo ◽

Michael Parra ◽

Carlos Alberto Ordoñez

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Damage Control ◽

Damage Control Surgery ◽

Severe Trauma ◽

Massive Hemorrhage ◽

Care Physician ◽

Trauma Patients ◽

Physiological Alterations ◽

Definitive Repair

When trauma patients are admitted into the intensive care unit after undergoing damage control surgery, they generally present some degree of bleeding, hypoperfusion, and injuries that require definitive repair. Trauma patients admitted into the intensive care unit after undergoing damage control surgery can present injuries that require a definite repair, which can cause bleeding and hypoperfusion. The intensive care team must evaluate the severity and systemic repercussions in the patient. This will allow them to establish the need for resuscitation, anticipate potential complications, and adjust the treatment to minimize trauma-associated morbidity and mortality. This article aims to describe the alterations present in patients with severe trauma who undergo damage control surgery and considerations in their therapeutic approach. The intensivist must detect the different physiological alterations presented in trauma patients undergoing damage control surgery, mainly caused by massive hemorrhage. Monitor and support strategies are defined by the evaluation of bleeding and shock severity and resuscitation phase in ICU admission. The correction of hypothermia, acidosis, and coagulopathy is fundamental in the management of severe trauma patients.

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Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review

World Journal of Emergency Surgery ◽

10.1186/s13017-021-00352-5 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Derek J. Roberts ◽

◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Systematic Review ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Clinical Scenario ◽

Cross Sectional ◽

Iliac Vessel ◽

Civilian Trauma ◽

Definitive Surgery

Abstract Background Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). Methods We searched 11 databases (1950–April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. Conclusions Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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Critical Care Considerations for Damage Control in a Trauma Patient

AACN Advanced Critical Care ◽

10.4037/aacnacc2021817 ◽

2021 ◽

Vol 32 (1) ◽

pp. 64-75

Author(s):

Shannon Gaasch

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Cause Of Death ◽

Damage Control ◽

Operative Procedure ◽

Fixed Ratio ◽

Damage Control Surgery ◽

Fluid Restriction ◽

Damage Control Resuscitation ◽

Lethal Triad

Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.

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Adding the Capacity for an Intensive Care Unit Dedicated to COVID 19, Preserving the Operational Capability of a French Golden Hour Offset Surgical Team in Sahel

Military Medicine ◽

10.1093/milmed/usaa273 ◽

2020 ◽

Author(s):

Henri de Lesquen ◽

Marie Bergez ◽

Antoine Vuong ◽

Alexandre Boufime-Jonqheere ◽

Nicolas de l’Escalopier

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Large Scale ◽

Damage Control ◽

Surgical Care ◽

Damage Control Surgery ◽

Surgical Team ◽

Golden Hour ◽

Surgical Teams

Abstract Introduction In April 2020, the military medical planning needs to be recalibrated to support the COVID-19 crisis during a large-scale combat operation carried out by the French army in Sahel. Material and Methods Since 2019, proper positioning of Forward Surgical Teams (FSTs) has been imperative in peer-to-near-peer conflict and led to the development of a far-forward surgical asset: The Golden Hour Offset Surgical Team (GHOST). Dedicated to damage control surgery close to combat, GHOST made the FST aero-mobile again, with a light logistical footprint and a fast setting. On 19 and 25 March 2020, Niger and Mali confirmed their first COVID-19 cases, respectively. The pandemic was ongoing in Sahel, where 5,100 French soldiers were deployed in the Barkhane Operation. Results For the first time, the FST had to provide, continuously, both COVID critical care and surgical support to the ongoing operation in Liptako. Its deployment on a Main Operating Base had to be rethought on Niamey, to face the COVID crisis and support ongoing operations. This far-forward surgical asset, embedded with a doctrinal Role-1, sat up a 4-bed COVID intensive care unit while maintaining a casualty surgical care capacity. A COVID training package has been developed to prepare the FST for this innovative employment. This far-forward surgical asset was designed to support a COVID-19 intensive care unit before evacuation, preserving forward surgical capability for battalion combat teams. Conclusion Far-forward surgical assets like GHOST have demonstrated their mobility and effectiveness in a casualty care system and could be adapted as critical care facilities to respond to the COVID crisis in wartime.

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Evidence for Use of Damage Control Surgery and Damage Control Interventions in Civilian Trauma Patients: A Systematic Review

10.21203/rs.3.rs-126134/v1 ◽

2020 ◽

Author(s):

Derek J. Roberts ◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Andrew W. Kirkpatrick ◽

Chad G. Ball ◽

...

Keyword(s):

Systematic Review ◽

Damage Control ◽

Penetrating Trauma ◽

Damage Control Surgery ◽

Trauma Patients ◽

Clinical Scenario ◽

Cross Sectional ◽

Iliac Vessel ◽

Civilian Trauma ◽

Definitive Surgery

Abstract Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring >10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.

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A protocol for a scoping and qualitative study to identify and evaluate indications for damage control surgery and damage control interventions in civilian trauma patients

BMJ Open ◽

10.1136/bmjopen-2014-005634 ◽

2014 ◽

Vol 4 (7) ◽

pp. e005634-e005634 ◽

Cited By ~ 11

Author(s):

D. J. Roberts ◽

D. A. Zygun ◽

A. W. Kirkpatrick ◽

C. G. Ball ◽

P. D. Faris ◽

...

Keyword(s):

Qualitative Study ◽

Damage Control ◽

Damage Control Surgery ◽

Trauma Patients ◽

Civilian Trauma

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Experience of the MALA Bag in the Open Abdomen Management in an Obstetrical Intensive Care Unit

Acta Médica Portuguesa ◽

10.20344/amp.2019 ◽

2013 ◽

Vol 26 (6) ◽

pp. 699

Author(s):

María de Jesús Angeles Vásquez ◽

Luis Emilio Reyes Mendoza ◽

Ricardo Mauricio Malagón Reyes ◽

Hugo Mendieta Zerón

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Open Abdomen ◽

Damage Control ◽

Damage Control Surgery ◽

Abdominal Sepsis ◽

History Of ◽

The Mean ◽

Surgical Option ◽

Previous Cesarean

Introduction: Current indications for open abdomen management are damage control surgery, severe intra-abdominal sepsis, abdominal compartment syndrome, abdominal wall closure under tension and mass loss of the abdominal wall.Objective: To describe the experience in open abdomen management using the MALA (mayor absorción de líquido abdominal [greater absorption of abdominal liquid]) bag at the Maternal-Perinatal Hospital Mónica Pretelini Saénz, Health Institute of the State of Mexico.Material and Methods: This was a bidirectional, descriptive and observational study. All patients with the diagnosis of open abdomen managed with the MALA bag admitted to the Obstetric Intensive Care Unit from February 2009 to June 2012 were included.Results: From 25 cases identified in the period of the study, seven were eliminated for incomplete files, remaining 18 cases for the analysis. The mean age was 31.5 years. 78% of the patients were multigravidas, 50% of them with a history of 2 or more deliveries, 83% had a previous cesarean section and 78% were hysterectomized. Evisceration was present in one patient. The main indication for surgical management was damage control. One patient died and a second was transferred to another institution, the rest were discharged by clinical improvement. 12 patients (67%) spent less than 14 days in the Obstetric Intensive Care Unit, only one patient required morethan 30 days in the unit. Discussion: Halve the women who required this surgical alternative, were above 30 years of age. Stressing is the fact that from the 18 admitted patients, 14 (78%) had undergone obstetric hysterectomy, with the etiology of uterine atony in most cases. Damage control surgery seems to be the most elective surgical option to use MALA bag followed by ACS and abdominal sepsis.Conclusion: The MALA bag can offer an economic and effective surgical option for the open abdomen management as well as adrainage technique.

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Indications for Use of Damage Control Surgery in Civilian Trauma Patients

Annals of Surgery ◽

10.1097/sla.0000000000001347 ◽

2016 ◽

Vol 263 (5) ◽

pp. 1018-1027 ◽

Cited By ~ 44

Author(s):

Derek J. Roberts ◽

Niklas Bobrovitz ◽

David A. Zygun ◽

Chad G. Ball ◽

Andrew W. Kirkpatrick ◽

...

Keyword(s):

Damage Control ◽

Damage Control Surgery ◽

Trauma Patients ◽

Civilian Trauma ◽

Indications For Use

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Open Abdomen in Trauma and Critical Care

Critical Care Nurse ◽

10.4037/ccn2017294 ◽

2017 ◽

Vol 37 (5) ◽

pp. 22-45 ◽

Cited By ~ 6

Author(s):

Eleanor R. Fitzpatrick

Keyword(s):

Critical Care ◽

Open Abdomen ◽

Damage Control ◽

Management Strategies ◽

Damage Control Surgery ◽

Standard Of Care ◽

Trauma Patients ◽

Temporary Abdominal Closure ◽

Abdominal Closure ◽

Planned Reoperation

The open abdomen technique and temporary abdominal closure after damage control surgery is fast becoming the standard of care for managing intra-abdominal bleeding and infectious or ischemic processes in critically ill patients. Expansion of this technique has evolved from damage control surgery in severely injured trauma patients to use in patients with abdominal compartment syndrome due to acute pancreatitis and other disorders. Subsequent therapies after use of the open abdomen technique and temporary abdominal closure are resuscitation in the intensive care unit and planned reoperation to manage the underlying cause of bleeding, infection, or ischemia. Determining the need for this potentially lifesaving intervention and managing the wound after the open abdomen has been created are all within the realm of critical care nurses. Case studies illustrate the implementation of the open abdomen technique and patient management strategies.

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