Elsevier

Injury

Volume 39, Issue 1, January 2008, Pages 93-101
Injury

The concept of damage control: Extending the paradigm to emergency general surgery

https://doi.org/10.1016/j.injury.2007.06.011Get rights and content

Summary

Objective

A damage control (DC) approach was developed to improve survival in severely injured trauma patients. The role of DC in acute surgery (AS) patients who are critically ill, as a result of sepsis or overwhelming haemorrhage continues to evolve. The goal of this study was to assess morbidity and mortality of AS patients who underwent DC, and to compare observed and predicted morbidity and mortality as calculated from APACHE II and physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scores.

Methods

Consecutive acute surgery patients who underwent DC from 2002 to 2004 were included. Retrospectively collected data included patient demographics, physiological parameters, surgical indications and procedures, mortality, morbidity, as well as volumes of crystalloid and colloid (plasma and red blood cell) resuscitation. Observed mortality and complications were compared to those calculated from APACHE II and POSSUM scores. Data were analysed using the Mann–Whitney test for median values, chi-square and Fisher's exact tests for proportions.

Results

Sixteen patients (mean age 53 years, seven men, nine women) underwent DC. The most common indications for DC included abdominal sepsis (6/15), intraoperative bleeding (5/15), and bowel ischaemia (3/15). The mean intraoperative blood loss during the index procedure was 2060 mL. There were 2.4 average procedures per patient. At the end of DC II (36.5 h), mean infusion of crystalloid was 17 L, packed red blood cells was 3.6 L, and plasma was 3 L. Eight of 16 patients required vasopressor administration during resuscitation. At 28 days, there were five unexpected survivors as predicted by POSSUM and three by APACHE II (observed mortality seven, predicted mortality by the two methods: 12 (P = 0.074), and 10 (P = 0.24), respectively). Five patients died prior to definitive abdominal closure. Split thickness skin grafting (4/16) and primary fascial closure (4/16) constituted the most common methods of abdominal closure. Surgical morbidity predicted by POSSUM (98%) and actual morbidity (100%) were similar.

Conclusion

Although the morbidity and mortality of AS patients undergoing DC is high, the application of DC principles in this group may reduce mortality compared to that predicted by POSSUM or APACHE II. In order to adequately demonstrate this contention, large, multi-institutional studies of DC in AS patients need to be performed. The POSSUM score appears to accurately estimate the high morbidity in general surgery DC patients, and supports the importance of team management of these complex patients by acute care surgery specialists.

Introduction

The concept of damage control (DC) surgery has evolved significantly since its inception2, 5, 25. It now spans an entire spectrum of traumatic and nontraumatic indications8, 13, 15, 31. The acute care surgery (AS) model, wherein the trauma/surgical critical care specialist evaluates, performs surgery, and manages critically ill nontrauma emergency general surgery patients is gaining popularity around the world1, 3, 7, 11, 17, 18, 22. This extension in scope of trauma/critical care surgeons seems logical because despite different initial aetiologies, the magnitude of physiological injury and its sequelae are similar in critically ill trauma and nontrauma patients22, 23, 28, 29, 30. In fact, both the American Association for the Surgery of Trauma (AAST) and the European Association for Trauma and Emergency Surgery (EATES) emphasise the important role of acute care surgery in the overall scheme of the evolving specialty of trauma, surgical critical care, and emergency surgery1, 11.

The purpose of this study is to examine the use and results of DC surgery for nontraumatic indications at an academic level I trauma centre. We hypothesise that use of DC in AS patients may contribute to improved outcomes. Specifically, our goal was to assess morbidity and mortality of AS patients who underwent DC, and to compare observed morbidity and mortality to those estimated by APACHE II and physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scores.

Section snippets

Methods

After obtaining Institutional Review Board approval, a retrospective evaluation of acute care general surgical patients was performed. Over a 2-year period (2002–2004), acute care surgery general surgical patients underwent damage control for one or more of the following indications: abdominal sepsis, massive intraoperative bleeding, ischaemic bowel and necrotising pancreatitis. Patients in this study constitute a consecutive sample of acute surgery patients who were identified from a

Results

Sixteen consecutive emergency general surgery patients (mean age 53; nine women; seven men) underwent damage control surgery at our institution from 2002 to 2004. Initial physiological parameters (including APACHE II and POSSUM scores), blood loss associated with the initial DC procedure, fluid resuscitation data, and the mean number of procedures per patient are listed in Table 3. Mean resuscitation to accomplish complete physiological restoration required 36 h, 17 L of crystalloid fluid

Discussion

The recognition of the lethal triad of acidosis, hypothermia, and coagulopathy has led to the evolution of the damage control approach, which was found to ameliorate the physiological effects of this triad25. Initially used in trauma patients, the DC approach has since been increasingly applied in critically ill nontrauma surgical patients8. This logical extension of DC is based on the premise that physiological derangements seen in severely injured trauma patients are also present in surgical

Conclusion

Although the morbidity and mortality of AS patients undergoing DC remains high, the application of DC principles in this patient group may reduce mortality compared to that predicted by physiologic scoring systems. In order to adequately demonstrate this contention, large, multi-institutional studies of DC in AS patients need to be performed. This study accurately demonstrates complications associated with DC approach in acute surgical patients and underscores the importance of the management

Conflict of interest statement

The authors of this manuscript report no conflicts of interest related to this work. None of the authors have any financial and/or personal relationships with other people or organisations that could inappropriately influence or bias their work.

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