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