DAMAGE CONTROL RESUSCITATION Duchesne JC ET al - article on clickUP 2013 Dr du Plessis 1

DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 2

(1.) DAMAGE CONTROL SURGERY NAVAL TERM FROM WAR- TO SAVE THE SHIP LIMIT DAMAGE CLOSE COMPARTMENTS TRADE OFF – PREPARED TO SACRIFICE SOME TO SAVE THE REST EMERGENCY REPAIR FINISH MISSION 3

(1.) DAMAGE CONTROL SURGERY SURGERY: TO SAVE THE PATIENT ABBREVIATED SURGERY UNCONVENTIONAL APPROACH CONTROL (STOP) BLEEDING STOP CONTAMINATION GET OUT (LESS THAN 1 HOUR) 4

(1.) DAMAGE CONTROL SURGERY LAPAROTOMY- CONTROL BLEEDING,CONTAMINATION SHORT PROCEDURE RESUSCITATE IN ICU:TEMPERATURE, BLOOD, CIRCULATION RELOOK WHEN OPTIMISED(<48 HR)- DEFINITIVE SURGERY, CLOSURE 5

DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 6

(2.) BLOOD TRANSFUSION Blood loss needs replacement with blood Cannot get whole blood from blood bank, only components Need Packed RBC's to carry oxygen No clotting factors: need FreshFrozenPlasma to replace clotting factors (cryoprecipitate) No platelets: need platelets to assist ith process of clotting Ideal ratio: 1:1:1 7

(2.) BLOOD TRANSFUSION 8 Store at 4 degrees Celsius Ave age (US) 24 days RBC: no nucleus, no mitochondria (anaerobic metabolism) Use glucose - lactate (acidosis) Low 2,3 DPG: less deformable (sphere) Preserve in Citrate Phosphate Dextrose No clotting factors No platelets Hemolysis of some RBC: more potassium 8

DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 9

(3.) PERMISSIVE HYPOTENTION Blood pressure lower than normal,but adequate for tissue perfusion Systolic: 90mmHg Renal perfusion usually 70mmHg Decr resus: decr BP: incr time to clot Incr resus: incr BP: incr bleed Danger: eg leaking aortic aneurysm, will loose 5L in one minte (CO = 5L/min) 10

DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 11

(4.) HYPERTONIC SOLUTIONS Sodium is most NB for resus Hypertonic solutions gives more sodium in a smaller volume Reduced danger of volume overload, oedema, cardiac failure, pulmonary oedema, and dysfunction(TRALI:transfusion related acute lung injury = part of ARDS, initial stage) Problem of hyperchloraemic acidosis (Na+Cl-) 12

DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 13

(5.) MORTAL TRIAD 14 ACIDOSIS COAGULAPTHY HYPOTHERMIA Treatment: Cover patient (Bair hugger) Preheat fluids to 40-42 degrees Heat gases without H2O bath Ringer's lactate in axilla (high blood flow area) Stop other fluid loss 14

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DAMAGE CONTROL QUESTIONS: What is damage control surgery? Why is blood necessary for resuscitation? What is permissive hypotension? Is there a role for hypotonic solutions? What is the mortal triad? Why is it bad to have it develop? 16

(6.) BAD TO HAVE IT DEVELOP Acidosis: treat with fluids (open capillary beds) to get rid of acids Give oxygen (aerobic metabolism) 17

DAMAGE CONTROL EXTENDED TO OTHER DISCIPLINES ORTHOPAEDIC SURGERY NEUROSURGERY PLASTIC AND RECONSTRUCTIVE S MAXILLOFACIAL SURGERY RESUSCITATION 18

DAMAGE CONTROL DAMAGE CONTROL RESUSCITATION LIMIT FLUIDS (CRYSTALLOIDS) GIVE BLOOD EARLY ADD FFP IN RATIO 1:1 ADD PLATELETS MIMIC FRESH WHOLE BLOOD TEG CONTROL with aFVII 19

End Thank you 20