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Damage Control Surgery in the Era of Damage Control Resuscitation

2009; BMJ; Volume: 155; Issue: 4 Linguagem: Inglês

10.1136/jramc-155-04-16

2052-0468

Mark J. Midwinter,

Abdominal Surgery and Complications

Damage Control Surgery (DCS) is an operative strategy that sacrifices the completeness of the immediate surgical repair in order to address the physiological consequences of the combined trauma (double hit) of injury and surgery. In the past this has been very much focussed on abdominal trauma and the idea of performing an “abbreviated laparotomy”. The concepts are however clearly applicable to injury beyond the abdomen [1-3]. Damage Control Resuscitation (DCR) is a more recent concept. It has variously been defined in the USA as ‘a proactive early treatment strategy that addresses the ‘lethal triad’ (rapid reversal of acidosis, prevention of hypothermia and coagulopathy) on admission to a combat hospital’ [4] and in UK as ‘systematic approach to major trauma combining the catastrophic bleeding, airway, breathing and circulation ( ABC) paradigm with a series of clinical techniques from point of wounding to definitive treatment in order to minimise blood loss, maximise tissue oxygenation and optimise outcome’ [5]. These two definitions express the DCR concept differently but consist of the same practical measures to achieve the aims of DCR. The UK definition extends the DCR principle forward to the point of wounding and is a more generalised statement. Central to both is early recognition and proactive management of the physiological consequences of the injury. The principles of Damage Control Surgery (DCS) have been well described for over 20 years but have been slow to gain universal acceptance. However, it is now recognised that severely injured trauma patients, who are still alive at the point of medical intervention, are now more likely to die from the metabolic consequences of the injury rather than the completeness of the immediate surgical repair to their damaged organs. While there has been academic recognition of the importance of addressing resuscitation and surgical issues concurrently, it is only with the development of the concept of DCR and emerging technological useful clinical tools, that this has been consolidated into practice. It is now timely to reassess both DCR and DCS.