Haemorrhagic shock
Septic shock
Preoperative Haemostatic resuscitation
Hypothermia correction
Phase 0
Preoperative resuscitation with fluids and vasoconstrictors
Hypothermia correction
Antibiotic administration
Identification of the patient: pathology and physiology
Phase 1
Identification of the patient: pathology and physiology
Haemorrhage control
Phase 2
Decontamination
Sepsis source control
Reassessment during surgery
Phase 3
Reassessment during surgery
Physiological restoration in intensive care
Optimisation of haemodynamics
Correction of acidosis, hypothermia and coagulopathy
Optimisation and support of vital organs
Phase 4
Physiological restoration in intensive care
Optimisation of haemodynamics
Correction of acidosis, hypothermia and coagulopathy
Optimisation and support of vital organs
Intra-operative reassessment
Definitive repair
Abdominal wall closure
Phase 5
Intra-operative reassessment
Definitive repair
Abdominal wall closure
Trauma patients differ pathophysiologically from patients with non-traumatic abdominal catastrophes [10, 11]: in trauma, the shock ensues from tissue injury, its associated inflammatory cascades, usually in combination with poor organ perfusion caused by the haemorrhage; in non-traumatic intra-abdominal emergencies, patients typically demonstrate either haemorrhagic shock in the absence of tissue injury (e.g. from a duodenal ulcer), or septic shock (e.g. from a perforated viscus). These fundamental pathophysiological differences require adaptations of precise clinical handling, and cannot be managed identically to trauma patients. For example in the case of septic shock, the initial, preoperative, resuscitation, and the administration of antibiotics are now both well established [13, 14]. As a result, we have proposed [10] the need for an additional phase (called this Phase 0), in the damage control surgery phases, which precedes the classic five phases of damage control surgery for trauma described above. Phase 0 focuses on preoperative resuscitation, and may be considered what is described as ‘damage control resuscitation’ elsewhere.
22.3 Evidence for Damage Control Strategies in Abdominal Emergencies
Relatively minimal, direct, evidence has been published to support the application of the damage control strategy to patients with critical intra-abdominal emergencies. The literature is all Level III and IV data, and is largely on the basis of retrospective case series, which at times are referenced to historic or non-randomised cohorts or data-sets [10]. The progress in this field has been largely driven by instinctive recognition of potential benefits in this treatment modality by experienced trauma, acute care and general surgeons, which are involved in the current management of both trauma and general surgery patients. This intuitively transfer of the lessons learnt from the trauma cohort, to their other critically ill patients with non-traumatic intra-abdominal emergencies, continues to require further study. In particular, the precise indications and nature of the interventions offered will undoubtedly continue to evolve. Further clarification between varying definitions and clinical systems in these studies is also required. Table 22.2 summarises the currently available studies reporting on damage control in general surgical abdominal emergencies (case reports have been excluded) [15–32].
Table 22.2
Studies reporting on damage control surgery in non-traumatic abdominal emergencies
Lead author | Year | Study design | Level of evidence | Number of cases | Pathology | Comparison cohort |
|---|---|---|---|---|---|---|
Finlay et al. [15] | 2003 | Prospective comparative study | III | 14 | 9 Intra-abdominal sepsis 2° visceral perforation 3 Ruptured abdominal aortic aneurysm 1 Post-operative bleed 1 Retroperitoneal bleed | POSSUMa P-POSSUMb |
Freeman and Graham [16] | 2004 | Retrospective comparative study | III | 3 | Acute mesenteric ischaemia | Non-randomised concurrent patients |
Banieghbal and Davies [17] | 2004 | Prospective series | IV | 27 | Neonatal generalised nectrotising enterocolitis | – |
Tamijmarane et al. [18] | 2006 | Retrospective series | IV | 25 | Complicated elective pancreatic surgery | – |
Stawicki et al. [19] | 2008 | Retrospective comparative study | III | 16 | 6 Sepsis 5 Intra-operative bleeding 3 Ischaemia 2 Necrotising pancreatitis | APACHE IIc POSSUMa |
Person et al. [20] | 2009 | Retrospective comparative series | III | 31 | 15 Peritonitis 10 Mesenteric ischaemia 3 Bleeding 2 Obstruction 1 Other | Non-randomised concurrent patients |
Ball et al. [21] | 2010 | Retrospective series | IV | 6 | Haemorrhage at pancreatic necrosectomy | – |
Filicori et al. [22] | 2010 | Retrospective comparative study | III | 8 | Intra-abdominal haemorrhage | APACHE IIc |
Gong et al. [23] | 2010 | Retrospective series | IV | 15 | Acute mesenteric ischaemia | – |
Morgan et al. [24] | 2010 | Retrospective series | IV | 8 | Complicated elective pancreatic resections 4 intra-operative haemorrhage 2 sepsis at reoperation 2 haemorrhage at reoperation | – |
Perathoner et al. [25] | 2010 | Prospective comparative series | III | 9 | Complicated diverticulitis | Non-randomised concurrent patients |
Subramanian et al. [26] | 2010 | Retrospective series | IV | 88 | 32 Planned relookd 26 Abdominal compartment syndrome 29 Contamination 15 Necrotising fasciitis 14 Ischaemic bowel 10 Haemodynamic instability | – |
Tadlock et al. [27] | 2010 | Retrospective comparative series | III | 13 | Ruptured abdominal aortic aneurysm | Non-randomised concurrent patients |
Kafka-Ritsch et al. [28] | 2012 | Prospective series | IV | 51 | Perforated diverticulitis | – |
Khan et al. [29] | 2013 | Retrospective series | IV | 42 | 13 Bowel ischaemia 13 Haemorrhage 10 Peritonitis 6 Physiological instability | – |
Goussous et al. [30] | 2013 | Retrospective series | IV | 99 | 25 Bowel ischaemia 21 Bowel perforation 15 Haemorrhage 10 Anastomotic leak 7 Abdominal compartment syndrome 6 Incarcerated hernia 5 Ruptured abdominal aortic aneurysm 3 Enterocutaneous fistula 2 Necrotising pancreatitis 2 Necrotising fasciitis 3 Other | – |
Liu et al. [31] | 2015 | Retrospective series | IV | 6 | 6 Acute mesenteric ischaemia | – |
Nentwich et al. [32] | 2015 | Retrospective series | IV | 20 | Completion of pancreatectomies after complicated Whipple’s procedures | Non-randomised concurrent patients
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