Resuscitative strategies to maintain homeostasis during damage control surgery

Abstract

Background: Successful outcome from damage control surgery (DCS) depends as much on elements of resuscitation and non-operative management as on details of the procedure itself. The early management of patients in haemorrhagic shock has undergone substantial revision in the past decade and is now known as 'haemostatic resuscitation'.Methods: An updated literature review describing the anaesthetic and resuscitative management of patients with active, ongoing traumatic haemorrhage was distilled to present the current knowledge of the pathophysiology, recommended treatments and areas of active controversy.Results: Current practice in military and civilian trauma centres is described, along with the degree of evidence in support of clinical decisions. Resuscitation of patients with ongoing traumatic haemorrhage has changed substantially in the past two decades. Optimal management now includes deliberate hypotension to minimize blood loss, early use of blood products (especially plasma) and administration of antifibrinolytic therapy. Areas of debate include the role of clotting factor concentrates and depth of anaesthesia. Conclusion: Resuscitation strategies during DCS may be as important as the anatomical repair itself.Recommendations include avoidance of hypothermia, maintenance of a lower than normal blood pressure, and early support of the coagulation system in patients likely to require massive transfusion. Controversies include the optimal ratio of plasma to red blood cells for empirical resuscitation, the ideal role of clotting factor concentrates, and the potential benefit of early, deep anaesthesia. Future research will centre on the complex interaction between the humoral elements of coagulation and the vascular endothelium that regulates perfusion, clotting and integrity of the circulation.

Complications of Massive Blood Transfusion

“…Treatment comprises of supportive care in form of mechanical ventilation, fluids and inotropes. [12] This condition needs to be differentiated from transfusion associated circulatory overload which is accompanied with hydrostatic pulmonary edema which occurs in 1% of transfusion reactions.…”

Reanimación con fluidos y hemoderivados en trauma

“…Ésta plantea que el manejo quirúrgico inicial del trauma debe enfocarse en el control del sangrado y de la contaminación (lesiones de víscera hueca), realizando las reconstrucciones definitivas una vez que el paciente se ha estabilizado y ha recuperado su homeostasis 4 . Su objetivo es restaurar la fisiología del paciente difiriendo la restauración de la anatomía, evitando las complicaciones de cirugías prolongadas, especialmente el desarrollo de la triada maligna del trauma (hipotermia, acidosis y coagulopatía).…”

Impact of crystalloids and colloids on coagulation cascade during trauma resuscitation-a literature review

“…This Ohm's law explains why aggressive resuscitation with IVF may inadvertently lead to more blood loss. This is due to an increase of pressure in the damaged blood vessels resulting in the disruption of the formed blood clot [7,8]. Despite this simple logic, the past management of trauma patients for many years was based on the belief that the use of large volumes of intravenous crystalloids is essential to restore the circulating volume and to achieve the best outcomes [9].…”

“…DCR aims to salvage the trauma patient from disturbed physiology by breaking the lethal triad [14]. DCR utilises three key concepts: permissive hypotension, rapid correction of the coagulopathy and early use of blood products as primary resuscitation fluids (instead of IVF) [8,11]. This appears to be logical giving the fact that all fluids including crystalloids and colloids have the ability to worsen the shock and coagulopathy [15].…”