Damage control resuscitation

Damage control resuscitation

Damage control resuscitation (DCR), also known as haemo - static resuscitation, is a paradigm that prioritises haemorrhage control in patients who are still actively bleeding. The rationale is that no aspect of the shock state /uni00A0 – /uni00A0 end-organ perfusion, blood pressure, temperature, lactic acidosis /uni00A0 – /uni00A0 can be corrected

Haemostasis Time Prioritise perfusion Perfusion-targeted resuscitation Goal: End-organ perfusion Adequate preload and afterload ( /f_l uids and pressors) Thromboprophylaxis Monitor : Cardiovascular: BP , HR, CO, SVR Perfusion: base excess, lactate, S O v 2 Organ function: PaO /F O , UO, GCS 2 i 2 Abdominal compartment: IAP O , fraction of inspired oxygen; i 2 , arterial oxygen tension; PT, prothrombin time; RBC, red 2 O , mixed venous oxygen saturation; TEG, thrombo

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resuscitation will exacerbate coagulopathy , hypothermia and metabolic derangements (acidosis, hyperkalaemia, hypocal caemia). The introduction of DCR has been associated with substantial reductions in mortality from haemorrhagic shock in the last decade. DCR applies only while patients are bleeding and is based on four key principles /uni00A0 – /uni00A0 rapid haemorrhage control; permissive hypotension; avoiding dilutional coagulopathy; and trea existing coagulation deficits ( Figure 2.2 ). Rapid haemorrhage control At all times, control of bleeding is the priority . Direct pres sure should be placed over the site of external haemorrhage. Temporary bleeding control should be achieved with tour niquets, balloon occlusion or other techniques. Intracavitary haemorrhage should be suspected and searched for, and the pathway should actively move patients forwards to the oper ating theatre or interventional radiology room to achieve this. The damage control approach is extended to the conduct of surgery to prioritise rapid bleeding control. In damage con trol surgery , surgical intervention is limited to the minimum necessary to stop bleeding and contr ol sepsis, in order to avoid additional tissue damage, bleeding and physiological stress. More definitive repairs can be delayed until the patient is hae modynamically stable and physiologically capable of sustain ing the procedure. Thus the operation is tailored to match the patient’s physiology , and is not focused on reconstructing anat omy . ‘Damage control’ is a term borrowed from the military: it ensures continued functioning of a damaged ship above con ducting complete repairs, which would prevent rapid return to battle. Summary box 2.3 Damage control surgery /uni25CF /uni25CF /uni25CF /uni25CF Permissive hypotension Permissive hypotension allows the patient to set their own blood pressure while bleeding and avoids continued volume resuscitation in the vain attempt to normalise perfusion while bleeding. This reduces blood loss from bleeding sites and reduces dilutional coagulopathy and hypothermia induced by fluids. It is important to maintain baseline perfusion of the coronary arteries at minimum, and thus a palpable central pulse (mean arterial pressure above ~50 /uni00A0 mmHg) must be maintained by whatever means are available. Avoid dilutional coagulopathy Avoid dilutional coagulopathy by avoiding clear fluids (crystal loids or colloids) and by giving a transfusion that approximates red blood cells and plasma. - Treat existing coagulation deficits Treat existing coagulopathies either empirically or by regular coagulation testing and acting on the results. Tranexamic acid should be given as soon as possible in almost all bleeding patients to stop hyperfibrinolysis. Blood component concen - ting trates should be given to correct existing deficits, such as cryoprecipitate for low fibrinogen levels or platelet transfusions for platelet dysfunctions. -

Arrest haemorrhage Control sepsis Protect from further injury Nothing else

Damage control resuscitation

Damage control resuscitation (DCR), also known as haemo - static resuscitation, is a paradigm that prioritises haemorrhage control in patients who are still actively bleeding. The rationale is that no aspect of the shock state /uni00A0 – /uni00A0 end-organ perfusion, blood pressure, temperature, lactic acidosis /uni00A0 – /uni00A0 can be corrected

Haemostasis Time Prioritise perfusion Perfusion-targeted resuscitation Goal: End-organ perfusion Adequate preload and afterload ( /f_l uids and pressors) Thromboprophylaxis Monitor : Cardiovascular: BP , HR, CO, SVR Perfusion: base excess, lactate, S O v 2 Organ function: PaO /F O , UO, GCS 2 i 2 Abdominal compartment: IAP O , fraction of inspired oxygen; i 2 , arterial oxygen tension; PT, prothrombin time; RBC, red 2 O , mixed venous oxygen saturation; TEG, thrombo

v 2

resuscitation will exacerbate coagulopathy , hypothermia and metabolic derangements (acidosis, hyperkalaemia, hypocal caemia). The introduction of DCR has been associated with substantial reductions in mortality from haemorrhagic shock in the last decade. DCR applies only while patients are bleeding and is based on four key principles /uni00A0 – /uni00A0 rapid haemorrhage control; permissive hypotension; avoiding dilutional coagulopathy; and trea existing coagulation deficits ( Figure 2.2 ). Rapid haemorrhage control At all times, control of bleeding is the priority . Direct pres sure should be placed over the site of external haemorrhage. Temporary bleeding control should be achieved with tour niquets, balloon occlusion or other techniques. Intracavitary haemorrhage should be suspected and searched for, and the pathway should actively move patients forwards to the oper ating theatre or interventional radiology room to achieve this. The damage control approach is extended to the conduct of surgery to prioritise rapid bleeding control. In damage con trol surgery , surgical intervention is limited to the minimum necessary to stop bleeding and contr ol sepsis, in order to avoid additional tissue damage, bleeding and physiological stress. More definitive repairs can be delayed until the patient is hae modynamically stable and physiologically capable of sustain ing the procedure. Thus the operation is tailored to match the patient’s physiology , and is not focused on reconstructing anat omy . ‘Damage control’ is a term borrowed from the military: it ensures continued functioning of a damaged ship above con ducting complete repairs, which would prevent rapid return to battle. Summary box 2.3 Damage control surgery /uni25CF /uni25CF /uni25CF /uni25CF Permissive hypotension Permissive hypotension allows the patient to set their own blood pressure while bleeding and avoids continued volume resuscitation in the vain attempt to normalise perfusion while bleeding. This reduces blood loss from bleeding sites and reduces dilutional coagulopathy and hypothermia induced by fluids. It is important to maintain baseline perfusion of the coronary arteries at minimum, and thus a palpable central pulse (mean arterial pressure above ~50 /uni00A0 mmHg) must be maintained by whatever means are available. Avoid dilutional coagulopathy Avoid dilutional coagulopathy by avoiding clear fluids (crystal loids or colloids) and by giving a transfusion that approximates red blood cells and plasma. - Treat existing coagulation deficits Treat existing coagulopathies either empirically or by regular coagulation testing and acting on the results. Tranexamic acid should be given as soon as possible in almost all bleeding patients to stop hyperfibrinolysis. Blood component concen - ting trates should be given to correct existing deficits, such as cryoprecipitate for low fibrinogen levels or platelet transfusions for platelet dysfunctions. -

Arrest haemorrhage Control sepsis Protect from further injury Nothing else

Damage control resuscitation

Damage control resuscitation (DCR), also known as haemo - static resuscitation, is a paradigm that prioritises haemorrhage control in patients who are still actively bleeding. The rationale is that no aspect of the shock state /uni00A0 – /uni00A0 end-organ perfusion, blood pressure, temperature, lactic acidosis /uni00A0 – /uni00A0 can be corrected

Haemostasis Time Prioritise perfusion Perfusion-targeted resuscitation Goal: End-organ perfusion Adequate preload and afterload ( /f_l uids and pressors) Thromboprophylaxis Monitor : Cardiovascular: BP , HR, CO, SVR Perfusion: base excess, lactate, S O v 2 Organ function: PaO /F O , UO, GCS 2 i 2 Abdominal compartment: IAP O , fraction of inspired oxygen; i 2 , arterial oxygen tension; PT, prothrombin time; RBC, red 2 O , mixed venous oxygen saturation; TEG, thrombo

v 2

resuscitation will exacerbate coagulopathy , hypothermia and metabolic derangements (acidosis, hyperkalaemia, hypocal caemia). The introduction of DCR has been associated with substantial reductions in mortality from haemorrhagic shock in the last decade. DCR applies only while patients are bleeding and is based on four key principles /uni00A0 – /uni00A0 rapid haemorrhage control; permissive hypotension; avoiding dilutional coagulopathy; and trea existing coagulation deficits ( Figure 2.2 ). Rapid haemorrhage control At all times, control of bleeding is the priority . Direct pres sure should be placed over the site of external haemorrhage. Temporary bleeding control should be achieved with tour niquets, balloon occlusion or other techniques. Intracavitary haemorrhage should be suspected and searched for, and the pathway should actively move patients forwards to the oper ating theatre or interventional radiology room to achieve this. The damage control approach is extended to the conduct of surgery to prioritise rapid bleeding control. In damage con trol surgery , surgical intervention is limited to the minimum necessary to stop bleeding and contr ol sepsis, in order to avoid additional tissue damage, bleeding and physiological stress. More definitive repairs can be delayed until the patient is hae modynamically stable and physiologically capable of sustain ing the procedure. Thus the operation is tailored to match the patient’s physiology , and is not focused on reconstructing anat omy . ‘Damage control’ is a term borrowed from the military: it ensures continued functioning of a damaged ship above con ducting complete repairs, which would prevent rapid return to battle. Summary box 2.3 Damage control surgery /uni25CF /uni25CF /uni25CF /uni25CF Permissive hypotension Permissive hypotension allows the patient to set their own blood pressure while bleeding and avoids continued volume resuscitation in the vain attempt to normalise perfusion while bleeding. This reduces blood loss from bleeding sites and reduces dilutional coagulopathy and hypothermia induced by fluids. It is important to maintain baseline perfusion of the coronary arteries at minimum, and thus a palpable central pulse (mean arterial pressure above ~50 /uni00A0 mmHg) must be maintained by whatever means are available. Avoid dilutional coagulopathy Avoid dilutional coagulopathy by avoiding clear fluids (crystal loids or colloids) and by giving a transfusion that approximates red blood cells and plasma. - Treat existing coagulation deficits Treat existing coagulopathies either empirically or by regular coagulation testing and acting on the results. Tranexamic acid should be given as soon as possible in almost all bleeding patients to stop hyperfibrinolysis. Blood component concen - ting trates should be given to correct existing deficits, such as cryoprecipitate for low fibrinogen levels or platelet transfusions for platelet dysfunctions. -

Arrest haemorrhage Control sepsis Protect from further injury Nothing else