Critical Care

The priority of the critical care phase of treatment is rapid and complete reversal of metabolic failure. The damage control procedure has controlled life-threatening injury, but the patient requires further surgery to remove packs and/or definitively complete the repairs. The next 24 to 48 hours are crucial if the patient is to be fit for a second procedure. After this time multiple organ dysfunction, especially acute respiratory distress syndrome (ARDS), and cardiovascular failure may render re-operation inadequate.

Damage Control Surgery

Overview
Metabolic failure
Damage control laparotomy
Organ-specific techniques
Critical Care
Abdominal Compartment Syndrome
Reoperation

The intensive care unit must act aggressive to reverse the metabolic failure. The patient must be actively warmed, with blankets, air-warming devices or even continuous arteriovenous warming techniques. This is vital to allow correction of coagulopathy and acidosis.

Acidosis is a reflection of impaired oxygen delivery and utilization. Perfusion must be restored to body tissues by warmed intravenous crystalloid and blood administration as necessary. Massive tissue and bowel oedema may ensue due to the activation and release of inflammatory mediators and large volumes of fluid are required. Right heart catheters should be employed as necessary to monitor cardiac filling pressures and determine oxygen delivery. Vasodilating agents such as dobutamine or the phsophodiesterase inhibitors may be necessary to help open up vascular beds. In the absence of technology that can monitor muscle and gut perfusion, the base deficit or lactate levels should be used to guide resuscitation.

Coagulopathy is treated by the administration of fresh frozen plasma, cryoprecipitate and platelets as necessary, and correcting the hypothermia and acidosis. If correction of metabolic failure is to succeed, all three derangements must be treated simultaneously and aggressively. Take care not to miss the patient who has started to actively bleed again. Large losses from thoracostomy tubes, abdominal distention or loss of control of an open abdomen, or repeated episodes of hypotension all suggest that mechanical bleeding is occurring that will require surgical control.

Abdominal Compartment Syndrome