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A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM THE YEAR 2005 TO 2010. A RETROSPECTIVE STUDY

INTRODUCTION: DAMAGE CONTROL SURGERY


The traditional approach to combat injury care is surgical exploration with definitive repair of all injuries. This approach is successful when there is a limited number of injuries. These are usually performed in patients with unstable conditions such as profound hemorrhagic shock which is known to affect the overall survival of the patient. Prolonged operative times and persistent bleeding lead to the lethal triad of coagulopathy, acidosis, and hypothermia, resulting in a mortality of about 90%.

Damage Control Surgery Steps

  1. Control of hemorrhage and contamination.
    Also known as bail-out surgery is the first stage. It is a life-saving procedure and is rapidly performed by the surgeon. The main goal this time is to control blood loss and minimize contamination. It includes control of hemorrhage from bleeding major vessels and solid organs through the packing of the abdomen, deviation from intestinal anastomosis, and temporary closure of the abdomen.
  2. Resuscitation:
    Once control of hemorrhage is achieved, the patient is now transferred to ICU for correction of any derangement. Rewarming of the patient to avoid hypothermia, correction of blood loss, hydration and stabilization of BP, and avoiding coagulopathy.
  3. Reoperation.
    Once a patient has been stabilized, especially within 24-48 hours, a definite procedure will be done in the operating room.

What is done in damage control surgery?

Damage control surgery is a relatively new technique, about 20 years old. It is well recognized that trauma patients especially those with profound shock have a higher chance to die secondary to intra-operative metabolic failure than from the trauma itself.

The analogy of damage control surgery is to stop all haemorrhage and gastrointestinal spillage as quickly as possible while a patient is having unstable vital signs in the operating room. It is coined from a U.S. Navy technique which is “the capacity of a ship to absorb damage and maintain mission integrity.”

Speed of decision and surgery in severely injured trauma patients is the key to avoiding the death of patients. The well-recognized consequence of hypovolemic, hypothermic patients is what we call the “lethal triad.” It comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. It is a vicious cycle that is very lethal if not recognized and controlled immediately.

A patient who is stable with acceptable laboratory results, good ventilator response, and non-hypothermic, is then returned to the operating room for the “definitive operation.” (figure 1). Bowel anastomoses and colostomy maturation, definitive vascular repair, removal of hemostatic packing, and closure of abdominal fascia where is done.

Figure 1.

A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM THE YEAR 2005 TO 2010. A RETROSPECTIVE STUDY

The documented mortality for the damage control is approximately 50% with a documented morbidity of approximately 40% as summarized in the following table.

A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM THE YEAR 2005 TO 2010. A RETROSPECTIVE STUDY
Mortality for Damage Control



WHAT IS NOT YET KNOWN ABOUT DAMAGE CONTROL SURGERY?

With the advent of modern technology and numerous studies, what is the outcome of patients undergoing Damage control surgery in SPMC from January 1, 2005, to December 31, 2010?

WHAT IS THE SIGNIFICANCE OF THE STUDY?

This study will give us data on the effectiveness of Damage Control Surgery done at SPMC from January 1, 2005 – December 31, 2010. It will give the surgeons the data on factors that determine the outcome of damage control surgery, thus giving ways of improving healthcare management to patients.

WHAT WILL THIS STUDY DO?

General Objective:

The study aims to determine the outcome of damage control surgery done in SPMC from January 1, 2005, to December 31, 2010

Specific Objective:

  1. To describe the demographic and clinical profile of patients who underwent damage control surgery
  1. To determine the number of patients who underwent definitive surgical

procedure after damage control surgery

3. To determine the mortality rate of patients who underwent undergoing damage control surgery in SPMC from January 1, 2005, to December 2010.

4. To determine the factors that affect the outcome of patients undergoing damage control surgery in SPMC from January 1, 2005, to December 2010 in terms of nature of the injury, time of operation from injury, and pre-operative vital signs.

Patient’s Demographic Profile

Describe the trauma patients according to the following variables:

  1. Sociodemographic characteristics
  • Age
  • Sex
  1. Clinical characteristics:
  • Pre-operative vital signs
  • Associated Injuries
  • GCS score
  • Organs Involved
  1. Co-morbidities
  2. Determine the interventions and clinical outcome of patients
  • Duration of Operation
  • Operations performed
  • Mortality rate
  • Re-operation performed
  • Disposition

Figure 1. Conceptual Framework













METHODOLOGY

General Design

The study employed is a retrospective, descriptive study design. Chart review of all patients who underwent damage control surgery from January 1, 2005 to 2010 will be done by the author with the permission of the medical records section and the hospital research committee.

Setting

The study will be conducted at Southern Philippines Medical Center, a tertiary hospital in Davao City in June 2013.

PARTICIPANTS:

INCLUSION CRITERIA:

This study will include all patients admitted and underwent Damage control surgery at Southern Philippines Medical center from 2005-2010. Damage control surgery includes resection of major injuries to the gastrointestinal tract without re-anastomosis; control of hemorrhage through peri-hepatic packing and temporary closure of the abdomen and use of an alternate closure of a cervical incision, thoracotomy, laparotomy, or site of exploration of an extremity.

EXLCLUSION CRITERIA:

None

SAMPLING PROCEDURES:

The study subjects (target population) of this research are the patients admitted and underwent Damage control surgery at Southern Philippines Medical Center from 2005-2010.

Randomization:

None

DATA GATHERING

Dependent Variable:

Number of Damage Control Surgery from 2005-2010

Main outcome measures and other dependent variables:

Number of patients who expired and number of patients who survived.

Independent Variables

  • Age and Sex
  • Nature of injury
  • Time of intervention from time of injury
  • Pre-Operative vital signs
  • Glasgow coma scale
  • Organs involved
  • Duration of Operation
  • Availability of Blood

Interventions:

None

Data Handling and Analysis:

All data will be computed as to the mortality rate by computing the number of patients who expired to the total number of patients who underwent Damage control surgery.

Furthermore, the determination of mortality will be computed by computing the ratio of mortality as of Age and Sex, Nature of injury, Time of operation from injury and Pre-op vital signs, Duration of Operation, Availability of blood, and Organs involved.

DAMAGE CONTROL SURGERY GUIDELINES

Ethics Review

The proponent of the study will secure an approval from the Cluster Ethics Research Committee of The Southern Philippines Medical Center prior to doing the research. Similar approval is also secured from the Department of Surgery of the same institution with the approval of a consultant in charge.

Privacy

No phone calls or home visits as follow up to participants.

Damage Control Surgery.
Doctors Conducting a Damage Control Surgery.

Confidentiality

The researchers will not disclose the identities of the patients at any time. The data obtained during the study will be under the Department of Surgery of Southern Philippines Medical Center and will be kept confidential.

The extent of the Use of Study Data

The data collected by the researcher will only be used to answer the objectives stated in the protocol. Data will be available to others as a finished paper.

Authorship and Contributorship

The main proponent of the study is the main author and researcher of the study. Consultant guidance and support will be provided by Dr. Benedict Valdez, head of the Section of Trauma, Department of Surgery, SPMC. He is the co-author who will aid in the study design. A professional statistician will help in the study write-up and data analysis. The author and co-author gives consent to use the data collected for further research.

Conflicts of Interest

The main proponent and the co-authors declare no conflict of interest.

Publication

The research will be submitted to national and international publication groups and may be chosen for publication. In all portions in the paper, the author and co-authors will be duly acknowledged.

Funding

The main proponent of the study is using personal funds to conduct the study. Funding of the braces will depend on the patients and their guardians.

REFERENCES

  1. Schwartz book of Surgery 8th Edition by F. Charles Brunicardi
  2. Trauma, Fifth Edition by David Feliciano, MD
  3. A logical approach to trauma – Damage control surgery Shibajyoti Ghosh, Gargi Banerjee, Susma Banerjee, D. K. Chakrabarti Department of Surgery, R. G. Kar Medical college, West Bengal, India.
  1. Townsend: Sabiston Textbook of Surgery, 17th ed., Copyright © 2004 Elsevier Combat Damage Control Resuscitation: Today and Tomorrow; Colonel Lorne H. Blackbourne, MDUS Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave. Fort Sam Houston, TX 78234USA
  2. Damage Control: Beyond the Limits of the Abdominal Cavity. A Review Maeyane S. Moeng, MB, BCh, FCS(SA),1 Jerome A. Loveland, MB, BCh, FCS(SA),2 and Kenneth D. Boffard, BSc(Hons), MB, BCh, FRCS, FRCS(Edin), FRCPS(Glas), FCS(SA), FACS, FCS(SA)
  3. Feasibility of Damage Control Surgery in the Management of Military Combat Casualties Ben Eiseman, MD, Ernest Moore, MD, Daniel Meldrum, MD, Christopher Raeburn MD

DUMMY TABLES

TABLE 1: Demographics and Clinical Characteristics.

CHARACTERISTICS
Nature of Injury Stab wound 62
Gunshot wound 98
Blunt Trauma 54
Penetrating Injuries 53
Initial Vital signs Normotensive 96
Hypotensive 157
Tachycardic (>100cpm) 105

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A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM THE YEAR 2005 TO 2010. A RETROSPECTIVE STUDY

 

 

 

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