Study on the Outcome of Damage Control Surgery

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

Submitted by:

Chris George C. Pales, MD

Co-Author:

Benedict Edward P. Valdez, MD

INTRODUCTION:

WHAT IS THE TOPIC ALL ABOUT?

The traditional approach to combat injury care is surgical exploration with definitive repair of all injuries. This approach is successful when there is limited number of injuries. These are usually performed in patients with unstable conditions such as profound hemorrhagic shock which known to affect the over-all 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%.

The Three stages of damage control are as follows:

1. Control of hemorrhage and contamination. Also known as bail-out surgery is the first stage. It is a life-saving procedures and is rapidly performed by the surgeon. The main goal this time is to control blood loss and minimizing contamination. It includes control of hemorrhage from bleeding major vessels and solid organs through packing of abdomen, deviation from intestinal anastomosis and temporary closure of abdomen.
2. Resuscitation: Once control of hemorrhage is achieved, 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. One patient has been stabilized, especially within 24-48 hours, definite procedure will be done at operating room.

WHAT IS ALREADY KNOWN ABOUT THE TOPIC?

Damage control surgery is relatively new technique, about 20 years old. It is well recognized that trauma patients especially those with profound shock has 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 patient is having unstable vital signs at 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 avoid death to patient. The well recognized consequence of hypovolemic, hypothermic patient is what we call the “lethal triad.” It comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. It is a viscous cycle that is very lethal if not recognized and controlled immediately.

Patient who is stable with acceptable laboratory results, good ventilator response, non-hypothermic, are then returned to the operating 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.

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

WHAT IS NOT YET KNOWN ABOUT THE TOPIC?

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 of 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

2. 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 affects the outcome of patients undergoing damage control surgery in SPMC from January 1, 2005 to December 2010 in terms of nature of 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

2. Clinical characteristics:

• Pre-operative vital signs

• Associated Injuries
• GCS score
• Organs Involved

3. Co-morbidities
4. 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 during 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 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 in 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 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 in 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 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, 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, Organs involved.

ETHICAL CONSIDERATIONS

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. A 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.

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 in confidentiality.

Extent of Use of Study Data

The data collected by the researcher will only be used to answer the objectives of 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 Dr. Benedict Valdez, head of Section of Trauma, Department of Surgery, SPMC. He is the co-author who will aide 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 for 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

.

REFERRENCES

1. Schwartz book of Surgery 8^th 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.

4. Townsend: Sabiston Textbook of Surgery, 17th ed., Copyright © 2004 Elsevier
5. 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
6. 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)

7. 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.

TABLE 2: OUTCOME

TABLE 3: BUDGET

TABLE 4: TIMETABLE

CURRICULUM VITAE

Name: Chris George C. Pales

Address: Unit 303, Palmetto Place, Maa road, Davao City

Telephone
Cell: 09238060856

Phone
Email: docpales@gmail.com/colicaab@yahoo.com

Personal Information


Date of Birth: April 9, 1983


Place of Birth: Koronadal City, South Cotabato


Citizenship: Filipino


Status: Married


Gender: Male

Education:

Elementary: Kipalbig Elementary School, Kipalbig, Tampakan, South Cotabato (SY 1990-1996)

High School: Notre Dame of Marbel University, Koronadal, South Cotabato (SY 1996-2000)

Colllege: West Visayas State University, Iloilo City (SY 2000-2004)

Medicine: West Visayas State University, Iloilo City (SY 2004-2008)

DATA COLLECTION SHEET

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

Chris George C. Pales, MD/Benedict Edward P. Valdez, MD

Hospital #:

Age:

Sex:

NATURE OF INJURY

Stab wound______

Gunshot wound______

Blunt Trauma______

Penetrating Injuries______

VITAL SIGNS ON ADMISSION

BP:

HR:

RR:

TEMP:

GCS score:

TIME OF ARRIVAL SINCE INJURY

_______ Minutes

_______ Hours

_______ Days

DURATION OF OPERATION:

UNITS OF BLOOD TRANSFUSED:

INTRA-OP VITAL SIGNS:

BP:

CR:

ORGANS INVOLVED:

RE-OPERATION DONE FOR DEFINITIVE PROCEDURE?

____Yes

____No

NUMBER OF HOSPITAL STAY:

DISPOSITION:

______DISCHARGED IMPROVED

______DIED

CAUSE OF DEATH: