POSTOPERATIVE CARE AND COMPLICATIONS OF DAMAGE CONTROL SURGERY

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The surgeon who, having completed a damage control procedure, rolls the patient into the recovery room is usually relieved to have a live patient. The anesthesia team, exhausted from a heroic resuscitation, tallies the many units of blood and plasma and platelets and colloid and crystalloid and amps of calcium. The lines are hooked up to the ICU monitors, the norepinephrine is infusing. The arterial line reads 98/68 mm Hg, a unit of packed cells that was brought over with the patient is hung, and the pulse oximeter reads 90% with an F io2 of 1.0. The anesthesia team retires triumphant; the patient made it out of the operating room and their exertions are over. A desperate situation has been escaped in which continued operative attempts to control bleeding led to more bleeding, and an accelerating downward spiral toward death has been averted. At least that is how it seems for the moment. But the surgeon's work is just beginning.

The challenges facing the surgeon postoperatively after a damage control procedure rival those faced in the operating room. The situation is not as urgent, but the many unknowns and options require a deliberate plan, flexibility, persistence, and stamina. A high degree of judgment and skill is required for the surgeon to manage the patient, lead the team, communicate effectively with the family, and recognize his or her own limitations.

Section snippets

THE IMMEDIATE POSTOPERATIVE PERIOD

The first concern in the surgical intensive care unit (SICU) is resuscitation. This has usually been an ongoing and losing battle in the operating room and is usually the reason for a damage control procedure in the first place. Much catching up must still be done. Most patients arrive in the SICU cold, coagulopathic, and acidotic, with ongoing hemorrhage. Steps to break this vicious circle must be aggressive and immediate.

RETURNING TO THE OPERATING ROOM

Returning a patient to the operating room after damage control can be either planned or unplanned. Damage control procedures usually imply that more work needs to be done in the operating room, so nearly all involve a planned reoperation. An unplanned return usually means that the surgeon decides to go back to the operating room sooner than planned or before resuscitation goals have been achieved. The indications for unplanned return have been discussed and include suspected surgical bleeding,

LATE POSTOPERATIVE CONCERNS AND COMPLICATIONS

These very ill patients benefit from an experienced surgical critical care team. The problems that must be addressed postoperatively include all organ systems and in many respects do not differ from those of other critically ill surgical patients. The consequences of shock, multiple transfusions, and massive injury result in the systemic inflammatory response syndrome, infection, and multiple organ failure in many of these patients. A primer of surgical critical care is not the purpose of this

SUMMARY

Damage control procedures are being used with increasing frequency as the physiologic limits of the surgical patient are approached and recognized. These patients are returned to the SICU, where rapid restoration of circulating volume, normothermia, maintenance of oxygen delivery, and correction of transfusion-associated coagulopathy are essential to the success of the technique, which requires expeditious reoperation and completion of definitive surgical management. The potential need for

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Address reprint requests to R. Russell Martin, MD Department of Surgery Brooke Army Medical Center San Antonio, TX 78234

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From Brooke Army Medical Center, San Antonio, Texas

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