Duodenal injury/DCR

Wed May 21 04:05:10 BST 2008

Although the data is coming out regarding early hemostatic resuscitation in both civilian and military, there are some important facts and problems:

-Fact: Massive transfusion defined as the transfusion of 10 or more packed red blood cell (PRBC) units in a 24-hour period  carries a high mortality rates between 25% and 50%. 

Problem: This definition doesn't take into consideration acute traumatic hemorrhage (15 units of PRBC transfused over 45 minutes) vs. ongoing blood loss over 24 hrs (15 units PRBC over 24 hours). For statistical purpose we can not compare this 2 group of patients. They are DIFFERENT.

-Fact: These patients frequently develop the "death triad" which consist of acidosis, hypothermia, and coagulopathy. 

Problem: Current teaching is to avoid reaching these conditions by using damage control surgery. However, conventional resuscitation practice  focuses on rapid reversal of acidosis and prevention of hypothermia using large volumes of crystalloid and without taking into consideration early correction of coagulopathy which is the main focus or Damage Control Resuscitation.

-Fact: Trauma induced coagulopathy can develop in 24.4% of patients independent of acidosis and hypothermia but secondary to trauma by itself.  

Problem: Direct treatment of coagulopathy has been relatively neglected and viewed as a byproduct of resuscitation, hemodilution, and hypothermia. 

New Frontiers: Currently management of coagulopathy-related bleeding is based on blood component replacement therapy. Recent military experience reported a high 1:1.4 plasma: RBC ratio is independently associated with improved survival primarily by decreasing death from hemorrhage. We presented similar results in the civilian trauma world (presented AAST 07, JTrauma in press) This approach to total resuscitation, including correction of early coagulopathy is more proactive rather than reactive after the hypocoagulopathic state has developed. 

My 2 cents

Juan

Juan C Duchesne MD, FACS, FCCP
Trauma and Critical Care Surgery Section
Surgical Hospital Center Director
Director Surgical Intensive Care Unit  
Louisiana ATLS / PHTLS State Faculty

Tulane University School of Medicine
1430 Tulane Ave., SL-22
New Orleans LA 70112-2699
Tel. 504-988-5111
Fax. 504-988-3683

>>> "Sise, Mike MD" <Sise.Mike at scrippshealth.org> 5/18/2008 10:25 PM >>>
Juan,

Thanks for the advice on the duodenum.

 We limit crystalloid to what it takes to keep the blood tubing clear - usually less than 2 liters normal saline. Two week ago I repaired a ruptured AAA who presented with a pressure of 60 and most of his blood volume in his retroperitoneum. To the OR in 5 minutes and no fluid until I had a clamp on his aorta. We gave 8 units pRBCs, 1.5 units cell saver, 8 units FFP, 12 pack of platelets, and 1,200 cc normal saline. He entered the OR with a base deficit of  -13 and left the OR with a damage control closure, a base deficit of -2 with a normal INR and no further bleeding. Had to bolus some normal saline the first day but was able to close him on the 2nd postop day and he did not develop ARDS.

1:1 seems to work but is it because we give blood or because we limit crystalloids - especially Ringer's lactate? We all need more studies to make sure that 1:1 is not the latest "American Idol" of trauma care.

Mike Sise

________________________________

From: Duchesne, Juan C [mailto:jduchesn at tulane.edu <mailto:jduchesn at tulane.edu> ]
Sent: Sun 5/18/2008 5:56 PM
To: Trauma &amp; Critical Care mailing list; trauma-list at trauma.org
Cc: Sise, Mike MD
Subject: RE: (no subject)

Mike- Good case. For 4th portion duodenal injury stapling the pylorus on the first phase of Damage Control (DC) might create (compromise the patient) more trouble than good at this time. If necessary I will do it on my second trip back to the OR (Third Phase of DC) in conjunction with a gastrojejunostomy...... if any question regarding my repair .
Attached I placed couple of cases where we used TA-60 stapler at the pylorus without cutting plus wide drainage.
Mike-
Good to hear more people using damage control resuscitation (DCR) with close ratio's for patients with severe hemorrhage..........
How much Crystalloids you guys allowed anesthesia to give while on DCR mode.........we have drastically lowered crystalloids use in this group of patients from average of 14L to 2.2L.....A BIG DIFFERENCE.

Nice to hear from you
Juan
CharityOne

________________________________

From: trauma-list-bounces at trauma.org on behalf of KMATTOX at aol.com
Sent: Sun 5/18/2008 7:05 PM
To: trauma-list at trauma.org
Cc: sise.mike at scrippshealth.org
Subject: Re: (no subject)

I personally would NOT close the pylorus on this first  operation.  If I did,
I would reach through the open stomach and grab  the pyloric ring with a
Dexon suture (an 0 or 00)    and occlude  it. 

k

In a message dated 5/18/2008 6:46:13 P.M. Central Daylight Time,
Sise.Mike at scrippshealth.org writes:

Duodenal  injuries - when to interrupt the pylorus and how to do it.

Difficult  duodenal repair for injury to the 4th portion not involving the
pancreas and  remote to the ampulla. Through and through 45 caliber gunshot
wound suture  closure but concern for the repair. Vena cava also repaired. 12
units of  pRBCs, 12 of FFP and, a 12 pack of platelets. Planning a temporary
abdominal  wall closure. Do you interrupt the pylorus and, if so, how do you do  it.

Mike Sise
San Diego

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