Damage Control Resuscitation
Year: 2010
Type: dissertation
Study design: Systematic Review
Abstract: Background: Damage control resuscitation is a novel strategy for the management of the exsanguinating trauma patient. It is a development of the damage control surgery concept, with emphasis on the integration of resuscitation and surgery, and the aggressive management of traumatic coagulopathy. Although pioneered by military surgeons, many aspects of damage control resuscitation are equally applicable to the management of civilian trauma, but awareness outside specialist circles is limited. This is at least in part related to the lack of a precise definition, and the rapid and continuing evolution of the strategy. Objectives: 1. To define the components of damage control resuscitation. 2. To conduct a systematic review of the evidence for damage control resuscitation. Methods: Systematic review of literature. Results: Damage control resuscitation encompasses haemostatic resuscitation, hypotensive resuscitation, hypothermia and acidaemia management and damage control surgery. Systematic review produced the following conclusions: In patients with traumatic haemorrhage predicted to require massive transfusion, a high ratio of fresh frozen plasma to packed red blood cells is associated with decreased mortality. (Evidence level: 2+) A ratio of approximately 1:1 units appears to be optimal, although this evidence is extrapolated from studies which retrospectively stratified intervention groups for survival analysis, rather than dose-finding studies. (2+) In patients with traumatic haemorrhage predicted to require massive transfusion, a high ratio of units of platelets to packed red blood cells is also associated with decreased mortality. A ratio of at least 1 (pooled) unit of platelets to 5 units of packed red blood cells appears to be optimal, although this evidence is again extrapolated. (2-) Recombinant factor VIIa reduces transfusion needs in blunt trauma patients requiring massive transfusion. The effect of recombinant factor VIIa on mortality in this setting is not known. (1-) Recombinant factor VIIa may also reduce transfusion needs in penetrating trauma patients requiring massive transfusion, but the evidence is less clear. As in blunt trauma, the effect on mortality in this setting is also not known. (1-) The use of cryoprecipitate in exsanguinating haemorrhage is founded on reasonable scientific principles, but its use in trauma patients is largely based on studies of poor methodology, and extrapolated data. Cryoprecipitate should be considered when hypofibrinogenaemia has been confirmed, or when traumatic coagulopathy is not responding to other methods of haemostatic resuscitation. (3) Although conceptually attractive, associated with few complications, and frequently recommended, there is no evidence for the use of antifibrinolytics in the trauma setting. There is no new evidence to suggest that pre-operative intravenous fluid resuscitation prior to control of bleeding is beneficial. There is, however, limited evidence to suggest that fluid resuscitation may be harmful, and that patients with penetrating injuries in particular may have better outcomes when fluids are withheld until surgical control of haemorrhage has been obtained. (1-) There is no evidence to support the use of tris-hydroxymethyl aminomethane (THAM) in trauma patients, although in theory appealing. Hypothermia in trauma patients is associated with increased mortality, and should be prevented whenever possible, and aggressively treated when present. (2+) There is no evidence to support the use of extracorporeal warming techniques. (2-) Patients with severe intra-abdominal injuries – in particular those with profound haemorrhagic shock, an existing or developing coagulopathy, a need for time- consuming procedures, or concomitant major injury outside the abdomen – benefit from the use of damage control surgical techniques, which may include curtailment of the procedure by ligation of hollow viscus injuries or resection without anastomosis, ligation or shunting of vascular injuries, packing, and temporary abdominal closure. (2-) The indications for damage control resuscitation remain poorly defined. This applies both in general, and for specific components, such as when resuscitation with predefined blood product ratios should be initiated, or at what stage recombinant factor VIIa should be utilised. Existing criteria are largely based on expert opinion. Discussion: Damage control resuscitation is a composite, multidisciplinary strategy which integrates haemostatic resuscitation, hypotensive resuscitation, hypothermia management, and damage control surgery. Hypotensive resuscitation and damage control surgery are not new concepts, but have been incorporated into an effective management paradigm. Greater appreciation of the importance of traumatic coagulopathy, and its manipulation through haemostatic resuscitation, has led to an explosion of interest in clotting factor and platelet replacement. The resulting resuscitation strategies with predefined ratios of blood products, and avoidance of synthetic fluids, together with the modulation of fibrinolysis, are an exciting development. Although much work remains to be done, these novel treatments, in combination with more established techniques, are revolutionising major trauma resuscitation. This systematic review should assist clinicians in applying damage control resuscitation principles, and maximising their patients’ survival.
Author: Jansen, Jan
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2948888022