Damage Control Anesthesia

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Damage Control Anesthesia

• Richard P. Dutton
• University of Maryland School of Medicine
• Director of Trauma Anesthesiology
  
• Fall 2005 The International Trauma Anesthesia
• and Critical Care Society (ITACCS)
• 2006.10.31
  Fellow ???

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• Trauma ranks first as the cause of death for
  persons up to age 40 and third for all age
  groups.

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History Of Trauma Care

• Golden hour in 1970s
• Fix everything now in 1980s
• Damage control

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Damage Control

• One of the buzzwords in modern trauma care.
• A plan of care for the badly injured patient.

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Prolonged Surgery Operating The Patient To Death

• Hypothermia
• Coagulopathy
• Acidosis

Trauma triangle of death Bloody vicious
cycle
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Second hit Straw That Breaks The Camels Back

• Fatal exacerbation of traumatic brain injury
• Systemic inflammatory response syndrome
• Acute lung injury
• Sepsis

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Traumatologist

• Now includes
• trauma surgeons
• emergency medicine physicians
• anesthesiologists
• other physician/nonphysician trauma care
• specialists
• nonclinical personnel such as
  epidemiologists

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• To date there has been nothing written about the
  anesthesia component of damage control.
• Little public discussion of what the
  anesthesiologist can do to facilitate the overall
  goals of the trauma team.
• Lack of specialized trauma anesthesiologists in
  the United States.

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• When one thinks about how many of these
  variables are under the control of the
  anesthesiologist it becomes obvious that
  anesthetic management may be as critical as
  surgical management in achieving the best
  possible patient outcome.

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The Goals of Damage Control Anesthesia
Airway and Ventilator Management Control of
Bleeding Preservation of Homeostasis Analgesia
and Sedation
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Airway and Ventilator Management
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• QA emergent cricothyroidotomy (0.1)

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Tidal Volume Ventilating Pressure

• As low as necessary to maintain O2 saturation
• Positive intrathoracic pressure will decrease
  venous return C.O.
• TV 56 ml/kg, PEEP 5 cm, 810 breaths/min
• Pressure controlled mode of ventilation

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Control of Bleeding
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• Surgeon
• Angiographer
• Fluid
• Blood products

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Controlled Volume Resuscitation

• Regional vasoconstriction.
• Clot formation.
• Reduce hypothermia.
• Limit dilution of RBC, platelets, clotting
  factors.
• Potential for worsening hypoperfusion,
• with risk for increased acidosis and
• organ injury.

Deliberate hypotensive resuscitation
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Maintenance of Blood Composition
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• Stabilization of BP without recourse to ongoing
  fluid administration is
• the best clinical sign of successful
  hemostasis

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Preservation of Homeostasis
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• Simple normalization of vital signs should not be
  equated with restoration of tissue perfusion.
• ?occult hypoperfusion is common in young
  trauma patients

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Recovery from Hemorrhagic Shock

• Resolution of metabolic acidosis on ABG analysis
  and normalization of serum lactate.
• Maximization of C.O. in response to fluid
  administration
• Normalization of gastric or sublingual tissue
  acidosis.
• Tolerance of a normal level of anesthesia and
  analgesia.

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Hypothermia?
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Homeostasis is especially important to the
brain-injured patient

• Any single episode of hypotension or hypoxia
  increase mortality from TBI by 4x
• Occurrence of hypotension hypoxia increase
  mortality from TBI by 10x

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Analgesia and Sedation
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Exacerbation of Hypotension Is NOT A
Contraindication To Anesthesia
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• Hemorrhage volumes and the duration of bleeding
  are known to be worse in the vasoconstricted
  subject.

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Use of Anesthetic or Analgesic Agents

• Move from a vasoconstricted to a vasodilated
  state.
• End-organ perfusion.

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• Achieve a deep and stable level of anesthesia as
  early as possible in the care of the unstable
  trauma patient.
• Begin loading the patient with fentanyl early in
  the resuscitation, using small doses at first and
  responding to drops in BP with boluses of fluid.
• Goal is to achieve a cardiac anesthetic 50 to
  100 mcg/kg over the first few hours.

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Conclusion