Surgery in difficult or problematic settings

Dimitrios TsiftsisGeneral Surgeon

1st Surgical Department General Hospital of Nikea, Greece

Difficult settings

John Hopkins Hospital

But even there difficulties exist

• Massachusetts General Hospital fined $1 million on March 03, 2011

• Medication Overdose: Boston Medical Malpractice Lawsuit Claims Massachusetts General Hospital Gave 76-Year-Old Woman the Wrong Blood Thinner

• In 2008, the most recent year with complete records, 116 wrong-site surgeries, up from 93 in 2007, were recorded by the Joint Commission

Any setting can become difficult or problematic

• Sudden spike of incoming surgical cases– Number– Severity– Endemic outbreaks

• Sudden drop in hospital facilities– Budget cuts– Personnel cuts– Malfunctioning equipment (eg. CT)

Pitfalls in the Evaluation and Management of the Trauma Patient

Curr Probl Surg 2007;44:778-833

Examples of Potential Problems (Failures) in Team Dynamics

Error in patient management due to incomplete information (PE, labs, physiology)

Errors in communication (plans, instruments, procedures)

Errors in workload distribution (Inexperience, underpowered, Distraction, Lack of supervision)

Conflict resolution issues

Prevention filters

• Date:– 24/11/1963

• Lee Harvey Oswald:– Shot

• Transport time: – 10 min

• Surgeon: – G.Tom Shires reports

3 liters of blood

Shattered spleen

Inferior vena cava, kidney, liver, hole

Shattered pancreas

Aortic bleeding

Superior mesenteric artery sheared off aorta

Any operation can become difficult or problematic

• Task execution errors: In surgery, this could include technical slips and psychomotor errors (eg, bowel injury during laparotomy), and judgment or perceptual errors causing a technical error such as laparoscopic bile duct injury.

• Procedural errors: Errors involving deviation from existing practice pattern or protocol (eg,failure to administer preoperative antibiotics for a bowel case).

• Communication errors: Communication of incorrect data, failure to communicate important data, delayed communication of critical data, etc.

• Decision errors: Errors in judgment related to patient management

Know your capacities

• Management of the alert: activation of the Hospital Emergency Response Plan

• Hospital Incident Management System--Hospital Incident Command Group (ICG)

• The reception of patients in MCI and external traffic flow-- and ambulatory treatment (OPD)

• Emergency Department and internal traffic flow• Management of human resources• Supplement Emergency Response Plans (SERPs) of the

departments and units of the hospital• Logistics and supplies• Management of information--risk communication--

communication systems and --Health Information System (HIS)

• Pharmacy: essential medicines, vaccines and preventive equipment and other supplies such as disinfectants

• Security• Maintenance and safety--essential technical services--

lifelines--rehabilitation of critical equipment

Pay someone to do it for you

The greatest mistake in the treatment ofdiseases is that there are physicians for the bodyand physicians for the soul, although the two cannot be separated

Plato

Planning

• Know your institution capacities• Pre-establish patient transfer protocols• Triage carefully• Stash critical drugs and equipment• Surgeons on call with emergency surgery

training

Modern surgeon balances

• Equipment• Other disciplines • Drugs• ICU• Personnel• Cost

• Case load• Case severity• Emergencies• Mass events

Do not move the disaster area from the ER

Radiology Surgery Laboratories Floor ICU (?)

Triage

Indications for and Techniques of Laparotomy

D. Demetriades, G. Velmahos• The full appreciation of the patient's picture,

taking into account all available information provided by clinical examination, radiographic findings, and laboratory tests is more useful than the adherence to rigid protocols that prevent individualization

• However, the two signs, which remain absolute indications for laparotomy following penetrating or blunt abdominal trauma are peritonitis and hemodynamic instability

Trauma, 6th Edition, 2008 McGraw-Hill

I learned a long time ago that minor surgery is when they do the operation on someone else, not you

Bill Walton

Once in the OR

• Intention to cure• Safe• Fast• Plan B

Damage control surgeryThe concept of ‘damage control’ (also known as ‘staged laparotomy’,

‘Bailout surgery’) has as its objective the delay in imposition of additional surgical stress at a moment of physiological frailty.

This is a technique where the surgeon minimizes operative time and intervention in the grossly unstable patient. The primary reason is to minimize hypothermia and coagulopathy, and to return the patient to the operating room in a few hours after stability has been achieved in an ICU setting. Enough appropriate surgery has to be carried out in order to minimize activation of the inflammatory cascade and the consequences of SIRS and organ dysfunction.

The concept of staging applies both to routine and to emergency procedures, and can apply equally well in the chest, pelvis and neck as in the abdomen.

Kenneth D Boffard ed., Manual of Definitive Surgical Trauma Care 2nd ed. Edward Arnold (Publishers) Ltd, England. 2007

Principles

• Shorten operation time • Employ damage control surgery• Get patient to ICU• Warm patient and correct coagulopathy • Prepare yourself and your team• Re-operate for definitive treatment

Shorten operation time

Shorten time in surgery

• Damage control surgery• Source control surgery• Restoration of physiology over restoration of

anatomy

Physiologic Guidelines That Predict the Need for Damage

Control• Hypothermia <34C• Acidosis Ph<7.2• Serum bicarbonate <15mEq/L• Transfusion >4000ml of RBC• Transfusion >4000ml of blood products• Intraoperative volume replacement >12000ml• Clinical evidence of intraoperative coagulopathyMohr A., Asensio J., Garcia L. et al. Guidelines for the institution for Damage Control in trauma patients,

International Trauma Care, 2005

Τ<34οC pH<7,2, lactate>5mmol/lt,Coagulopathy

Complete operation in 60’Transfer to ICU in<90’

• Control hemorrhage - Ligate all large bleeding vessels

• Explore the abdomen• Contamination control• Pack the abdomen• Temporarily close the abdomen • Transfer to the ICU

Timeframe

Abdominal Vessel Ligation and Expected Complications

Cirocchi R, Abraha I, Montedori A, Farinella E, Bonacini I, Tagliabue L, Sciannameo F. Damage control surgery for abdominal trauma. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD007438. DOI:

10.1002/14651858.CD007438.pub2

Evidence that supports the efficacy of DCS with respect to traditional laparotomy in patients with major abdominal trauma is limited

He who fights and runs away will live to fight another day

Demosthenes

Damage control essential equipment

Basic:• Abdominal, vascular, and chest instruments (including sternal saw)

Damage control essentials:• Packs• Shunts (sterile plastic conduits)• Balloon catheters (large Foley of various sizes with 30 cc balloons)• Sterile silastic bags• Adhesive plastic• Hemostatic agents• Suction drains

Hoey B., Schwab C., Damage control surgery. Scan J Surg, 2002;91: 92–103

Damage control surgery

• No high-tech equipment necessary• No multidisciplinary approach required• No need for complex and fine maneuvers• We can move on to brain - thorax -

extremities immediately

Damage control of extremities trauma

• Stable patient – osteosynthesis

• Polytrauma patient- External fixation

• Do not insist on anatomical reposition, but on fracture stabilisation

• Open fracture-debridment

• Timing is individual considering clinical state

Dedicated trauma surgery courses

Dedicated trauma fellowships

• Brigham and Women’s Hospital, Boston, USA • Sunnybrook Health Sciences Centre, University of

Toronto, Canada• Universidad del Valle, Colombia• The Johns Hopkins University, Baltimore, USA• University of Pittsburgh, USA• University of Nevada School of Medicine, USA• Wake Forest University Baptist Medical Center, USA• Liverpool Hospital, Sydney, Australia• Canberra Hospital, Canberra, Australia

Summary

• Any setting can become problematic for the practicing surgeon

• Beforehand planning for MCI’s is advised• The knowledge of damage control techniques

is life saving in both trauma and non-trauma cases

• Damage control surgery is possible with a minimum technical armamentarium

• Surgical trauma training is widely available

Thank you for your attention