Damage control surgery: are we losing control over indications?

ABSTRACT Objective: to analyze the surgeons’ subjective indications for damage control surgery, correlating with objective data about the patients’ physiological state at the time the surgery was chosen. Methods: we carried out a prospective study between January 2016 and February 2017, with 46 trauma victims who were submitted to damage control surgery. After each surgery, we applied a questionnaire to the attending surgeon, addressing the motivations for choosing the procedure. We collected data in the medical records to assess hemodynamic conditions, systolic blood pressure and heart rate on arrival at the emergency room (grade III or IV shock on arrival at the emergency room would partially justify the choice). We considered elevation of serum lactate level, prolonged prothrombin time and blood pH below 7.2 as laboratory indicators of worse prognosis, objectively corroborating the subjective choice of the procedure. Results: the main indications for damage control surgery were hemodynamic instability (47.8%) and high complexity lesions (30.4%). Hemodynamic and laboratory changes corroborated the choice in 65.2% of patients, regardless of the time; 23.9% presented hemodynamic changes compatible with degree III and IV shock, but without laboratory alterations; 4.3% had only laboratory abnormalities and 6.5% had no alterations at all. Conclusion: in the majority of cases, there was early indication for damage control surgery, based mainly on hemodynamic status and severity of lesions, and in 65.2%, the decision was compatible with alterations in objective hemodynamic and laboratory data.摘要 目的：分析外科医师实施损伤控制性手术（damage control surgery）的主观指征，并将其与手术选择时患者的生理状态客观数据进行关联分析。方法：本研究为前瞻性研究，纳入2016年1月至2017年2月期间接受损伤控制性手术的46名创伤患者。每例手术完成后，向主刀医师发放调研问卷，询问其选择该术式的动机。通过查阅患者病历，收集其抵达急诊室时的血流动力学状态、收缩压及心率数据（抵达急诊时处于Ⅲ级或Ⅳ级休克可部分作为手术指征）。将血清乳酸水平升高、凝血酶原时间延长及动脉血pH值低于7.2列为预后不良的实验室指标，以客观佐证术式选择的合理性。结果：损伤控制性手术的主要指征为血流动力学不稳定（47.8%）及高复杂性创伤病变（30.4%）。无论手术时机如何，65.2%的患者的术式选择均得到血流动力学及实验室指标变化的佐证；23.9%的患者存在符合Ⅲ、Ⅳ级休克的血流动力学变化，但无实验室指标异常；4.3%仅存在实验室指标异常；6.5%未出现任何相关指标异常。结论：多数病例中，临床医师主要基于血流动力学状态及创伤病变严重程度早期选择损伤控制性手术，其中65.2%的手术决策与客观血流动力学及实验室指标异常相符。