Surgery in difficult or problematic settings

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Surgery in difficult or problematic settings

• Dimitrios Tsiftsis
• General Surgeon
• 1st Surgical Department
• General Hospital of Nikea, Greece

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Difficult settings
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John Hopkins Hospital
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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

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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)

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Pitfalls in the Evaluation and Management of the
Trauma PatientCurr Probl Surg 200744778-833
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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)
• Con?ict resolution issues

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Prevention filters
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T R A U M A

• Date
• 24/11/1963
• Lee Harvey Oswald
• Shot
• Transport time
• 10 min
• Surgeon
• G.Tom Shires reports

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3 liters of blood
Shattered spleen
Inferior vena cava, kidney, liver, hole
Shattered pancreas
Aortic bleeding
Superior mesenteric artery sheared off aorta
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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

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Know your capacities

• Know the enemy and know yourself, and you can
  fight a hundred battles with no danger of defeat
• Sun-Tzu

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• 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

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Pay someone to do it for you
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• The greatest mistake in the treatment of
• diseases is that there are physicians for the
  body
• and physicians for the soul,
• although the two cannot be separated
• Plato

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Planning

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

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Modern surgeon balances

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

• Case load
• Case severity
• Emergencies
• Mass events

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Do not move the disaster area from the ER

• Radiology
• Surgery
• Laboratories
• Floor
• ICU (?)

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Triage
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Indications for and Techniques of LaparotomyD.
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

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

• Intention to cure
• Safe
• Fast
• Plan B

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Damage control surgery

• The 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 De?nitive
  Surgical Trauma Care 2nd ed. Edward Arnold
  (Publishers) Ltd, England. 2007

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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

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Shorten operation time
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Shorten time in surgery

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

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Physiologic Guidelines That Predict the Need for
Damage Control

• Hypothermia lt34C
• Acidosis Phlt7.2
• Serum bicarbonate lt15mEq/L
• Transfusion gt4000ml of RBC
• Transfusion gt4000ml of blood products
• Intraoperative volume replacement gt12000ml
• Clinical evidence of intraoperative coagulopathy
• Mohr A., Asensio J., Garcia L. et al. Guidelines
  for the institution for Damage Control in trauma
  patients, International Trauma Care, 2005

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Timeframe
?lt34?C pHlt7,2, lactategt5mmol/lt, Coagulopathy
Complete operation in 60 Transfer to ICU inlt90
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• Control hemorrhage - Ligate all large bleeding
  vessels
• Explore the abdomen
• Contamination control
• Pack the abdomen
• Temporarily close the abdomen
• Transfer to the ICU

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Timeframe
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Abdominal Vessel Ligation and Expected
Complications
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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

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

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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, 200291 92103

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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

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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

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Dedicated trauma surgery courses
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Dedicated trauma fellowships

• Brigham and Womens 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

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Summary

• Any setting can become problematic for the
  practicing surgeon
• Beforehand planning for MCIs 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

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• Thank you for your attention