Advances in trauma systems and access to
surgery along with immediate resuscitation strategies including massive
transfusion protocols have significantly reduced the number of early deaths
from hemorrhage after wounding. However, late effects of shock plus adverse
consequences of resuscitation have continued to result in multiple organ
failure and death in the intensive care unit. Thus, modern resuscitation for
hemorrhagic shock must target these late deaths from MOF in order to reduce
overall mortality from injury. Direct peritoneal resuscitation (DPR) has been studied at UofL and could help
reduce MOF after shock. The concept is based upon instillation
of hypertonic peritoneal dialysate into the peritoneal cavity of injured patients
continuously for at least 24 hours. The hypertonic nature of the dialysate
reduces visceral edema and accelerates fascial closure in patients undergoing
temporary abdominal closure (TAC) at the initial operation and DPR has also
been applied to patients undergoing definitive fascial closure at the initial
trauma laparotomy. Abdominal complications are thereby reduced. DPR also
appears to enhance hepatic blood flow and reduce transfusion requirement at 72
hours post-injury. The result is lower levels of ALT and faster normalization
of INR (as an indicators of lesser hepatic ‘injury’ due to shock). Therefore DPR shows promise as an adjunct to
trauma resuscitation strategies we currently use. Further study of DPR is
ongoing via a multi-center trial in the U.S.
Since the dialysate is FDA approved, no special permission is needed to
apply this technique other than the good judgment of the operating surgeon who
is knowledgeable in the technique. The protocol for DPR is as
follows:
1.
Eligible patient’s
are those whose injuries or condition necessitate laparotomy to treat
hemorrhagic shock, defined within 4 hours of hospital
presentation by presence of 3 of the following:
a. Tachycardia
(>120 beats/min);
b. Hypotension
(Systolic BP <90 mmHg or initiation of vasopressor Rx);
c. Global
hypoperfusion (pH<7.32, BD<-4, Serum Lactate>3.0, SvO2<60%);
d. Oliguria
(Urine Output < 0.5 cc/kg/hr for 2 hrs);
e. Blood
Transfusion requirement of >4 units in the initial 4 hrs.
2.
In Patient
requiring Temporary Abdominal Closure.
a.
A single 19-Fr
round Blake drain is placed through the skin of the left upper quadrant and
directed along the left pericolic gutter and into the pelvis near the base of
the mesentery. This is sutured in place
using a 2-0 Nylon.
b.
A 10-10 drape
will be placed over the internal organs and under the internal fascia/parietal
peritoneum.
c.
Two sterile blue
OR towels will be placed over the cassette cover in the open abdominal wall defect. Two 19 Fr round Blake drains will be placed
along the blue towels and brought out the top right side of the wound. A large sterile Ioban® will then be used to
cover the entirety of the wound with at least 6-8 cm of overlap along the
abdominal wall.
d.
The two external
drains on the blue towel will be placed to suction to check integrity of the
seal and will be removed from suction for transport. These drains will be placed to low wall
suction once the patient is in the ICU.
e.
In patients
receiving DPR, it will be given using 2.5% Dianeal solution via the internal
catheter in the left upper quadrant. (*Note--UofL reported Delflex in their
paper describing DPR. See table at end.) An initial bolus of 800ml for the
first hour will be given and will be followed a constant infusion of 5ml/kg/hr
until relaparotomy. This is not titrated, changed or shut off for the entirety of the
protocol without the permission of the attending.
3.
In Patients not
requiring temporary abdominal closure.
a.
A single 19-Fr
round Blake drain is placed through the skin n the left upper quadrant and
directed along the left pericolic gutter and into the pelvis near the base of
the mesentery. (Similar to other trauma laparotomies.) This is sutured in place using a 2-0 Nylon.
b.
The patient’s
laparotomy incision will be closed in whatever manner deemed appropriate by the
attending surgeon.
4.
Resuscitation
will be conducted at the discretion of the treating physicians with an aim
towards restoring hemodynamic stability (MAP>60 off IV vasopressor therapy),
correcting coagulopathy (INR less than 1.6), achieving normothermia
(temperature ≥37°C), correcting acidosis (base excess ≥ -4 or serum lactate ≤ 3) and
adequate tissue oxygenation (sequential serum lactate levels and SvO2≥60%).
Crystalloid and blood component therapy will be initiated to achieve these
goals.
|
|
DELFLEX w/2.5%
dextrose
(what UofL reported)
|
DIANEAL PD-2
w/2.5% glucose
(what we use)
|
|
[Ionic](mEq/L)
|
||
|
Sodium
|
132
|
132
|
|
Calcium
|
3.5
|
3.5
|
|
Magnesium
|
1.5
|
0.5
|
|
Chloride
|
102
|
96
|
|
Lactate
|
35
|
40
|
|
Osmolarity
(mOsmol/L)
|
398
|
396
|
