Patient in Extremis or Deteriorating in OR
Severely injured trauma patient OR critically ill non-trauma patient (e.g., ruptured AAA, mesenteric ischemia, perforated viscus with sepsis) showing physiologic deterioration.
All Pathways
General SurgeryEmergency
Damage Control Surgery Principles (WSES 2018)
Damage Control Surgery Principles (WSES 2018): Patient in Extremis or Deteriorating in OR → Assess for Lethal Triad / DCS Indications → Damage Control S...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Decision Assess for Lethal Triad / DCS Indications
LETHAL TRIAD: 1) Hypothermia: Core temp <35°C (especially <34°C). 2) Acidosis: pH <7.2, base deficit <-6 (or <-15 if age <55), lactate >5 mmol/L. 3) Coagulopathy: INR >1.5, clinical oozing, massive transfusion (>10 units pRBC). OTHER: Ongoing hemodynamic instability, prolonged surgery >90 min without control.
03Decision Damage Control Surgery Indicated?
Consider DCS if: Any component of lethal triad present or developing, inability to achieve hemostasis, anticipated prolonged surgery in unstable patient. Do NOT over-apply: Some patients can tolerate definitive repair. Surgeon judgment is key.
04Action Proceed with Definitive Repair
Patient physiologically stable. No lethal triad. Complete definitive repair: vascular repair, bowel anastomosis, fascial closure. Standard postoperative care.
05Outcome Fascia Closed - Recovery
Definitive repair complete. Fascia closed. Continue postoperative care. Monitor for complications: Fistula, abscess, wound issues.
06Action DCS Phase 1: Abbreviated Laparotomy
GOAL: Stop bleeding, control contamination, <90 minutes. HEMORRHAGE: Pack all four quadrants, ligate bleeding vessels, NO definitive vascular repair unless rapid. Damage control for liver/spleen (packing, no resection). CONTAMINATION: Staple transected bowel (no anastomosis), drain/ligate bile ducts, temporary ostomy if needed. DO NOT: Anastomose bowel, close fascia definitively.
07Action Temporary Abdominal Closure (TAC)
Options: 1) NPWT with continuous fascial traction (preferred - best closure rates). 2) Bogota bag. 3) Vacuum-assisted closure. 4) Wittmann patch. KEY: Protect bowel, control fluid loss, allow fascial approximation attempts. Avoid lateral fascial retraction.
08Action DCS Phase 2: ICU Resuscitation
GOALS (24-72 hours): 1) REWARM: Core temp >35°C (active warming). 2) CORRECT ACIDOSIS: Lactate clearing, pH normalizing (bicarbonate if pH <7.1). 3) CORRECT COAGULOPATHY: FFP, platelets, cryoprecipitate, TXA. Massive transfusion protocol if ongoing hemorrhage. 4) HEMODYNAMIC OPTIMIZATION: MAP >65, adequate UOP, vasopressors as needed. 5) MONITOR IAP: Prevent ACS.
09Decision Ready for Return to OR?
Criteria for Phase 3: Temp >35°C, pH >7.25, INR <1.5, lactate trending down, hemodynamically stable off high-dose vasopressors. Typically 24-72 hours. Do not rush back if still physiologically deranged.
10Action Continue ICU Resuscitation
Not yet ready. Continue warming, resuscitation, blood product administration. Reassess q6-12h. If deteriorating despite resuscitation, may need emergent return to OR for missed injury or ongoing hemorrhage.
- Path rejoins step 09Shared downstream outcome
11Action DCS Phase 3: Definitive Repair
Return to OR when physiologically optimized. REMOVE: Packing (carefully - may restart bleeding). REPAIR: Definitive vascular repair, bowel anastomosis or ostomy formation, assess bowel viability. CLOSE: Attempt primary fascial closure if possible. If not, apply component separation or biological mesh.
12Decision Fascial Closure Achievable?
Attempt primary fascial closure at each OR visit. Goal: Close within 5-7 days to prevent frozen abdomen. If unable: Component separation, mesh-mediated closure, or accept planned ventral hernia.
- Path rejoins step 05Shared downstream outcome
13Outcome Planned Ventral Hernia
Unable to close fascia. Skin-only closure or skin graft over granulation tissue. Plan delayed hernia repair in 6-12 months.
14Warning ⚠️ Timing is Critical
Early decision for DCS saves lives - don't wait until patient is moribund. But over-application leads to unnecessary morbidity from open abdomen. Surgeon must weigh benefit of abbreviated surgery vs. complications of leaving abdomen open.
Guideline Source
WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Decision for DCS is surgeon judgment - algorithm provides framework
- Resource availability affects implementation
- Pediatric thresholds may differ
- Non-trauma indications less well established
- Open abdomen management requires specialized training
Applicable Regions
USEUGlobal
Global: WSES damage control principles widely adopted
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Damage Control Surgery Principles (WSES 2018)?
The Damage Control Surgery Principles (WSES 2018) is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients.
What guideline is the Damage Control Surgery Principles (WSES 2018) based on?
This algorithm is based on WSES 2018 Guidelines: The Open Abdomen in Trauma and Non-Trauma Patients (DOI: 10.1186/s13017-018-0167-4).
What are the limitations of the Damage Control Surgery Principles (WSES 2018)?
Known limitations include: Decision for DCS is surgeon judgment - algorithm provides framework; Resource availability affects implementation; Pediatric thresholds may differ; Non-trauma indications less well established; Open abdomen management requires specialized training. Individual patient factors may require deviation from these recommendations.
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