Page 1645 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1164 PART 10: The Surgical Patient

rectal injuries require proctosigmoidoscopic assessment preoperatively. is identified. Such lacerations require drainage and no further surgical
Recent data do not support presacral drainage or rectal washout. exploration. If hepatic bleeding is still active at the time of laparotomy,
Primary repair after appropriate debridement with or without a then the initial maneuver is to pack the liver area very tightly with dry
defunctioning colostomy is recommended. gauze and continue with the remainder of the laparotomy for approxi-
The abdomen remains a frequent source of sepsis in surgical patients mately 15 minutes. This allows time for stabilization of the patient’s
in the ICU setting. These complications arise primarily after operations hemodynamic status, as well as time for replacement of fluid deficits.
on the bowel, so any traumatized patient who has had bowel lesions If, on removal of the pack, the bleeding has stopped, as is frequently
treated surgically and who remains septic should be considered as the case, then the treatment is drainage of the perihepatic space.
having an intra-abdominal source for that sepsis. This requires inten- Failure to control bleeding by this technique necessitates clamping the
sive investigation using modalities such as CT scan and ultrasound; portal triad, examining the wounds to determine the source of hem-
drainable lesions may be treated by percutaneous techniques under CT orrhage, and direct suture ligation of the bleeding points. Intermittent
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or ultrasound guidance. When such techniques are contraindicated or release of the clamp will allow examination for hemostasis.
are likely to be ineffective, or when the source is not obvious despite When bleeding arises from the retrohepatic vena cava, clamping of
investigations, laparotomy may be necessary to identify and treat septic the portal triad (Pringle maneuver) fails to control the bleeding. It is
complications. With the availability of sophisticated technology in the then necessary to rotate the liver medially and visualize the retrohepatic
form of CT and ultrasound investigations, it is usually possible to make vena cava. Earlier reports have suggested the use of intracaval shunts
a diagnosis prior to laparotomy, and only under very unusual circum- to assist in preserving a dry field so that the injured hepatic veins and
stances is the lesion not identified prior to laparotomy. retrohepatic vena cava may be identified and repaired. However, recent
One of the common areas of sepsis in patients with a perforated bowel data have shown a very high mortality associated with the use of the
is wound infection. Although the incisions in these patients frequently intracaval shunts, and aggressive hepatic packing has been an alternative
are left packed and open, in some instances the wound is closed pri- that results in a better outcome. In extreme circumstances, complete
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marily. The possibility of suppuration in the wound always should be vascular isolation of the liver by also clamping the suprahepatic and
considered at the first sign of sepsis, and the wound should be opened infrahepatic vena cava may be successful, although this maneuver
for diagnosis as well as treatment. frequently results in cardiac arrest in the already hypovolemic patient.
Bleeding from through-and-through penetrating wounds of the liver
■ LIVER INJURIES also can be tamponaded by insertion of inflatable devices directly into
Although liver injuries may occur from both blunt and penetrating the hepatic wound. In some instances, formal resection of liver tissue is
required to control hemorrhage, particularly when there is major devi-
trauma, patients with blunt injury to the liver tend to have a higher mor- talization of liver tissue. This measure usually does not require formal
bidity and mortality because of the irregular type of laceration and the anatomic lobectomy but instead consists of resectional débridement of
involvement of an entire lobe or frequently both lobes of the liver. The the bleeding, devitalized liver tissue as demarcated by the edges of the
signs of liver injuries are very nonspecific, and the diagnosis frequently laceration itself. The bare area of the liver is then treated with suture
is made only at laparotomy, the patient presenting with signs of intra- ligature, cautery, and the application of microfibrillar collagen or other
abdominal hemorrhage. Liver hemorrhage is sometimes the chief cause of types of topical hemostatic agents. With massive blood transfusions, the
a patient presenting in hemorrhagic shock. Although DPL for hemorrhage patient may show signs of coagulopathy. In such instances, it is advisable
may suggest liver injuries, it is not as specific as CT or ultrasound and is to pack the liver temporarily, close the abdominal wound, and correct
indicated in the hemodynamically compromised patient when FAST is the coagulopathy in the ICU with the hope of stabilizing the patient.
not available or the patient cannot be transferred safely to the CT suite. The patient may then be taken back to the OR in 48 hours for removal
Otherwise, these injuries are very clearly outlined by CT or ultrasound of the pack, after which the bleeding will have either ceased or decreased
examination of the abdomen. Other signs that suggest the possibility of considerably, allowing formal treatment of the bleeding source. The
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liver injuries include bruising of the lower chest, particularly on the right use of massive transfusion protocols (warm blood, fresh frozen plasma,
side; contusions over the upper abdomen; fractured lower ribs: an elevated platelets, and coagulation factors) is important in preventing this lethal
hemidiaphragm; and increased size of the liver shadow on plain films of triad of hypothermia, acidosis and coagulopathy in these patients.
the abdomen. The usual indication for surgery in a patient with liver
injury is intra-abdominal hemorrhage. Damage-Control Surgery: Patients presenting with major liver injury
Although reported mortality rates from major liver trauma vary from frequently sustain other intra-abdominal, thoracic, extremity, and head
20% to 60%, most of the deaths are due to severe associated injuries, injuries. Such patients pose a great challenge to the surgeon and anes-
particularly of the head and thorax. When death is attributed to the thetist. Massive blood transfusions with hemodynamic and respiratory
liver injury itself, it is usually secondary to uncontrollable hemorrhage compromise are seen in such patients, who become hypothermic,
and later in the course is due to sepsis and multiorgan failure. Careful hypocoagulopathic, acidotic, and hypoperfused. These responses are
surgical technique and postoperative management of these patients will not entirely confined to the patient with major liver injuries but also
decrease the morbidity and mortality. The objectives of surgical man- accompany other injuries to the chest and abdomen. In these circum-
agement of liver injuries are (1) control of hemorrhage, (2) removal of stances, operative strategy should be directed at temporarily controlling
nonviable tissue, and (3) provision of adequate drainage. hemorrhage and contamination by the most expeditious means and
Exposure must be adequate, which necessitates a midline upper allowing the patient to return to the ICU setting, where the cardio-
abdominal incision with the ability to extend into the chest. The liver respiratory, renal, metabolic, hypocoagulable, and hypothermic states
itself should be mobilized completely by transection of the triangular can be monitored and corrected before returning the patient to the OR
ligaments, as well as the falciform ligament, with care taken to secure the for more definitive surgical care. In the setting of abdominal injuries,
inferior phrenic artery. The operative strategy should allow exposure of this involves control of hemorrhage by packing and ligation of vessels
all structures that are likely to be injured or have an impact on manage- without attempts at formal repair, as well as ligation and temporary
ment of the injury, including the vena cava and other retroperitoneal stapling of injured bowel ends with evacuation of intestinal contents
structures, and the surgeon must be prepared to perform the Kocher by suction, followed by temporary rapid skin closure of the abdomen.
maneuver, right medial visceral rotation (Cattell-Braasch maneuver) Similar damage-control techniques for thoracic injuries, including trac-
and left medial visceral rotation (Mattox maneuver). totomy and quick stapling of vascular and bronchial structures, allow
the patient to return to the ICU environment for correction of these
Control of Hemorrhage in Hepatic Trauma: In most instances, once the immediately life-threatening abnormalities before being returned to the
peritoneal blood has been aspirated, a nonbleeding hepatic laceration OR for formal, definitive surgical repair of the injuries.

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