Source control and damage control

damage controlI got a couple of questions about what is source and damage control?


The group of people I interact with began thinking about the problem ten years ago. At the time we did not have good data but this was later provided by the German group. It is now known that inadequate source control is a major factor for bad outcome. We still lack a good language to describe it in writing but I will give a short account.

The surgeon is requested to answer the question: How certain am I (the surgeon) that the operation has cleared the problem of this patient allowing the patient to recover without further intervention?

Acute appendicitis is an index situation. The appendix is removed and the expectation is swift recovery. A single operation and a single course of antibiotics is all it takes.

The percutaneous (or operative ) drainage of an intraperitoneal abscess is an interesting intermediate. Think about the answer you can give to the question above next time you drain an abscess.

In more complex situations it may not be possible to excise a single local source, or there may be a more generalized problem of the patient. An example could be necrotizing pancreatitis with abscess , and SIRS/MODS. Source control here may be difficult or even impossible, so a different strategy is needed. The surgeon needs to plan ahead the next step, because there will be, almost certainly, a next step.


This brings us to the concept of damage control, a concept which originates in trauma surgery. Here we consider that the operation itself is a trauma to the patient and will have physiological consequences, like any mechanical trauma. (the body does not make a difference between being run over by the bus or by the surgeon).

Not only the operation is expressed in physiology but even more so any failure of the operation to achieve its goal. An example: Resecting acute diverticulitis with primary anastomosis may be wonderful source control, but secondary failure of that anastomosis is bad damage control and may kill the patient.


Perhaps, the concept underlying it all is pathophysiology. Disease, operations, and complications are all expressed in patients as pathophysiology. So the surgeon needs to answer the question: How certain am I (the surgeon) that the pathophysiology I record in this patient comes from a local disease process which can be completely excised (source control) with little risk of complications of the operation (damage control).

When one begins to analyze the surgery we do in this fashion, and we try to put percentage figures to the estimates, it all becomes very interesting how surgeons interact with these estimates.

In emergency surgery we need to balance degrees of source control with degrees of damage control, and all the time measure, and anticipate, the pathophysiological responses of the patient. You need to understand if this patient has normal responses or deficient repsonses because of longstanding illness. Is wound healing capacity retained or deficient. Are the instestines normal or deficient.


Although I have my scientific background in surgical infection you may have noticed in this message and others that I almost never describe the situation in terms of bacteria and antibiotics, or irrigations. Along with many other surgeons with similar background the focus is on how tissues of the body behave and the pathophysiology the patient expresses. The bacteria means nothing Pasteur said, it is all a matter of the environment. It takes a while to come around to this insight.

  1. Herky
  2. Montag surgeon
  3. Quape
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