Worth looking! venous thromboembolism in patients who undergo preperitoneal pelvic packing warrants screening duplex

Pelvic packing - status 2024

Patients with unstable hemodynamics and unstable pelvic ring injuries are still demanding patients regarding initial treatment and survival. Several concepts were reported during the last 30 years. Mechanical stabilization of the pelvis together with hemorrhage control offer the best treatment option in these patients. While pelvic ring stabilization using pelvic binders, external fixators and the pelvic C-clamp are the basis for mechanical stability of the pelvic ring, the optimal modality for pelvic bleeding control is still under discussion. Beside angioembolization (AE) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), pelvic packing PP (predominantly extraperitoneal) with direct access to the pelvic bleeding sources, are potential options. The present overview represents the present status, results and the value of pelvic packing in treating these patients. Interpretation of these results must consider the difference between the initial European concept of pelvic ring stabilization followed by PP in contrast to the North American concept with a reduced rate of pelvic ring stabilizations.

Does preperitoneal packing increase venous thromboembolim risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers

INTRODUCTION

Pelvic fractures are associated with a high risk of venous thromboembolism (VTE). Among treatment options, including pelvic angioembolization (PA), preperitoneal pelvic packing (PPP), and pelvic open reduction internal fixation (ORIF), PPP has been postulated as a VTE risk factor. We aimed to characterize the risk of VTE among pelvic fracture patients receiving PPP, PA or ORIF.

METHODS

We used observational data from a 17-site Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group, a US level I trauma center collaborative working to identify factors associated with posttraumatic VTE, deep venous thrombosis, pulmonary embolism, or pulmonary thrombosis. The CLOTT criteria included age 18 to 40 years with at least one independent VTE risk factor. We compared outcomes of PPP, PA, and pelvic ORIF to reference of no pelvic intervention. Our primary outcome was VTE. A competing risk analysis was performed.

RESULTS

Among 1,387 pelvic fracture patients, VTE incidence was 5.6%. The ORIF patients were most likely to develop VTE (24.7%), while VTE incidence for PPP was 9.0% and 2.6% for PA. After multivariate, risk-competing analysis, none of the three treatment interventions for pelvic fractures were significantly associated with VTE. Initiation of VTE prophylaxis in the first 24 hours of admission independently halved VTE incidence (hazard ratio, 0.55; confidence interval, 0.33-0.91).

CONCLUSION

Pelvic fracture interventions do not appear to be independent risk factors for VTE in our study. Initiation of VTE pharmacoprophylaxis within the first 24 hours of admission remains critical to significantly decreasing VTE formation in this high-risk population.

LEVEL OF EVIDENCE

Therapeutic Study; Level III.

Emergency treatment of pelvic ring injuries: state of the art

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

Preperitoneal pelvic packing in isolated severe pelvic fractures is associated with higher mortality and venous thromboembolism: A matched-cohort study

INTRODUCTION

Preperitoneal pelvic packing (PPP) has been advocated as a damage control procedure for pelvic fracture bleeding, despite of weak evidence.

METHODS

Matched cohort study, TQIP database. Patients with isolated severe blunt pelvic fractures (pelvis abbreviated injury score [AIS] ​≥ ​3, AIS ≤2 in all other body regions) were included. Patients who underwent PPP were matched to patients with no PPP, 1:3 nearest propensity score. Matching was performed based on demographics, vital signs on admission, comorbidities, injury characteristics, type and timing of initiation of VTE prophylaxis, and additional procedures including laparotomy, REBOA, and angioembolization.

RESULTS

64 patients with PPP were matched with 182 patients with No-PPP. PPP patients had higher in-hospital mortality (14.1 ​% vs 2.2 ​% p ​< ​0.001) and higher rates of VTE and DVT (VTE: 14.1 ​% vs 4.4 ​% p ​= ​0.018, DVT: 10.9 ​% vs 2.2 ​% p ​= ​0.008).

CONCLUSION

PPP is associated with worse survival outcomes and increased rate of VTE and DVT complications.

Comparison of Conventional versus Modified Preperitoneal Pelvic Packing in Patients with Bleeding Pelvic Fractures: A Single-Center Retrospective Pilot Study

Background: Bleeding pelvic fractures have high mortality rates, primarily due to severe hemorrhage. Treatment options include mechanical stabilization based on preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta, and angioembolization (AE). The bilateral preperitoneal approach, which uses three pads on each side, is the conventional PPP method. We aimed to compare the bilateral preperitoneal approach with a modified approach, involving selectively packing only heavily bleeding areas, in terms of clinical outcomes and mortality risks. Methods: We included patients who underwent PPP and compared the outcomes between conventional (three sponges placed on each side) and modified PPP (selective packing of critical areas). The primary outcome was 30-day mortality; the secondary outcomes included 24 h mortality, pelvic complications, and transfusion requirements. Univariate and multivariate analyses were performed to determine risk factors for 30-day and 24 h mortality. Results: Among the 47 included patients, 19 and 28 underwent conventional and modified PPP, respectively. There were no significant between-group differences in the 24 h (26.3% vs. 42.9%, p = 0.247) and 30-day mortality rates (47.4% vs. 60.7%, p = 0.366). Using univariate and multivariate analyses, initial lactate levels and the decision to perform AE were found to be significant risk factors for mortality. However, the selected PPP method was not a risk factor for 30-day mortality (odds ratio [OR], 2.22; 95% confidence interval [CI], 0.27-18.26; p = 0.457) or 24 hr mortality (OR, 1.77; 95% CI, 0.24-13.19; p = 0.557). Conclusions: The modified PPP method may be considered in patients with bleeding pelvic fractures for effective bleeding control while minimizing potential complications associated with the conventional PPP.

Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study

BACKGROUND

Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location.

METHODS

Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures.

RESULTS

A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 + 1.1 cm from the sacroiliac joint, 3.5 + 1.6 cm from the common iliac artery, 1.1 + 1.2 cm from the external iliac artery, 2.8 + 0.8 cm from the internal iliac artery, and 2.3 + 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point.

CONCLUSION

This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies.

Preperitoneal Pelvic Packing is Associated With Increased Risk of Venous Thromboembolism

INTRODUCTION

Preperitoneal pelvic packing (PPP) is an important intervention for control of severe pelvic hemorrhage in blunt trauma patients. We hypothesized that PPP is associated with an increased incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A retrospective cohort analysis of blunt trauma patients with severe pelvic fractures (AIS ≥4) using the 2015-2017 American College of Surgeons-Trauma Quality Improvement Program database was performed. Patients who underwent PPP within four hours of admission were matched to patients who did not using propensity score matching. Matching was performed based on demographics, comorbidities, injury- and resuscitation-related parameters, vital signs at presentation, and initiation and type of prophylactic anticoagulation. The rates of DVT and PE were compared between the matched groups.

RESULTS

Out of 5129 patients with severe pelvic fractures, 157 (3.1%) underwent PPP within four h of presentation and were matched with 157 who did not. No significant differences were detected between the two matched groups in any of the examined baseline variables. Similarly, mortality and end-organ failure rates were not different. However, PPP patients were significantly more likely to develop DVT (12.7% versus 5.1%, P = 0.028) and PE (5.7% versus 0.0%, P = 0.003).

CONCLUSIONS

PPP in severe pelvic fractures secondary to blunt trauma is associated with an increased risk of DVT and PE. A high index of suspicion and a low threshold for screening for these conditions should be maintained in patients who undergo PPP.

Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury

BACKGROUND

Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.

METHODS

Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay.

RESULTS

In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching.

CONCLUSIONS

PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control

ABSTRACT

Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined.

LEVEL OF EVIDENCE

Review, level IV.

The Perioperative Deep Vein Thrombosis in Lower Extremities in Patients With Pelvic Fracture: A Case-Control Study

This study was to investigate the incidences of DVT in lower extremities after pelvic fracture before and after operation, and explore the risk factors. The records of patients with pelvic fractures receiving operation were collected. The patients were examined by preoperative and postoperative ultrasonography, and divided into thrombosis group and non-thrombosis group according to the preoperative and postoperative ultrasonographic results. Totally, 128 patients with pelvic fractures were included in this study. The incidence of DVT was 21.09% preoperatively, and increased to 35.16% postoperatively. Peripheral DVT constituted 92.60% and 86.67% of preoperative and postoperative DVTs, respectively. The results showed that age (odds ratio [OR] = 1.07; 95% CI: 1.01-1.12; P = 0.013), fracture classification (OR = 3.80; 95% CI: 1.31-11.00; P = 0.014) and D-dimer at admission (OR = 1.04; 95% CI: 1.00-1.08; P = 0.029) were independent risk factors of preoperative DVT, and female (OR = 0.21; 95% CI: 0.06-0.81; P = 0.023) was independent protective factor. In addition, age (OR, 1.06; 95% CI, 1.00-1.11; P = 0.026), operative blood transfusion (OR, 1.34; 95% CI, 1.05-1.72; P = 0.020) were independent risk factors of postoperative DVT. In conclusion, the DVT prevention strategy has not changed the high incidence of DVT in pelvic fractures, and orthopedic surgeons should pay more attention to perioperative DVT. When a male or patient with Tile-C type pelvic fracture is at admission, it is should be reminded that the screening the DVT in lower extremities. In addition, the surgeon should stanch bleeding completely, to reduce the blood transfusion and formation of DVT.