The effect of preperitoneal pelvic packing for hemodynamically unstable patients with pelvic fractures

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.

Clinical efficacy on the reconstruction of bone defects using modular hemipelvic prosthesis in patients with pelvic tumors

OBJECTIVE

To evaluate the clinical efficacy of modular hemipelvic prosthesis replacement in the treatment of pelvic tumors and the relationship between postoperative functional recovery and the position deviation of the hip rotation center.

METHODS

A retrospective research was conducted involving 56 patients who underwent surgical resection of pelvic tumors followed by modular hemipelvic prosthesis reconstruction between 2010 and 2016. Comprehensive data encompassing preoperative conditions, intraoperative and postoperative follow-up information were systematically collected. Limb function was evaluated at 1, 3, 6, and 12 months postoperatively using the Musculoskeletal Tumor Society Scores (MSTS). The positional deviation of the hip joint's rotational center was quantified. Statistical analyses were performed utilizing SPSS 26.0 software.

RESULTS

All surgical interventions were successful, with an average operation time of 268.82 ± 42.17 min and mean intraoperative blood loss of 1086.64 ± 538.28 ml. Postoperative complications were noted in 26.79% of patients, predominantly comprising incision-related issues. Hip dislocation was documented in 5.4% of cases, while seven patients experienced prosthesis loosening or fracture during follow-up. A statistically significant improvement in MSTS scores was observed, increasing from an average of 14.3 at 1 month to 21.1 at 12 months postoperatively. The recorded minor deviations in the position of the prosthetic hip joint's rotational center did not exhibit a significant correlation with functional outcomes. The observed survival rates were 94.64%, 83.93%, 73.21%, and 48.21% at 1, 2, 3, and 5 years, respectively.

CONCLUSIONS

The modular hemipelvic prosthesis serves as an effective reconstructive solution for bone defects resulting from pelvic tumor resection, facilitating early functional rehabilitation. The prosthesis demonstrates commendable adaptability and mechanical properties, with a low incidence of complications such as hip dislocation and wound-related issues, thereby contributing to favorable functional recovery of the affected limb.

Hidden blood loss and the influential factors after minimally invasive treatment of posterior pelvic ring injury with sacroiliac screw

BACKGROUND

To analyze the perioperative bleeding and hidden blood loss (HBL) of sacroiliac screw minimally invasive treatment of pelvic posterior ring injury and explore the influential factors of HBL after operation for providing reference for clinical treatment.

METHOD

A retrospective analysis was conducted on data from 369 patients with posterior pelvic ring injuries treated with sacroiliac screws internal fixation at our hospital from January 2015 to January 2022. The research was registered in the Chinese Clinical Trial Registry in July 2022 (ChiCTR2200061866). The total blood loss (TBL) and HBL of patients were counted, and the factors such as gender, age, and surgical duration were statistically analyzed. The influential factors of HBL were analyzed by multiple linear regression.

RESULTS

The TBL was 417.96 ± 98.05 ml, of which the visible blood loss (VBL) was 37.00 ± 9.0 ml and the HBL was 380.96 ± 68.8 ml. The HBL accounted for 91.14 ± 7.36% of the TBL. Gender, surgical duration, fixed position, and fixed depth had significant effects on the HBL (P < 0.05).

CONCLUSIONS

The HBL was the main cause of anemia after minimally invasive treatment of posterior pelvic ring injury with a sacroiliac screw. Gender, surgical duration, fixed position, and fixed depth were closely related to the occurrence of HBL. In clinical treatment, we should consider these influential factors and take effective measures to reduce the impact of HBL on patients.

Preperitoneal pelvic balloon tamponade-an effective intervention to control pelvic injury hemorrhage in a swine model

Objective: This study aimed to estimate the effects of the volume of preperitoneal balloon (PPB) on arterial and venous hemorrhage in a swine pelvic fracture model. Methods: Twenty-four swine were randomized into 0-mL, 500-mL, 800-mL, and 1000-mL intra-hematoma PPB groups. They were subjected to open-book pelvic fracture and reproducible injuries in the external iliac artery and vein. The pelvic binder and IH-PPBs with different volumes of fluid were applied to control the active hemorrhage after arterial and venous injuries. The survival time and rate during 60-min observation and digital subtraction angiography (DSA) images were the primary endpoints in this study. Secondary endpoints included survival rate within 70 min, peritoneal pressure, hemodynamics, blood loss, infusion fluid, blood pH, and lactate concentration. Results: Our results indicated that the 800-mL and 1000-mL groups had a higher survival rate (0%, 50%, 100% and 100% for 0, 500, 800, and 1000-mL groups respectively; p < 0.0001) and longer survival time (13.83 ± 2.64, 24.50 ± 6.29, 55.00 ± 6.33, and 60.00 ± 0.00 min for 0, 500, 800, and 1,000 groups respectively; p < 0.0005) than the 0-mL or 500-mL groups during the 60 min observation. Contrastingly, survival rate and time were comparable between 800-mL and 1000-mL groups during the 60-min observation. The IH-PPB volume was associated with an increase in the pressure of the balloon and the preperitoneal pressure but had no effect on the bladder pressure. Lastly, the 1000-mL group had a higher mean arterial pressure and systemic vascular resistance than the 800-mL group. Conclusion: IH-PPB volume-dependently controls vascular bleeding after pelvic fracture in the swine model. IH-PPB with a volume of 800 mL and 1000 mL efficiently managed pelvic fracture-associated arterial and venous hemorrhage and enhanced survival time and rate in the swine model without evidences of visceral injury.

Predictive factors of mortality in patients with pelvic fracture and shock submitted to extraperitoneal pelvic packing

INTRODUCTION

in recent decades, the extraperitoneal pelvic packing technique has been disseminated, but there are still few studies. Thus, it was decided to analyze the results of extraperitoneal pelvic tamponade, in patients with pelvic fracture and shock, in order to identify predictive factors for mortality.

METHODS

a retrospective review of medical records of patients submitted to extraperitoneal pelvic packing was conduced. We analyzed their characteristics, prehospital and emergency room data, pelvic fracture classification, associated and severity injuries, laboratory and imaging exams, data on packing, arteriography, and other procedures performed, complications, hemodynamic parameters, and amount of transfused blood products before and after packing.

RESULTS

data were analyzed from 51 patients, who showed signs of shock from prehospital care, presence of acidosis, with high base deficit and arterial lactate levels. Most patients underwent multiple surgical procedures due to severe associated injuries. The incidence of coagulopathy was 70.58%, and overall mortality was 56.86%. The group of non-surviving patients presented significantly higher age, prehospital endotracheal intubation, and lower Glasgow Coma Scale scores (p<0.05). The same group presented, before and after extraperitoneal pelvic packing, significantly worse hemodynamic parameters of mean arterial pressure, pH, base deficit, hemoglobin, and arterial lactate (p<0.05). The non-surviving group received significantly more units of packed red blood cells, fresh frozen plasma and platelets within 24 hours following extraperitoneal pelvic packing (p<0.05).

CONCLUSION

age and base deficit are independent predictors of mortality in patients submitted to extraperitoneal pelvic packing.

Fatores preditivos de mortalidade em pacientes com fratura de pelve e instabilidade hemodinâmica submetidos ao tamponamento extraperitoneal de pelve

RESUMO Introdução: nas últimas décadas, tem sido difundida a técnica de tamponamento pélvico extraperitoneal, porém ainda existem poucos estudos. Decidiu-se analisar os resultados do tamponamento extraperitoneal de pelve, em pacientes com fratura pélvica e choque, com objetivo de identificar fatores preditivos de mortalidade. Métodos: foi realizada revisão do prontuário dos pacientes submetidos ao tamponamento extraperitoneal de pelve. Foram analisadas as características dos pacientes, dados do atendimento pré-hospitalar e na sala de emergência, classificação da fratura, presença de lesões associadas, exames laboratoriais e de imagem, dados relativos ao tamponamento, e outros procedimentos realizados, complicações, parâmetros hemodinâmicos e quantidade de hemoderivados transfudidos. Resultados: foram analisados os dados de 51 pacientes, com sinais de choque desde o atendimento pré-hospitalar, presença de acidose, elevado déficit de bases e lactato arterial. Houve alta prevalência de lesões graves associadas, requerendo múltiplos procedimentos cirúrgicos. A incidência de coagulopatia foi 70,58% e mortalidade 56,86%. O grupo de pacientes não sobreviventes apresentou idade e intubação orotraqueal pré-hospitalar maiores, e escores na escala de coma de Glasgow menores (p<0,05). O mesmo grupo apresentou, antes e após o tamponamento extraperitoneal de pelve, parâmetros hemodinâmicos menores de pressão arterial média, pH, déficit de bases e hemoglobina, e maior de lactato arterial (p<0,05). O grupo de pacientes não sobreviventes recebeu mais concentrados de hemácias, plasma fresco congelado e concentrado de plaquetas nas 24h seguintes ao tamponamento extraperitoneal de pelve (p<0,05). Conclusão: idade e o excesso de bases são fatores preditivos independentes de mortalidade em pacientes submetidos ao tamponamento extraperitoneal de pelve.