1
|
Yu TP, Chen YT, Ko PY, Wu CH, Yang TH, Hung KS, Wu PT, Wang CJ, Yen YT, Shan YS. Is delayed fixation worthwhile in patients with long bone fracture concomitant with mild traumatic brain injury? A propensity score-matched study. Injury 2023:110804. [PMID: 37225544 DOI: 10.1016/j.injury.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Early definite treatment for orthopedic patients is strongly advocated. However, a consensus has not been reached on the optimal timing of long bone fracture fixation for patients with associated mild traumatic brain injury (TBI). Surgeons lack evidence on the basis on which they should decide on the operation timing. METHODS We retrospectively reviewed the data of patients with mild TBI and lower extremity long bone fractures from 2010 to 2020. The patients receiving internal fixation within and after 24 h were defined as the early- and delayed-fixation groups. We compared the discharge Glasgow Coma Scale (GCS) scores, lengths of stay, and in-hospital complications. Propensity score matching (PSM) with multiple adjusted variables and a 1:1 matching ratio was applied to reduce selection bias. RESULTS In total, 181 patients were enrolled; 78 (43.1%) and 103 (56.9%) patients received early and delayed fracture fixation, respectively. After matching, each group had 61 participants and were statistically identical. The delayed group did not have better discharge GCS scores (early vs. delayed: 15.0 ± 0 vs. 15.0 ± 0.1; p = 0.158). The groups did not differ in their lengths of hospital stay (15.3 ± 10.6 vs. 14.8 ± 7.9; p = 0.789), intensive care unit stay (2.7 ± 4.3 vs. 2.7 ± 3.8; p = 0.947), or incidence of complications (23.0% vs. 16.4%; p = 0.494). CONCLUSIONS Delayed fixation for patients with lower extremity long bone fractures concurrent with mild TBI does not result in fewer complications or improved neurologic outcomes compared with early fixation. Delaying fixation may not be necessary to prevent the second hit phenomenon and has not demonstrated any clear benefits.
Collapse
Affiliation(s)
- Tzu-Ping Yu
- School of Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Chen
- School of Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Po-Yen Ko
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Ting Wu
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
2
|
Beucler N, Sellier A, Joubert C, Lesquen HD, Schlienger G, Caubere A, Holay Q, Desse N, Esnault P, Dagain A. Severe trauma patients requiring undelayable combined cranial and extracranial surgery: A scoping review of an emerging concept. J Neurosci Rural Pract 2022; 13:585-607. [PMID: 36743747 PMCID: PMC9893946 DOI: 10.25259/jnrp-2022-1-38-r1-(2348)] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives Although patients suffering from severe traumatic brain injury (sTBI) and severe trauma patients (STP) have been extensively studied separately, there is scarce evidence concerning STP with concomitant sTBI. In particular, there are no guidelines regarding the emergency surgical management of patients presenting a concomitant life-threatening intracranial hematoma (ICH) and a life-threatening non-compressible extra-cranial hemorrhage (NCEH). Materials and Methods A scoping review was conducted on Medline database from inception to September 2021. Results The review yielded 138 articles among which 10 were retained in the quantitative analysis for a total of 2086 patients. Seven hundrer and eighty-seven patients presented concomitant sTBI and extra-cranial severe injuries. The mean age was 38.2 years-old and the male to female sex ratio was 2.8/1. Regarding the patients with concomitant cranial and extra-cranial injuries, the mean ISS was 32.1, and the mean AIS per organ were 4.0 for the head, 3.3 for the thorax, 2.9 for the abdomen and 2.7 for extremity. This review highlighted the following concepts: emergency peripheric osteosynthesis can be safely performed in patients with concomitant sTBI (grade C). Invasive intracranial pressure monitoring is mandatory during extra-cranial surgery in patients with sTBI (grade C). The outcome of STP with concomitant sTBI mainly depends on the seriousness of sTBI, independently from the presence of extra-cranial injuries (grade C). After exclusion of early-hospital mortality, the impact of extra-cranial injuries on mortality in patients with concomitant sTBI is uncertain (grade C). There are no recommendations regarding the combined surgical management of patients with concomitant ICH and NCEH (grade D). Conclusion This review revealed the lack of evidence for the emergency surgical management of patients with concomitant ICH and NCEH. Hence, we introduce the concept of combined cranial and extra-cranial surgery. This damage-control surgical strategy aims to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. Further studies are required to validate this concept in clinical practice.
Collapse
Affiliation(s)
- Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | - Aurore Sellier
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Christophe Joubert
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Henri De Lesquen
- Department of Thoracic and Vascular Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Ghislain Schlienger
- Department of Visceral Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Alexandre Caubere
- Department of Orthopaedic Surgery, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Quentin Holay
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
- Department of Diagnostic and Interventional Radiology, Sainte-Anne Military Teaching Hospital, Paris, France
| | - Nicolas Desse
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Pierre Esnault
- Department of Intensive care unit, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, Paris, France
- Department of Val-de-Grâce Military Academy, Paris, France
| |
Collapse
|
3
|
Beucler N, Sellier A, Joubert C, Bernard C, Desse N, Esnault P, Dagain A. Severe Trauma Patients Requiring Undelayable Combined Cranial and Extra-Cranial Surgery: A Proof-of-Concept Monocentric Study. Mil Med 2022; 187:1127-1135. [PMID: 35038725 DOI: 10.1093/milmed/usab555] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 12/06/2021] [Accepted: 12/23/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome. MATERIALS AND METHODS We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting. RESULTS The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%). CONCLUSION Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.
Collapse
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, Ile-de-France 75230, France
| | - Aurore Sellier
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Christophe Joubert
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Cédric Bernard
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Nicolas Desse
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Pierre Esnault
- Intensive Care Unit, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
| | - Arnaud Dagain
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, Provence-Alpes-Côte d'Azur 83800, France
- Val-de-Grâce Military Academy, Paris, Ile-de-France 75230, France
| |
Collapse
|
4
|
Timing of Extremity Fracture Fixation in Patients with Traumatic Brain Injury: A Meta-Analysis of Prognosis. World Neurosurg 2020; 133:227-236. [DOI: 10.1016/j.wneu.2019.09.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023]
|
5
|
Abstract
Background Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3–4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. Materials and methods From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. Result All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05). Discussion In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.
Collapse
|
6
|
Zhang Y, Sun K, Wang Y, Qin Y, Li H. Early vs late fracture fixation in severe head and orthopedic injuries. Am J Emerg Med 2018; 36:1410-1417. [DOI: 10.1016/j.ajem.2017.12.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022] Open
|
7
|
Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury. J Neurosurg Anesthesiol 2018; 29:228-235. [PMID: 26954768 DOI: 10.1097/ana.0000000000000292] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery. MATERIALS AND METHODS We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score <13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure<90 mm Hg), intracranial hypertension (ICP>20 mm Hg), cerebral hypotension (cerebral perfusion pressure<50 mm Hg), hypercarbia (end-tidal CO2>40 mm Hg), hypocarbia (end-tidal CO2<30 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose>200 mg/dL), hypoglycemia (glucose<60 mg/dL), and hyperthermia (temperature >38°C). RESULTS A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P<0.001). CONCLUSIONS Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.
Collapse
|
8
|
Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
Collapse
Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | | | | | | | | | | | | | | |
Collapse
|
9
|
Boutin A, Chassé M, Shemilt M, Lauzier F, Moore L, Zarychanski R, Griesdale D, Desjardins P, Lacroix J, Fergusson D, Turgeon AF. Red Blood Cell Transfusion in Patients With Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Transfus Med Rev 2015; 30:15-24. [PMID: 26409622 DOI: 10.1016/j.tmrv.2015.08.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 06/14/2015] [Accepted: 08/15/2015] [Indexed: 01/23/2023]
Abstract
Our objectives were to evaluate the frequency of red blood cell (RBC) transfusion in patients with traumatic brain injury (TBI) as well as potential determinants and outcomes associated with RBC transfusion in this population. We conducted a systematic review of cohort studies and randomized trials of patients with TBI. We searched Medline, Embase, the Cochrane Library, and BIOSIS databases from their inception up to April 2015. We selected studies of adult patients with acute TBI reporting data on RBC transfusions. Cumulative incidences of transfusion were pooled using random-effect models with a DerSimonian approach. To evaluate the association between RBC transfusion and potential determinants or clinical outcomes, we pooled risk ratios or mean differences with random-effect models and the Mantel-Haenszel method. We identified 24 eligible studies (17414 patients). After pooling data from 23 studies (7524 patients), approximately 36% (95% confidence interval [CI], 28-44; I(2) = 98%) of patients received RBC transfusion at some point during their hospital stay. Hemoglobin thresholds for transfusion were rarely available (reported in 9 studies) and varied from 6 to 10 g/dL. Glasgow Coma Scale scores at admission were lower in patients who were transfused than those who were not (3 cohort studies; 1371 patients; mean difference of 1.38 points [95% CI, 0.86-1.89]; I(2) = 12%). Mortality was not significantly different among transfused and nontransfused patients in univariate and multivariate meta-analyses. Hospital length of stay was longer among patients receiving RBC transfusion compared to those who did not (3 studies; n = 455; mean difference, 9.58 days [95% CI, 3.94-15.22]; I(2) = 74%). Results should be considered cautiously due to the high heterogeneity and high risk of confounding from the observational nature of included studies. Red blood cell transfusion is frequent in patients with TBI, and transfusion practices varied widely between studies. Current published data highlight the lack of clinical evidence guiding transfusion strategies in TBI.
Collapse
Affiliation(s)
- Amélie Boutin
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Michaël Chassé
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Michèle Shemilt
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine and of Haematology & Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Griesdale
- Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
| | - Philippe Desjardins
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Critical Care Medicine, Université de Montréal, Montreal, QC, Canada
| | - Dean Fergusson
- Clinical Epidemiology Unit, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Health Practices Research Unit, Université Laval, Quebec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
| |
Collapse
|
10
|
Fujita Y, Algarra NN, Vavilala MS, Prathep S, Prapruettham S, Sharma D. Intraoperative secondary insults during extracranial surgery in children with traumatic brain injury. Childs Nerv Syst 2014; 30:1201-8. [PMID: 24429505 DOI: 10.1007/s00381-014-2353-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 01/02/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Data on intraoperative secondary insults in pediatric traumatic brain injury (TBI) are limited. METHODS We examined intraoperative secondary insults during extracranial surgery in children with moderate-severe TBI and polytrauma and their association with postoperative head computed tomography (CT) scans, intracranial pressure (ICP), and therapeutic intensity level (TIL) scores 24 h after surgery. After IRB approval, we reviewed the records of children <18 years with a Glasgow Coma Scale score <13 who underwent extracranial surgery within 72 h of TBI. Definitions of secondary insults were as follows: systemic hypotension (SBP <70 + 2 × age or 90 mmHg), cerebral hypotension (cerebral perfusion pressure <40 mmHg), intracranial hypertension (ICP >20 mmHg), hypoxia (oxygen saturation <90 %), hypercarbia (end-tidal CO2 >45 mmHg), hypocarbia (end-tidal CO2 <30 mmHg without hypotension and in the absence of intracranial hypertension), hyperglycemia (blood glucose >200 mg/dL), hyperthermia (temperature >38 °C), and hypothermia (temperature <35 °C). RESULTS Data from 50 surgeries in 42 patients (median age 15.5 years, 25 males) revealed systemic hypotension during 78 %, hypocarbia during 46 %, and hypercarbia during 25 % surgeries. Intracranial hypertension occurred in 64 % and cerebral hypotension in 18 % surgeries with ICP monitoring (11/50). Hyperglycemia occurred during 17 % of the 29 surgeries with glucose monitoring. Cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension (p = 0.02 and 0.03, respectively). We did not observe an association between intraoperative secondary insults and postoperative worsening of head CT scan or TIL score. CONCLUSIONS Intraoperative secondary insults were common during extracranial surgery in pediatric TBI. Intraoperative cerebral hypotension and hypoxia were associated with postoperative intracranial hypertension. Strategies to prevent secondary insults during extracranial surgery in TBI are needed.
Collapse
Affiliation(s)
- Yasuki Fujita
- Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | | | | |
Collapse
|
11
|
Mrozek S, Gaussiat F, Geeraerts T. The management of femur shaft fracture associated with severe traumatic brain injury. ACTA ACUST UNITED AC 2013; 32:510-5. [DOI: 10.1016/j.annfar.2013.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
12
|
Time course of recovery from cerebral vulnerability after severe traumatic brain injury: a microdialysis study. ACTA ACUST UNITED AC 2011; 71:1235-40. [PMID: 21502877 DOI: 10.1097/ta.0b013e3182140dd7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the time course of recovery from cerebral vulnerability, using microdialysis (MD) technique and cerebral vascular autoregulation measurement, to clarify the appropriate timing of subsequent major surgical procedures, and to minimize the possibility of secondary brain injury in patients with severe traumatic brain injury (STBI). METHODS In 3,470 MD samples of 25 patients with STBI, cerebral extracellular biomarkers (glucose, lactate, pyruvate, glycerol, and glutamate) were measured. In addition, to estimate cerebral vascular autoregulaton, the pressure reactivity index (PRx) was calculated with intracranial pressure (ICP) and mean arterial pressure. The data with ICP, cerebral perfusion pressure (CPP), and PRx were collected hourly for 7 days after injury and they were compared with MD biomarkers daily. RESULTS During the study period, the average ICP and CPP remained stable and were within the threshold of STBI treatment guidelines. After injury, the extracellular glucose concentration decreased, and the levels of glycerol, glutamate, and lactate/pyruvate ratio (LPR), which indicate cerebral ischemia and neural cell damage, increased. On the fourth day after injury, the extracellular glucose concentration improved, and the value of LPR decreased. The average PRx decreased daily and became negative on the fifth day after injury. CONCLUSION Our results indicated that cerebral vascular autoregulation would recover on the fourth day after STBI, and cerebral perfusion might be increased by recovery of autoregulation. Thus, subsequent nonemergent surgery should be performed at least 4 days after STBI to prevent secondary brain injury. In addition, we should keep in mind that the cerebral vulnerability might persist for 4 days after suffering STBI.
Collapse
|
13
|
Abstract
OBJECTIVES To examine the association of reamed intramedullary nailing (IMN) and long-term cognitive impairment in trauma intensive care unit survivors. DESIGN Prospective observational cohort. SETTING Academic Level I trauma center. PATIENTS One hundred seventy-three patients with multiple trauma (Injury Severity Score greater than 15) who presented to a Level I trauma intensive care unit from July 2006 to July 2007 without evidence of intrancranial hemorrhage. INTERVENTION None. MAIN OUTCOME MEASURE Twelve-month cognitive impairment defined a priori as two neuropsychological test scores 1.5 standard deviation below the mean or 1 neuropsychologic test score 2 standard deviations below the mean. RESULTS One hundred eight of 173 patients (62.4%) were evaluated 12 months after injury with a comprehensive battery of neuropsychological tests. There were 18 patients who received a reamed IMN and 14 of 18 (78%) of these patients had cognitive deficit at follow-up. Fracture treatment with a reamed IMN was associated with long-term impairment (27.4% vs 8.2%, P = 0.03). Multivariable logistic regression found that a reamed IMN (odds ratio, 3.2; 95% confidence interval, 0.95-10.9; P = 0.06) was a moderate risk factor for the development of cognitive impairment 12 months after injury after controlling for Injury Severity Score, level of education, intraoperative hypotension, and duration of mechanical ventilation. CONCLUSIONS Fracture fixation with a reamed IMN is moderately associated with cognitive impairment in this cohort of multiple trauma patients without intrancranial hemorrhage at 1 year postinjury. Orthopaedic trauma research should continue to investigate a potential association of acute fracture management and long-term cognitive outcome.
Collapse
|
14
|
Velly L, Pellegrini L, Bruder N. [Early or delayed peripheral surgery in patients with severe head injury?]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2010; 29:e183-e188. [PMID: 20656447 DOI: 10.1016/j.annfar.2010.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Head injuries are present in up to 65 % of multiple trauma patients with a frequent association with orthopaedic injuries. The concept of early surgical stabilization of long-bone fractures in patients with multiple injuries became firmly established in the 1980s. However, optimal timing of long bone fracture fixation in trauma patients with associated severe traumatic brain injury has been a lively topic. The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. In recent years, some studies reported a worse outcome, with secondary brain damage, resulting from hypotension, hypoxia and increased intraoperative fluid administration. This review summarises the current evidence available regarding the management of these patients in particular the recent concept of early temporary surgical stabilization in the era of "damage control orthopaedic surgery".
Collapse
Affiliation(s)
- L Velly
- Service d'anesthésie-réanimation, CHU Timone-Adultes, 264 rue Saint-Pierre, Marseille, France.
| | | | | |
Collapse
|
15
|
Hildebrand F, Frink M, Mommsen P, Zeckey C, Krettek C. Die Damage-control-Strategie. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10039-010-1635-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
16
|
The beneficial effects of early stabilization of thoracic spine fractures depend on trauma severity. ACTA ACUST UNITED AC 2010; 68:1208-12. [PMID: 19826315 DOI: 10.1097/ta.0b013e3181a0e558] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The timing of stabilization for thoracic spine injuries is discussed controversial. Although early repair of long bone fractures is known to reduce complications, few studies investigate this issue in spine trauma. METHODS We retrospectively investigated 160 patients (January 2000 to March 2003) with spine fractures from Th1 to L1, which were stabilized. Patients were divided into two groups: early stabilization within 72 hours or later. Other subgroups were analyzed for the relationship of neurologic status, injury severity, and incidence of preoperative lung failure. RESULTS : Severely injured patients (Injury Severity Score >or=38 pts) with early stabilization had a significantly shorter intensive care unit-stay (14 days [1-34 days] vs. 20 days [1-39 days]; p < 0.05) and overall shorter hospital stay (56 days [9-147 days] vs. 108 days [11-198 days]; p < 0.05). Similar patterns were seen for patients with Frankel A deficits (Frankel Score) and preoperative lung failure. The clinical course of less severe-injured patients was not influenced at all. CONCLUSIONS Our data provide further evidence that early stabilization of spine injuries is safe. In severely injured patients, it does not impair perioperative lung function and results in a reduced overall intensive care unit and hospital stay.
Collapse
|
17
|
Abstract
The ideal timing and modality of femur shaft fracture fixation in head-injured patients remains a topic of debate. Several groups advocate the immediate definitive fixation of femur fractures ("early total care"), whereas others support the concept of "damage control orthopaedics" with temporary fracture fixation by means of external fixation and staged, planned conversion to internal fixation. The present review was designed to address this unresolved controversy by outlining the underlying immunopathophysiology of traumatic brain injury and providing clinical recommendations on the timing of femur shaft fracture fixation in patients with severe head injuries.
Collapse
|
18
|
Optimal Timing of Fracture Fixation: Have We Learned Anything In the Past 20 Years? ACTA ACUST UNITED AC 2008; 65:253-60. [DOI: 10.1097/ta.0b013e31817fa475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
19
|
Lorich DG, Gardner MJ, Helfet DL. Trauma to the Pelvis and Extremities. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
20
|
Frangen TM, Ruppert S, Muhr G, Schinkel C. [Respiratory failure in thoracic spine injuries. Does the timing of dorsal stabilization have any effect on the clinical course in multiply injured patients?]. DER ORTHOPADE 2007; 36:365-71. [PMID: 17262180 DOI: 10.1007/s00132-007-1049-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Proper timing of stabilization for spinal injuries is discussed controversially. Whereas early repair of long bone fractures is known to reduce complications, few studies exist that investigate this issue in acute spinal trauma. In particular, the importance of coexisting lung injuries has to be determined, as it might influence clinical course and outcome. MATERIAL AND METHODS We investigated retrospectively 30 severely injured patients who were stabilized dorsally for fractures of the thoracic and upper lumbar spine. The mean Injury Severity Score (ISS) was 41 points. Patients were divided into two groups: group I: acute trauma/stabilization <72 h and group II: acute trauma/stabilization >72 h. All patients in groups I and II presented radiological or clinical signs of lung contusion. RESULTS The average duration of the procedures in group I was 199 min (115-312 min) and in group II 139 min (98-269 min). Intraoperative blood loss and P(a)O(2)/F(i)O(2)-ratio did not differ significantly between the two groups. The overall in ICU and hospital stay was significantly shorter in group I: 16 days (1-78 days) versus 24 days (7-86 days) in the late group II. Postoperative respirator therapy was necessary in group I for 15 days (0-79 days) and in group II for 19 days (4-31 days). The mortality rate was 10% in this series. CONCLUSION Our data provide further evidence that early stabilization of spinal injuries is safe in severely injured patients, does not impair perioperative lung function, and results in a reduced overall ICU and hospital stay. Further prospective randomized investigations are warranted to prove these results.
Collapse
Affiliation(s)
- Thomas M Frangen
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität, Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Deutschland.
| | | | | | | |
Collapse
|
21
|
Schinkel C, Greiner-Perth R, Schwienhorst-Pawlowsky G, Frangen TM, Muhr G, Böhm H. [Does timing of thoracic spine stabilization influence perioperative lung function after trauma?]. DER ORTHOPADE 2007; 35:331-6. [PMID: 16322967 DOI: 10.1007/s00132-005-0898-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Proper timing of stabilization for spine injuries is discussed controversially. Whereas early repair of long bone fractures is known to reduce complications. PATIENTS AND METHODS We investigated retrospectively 48 patients who were stabilized in a ventrodorsal approach for fractures of the thoracic spine. Patients were divided into three groups. All patients in groups I and II presented radiological or clinical signs of lung contusion. Patients were stabilized in the prone position via single-step dorsal stabilization with internal transpedicular fixation and ventral fusion with titanium cage or autologous bone graft using a minimally invasive video-assisted thoracotomy. RESULTS The average duration of the procedures in group I was 213+/-40 min, in group II 250+/-75 min, and in group III 255+/-65 min (p: n.s.). Intraoperative blood loss did not differ significantly between the three groups. The PaO(2)/FiO(2) ratio improved in groups I and III, whereas in group II an significant impairment of lung function occurred perioperatively. Postoperative ICU stay was comparable in groups I and II (I: 10+/-5 days; II: 9+/-7 days); overall ICU stay tended to be shorter in group I versus II. The postoperative dependence on ventilator support did not differ significantly among the three groups. The mortality rate was 0% in this series. CONCLUSION Our data provide further evidence that early stabilization of combined thoracic and thoracic spine injuries is safe, does not alter perioperative lung function, and results in a reduced overall ICU stay.
Collapse
Affiliation(s)
- C Schinkel
- Chirurgische Klinik, BG Kliniken Bergmannsheil, Ruhr-Universität, Bochum.
| | | | | | | | | | | |
Collapse
|
22
|
Schinkel C, Frangen TM, Kmetic A, Andress HJ, Muhr G. Timing of Thoracic Spine Stabilization in Trauma Patients: Impact on Clinical Course and Outcome. ACTA ACUST UNITED AC 2006; 61:156-60; discussion 160. [PMID: 16832264 DOI: 10.1097/01.ta.0000222669.09582.ec] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Optimal timing of stabilization for thoracic spine injuries in multiply injured patients is still controversial because additional lung injury occurs frequently. Early operation might benefit clinical course and outcome in these patients. METHODS We analyzed the German National Trauma Database (n = 8,057) and compared clinical parameters and outcome of patients with severe thoracic spine injuries (Abbreviated Injury Scale >2; n = 298) who underwent spine stabilization within 72 hours posttrauma (group I) or later (group II). RESULTS In all, 95% of all patients had additional severe thoracic injuries such as lung contusion. In spite of comparable demographic data, patients in group I had a significant shorter intensive care unit (ICU) stay (median [range]: group I, 8 [0-237] days; group II, 16 [2-91] days; p = 0.001), shorter dependence on mechanical ventilation (group I: 2 [0-48] days; group II: 5 [0-91] days; p = 0.02), and shorter hospital stay (group I: 22 [1-255] days; group II: 31 [2-274] days; p = 0.048). Expected mortality calculated by Trauma and Injury Severity Score was significantly reduced in group I (calculated: 16%; documented: 6%; p < 0.05) but not in group II (19% versus 17%; p = NS). CONCLUSIONS Almost 10% of all patients in the German National Trauma Registry had severe spine injuries. Severe thoracic injuries occurred in 95% of these patients with thoracic spine trauma. We provide further evidence that early stabilization of thoracic spine injuries in trauma patients reduces overall hospital and ICU stay and improves outcome. Thus early stabilization of thoracic spine injuries within 3 days after trauma appears to be favorable.
Collapse
Affiliation(s)
- Christian Schinkel
- Berufsgenossenschaftliche Kliniken Bergmannsheil, Department of Surgery, Ruhr University, Bochum, Germany.
| | | | | | | | | |
Collapse
|
23
|
Oztuna V, Ersoz G, Ayan I, Eskandari MM, Colak M, Polat A. Early internal fracture fixation prevents bacterial translocation. Clin Orthop Relat Res 2006; 446:253-8. [PMID: 16672892 DOI: 10.1097/01.blo.0000203468.66055.23] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The aim of our study was to determine whether early internal fixation of major bone fractures helps prevent bacterial translocation in patients with multitrauma. Thirty-seven Sprague-Dawley rats were divided into three groups: (1) anesthesia only (n = 12); (2) the trauma group: tibia and femur fractures and moderate head trauma under anesthesia (n = 14); and (3) the fixation group: fixation of tibia and femur fractures and moderate head trauma under anesthesia (n = 11). After 24 hours, mesenteric lymph nodes, liver, spleen, and systemic blood samples were quantitatively cultured. The terminal ileum was assessed histopathologically. The incidence of bacterial translocation was less in the anesthesia group (two of 12 rats) and the fixation group (two of 11 rats) than in the trauma group (10 of 14 rats). The number of organs containing viable bacteria was significantly lower in the fixation group than in the trauma group. Histopathologically, villous architecture was preserved mostly in the fixation group; however, marked mucosal damage was detected in the trauma group. Our data suggest early internal fixation of long bone fractures in polytraumatized experimental animals with head injury results in preservation of the intestinal mucosal barrier and decreased bacterial translocation from the gut.
Collapse
Affiliation(s)
- Volkan Oztuna
- Department of Orthopaedics, Mersin University, School of Medicine, Mersin, Turkey.
| | | | | | | | | | | |
Collapse
|
24
|
Rixen D, Grass G, Sauerland S, Lefering R, Raum MR, Yücel N, Bouillon B, Neugebauer EAM. Evaluation of criteria for temporary external fixation in risk-adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients: "evidence-based medicine" versus "reality" in the trauma registry of the German Trauma Society. ACTA ACUST UNITED AC 2006; 59:1375-94; discussion 1394-5. [PMID: 16394911 DOI: 10.1097/01.ta.0000198364.50334.39] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database. METHODS A systematic literature analysis was performed. The German Trauma Society trauma registry was used to assess variables predictive of treatment concept. RESULTS Contradictory results in 63 controlled trials failed to support a "generalized management strategy." In all, 1,465 FSFTs in 8,057 trauma registry patients (age 39 +/- 19.5 years; Injury Severity Score [ISS] 23.5 +/- 14.9; 17.3% mortality) were treated initially (<24 hour) by EF, nail, or plate in 47.0%, 41.1%, and 11.9%, respectively. Despite large interhospital variability, EF was more likely with increasing severity of ISS, Glasgow Coma Score, thorax trauma, base excess, coagulation abnormalities, and initial probability of death. CONCLUSIONS Clinical "reality" reflects the controversies of "scientific evidence" for FSFT after multiple trauma in Germany. Although decision making is currently based on unvalidated criteria, anatomic and physiologic injury severity appears to influence the choice of management concept.
Collapse
Affiliation(s)
- Dieter Rixen
- Department of Trauma/Orthopedic Surgery, University of Witten/Herdecke at the Hospital Merheim, Cologne, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
25
|
Audibert G, Steinmann G, Charpentier C, Mertes PM. Réunion de neuroanesthésie-réanimation. Prise en charge anesthésique du patient en hypertension intracrânienne aiguë. ACTA ACUST UNITED AC 2005; 24:492-501. [PMID: 15885971 DOI: 10.1016/j.annfar.2005.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transcranial Doppler and, if possible, measurement of intracranial pressure (ICP) allow preoperative diagnosis of acute intracranial hypertension (ICH) after brain trauma. The main goal of the anaesthesiologist is to prevent the occurrence of secondary brain injuries and to avoid cerebral ischaemia. Treatment of high ICP is mainly achieved with osmotherapy. High-dose mannitol administration (1.4 to 2 g/kg given in bolus doses) may be considered a better option than conventional doses, especially before emergency evacuation of a cerebral mass lesion. Hypertonic saline seems as effective as mannitol without rebound effect and without diuresis increase. Haemostasis should be normalized before neurosurgery and invasive blood pressure monitoring is mandatory. For anaesthesia induction, thiopental or etomidate may be used. In case of ICH, halogenated and nitrous oxide should be avoided. Until the dura is open, mean arterial pressure should be maintained around 90 mmHg (or cerebral perfusion pressure around 70 mmHg). If a long-lasting (several hours) extracranial surgery is necessary, ICP should be monitored and treatment of ICH should have been instituted before.
Collapse
MESH Headings
- Acute Disease
- Anesthesia, General/methods
- Blood Pressure
- Brain Injuries/complications
- Brain Injuries/surgery
- Brain Ischemia/etiology
- Brain Ischemia/prevention & control
- Case Management
- Combined Modality Therapy
- Comorbidity
- Contraindications
- Diuretics, Osmotic/administration & dosage
- Diuretics, Osmotic/therapeutic use
- Etomidate
- Humans
- Hyperventilation
- Intracranial Hypertension/complications
- Intracranial Hypertension/diagnostic imaging
- Intracranial Hypertension/drug therapy
- Intracranial Hypertension/surgery
- Jugular Veins
- Mannitol/administration & dosage
- Mannitol/therapeutic use
- Monitoring, Intraoperative
- Monitoring, Physiologic
- Nitrous Oxide
- Oxygen/blood
- Preoperative Care
- Saline Solution, Hypertonic/administration & dosage
- Saline Solution, Hypertonic/therapeutic use
- Thiopental
- Tomography, X-Ray Computed
- Ultrasonography, Doppler, Transcranial
- Wounds and Injuries/surgery
Collapse
Affiliation(s)
- G Audibert
- Département d'anesthésie-réanimation, hôpital central, CHU de Nancy, 54000 Nancy, France.
| | | | | | | |
Collapse
|
26
|
Grotz MRW, Giannoudis PV, Pape HC, Allami MK, Dinopoulos H, Krettek C. Traumatic brain injury and stabilisation of long bone fractures: an update. Injury 2004; 35:1077-86. [PMID: 15488496 DOI: 10.1016/j.injury.2004.05.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2004] [Indexed: 02/02/2023]
Abstract
In the era of "damage control orthopaedics", the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate. This review summarises the current evidence available regarding the management of these patients. There appear to be no clear treatment guidelines. Irrespective of the treatment protocol followed, if secondary brain damage is to be avoided at all times, ICP monitoring should be used, both in the intensive care unit and in the operating theatre during surgical procedures, since aggressive ICP management appears to be related to improved outcomes. Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures.
Collapse
Affiliation(s)
- M R W Grotz
- Department of Trauma & Orthopaedics, St James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | | | | | | | | | | |
Collapse
|
27
|
Chipman JG, Deuser WE, Beilman GJ. Early surgery for thoracolumbar spine injuries decreases complications. ACTA ACUST UNITED AC 2004; 56:52-7. [PMID: 14749565 DOI: 10.1097/01.ta.0000108630.34225.85] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The proper timing for surgical fracture repair is controversial. Early repair of long bone and cervical fractures reduces complications and is safe. Few studies exist to compare time to surgery with outcomes in thoracolumbar (TL) spine injuries. METHODS Patients with TL spine injuries were identified from the trauma registry and divided into two cohorts on the basis of Injury Severity Score (ISS). Cohorts were compared for infectious, respiratory, and total complications in patients who had early (<72 hours from injury) versus late (>72 hours from injury) surgical repair. A retrospective chart review was performed on High ISS patients (> or =15) to identify differences in resuscitation needs and neurologic, respiratory, and infectious complications. RESULTS Early surgery, Low ISS patients were younger, received fewer anterior repairs, and had shorter hospitalizations. Early patients in the High ISS cohort had significantly fewer total complications and shorter hospital and intensive care unit lengths of stay. Resuscitative requirements were similar for both surgery groups. More late surgery patients required ventilator support for noninfectious reasons. There was no difference in admission or postoperative neurologic status or the incidence of head injury. CONCLUSION Early surgery in severely injured patients with thoracolumbar spine trauma was associated with fewer complications and shorter hospital and intensive care unit lengths of stay, required less ventilator support for noninfectious reasons, and did not increase neurologic deficits.
Collapse
Affiliation(s)
- Jeffrey G Chipman
- Department of Surgery, University of Minnesota, Minneapolis, 55455, USA
| | | | | |
Collapse
|
28
|
Anglen JO, Luber K, Park T. The effect of femoral nailing on cerebral perfusion pressure in head-injured patients. THE JOURNAL OF TRAUMA 2003; 54:1166-70. [PMID: 12813339 DOI: 10.1097/01.ta.0000057232.66613.ac] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The timing of fracture fixation in patients with head trauma is controversial. Early fracture fixation may be associated with secondary brain injury. We undertook this study to investigate the effect of reamed intramedullary nailing on cerebral perfusion. METHODS Seventeen patients were identified who had placement of an intracranial pressure monitor and reamed rodding of the femur. Retrospective chart review was performed. RESULTS Average Injury Severity Score was 35 (range, 17-50). Cerebral perfusion pressure (CPP) decreased intraoperatively for all except one. The average decrease in CPP from pre- to intraoperative values was 17 mm Hg (p = 0.0012). Seventy percent had an average intraoperative CPP below 75 mm Hg, and all patients had a minimum CPP below 75 mm Hg. The decrease in CPP was mostly attributable to a corresponding decrease in mean arterial pressure. CONCLUSION Patients with head trauma undergoing femoral rodding need careful attention paid to managing blood pressure to minimize CPP decreases.
Collapse
|
29
|
Bhandari M, Guyatt GH, Khera V, Kulkarni AV, Sprague S, Schemitsch EH. Operative management of lower extremity fractures in patients with head injuries. Clin Orthop Relat Res 2003:187-98. [PMID: 12567146 DOI: 10.1097/00003086-200302000-00027] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Treatment of patients with lower extremity fractures and concomitant head injury is controversial. The authors compared reamed intramedullary nailing versus plating of femoral and tibial fractures in patients with polytrauma and concomitant head injury. One thousand five hundred twenty-five patients with head injuries were identified from a prospective trauma database. Of those, 1211 patients sustained severe head injuries (Abbreviated Injury Score >/= 3). One hundred nineteen patients with severe head injuries and lower extremity long bone fractures met the inclusion criteria. Ultimately, four patient groups were identified: Group A, reamed femoral nail (n = 21); Group B, femoral plate (n = 29); Group C, reamed tibial nail (n = 23); and Group D, tibial plate (n = 46). Reamed intramedullary nails did not significantly alter the risk of mortality when compared with plates in femoral (relative risk 0.46; 95% confidence interval, 0.04-4.6) and tibial (relative risk 1.18; 95% confidence interval, 0.05-11.9) fractures. The severity of the initial head injury (Glasgow Coma Scale score) was the strongest predictor of mortality. Functional independence scores between patients with reamed nails and patients with plates were similar at 1 year. Head injury does not seem to be a contraindication to reamed intramedullary nailing in patients with lower extremity fractures. The severity of head injury alone is an important predictor of outcome. A large, randomized trial with sufficient study power is needed to clarify this issue.
Collapse
Affiliation(s)
- Mohit Bhandari
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
30
|
Giannoudis PV, Veysi VT, Pape HC, Krettek C, Smith MR. When should we operate on major fractures in patients with severe head injuries? Am J Surg 2002; 183:261-7. [PMID: 11943123 DOI: 10.1016/s0002-9610(02)00783-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The widely accepted practice of early fracture fixation (EFF) in multiply injured patients has recently been challenged in the presence of head injury. DATA SOURCES English and German language articles on the subject were searched using Medline. Keywords included head trauma, intracranial trauma, brain injuries, fractures, fracture fixation, timing, femur fracture, and tibia fracture. CONCLUSIONS The available literature does not provide clear-cut guidance on the management of fractures in the presence of head injuries. The trend is toward a better outcome if the fractures are fixed early. Treatment should therefore be tailored to the individual patient, with the assumption that full neurologic recovery will take place.
Collapse
Affiliation(s)
- Peter V Giannoudis
- Department of Trauma and Orthopaedics, St. James' University Hospital, Leeds, Beckett St., LS9 7TF, Leeds, United Kingdom
| | | | | | | | | |
Collapse
|