1
|
Maya P, Moran B, Khan M, Yehuda H, Adi G, Joseph DJ, Boris K. Immediate versus expedient emergent laparotomy in unstable isolated abdominal trauma patients. Ann R Coll Surg Engl 2024. [PMID: 38836369 DOI: 10.1308/rcsann.2023.0081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Unstable abdominal trauma patients should be treated with emergent laparotomy. However, few studies have evaluated the association between time to surgery and survival in these patients. We aimed to assess the influence of time to laparotomy on outcomes in blunt and penetrating unstable abdominal trauma patients. METHODS This retrospective study includes patients with abdominal injuries, systolic blood pressure <90mmHg on arrival, admitted in Israel during 2000-2018. Data regarding patients' characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS), time to surgery, length of hospital stay and mortality were collected via The Israeli National Trauma Registry. RESULTS Overall, 69 blunt and 127 penetrating injury patients were included in the study. For blunt and penetrating trauma patients with ISS ≤14, no differences in outcome were found between patients who underwent laparotomy within 60min of admission and those who underwent laparotomy within 60-120min of admission. In patients with blunt trauma, ISS ≥16, and GCS <15, mortality was higher in the immediate laparotomy group (p = 0.004 and 0.049, respectively). CONCLUSIONS In patients with a penetrating injury, no differences in mortality between immediate and expedient laparotomy were demonstrated. In patients with a blunt injury, with ISS ≥16 and GCS <15, mortality was higher among the immediate laparotomy group.
Collapse
Affiliation(s)
- P Maya
- Schneider Children's Medical Center, Petah Tikva, Israel
- Tel Aviv University, Israel
| | - B Moran
- Tel Aviv University, Israel
- Gertner Institute for Epidemiology and Health Policy Research, Tel HaShomer, Israel
| | - M Khan
- Brighton and Sussex Medical School, UK
| | - H Yehuda
- Tel Aviv University, Israel
- Shamir Medical Center, Be'er Ya'akov, Israel
| | - G Adi
- Tel Aviv University, Israel
| | | | - K Boris
- Hillel Yaffe Medical Center, Hadera, Israel
- Technion, Haifa, Israel
| |
Collapse
|
2
|
Jeong E, Park Y, Jang H, Lee N, Jo Y, Kim J. Timing of Re-Laparotomy in Blunt Trauma Patients With Damage-Control Laparotomy. J Surg Res 2024; 296:376-382. [PMID: 38309219 DOI: 10.1016/j.jss.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 10/26/2023] [Accepted: 11/12/2023] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Damage-control laparotomy (DCL) was initially designed to treat patients with severe hemorrhage. There are various opinions on when to return to the operating room after DCL and there are no definitive data on the exact timing of re-laparotomy. METHODS All patients at regional referral trauma center requiring a DCL due to blunt trauma between January 2012 and September 2021 (N = 160) were retrospectively reviewed from patients' electronic medical records. The primary fascial closure rate, lengths of intensive care unit stay and mechanical ventilation, mortality, and complications were compared in patients who underwent re-laparotomy before and after 48 h. RESULTS One hundred one patients (70 in the ≤48 h group [early] and 31 in the >48 h group [late]) were included. Baseline patient characteristics of age, body mass index, injury severity score, and initial systolic blood pressure and laboratory finding such as hemoglobin, base excess, and lactate were similar between the two groups. Also, there were no differences in reason for DCL and operation time. The time interval from the DCL to the first re-laparotomy was 39 (29-43) h and 59 (55-66) h in the early and late groups, respectively. There were no significant differences in the rate of the primary fascial closure rate (91.4% versus 93.5%, P = 1.00), lengths of stay in the intensive care unit (10 [7-18] versus 12 [8-16], P = 0.553), ventilator days (6 [4-10] versus 7 [5-10], P = 0.173), mortality (20.0% versus 19.4%, P = 0.94), and complications between the two groups. CONCLUSIONS The timing of re-laparotomy after DCL due to blunt abdominal trauma should be determined in consideration of various factors such as correction of coagulopathy, primary fascial closure, and complications. This study showed there was no significant difference in patient groups who underwent re-laparotomy before and after 48 h after DCL. Considering these results, it is better to determine the timing of re-laparotomy with a focus on physiologic recovery rather than setting a specific time.
Collapse
Affiliation(s)
- Euisung Jeong
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Yunchul Park
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Hyunseok Jang
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Naa Lee
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Younggoun Jo
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea.
| | - Jungchul Kim
- Division of Trauma, Department of Surgery, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| |
Collapse
|
3
|
Bruyninckx L, Jennes S, Pirnay JP, de Schoutheete JC. Burn or trauma scoring: experience of the burn unit of the Queen Astrid Military Hospital during the terror attacks on 22 March 2016. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02486-y. [PMID: 38509185 DOI: 10.1007/s00068-024-02486-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/22/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE On 22 March 2016, the burn unit (BU) of Queen Astrid Military Hospital assessed a surge in severely injured victims from terror attacks at the national airport and Maalbeek subway station according to the damage control resuscitation (DCR) and damage control surgery (DCS) principles. This study delves into its approach to identify a suitable triage scoring system and to determine if a BU can serve as buffer capacity for mass casualty incidents (MCIs). METHODS The study reviewed retrospectively the origin of explosion, demographic data, sustained injuries, performed surgery, and length of stay of all admitted patients. Trauma scores (Injury Severity Score (ISS) and New Injury Severity Score (NISS)) and triage scores (Revised Trauma Score (RTS), New Trauma Score (NTS), and Trauma Score Injury Severity Score (TRISS)), were compared to burn mortality scores (Osler updated Baux Score and Tobiasen's Abbreviated Burn Severity Index (ABSI)). RESULTS Of the 23 casualties admitted to the BU, the scores calculated on average 3.5 indications for a level 1 trauma center (ISS 4, NISS 6, RTS 0, T-NTS 4). Nevertheless, no deaths occurred during admission or the 1-year follow-up. CONCLUSION MCIs create chaos and a high demand for care. Avoiding bottlenecks and adhering to the DCR/DCS principles are necessary to deliver the best care to the largest number of people. This study indicates that a BU can serve as buffer capacity for MCIs. Nevertheless, its integration into the medical resilience plan depends on accurate scoring, comprehensive care availability, and understanding of the DCR/DCS concept. NTS for triage seems the best fit for scoring polytrauma referrals to a BU during MCIs.
Collapse
Affiliation(s)
| | - Serge Jennes
- Burn Unit, Queen Astrid Military Hospital, Brussels, Belgium
| | - Jean-Paul Pirnay
- Laboratory for Molecular and Cellular Technology, Queen Astrid Military Hospital, Brussels, Belgium
| | | |
Collapse
|
4
|
Sanchez T, Coisy F, Grau-Mercier L, Occelli C, Ajavon F, Claret PG, Markarian T, Bobbia X. Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets. Am J Emerg Med 2024; 75:59-64. [PMID: 37922831 DOI: 10.1016/j.ajem.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.
Collapse
Affiliation(s)
- Thomas Sanchez
- University of Montpellier, Research Unit IMAGINE, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France.
| | - Fabien Coisy
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Laura Grau-Mercier
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Occelli
- University of Côte d'Azur, Faculty of Medecine, Transporter in Imaging and Radiotherapy in Oncology Laboratory, Basic Research Direction - Department of Emergency Medicine, Nice University Hospital, Nice, France
| | - Florian Ajavon
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Pierre-Géraud Claret
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Thibaut Markarian
- University of Aix-Marseille, UMR 1263 Center of Cardiovascular and Nutrition Research (C2VN), INSERM, INRAE - Department of Emergency Medicine, Timone University Hospital, Marseille, France
| | - Xavier Bobbia
- University of Montpellier, Research Unit IMAGINE, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
| |
Collapse
|
5
|
Fernández LG. Treatment of Complex Thoracic and Abdominal Trauma Patients: A Review of Literature and Negative Pressure Wound Therapy Treatment Options. Adv Wound Care (New Rochelle) 2023. [PMID: 37672527 DOI: 10.1089/wound.2023.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
Significance: In trauma care, extensive surgical intervention may be required. Damage control surgery (DCS) is applicable to patients with life or limb-threatening conditions that are incapable of tolerating a traditional surgical approach. Recent Advances: The current resuscitation strategy for complex trauma patients includes limiting crystalloid fluids, balanced mass transfusion protocols, permissive hypotension, and damage control resuscitation. Recent technological advancements in surgical critical care have improved outcomes in these critically ill patients. Critical Issues: DCS, which is often required in patients with trauma injuries, is typically followed by surgical correction of the injury once the immediate patient survival procedures have been completed. However, DCS and the subsequent injury repair procedures have a high risk for postsurgical complication development. Future Directions: Negative pressure therapy modalities can offer clinicians additional adjunctive and cost-effective tools for the management of the trauma care patient, as these systems can be utilized during both the DCS and the postoperative injury management phases of trauma care.
Collapse
Affiliation(s)
- Luis G Fernández
- Division of Trauma Surgery/Surgical Critical Care, Department of Surgery, University of Texas Health Science Center, Tyler, Texas, USA
- School of Medicine Bill Barrett Endowed Chair in Trauma Surgery, The University of Texas-Tyler, Tyler, Texas, USA
| |
Collapse
|
6
|
Pfeifer R, Klingebiel FKL, Halvachizadeh S, Kalbas Y, Pape HC. How to Clear Polytrauma Patients for Fracture Fixation: Results of a systematic review of the literature. Injury 2023; 54:292-317. [PMID: 36404162 DOI: 10.1016/j.injury.2022.11.008] [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: 09/08/2022] [Revised: 11/03/2022] [Accepted: 11/06/2022] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Early patient assessment is relevant for surgical decision making in severely injured patients and early definitive surgery is known to be beneficial in stable patients. The aim of this systematic review is to extract parameters indicative of risk factors for adverse outcome. Moreover, we aim to improve decision making and separate patients who would benefit from early versus staged definitive surgical fixation. METHODS Following the PRISMA guidelines, a systematic review of peer-reviewed articles in English or German language published between (2000 and 2022) was performed. The primary outcome was the pathophysiological response to polytrauma including coagulopathy, shock/haemorrhage, hypothermia and soft tissue injury (trauma, brain injury, thoracic and abdominal trauma, and musculoskeletal injury) to determine the treatment strategy associated with the least amount of complications. Articles that had used quantitative parameters to distinguish between stable and unstable patients were summarized. Two authors screened articles and discrepancies were resolved by consensus. Quantitative values for relevant parameters indicative of an unstable polytrauma patient were obtained. RESULTS The initial systematic search using MeSH criteria yielded 1550 publications deemed relevant to the following topics (coagulopathy (n = 37), haemorrhage/shock (n = 7), hypothermia (n = 11), soft tissue injury (n = 24)). Thresholds for stable, borderline, unstable and in extremis conditions were defined according to the existing literature as follows: Coagulopathy; International Normalized Ratio (INR) and viscoelastic methods (VEM)/Blood/shock; lactate, systolic blood pressure and haemoglobin, hypothermia; thresholds in degrees Celsius/Soft tissue trauma: traumatic brain injury, thoracic and abdominal trauma and musculoskeletal trauma. CONCLUSION In this systematic literature review, we summarize publications by focusing on different pathways that stimulate pathophysiological cascades and remote organ damage. We propose that these parameters can be used for clinical decision making within the concept of safe definitive surgery (SDS) in the treatment of severely injured patients.
Collapse
Affiliation(s)
- Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | | | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland.
| |
Collapse
|
7
|
Bonanno FG. Management of Hemorrhagic Shock: Physiology Approach, Timing and Strategies. J Clin Med 2022; 12:jcm12010260. [PMID: 36615060 PMCID: PMC9821021 DOI: 10.3390/jcm12010260] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 12/30/2022] Open
Abstract
Hemorrhagic shock (HS) management is based on a timely, rapid, definitive source control of bleeding/s and on blood loss replacement. Stopping the hemorrhage from progressing from any named and visible vessel is the main stem fundamental praxis of efficacy and effectiveness and an essential, obligatory, life-saving step. Blood loss replacement serves the purpose of preventing ischemia/reperfusion toxemia and optimizing tissue oxygenation and microcirculation dynamics. The "physiological classification of HS" dictates the timely management and suits the 'titrated hypotensive resuscitation' tactics and the 'damage control surgery' strategy. In any hypotensive but not yet critical shock, the body's response to a fluid load test determines the cut-off point between compensation and progression between the time for adopting conservative treatment and preparing for surgery or rushing to the theater for rapid bleeding source control. Up to 20% of the total blood volume is given to refill the unstressed venous return volume. In any critical level of shock where, ab initio, the patient manifests signs indicating critical physiology and impending cardiac arrest or cardiovascular accident, the balance between the life-saving reflexes stretched to the maximum and the insufficient distal perfusion (blood, oxygen, and substrates) remains in a liable and delicate equilibrium, susceptible to any minimal change or interfering variable. In a cardiac arrest by exsanguination, the core of the physiological issue remains the rapid restoration of a sufficient venous return, allowing the heart to pump it back into systemic circulation either by open massage via sternotomy or anterolateral thoracotomy or spontaneously after aorta clamping in the chest or in the abdomen at the epigastrium under extracorporeal resuscitation and induced hypothermia. This is the only way to prevent ischemic damage to the brain and the heart. This is accomplishable rapidly and efficiently only by a direct approach, which is a crush laparotomy if the bleeding is coming from an abdominal +/- lower limb site or rapid sternotomy/anterolateral thoracotomy if the bleeding is coming from a chest +/- upper limbs site. Without first stopping the bleeding and refilling the heart, any further exercise is doomed to failure. Direct source control via laparotomy/thoracotomy, with the concomitant or soon following venous refilling, are the two essential, initial life-saving steps.
Collapse
Affiliation(s)
- Fabrizio G Bonanno
- Department of Surgery, Polokwane Provincial Hospital, Cnr Hospital & Dorp Street, Polokwane 0700, South Africa
| |
Collapse
|
8
|
Hatchimonji JS, Holena DN, Xiong R, Scantling DR, Hornor MA, Dowzicky PM, Reilly PM, Kaufman EJ. The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania. Surgery 2022; 173:1289-1295. [PMID: 36517291 DOI: 10.1016/j.surg.2022.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.
Collapse
Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Daniel N Holena
- Division of Trauma and Critical Care, Medical College of Wisconsin, Milwaukee, WI. https://twitter.com/Daniel_Holena
| | - Ruiying Xiong
- Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/AriaXiong
| | - Dane R Scantling
- Section of Acute Care and Trauma Surgery, Boston University School of Medicine, MA. https://twitter.com/Dane_Scantling
| | - Melissa A Hornor
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/HornorMD
| | - Phillip M Dowzicky
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/PDowzicky
| | - Patrick M Reilly
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/reillyp648
| | - Elinore J Kaufman
- Division of Traumatology, Emergency Surgery, and Surgical Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. https://twitter.com/ElinoreJKaufman
| |
Collapse
|
9
|
Mills H, Acquah R, Tang N, Cheung L, Klenk S, Glassen R, Pirson M, Albert A, Hoang DT, Van TN. Emergency Medicine with Advanced Surgery Protocols: A Review. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2022; 2022:3513250. [PMID: 36200087 PMCID: PMC9529385 DOI: 10.1155/2022/3513250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/17/2022]
Abstract
One of the most burning issues in health system is the concern of handling patients that requires emergency surgery. Emergency general surgery is done on both traumatic and nontraumatic acute disorders. Severe traumatic injury and bleeding is one of the causing agents for high mortality rate globally. Another group of patients that are in need of emergency surgery are those with heart failure, and in this particular paper, we analyzed emergency medicine with advanced surgery protocols focusing on gastric cancer, cardiac surgery, and bleeding as well as coagulopathy following traumatic injury.
Collapse
Affiliation(s)
- Hilla Mills
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Ronald Acquah
- Clinical Center of Vojvodina, Novi Sad, Serbia
- Clinical Analysis Lab, Center of Bio-Medicine, Hanoi, Vietnam
| | - Nova Tang
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Luke Cheung
- RD Lab, The Hospital Institute for Herbal Research, 50200 Toluca, MEX, Mexico
| | - Susanne Klenk
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Ronald Glassen
- Research Institution of Clinical Biomedicine, Hospital University Medical Centre, 89000 Ulm, Germany
| | - Magali Pirson
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
| | - Alain Albert
- Industrial Research Group, International College of Science and Technology, Route de Lennik 800, CP 590, 1070 Brussels, Belgium
| | | | | |
Collapse
|
10
|
Steffey DC, Chishti EA, Acevedo MJ, Acosta LF, Lee JT. Single Center Retrospective Review of Post-laparotomy CT Abdomen and Pelvis Findings and Trends. FRONTIERS IN RADIOLOGY 2022; 2:850911. [PMID: 37492676 PMCID: PMC10365115 DOI: 10.3389/fradi.2022.850911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/03/2022] [Indexed: 07/27/2023]
Abstract
Purpose To identify common findings visualized on CT following damage control laparotomy, including post-surgical changes and additional injuries, and to determine change in frequency of post-laparotomy CT at our institution over time. Methods Single institution, IRB-Exempt, retrospective review of the University of Kentucky trauma registry from 1/2006 to 2/2019 for all trauma patients undergoing exploratory laparotomy initially and subsequently undergoing CT of the abdomen and pelvis within 24 hours. Operative findings from surgical operation notes and findings reported on post-laparotomy CT were recorded, including vascular and solid organ injuries, operative changes, free intraperitoneal fluid/air, and retroperitoneal findings. Next steps in management were also recorded. Results In total 1,047 patients underwent exploratory laparotomy initially at our institution between 1/2006-2/2019. Of those, only 96 had a diagnostic CT of the abdomen and pelvis within 24 h after initial surgery, first occurring in 2010. Among these 96, there were 71 blunt and 25 penetrating injuries. Most common injuries recognized during exploratory laparotomy were bowel/mesentery (55), spleen (34), and liver (26). Regarding CT findings, all patients (96/96, 100%) had residual pneumoperitoneum, 84/96 (87.5%) had residual hemoperitoneum, 36/96 (37.5%) noted post-surgical changes or additional injuries to the spleen, 36/96 (37.5%) to the bowel/mesentery, and 32/96 (33.3%) to the liver, and 34/96 (35.4%) were noted to have pelvic fractures. After CT, 31/96 (32.3%) went back to the OR for relook laparotomy and additional surgical intervention and 7/96 (7.3%) went to IR for embolization. Most common procedures during relaparotomy involved the bowel (8) and solid organs (6). Conclusions CT examination within 24 h post damage control laparotomy was exceedingly rare at our institution prior to 2012 but has steadily increased. Frequency now averages 20.5% yearly. Damage control laparotomy is an uncommon clinical scenario; however, knowledge of frequent injuries and common post-operative changes will aid in radiologist detection of additional injuries helping shape next step management and provide adequate therapy.
Collapse
Affiliation(s)
- Dylan C. Steffey
- University of Kentucky College of Medicine, Lexington, KY, United States
| | - Emad A. Chishti
- University of Kentucky College of Medicine, Lexington, KY, United States
| | - Maximo J. Acevedo
- University of Kentucky College of Medicine, Lexington, KY, United States
| | - Luis F. Acosta
- Department of Radiology, University of Kentucky College of Medicine, Lexington, KY, United States
| | - James T. Lee
- Department of Radiology, University of Kentucky College of Medicine, Lexington, KY, United States
| |
Collapse
|
11
|
Vargas M, García A, Caicedo Y, Parra MW, Ordoñez CA. Damage control in the intensive care unit: what should the intensive care physician know and do? Colomb Med (Cali) 2021; 52:e4174810. [PMID: 34908625 PMCID: PMC8634272 DOI: 10.25100/cm.v52i2.4810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/13/2021] [Accepted: 06/02/2021] [Indexed: 12/03/2022] Open
Abstract
Damage control surgery has transformed the management of severely injured trauma patients. It was initially described as a three-step process that included bleeding control, abdominal cavity contamination, and resuscitation in the intensive care unit (ICU) before definitive repair of the injuries. When the patient is admitted into the ICU, the physician should identify all the physiological alterations to establish resuscitation management goals. These strategies allow an early correction of trauma-induced coagulopathy and hypoperfusion increasing the likelihood of survival. The objective of this article is to describe the physiological alterations in a severely injured trauma patient who undergo damage control surgery and to establish an adequate management approach. The physician should always be aware and correct the hypothermia, acidosis, coagulopathy and hypocalcemia presented in the severely injured trauma patients.
Collapse
Affiliation(s)
- Mónica Vargas
- Fundación Valle del Lili, Department of Intensive Care, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad ICESI, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad ICESI, Cali, Colombia
| |
Collapse
|
12
|
Cytological Effects of Serum Isolated from Polytraumatized Patients on Human Bone Marrow-Derived Mesenchymal Stem Cells. Stem Cells Int 2021; 2021:2612480. [PMID: 34876907 PMCID: PMC8645412 DOI: 10.1155/2021/2612480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
Due to their immunomodulatory and regenerative capacity, human bone marrow-derived mesenchymal stem cells (hBMSCs) are promising in the treatment of patients suffering from polytrauma. However, few studies look at the effects of sera from polytraumatized patients on hBMSCs. The aim of this study was to explore changes in hBMSC properties in response to serum from polytrauma patients taken at different time points after the trauma incident. For this, sera from 84 patients with polytrauma (collected between 2010 and 2020 in our department) were used. In order to test the differential influence on hBMSC, sera from the 1st (D1), 5th (D5), and 10th day (D10) after polytrauma were pooled, respectively. As a control, sera from three healthy donors (HS), matched with respect to age and gender to the polytrauma group, were collected. Furthermore, hBMSCs from four healthy donors were used in the experiments. The pooled sera of HS, D1, D5, and D10 were analyzed by multicytokine array for pro-/anti-inflammatory cytokines. Furthermore, the influence of the different sera on hBMSCs with respect to cell proliferation, colony forming unit-fibroblast (CFU-F) assay, cell viability, cytotoxicity, cell migration, and osteogenic and chondrogenic differentiation was analyzed. The results showed that D5 serum significantly reduced hBMSC cell proliferation capacity compared with HS and increased the proportion of dead cells compared with D1. However, the frequency of CFU-F was not reduced in polytrauma groups compared with HS, as well as the other parameters. The serological effect of polytrauma on hBMSCs was related to the time after trauma. It is disadvantageous to use BMSCs in polytraumatized patients at least until the fifth day after polytrauma as obvious cytological changes could be found at that time point. However, it is promising to use hBMSCs to treat polytrauma after five days, combined with the concept of “Damage Control Orthopedics” (DCO).
Collapse
|
13
|
Hagiwara M, Iwata Y, Takahashi H, Imai K, Yokoo H, Ishitoya S, Ogata M, Matsuno N, Sumi Y, Furukawa H. Severe liver injury with traumatic cardiac arrest successfully treated by damage control surgery and transcatheter arterial embolization in the hybrid operating room: a case report. Surg Case Rep 2021; 7:234. [PMID: 34718909 PMCID: PMC8556852 DOI: 10.1186/s40792-021-01317-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background The damage control approach is known to reduce the mortality rate in severely injured patients and has now become a common practice. Transcatheter arterial embolization (TAE) has been shown to be useful with combining with damage control laparotomy in identifying and controlling active arterial hemorrhage. Hybrid operating room (OR) allows both damaged control surgery and TAE in the same location in minimal time. We report a case of a patient with three cardiac arrests who was saved by early intervention using damage control surgery (DCS) with interventional radiology (IVR) in the hybrid OR. Case presentation A 46-year-old woman was injured in a collision with a tree while snowboarding. She was eventually transported to hybrid operating room in our hospital with the diagnosis of significant liver laceration and hemorrhagic shock. Damage control surgery was performed with perihepatic packing (PHP) and TAE was conducted to stop active bleeding from right hepatic artery. She experienced 3 times of cardiopulmonary arrest, which was successfully resuscitated on each occasion. Although she had total of 3 times of laparotomy but tolerated well. She was discharged on day 82 of hospitalization and showed no neurological sequelae. Conclusion Saving the life of a patient with severe trauma requires a multidisciplinary approach with cooperation and early information sharing among trauma team members. Sharing treatment strategy with the trauma team and early intervention using DCS with IVR in the hybrid operating room could save the patient’s life.
Collapse
Affiliation(s)
- Masahiro Hagiwara
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan.
| | - Yoshihiro Iwata
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| | - Hiroyuki Takahashi
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| | - Koji Imai
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| | - Hideki Yokoo
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| | - Shunta Ishitoya
- Department of Radiology, Asahikawa Medical University, Asahikawa, Japan
| | - Miki Ogata
- Department of Radiology, Asahikawa Medical University, Asahikawa, Japan
| | - Naoto Matsuno
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| | - Yasuo Sumi
- Division of Gastrointestinal Surgery, Department of Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Furukawa
- Division of Hepato-Biliary-Pancreatic and Transplant Surgery, Department of Surgery, Asahikawa Medical University, 2-1, Midorigaoka-Higashi, Asahikawa, Hokkaido, Japan
| |
Collapse
|
14
|
Roberts DJ, Faris PD, Ball CG, Kirkpatrick AW, Moore EE, Feliciano DV, Rhee P, D'Amours S, Stelfox HT. Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia. World J Emerg Surg 2021; 16:53. [PMID: 34649583 PMCID: PMC8515656 DOI: 10.1186/s13017-021-00396-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy. Methods A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy. Results Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year. Conclusions The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00396-7.
Collapse
Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Room A-280, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,The Ottawa Hospital Trauma Program, The Ottawa Hospital, Ottawa, ON, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada. .,The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
| | - Peter D Faris
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Health Services Statistical and Analytic Methods, Data and Analytics (DIMR), Alberta Health Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Chad G Ball
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada.,Regional Trauma Services, Foothills Medical Centre, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Ernest E Moore
- Department of Surgery, School of Medicine and the Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - David V Feliciano
- Department of Surgery and Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Peter Rhee
- Department of Surgery, Westchester Medical Center, Section of Trauma and Acute Care Surgery, New York Medical College, Valhalla, NY, USA
| | - Scott D'Amours
- South Western Sydney Clinical School, UNSW, Sydney, NSW, Australia.,Acute Care Surgery Unit, Liverpool Hospital, Liverpool, NSW, Australia
| | - Henry T Stelfox
- The O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| |
Collapse
|
15
|
Willms A, Güsgen C, Schwab R, Lefering R, Schaaf S, Lock J, Kollig E, Jänig C, Bieler D. Status quo of the use of DCS concepts and outcome with focus on blunt abdominal trauma : A registry-based analysis from the TraumaRegister DGU®. Langenbecks Arch Surg 2021; 407:805-817. [PMID: 34611749 DOI: 10.1007/s00423-021-02344-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Damage control surgery (DCS) is a standardized treatment concept in severe abdominal injury. Despite its evident advantages, DCS bears the risk of substantial morbidity and mortality, due to open abdomen therapy (OAT). Thus, identifying the suitable patients for that approach is of utmost importance. Furthermore, little is known about the use of DCS and the related outcome, especially in blunt abdominal trauma. METHODS Patients recorded in the TraumaRegister DGU® from 2008 to 2017, and with an Injury Severity Score (ISS) ≥ 9 and an abdominal injury with an Abbreviated Injury Scale (AIS) score ≥ 3 were included in that registry-based analysis. Patients with DCS and temporary abdominal closure (TAC) were compared with patients who were treated with a laparotomy and primary closure (non-DCS) and those who did receive non-operative management (NOM). Following descriptive analysis, a matched-pairs study was conducted to evaluate differences and outcomes between DCS and non-DCS group. Matching criteria were age, abdominal trauma severity, and hemodynamical instability at the scene. RESULTS The injury mechanism was predominantly blunt (87.1%). Of the 8226 patients included, 2351 received NOM, 5011 underwent laparotomy and primary abdominal closure (non-DCS), and 864 were managed with DCS. Thus, 785 patient pairs were analysed. The rate of hepatic injuries AIS > 3 differed between the groups (DCS 50.3% vs. non-DCS 18.1%). DCS patients had a higher ISS (p = 0.023), required more significant volumes of fluids, more catecholamines, and transfusions (p < 0.001). More DCS patients were in shock at the accident scene (p = 0.022). DCS patients had a higher number of severe hepatic (AIS score ≥ 3) and gastrointestinal injuries and more vascular injuries. Most severe abdominal injuries in non-DCS patients were splenic injuries (AIS, 4 and 5) (52.1% versus 37.9%, p = 0.004). CONCLUSION DCS is a strategy used in unstable trauma patients, severe hepatic, gastrointestinal, multiple abdominal injuries, and mass transfusions. The expected survival rates were achieved in such extreme trauma situations.
Collapse
Affiliation(s)
- Arnulf Willms
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Christoph Güsgen
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany.
| | - Robert Schwab
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Sebastian Schaaf
- Department of General, Visceral and Thoracic Surgery, German Armed Forces Central Hospital of Koblenz, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Johan Lock
- Department of General, Transplantation, Vascular and Paediatric Surgery, University Hospital of Würzburg, VisceralWürzburg, Germany
| | - Erwin Kollig
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany
| | - Christoph Jänig
- Department of Anesthesiology and Intensive Care, German Armed Forces Central Hospital, Koblenz, Germany
| | - Dan Bieler
- Department of Orthopaedics, Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery, and Burn Medicine, German Armed Forces Central Hospital, Koblenz, Germany.,Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Medical School, Düsseldorf, Germany
| | | |
Collapse
|
16
|
KURT F. Comparison of negative-pressure wound therapy and Bogota bag technique in open abdomen: a retrospective clinical study. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05149-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
17
|
[Emergency thoracotomy in a severely injured patient after hemorrhagic shock in traumatic pelvic bleeding : Case report]. Unfallchirurg 2021; 125:568-573. [PMID: 34255104 DOI: 10.1007/s00113-021-01055-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
A case of in-hospital thoracotomy with subsequent open chest cardiopulmonary resuscitation of a polytraumatized patient is reported. Emergency thoracotomies are rare interventions in challenging situations. Up to now there are only few standards or uniform education and training concepts. The indications are often a borderline decision. The aim of thoracotomy and open resuscitation in combination with a reduction in circulation, for example by cross-clamping the aorta, is to save time to address reversible causes of the hemorrhage, redirect the blood volume into the vital cerebral and coronary circulation and minimize bleeding from subdiaphragmatic bleeding sources. Ultimately, in case of doubt, the thoracotomy can be performed for the patient's benefit with the appropriate indications.
Collapse
|
18
|
Shock, Not Blood Pressure or Shock Index, Determines the Need for Thoracic Damage Control Following Penetrating Trauma. Shock 2021; 54:4-8. [PMID: 31693631 DOI: 10.1097/shk.0000000000001472] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Damage control laparotomy has increased survival for critically injured patient with penetrating abdominal trauma. There has been a slower adoption of a damage control strategy for thoracic trauma despite the considerable mortality associated with emergent thoracotomy for patients in profound shock. We postulated admission physiology, not blood pressure or shock index, would identify patients who would benefit from thoracic damage control. STUDY DESIGN Retrospective trauma registry review from 2002 to 2017 at a busy, urban trauma center. Three hundred one patients with penetrating thoracic trauma operated on within 6 h of admission were identified. Of those 66 (21.9%) required thoracic damage control and comprise the study population. RESULTS Compared with the non-damage control group, the 66 damage control patients had significantly higher Injury Severity Score, chest Abbreviated Injury Scale, lactate and base deficit, and lower pH and temperature. In addition, the damage control thoracic surgery group had significantly more gunshot wounds, transfusions, concomitant laparotomies, vasoactive infusions, and shorter time to the operating room. Notably, however, there were no significant differences in admission systolic blood pressure or shock index between the groups. Once normal physiology was restored, chest closure was performed 1.7 (0.7) days after the index operation. Mortality for thoracic damage was 15.2%, significantly higher than the 4.3% in the non-damage control group. Over two-thirds of damage control deaths occurred prior to chest closure. CONCLUSIONS Mortality in this series of severely injured, profoundly physiologically altered patients undergoing thoracic damage control is substantially lower than previously reported. Rather than relying on blood pressure and shock index, early recognition of shock identifies patients in whom thoracic damage control is beneficial.
Collapse
|
19
|
The Presence of Hemorrhagic Shock on Admission Is the Strongest Predictor of Mortality in Trauma Patients Who Require Packing. Indian J Surg 2021. [DOI: 10.1007/s12262-019-01940-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
20
|
Abstract
Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.
Collapse
Affiliation(s)
- Shannon Gaasch
- Shannon Gaasch is Senior Nurse Practitioner II, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201 (Shannon. )
| |
Collapse
|
21
|
Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, Stelfox HT. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World J Emerg Surg 2021; 16:10. [PMID: 33706763 PMCID: PMC7951941 DOI: 10.1186/s13017-021-00352-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/11/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes). METHODS We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions. RESULTS Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications. CONCLUSIONS Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
Collapse
Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, University of Ottawa, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada.
| | - Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David A Zygun
- Division of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - Andrew W Kirkpatrick
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,The Regional Trauma Program, University of Calgary and the Foothills Medical Center, Calgary, AB, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, AB, Canada.,The Regional Trauma Program, University of Calgary and the Foothills Medical Center, Calgary, AB, Canada.,Department of Oncology, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
| | - Peter D Faris
- Alberta Health Sciences Research-Research Analytics, University of Calgary and the Foothills Medical Centre, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.,O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | | |
Collapse
|
22
|
Romero Díaz C, Mayoral LPC, Hernández Huerta MT, Majluf-Cruz AS, Plascencia Mora SE, Pérez-Campos Mayoral E, Mayoral Andrade G, Martínez Cruz M, Zenteno E, Matias Cervantes CA, Vásquez Martínez G, Martínez Cruz R, Ángel Reyes Franco M, Cruz Parada E, Pina Canseco S, Mayoral EPC. The influence of hydrogen ions on coagulation in traumatic brain injury, explored by molecular dynamics. Brain Inj 2021; 35:842-849. [PMID: 33678100 DOI: 10.1080/02699052.2021.1895312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Patients in intensive care units with traumatic brain injuries (TBI) frequently present acid-base abnormalities and coagulability disorders, which complicate their condition.Objective: To identify protonation through in silico simulations of molecules involved in the process of coagulation in standard laboratory tests.Materials and methods: Ten patients with TBI were selected from the intensive care unit in addition to ten "healthy control subjects", and another nine patients as "disease control subjects"; the latter being a comparative group, corresponding to subjects with diabetes mellitus 2 (DM2). Fibrinogen, FVII, FVIII, FIX, FX, and D-dimer in the presence of acidification were evaluated in 20 healthy subjects in order to compare clinical results with molecular dynamics (MD), and to explain proton interactions and coagulation molecules.Results: The TBI group presented a slight, non-significant increase in D-dimer; but this was not present in "disease control subjects". Levels of fibrinogen, FVII, FIX, FX, and D-dimer were affected in the presence of acidification. We observed that various specific residues of coagulation factors "trap" ions.Conclusion: Protonation of tissue factor and factor VIIa may favor anticoagulant mechanisms, and protonation does not affect ligand binding sites of GPIIb/IIIa (PAC1) suggesting other causes for the low affinity to PAC1.
Collapse
Affiliation(s)
| | - Laura Pérez Campos Mayoral
- Research Centre Medicine UNAM-UABJO, Faculty of Medicine, Benito Juárez Autonomous University of Oaxaca, Oaxaca, Mexico
| | | | - Abraham Salvador Majluf-Cruz
- Medical Research Unit in Thrombosis, Haemostasis and Atherogenesis, Mexican Institute of Social Security/IMSS, Mexico City, Mexico
| | | | - Eduardo Pérez-Campos Mayoral
- Research Centre Medicine UNAM-UABJO, Faculty of Medicine, Benito Juárez Autonomous University of Oaxaca, Oaxaca, Mexico
| | - Gabriel Mayoral Andrade
- Research Centre Medicine UNAM-UABJO, Faculty of Medicine, Benito Juárez Autonomous University of Oaxaca, Oaxaca, Mexico
| | | | - Edgar Zenteno
- School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | | | | | - Ruth Martínez Cruz
- Research Centre Medicine UNAM-UABJO, Faculty of Medicine, Benito Juárez Autonomous University of Oaxaca, Oaxaca, Mexico
| | | | | | - Socorro Pina Canseco
- Research Centre Medicine UNAM-UABJO, Faculty of Medicine, Benito Juárez Autonomous University of Oaxaca, Oaxaca, Mexico
| | - Eduardo Pérez-Campos Mayoral
- National Technological of Mexico/ITOaxaca, Oaxaca, Mexico.,Clinical Pathology Laboratory, "Dr. Eduardo Pérez Ortega", Oaxaca, Mexico
| |
Collapse
|
23
|
Gakumazawa M, Toida C, Muguruma T, Shinohara M, Abe T, Takeuchi I. In-Hospital Mortality Risk of Transcatheter Arterial Embolization for Patients with Severe Blunt Trauma: A Nationwide Observational Study. J Clin Med 2020; 9:jcm9113485. [PMID: 33126724 PMCID: PMC7692569 DOI: 10.3390/jcm9113485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/05/2022] Open
Abstract
This study investigated the risk factors for in-hospital mortality of severe blunt trauma patients who underwent transcatheter arterial embolization (TAE). We analysed data from the Japan Trauma Data Bank from 2009 to 2018. Patients with severe blunt trauma and an Injury Severity Score (ISS) ≥ 16 who underwent TAE were enrolled. The primary analysis evaluated patient characteristics and outcomes, and variables with significant differences were included in the secondary multivariate logistic regression analysis. In total, 5800 patients (6.4%) with ISS ≥ 16 underwent TAE. There were significant differences in the proportion of male patients, transportation method, injury mechanism, injury region, Revised Trauma Score, survival probability values, and those who underwent urgent blood transfusion and additional urgent surgery. In multivariable regression analyses, higher age, urgent blood transfusion, and initial urgent surgery were significantly associated with higher in-hospital mortality risk [p < 0.001, odds ratio (OR), 95% confidence interval (CI): 1.01 (1.00–1.01); p < 0.001, 3.50 (2.55–4.79); and p = 0.001, 1.36 (1.13–1.63), respectively]. Inter-hospital transfer was significantly associated with lower in-hospital mortality risk (p < 0.001, OR = 0.56, 95% CI = 0.44–0.71). Treatment protocols for urgent intervention before and after TAE and a safe, rapid inter-hospital transport system are needed to improve mortality risks for severe blunt trauma patients.
Collapse
|
24
|
Is the "Death Triad" a Casualty of Modern Damage Control Resuscitation. J Surg Res 2020; 259:393-398. [PMID: 33092859 DOI: 10.1016/j.jss.2020.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Principles of damage control laparotomy (DCL) focus on early surgical control of hemorrhage and contamination in addition to damage control resuscitation (DCR) to combat the significant mortality associated with the "death triad" of hypothermia, acidosis, and coagulopathy. We hypothesized that DCL patients managed with DCR would have lower mortality from the death triad than historical studies. METHODS A 5-y retrospective chart review of all consecutive adult trauma patients presenting to a Level I trauma center who underwent DCL was conducted. Parameters associated with the death triad were evaluated on admission and 24 h after the presentation. Kaplan Meier survival plots were used to compare the components of the death triad. Univariate and multivariate analyses were performed. RESULTS A total of 149 adult patients were identified. The overall incidence of death triad was 20.8% (n = 31/149). 24-h mortality for all patients was 5.4% (n = 8/149). Kaplan Meier plots showed that 24-h mortality was significantly increased if 3/3 components of the death triad were present (P < 0.05). At 24-h after admission, mortality occurred in 16.6% (n = 5/30) of patients with the death triad. CONCLUSIONS This study confirms that the 24-h mortality of trauma patients increased with the addition of all three death triad components. The death triad predicted death in 16.6% of patients treated with DCL and DCR at 24 h. Results suggest that the death triad might not be as applicable in the modern era of DCL in combination with DCR. Other factors contributing to in-hospital mortality need to be further elucidated.
Collapse
|
25
|
Hanna K, Asmar S, Ditillo M, Chehab M, Khurrum M, Bible L, Douglas M, Joseph B. Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma. J Surg Res 2020; 257:69-78. [PMID: 32818786 DOI: 10.1016/j.jss.2020.07.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/13/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE Level III Prognostic.
Collapse
Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Samer Asmar
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Mohamad Chehab
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Muhammad Khurrum
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Letitia Bible
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Molly Douglas
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
| |
Collapse
|
26
|
Kang WS, Jo YG, Park YC. Quality Improvement of Damage Control Laparotomy: Impact of the Establishment of a Single Korean Regional Trauma Center. World J Surg 2020; 43:2814-2821. [PMID: 31297581 DOI: 10.1007/s00268-019-05083-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Damage control laparotomy (DCL) is a lifesaving technique to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. The government has nominated and supported our center as one of the regional trauma centers of South Korea since 2014. This study aimed to investigate the improving outcomes of patients undergoing DCL before and after the establishment of the trauma center. METHOD The period from January 2011 to December 2017 was divided into pre-trauma center (pre-TC) (2011-2013) and trauma center (TC) (2014-2017) periods. Multivariable logistic regression was performed to identify the risk factors and risk-adjusted cumulative sum (RA-CUSUM), and graphs were used to monitor the change in mortality. RESULT Of the 485 patients who underwent trauma laparotomy, DCL was performed for 119 patients (24.5%). The operation time (99 vs. 80 min, p = 0.022), time from admission to operation (125 vs. 112 min, p = 0.010), time from admission to first treatment (119 vs. 99 min, p = 0.004), and time from admission to first transfusion (70 vs. 52 min, p = 0.009) were significantly shortened in the TC period. The ratio of plasma to packed red blood cells in massive transfusions (≥PRBCs 10 units within the first 24 h) was significantly increased in the TC period (0.56 vs. 0.72, p = 0.004). RA-CUSUM curves revealed that the risk-adjusted 30-day mortality improved and then plateaued in the TC period. CONCLUSION After the implementation of a trauma center, more prompt intervention and damage control resuscitation could be achieved. Moreover, risk-adjusted mortality of DCL was improved.
Collapse
Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea.,Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea.
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, Korea
| |
Collapse
|
27
|
Manzano-Nunez R, Chica J, Gómez A, Naranjo MP, Chaves H, Muñoz LE, Rengifo JE, Caicedo-Holguin I, Puyana JC, García AF. The tenets of intrathoracic packing during damage control thoracic surgery for trauma patients: a systematic review. Eur J Trauma Emerg Surg 2020; 47:423-434. [PMID: 32594214 DOI: 10.1007/s00068-020-01428-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Although Damage Control Thoracic Surgery (DCTS) has become a provocative alternative to treat patients with chest injuries who are critically ill and physiologically depleted, the management approaches of chest-packing and the measurement of clinically relevant outcomes are not well established. In this paper, we systematically reviewed the available knowledge and evidence about intra-thoracic packing during DCTS for trauma patients. We furthermore inform on the management approaches, surgical strategies, and mortality associated with this intervention. METHODS We identified articles in MEDLINE and SCOPUS. We reviewed all studies that included trauma patients with chest injuries and managed with intrathoracic packing during DCTS. Studies were eligible if the use of intrathoracic packing in trauma populations was reported. RESULTS We identified 14 studies with a total of 211 patients. Overall, intrathoracic packing was used in 131 trauma patients. Packing was most commonly used to arrest persistent coagulopathic bleeding or oozing either from raw surfaces or repaired structures and in conjunction with other operative techniques. Pneumonectomy was a deadly intervention; however, one study reported survivors when pneumonectomy was deferred. CONCLUSION Packing is a feasible, reliable and potentially effective complementary method for hemorrhage control. Therefore, we recommend that packing can be used liberally as a complement to rapid lung-sparing techniques.
Collapse
Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia. .,Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.
| | - Julian Chica
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia.,Department of Surgery, Fundacion Valle del Lili, Cali, Colombia
| | - Alexandra Gómez
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia
| | - Maria P Naranjo
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia
| | - Harold Chaves
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Luis E Muñoz
- Department of Surgery, Universidad del Valle, Cali, Colombia
| | - Javier E Rengifo
- Department of Radiology, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | | | - Juan C Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alberto F García
- Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.,Department of Surgery, Universidad del Valle, Cali, Colombia
| |
Collapse
|
28
|
Müller V, Piper SK, Pratschke J, Raue W. Intraabdominal continuous negative pressure therapy for secondary peritonitis: an observational trial in a maximum care center. Acta Chir Belg 2020; 120:179-185. [PMID: 30947631 DOI: 10.1080/00015458.2019.1576448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Acute secondary peritonitis is afflicted with a high morbidity and mortality. Intensive care therapy, antibiotics and surgical procedures are mandatory. Continuous negative pressure therapy (cNPT) seems to be beneficial but it is unclear which patients will benefit most from this procedures.Methods: We performed a prospective observational trial including all patients that needed to undergo an exploratory laparotomy for the suspicion of acute secondary peritonitis and were treated with cNPT in one year.Results: Thirty nine patients fitted the criteria. Median hospitalization length was 40 days. The vacuum therapy treatment was applied for a median of 4 days. The subgroup analysis between patients, who received the cNPT-dressing for one time (Group A) and patients, in whom the cNPT was continued after first relaparotomy (Group B) showed no differences concerning patients' characteristics. The Mannheimer Peritonitis Index (MPI) during the first operation was significantly correlated with the number of dressing changes (Spearman's rho 0.518, p = .002).Conclusions: Fast acting in acute secondary peritonitis for elimination of the source, abdominal lavage, derivation of the exsudat and interdisciplinary treatment is the treatment of choice. The MPI could be beneficial for the decision process of using cNPT.
Collapse
Affiliation(s)
- V. Müller
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - S. K. Piper
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - J. Pratschke
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - W. Raue
- Clinic of General-, Visceral- and Thoracic Surgery, AKH Celle, Celle, Germany
| |
Collapse
|
29
|
Poillucci G, Podda M, Russo G, Perri SG, Ipri D, Manetti G, Lolli MG, De Angelis R. Open abdomen closure methods for severe abdominal sepsis: a retrospective cohort study. Eur J Trauma Emerg Surg 2020; 47:1819-1825. [PMID: 32377924 DOI: 10.1007/s00068-020-01379-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 04/24/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The open abdomen (OA) procedure as part of damage control surgery represents a significant surgical advance in severe intra-abdominal infections. Major techniques used for OA are negative pressure wound therapy (NPWT) and non-NPWT. The aim of this retrospective study is to evaluate the effects of different abdominal closure methods and their outcomes in patients presenting with abdominal sepsis treated with OA. MATERIALS AND METHODS We retrospectively analyzed clinical outcomes of patients affected by severe intra-abdominal sepsis treated with OA. Demographic features, mortality prediction score, abdominal closure methods, length of hospital stay, complications and mortality rates of patients were determined and compared. RESULTS This study included 106 patients, of whom 77 underwent OA with NPWT and 29 with non-NPWT. OA duration was longer in NPWT patients (p = 0.007). In-hospital mortality rates in NPWT and in non-NPWT patients were 40.3% and 51.7%, respectively (p = 0.126), with an overall 30-day mortality rate of 18.2% and 51.7%, respectively (p = 0.0002). After emergency colorectal surgery, patients who underwent OA with NPWT had a lower rate of colostomy (p = 0.025). CONCLUSIONS NPWT is the best temporary abdominal closure technique to decrease mortality and colostomy rates in patients managed with OA for severe intra-abdominal infections.
Collapse
Affiliation(s)
- Gaetano Poillucci
- Department of General and Specialized Surgery "Paride Stefanini", Policlinico Universitario Umberto I, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Mauro Podda
- Department of General, Emergency and Minimally Invasive Surgery, Policlinico Universitario "D. Casula", University of Cagliari, Monserrato, Italy
| | - Giulia Russo
- Department of General Surgery, San Camillo De Lellis Hospital, Rieti, Italy
| | | | - Domenico Ipri
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Gabriele Manetti
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Maria Giulia Lolli
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| | - Renato De Angelis
- Department of General Surgery, San Giovanni Addolorata Hospital, Rome, Italy
| |
Collapse
|
30
|
Leibner E, Andreae M, Galvagno SM, Scalea T. Damage control resuscitation. Clin Exp Emerg Med 2020; 7:5-13. [PMID: 32252128 PMCID: PMC7141982 DOI: 10.15441/ceem.19.089] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 12/10/2019] [Indexed: 01/24/2023] Open
Abstract
The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.
Collapse
Affiliation(s)
- Evan Leibner
- Department of Emergency Medicine, Institute of Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark Andreae
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samuel M Galvagno
- Program in Trauma, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Program in Trauma, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
31
|
Aiolfi A, Inaba K, Martin M, Matsushima K, Bonitta G, Bona D, Demetriades D. Lung Resection for Trauma: A Propensity Score Adjusted Analysis Comparing Wedge Resection, Lobectomy, and Pneumonectomy. Am Surg 2020. [DOI: 10.1177/000313482008600338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The resection of lung parenchyma for thoracic trauma is uncommon. Different surgical procedures with a wide range of complexities have been described depending on the severity of trauma and the presence of associated injuries. The aim of this study was to analyze outcomes of wedge resection, lobectomy, and pneumonectomy. Data for this study were obtained from an eight-year retrospective National Trauma Data Bank study (2007–2015). Adult patients who sustained severe chest trauma (Abbreviated Injury Scale > 3) that required any type of lung resection were included. Propensity score (PS) analysis was adopted. Overall, 3107 patients were included. Wedge resection was performed in 54.3 per cent, lobectomy in 38.2 per cent, and pneumonectomy in 7.5 per cent of patients. Longer in-hospital length of stay ( P = 0.01), ICU length of stay ( P = 0.002), and mechanical ventilation days ( P = 0.038) were found in case of major resections. The overall morbidity and mortality were 32 per cent and 27.5 per cent, respectively. A stepwise increase in mortality occurred when comparing wedge (20.3%), lobectomy (30.8%), and pneumonectomy (63.4%) ( P < 0.001). After PS analysis, lobectomy and pneumonectomy were associated with higher mortality compared with wedge resection (odds ratio [OR] 1.42; 95% confidence interval 1.26–1.71 and OR 4.16; 95% confidence interval 2.84–6.07, respectively). Similarly, after PS analysis, lobectomy and pneumonectomy were associated with higher overall complications compared with wedge resection (OR 1.21 and OR 1.56, respectively). Comparable results were found in the subgroup analysis of patients with isolated lung injury. After PS matching, lobectomy and pneumonectomy were associated with significantly higher morbidity and mortality compared with nonanatomical wedge resection.
Collapse
Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California; and
| | - Matthew Martin
- Trauma and Emergency Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, Los Angeles, California; and
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Demetrios Demetriades
- Trauma and Emergency Surgery Service, Legacy Emanuel Medical Center, Portland, Oregon
| |
Collapse
|
32
|
Dayani Y, Stierwalt J, White A, Chen Y, Arnaud F, Jefferson MA, Goforth C, Malone D, Scultetus AH. Hypobaria during aeromedical evacuation exacerbates histopathological injury and modifies inflammatory response in rats exposed to blast overpressure injury. J Trauma Acute Care Surg 2020; 87:205-213. [PMID: 31033888 DOI: 10.1097/ta.0000000000002337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Aeromedical evacuation (AE) is often used as a rapid and effective way to evacuate patients. However, little is known about the possible effects of AE on patients with blast and traumatic brain injury. In the current study, we used blast overpressure (BOP) as a method to introduce traumatic brain injury in rats and investigated the effects of hypobaria during AE on histology and inflammatory response. METHODS Animals were exposed to a 12-hour flight 2 days after BOP and euthanized 48 hours after flight. Control animals were kept at normobaria. RESULTS Overall, BOP animals exposed to flight demonstrated higher histopathologic injury scores as compared to control animals in lungs, brain, kidney, heart, and intestine. The BOP animals exposed to normobaria exhibited a proinflammatory response compared to those that were not blasted, an observation that was not seen in BOP animals exposed to hypobaria. CONCLUSION These data suggest that AE 48 hours post blast may lead to impairment in the inflammatory process and worsening of long-term outcomes. LEVEL OF EVIDENCE Animal research, level II.
Collapse
Affiliation(s)
- Yaron Dayani
- From the NeuroTrauma Department (Y.D., J.S., A.W., Y.C., F.A., C.G., D.M., A.H.S.), Naval Medical Research Center, Silver Spring; Henry M. Jackson Foundation for the Advancement of Military Medicine (Y.D., A.W., Y.C., F.A., D.M., A.H.S.); School of Medicine (J.S.); Department of Surgery (F.A., C.G., D.M., A.H.S.).Uniformed Services University of the Health Sciences, Bethesda; and Department of Pathology (M.A.J., D.M.), Walter Reed Army Institute of Research, Silver Spring, Maryland
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Accuracy of Published Indications for Predicting Use of Damage Control During Laparotomy for Trauma. J Surg Res 2019; 248:45-55. [PMID: 31863936 DOI: 10.1016/j.jss.2019.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/24/2019] [Accepted: 11/02/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Although studies have identified published indications that experts and practicing surgeons agree indicate use of damage control (DC) laparotomy, it is unknown whether these indications predict use of the procedure in practice. MATERIALS AND METHODS We conducted a diagnostic performance study of the accuracy of a set of published appropriateness indications for predicting use of DC laparotomy. We included consecutive adults that underwent emergent laparotomy for trauma (2011-2016) at Memorial Hermann Hospital. RESULTS We included 1141 injured adults. Two published preoperative appropriateness indications [a systolic blood pressure (BP) persistently <90 mmHg or core body temperature <34°C] produced moderate shifts in the pretest probability of conducting DC instead of definitive laparotomy. Five published intraoperative appropriateness indications produced large and often conclusive changes in the pretest probability of conducting DC during emergent laparotomy. These included the finding of a devascularized or completely disrupted pancreas, duodenum, or pancreaticoduodenal complex; an estimated intraoperative blood loss >4 L; administration of >10 U of packed red blood cells (PRBCs); and a systolic BP persistently <90 mmHg or arterial pH persistently <7.2 during operation. Most indications that produced large changes in the pretest probability of conducting DC laparotomy had an incidence of 2% or less. CONCLUSIONS This study suggests that published appropriateness indications accurately predict use of DC laparotomy in practice. Intraoperative variables exert greater influence on the decision to conduct DC laparotomy than preoperative variables, and those indications that produce large shifts in the pretest probability of conducting DC laparotomy are uncommonly encountered.
Collapse
|
34
|
Management of disseminated intravascular coagulation associated with placental abruption and measures to improve outcomes. Obstet Gynecol Sci 2019; 62:299-306. [PMID: 31538072 PMCID: PMC6737058 DOI: 10.5468/ogs.2019.62.5.299] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/26/2019] [Accepted: 04/17/2019] [Indexed: 11/08/2022] Open
Abstract
Placental abruption is a condition that should be carefully considered in perinatal management because it is associated with serious events in both the mother and neonate, such as intrauterine fetal death, cerebral palsy, obstetric critical bleeding, and uncontrollable bleeding. The concomitant presence of disseminated intravascular coagulation (DIC) more easily causes critical bleeding that may necessitate hysterectomy or multi-organ failure resulting in maternal death. Therefore, early management should be provided to prevent progression to serious conditions by performing both hemostatic procedures and DIC treatment. To take measures to improve the outcomes in both the mother and neonate, health guidance for pregnant women, early diagnosis, early treatment, development of the emergency care system, and provision of a system for transport to higher-level medical institutions should be implemented.
Collapse
|
35
|
Apelqvist J, Willy C, Fagerdahl AM, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Vowden P. EWMA Document: Negative Pressure Wound Therapy. J Wound Care 2019; 26:S1-S154. [PMID: 28345371 DOI: 10.12968/jowc.2017.26.sup3.s1] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.1 NPWT has been described as a effective treatment for wounds of many different aetiologies2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,4-6 dehisced sternal wounds following cardiac surgery7,8 and as a valuable agent in complex non-healing wounds.9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.11 While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.
Collapse
Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, 205 02 Malmö, Sweden and Division for Clinical Sciences, University of Lund, 221 00 Lund, Sweden
| | - Christian Willy
- Department of Trauma & Orthopedic Surgery, Septic & Reconstructive Surgery, Bundeswehr Hospital Berlin, Research and Treatment Center for Complex Combat Injuries, Federal Armed Forces of Germany, 10115 Berlin, Germany
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Karolinska Institutet, and Wound Centre, Södersjukhuset AB, SE-118 83 Stockholm, Sweden
| | - Marco Fraccalvieri
- Plastic Surgery Unit, ASO Città della Salute e della Scienza of Turin, University of Turin, 10100 Turin, Italy
| | | | - Alberto Piaggesi
- Department of Endocrinology and Metabolism, Pisa University Hospital, 56125 Pisa, Italy
| | - Astrid Probst
- Kreiskliniken Reutlingen GmbH, 72764 Reutlingen, Germany
| | - Peter Vowden
- Faculty of Life Sciences, University of Bradford, and Honorary Consultant Vascular Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, United Kingdom
| |
Collapse
|
36
|
Rocca A, Andolfi E, Zamboli AGI, Surfaro G, Tafuri D, Costa G, Frezza B, Scricciolo M, Amato M, Bianco P, Brongo S, Ceccarelli G, Giuliani A, Amato B. Management of Complications of First Instance of Hepatic Trauma in a Liver Surgery Unit: Portal Vein Ligation as a Conservative Therapeutic Strategy. Open Med (Wars) 2019; 14:376-383. [PMID: 31157303 PMCID: PMC6534101 DOI: 10.1515/med-2019-0038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 03/15/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND According to the National Trauma Data Bank, the liver, after the spleen, is the first most injured organ in closed abdominal trauma. METHODS From June 2010 to December 2015 we observed in our department of Hepato-biliary Surgery and Liver Transplant Unit of the A.O.R.N. A. Cardarelli of Naples 40 patients affected by hepatic trauma. In our retrospective study, we review our experience and propose portal vein ligation (PVL) as a first - line strategy for damage control surgery (DCS) in liver trauma. RESULTS 26/40 patients (65%) which received gauze-packing represented our study group. In 10 cases out of 26 patients (38,4%) the abdominal packing was enough to control the damage. In 7 cases (18,4%) we performed a liver resection. In 7 cases, after de-packing, we adopted PVL to achieve DCS. Trans Arterial Embolization was chosen in 6 patients. 2 of them were discharged 14 days later without performing any other procedure.In 3 cases we had to perform a right epatectomy in second instance. Two hepatectomies were due to hemoperitoneum, and the other for coleperitoneum. Two patients were treated in first instance by only doing hemostasis on the bleeding site. We observed 6 patients in first instance. Five of them underwent surgery with hepatic resection and surgical hemostasis of the bleeding site. The other one underwent to conservative management. In summary we performed 15 hepatic resections, 8 of them were right hepatectomies, 1 left hepatectomy, 2 trisegmentectomies V-VI-VII. So in second instance we operated on 10 patients out of 34 (30%). CONCLUSIONS The improved knowledge of clinical physio-pathology and the improvement of diagnostic and instrumental techniques had a great impact on the prognosis of liver trauma. We think that a rigid diagnostic protocol should be applied as this allows timely pathological finding, and consists of three successive but perfectly integrated steps: 1) patient reception, in close collaboration with the resuscitator; 2) accurate but quick diagnostic framing 3) therapeutic decisional making. Selective portal vein ligation is a well-tolerated and safe manoeuvre, which could be effective, even if not definitive, in treating these subjects. That is why we believe that it can be a choice to keep in mind especially in post-depacking bleeding.
Collapse
Affiliation(s)
- Aldo Rocca
- Department of Translational Medical Sciences, University of Naples “Federico II”, Naples, Italy
- Via Sergio Pansini, 80131 Naples, Italy General Surgery Unit, Clinica Padre Pio, Mondragone (CE), Italy Department of Abdominal Oncology, Fondazione Giovanni Pascale, IRCCS, Naples, Italy
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Enrico Andolfi
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | | | | | - Domenico Tafuri
- Department of Sport Sciences and Wellness, University of Naples “Parthenope”, Naples, Italy
| | - Gianluca Costa
- Surgical and Medical Department of Traslational Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Via di Grottarossa 1035-39, 00189Rome, Italy
| | - Barbara Frezza
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Marta Scricciolo
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Maurizio Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
| | - Paolo Bianco
- Centre of Hepatobiliarypancreatic surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Sergio Brongo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", San Giovanni di Dio e Ruggi D'Aragona University Hospital, University of Salerno, Salerno, Italy
| | - Graziano Ceccarelli
- Department of Surgery, Division of general Surgery, San Donato Hospital, via Pietro Nenni 20-22, 52100Arezzo, Italy
| | - Antonio Giuliani
- Department of Transplantation, Unit of Hepatobiliary Surgery and Liver Transplant Center, ‘A. Cardarelli’ Hospital, Naples, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University Federico II of Naples. Naples, Italy
| |
Collapse
|
37
|
Abstract
BACKGROUND The presence of abdominal injuries has a major impact on the mortality of severely injured patients. For injuries that require surgery, laparotomy is still the gold standard for early surgical care; however, there is increasing evidence that laparoscopy may be an alternative in the early clinical care of polytrauma patients. OBJECTIVE The present registry-based study analyzed the utilization and the outcome of laparoscopy in severely injured patients with abdominal trauma in Germany. MATERIAL AND METHODS A retrospective analysis of 12,447 patients retrieved from the TraumaRegister DGU® (TR-DGU) was performed. The primary inclusion criteria were an injury severity score (ISS) ≥ 9 and an abbreviated injury scale (AIS) [abdomen] ≥ 1. The included patients were grouped according to early treatment management: (1) laparoscopy, (2) laparotomy and (3) non-operative management (NOM). Finally, group-specific patient characteristics and outcome were analyzed. RESULTS The majority of patients were treated by NOM (52.4%, n = 6069), followed by laparotomy (50,6%, n = 6295) and laparoscopy (0.7%, n = 83). The majority of laparoscopies were performed in patients with an AIS [abdomen] ≤ 3 (86.7%). The ISS of the laparoscopy group was significantly lower compared to that of the laparotomy and NOM groups (ISS 23.4 vs. 34.5 vs. 28.2, respectively, p ≤ 0.001). The standardized mortality rate (SMR), defined as the ratio between observed and expected mortality, was lowest in the patients receiving laparoscopy followed by laparotomy and NOM (SMR 0.688 vs. 0.931 vs. 0.932, respectively, p-value = 0.2128) without achieving statistical significance. CONCLUSION Despite being rarely employed the data indicate the effectiveness of laparoscopy for the early treatment of severely injured, hemodynamically stable patients with an AIS [abdomen] ≤ 3.
Collapse
|
38
|
Kang WS, Park YC, Jo YG. Laparotomy following cardiopulmonary resuscitation after traumatic cardiac arrest: is it futile? Eur J Trauma Emerg Surg 2019; 46:657-661. [PMID: 30949739 DOI: 10.1007/s00068-019-01118-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 03/27/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The outcome of cardiopulmonary resuscitation (CPR) after traumatic cardiac arrest is very poor. Moreover, some consider laparotomy for abdominal trauma after CPR futile. This study aimed to investigate the outcomes of trauma patients who were pulseless and received CPR followed by laparotomy. METHOD We conducted a retrospective review of 28,255 trauma patients from our hospital from January 2009 to November 2017. Patient demographics, injury severity scores, duration of CPR, operative data, and mortality of patients with laparotomy after CPR were collected and analyzed. RESULT We identified 120 trauma patients (0.42%) who underwent CPR at admission. Twenty-three patients (0.08%) underwent laparotomy following CPR. Of these, 19 patients (82.6%) died after laparotomy. Of four survivors after laparotomy, three (13.0%) survived with a good neurologic outcome. One survivor required rehabilitation due to poor neurologic outcome. All patients had suffered a blunt injury. CONCLUSION The survival rate for laparotomy following CPR after traumatic cardiac arrest was very poor. However, laparotomy following CPR is not always futile.
Collapse
Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea.,Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea.
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 61469, Korea
| |
Collapse
|
39
|
Takeda S, Takeda J, Makino S. A minimally invasive hemostatic strategy in obstetrics aiming to preserve uterine function and enhance the safety of subsequent pregnancies. HYPERTENSION RESEARCH IN PREGNANCY 2019. [DOI: 10.14390/jsshp.hrp2018-013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Satoru Takeda
- Department of Obstetrics and Gynecology, Faculty of Medicine Juntendo University
| | - Jun Takeda
- Department of Obstetrics and Gynecology, Faculty of Medicine Juntendo University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine Juntendo University
| |
Collapse
|
40
|
Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| |
Collapse
|
41
|
Prezman-Pietri M, Rabinel P, Périé G, Georges B, Brouchet L, Bounes FV. Thoracic Damage Control: Let's Think About Intrathoracic Packing. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:1526-1529. [PMID: 30581190 PMCID: PMC6320551 DOI: 10.12659/ajcr.911097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 07/23/2018] [Indexed: 11/09/2022]
Abstract
BACKGROUND In cases of hemorrhagic shock following thoracic trauma, thoracotomy is indicated as primary surgical management, as a chest tube might lead to exsanguination. Thoracic packing is an alternative, particularly in severe injury trauma. CASE REPORT A 48-year-old male was involved in an accident in which 2 cars collided. The patient suffered from right-sided hemothorax due to diaphragm rupture and stripping of the diaphragmatic pillar. A right anterolateral thoracotomy revealed an active bleed due to diaphragmatic pillar stripping and laceration with liver herniation. Right thoracic packing was established to stop the bleeding. CONCLUSIONS The primary objectives of thoracic damage control are to prevent cardiac tamponade, to control intrathoracic bleeding and massive air embolism or bronchopleural fistula, and to allow open cardiac massage. These patients represent challenging cases of both rapid therapeutic decision-making and operative intervention. Thoracic packing is a part of damage control in cases of hemorrhagic shock after thoracic trauma.
Collapse
Affiliation(s)
- Maud Prezman-Pietri
- Anesthesiology and Critical Care Unit, University Teaching Hospital of Toulouse, Toulouse, France
| | - Pierre Rabinel
- Department of Thoracic Surgery, University Teaching Hospital of Toulouse, Toulouse, France
| | - Grégoire Périé
- Department of Thoracic Surgery, University Teaching Hospital of Toulouse, Toulouse, France
| | - Bernard Georges
- Anesthesiology and Critical Care Unit, University Teaching Hospital of Toulouse, Toulouse, France
| | - Laurent Brouchet
- Department of Thoracic Surgery, University Teaching Hospital of Toulouse, Toulouse, France
| | - Fanny Vardon Bounes
- Anesthesiology and Critical Care Unit, University Teaching Hospital of Toulouse, Toulouse, France
| |
Collapse
|
42
|
Kang WS. Damage Control Surgery with Pad Packing for Active Bleeding in Crushing Wound of Perineum and Amputated Leg Stump. JOURNAL OF ACUTE CARE SURGERY 2018. [DOI: 10.17479/jacs.2018.8.2.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Wu Seong Kang
- Department of Trauma Surgery, Wonkwang University Hospital, Iksan, Korea
| |
Collapse
|
43
|
Otsuka H, Sato T, Sakurai K, Aoki H, Yamagiwa T, Iizuka S, Inokuchi S. Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study. World J Emerg Surg 2018; 13:49. [PMID: 30386415 PMCID: PMC6202823 DOI: 10.1186/s13017-018-0210-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/10/2018] [Indexed: 01/27/2023] Open
Abstract
Background Although resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear. Methods We performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes. Results Trauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081–51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0–80.3) min vs. without REBOA 57.0 (35.0–100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min. Conclusions The use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.
Collapse
Affiliation(s)
- Hiroyuki Otsuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Toshiki Sato
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Keiji Sakurai
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Hiromichi Aoki
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Takeshi Yamagiwa
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Shinichi Iizuka
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara city, Kanagawa Prefecture 259-1193 Japan
| |
Collapse
|
44
|
Does Negative-Pressure Wound Therapy for the Open Abdomen Benefit the Patient? A Retrospective Cohort Study. Adv Skin Wound Care 2018; 30:256-261. [PMID: 28520603 DOI: 10.1097/01.asw.0000516196.19330.6f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Negative-pressure wound therapy (NPWT) is the most modern and sophisticated method of temporary abdominal closure. The aim of the study was to determine the significant predictors for mortality in patients with NPWT. SETTING University Clinical Centre Maribor, Slovenia MATERIALS AND METHODS:: The authors performed a retrospective cohort study of all patients treated with NPWT between January 1, 2011, and December 31, 2014. RESULTS In the univariate analysis, the type of wound closure, more than 7 NPWT changes, the total days with NPWT, and time to wound closure were significantly associated with death of the patient. In the multivariate analysis, only the number of more than 7 NPWT changes was found as a significant predictor for death (P = .038). CONCLUSIONS Negative-pressure wound therapy is a method of choice for the treatment of open abdomen if there is a clear indication. However, clinicians should try all measures to remove the NPWT system and close the abdomen as soon as possible because prolonged use is associated with significantly higher mortality.
Collapse
|
45
|
Hwang K, Kwon J, Cho J, Heo Y, Lee JCJ, Jung K. Implementation of Trauma Center and Massive Transfusion Protocol Improves Outcomes for Major Trauma Patients: A Study at a Single Institution in Korea. World J Surg 2018; 42:2067-2075. [PMID: 29290073 DOI: 10.1007/s00268-017-4441-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND This study evaluated the effectiveness and clinical outcomes of the implementation of a trauma center and massive transfusion protocol (TCMTP) in a developing country without a well-established trauma system. METHODS We included patients (1) aged >15 years, (2) with an Injury Severity Score >15, (3) who received ≥10 units of packed red blood cells (PRBCs) within 24 h, (4) who directly visited our institution from 2010 to 2016, and (5) who survived for ≥24 h. Patients treated during the post-TCMTP period (2015-2016) were compared with historical groups treated pre-TCMTP (2010-2012) and interim-TCMTP (2013-2014). Demographics, transfusion and fluid therapy performance, and clinical outcomes were compared between the three groups. RESULTS Overall, 190 patients were included: 64, 64, and 62 patients in the pre-TCMTP, interim-TCMTP, and post-TCMTP groups, respectively. Comparison between the three groups revealed significant differences in the fresh-frozen plasma/PRBC ratio (p = 0.001) and crystalloid infusion (p = 0.007); these variables gradually increased from pre- to post-TCMTP. Conversely, colloid infusion showed a reduction post-TCMTP (p < 0.001). Kaplan-Meier curves revealed that the 90-day survival rate was significantly higher in the post-TCMTP group (pre-TCMTP: 45.3 vs. 75.8%, p = 0.001; interim-TCMTP: 56.3 vs. 75.8%, p = 0.027). In Cox regression hierarchical survival analysis, TCMTP showed a hazard ratio for mortality of 0.380 after adjusting for all potentially confounding factors. CONCLUSIONS Our results suggest that building trauma centers and establishing a massive transfusion protocol according to the specific situations of a country will help improve outcomes for major trauma patients, even in developing countries without a well-established trauma system.
Collapse
Affiliation(s)
- Kyungjin Hwang
- Division of Trauma, Department of Surgery, Ajou University School of Medicine and Graduate School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Korea
| | - Junsik Kwon
- Division of Trauma, Department of Surgery, Ajou University School of Medicine and Graduate School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Korea
| | - Jayun Cho
- Division of Trauma, Department of Surgery, Ajou University School of Medicine and Graduate School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Korea
| | - Yunjung Heo
- Department of Medical Humanities and Social Medicine, Ajou University School of Medicine and Graduate School of Medicine, Suwon, Gyeonggi-do, Korea
| | - John Cook-Jong Lee
- Division of Trauma, Department of Surgery, Ajou University School of Medicine and Graduate School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Korea
| | - Kyoungwon Jung
- Division of Trauma, Department of Surgery, Ajou University School of Medicine and Graduate School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, 16499, Korea.
| |
Collapse
|
46
|
Rogers A, Saggaf M, Ziolkowski N. A quality improvement project incorporating preoperative warming to prevent perioperative hypothermia in major burns. Burns 2018. [DOI: 10.1016/j.burns.2018.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
47
|
Bower KL, Collier BR. Update on Feeding the Open Abdomen in the Trauma Patient. CURRENT SURGERY REPORTS 2018. [DOI: 10.1007/s40137-018-0212-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
48
|
Abstract
PURPOSE OF REVIEW Damage control surgery (DCS) represents a staged surgical approach to the treatment of critically injured trauma patients. Originally described in the context of hepatic trauma and postinjury-induced coagulopathy, the indications for DCS have expanded to the management of extra abdominal trauma and to the management of nontraumatic acute abdominal emergencies. Despite being an accepted treatment algorithm, DCS is based on a limited evidence with current concerns of the variability in practice indications, rates and adverse outcomes in poorly selected patient cohorts. RECENT FINDINGS Recent efforts have attempted to synthesize evidence-based indication to guide clinical practice. Significant progress in trauma-based resuscitation techniques has led to improved outcomes in injured patients and a reduction in the requirement of DCS techniques. SUMMARY DCS remains an important treatment strategy in the management of specific patient cohorts. Continued developments in early trauma care will likely result in a further decline in the required use of DCS in severely injured patients.
Collapse
|
49
|
Kang WS, Park YC, Jo YG, Kim JC. Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center. Ann Surg Treat Res 2018; 95:29-36. [PMID: 29963537 PMCID: PMC6024086 DOI: 10.4174/astr.2018.95.1.29] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 12/15/2022] Open
Abstract
Purpose Pancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation. Methods We reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses. Results Data from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%. Conclusion The pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.
Collapse
Affiliation(s)
- Wu Seong Kang
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Yun Chul Park
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Young Goun Jo
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Jung Chul Kim
- Division of Trauma Surgery, Department of Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| |
Collapse
|
50
|
Abstract
PURPOSE OF REVIEW To discuss the recent developments in and evolvement of next generation haemostatic resuscitation in bleeding trauma. RECENT FINDINGS Mortality from major trauma is a worldwide problem, and massive haemorrhage remains a major cause of potentially preventable deaths. Development of coagulopathy further increases trauma mortality emphasizing that coagulopathy is a key target in the phase of bleeding. The pathophysiology of coagulopathy in trauma reflects at least three distinct mechanisms that may be present isolated or coexist: acute traumatic coagulopathy, coagulopathy associated with the lethal triad, and consumptive coagulopathy. The concepts of 'damage control surgery' and 'damage control resuscitation' have been developed to ensure early control of bleeding and coagulopathy to improve outcome in bleeding trauma. Haemostatic resuscitation aims at controlling coagulopathy and consists of a ratio driven strategy aiming at 1 : 1 : 1, using tranexamic acid according to CRASH-2, and applying haemostatic monitoring enabling a switch to a goal-directed approach when bleeding slows. Haemostatic resuscitation is the mainstay of trauma resuscitation and is associated with improved survival. SUMMARY The next generation of haemostatic resuscitation aims at applying a ratio 1 : 1 : 1 driven strategy while using antifibrinolytics, haemostatic monitoring and avoiding critical fibrinogen deficiency by substitution.
Collapse
|