Western Trauma Association critical decisions in trauma: Management of the open abdomen after damage control surgery

Bilateral internal iliac artery ligation in trauma patients with severe pelvic hemorrhage: A systematic review

INTRODUCTION

Severe pelvic hemorrhage significantly contributes to mortality in trauma patients, yet the most effective treatment for severe pelvic injuries remains unclear. This systematic review evaluates the mortality and morbidity associated with bilateral internal iliac artery ligation (BIIAL) in patients experiencing severe hemorrhage from traumatic pelvic fractures.

METHODS

Comprehensive searches were conducted in MEDLINE PubMed, EMBASE, and Cochrane databases until February 7, 2024, to identify relevant articles. The risk of bias in observational studies was assessed using the ROBINS-I tool, which evaluates bias risk in nonrandomized intervention studies. The primary outcome was mortality following BIIAL, with the secondary outcome being complications related to the procedure.

RESULTS

The review included eight studies, all observational. The overall mortality rate after BIIAL ranged from 45.0% to 76.9%. Ischemic complications from BIIAL were infrequent. A high and unclear risk of bias due to confounding and participant selection was noted across the studies. Four studies highlighted distinct indications for BIIAL compared to angioembolization. BIIAL was employed for patients with severe hemodynamic instability or when angiography was not available.

CONCLUSION

Due to geographical limitations and significant heterogeneity among the studies reviewed, the true effect size of BIIAL remains indeterminate. Nevertheless, further prospective studies with robust designs are necessary. BIIAL holds potential as a viable option when angioembolization is not accessible or in cases of critical patient instability.

Damage control packing: How long can it stay?

Damage control (DC) packing is used selectively in patients in shock with extensive abdominal, thoracic, perineal/genital/perirectal, neck/axillae/groin (junctional), and extremity injury to stop bleeding. In multiple casualty scenarios, DC packing may be used to facilitate an abbreviated surgery and thus "buy time". The packing is by guideline or military doctrine removed or exchanged 1-3 days later in a planned reoperation. In remote environments, however, where timely evacuation cannot occur and resources are limited, it may be necessary for packing to be left in place longer than 3 days. Also, in Large Scale Combat Operations, Multi-Domain Operations, and Distributed Maritime Operations, evacuation will be accomplished by nonsurgeons and may last several days. Prolonged retention of packing is associated with complications, but significant rebleeding may occur upon removal. This article reviews the benefits and hazards of DC packing removal to inform decision making by both surgeons and nonsurgeons. We conclude that except for Dismounted Complex Blast Injury most DC gauze packing does not mandatorily need to be removed or exchanged within a three-day window.

Clinical Characteristics and Risk Factors of Surgical Site Infection in Patients with Open Abdomen with Fistula Undergoing the Abdominal Wall Reconstruction Utilizing Biological Mesh: A Single-Center Retrospective Study

Objective: This study aimed to evaluate the clinical characteristics and identify risk factors for surgical site infection (SSI) following abdominal wall reconstruction using biological mesh. Methods: A retrospective analysis was conducted on patients with open abdomen (OA) with fistula who underwent abdominal wall reconstruction with biological mesh at Jinling Hospital between January 2010 and August 2023. Patients were divided into SSI and non-SSI groups, and their perioperative data were compared to identify potential risk factors. Results: The SSI rate following abdominal wall reconstruction was 23.71% (23/97) in patients with OA with fistula. Significant differences (p < 0.05) were found between the SSI and non-SSI groups in body mass index (BMI), BMI classification, nutritional risk index (NRI) classification, abdominal wall defect partition, pre-operative day one neutrophil count (NEUT), post-perative day one white blood cells (WBCs) and NEUT, post-operative day three WBCs and NEUT, post-operative day seven procalcitonin (PCT) and NEUT, length of hospitalization, and total hospitalization cost. Multifactorial analysis identified normal BMI (odds ratio [OR]: 0.151, 95% confidence interval [CI]: 0.041-0.551, p = 0.004) and high BMI (OR: 0.072, 95% CI: 0.010-0.546, p = 0.011) as protective factors against SSI and moderate NRI (OR: 4.054, 95% CI: 1.069-15.376, p = 0.004), severe NRI (OR: 18.233, 95% CI: 2.971-111.897, p = 0.002), and abdominal wall defect partition (OR: 4.032, 95% CI: 1.218-13.349, p = 0.022) as independent risk factors for SSI. Conclusions: Normal BMI and high BMI act as protective factors against SSI, whereas moderate NRI, severe NRI, and abdominal wall defect partition are independent risk factors for SSI. Nutritional management and surgical care should be emphasized to reduce SSI incidence in patients with OA with fistula undergoing abdominal wall reconstruction.

Investigation and validation of the TEG6s during rotary wing aeromedical flight

INTRODUCTION

To improve rural and austere trauma care, hospital-based testing performed at the point of injury may shorten the time lapsed from injury to intervention. This study aimed to evaluate the use of the TEG6s device (Haemonetics(R), Clinton, PA) in a rotary wing aircraft. Prior attempts suffered from limitation related to lack of vibration mitigation.

METHODS

This was an investigator-initiated, industry-supported study. Haemonetics provided a TEG6s analyzer. The device underwent a standard validation. It was secured in place on the aircraft using shipping foam for vibration mitigation. Donors provided two tubes of sample blood in one sitting. Paired studies were performed on the aircraft during level flight and in the hospital, using the Global Hemostasis with Lysis Cartridge(Haemonetics (R), Clinton, PA). Both normal and presumed pathologic samples were tested in separate phases. Paired t tests were performed.

RESULTS

For normal donors, the mean R for laboratory compared with the aircraft was 6.2 minutes versus 7.2 minutes ( p = 0.025). The mean ± SD Citrated Rapid TEG Maximum Amplitude (CRT MA) was 59.3 ± 5.6 mm and 55.9 ± 7.3 mm ( p < 0.001) for laboratory and aircraft ( p < 0.001). Among normal donors, R was within normal range for 17 of 18 laboratory tests and 18 of 18 aircraft tests ( p > 0.99). During the testing of pathologic samples, the mean R time was 14.8 minutes for laboratory samples and 12.6 minutes for aircraft ( p = 0.02). Aircraft samples were classified as abnormal in 78% of samples; this was not significantly different than laboratory samples ( p = 0.5).

CONCLUSION

The use of the TEG6s for inflight viscoelastic testing appears promising. While statistically significant differences are seen in some results, these values are not considered clinically significant. Classifying samples as normal or abnormal demonstrated a higher correlation. Future studies should focus on longer flight times to evaluate for LY30, takeoff, and landing effects. Overall, this study suggests that TEG6s can be used in a prehospital environment, and further study is warranted.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level III.

Surgical and procedural antibiotic prophylaxis in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee clinical consensus document

The use of prophylactic measures, including perioperative antibiotics, for the prevention of surgical site infections is a standard of care across surgical specialties. Unfortunately, the routine guidelines used for routine procedures do not always account for many of the factors encountered with urgent/emergent operations and critically ill or high-risk patients. This clinical consensus document created by the American Association for the Surgery of Trauma Critical Care Committee is one of a three-part series and reviews surgical and procedural antibiotic prophylaxis in the surgical intensive care unit. The purpose of this clinical consensus document is to provide practical recommendations, based on expert opinion, to assist intensive care providers with decision-making for surgical prophylaxis. We specifically evaluate the current state of periprocedural antibiotic management of external ventricular drains, orthopedic operations (closed and open fractures, silver dressings, local, antimicrobial adjuncts, spine surgery, subfascial drains), abdominal operations (bowel injury and open abdomen), and bedside procedures (thoracostomy tube, gastrostomy tube, tracheostomy).

Evaluating the effectiveness and outcomes associated with direct peritoneal resuscitation in damage control surgery patients with and without hemorrhagic shock

INTRODUCTION

This narrative review aims to evaluate the efficacy of adjunct direct peritoneal resuscitation (DPR) in the treatment of adult damage control surgery (DCS) patients both with and without hemorrhagic shock, and its impact on associated outcomes.

METHODS

PubMed, Google Scholar, EMBASE, ProQuest, and Cochrane were searched for relevant articles published through April 13th, 2023. Studies assessing the utilization of DPR in adult DCS patients were included. Outcomes included time to abdominal closure, intra-abdominal complications, in-hospital mortality, and ICU length of stay (ICU LOS).

RESULTS

Five studies evaluating 437 patients were included. In patients with hemorrhagic shock, DPR was associated with reduced time to abdominal closure (DPR 4.1 days, control 5.9 days, p = 0.002), intra-abdominal complications including abscess formation (DPR 27 %, control 47 %, p = 0.04), and ICU LOS (DPR 8 days, control 11 days, p = 0.004). Findings in patients without hemorrhagic shock were conflicting. Closure times were decreased in one study (DPR 5.9 days, control 7.7 days, p < 0.02) and increased in another study (DPR 3.5 days, control 2.5 days, p = 0.02), intra-abdominal complications were decreased in one study (DPR 27 %, control 47 %, p = 0.04) and similar in another, and ICU LOS was decreased in one study (DPR 17 days, control 24 days, p < 0.002) and increased in another (DPR 13 days, control 11.4 days, p = 0.807).

CONCLUSION

In patients with hemorrhagic shock, adjunct DPR is associated with reduced time to abdominal closure, intra-abdominal complications such as abscesses, fistula, bleeding, anastomotic leak, and ICU LOS. Utilization of DPR in patients without hemorrhagic shock showed promising but inconsistent findings.

Manejo del abdomen abierto en el paciente crítico en un centro de nivel III de Popayán

Introducción. El abdomen abierto es un recurso útil para el tratamiento de pacientes con patología abdominal compleja, con potencial de complicaciones. El objetivo de este estudio fue adaptar la guía de World Society of Emergency Surgery (WSES) 2018, en un hospital de nivel III de atención de la ciudad de Popayán, Colombia, y comparar los resultados obtenidos con los previos a su implementación. Métodos. Estudio cuasi-experimental en dos mediciones de pacientes con abdomen abierto y estancia en cuidado crítico, durante los meses de abril a octubre de los años 2018 y 2019, antes y después de la adaptación con el personal asistencial de la guía de práctica clínica WSES 2018. Se utilizó estadística descriptiva, prueba de Chi cuadrado y se empleó el software SPSS V.25. Resultados. Se incluyeron 99 pacientes críticos, con una edad media de 53,2 años, con indicación de abdomen abierto por etiología traumática en el 28,3 %, infecciosa no traumática en el 32,3 % y no traumática ni infecciosa en el 37,4 %. La mortalidad global fue de 25,3 %, de los cuales, un 68 % se debieron a causas ajenas a la patología abdominal. Las complicaciones postoperatorias se presentaron en 10 pacientes con infección de sitio operatorio y 9 pacientes con fístula enterocutánea. El uso del doble Viaflex se implementó en un 63,6 %, logrando un cierre de la pared abdominal en el 79,8 % de los casos (p=0,038). Conclusión. El abdomen abierto requiere de un abordaje multidisciplinar. El uso de doble Viaflex es una herramienta simple y efectiva. La implementación de la guía disminuyó el porcentaje de mortalidad, los días de abdomen abierto y la estancia en cuidados intensivos.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial

BACKGROUND

Fluid overload (FO) after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen (OA) patients. Bioelectrical impedance analysis (BIA) is a promising tool for monitoring fluid status and FO. Therefore, we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.

METHODS

A pragmatic, prospective, randomized, observer-blind, single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center. A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation (BIA) protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level (HL) measured by BIA or a traditional fluid resuscitation (TRD) in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 days of ICU management. The primary outcome was the 30-day primary fascial closure (PFC) rate. The secondary outcomes included the time to PFC, postoperative 7-day cumulative fluid balance (CFB) and adverse events within 30 days after OA. The Kaplan-Meier method and the log-rank test were utilized for PFC after OA. A generalized linear regression model for the time to PFC and CFB was built.

RESULTS

A total of 134 patients completed the trial (BIA, n = 66; TRD, n = 68). The BIA patients were significantly more likely to achieve PFC than the TRD patients (83.33% vs. 55.88%, P < 0.001). In the BIA group, the time to PFC occurred earlier than that of the TRD group by an average of 3.66 days (P < 0.001). Additionally, the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml (P < 0.001) and fewer complications.

CONCLUSION

Among postinjury OA patients in the ICU, the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

New non-invasive device to promote primary closure of the fascia and prevent loss of domain in the open abdomen: a pilot study

Background

Primary closure of the fascia at the conclusion of a stage laparotomy can be a challenging task. Current techniques to medialize the fascial edges in open abdomens entail several trips to the operating room and could result in fascial damage. We conducted a pilot study to investigate a novel non-invasive device for gradual reapproximation of the abdominal wall fascia in the open abdomen.

Methods

Mechanically ventilated patients ≥16 years of age with the abdominal fascia deliberately left open after a midline laparotomy for trauma and acute care surgery were randomized into two groups. Control group patients underwent standard care with negative pressure therapy only. Device group patients were treated with negative pressure therapy in conjunction with the new device for fascial reapproximation. Exclusion criteria: pregnancy, traumatic hernias, pre-existing ventral hernias, burns, and body mass index ≥40 kg/m². The primary outcome was successful fascial closure by direct suture of the fascia without mesh or component separation. Secondary outcomes were abdominal wall complications.

Results

Thirty-eight patients were investigated, 20 in the device group and 18 in the control group. Primary closure of the fascia by direct suture without mesh or component separation was achieved in 17 patients (85%) in the device group and only 10 patients (55.6%) in the control group (p=0.0457). Device group patients were 53% more likely to experience primary fascial closure by direct suture than control group patients. Device group showed gradual reduction (p<0.005) in the size of the fascial defects; not seen in control group. There were no complications related to the device.

Conclusions

The new device applied externally on the abdominal wall promoted reapproximation of the fascia in the midline, preserved the integrity of the fascia, and improved primary fascial closure rate compared with negative pressure therapy system only.

Level of evidence

I, randomized controlled trial.