Fibrin patch in a pig model with blunt liver injury under severe hypothermia

BACKGROUND

Rapid control of hemorrhage is one of the key aspects in trauma handling. To cope with bleeding, local hemostatic approaches are useful, along with surgical and systemic homostatic therapy. In this experimental study, we investigated the efficacy of a fibrinogen/thrombin containing collagen patch (TachoSil) in a coagulopathic pig model with blunt liver trauma under severe hypothermia.

METHODS

Eighteen anesthetized pigs underwent hemodilution by exchanging 70% of the blood volume with Ringer Lactate solution and hydroxyethyl starch 130/0.4 (1:1). Ten minutes after induction of a grade III blunt liver trauma, the animals randomly received treatment with TachoSil (FT-patch, n = 9) or a collagen patch (Tachotop, control group, n = 9). Blood loss, hemodynamics, and coagulation parameters were observed for 2 h. To confirm the consistency of liver trauma, pathologic examination of the liver tissue was performed.

RESULTS

Hypothermia (33.5°C ± 0.5°C) and hemodilution led to severe coagulopathy as measured by thromboelastometry and coagulation parameters. After trauma and patch application, thromboelastometry and coagulation parameters in the control group showed further deterioration compared with the stable parameters in the FT-patch group. The total blood loss was significantly reduced in the FT-patch group (FT-patch: 1195 mL; control group: 2495 mL; P < 0.001). Concordantly, the control animals were hemodynamically jeopardized to a higher degree. Microscopy confirmed a similar degree of liver injury.

CONCLUSIONS

Despite severe hypothermia and coagulopathy, TachoSil provided effective hemorrhage control in pigs with blunt liver injury. Therefore, TachoSil demonstrated usefulness as an additional early therapy in cases of uncontrolled bleeding following severe trauma.

Management of biliary complications following damage control surgery for liver trauma

BACKGROUND

The liver is the most frequently injured solid intra-abdominal organ. The major cause of early death following severe liver trauma is exsanguination. Although perihepatic packing improves survival in severe liver trauma, this leaves parenchymal damage untreated, often resulting in post-traumatic biliary leakage and a subsequent rise in morbidity. The aim of this study was to analyze the incidence and treatment of biliary leakage following the operative management of liver trauma.

METHODS

Patients presenting between 2000 and 2009 to Erasmus University Medical Centre with traumatic liver injury were identified. Data from 125 patients were collected and analyzed. Sixty-eight (54 %) patients required operation. All consecutive patients with post-operative biliary complications were analyzed. Post-operative biliary complications were defined as biloma, biliary fistula, and bilhemia.

RESULTS

Ten (15 %) patients were diagnosed with post-operative biliary leakage following liver injury. Three patients with a biloma were treated with percutaneous drainage, without further intervention. Seven patients with significant biliary leakage were managed by endoscopic stenting of the common bile duct to decompress the internal biliary pressure. One patient had a relaparotomy and right hemihepatectomy to control biliary leakage and injury of the right hepatic duct.

CONCLUSION

Biliary complications continue to occur frequently following damage control surgery for liver trauma. The majority of biliary complications can be managed without an operation. Endoscopic retrograde cholangiopancreatography (ERCP) and internal stenting represent a safe strategy to manage post-operative biliary leakage and bilhemia in patients following liver trauma. Minor biliary leakage should be managed by percutaneous drainage alone.

Nursing challenges with a severely injured patient in critical care

BACKGROUND

Patients with severe, multiple, traumatic injuries are challenging to manage in critical care. Early identification of injuries and optimal resuscitation is essential for favourable outcomes. Trauma-related haemorrhage can lead to the lethal triad of hypothermia, coagulopathy and acidosis. Many trauma patients require urgent haemorrhage control and structural fixation through operative intervention. However, metabolic derangement and cardiovascular instability may delay surgery, resulting in an ongoing cycle of deterioration. Damage control surgery (DCS) may be used as a temporizing measure until the patient is stabilized in critical care. The aim of this case study is to discuss the complex issues faced in the critical care management of a severely injured patient.

DESIGN

We conducted a patient case study, with analysis of care using published evidence. The key terms used to search for evidence were trauma, injury, damage control surgery, spinal fixation, critical/intensive care and nurse.

RESULTS

We report the care of a trauma patient with complex, conflicting injuries requiring management of the lethal triad and DCS. The delay in subsequent definitive repair of spinal column fractures provided many challenges for critical care nurses including restricted patient mobilization, positioning and pressure ulcer prevention. A review of contemporary evidence relating to DCS reveals that whilst this technique is used increasingly in trauma, the research focuses on single system injuries.

CONCLUSION

Evidence and guidelines are required to support DCS for critical care patients with multiple, conflicting injuries including spinal fractures. For patients with delayed surgical intervention, rotational bed therapy may assist critical care nurses in meeting needs.

Damage control in severely injured trauma patients - A ten-year experience

BACKGROUND

This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality.

MATERIALS AND METHODS

The trauma registry of our level I trauma centre was utilized to identify all patients from 01/96 through 12/05 who underwent initial damage control procedures. Demographics, clinical and physiological parameters, and outcomes were abstracted. Patients were categorized as either early survivors (surviving the first 72 hours after admission) or early deaths.

RESULTS

During the study period, 319 patients underwent damage control management. Overall, 52 patients (16.3%) died (early deaths) and 267 patients (83.7%) survived the first 72 hours (early survivors). Early deaths showed significantly deranged serum lactate (5.81±0.55 vs. 3.46±0.13 mmol/L; P<0.001), base deficit (10.10±0.95 vs. 4.90±0.28 mmol/L; P<0.001) and pH (7.16±0.03 vs. 7.29±0.01; P<0.001) levels compared to early survivors on hospital admission. An International Normalized Ratio >1.2, base deficit >3 mmol/L, head Abbreviated Injury Scale ≥3, body temperature <35°C, serum lactate >6 mmol/L, and hemoglobin <7 g/dL proved to be independent risk factors for early mortality on hospital admission.

CONCLUSIONS

Several risk factors for early mortality such as severe head injury and the lethal triad (coagulopathy, acidosis and hypothermia) in patients undergoing damage control procedures were identified and should trigger the trauma surgeon to maintain aggressive resuscitation in the intensive care unit.

Key details of the duodenal-jejunal bypass in type 2 diabetes mellitus rats

AIM: To investigate which surgical techniques and perioperative regimens yielded the best survival rates for diabetic rats undergoing gastric bypass.

METHODS: We performed Roux-en-Y gastric bypass with reserved gastric volume, a procedure in which gastrointestinal continuity was reestablished while excluding the entire duodenum and proximal jejunal loop. We observed the procedural success rate, long-term survival, and histopathological sequelae associated with a number of technical modifications. These included: use of anatomical markers to precisely identify Treitz’s ligament; careful dissection along surgical planes; careful attention to the choice of regional transection sites; reconstruction using full-thickness anastomoses; use of a minimally invasive procedure with prohemostatic pretreatment and hemorrhage control; prevention of hypothermic damage; reduction in the length of the procedure; and accelerated surgical recovery using fast-track surgical modalities such as perioperative permissive underfeeding and goal-directed volume therapy.

RESULTS: The series of modifications we adopted reduced operation time from 110.02 ± 12.34 min to 78.39 ± 7.26 min (P < 0.01), and the procedural success rate increased from 43.3% (13/30) to 90% (18/20) (P < 0.01), with a long-term survival of 83.3% (15/18) (P < 0.01).

CONCLUSION: Using a number of fast-track and damage control surgical techniques, we have successfully established a stable model of gastric bypass in diabetic rats.

Damage Control Surgery for Abdominal Trauma

Damage control is not a modern concept, but the application of this approach represents a new paradigm in surgery, borne out of a need to save patients with severe exsanguinating injuries. Definitive control and repair may be accomplished in the immediate post injury setting but the physiological derangement due to massive shock state resulting from the severe injury and the resuscitation that follows, often leads to a fully repaired but dead patient. The vicious triad of death in trauma, namely hypothermia, acidosis and coagulopathy should be tackled by initial abbreviated laparotomy, correction of physiological derangements and finally definitive repair of all injuries at second laparotomy. The concept needs a dedicated team effort with careful patient selection for achieving the optimal results.