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Klingebiel FKL, Hasegawa M, Strähle O, Kalbas Y, Teuben M, Halvachizadeh S, Kumabe Y, Pape HC, Pfeifer R. Surgical load in major fractures - results of a survey on the optimal quantification and timing of surgery in polytraumatized patients. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05828-4. [PMID: 37195466 PMCID: PMC10267260 DOI: 10.1007/s00264-023-05828-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/25/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE It is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions. METHODS A standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between "1," defined as the surgical load equivalent to external (monolateral) fixator application, and "5," defined as the maximal surgical load possible in that specific anatomic region. RESULTS This questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load. CONCLUSION This study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient's physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.
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Affiliation(s)
- Felix Karl-Ludwig Klingebiel
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland.
| | - Morgan Hasegawa
- Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI, USA
| | - Oliver Strähle
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Yohei Kumabe
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
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Battistini A, Gottlieb LJ, Vrouwe SQ. Topical Hemostatic Agents in Burn Surgery: A Systematic Review. J Burn Care Res 2023; 44:262-273. [PMID: 36516423 DOI: 10.1093/jbcr/irac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Indexed: 12/15/2022]
Abstract
Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 nonduplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/ml. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.
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Affiliation(s)
- Andrea Battistini
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
| | - Lawrence J Gottlieb
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
| | - Sebastian Q Vrouwe
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
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Rizzo JA, Ross E, Ostrowski ML, Gomez BG, Aden JK, Cap AP. Intraoperative blood transfusions in burn patients. Transfusion 2021; 61 Suppl 1:S183-S187. [PMID: 34269462 DOI: 10.1111/trf.16505] [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: 12/30/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Donated blood is a valuable and limited resource. Excision of burn wounds often leads to significant blood loss requiring transfusion. Accurately estimating blood loss is difficult, so examining the amount of blood products given intraoperatively is a clinically relevant way to measure utilization of this valuable resource. In this study, we examined the factors that influenced the amount of blood given intraoperatively during burn wound excisions. STUDY DESIGN AND METHODS A retrospective analysis of patients admitted to a single burn center over 5 years who underwent excision of their burn wounds and received intraoperative blood products was performed. Patient and burn characteristics as well as pertinent surgical data and laboratory values on the day of surgery and postoperatively were gathered. A linear regression analysis examined factors influencing the number of units of products given and a predictive model was generated. RESULTS A total of 563 operations performed on 166 patients were included. The amount of burn excised was the most influential variable on the amount of blood products given. Hemoglobin level, international normalized ratio, and platelet count on the day of surgery were associated with transfusion of different blood products. A predictive model was generated to aid in preoperative ordering of blood products. CONCLUSION The amount of burn excised and common hematology and coagulation lab values were associated with the amount of different blood products administered during burn surgery. The predictive model generated needs to be validated prospectively to aid in preoperative planning for burn excisions.
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Affiliation(s)
- Julie A Rizzo
- U.S. Army Institute of Surgical Research, Research Directorate, Fort Sam Houston, Texas, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Evan Ross
- U.S. Army Institute of Surgical Research, Research Directorate, Fort Sam Houston, Texas, USA
| | - Megan L Ostrowski
- Brooke Army Medical Center, Department of Surgery, Fort Sam Houston, San Antonio, Texas, USA
| | - Brian G Gomez
- Brooke Army Medical Center, Department of Surgery, Fort Sam Houston, San Antonio, Texas, USA
| | - James K Aden
- Brooke Army Medical Center, Department of Surgery, Fort Sam Houston, San Antonio, Texas, USA
| | - Andrew P Cap
- U.S. Army Institute of Surgical Research, Research Directorate, Fort Sam Houston, Texas, USA.,Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
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