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Prolonged Prehospital Time is a Risk Factor for Pneumonia in Trauma (the PRE-TRIP study): A Retrospective Analysis of the United States National Trauma Data Bank. Chest 2021; 161:85-96. [PMID: 34186039 DOI: 10.1016/j.chest.2021.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/19/2021] [Accepted: 06/08/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although multiple risk factors for development of pneumonia in patients with trauma sustained in a motor vehicle accident have been studied, the effect of prehospital time on pneumonia incidence post-trauma is unknown. RESEARCH QUESTION Is prolonged prehospital time an independent risk factor for pneumonia? STUDY DESIGN AND METHODS We retrospectively analyzed prospectively collected clinical data from 806,012 motor vehicle accident trauma incidents from the roughly 750 trauma hospitals contributing data to the National Trauma Data Bank between 2010 and 2016. RESULTS Prehospital time was independently associated with development of pneumonia post-motor vehicle trauma (p < 0.001). This association was primarily driven by patients with low Glasgow Coma Scale scores. Post-trauma pneumonia was uncommon (1.5% incidence) but was associated with a significant increase in mortality (p < 0.001, 4.3% mortality without pneumonia vs. 12.1% mortality with pneumonia). Other pneumonia risk factors included age, sex, race, primary payor, trauma center teaching status, bed size, geographic region, intoxication, comorbid lung disease, steroid use, lower Glasgow Coma Scale score, higher Injury Severity Scale score, blood product transfusion, chest trauma, and respiratory burns. INTERPRETATION Increased prehospital time is an independent risk factor for development of pneumonia and increased mortality in patients with trauma caused by a motor vehicle accident. Although prehospital time is often not modifiable, its recognition as a pneumonia risk factor is important as prolonged prehospital time may need to be considered in subsequent decision making. CLINICAL TRIAL REGISTRATION Not applicable.
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Accidental Hypothermia and Related Risk Factors among Trauma Patients Admitted to the Emergency Department. PREVENTIVE CARE IN NURSING AND MIDWIFERY JOURNAL 2021. [DOI: 10.52547/pcnm.11.1.63] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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3
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Lukusa M, Allorto N, Wall S. Hypothermia in acutely presenting burn injuries to a regional burn service: The incidence and impact on outcome. BURNS OPEN 2021. [DOI: 10.1016/j.burnso.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Böhm JK, Güting H, Thorn S, Schäfer N, Rambach V, Schöchl H, Grottke O, Rossaint R, Stanworth S, Curry N, Lefering R, Maegele M. Global Characterisation of Coagulopathy in Isolated Traumatic Brain Injury (iTBI): A CENTER-TBI Analysis. Neurocrit Care 2020; 35:184-196. [PMID: 33306177 PMCID: PMC8285342 DOI: 10.1007/s12028-020-01151-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Trauma-induced coagulopathy in patients with traumatic brain injury (TBI) is associated with high rates of complications, unfavourable outcomes and mortality. The mechanism of the development of TBI-associated coagulopathy is poorly understood. METHODS This analysis, embedded in the prospective, multi-centred, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, aimed to characterise the coagulopathy of TBI. Emphasis was placed on the acute phase following TBI, primary on subgroups of patients with abnormal coagulation profile within 4 h of admission, and the impact of pre-injury anticoagulant and/or antiplatelet therapy. In order to minimise confounding factors, patients with isolated TBI (iTBI) (n = 598) were selected for this analysis. RESULTS Haemostatic disorders were observed in approximately 20% of iTBI patients. In a subgroup analysis, patients with pre-injury anticoagulant and/or antiplatelet therapy had a twice exacerbated coagulation profile as likely as those without premedication. This was in turn associated with increased rates of mortality and unfavourable outcome post-injury. A multivariate analysis of iTBI patients without pre-injury anticoagulant therapy identified several independent risk factors for coagulopathy which were present at hospital admission. Glasgow Coma Scale (GCS) less than or equal to 8, base excess (BE) less than or equal to - 6, hypothermia and hypotension increased risk significantly. CONCLUSION Consideration of these factors enables early prediction and risk stratification of acute coagulopathy after TBI, thus guiding clinical management.
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Affiliation(s)
- Julia K Böhm
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Helge Güting
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Sophie Thorn
- Emergency and Trauma Centre, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Nadine Schäfer
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Victoria Rambach
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital, Academic Teaching Hospital of the Paracelsus Medical University, Doktor-Franz-Rehrl-Platz 5, 5010, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Donaueschingenstr. 13, 1200, Vienna, Austria
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford University Hospital NHS Foundation Trust, Headley Way, OX3 9DU, Oxford, UK
| | - Nicola Curry
- NHS Blood and Transplant, Oxford University Hospital NHS Foundation Trust, Headley Way, OX3 9DU, Oxford, UK
| | - Rolf Lefering
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany
| | - Marc Maegele
- Department of Medicine, Faculty of Health, Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, Building 38, 51109, Cologne, Germany. .,Department of Traumatology, Orthopaedic Surgery and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Campus Cologne-Merheim, Ostmerheimer Str. 200, 51109, Cologne, Germany.
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Ishimaru N, Kinami S, Shimokawa T, Seto H, Kanzawa Y. Hypothermia in a Japanese subtropical climate: Retrospective validation study of severity score and mortality prediction. J Gen Fam Med 2020; 21:134-139. [PMID: 32742902 PMCID: PMC7388666 DOI: 10.1002/jgf2.323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION This study aimed to clarify the accuracy of an in-hospital mortality prediction score for patients with hypothermia. The score consists of five variables (age ≥70 years, mean arterial pressure <90 mm Hg, pH < 7.35, creatinine >1.5 mg/dL, and confusion). In contrast to the previously reported population in southern Israel, a desert climate, we apply the score system to a Japanese humid subtropical climate. METHODS The study included patients with a principal diagnosis of hypothermia who were admitted to our community hospital between January 2008 and January 2019. Using the medical records from initial visits, we retrospectively calculated in-hospital mortality prediction scores along with sensitivity and specificity. RESULTS We recruited 69 patients, 67 of which had analyzable data. Among them, the in-hospital mortality rate was 25.4%. Hypothermia was defined as mild (32-35°C) in 34 cases (50.7%), moderate (28-32°C) in 23 cases (34.3%), and severe (<28°C) in 10 cases (14.9%). The C-statistics of the in-hospital mortality prediction score was 0.703 (95% confidence interval, 0.55-0.84) for thirty-day survival prediction. After adjustment of the cutoff point of each item with ROC analysis and selection of the variants, the C-statistics of the in-hospital mortality prediction score rose to 0.81 (95% confidence interval, 0.69-0.92). CONCLUSION The in-hospital mortality prediction scores showed slightly less predictive value than those in the previous report. With some modification, however, the score system could still be applied efficiently in the humid Japanese subtropical climate. An appropriate management strategy could be established based on the predicted mortality risk.
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Affiliation(s)
- Naoto Ishimaru
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Saori Kinami
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Toshio Shimokawa
- Clinical Study Support CentreWakayama Medical UniversityWakayamaJapan
| | - Hiroyuki Seto
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
| | - Yohei Kanzawa
- Department of General Internal MedicineAkashi Medical CenterAkashiJapan
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Hsieh TM, Kuo PJ, Hsu SY, Chien PC, Hsieh HY, Hsieh CH. Effect of Hypothermia in the Emergency Department on the Outcome of Trauma Patients: A Cross-Sectional Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15081769. [PMID: 30126107 PMCID: PMC6121888 DOI: 10.3390/ijerph15081769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/11/2018] [Indexed: 11/21/2022]
Abstract
This study aimed to assess whether hypothermia is an independent predictor of mortality in trauma patients in the condition of defining hypothermia as body temperatures of <36 °C. Data of all hospitalized adult trauma patients recorded in the Trauma Registry System at a level I trauma center between 1 January 2009 and 12 December 2015 were retrospectively reviewed. A multivariate logistic regression analysis was performed in order to identify factors related to mortality. In addition, hypothermia and normothermia were defined as temperatures <36 °C and from 36 °C to 38 °C, respectively. Propensity score-matched study groups of hypothermia and normothermia patients in a 1:1 ratio were grouped for mortality assessment after adjusting for potential confounders such as age, sex, preexisting comorbidities, and injury severity score (ISS). Of 23,705 enrolled patients, a total of 401 hypothermic patients and 13,368 normothermic patients were included in this study. Only 3.0% of patients had hypothermia upon arrival at the emergency department (ED). Compared to normothermic patients, hypothermic patients had a significantly higher rate of abbreviated injury scale (AIS) scores of ≥3 in the head/neck, thorax, and abdomen and higher ISS. The mortality rate in hypothermic patients was significantly higher than that in normothermic patients (13.5% vs. 2.3%, odds ratio (OR): 6.6, 95% confidence interval (CI): 4.86–9.01, p < 0.001). Of the 399 well-balanced propensity score-matched pairs, there was no significant difference in mortality (13.0% vs. 9.3%, OR: 1.5, 95% CI: 0.94–2.29, p = 0.115). However, multivariate logistic regression analysis revealed that patients with low body temperature were significantly associated with the mortality outcome. This study revealed that low body temperature is associated with the mortality outcome in the multivariate logistic regression analysis but not in the propensity score matching (PSM) model that compared patients with hypothermia defined as body temperatures of <36 °C to those who had normothermia. These contradicting observations indicated the limitation of the traditional definition of body temperature for the diagnosis of hypothermia. Prospective randomized control trials are needed to determine the relationship between hypothermia following trauma and the clinical outcome.
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Affiliation(s)
- Ting-Min Hsieh
- Division of Trauma Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Pao-Jen Kuo
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Shiun-Yuan Hsu
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Peng-Chen Chien
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
| | - Ching-Hua Hsieh
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, 123 Ta Pei Road, Niao-Song District, Kaohsiung 833, Taiwan.
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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]
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Nel MJ, Hardcastle TC. Preventative measures taken against hypothermia in selected Durban hospitals' emergency centres and operating theatres. Afr J Emerg Med 2017; 7:172-176. [PMID: 30456134 PMCID: PMC6234136 DOI: 10.1016/j.afjem.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 04/03/2017] [Accepted: 05/05/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Hypothermia is common in emergency general surgical patients. It is known to be associated with major complications in multiple organ systems. It is also easily preventable with the use of safe and cost-effective equipment. However, by observation, it appears that this equipment is used too infrequently thus resulting in unnecessary harm to patients. Methods This descriptive, observational, cross-sectional study was conducted in two arms to evaluate both emergency centres and operating theatres in the major state hospitals in Durban. It was conducted as an audit as well as a questionnaire-based study, to ascertain the availability of equipment used to prevent hypothermia and also how appropriately the equipment was being used. Results There was good availability of equipment in both the operating theatres and the emergency centres. However it was being used very poorly, particularly in emergency centres (41% of responses deemed not beneficial to patients versus 29% from operating theatres; 39% of answers beneficial versus 54% from operating theatres). Institutions with hypothermia-prevention protocols scored significantly better than those without a protocol (59% versus 25% beneficial; p = 0.01). Conclusion In the field of hypothermia prevention, there was sufficient equipment to result in optimal patient care. However there appears to be a lack of knowledge amongst health care providers, resulting in suboptimal use of this equipment. Protocolised management may provide a solution to this problem and improve patient outcomes.
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9
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Bennett BL, Holcomb JB. Battlefield Trauma-Induced Hypothermia: Transitioning the Preferred Method of Casualty Rewarming. Wilderness Environ Med 2017; 28:S82-S89. [DOI: 10.1016/j.wem.2017.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/22/2022]
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10
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Pino JMV, da Luz MHM, Antunes HKM, Giampá SQDC, Martins VR, Lee KS. Iron-Restricted Diet Affects Brain Ferritin Levels, Dopamine Metabolism and Cellular Prion Protein in a Region-Specific Manner. Front Mol Neurosci 2017; 10:145. [PMID: 28567002 PMCID: PMC5434142 DOI: 10.3389/fnmol.2017.00145] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 04/28/2017] [Indexed: 01/03/2023] Open
Abstract
Iron is an essential micronutrient for several physiological functions, including the regulation of dopaminergic neurotransmission. On the other hand, both iron, and dopamine can affect the folding and aggregation of proteins related with neurodegenerative diseases, such as cellular prion protein (PrPC) and α-synuclein, suggesting that deregulation of iron homeostasis and the consequential disturbance of dopamine metabolism can be a risk factor for conformational diseases. These proteins, in turn, are known to participate in the regulation of iron and dopamine metabolism. In this study, we evaluated the effects of dietary iron restriction on brain ferritin levels, dopamine metabolism, and the expression levels of PrPC and α-synuclein. To achieve this goal, C57BL/6 mice were fed with iron restricted diet (IR) or with normal diet (CTL) for 1 month. IR reduced iron and ferritin levels in liver. Ferritin reduction was also observed in the hippocampus. However, in the striatum of IR group, ferritin level was increased, suggesting that under iron-deficient condition, each brain area might acquire distinct capacity to store iron. Increased lipid peroxidation was observed only in hippocampus of IR group, where ferritin level was reduced. IR also generated discrete results regarding dopamine metabolism of distinct brain regions: in striatum, the level of dopamine metabolites (DOPAC and HVA) was reduced; in prefrontal cortex, only HVA was increased along with the enhanced MAO-A activity; in hippocampus, no alterations were observed. PrPC levels were increased only in the striatum of IR group, where ferritin level was also increased. PrPC is known to play roles in iron uptake. Thus, the increase of PrPC in striatum of IR group might be related to the increased ferritin level. α-synuclein was not altered in any regions. Abnormal accumulation of ferritin, increased MAO-A activity or lipid peroxidation are molecular features observed in several neurological disorders. Our findings show that nutritional iron deficiency produces these molecular alterations in a region-specific manner and provide new insight into the variety of molecular pathways that can lead to distinct neurological symptoms upon iron deficiency. Thus, adequate iron supplementation is essential for brain health and prevention of neurological diseases.
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Affiliation(s)
- Jessica M V Pino
- Departamento de Bioquímica, Universidade Federal de São PauloSão Paulo, Brazil
| | - Marcio H M da Luz
- Departamento de Bioquímica, Universidade Federal de São PauloSão Paulo, Brazil
| | - Hanna K M Antunes
- Departamento de Psicobiologia, Universidade Federal de São PauloSão Paulo, Brazil.,Departamento de Biociências, Universidade Federal de São PauloSão Paulo, Brazil
| | | | | | - Kil S Lee
- Departamento de Bioquímica, Universidade Federal de São PauloSão Paulo, Brazil
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Lapostolle F, Couvreur J, Koch FX, Savary D, Alhéritière A, Galinski M, Sebbah JL, Tazarourte K, Adnet F. Hypothermia in trauma victims at first arrival of ambulance personnel: an observational study with assessment of risk factors. Scand J Trauma Resusc Emerg Med 2017; 25:43. [PMID: 28438222 PMCID: PMC5402666 DOI: 10.1186/s13049-017-0349-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 01/13/2017] [Indexed: 11/23/2022] Open
Abstract
Background Hypothermia is common in trauma victims and is associated with increased mortality, however its causes are little known. The objective of this study was to identify the risk factors associated with hypothermia in prehospital management of trauma victims. Methods This was an ancillary analysis of data recorded in the HypoTraum study, a prospective multicenter study conducted by the emergency medical services (EMS) of 8 hospitals in France. Inclusion criteria were: trauma victim, age over 18 years, and victim receiving prehospital care from an EMS team and transported to hospital by the EMS team in a medically equipped mobile intensive care unit. The following data were recorded: victim demographics, circumstances of the trauma, environmental factors, patient presentation, clinical data and time from accident to EMS arrival. Independent risk factors for hypothermia were analyzed in a multivariate logistic regression model. Results A total of 461 trauma patients were included in the study. Road traffic accidents (N = 261; 57%) and falls (N = 65; 14%) were the main causes of trauma. Hypothermia (<35 °C) was present in 136/461 cases (29%). Independent factors significantly associated with the presence of hypothermia were: a low GCS (Odds Ratio (OR) = 0,87 ([0,81-0,92]; p < 0.0001), a low air temperature (OR = 0,93 [0,91-0,96]; p < 0.0001) and a wet patient (OR = 2,08 [1,08-4,00]; p = 0.03). Conclusion The incidence of hypothermia was high on EMS arrival at the scene. Body temperature measurement and immediate thermal protection should be routine, and special attention should be given to patients who are wet. Level of evidence Prospective, multicenter, open, observational study; Level IV.
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Affiliation(s)
- Frédéric Lapostolle
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France. .,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France.
| | - James Couvreur
- Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | | | | | - Armelle Alhéritière
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | - Michel Galinski
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
| | | | - Karim Tazarourte
- Pôle urgence-réanimation-SAMU 77, Centre hospitalier Marc Jacquet, Melun, France
| | - Frédéric Adnet
- SAMU 93, Unité de recherche-enseignement-qualité, Avicenne125, rue de Stalingrad, 93009, Bobigny, France.,Université Paris 13, Sorbonne Paris Cité, 93000, Bobigny, France
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Swiniarski GV, Mah J, Bulbuc CF, Norris CM. A comprehensive literature review on hypothermia and early extubation following coronary artery bypass surgery. Appl Nurs Res 2014; 28:137-41. [PMID: 25448056 DOI: 10.1016/j.apnr.2014.09.009] [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: 06/20/2014] [Revised: 09/12/2014] [Accepted: 09/19/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to comprehensively review the literature addressing the physiological effects of hypothermia and its association with the appropriate core body temperature for extubation following coronary artery bypass surgery. METHODS The electronic databases MEDLINE, CINAHL and Web of Science via OVID were used to identify studies for the literature review. Search words used included 'core temperature', 'arrhythmia', 'cardiac', 'cardiac surgery', 'hypothermia', 'extubation', 'temperature', 'rewarming', and 'shivering'. RESULTS The literature search yielded 55 articles that met our inclusion criteria. No studies specifically identified the benefit of extubation at 36.5 ° C. Although temperatures varied, arrhythmias resulting from hypothermia were not reported until core body temperature dropped below 33 ° C. CONCLUSION This comprehensive literature review suggests extubation at lower temperatures (between 34 ° C and 36 ° C) may be viable if shivering and other factors known to contribute to myocardial stress can be controlled. These findings offer the possibility of earlier extubation which may promote beneficial health outcomes.
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Affiliation(s)
| | - Jean Mah
- Mazankowski Alberta Heart Institute, Edmonton, AB T6G 2B7, Canada
| | | | - Colleen M Norris
- Faculty of Nursing, University of Alberta, Edmonton, AB T6G 2G3, Canada; Mazankowski Alberta Heart Institute, Edmonton, AB T6G 2B7, Canada; Division of Cardiovascular Surgery, University of Alberta, Edmonton, AB T6G 2G3, Canada.
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Abstract
Trauma is a leading cause of death and disability. Hemorrhage is the major mechanism responsible for death during the first 24 hours following trauma. One quarter of severely injured patients present in the emergency room with acute coagulopathy of trauma and shock (ACOT). The drivers of ACOT are tissue hypoperfusion, inflammation, and activation of the neurohumoral system. ACOT is a result of protein C activation with cleavage of activated factor VIII and V and inhibition of plasminogen activator inhibitor-1 (PAI-1). The resuscitation-associated coagulopathy (RAC) is secondary to a combination of acidosis, hypothermia and dilution from intravenous blood and fluid therapy. RAC may further aggravate acidosis and hypoxia resulting in a vicious cycle. This review focuses on the biology of the trauma-associated coagulopathy, and reviews current therapeutic strategies.
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Affiliation(s)
- Pierre Noel
- Division of Hematology, Mayo College of Medicine, Phoenix, AZ 85054, USA.
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Karlsen AM, Thomassen O, Vikenes BH, Brattebø G. Equipment to prevent, diagnose, and treat hypothermia: a survey of Norwegian pre-hospital services. Scand J Trauma Resusc Emerg Med 2013; 21:63. [PMID: 23938145 PMCID: PMC3751018 DOI: 10.1186/1757-7241-21-63] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 08/12/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction Hypothermia is associated with increased morbidity and mortality in trauma patients and poses a challenge in pre-hospital treatment. The aim of this study was to identify equipment to prevent, diagnose, and treat hypothermia in Norwegian pre-hospital services. Method In the period of April-August 2011, we conducted a survey of 42 respondents representing a total of 543 pre-hospital units, which included all the national ground ambulance services, the fixed wing and helicopter air ambulance service, and the national search and rescue service. The survey explored available insulation materials, active warming devices, and the presence of protocols describing wrapping methods, temperature monitoring, and the use of warm i.v. fluids. Results Throughout the services, hospital duvets, cotton blankets and plastic “bubble-wrap” were the most common insulation materials. Active warming devices were to a small degree available in vehicle ambulances (14%) and the fixed wing ambulance service (44%) but were more common in the helicopter services (58-70%). Suitable thermometers for diagnosing hypothermia were lacking in the vehicle ambulance services (12%). Protocols describing how to insulate patients were present for 73% of vehicle ambulances and 70% of Search and Rescue helicopters. The minority of Helicopter Emergency Medical Services (42%) and Fixed Wing (22%) units was reported to have such protocols. Conclusion The most common equipment types to treat and prevent hypothermia in Norwegian pre-hospital services are duvets, plastic “bubble wrap”, and cotton blankets. Active external heating devices and suitable thermometers are not available in most vehicle ambulance units.
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Affiliation(s)
- Anders M Karlsen
- Department of Anaesthesia & Intensive Care, Haukeland University Hospital, Bergen, N-5021, Norway
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Abstract
Homeostasis refers to the capacity of the human body to maintain a stable constant state by means of continuous dynamic equilibrium adjustments controlled by a medley of interconnected regulatory mechanisms. Patients who sustain tissue injury, such as trauma or surgery, undergo a well-understood reproducible metabolic and neuroendocrine stress response. This review discusses 3 issues that concern homeostasis in the acute care of trauma patients directly related to the stress response: hyperglycemia, lactic acidosis, and hypothermia. There is significant reason to question the "conventional wisdom" relating to current approaches to restoring homeostasis in critically ill and trauma patients.
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Affiliation(s)
- Patrick J Neligan
- Department of Anaesthesia and Intensive Care, Galway University Hospitals, Galway, Ireland.
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16
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Rahmany MB, Hantgan RR, Van Dyke M. A mechanistic investigation of the effect of keratin-based hemostatic agents on coagulation. Biomaterials 2013; 34:2492-500. [DOI: 10.1016/j.biomaterials.2012.12.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/13/2012] [Indexed: 10/27/2022]
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Abstract
BACKGROUND The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with the acceptance of evidence-based practices and decreases in trauma practice variability. METHODS The current evaluation was designed as a single time-series quasi-experimental study as a preanalysis and postanalysis relative to the implementation of clinical practice guidelines and process improvement interventions. Data captured from patients admitted to hospital-level (Level III) military treatment facilities in Iraq and Afghanistan from 2003 to 2010 were retrospectively analyzed from the Joint Theater Trauma Registry (JTTR) to determine the potential impact of process improvement initiatives on clinical practice. RESULTS The JTTS clinical practice guidelines for massive transfusion led to increased compliance with balanced component transfusion and decreased practice variability. During the course of the evaluation period, hypothermia on presentation decreased dramatically after the publication of the hypothermia prevention and management clinical practice guideline. CONCLUSION Developed metrics demonstrate that evidence-based quality improvement initiatives disseminated through the JTTS were associated with improved clinical practice of resuscitation following battlefield injury. LEVEL OF EVIDENCE Therapeutic/care management study, level IV.
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18
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Newell MA, Skarupa DJ, Rotondo MF. The damage control sequence in the elderly: Strategy, complexities, and outcomes. TRAUMA-ENGLAND 2012. [DOI: 10.1177/1460408612463867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traditional management in cases of exsanguinating abdominal trauma led to poor outcomes in critically injured patients. Because prolonged operations were not well tolerated due to the severe physiologic derangements, an abbreviated laparotomy began to be used. Patients were then resuscitated in the intensive care unit and brought back to the operating room once their physiology had been normalised. This approach has been termed the damage control sequence. Elderly trauma patients are susceptible to significant injury that may mandate a damage control sequence. For myriad reasons, including pre-existing medical conditions, decreased physiologic reserve, and the emergent nature of their injuries, the application of this management approach in the elderly is fraught with challenges. The purpose of this review is to enumerate the damage control sequence, describe the complexities of its use in the elderly, and discuss associated outcomes in this challenging patient population.
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Affiliation(s)
- Mark A Newell
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - David J Skarupa
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
| | - Michael F Rotondo
- Department of Surgery, The Brody School of Medicine at East Carolina University, The Center of Excellence for Trauma and Surgical Critical Care, Vidant Health, Greenville, NC, USA
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Cohen MJ. Towards hemostatic resuscitation: the changing understanding of acute traumatic biology, massive bleeding, and damage-control resuscitation. Surg Clin North Am 2012; 92:877-91, viii. [PMID: 22850152 DOI: 10.1016/j.suc.2012.06.001] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
During the past decade there has been a profound change in the understanding of postinjury coagulation. Concurrently, new data suggest that a resuscitative strategy to minimize large volumes of crystalloid while recreating whole is associated with reduced morbidity and mortality. This article outlines the history of resuscitation and transfusion practices in trauma, the changing understanding of coagulation and inflammation, and clinical data driving changes in resuscitative conduct. Finally, the current state of the science suggests future basic science and clinical investigation that will drive changes in transfusion and resuscitation in severely injured military personnel and civilian patients.
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Affiliation(s)
- Mitchell Jay Cohen
- Department of Surgery, San Francisco General Hospital and the University of California, San Francisco, 1001 Potrero Avenue, Ward 3A, San Francisco, CA 94110, USA.
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Frischknecht A, Lustenberger T, Bukur M, Turina M, Billeter A, Mica L, Keel M. Damage control in severely injured trauma patients - A ten-year experience. J Emerg Trauma Shock 2012; 4:450-4. [PMID: 22090736 PMCID: PMC3214499 DOI: 10.4103/0974-2700.86627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 03/05/2011] [Indexed: 11/04/2022] Open
Abstract
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.
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Lapostolle F, Sebbah JL, Couvreur J, Koch FX, Savary D, Tazarourte K, Egman G, Mzabi L, Galinski M, Adnet F. Risk factors for onset of hypothermia in trauma victims: the HypoTraum study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R142. [PMID: 22849694 PMCID: PMC3580728 DOI: 10.1186/cc11449] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Accepted: 07/31/2012] [Indexed: 11/11/2022]
Abstract
Introduction Hypothermia is common in trauma victims and is associated with an increase in mortality. Its causes are not well understood. Our objective was to identify the factors influencing the onset of hypothermia during pre-hospital care of trauma victims. Methods This was a multicenter, prospective, open, observational study in a pre-hospital setting. The subjects were trauma victims, over 18 years old, receiving care from emergency medical services (EMS) and transported to hospital in a medically staffed mobile unit. Study variables included: demographics and morphological traits, nature and circumstances of the accident, victim's presentation (trapped, seated or lying down, on the ground, unclothed, wet or covered by a blanket), environmental conditions (wind, rain, ground temperature and air temperature on site and in the mobile unit), clinical factors, Revised Trauma Score (RTS), tympanic temperature, care provided (including warming, drugs administered, infusion fluid temperature and volume), and EMS and hospital arrival times. Results A total of 448 patients were included. Hypothermia (<35°C) on hospital arrival was present in 64/448 patients (14%). Significant factors associated with the absence of hypothermia in a multivariate analysis were no intubation: Odds Ratio: 4.23 (95% confidence interval 1.62 to 1.02); RTS: 1.68 (1.29 to 2.20); mobile unit temperature: 1.20 (1.04 to 1.38); infusion fluid temperature: 1.17 (1.05 to 1.30); patient not unclothed: 0.40 (0.18 to 0.90); and no head injury: 0.36 (0.16 to 0.83). Conclusions The key risk factor for the onset of hypothermia was the severity of injury but environmental conditions and the medical care provided by EMS were also significant factors. Changes in practice could help reduce the impact of factors such as infusion fluid temperature and mobile unit temperature.
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The effects of intraoperative hypothermia on surgical site infection: an analysis of 524 trauma laparotomies. Ann Surg 2012; 255:789-95. [PMID: 22388109 DOI: 10.1097/sla.0b013e31824b7e35] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Our primary study objective was to determine whether intraoperative hypothermia predisposes patients to postoperative surgical site infections (SSI) after trauma laparotomy. BACKGROUND Although intraoperative normothermia is an important quality performance measure for patients undergoing colorectal surgery, the effects of intraoperative hypothermia on SSI remain unstudied in trauma. METHODS A review of all patients (July 2003-June 2008) who survived 4 days or more after urgent trauma laparotomy at a level I trauma center revealed 524 patients. Patient characteristics, along with preoperative and intraoperative care focusing on SSI risk factors, including the depth and duration of intraoperative hypothermia, were evaluated. The primary outcome measure was the diagnosis of SSI within 30 days of surgery. Cut-point analysis of the entire range of lowest intraoperative temperature measurements established the temperature nadir that best predicted SSI development. Single and multiple variable logistic regression determined SSI predictors. RESULTS The mean intraoperative temperature nadir of the study population (n = 524) was 35.2°C ± 1.1°C and 30.5% had at least 1 temperature measurement less than 35°C. Patients who developed SSI (36.1%) had a lower mean intraoperative temperature nadir (P = 0.009) and had a greater number of intraoperative temperature measurements <35°C (P < 0.001) than those who did not. Cut-point analysis revealed an intraoperative temperature of 35°C as the nadir temperature most predictive of SSI development. Multivariate analysis determined that a single intraoperative temperature measurement less than 35°C independently increased the site infection risk 221% per degree below 35°C (OR: 2.21; 95% CI: 1.24-3.92, P = 0.007). CONCLUSIONS Just as intraoperative hypothermia is an SSI risk factor in patients undergoing elective colorectal procedures, intraoperative hypothermia less than 35°C adversely affects SSI rates after trauma laparotomy. Our results suggest that intraoperative normothermia should be strictly maintained in patients undergoing operative trauma procedures.
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Intraventricular cooling during CSF infusion studies. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012. [PMID: 22327699 DOI: 10.1007/978-3-7091-0956-4_45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
We implemented ventricular infusion studies on 33 patients suspected of idiopathic normal pressure hydrocephalus (iNPH), benign intracranial hypertension (BIH) or occlusive hydrocephalus (HOC) in order to confirm shunt indications. The initial scope was to study O(2) supply during infusion tests to exclude further violation of already vulnerable brains during ICP elevation. Intraventricular infusion was performed via ventricle catheters with the ICP tip sensor, while brain tissue oxygenation was measured with intraparenchymal Raumedic PTO probes. In 15 out of 23 (65%; 8 NPH, 2BIH, 5 HOC), pO(2) increased constantly (average 140%), while brain temperature decreased (range: 0.2-4.5°C) during the infusion studies. In another six patients, O(2) values remained largely stable during the infusion studies (4NPH, 1BIH, 1HOC). Cerebral deoxygenation during infusion tests occurred only in two patients (1NPH, 1HOC).Overall cerebral oxygenation and temperature inversely correlated well with some temporary delay regarding oxygenation state as a consequence of cerebral temperature. Probably, this effect is a consequence of reduced cerebral metabolism caused by local cooling. We hypothesise that such cooling is mediated via the large basal arteries and suggest that such a pathophysiology, ICP-controlled local cooling, might offer a new option for brain protection (e.g. in an ICP crisis).
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Laupland KB, Zahar JR, Adrie C, Minet C, Vésin A, Goldgran-Toledano D, Azoulay E, Garrouste-Orgeas M, Cohen Y, Schwebel C, Jamali S, Darmon M, Dumenil AS, Kallel H, Souweine B, Timsit JF. Severe hypothermia increases the risk for intensive care unit-acquired infection. Clin Infect Dis 2012; 54:1064-70. [PMID: 22291110 DOI: 10.1093/cid/cir1033] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although hypothermia is widely accepted as a risk factor for subsequent infection in surgical patients, it has not been well defined in medical patients. We sought to assess the risk of acquiring intensive care unit (ICU)--acquired infection after hypothermia among medical ICU patients. METHODS Adults (≥18 years) admitted to French ICUs for at least 2 days between April 2000 and November 2010 were included. Surgical patients were excluded. Patient were classified as having had mild hypothermia (35.0°C-35.9°C), moderate hypothermia (32°C-34.9°C), or severe hypothermia (<32°C), and were followed for the development of pneumonia or bloodstream infection until ICU discharge. RESULTS A total of 6237 patients were included. Within the first day of admission, 648 (10%) patients had mild hypothermia, 288 (5%) patients had moderate hypothermia, and 45 (1%) patients had severe hypothermia. Among the 5256 patients who did not have any hypothermia at day 1, subsequent hypothermia developed in 868 (17%), of which 673 (13%), 176 (3%), and 19 (<1%) patients had lowest temperatures of 35.0°C-35.9°C, 32.0°C-34.9°C, and <32°C, respectively. During the course of ICU admission, 320 (5%) patients developed ICU-acquired bloodstream infection and 724 (12%) patients developed ICU-acquired pneumonia. After controlling for confounding variables in multivariable analyses, severe hypothermia was found to increase the risk for subsequent ICU-acquired infection, particularly in patients who did not present with severe sepsis or septic shock. CONCLUSIONS The presence of severe hypothermia is a risk factor for development of ICU-acquired infection in medical patients.
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Affiliation(s)
- Kevin B Laupland
- Team 11: Outcome of Respiratory Cancers and Mechanically Ventilated Patients, Integrated Research Center U823-Albert Bonniot Institute, Rond Point de la Chantourne, La Tronche, France
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Abstract
Damage control surgery, initially formalized <20 yrs ago, was developed to overcome the poor outcomes in exsanguinating abdominal trauma with traditional surgical approaches. The core concepts for damage control of hemorrhage and contamination control with abbreviated laparotomy followed by resuscitation before definitive repair, although simple in nature, have led to an alteration in which emergent surgery is handled among a multitude of problems, including abdominal sepsis and battlefield surgery. With the aggressive resuscitation associated with damage control surgery, understanding of abdominal compartment syndrome has expanded. It is probably through avoiding this clinical entity that the greatest improvement in surgical outcomes for various emergent surgical problems has occurred in the past two decades. However, with its success, new problems have emerged, including increases in enterocutaneous fistulas and open abdomens. But as with any crisis, innovative strategies are being developed. New approaches to control of the open abdomen and reconstruction of the abdominal wall are being developed from negative pressure dressing therapies to acellular allograft meshes. With further understanding of new resuscitative strategies, the need for damage control surgery may decline, along with its concomitant complications, at the same time retaining the success that damage control surgery has brought to the critically ill trauma and general surgery patient in the past few years.
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