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Khurshid MH, Yang AR, Hosseinpour H, Colosimo C, Hejazi O, Spencer AL, Bhogadi SK, Ditillo M, Magnotti LJ, Joseph B. Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries. J Surg Res 2024; 301:385-391. [PMID: 39029261 DOI: 10.1016/j.jss.2024.06.031] [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: 03/01/2024] [Revised: 05/22/2024] [Accepted: 06/22/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. METHODS This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [<18 y], adults [18-64 y], and older adults [≥65 y]). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. RESULTS We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric [n = 17], adults [n = 175], and older adults [n = 21]). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] Glasgow Coma Scale of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults. CONCLUSIONS One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.
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Affiliation(s)
- Muhammad Haris Khurshid
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Audrey R Yang
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Hamidreza Hosseinpour
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Christina Colosimo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Omar Hejazi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Audrey L Spencer
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Sai Krishna Bhogadi
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Michael Ditillo
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Louis J Magnotti
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
| | - Bellal Joseph
- Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona.
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Fujiwara G, Okada Y, Ishii W, Echigo T, Shiomi N, Ohtsuru S. High Fresh Frozen Plasma to Red Blood Cell Ratio and Survival Outcomes in Blunt Trauma. JAMA Surg 2024:2822573. [PMID: 39167374 PMCID: PMC11339704 DOI: 10.1001/jamasurg.2024.3097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 06/11/2024] [Indexed: 08/23/2024]
Abstract
Importance Current trauma-care protocols advocate early administration of fresh frozen plasma (FFP) in a ratio close to 1:1 with red blood cells (RBCs) to manage trauma-induced coagulopathy in patients with severe blunt trauma. However, the benefits of a higher FFP to RBC ratio have not yet been established. Objective To investigate the effectiveness of a high FFP to RBC transfusion ratio in the treatment of severe blunt trauma and explore the nonlinear relationship between the ratio of blood products used and patient outcomes. Design, Setting, and Participants This was a multicenter cohort study retrospectively analyzing data from the Japan Trauma Data Bank, including adult patients with severe blunt trauma without severe head injury (Injury Severity Score ≥16 and head Abbreviated Injury Scale <3) between 2019 and 2022. Exposures Patients were categorized into 2 groups based on the ratio of FFP to RBC: the high-FFP group (ratio >1) and the low-FFP group (ratio ≤1). Main Outcomes and Measures All-cause in-hospital mortality was the primary outcome. Additionally, the occurrence of transfusion-related adverse events was evaluated. Results Among the 1954 patients (median [IQR] age, 61 [41-77] years; 1243 male [63.6%]) analyzed, 976 (49.9%) had a high FFP to RBC ratio. Results from logistic regression, weighted by inverse probability treatment weighting, demonstrated an association between the group with a high-FFP ratio and lower in-hospital mortality (odds ratio, 0.73; 95% CI, 0.56-0.93) compared with a low-FFP ratio. Nonlinear trends were noted, suggesting a potential ceiling effect on transfusion benefits. Conclusions and Relevance In this cohort study, a high FFP to RBC ratio was associated with favorable survival in patients with severe blunt trauma. These outcomes highlight the importance of revising the current transfusion protocols to incorporate a high FFP to RBC ratio, warranting further research on optimal patient treatment.
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Affiliation(s)
- Gaku Fujiwara
- Department of Management of Technology and Intellectual Property, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Pharmacoepidemiology, School of Public Health, Kyoto University, Kyoto, Japan
- Department of Neurosurgery, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yohei Okada
- Department of Preventive Services, School of Public Health, Kyoto University. Yoshidahonmachi, Sakyo-ku, Kyoto, Japan
- Health Services and Systems Research, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Wataru Ishii
- Department of Emergency Medicine and Critical Care, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Tadashi Echigo
- Department of Emergency and Critical Care Medicine, Saiseikai Shiga Hospital, Shiga, Japan
| | - Naoto Shiomi
- Department of Critical and Intensive Care Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Shigeru Ohtsuru
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Koguchi H, Nakatsutsumi K, Ikuta T, Fujita A, Otomo Y, Morishita K. Gastric rupture caused by intragastric perforation of splenic artery aneurysm: a case report and literature review. Surg Case Rep 2024; 10:147. [PMID: 38884824 PMCID: PMC11182992 DOI: 10.1186/s40792-024-01944-4] [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: 04/05/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND The rupture of splenic artery pseudoaneurysm (SAP) is life-threatening disease, often caused by trauma and pancreatitis. SAPs often rupture into the abdominal cavity and rarely into the stomach. CASE PRESENTATION A 70-year-old male with no previous medical history was transported to our emergency center with transient loss of consciousness and tarry stools. After admission, the patient become hemodynamically unstable and his upper abdomen became markedly distended. Contrast-enhanced computed tomography performed on admission showed the presence of a splenic artery aneurysm (SAP) at the bottom of a gastric ulcer. Based on the clinical picture and evidence on explorative tests, we established a preliminary diagnosis of ruptured SAP bleeding into the stomach and performed emergency laparotomy. Intraoperative findings revealed the presence of a large intra-abdominal hematoma that had ruptured into the stomach. When we performed gastrotomy at the anterior wall of the stomach from the ruptured area, we found pulsatile bleeding from the exposed SAP; therefore, the SAP was ligated from inside of the stomach, with gauze packing into the ulcer. We temporarily closed the stomach wall and performed open abdomen management, as a damage control surgery (DCS) approach. On the third day of admission, total gastrectomy and splenectomy were performed, and reconstruction surgery was performed the next day. Histopathological studies of the stomach samples indicated the presence of moderately differentiated tubular adenocarcinoma. Since no malignant cells were found at the rupture site, we concluded that the gastric rupture was caused by increased internal pressure due to the intra-abdominal hematoma. CONCLUSIONS We successfully treated a patient with intragastric rupture of the SAP that was caused by gastric cancer invasion, accompanied by gastric rupture, by performing DCS. When treating gastric bleeding, such rare causes must be considered and appropriate diagnostic and therapeutic strategies should be designed according to the cause of bleeding.
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Affiliation(s)
- Hazuki Koguchi
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan.
| | - Keita Nakatsutsumi
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Takahiro Ikuta
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Akihiro Fujita
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
| | - Yasuhiro Otomo
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Koji Morishita
- Department of Emergency and Disaster Medicine, Trauma and Acute Critical Care Center, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-0034, Japan
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Douglas AD, Puzio TJ, Murphy PB, Kinnaman GB, Meagher AD. Pack the chest: Damage control strategy for management in thoracic trauma. Injury 2024; 55:111490. [PMID: 38523031 DOI: 10.1016/j.injury.2024.111490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 01/30/2024] [Accepted: 03/02/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Damage control surgery aims to control hemorrhage and contamination in the operating room (OR) with definitive management of injuries delayed until normal physiology is restored in the intensive care unit (ICU). There are limited studies evaluating the use of damage control thoracotomy (DCT) in trauma, and the best method of temporary closure is unclear. METHODS A retrospective review of trauma patients at two level I trauma centers who underwent a thoracotomy operation was performed. Subjects who underwent a thoracotomy after 24 h, age less than 16, expired in the trauma bay, or in the OR prior to ICU admission were excluded. One-way ANOVA and Kruskal-Wallis test were used to compare continuous and categorical variables between DCT and definitive thoracotomy (DT) patients. RESULTS 207 trauma patients underwent thoracotomy, 76 met our inclusion criteria. DCT was performed in 30 patients (39%), 46 (61 %) underwent DT operation. Techniques for temporizing the chest varied from skin closure with suture (8), adhesive dressing (5), towel clamps (2), or negative pressure devices (12). Compared to definitive closure, DCT had more derangements in HR, pH, (110 vs. 95, p = 0.04; 7.05 vs 7.24, p < 0.001), and injury severity score (41 vs 25, p < 0.001), and required more blood transfusions (40 vs 6, p < 0.001). Eleven (36.7 %) DCT patients survived to discharge compared to 38 patients (95.0 %) in the DT group. DCT showed significantly higher differences in cardiac arrest and unplanned returns to the OR rates. No differences were observed in ventilator days, or ICU length of stay. CONCLUSIONS DCT is a viable option for management of patients in extremis following thoracic trauma. DCT was associated with higher mortality rates, likely due to differences in injury and physiologic derangement. Despite this, DCT was associated with similar rates of complications, ICU stay, and ventilator days.
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Affiliation(s)
| | - Thaddeus J Puzio
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Patrick B Murphy
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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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.
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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
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Yao Z, Zhao G, Luo S, Chen K, Tian W, Xu X, Huang Q, Zhao R. Comparative efficacy of sequential treatment and open abdomen approaches for corrosive abdominal hemorrhage due to inadequate drainage of duodenal leakage: a cohort study. Surg Endosc 2024; 38:85-96. [PMID: 37914952 DOI: 10.1007/s00464-023-10525-9] [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: 04/02/2023] [Accepted: 10/08/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Intra-abdominal bleeding resulting from inadequate drainage of duodenal leakage (DL) is typically caused by the corrosiveness of duodenal fluid. Open abdomen (OA) treatment addresses both the drainage and bleeding simultaneously. However, a sequential treatment (ST) approach involving hemostasis through transcatheter arterial embolization (TAE) followed by percutaneous drainage of source control has emerged as an alternative method. This study aimed to evaluate the prognosis of ST in cases of DL-induced intra-abdominal bleeding. METHODS This retrospective cohort study included 151 participants diagnosed with DL-induced intra-abdominal bleeding from January 2004 to December 2010, and January 2013 to December 2021. The ST and OA groups were established based on the treatment method applied. Propensity score-matching (PSM) matched patients in the ST group with those in the OA group. RESULTS Among the 151 patients, 61 (40.4%) died within 90 days after the bleeding episode. ST was associated with a lower mortality rate (28.2% vs. 51.3% adjusted odds ratio [OR] = 0.34; 95% confidence interval [CI] 0.17-0.68; P = 0.003) compared to OA. Following PSM, ST remained the only factor associated with reduced mortality (OR = 0.32; 95% CI 0.13-0.75; P = 0.009). Moreover, ST demonstrated a higher rate of initial hemostasis success before (90.1% [64/71] vs. 77.5% [62/80]; adjusted OR = 2.84; 95% CI 1.07-7.60; P = 0.04) and after PSM (94.4% [51/54] vs. 77.8% [42/54], adjusted OR = 3.85; 95% CI 2.15-16.82; P = 0.04). Additionally, ST was associated with a lower incidence of rebleeding within 90 days after the initial bleeding, before (7 vs. 23; adjusted OR 0.41; 95% CI 0.18-0.92; P = 0.03) and after PSM (5 vs. 14; adjusted OR 0.37; 95% CI 0.15-0.93; P = 0.03). CONCLUSIONS Applying ST involving TAE and subsequent percutaneous drainage might be superior to OA in lowering the mortality in DL-induced intra-abdominal hemorrhage.
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Affiliation(s)
- Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Guoping Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Shikun Luo
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Ke Chen
- Department of General Surgery, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China.
| | - Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu, China.
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Alexandrino H, Martinho B, Ferreira L, Baptista S. Non-technical skills and teamwork in trauma: from the emergency department to the operating room. Front Med (Lausanne) 2023; 10:1319990. [PMID: 38116034 PMCID: PMC10728672 DOI: 10.3389/fmed.2023.1319990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/07/2023] [Indexed: 12/21/2023] Open
Abstract
Management of a trauma patient is a challenging process. Swift and accurate clinical assessment is required and time-sensitive decisions and life-saving procedures must be performed in an unstable patient. This requires a coordinated response by both the emergency room (ER) and operating room (OR) teams. However, a team of experts does not necessarily make an expert team. Root cause analysis of adverse events in surgery has shown that failures in coordination, planning, task management and particularly communication are the main causes for medical errors. While most research is focused on the ER trauma team, the trauma OR team also deserves attention. In fact, OR team dynamics may resemble more the ER team than the elective OR team. ER and OR trauma teams assemble on short notice, and their members, who are from different specialties and backgrounds, may not train regularly together or even know each other beforehand. And yet, they have to perform high-risk procedures and make high stake decisions, in a time-sensitive manner. The airline industry has long recognized the role of team training and non-technical skills (NTS) in reducing hazards. The implementation of the so called crew resource management or crisis resource management (CRM) has significantly made airline travel safer and the transposition to the medical context, with specific training in non-technical skills, has also brought great benefits. In fact, it is clear that adoption of non-technical skills (NTS) in healthcare has led to an increase in patient safety. In this narrative review we recapitulate some of the key non-technical skills and their relevance in trauma, with a focus on both the emergency department (ER) and the operating room (OR) teams, as well as on the transition of care from one to the other. Also, we explore the use of debriefing the team, as well as the roles of NTS training in both undergraduate and postgraduate settings. We review some of the existing trauma training courses and their roles in developing NTS. Finally, we briefly address the challenges posed by the development of trauma hybrid operating rooms.
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Affiliation(s)
- Henrique Alexandrino
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Department of Surgery, Coimbra University Hospital Center, Coimbra, Portugal
- Lusitanian Association for Trauma and Emergency Surgery, Coimbra, Portugal
| | - Bárbara Martinho
- Department of Surgery, Coimbra University Hospital Center, Coimbra, Portugal
| | - Luís Ferreira
- Lusitanian Association for Trauma and Emergency Surgery, Coimbra, Portugal
- Hospital Dr. Nélio Mendonça, Funchal, Madeira, Portugal
| | - Sérgio Baptista
- Lusitanian Association for Trauma and Emergency Surgery, Coimbra, Portugal
- Medio Tejo Hospital Center, Tomar, Portugal
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Fernandez CA. Damage Control Surgery and Transfer in Emergency General Surgery. Surg Clin North Am 2023; 103:1269-1281. [PMID: 37838467 DOI: 10.1016/j.suc.2023.06.004] [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] [Indexed: 10/16/2023]
Abstract
Selective non traumatic emergency surgery patients are targets for damage control surgery (DCS) to prevent or treat abdominal compartment syndrome and the lethal triad. However, DCS is still a subject of controversy. As a concept, DCS describes a series of abbreviated surgical procedures to allow rapid source control of hemorrhage and contamination in patients with circulatory shock to allow resuscitation and stabilization in the intensive care unit followed by delayed return to the operating room for definitive surgical management once the patient becomes physiologic stable. If appropriately applied, the DCS morbidity and mortality can be significantly reduced.
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Affiliation(s)
- Carlos A Fernandez
- Department of Surgery, Creighton University Medical Center, 7710 Mercy Road, Suite 2000, Omaha, NE 68124, USA.
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Elkbuli A, Andrade R, Ngatuvai M, Khan A, Liu H, Bilski T, Ang D. Assessment of Outcomes in Laparotomy vs Laparoscopy: A Propensity Score Matched Analysis of Patients Sustaining Single Penetrating Left Upper Quadrant Injury. Am Surg 2023; 89:5282-5291. [PMID: 36526271 DOI: 10.1177/00031348221146969] [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] [Indexed: 12/22/2023]
Abstract
BACKGROUND We aim to compare outcomes between laparotomy and laparoscopy in trauma patients with single penetrating left upper quadrant injuries. METHODS Using a 1:1 propensity score match, a retrospective study was conducted utilizing data from the ACS-TQP-PUF between 2016 and 2019. Adults sustaining a single penetrating left upper quadrant injury who received either a laparotomy or laparoscopy were included for analysis. The primary outcome was inpatient mortality. Secondary outcomes included ICU-LOS, H-LOS, and complication rates. Multivariable regression and reliability adjustments were performed to control for confounding. RESULTS 486 patients receiving laparotomy were matched to 486 patients receiving laparoscopy. No differences in inpatient mortality (1.2% vs 2.9%, aOR: 2.92, 95% CI: .32, 26.31); however, patients undergoing laparotomy experienced higher complication rates (7.0% vs 1.2%, aOR: 9.61, 95% CI: 1.94, 47.48), pRBC transfusions (21.8% vs 6.4%, aOR: 3.19, 95% CI: 1.66, 6.13), and H-LOS (Mean ± SD: 8.1 ± 9.8 vs 3.9 ± 4.0, P = .0002). Lower ISS (1 - 15) undergoing laparotomy had more complications (4.3% vs .7%, aOR: 13.52, 95% CI: 1.39, 131.69), pRBC transfusions (13.9% vs 4.9%, aOR: 3.21, 95% CI: 1.53, 6.75), and H-LOS (Mean ± SD: 6.7 ± 7.1 vs 3.6 ± 3.2, P < .0001). There were no differences in mortality among patients with a lower ISS (1.5% vs .4%, aOR: 77.2, 95% CI: (<.001, >999). CONCLUSIONS Laparotomy is associated with increased rates of complications for single penetrating LUQ trauma. For patients with low ISS, laparoscopy is associated with better outcomes without increase in mortality.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Ryan Andrade
- School of Osteopathic Medicine, A.T. Still University, Mesa, AZ, USA
| | - Micah Ngatuvai
- Dr Kiran.C. Patel College of Allopathic Medicine, NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Areeba Khan
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, Ocala Regional Medical Center, Ocala, FL, USA
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Risinger WB, Smith JW. Damage control surgery in emergency general surgery: What you need to know. J Trauma Acute Care Surg 2023; 95:770-779. [PMID: 37439768 DOI: 10.1097/ta.0000000000004112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
ABSTRACT Damage-control surgery (DCS) is a strategy adopted to limit initial operative interventions in the unstable surgical patient, delaying definitive repairs and abdominal wall closure until physiologic parameters have improved. Although this concept of "physiology over anatomy" was initially described in the management of severely injured trauma patients, the approaches of DCS have become common in the management of nontraumatic intra-abdominal emergencies.While the utilization of damage-control methods in emergency general surgery (EGS) is controversial, numerous studies have demonstrated improved outcomes, making DCS an essential technique for all acute care surgeons. Following a brief history of DCS and its indications in the EGS patient, the phases of DCS will be discussed including an in-depth review of preoperative resuscitation, techniques for intra-abdominal source control, temporary abdominal closure, intensive care unit (ICU) management of the open abdomen, and strategies to improve abdominal wall closure.
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Affiliation(s)
- William B Risinger
- From the Department of Surgery, University of Louisville School of Medicine, Louisville, KY
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Roberts DJ, Leppäniemi A, Tolonen M, Mentula P, Björck M, Kirkpatrick AW, Sugrue M, Pereira BM, Petersson U, Coccolini F, Latifi R. The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review. BJS Open 2023; 7:zrad084. [PMID: 37882630 PMCID: PMC10601091 DOI: 10.1093/bjsopen/zrad084] [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: 03/10/2023] [Revised: 07/28/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery. METHODS A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen. RESULTS The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible. CONCLUSION Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ari Leppäniemi
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Tolonen
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Panu Mentula
- Abdominal Center, Department of Abdominal Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Andrew W Kirkpatrick
- TeleMentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group, Calgary, Alberta, Canada
- Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael Sugrue
- Department of Surgery Letterkenny, University Hospital Donegal, Donegal, Ireland
| | - Bruno M Pereira
- Department of Surgery, Masters Program in Health Applied Sciences, Vassouras University, Vassouras, Rio de Janeiro, Brazil
- Department of Surgery, Campinas Holy House General Surgery Residency Program Director, Campinas, Sao Paulo, Brazil
| | - Ulf Petersson
- Department of Surgery, Skane University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Federico Coccolini
- Department of General, Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, New York, USA
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12
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LaCroix IS, Cohen M, Moore EE, Dzieciatkowska M, Silliman CC, Hansen KC, D'Alessandro A. Omics markers of platelet transfusion in trauma patients. Transfusion 2023; 63:1447-1462. [PMID: 37466356 DOI: 10.1111/trf.17472] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/26/2023] [Accepted: 05/30/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Even in the era of the COVID-19 pandemic, trauma remains the global leading cause of mortality under the age of 49. Trauma-induced coagulopathy is a leading driver of early mortality in critically ill patients, and transfusion of platelet products is a life-saving intervention to restore hemostasis in the bleeding patient. However, despite extensive functional studies based on viscoelastic assays, limited information is available about the impact of platelet transfusion on the circulating molecular signatures in trauma patients receiving platelet transfusion. MATERIALS AND METHODS To bridge this gap, we leveraged metabolomics and proteomics approaches to characterize longitudinal plasma samples (n = 118; up to 11 time points; total samples: 759) from trauma patients enrolled in the Control Of Major Bleeding After Trauma (COMBAT) study. Samples were collected in the field, in the emergency department (ED), and at intervals up to 168 h (7 days) post-hospitalization. Transfusion of platelet (PLT) products was performed (n = 30; total samples: 250) in the ED through 24 h post-hospitalization. Longitudinal plasma samples were subjected to mass spectrometry-based metabolomics and proteomics workflows. Multivariate analyses were performed to determine omics markers of transfusion of one, two, three, or more PLT transfusions. RESULTS Higher levels of tranexamic acid (TXA), inflammatory proteins, carnitines, and polyamines were detected in patients requiring PLT transfusion. Correlation of PLT units with omics data suggested sicker patients required more units and partially overlap with the population requiring transfusion of packed red blood cell products. Furthermore, platelet activation was likely increased in the most severely injured patients. Fatty acid levels were significantly lower in PLT transfusion recipients (at time of maximal transfusion: Hour 4) compared with non-recipients, while carnitine levels were significantly higher. Fatty acid levels restore later in the time course (e.g., post-PLT transfusion). DISCUSSION The present study provides the first multi-omics characterization of platelet transfusion efficacy in a clinically relevant cohort of trauma patients. Physiological alterations following transfusion were detected, highlighting the efficacy of mass spectrometry-based omics techniques to improve personalized transfusion medicine. More specialized clinical research studies focused on PLT transfusion, including organized pre and post transfusion sample collection and limitation to PLT products only, are required to fully understand subsequent metabolomic and proteomic alterations.
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Affiliation(s)
- Ian S LaCroix
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Ernest E Moore
- Department of Surgery, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
- "Ernest E Moore" Trauma Center at Denver Health, Denver, Colorado, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Christopher C Silliman
- Vitalant Research Institute, Denver, Colorado, USA
- Department of Pediatrics, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kirk C Hansen
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Angelo D'Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Tang WR, Wu CH, Yang TH, Yen YT, Hung KS, Wang CJ, Shan YS. Impact of trauma teams on high grade liver injury care: a two-decade propensity score approach study in Taiwan. Sci Rep 2023; 13:5429. [PMID: 37012308 PMCID: PMC10070483 DOI: 10.1038/s41598-023-32760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 04/01/2023] [Indexed: 04/05/2023] Open
Abstract
High-grade liver laceration is a common injury with bleeding as the main cause of death. Timely resuscitation and hemostasis are keys to the successful management. The impact of in-hospital trauma system on the quality of resuscitation and management in patients with traumatic high-grade liver laceration, however, was rarely reported. We retrospectively reviewed the impact of team-based approach on the quality and outcomes of high-grade traumatic liver laceration in our hospital. Patients with traumatic liver laceration between 2002 and 2020 were enrolled in this retrospective study. Inverse probability of treatment weighting (IPTW)-adjusted analysis using the propensity score were performed. Outcomes before the trauma team establishment (PTTE) and after the trauma team establishment (TTE) were compared. A total of 270 patients with liver trauma were included. After IPTW adjustment, interval between emergency department arrival and managements was shortened in the TTE group with a median of 11 min (p < 0.001) and 28 min (p < 0.001) in blood test reports and duration to CT scan, respectively. Duration to hemostatic treatments in the TTE group was also shorter by a median of 94 min in patients receiving embolization (p = 0.012) and 50 min in those undergoing surgery (p = 0.021). The TTE group had longer ICU-free days to day 28 (0.0 vs. 19.0 days, p = 0.010). In our study, trauma team approach had a survival benefit for traumatic high-grade liver injury patients with 65% reduction of risk of death within 72 h (Odds ratio (OR) = 0.35, 95% CI = 0.14-0.86) and 55% reduction of risk of in-hospital mortality (OR = 0.45, 95% CI = 0.23-0.87). A team-based approach might contribute to the survival benefit in patients with traumatic high-grade liver laceration by facilitating patient transfer from outside the hospital, through the diagnostic examination, and to the definitive hemostatic procedures.
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Affiliation(s)
- Wen-Ruei Tang
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Hsien Wu
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Tsung-Han Yang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Yi-Ting Yen
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Kuo-Shu Hung
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704
| | - Chih-Jung Wang
- Division of Trauma, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, 138 Sheng-Li Road, Tainan, Taiwan, 704.
| | - Yan-Shen Shan
- Division of General Surgery, Department of Surgery, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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14
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department 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
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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15
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Fitzpatrick ER. Evidence-Based Pearls. Crit Care Nurs Clin North Am 2023; 35:129-144. [PMID: 37127370 DOI: 10.1016/j.cnc.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
The challenge in caring for patients who sustain traumatic chest injuries centers on their complex needs from high acuity and the potential for multisystem effects and complications. Hemorrhage and respiratory compromise are common sequela of thoracic trauma. Patients must be resuscitated and their injuries managed with the primary goals of restoring cardiopulmonary structural integrity and preventing complications. There are evolving strategies for the management of the thoracic trauma victim including damage control resuscitation and surgery, endovascular repairs, and assessments implementing severity scores to aid in planning interventions.
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16
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Panasenko SI, Guriev SO, Lysun DM, Kushnir VA, Saliutin RV. Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control. KLINICHESKAIA KHIRURGIIA 2022. [DOI: 10.26779/2522-1396.2022.3-4.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Closed abdominal trauma in polytrauma. Part II: surgical tactics for the damages control
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17
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Proaño-Zamudio JA, Gebran A, Argandykov D, Dorken-Gallastegi A, Saillant NN, Fawley JA, Onyewadume L, Kaafarani HMA, Fagenholz PJ, King DR, Velmahos GC, Hwabejire JO. Delayed fascial closure in nontrauma abdominal emergencies: A nationwide analysis. Surgery 2022; 172:1569-1575. [PMID: 35970609 DOI: 10.1016/j.surg.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Initially used in trauma management, delayed abdominal closure endeavors to decrease operative time during the index operation while still being lifesaving. Its use in emergency general surgery is increasing, but the data evaluating its outcome are sparse. We aimed to study the association between delayed abdominal closure, mortality, morbidity, and length of stay in an emergency surgery cohort. METHODS The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program database was examined for patients undergoing emergency laparotomy. The patients were classified by the timing of abdominal wall closure: delayed fascial closure versus immediate fascial closure. Propensity score matching was performed based on preoperative covariates, wound classification, and performance of bowel resection. The outcomes were then compared by univariable analysis. RESULTS After matching, both the delayed fascial closure and immediate fascial closure groups consisted of 3,354 patients each. Median age was 65 years, and 52.6% were female. The delayed fascial closure group had a higher in-hospital mortality (35.3% vs 25.0%, P < .001), a higher 30-day mortality (38.6% vs 29.0%, P < .001), a higher proportion of acute kidney injury (9.5% vs 6.6%, P < .001), a lower proportion of postoperative sepsis (11.8% vs 15.6%, P < .001), and a lower proportion of surgical site infection (3.4% vs 7.0%, P < .001). CONCLUSION Compared with immediate fascial closure, delayed fascial closure is associated with an increased mortality in the patients matched based on comorbidities and surgical site contamination. In emergency general surgery, delaying abdominal closure may not have the presumed overarching benefits, and its indications must be further defined in this population.
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Affiliation(s)
- Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/eljefe_md
| | - Anthony Gebran
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/AnthonyGebran
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/argandykov
| | - Ander Dorken-Gallastegi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/AnderDorken
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/MGHSurgery
| | - Jason A Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/fawley85
| | - Louisa Onyewadume
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/TraumaMGH
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. https://twitter.com/hayfaarani
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA. http://
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18
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de Launay D, Shiga S, Laschuk M, Brandys T, Roberts DJ. Extra-Anatomic Temporary Intravascular Shunting to Assist with Replantation of An Amputated Hand with Prolonged Ischemic Time. J Vasc Surg Cases Innov Tech 2022; 8:598-601. [PMID: 36248399 PMCID: PMC9556574 DOI: 10.1016/j.jvscit.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/10/2022] [Indexed: 12/01/2022] Open
Abstract
Although temporary intravascular shunting has been reported to assist with hand revascularization and replantation after traumatic amputation, most reports have described using ipsilateral upper limb inflow. We present a case of a traumatic hand amputation in a patient who had presented with 4 to 5 hours of warm ischemic time. Because the replantation team believed that extra-anatomic revascularization would be necessary, we performed a novel type of temporary intravascular shunting by connecting two arterial sheaths placed in the ulnar and superficial femoral arteries. This permitted the hand to be successfully replanted away from the inflow source and resulted in a good long-term functional outcome.
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Affiliation(s)
- David de Launay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Sarah Shiga
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Matthew Laschuk
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Derek J. Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Ottawa, ON, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Correspondence: Derek J. Roberts, MD, PhD, FRCSC, Division of Vascular and Endovascular Surgery, Department of Surgery, School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Division of Vascular and Endovascular Surgery, The Ottawa Hospital, Civic Campus, Room A-280, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
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19
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Elkbuli A, Newsome K, Fanfan D, Sutherland M, Bilski T, Liu H, Ang D. Laparoscopic Versus Laparotomy Surgical Interventions for Trauma Patients with Single Upper Left Quadrant Penetrating Injuries: Analysis of the American College of Surgeons Trauma Quality Improvement Program Dataset. Am Surg 2022; 88:2182-2193. [PMID: 35592893 DOI: 10.1177/00031348221101510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aim to identify patient cohorts where laparoscopy can be safely utilized with comparable or better outcomes to laparotomy among patients with single penetrating LUQ injuries with a hypothesis that compared to laparotomy, laparoscopy may be associated with equal or improved outcomes of low injury severity patients. METHODS Retrospective review of the ACS-TQP-Participant Use File 2016-2019 dataset. Patients with single LUQ penetrating injuries were included. Primary outcome was risk-adjusted in-hospital mortality. Secondary outcomes included: risk-adjusted complication rates, hospital length-of-stay (H-LOS), and ICU-LOS. Descriptive statistics and multivariable regression with reliability adjustments to account for variations in practice were performed. RESULTS Of 4149 patients analyzed, 3571 (86.1%) underwent laparotomy, 489 (11.8%) underwent laparoscopy, and 89 (2.1%) underwent laparoscopy-to-laparotomy conversion. Adjusted mortality rates were not significantly different among all study cohorts (P > .05). Compared to laparoscopy, adjusted odds of complications were 4.3-fold higher for all patients who underwent laparotomy and 4-fold higher for laparoscopy-to-laparotomy (LtL) patients (P < .05). Diaphragmatic injuries were associated with significantly increased odds of undergoing LtL, whereas sustaining a colonic injury, gastric injury, hepatic injury, or requiring PRBC transfusions were associated with significantly increased odds of undergoing laparotomy (P < .05). H-LOS (days) was significantly longer for patients who underwent laparotomy compared to laparoscopy (3.9 ± 4.0 vs. 10.8 ± 13.4, P < .0001). CONCLUSIONS Laparoscopy may be considered a viable alternative to laparotomy for hemodynamically stable adult patients with single penetrating LUQ injuries of low injury burden validating our hypothesis. Laparoscopy may be less safe for patients with associated diaphragmatic, colonic, or hepatic injuries.
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Affiliation(s)
- Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Kevin Newsome
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Dino Fanfan
- 5450Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Mason Sutherland
- 2814NSU NOVA Southeastern University, Dr. Kiran.C. Patel College of Allopathic Medicine, Fort Lauderdale, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, 25105Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Division of Medical Education, 25105Orlando Regional Medical Center, Orlando, FL, USA
| | - Huazhi Liu
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
| | - Darwin Ang
- Department of Surgery, Division of Trauma and Surgical Critical Care, 23703Ocala Regional Medical Center, Ocala, FL, USA
- University of South Florida, Tampa, FL, USA
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20
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Smith S, Allen L, Khwaja K, Joos E, Ball CG, Engels PT, Naji F, Lampron J, Widder S, Minor S, Jessula S, Parry NG, Vogt KN. Management of vascular trauma across Canada: A cohort study with implications for practice. Injury 2022; 53:1662-1666. [PMID: 35012752 DOI: 10.1016/j.injury.2021.12.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/30/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada. METHODS This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes. RESULTS A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for <5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation. CONCLUSION This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.
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Affiliation(s)
- Shane Smith
- London Health Sciences Centre, London, Ontario, Canada.
| | - Laura Allen
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kosar Khwaja
- McGill University Health Centre, Montreal, Quebec, Canada.
| | - Emilie Joos
- Vancouver Costal Health, Vancouver, British Columbia, Canada.
| | - Chad G Ball
- Foothills Medical Centre, Calgary, Alberta, Canada
| | - Paul T Engels
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | - Faysal Naji
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada.
| | | | - Sandy Widder
- Alberta Health Services, Edmonton, Alberta, Canada.
| | - Sam Minor
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada.
| | - Samuel Jessula
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Neil G Parry
- London Health Sciences Centre, London, Ontario, Canada.
| | - Kelly N Vogt
- London Health Sciences Centre, London, Ontario, Canada.
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21
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Kojima M, Endo A, Shiraishi A, Shoko T, Otomo Y, Coimbra R. Association between the plasma-to-red blood cell ratio and survival in geriatric and non-geriatric trauma patients undergoing massive transfusion: a retrospective cohort study. J Intensive Care 2022; 10:2. [PMID: 35016735 PMCID: PMC8753889 DOI: 10.1186/s40560-022-00595-7] [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: 11/15/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The benefits of a high plasma-to-red blood cell (RBC) ratio on the survival of injured patients who receive massive transfusions remain unclear, especially in older patients. We aimed to investigate the interaction of age with the plasma-to-RBC ratio and clinical outcomes of trauma patients. METHODS In this retrospective study conducted from 2013 to 2016, trauma patients who received massive transfusions were included. Using a generalized additive model (GAM),we assessed how the plasma-to-RBC ratio and age affected the in-hospital mortality rates. The association of the plasma-to-RBC ratio [low (< 0.5), medium (0.5-1.0), and high (≥ 1.0)] with in-hospital mortality and the incidence of adverse events were assessed for the overall cohort and for patients stratified into non-geriatric (16-64 years) and geriatric (≥ 65 years) groups using logistic regression analyses. RESULTS In total, 13,894 patients were included. The GAM plot of the plasma-to-RBC ratio for in-hospital mortality demonstrated a downward convex unimodal curve for the entire cohort. The low-transfusion ratio group was associated with increased odds of in-hospital mortality in the non-geriatric cohort [odds ratio 1.38, 95% confidence interval (CI) 1.22-1.56]; no association was observed in the geriatric group (odds ratio 0.84, 95% CI 0.62-1.12). An increase in the transfusion ratio was associated with a higher incidence of adverse events in the non-geriatric and geriatric groups. CONCLUSION The association of the non-geriatric age category and plasma-to-RBC ratio for in-hospital mortality was clearly demonstrated. However, the relationship between the plasma-to-RBC ratio with mortality among geriatric patients remains inconclusive.
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Affiliation(s)
- Mitsuaki Kojima
- Emergency and Critical Care Medicine, Tokyo Women's Medical University Adachi Medical Center, 4-33-1 Kohoku, Adachi-ku, Tokyo, Japan. .,Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan.
| | - Akira Endo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Atsushi Shiraishi
- Emergency and Trauma Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, Japan
| | - Tomohisa Shoko
- Emergency and Critical Care Medicine, Tokyo Women's Medical University Adachi Medical Center, 4-33-1 Kohoku, Adachi-ku, Tokyo, Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center, Tokyo Medical and Dental University Hospital, 1-5-45 Yushima, Bunkyo-ku, Tokyo, Japan
| | - Raul Coimbra
- Comparative Effectiveness and Clinical Outcomes Research Center-CECORC, Riverside University Health System Medical Center, 26520 Cactus Ave., Moreno Valley, CA, USA
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22
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Rodríguez-Holguín F, González Hadad A, Mejia D, García A, Cevallos C, Himmler AN, Caicedo Y, Salcedo A, Serna JJ, Herrera MA, Pino LF, Parra MW, Ordoñez CA. Abdominal and thoracic wall closure: damage control surgery's cinderella. Colomb Med (Cali) 2021; 52:e4144777. [PMID: 34908622 PMCID: PMC8634273 DOI: 10.25100/cm.v52i2.4777] [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: 03/16/2021] [Revised: 04/18/2021] [Accepted: 06/30/2021] [Indexed: 11/11/2022] Open
Abstract
Damage control surgery principles allow delayed management of traumatic lesions and early metabolic resuscitation by performing abbreviated procedures and prompt resuscitation maneuvers in severely injured trauma patients. However, the initial physiological response to trauma and surgery, along with the hemostatic resuscitation efforts, causes important side effects on intracavitary organs such as tissue edema, increased cavity pressure, and hemodynamic collapse. Consequently, different techniques have been developed over the years for a delayed cavity closure. Nonetheless, the optimal management of abdominal and thoracic surgical closure remains controversial. This article aims to describe the indications and surgical techniques for delayed abdominal or thoracic closure following damage control surgery in severely injured trauma patients, based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. We recommend negative pressure dressing as the gold standard technique for delayed cavity closure, associated with higher wall closure success rates and lower complication and mortality rates.
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Affiliation(s)
- Fernando Rodríguez-Holguín
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellín, Colombia.,Universidad de Antioquia, Department of Surgery, Medellín, 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
| | - Cecibel Cevallos
- Hospital Vicente Corral Moscoso. Department of Surgery. Division of Trauma and Acute Care Surgery, Cuenca, Ecuador.,Universidad de Cuenca. Cuenca, Ecuador
| | - Amber Nicole Himmler
- Medstar Georgetown University Hospital and Washington Hospital Center. Department of Surgery, Washington, D.C., USA
| | - Yaset Caicedo
- , Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC)Cali, Colombia
| | - Alexander Salcedo
- 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.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - José Julián Serna
- 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.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, 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.,, Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC)Cali, Colombia
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23
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Ordoñez CA, Caicedo Y, Parra MW, Rodríguez-Holguín F, Serna JJ, Salcedo A, Franco MJ, Toro LE, Pino LF, Guzmán-Rodríguez M, Orlas C, Herrera-Escobar JP, González-Hadad A, Herrera MA, Aristizábal G, García A. Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness. Colomb Med (Cali) 2021; 52:e4194809. [PMID: 34908626 PMCID: PMC8634274 DOI: 10.25100/cm.v52i2.4809] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/30/2021] [Accepted: 06/07/2021] [Indexed: 11/11/2022] Open
Abstract
Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.
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Affiliation(s)
- 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
| | - 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
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- 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.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- 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.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - María Josefa Franco
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Eduardo Toro
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina,Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Claudia Orlas
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Department of Surgery, Center for Surgery and Public Health, Brigham & Women's Hospital, Boston - USA
| | - Juan Pablo Herrera-Escobar
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Department of Surgery, Center for Surgery and Public Health, Brigham & Women's Hospital, Boston - USA
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, 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
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24
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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.
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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
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25
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Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen: a randomized controlled trial. Mil Med Res 2021; 8:36. [PMID: 34099065 PMCID: PMC8180439 DOI: 10.1186/s40779-021-00329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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26
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Feliciano DV. Needs damage control. Trauma Surg Acute Care Open 2021; 6:e000757. [PMID: 34151027 PMCID: PMC8183274 DOI: 10.1136/tsaco-2021-000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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27
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García A, Millán M, Ordoñez CA, Burbano D, Parra MW, Caicedo Y, González Hadad A, Herrera MA, Pino LF, Rodríguez-Holguín F, Salcedo A, Franco MJ, Ferrada R, Puyana JC. Damage control surgery in lung trauma. Colomb Med (Cali) 2021; 52:e4044683. [PMID: 34188322 PMCID: PMC8216053 DOI: 10.25100/cm.v52i2.4683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.
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Affiliation(s)
- Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Daniela Burbano
- Fundación Valle del Lili, Departamento de Urgencias Adultos. Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Maria Josefa Franco
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
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Douglas A, Puzio T, Murphy P, Menard L, Meagher AD. Damage Control Thoracotomy: A Systematic Review of Techniques and Outcomes. Injury 2021; 52:1123-1127. [PMID: 33386155 DOI: 10.1016/j.injury.2020.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/19/2020] [Accepted: 12/20/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Damage control surgery is the practice of delaying definitive management of traumatic injuries by controlling hemorrhage in the operating room and restoring normal physiology in the intensive care unit prior to definitive therapy. Presently, damage control or "abbreviated" laparotomy is used extensively for abdominal trauma in an unstable patient. The application of a damage control approach in thoracic trauma is less established and there is a paucity of literature supporting or refuting this practice. We aimed to systematically review the current data on damage control thoracotomy (DCT), to identify gaps in the literature and techniques in temporary closure. METHODS An electronic literature search of Pubmed, MEDLINE, and the Cochrane Database of Collected Reviews from 1972-2018 was performed using the keywords "thoracic," "damage control," and "thoracotomy." Studies were included if they reported the use of DCT following thoracic trauma and included survival as an outcome. RESULTS Of 723 studies, seven met inclusion criteria for a total of a 130 DCT operations. Gauze packing with temporary closure of the skin with suture was the most frequently reported form of closure. The overall survival rate for the seven studies was 67%. Survival rates ranged from 42-77%. Average injury severity score was 30, and 64% of injuries were penetrating in nature. The most common complications included infections (57%; pneumonia, empyema, wound infection, bacteremia), respiratory failure (21%), ARDS (8%), and renal failure (18%). CONCLUSION DCT may be associated with improved survival in the critically injured patient population. Delaying definitive operation by temporarily closing the thorax in order to allow time to restore normal physiology may be considered as a strategy in the unstable thoracic trauma patient population. The impact an open chest has on respiratory physiology remains inconclusive as well as best mechanisms of temporary closure. Multi-center studies are required to elucidate these important questions.
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Affiliation(s)
- Anthony Douglas
- Indiana University School of Medicine, 340 W. 10(th) St. Fairbanks Hall Suite 6200. Indianapolis, IN, 46202 USA.
| | - Thaddeus Puzio
- Department of Surgery, University of Texas Health Science Center at Houston, 7000 Fannin St. Houston, TX, 77030, USA.
| | - Patrick Murphy
- Department of Surgery, Department of Surgery, Medical College of Wisconsin, 8701 W. Watertown Plank Rd. Wauwatosa, WI, 53226, USA.
| | - Laura Menard
- Indiana University School of Medicine, 340 W. 10(th) St. Fairbanks Hall Suite 6200. Indianapolis, IN, 46202 USA.
| | - Ashley D Meagher
- Department of Surgery, Indiana University School of Medicine, 340 W. 10(th) St. Fairbanks Hall Suite 6200. Indianapolis, IN, 46202, USA.
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29
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Thurman P. Hemostatic Strategies in Trauma. AACN Adv Crit Care 2021; 32:51-63. [PMID: 33725103 DOI: 10.4037/aacnacc2021473] [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: 11/01/2022]
Abstract
Bleeding is a leading cause of early death from trauma. Consequently, effective hemostasis can improve the odds of survival after severe traumatic injury. Understanding the pathophysiology of trauma-induced coagulopathy can provide insights into effective strategies to assess and halt hemorrhage. Both physical assessment and appropriate laboratory studies are important in the diagnosis and evaluation of coagulopathy to identify the most effective mechanical and pharmacological strategies to achieve hemostasis. This article uses a case study approach to explore evidence-based techniques to evaluate hemorrhage and strategies to promote hemostasis.
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Affiliation(s)
- Paul Thurman
- Paul Thurman is Nurse-Scientist, Trauma and Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Paca Pratt, 3-S-134, 110 S Paca St, Baltimore, MD 21201
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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: 20] [Impact Index Per Article: 6.7] [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.
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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
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Okishio Y, Ueda K, Nasu T, Kawashima S, Kunitatsu K, Kato S. Is open abdominal management useful in nontrauma emergency surgery for older adults? A single-center retrospective study. Surg Today 2021; 51:1285-1291. [PMID: 33420826 DOI: 10.1007/s00595-020-02214-0] [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: 09/16/2020] [Accepted: 12/01/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Open abdominal management (OAM) is being adopted increasingly frequently in nontrauma patients. This study assessed the effectiveness of OAM in nontrauma older adults. METHODS We retrospectively reviewed all adults who underwent nontrauma emergency laparotomy requiring postoperative intensive care unit (ICU) management between September 2012 and August 2017 at our hospital. Patients ≥ 80 years old, who underwent OAM, were compared with those < 80 years old. The primary outcome was the 90-day mortality. Secondary outcomes were the 30-day mortality, unplanned relaparotomy, and the ICU length of stay (LOS). RESULTS The OAM group comprised 58 patients, including 27 who were ≥ 80 years old. The patients ≥ 80 years old in the OAM group had a significantly higher 90-day mortality rate (33% vs. 10%; p = 0.027) than those < 80 years old. There were no significant differences in the 30-day mortality rate, patients' unplanned relaparotomy rate, or ICU LOS between the patients ≥ 80 years old and those < 80 in the OAM group. CONCLUSIONS Older adults who underwent OAM had a significantly higher mortality rate than younger patients. However, the OAM strategy for older nontrauma patients may still be useful and reasonable considering the severe condition of these patients.
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Affiliation(s)
- Yuko Okishio
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Kentaro Ueda
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Toru Nasu
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Shuji Kawashima
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kosei Kunitatsu
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Seiya Kato
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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Streith L, Silverberg J, Kirkpatrick AW, Hameed SM, Bathe OF, Ball CG. Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review. Can J Surg 2020. [PMID: 33009897 DOI: 10.1503/cjs.013919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
SUMMARY Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.
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Affiliation(s)
- Lucas Streith
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
| | - Jenna Silverberg
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
| | - Andrew W Kirkpatrick
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
| | - S Morad Hameed
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
| | - Oliver F Bathe
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
| | - Chad G Ball
- From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed)
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Petrenko AP, Castelo Branco C, Marshalov DV, Salov IA, Kuligin AV, Shifman EM, Chauke SS. Alternative strategies for the management of ovarian hyperstimulation syndrome, the role of intra-abdominal hypertension control. Gynecol Endocrinol 2020; 36:197-203. [PMID: 31668111 DOI: 10.1080/09513590.2019.1683822] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
The aim of this study is to analyze the methods for reducing intra-abdominal pressure (IAP) in the management of the moderate and severe forms of ovarian hyperstimulation syndrome (OHSS). We carried out a systematic review of the literature. An evaluation of clinical trials, meta-analysis, case-reports, and reviews assessing the management of conditions associated with OHSS and intra-abdominal hypertension (IAH)/abdominal compartment syndrome (ACS) was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2019) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2019). The principles of treatment of IAH syndrome can be considered in the treatment of moderate and severe forms of OHSS. Medical treatment of patients with increased IAP in OHSS should be started early to prevent further organ dysfunction and avoid a transition to a more severe stage of IAH and ACS. Some of the new, non-surgical methods, such as continuous negative extra-abdominal pressure, are a promising option in specific groups of patients with OHSS. This review provides suggestions for the management of OHSS based on the principles of therapy for IAH syndrome. Further well-designed studies are needed to confirm these initial data.
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Affiliation(s)
- Aleksei Petrovich Petrenko
- Faculty of Medicine, Clinic Institute of Gynecology, Obstetrics and Neonatology, University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Emergency Anesthesiology-Resuscitation Care and Simulation Technologies in Medicine, Saratov State Medical University Named after V. I. Razumovsky, Saratov, Russian Federation
- City Clinical Hospital №1 Named after Y.Ya. Gordeev, Saratov, Russian Federation
| | - Camil Castelo Branco
- Faculty of Medicine, Clinic Institute of Gynecology, Obstetrics and Neonatology, University of Barcelona, Hospital Clinic-Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Dimitry Vasilevich Marshalov
- Department of Emergency Anesthesiology-Resuscitation Care and Simulation Technologies in Medicine, Saratov State Medical University Named after V. I. Razumovsky, Saratov, Russian Federation
- City Clinical Hospital №1 Named after Y.Ya. Gordeev, Saratov, Russian Federation
| | - Igor Arkadevich Salov
- City Clinical Hospital №1 Named after Y.Ya. Gordeev, Saratov, Russian Federation
- Department of Obstetrics and Gynecology, Faculty of Medicine, Saratov State Medical University Named after V. I. Razumovsky, Saratov, Russian Federation
| | - Alexander Valerievich Kuligin
- Department of Emergency Anesthesiology-Resuscitation Care and Simulation Technologies in Medicine, Saratov State Medical University Named after V. I. Razumovsky, Saratov, Russian Federation
| | - Efim Munevich Shifman
- Department of Anesthesiology and Critical Care, State Budgetary Healthcare Institution of Moscow Region M.F. Vladimirskiy Moscow's Regional Research Clinical Institute, Moscow, Russian Federation
| | - Shane Shitsundzuxo Chauke
- Kananelo Community Health Centre, HIV/AIDS Clinic, Vredefort, South Africa
- Department of Surgery, Parys Hospital, Parys, South Africa
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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: 6] [Impact Index Per Article: 1.2] [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.
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35
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Zhao C, Wu X, Huang J, Chen C, Yu J, Fang M, Wang G, Ren J. Hybrid material for open abdomen: saving the wound from intestinal fistula. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2019; 30:109. [PMID: 31535210 DOI: 10.1007/s10856-019-6311-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/04/2019] [Indexed: 06/10/2023]
Abstract
Treatment of an open abdomen (OA) wound combined with an intestinal fistula is a challenge in the clinic. Here, inspired by the antibacterial activity of graphene (G) and its derivatives, we present a hybrid patch based on the ability of graphene and polycaprolactone (PCL) to kill bacteria and save the cells in a wound. Benefiting from the antibacterial ability of graphene oxide (GO), cells could survive in the presence of bacteria. With the increased ability to protect cells, this patch accelerated wound healing in an OA and intestinal fistula wound model. Additionally, the sub-acute toxicity score showed no extra damage to organs. In conclusion, the employment of the hybrid material for an OA and an intestinal fistula wound healing is encouraging. A hybrid patch based on graphene oxide and polycaprolactone electrospun was generated for open abdomen and fistula wound. The application of the hybrid patch could save the cells from bacteria which contribute to accelerating wound healing.
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Affiliation(s)
- Cheng Zhao
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China.
| | - Jinjian Huang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Canwen Chen
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Jiafei Yu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Miao Fang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Gefei Wang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, 210002, Nanjing, China.
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36
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Roberts DJ, Zygun DA, Ball CG, Kirkpatrick AW, Faris PD, James MT, Mrklas KJ, Hemmelgarn BD, Manns B, Stelfox HT. Challenges and potential solutions to the evaluation, monitoring, and regulation of surgical innovations. BMC Surg 2019; 19:119. [PMID: 31455337 PMCID: PMC6712595 DOI: 10.1186/s12893-019-0586-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/18/2019] [Indexed: 01/09/2023] Open
Abstract
Background As it may be argued that many surgical interventions provide obvious patient benefits, formal, staged assessment of the efficacy and safety of surgical procedures has historically been and remains uncommon. The majority of innovative surgical procedures have therefore often been developed based on anatomical and pathophysiological principles in an attempt to better manage clinical problems. Main Body In this manuscript, we sought to review and contrast the models for pharmaceutical and surgical innovation in North America, including their stages of development and methods of evaluation, monitoring, and regulation. We also aimed to review the present structure of academic surgery, the role of methodological experts and funding in conducting surgical research, and the current system of regulation of innovative surgical procedures. Finally, we highlight the influence that evidence and surgical history, education, training, and culture have on elective and emergency surgical decision-making. The above discussion is used to support the argument that the model used for assessment of innovative pharmaceuticals cannot be applied to that for evaluating surgical innovations. It is also used to support our position that although the evaluation and monitoring of innovative surgical procedures requires a rigorous, fit-for-purpose, and formal system of assessment to protect patient safety and prevent unexpected adverse health outcomes, it will only succeed if it is supported and championed by surgical practice leaders and respects surgical history, education, training, and culture. Conclusion We conclude the above debate by providing a recommended approach to the evaluation, monitoring, and regulation of surgical innovations, which we hope may be used as a guide for all stakeholders involved in interpreting and/or conducting future surgical research.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Room A280, 1053 Carling Avenue, Ottawa, Ontario, K1Y 4E9, Canada.
| | - David A Zygun
- Division of Critical Care Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Chad G Ball
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | | | - Peter D Faris
- Alberta Health Sciences Research - Research Analytics, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Matthew T James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Strategic Clinical Networks, System Programs, and Innovation, Alberta Health Services, Calgary, Alberta, Canada
| | - Brenda D Hemmelgarn
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Braden Manns
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Henry T Stelfox
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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LeBedis CA. Invited Commentary on "Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries". Radiographics 2019; 39:1202-1204. [PMID: 31283456 DOI: 10.1148/rg.2019190056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Christina A LeBedis
- Department of Radiology, Boston University Medical Center Boston, Massachusetts
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38
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Romagnoli A, DuBose J, Brenner M. Damage Control Vascular Surgery. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-00172-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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39
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Ahmad ZY, Baghdanian AH, Baghdanian AA. Multidetector Computed Tomography Imaging of Damage Control Surgery Patients. Radiol Clin North Am 2019; 57:671-687. [PMID: 31076025 DOI: 10.1016/j.rcl.2019.02.003] [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] [Indexed: 11/24/2022]
Abstract
Damage control surgery is a staged surgical procedure in a patient who has suffered penetrating or blunt abdominal traumatic injury with severe metabolic derangements. Multidetector computed tomography scanning is a vital tool for patient management in the damage control patient, providing many uses, including assessing the extent of traumatic injury, evaluating areas that were not surgically explored, evaluating for injuries that were missed during the initial surgery, and assessing the stability of surgical repair. Understanding the postsurgical multidetector computed tomography appearance of these patients can aid the radiologist in protocol optimization and provide immediate accurate diagnoses.
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Affiliation(s)
- Zohaib Y Ahmad
- Department of Radiology, Boston University Medical Center, 820 Harrison Avenue, FGH Building, 4th Floor, Boston, MA 02115, USA
| | - Arthur H Baghdanian
- Department of Radiology, University of San Francisco, 505 Parnassus Avenue, Room M392, Box 0628, San Francisco, CA 94143, USA
| | - Armonde A Baghdanian
- Department of Radiology, University of San Francisco, 505 Parnassus Avenue, Room M392, Box 0628, San Francisco, CA 94143, USA.
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40
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González Posada MA, Biarnés Suñe A, Naya Sieiro JM, Salvadores de Arzuaga CI, Colomina Soler MJ. Damage Control Resuscitation in polytrauma patient. ACTA ACUST UNITED AC 2019; 66:394-404. [PMID: 31031044 DOI: 10.1016/j.redar.2019.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/13/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
Haemorrhagic shock is one of the main causes of mortality in severe polytrauma patients. To increase the survival rates, a combined strategy of treatment known as Damage Control has been developed. The aims of this article are to analyse the actual concept of Damage Control Resuscitation and its three treatment levels, describe the best transfusion strategy, and approach the acute coagulopathy of the traumatic patient as an entity. The potential changes of this therapeutic strategy over the coming years are also described.
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Affiliation(s)
- M A González Posada
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España.
| | - A Biarnés Suñe
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España; Universidad Autónoma de Barcelona, Barcelona, España
| | - J M Naya Sieiro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Vall d'Hebron, Barcelona, España
| | | | - M J Colomina Soler
- Servicio de Anestesiología y Reanimación, Hospital Universitario de Bellvitge, l'Hospitalet de Llobregat, Barcelona, España; Universidad Barcelona, Barcelona, España
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41
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Smith SE, Hamblin SE, Dennis BM. Effect of Neuromuscular Blocking Agents on Sedation Requirements in Trauma Patients with an Open Abdomen. Pharmacotherapy 2019; 39:271-279. [PMID: 30672000 DOI: 10.1002/phar.2225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The appropriate level of sedation in patients with an open abdomen following damage control laparotomy (DCL) is debated. Chemical paralysis with neuromuscular blocking agents (NMBAs) has been used to decrease time to abdominal closure. We sought to evaluate the effect of NMBA use on sedation requirements in patients with an open abdomen and to determine the effect of sedation on patient outcomes. A retrospective cohort study was conducted at an American College of Surgeons' verified level 1 trauma center. Adult trauma patients who underwent DCL between 2009 and 2015 were included. Patients with an intensive care unit length of stay of less than 48 hours and those who died before abdominal closure were excluded. The NMBA+ group received continuous NMBA within 24 hours of DCL; the NMBA- group did not. The primary outcome was cumulative sedation dose during the 7 days following DCL. Secondary outcomes included Richmond Agitation-Sedation Scale (RASS) score, mechanical ventilation-free days, and delirium-coma-free days. Delirium-coma-free days were analyzed with linear regression. A total of 222 patients were included (NMBA+ 125; NMBA- 97). Demographics were similar between groups including age, Injury Severity Score, and mechanism of injury. The median time to closure in the overall cohort was 2 days (interquartile range [IQR] 1-2 days). Propofol and fentanyl were the primary sedatives used. The NMBA+ group received higher cumulative doses of propofol (NMBA+ 5405 mg, IQR 3103-10,573 mg; NMBA- 3601 mg, IQR 1605-6887 mg; p=0.007), but not of fentanyl. Time to abdominal closure, but not NMBA use, was associated with a higher cumulative propofol dose on multivariate analysis. The NMBA+ group had significantly lower RASS scores on the first 3 days following DCL. Mechanical ventilation-free days (NMBA+ 20 days vs NMBA- 18 days, p=0.960) and delirium-coma-free days (NMBA+ 18 days vs NMBA- 18 days, p=0.610) were similar between the groups. On linear regression, cumulative propofol dose was associated with fewer delirium-coma-free days (β-coefficient -0.007, 95% confidence interval -0.015 to -0.003). In trauma patients managed with DCL, higher cumulative sedative doses were administered in patients who received adjunctive NMBA, although NMBA therapy was not associated with a higher cumulative propofol dose on multivariate analysis. Consideration must be given to the potential effect of sedation on delirium and awakening following DCL.
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Affiliation(s)
- Susan E Smith
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Susan E Hamblin
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, Tennessee
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Aiolfi A, Matsushima K, Chang G, Bardes J, Strumwasser A, Lam L, Inaba K, Demetriades D. Surgical Trends in the Management of Duodenal Injury. J Gastrointest Surg 2019; 23:264-269. [PMID: 30215200 DOI: 10.1007/s11605-018-3964-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 09/03/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical management of traumatic duodenal injury remains challenging. While various surgical techniques have been described in the attempt to reduce complications and mortality, recent data suggests that surgical approach using less invasive procedures might be associated with improved patient outcomes. The purpose of this study was to determine the recent trend of surgical procedures performed for patients with duodenal injury and their outcome. METHODS A retrospective analysis of the National Trauma Data Bank (NTDB) from 2002 to 2014 was performed. A total of 2163 patients who sustained a traumatic duodenal injury requiring surgical intervention were included. Patient characteristics, injury data, procedures, and outcomes were examined. Types of duodenal procedures and patient outcomes were compared between two study periods (2002-2006 vs. 2007-2014). RESULTS The median age was 27 (IQR 20-39), 78.9% were male, and 63.8% sustained penetrating duodenal injury. The median injury severity score was 18 (IQR 13-26). In patients with isolated duodenal injury, the later study period (2007-2014) was significantly associated with the increased use of primary repair (OR 1.77; 95% CI 1.11-2.83, p = 0.017). Overall mortality was 11.7%. Patients in the later study group were significantly associated with lower odds of inhospital mortality (OR 0.47, 95% CI 0.22-0.95, p = 0.041). CONCLUSIONS A progressive trend toward less invasive procedures for duodenal injury was noted in the current study. Inhospital mortality has improved in the late study period.
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Affiliation(s)
- Alberto Aiolfi
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA.
| | - Gloria Chang
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - James Bardes
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Aaron Strumwasser
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Lydia Lam
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, LAC+USC Medical Center, University of Southern California, 2051 Marengo Street, IPT, C5L100, Los Angeles, CA, 90033, USA
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Abstract
Thoracic damage control surgery (TDCS) is a decision making tool and derivate of the damage control concept (DCC), where physiological stabilization has a priority over anatomical reconstruction under the pressure of time. Intrathoracic haemorrhage control and pleural decompression are the two main immediate tasks of TDCS, while definitive procedures follow when the patient is stabilised in 24-48 hours. The focus of the thoracic surgeon is on the prevention of the haemorrhage induced coagulopathy, metabolic acidosis and hypothermy formed triad of death. Surgical haemorrhage control and pleural space decompression are to be performed. The individual patients benefit from TDCS procedures whose condition is too severe for a complex immediate reconstruction (polytrauma). Life threatening chest injuries in multiple/mass casualty scenarios in civilian and military environment alike are triaged and treated accordingly. Onset of acute mismatch between the resources (available hands, OP theaters, resources, hardware) and the needs (number and severity of chest trauma cases), a mindset shift should take place, where time and space the two main limiting factors. Airway obstruction, tension haemo/pneumothorax falls into the preventable death category. Chest drainage and emergency thoracotomy are the two main procedures offered by TDCS. An intervention structured organ/injury specific list of procedures is detailed. This is a mix of emergency surgery and cardiothoracic surgery, where less is more. TDSC is not the Holy Grail found to solve all complex thoracic trauma cases, but is a good tool to increase the chance for survival in challenging, and frequently quite hopeless situations.
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Affiliation(s)
- Tamas F Molnar
- Department of Operational Medicine, Medical Humanities Unit, University of Pécs, Pécs, Hungary.,Department Surgery, St Sebastian Thoracic Surgery Unit, Petz A University Teaching Hospital, Győr, Hungary
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The Difficult Abdominal Wound: Management Tips. CURRENT TRAUMA REPORTS 2019. [DOI: 10.1007/s40719-019-0156-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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45
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Cesareo E, Raux M, Soulat L, Huot-Marchand F, Voiglio E, Puidupin A, Claret PG, Desclef JP, Douay B, Duchenne J, Gloaguen A, Lefort H, Rerbal D, Zanker C, Cook F, Pelée de Saint Maurice G, Lachenaud L, Gabilly L, Prieto N, Levraut J, Gueugniaud PY. Recommandations de bonne pratique clinique concernant la prise en charge médicale des victimes d’une « tuerie de masse ». ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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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]
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Abstract
PURPOSE OF REVIEW Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. RECENT FINDINGS Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. SUMMARY Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.
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Vascular Damage Control. CURRENT TRAUMA REPORTS 2018. [DOI: 10.1007/s40719-018-0131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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49
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Mashbari H, Hemdi M, Chow KL, Doherty JC, Merlotti GJ, Salzman SL, Singares ES. A Randomized Controlled Trial on Intra-Abdominal Irrigation during Emergency Trauma Laparotomy; Time for Yet Another Paradigm Shift. Bull Emerg Trauma 2018; 6:100-107. [PMID: 29719839 PMCID: PMC5928265 DOI: 10.29252/beat-060203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/17/2018] [Accepted: 01/20/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To determine the optimal volume of abdominal irrigation that will prevent surgical site infections (both deep and superficial), eviscerations and fistula formations; and improve 30-day mortality in trauma patients. METHODS We conducted a three-arm parallel clinical superiority randomized controlled trial comparing different volumes of effluent (5, 10 and 20 liters) used in trauma patients (both blunt and penetrating) age 14 and above undergoing an emergency laparotomy between April 2002 and July 2004 in a busy urban Level 1 trauma center. RESULTS After randomization, a total of 204 patients were analyzed. All patient groups were comparable with respect to age, gender distribution, admission injury severity score, and mechanism of injury, estimated blood loss and degree of contamination. The mortality rate overall was 1.96% (4/204).No differences were noted with respect to contamination, wound infection, fistula formation, and evisceration. The twenty liter group (Group III) showed a trend toward an increased incidence of deep surgical site infections when compared to the five liter (Group I) (p=0.051) and ten liter (Group II) (p=0.057) groups. This did not however reach statistical significance. CONCLUSION The old surgical adage "the solution to pollution is dilution" is not applicable to trauma patients. Our results suggest that using more irrigation, even when large amounts of contamination have occurred, does not reduce post-operative complications or affect mortality; and it may predispose patients to increased incidence of abscess formation. (Trial registration number: ISRCTN66454589).
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Affiliation(s)
| | - Mohannad Hemdi
- University of Illinois, College of Medicine, Chicago, USA
| | - Kevin L. Chow
- University of Illinois, College of Medicine, Chicago, USA
| | | | | | | | - Eduardo Smith Singares
- University of Illinois, College of Medicine, Chicago, USA
- Advocate Christ Medical Center, USA
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50
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Pikoulis E, Salem KM, Avgerinos ED, Pikouli A, Angelou A, Pikoulis A, Georgopoulos S, Karavokyros I. Damage Control for Vascular Trauma from the Prehospital to the Operating Room Setting. Front Surg 2017; 4:73. [PMID: 29312951 PMCID: PMC5742177 DOI: 10.3389/fsurg.2017.00073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 11/20/2017] [Indexed: 01/12/2023] Open
Abstract
Early management of vascular injury, starting at the field, is imperative for survival no less than any operative maneuver. Contemporary prehospital management of vascular trauma, including appropriate fluid and volume infusion, tourniquets, and hemostatic agents, has reversed the historically known limb hemorrhage as a leading cause of death. In this context, damage control (DC) surgery has evolved to DC resuscitation (DCR) as an overarching concept that draws together preoperative and operative interventions aiming at rapidly reducing bleeding from vascular disruption, optimizing oxygenation, and clinical outcomes. This review addresses contemporary DCR techniques from the prehospital to the surgical setting, focusing on civilian vascular injuries.
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Affiliation(s)
- Emmanouil Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Karim M Salem
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anastasia Pikouli
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Anastasios Angelou
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Antreas Pikoulis
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Sotirios Georgopoulos
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Ioannis Karavokyros
- 1st Department of Surgery, Laiko Hospital, School of Medicine, University of Athens, Athens, Greece
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