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Le KDR, Martin K, Read D. The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis. ANZ J Surg 2024; 94:604-613. [PMID: 38456319 DOI: 10.1111/ans.18925] [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: 01/08/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. METHODS A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. RESULTS Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. DISCUSSION This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.
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Affiliation(s)
- Khang Duy Ricky Le
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
- Department of Surgical Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Katherine Martin
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Read
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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4
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Agarwal H, Gupta A, Choudhary N, Kumar S, Sagar S, Mishra B. Evaluation of Risk Factors for Enteric Fistula and Intra-abdominal Sepsis in Patients with Open Abdomen in Trauma—a Level 1 Trauma Centre Study. Indian J Surg 2021. [DOI: 10.1007/s12262-019-01934-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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5
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von der Forst M, Weiterer S, Dietrich M, Loos M, Lichtenstern C, Weigand MA, Siegler BH. [Perioperative fluid management in major abdominal surgery]. Anaesthesist 2021; 70:127-143. [PMID: 33034685 PMCID: PMC7851019 DOI: 10.1007/s00101-020-00867-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intravascular fluid administration belongs to the cornerstones of perioperative treatment with a substantial impact on surgical outcome especially with respect to major abdominal surgery. By avoidance of hypovolemia and hypervolemia, adequate perioperative fluid management significantly contributes to the reduction of insufficient tissue perfusion as a determinant of postoperative morbidity and mortality. The effective use of intravascular fluids requires detailed knowledge of the substances as well as measures to guide fluid therapy. Fluid management already starts preoperatively and should be continued in the postoperative setting (recovery room, peripheral ward) considering a patient-adjusted and surgery-adjusted hemodynamic monitoring. Communication between all team members participating in perioperative care is essential to optimize fluid management.
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Affiliation(s)
- M von der Forst
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - S Weiterer
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
- Klinik für Anästhesie und operative Intensivmedizin, Rheinland Klinikum Neuss/Lukaskrankenhaus, Preußenstraße 84, 41464, Neuss, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Loos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - C Lichtenstern
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - B H Siegler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Meléndez-Lugo JJ, Caicedo Y, Guzmán-Rodríguez M, Serna JJ, Ordoñez J, Angamarca E, García A, Pino LF, Quintero L, Parra MW, Ordoñez CA. Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding! COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4024486. [PMID: 33795898 PMCID: PMC7968431 DOI: 10.25100/cm.v51i4.4486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the “Stop the Bleed” initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the “Stop the Bleed” initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
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Affiliation(s)
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Instituto de Ciencias Biomédicas, Facultad de Medicina, Santiago de Chile, Chile
| | - 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, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Juliana Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, 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, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Hospital Universitario del Valle, Sección de Cirugía de Trauma y Emergencias, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Centro Médico Imbanaco, 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, Sección de Cirugía de Trauma y Emergencias, Cali Colombia.,Universidad Icesi, Cali, Colombia
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Mazzotta E, Villalobos-Hernandez EC, Fiorda-Diaz J, Harzman A, Christofi FL. Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols. Front Pharmacol 2020; 11:583422. [PMID: 33390950 PMCID: PMC7774512 DOI: 10.3389/fphar.2020.583422] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.
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Affiliation(s)
- Elvio Mazzotta
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | | | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Alan Harzman
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Fievos L. Christofi
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Suzuki T, Koyama K. Open randomized trial of the effects of 6% hydroxyethyl starch 130/0.4/9 and 5% albumin on safety profile, volume efficacy, and glycocalyx degradation in hepatic and pancreatic surgery. J Anesth 2020; 34:912-923. [DOI: 10.1007/s00540-020-02847-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/21/2020] [Indexed: 01/08/2023]
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Abstract
The colon is the second most commonly injured intra-abdominal organ in penetrating trauma. Management of traumatic colon injuries has evolved significantly over the past 200 years. Traumatic colon injuries can have a wide spectrum of severity, presentation, and management options. There is strong evidence that most non-destructive colon injuries can be successfully managed with primary repair or primary anastomosis. The management of destructive colon injuries remains controversial with most favoring resection with primary anastomosis and others favor colonic diversion in specific circumstances. The historical management of traumatic colon injuries, common mechanisms of injury, demographics, presentation, assessment, diagnosis, management, and complications of traumatic colon injuries both in civilian and military practice are reviewed. The damage control revolution has added another layer of complexity to management with continued controversy.
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Affiliation(s)
- Cpt Lauren T. Greer
- Department of Surgery, General Surgery Service, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Maj Amy E. Vertrees
- Department of Surgery, General Surgery Service, Walter Reed National Military Medical Center, Bethesda, Maryland
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Sapp A, Drahos A, Lashley M, Christie A, Christie DB. The Impact of Hemodynamic Transesophageal Echocardiography on Acute Kidney Injury Management and Use of Continuous Renal Replacement Therapy in Trauma. Am Surg 2020. [DOI: 10.1177/000313482008600326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Resuscitation of critically ill trauma patients can be precarious, and errors can cause acute kidney injuries. If renal failure develops, continuous renal replacement therapy (CRRT) may be necessary, but adds expense. Hemodynamic transesophageal echocardiography (hTEE) provides objective data to guide resuscitation. We hypothesized that hTEE use improved acute kidney injury (AKI) management, reserved CRRT use for more severe AKIs, and decreased cost and resource utilization. We retrospectively reviewed 2413 trauma patients admitted to a Level I trauma center's ICU between 2009 and 2015. Twenty-three patients required CRRT before standard hTEE use and 11 required CRRTafter; these are the “CRRT” and “CRRT/hTEE” groups, respectively. The hTEE group comprised 83 patients evaluated with hTEE, with AKI managed without CRRT. We compared the average creatinine, change in creatinine, and Acute Kidney Injury Network (AKIN) of “CRRT” with “CRRT/hTEE” and “hTEE.” We also analyzed several quality measures including ICU length of stay and cost. “CRRT” had a lower AKIN score (1.6) than “CRRT/hTEE” (2.9) ( P = 0.0003). “hTEE” had an AKIN score of 2.1 ( P = 0.0387). “CRRT” also had increased ICU days (25.1) compared with “CRRT/hTEE” (20.2) ( P = 0.014) and “hTEE” (16.8) ( P = 0.003). “CRRT” accrued on average $198,695.81 per patient compared with “CRRT/ hTEE” ($167,534.19) and “hTEE” ($53,929.01). hTEE provides valuable information to tailor resuscitation. At our institution, hTEE utilization reserved CRRT for worse AKIs and decreased hospital costs.
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Affiliation(s)
- Alex Sapp
- From the Department of Surgery, Medical Center Navicent Health, Macon, Georgia
| | - Andrew Drahos
- From the Department of Surgery, Medical Center Navicent Health, Macon, Georgia
| | - Madison Lashley
- From the Department of Surgery, Medical Center Navicent Health, Macon, Georgia
| | - Amy Christie
- From the Department of Surgery, Medical Center Navicent Health, Macon, Georgia
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Erstad BL. The Revised Starling Equation: The Debate of Albumin Versus Crystalloids Continues. Ann Pharmacother 2020; 54:921-927. [PMID: 32059617 DOI: 10.1177/1060028020907084] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives: The purpose of this critical narrative review is to discuss the revised Starling equation for microvascular fluid exchange and the associated implications for intravenous fluid administration. Data Sources: PubMed (1946 to December 2019) and EMBASE (1947 to December 2019) were used, and bibliographies of retrieved articles were searched for additional articles. Study Selection and Data Extraction: Articles pertaining to the revised Starling equation and microvascular fluid exchange. Additionally, prospective human studies involving the disposition and oncotic action of radiolabeled albumin and large randomized trials comparing fluid requirements associated with isotonic crystalloid and albumin administration were included. Data Synthesis: In the revised Starling equation, oncotic forces act across the endothelial cell layer, more specifically between the fluid in the vessel lumen and the protein-sparse subglycocalyx space. The revised Starling equation and radiolabeled investigations of albumin necessitate a reconsideration of conventional views of the plasma-expanding properties of exogenous albumin. Large clinical trials demonstrate that the administration of iso-oncotic or hyper-oncotic albumin solutions in patients undergoing resuscitation does not have the reductions in fluid requirements anticipated from a traditional understanding of the oncotic actions of albumin. Relevance to Patient Care and Clinical Practice: When used as a resuscitation fluid, albumin does not have the degree of plasma expansion or intravascular retention commonly used to justify its use. Conclusions: The principles underlying the revised Starling equation in conjunction with data from radiolabeled studies of albumin and large clinical trials demonstrate that albumin does not have the perceived degree of plasma expansion or duration of intravascular retention beyond crystalloid solutions predicted by the classic Starling equation.
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12
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Impact of Intravenous Fluids and Enteral Nutrition on the Severity of Gastrointestinal Dysfunction: A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2020; 6:5-24. [PMID: 32104727 PMCID: PMC7029405 DOI: 10.2478/jccm-2020-0009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/30/2020] [Indexed: 12/11/2022]
Abstract
Introduction Gastrointestinal dysfunction (GDF) is one of the primary causes of morbidity and mortality in critically ill patients. Intensive care interventions, such as intravenous fluids and enteral feeding, can exacerbate GDF. There exists a paucity of high-quality literature on the interaction between these two modalities (intravenous fluids and enteral feeding) as a combined therapy on its impact on GDF. Aim To review the impact of intravenous fluids and enteral nutrition individually on determinants of gut function and implications in clinical practice. Methods Randomized controlled trials on intravenous fluids and enteral feeding on GDF were identified by a comprehensive database search of MEDLINE and EMBASE. Extraction of data was conducted for study characteristics, provision of fluids or feeding in both groups and quality of studies was assessed using the Cochrane criteria. A random-effects model was applied to estimate the impact of these interventions across the spectrum of GDF severity. Results Restricted/ goal-directed intravenous fluid therapy is likely to reduce ‘mild’ GDF such as vomiting (p = 0.03) compared to a standard/ liberal intravenous fluid regime. Enterally fed patients experienced increased episodes of vomiting (p = <0.01) but were less likely to develop an anastomotic leak (p = 0.03) and peritonitis (p = 0.03) compared to parenterally fed patients. Vomiting (p = <0.01) and anastomotic leak (p = 0.04) were significantly lower in the early enteral feeding group. Conclusions There is less emphasis on the combined approach of intravenous fluid resuscitation and enteral feeding in critically ill patients. Conservative fluid resuscitation and aggressive enteral feeding are presumably key factors contributing to severe life-threatening GDF. Future trials should evaluate the impact of cross-interaction between conservative and aggressive modes of these two interventions on the severity of GDF.
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13
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Shen J, Zhang Y, Hu J, Wei R, Wu H. Albumin difference as a new predictor of pancreatic fistula following distal pancreatectomy: a retrospective study of 211 consecutive patients. Langenbecks Arch Surg 2020; 405:55-62. [PMID: 31900605 DOI: 10.1007/s00423-019-01849-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/11/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The level of albumin declines after surgery, and whether the difference between preoperative and postoperative albumin levels on postoperative day 1 has an effect on the development of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is unclear. Our aim was to evaluate the effect of albumin difference on POPF. METHODS A retrospective analysis of consecutive patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data and perioperative data were analysed using univariate and multivariate models. Pancreatic fistula was defined by the 2016 International Study Group of Pancreatic Surgery criteria. All patients were followed for up to 90 days. RESULTS A total of 211 consecutive patients were identified. The POPF rate was 15.64%, and no 90-day mortality was observed. Five predictors were independently associated with POPF: albumin difference (OR 6.60, 95% CI 2.36-18.45, P < 0.001), pancreatic texture (OR 4.15, 95% CI 1.62-10.63, P = 0.003), operative time (OR 3.13, 95% CI 1.19-8.24, P = 0.021), intraoperative fluid transfusion (OR 4.85, 95% CI 1.70-13.79, P = 0.003), and cardiovascular disease (OR 5.38, 95% CI 1.99-14.55, P = 0.001). CONCLUSIONS Although DP can be performed with a low rate of mortality, POPF remains a common complication. Albumin difference is a new, accessible predictor for POPF following DP.
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Affiliation(s)
- Jian Shen
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Yushun Zhang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Jin Hu
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruozheng Wei
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- , Wuhan, 430022, China.
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Hietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, van Wessem K, Simmermacher R, Govaert G, de Jong M, de Bruin I, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg 2019; 14:40. [PMID: 31428187 PMCID: PMC6694503 DOI: 10.1186/s13017-019-0257-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederik Smeeing
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Henk Formijne Jonkers
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Geertje Govaert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Miriam de Jong
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ivar de Bruin
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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15
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Cullinane DC, Jawa RS, Como JJ, Moore AE, Morris DS, Cheriyan J, Guillamondegui OD, Goldberg SR, Petrey L, Schaefer GP, Khwaja KA, Rowell SE, Barbosa RR, Bass GA, Kasotakis G, Robinson BRH. Management of penetrating intraperitoneal colon injuries: A meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019; 86:505-515. [PMID: 30789470 DOI: 10.1097/ta.0000000000002146] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications. RESULTS Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (R&A) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or R&A was not feasible due to inadequate data. CONCLUSIONS In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or R&A be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or R&A be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed R&A or anastomosis at initial operation should be performed rather than routine colostomy. LEVEL OF EVIDENCE Systematic review/meta-analysis, level III.
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Affiliation(s)
- Daniel C Cullinane
- From the Department of Surgery, Marshfield Clinic, Marshfield, Wisconsin (D.C.C.); Division of Trauma, Stony Brook University School of Medicine, Stony Brook, New York (R.S.J.); Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio (J.J.C.); Department of Surgery, Holmes Medical Center, Melbourne, Florida (A.M.); Department of Surgery, Intermountain Health Care, Murray, Utah (D.S.M.); Department of Surgery, Kern Medical Center, Bakersfield, California (J.C.); Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee (O.D.G.); Department of Surgery, Virginia Commonwealth University, Richmond, Virginia (S.R.G.); Department of Surgery, Baylor University Medical Center, Dallas, Texas (L.P.); Department of Surgery, West Virginia University Medical Center, Morgantown, West Virginia (G.S.); Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada (K.A.K.); Department of Surgery, Oregon Health & Science University, Portland, Oregon (S.E.R.); Department of Surgery, Legacy Emmanuel Medical Center, Portland, Oregon (R.R.B.); Department of Surgery, St. Vincent's Hospital, Dublin, Ireland (G.A.B.); Department of Surgery, Boston Medical Center, Boston, Massachusetts (G.K.); and Department of Surgery, University of Washington, Seattle, Washington (B.R.H.R.)
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16
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Mauser M, Bartsokas C, Brand M, Plani F. Postoperative CD4 counts predict anastomotic leaks in patients with penetrating abdominal trauma. Injury 2019; 50:167-172. [PMID: 30471941 DOI: 10.1016/j.injury.2018.11.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 10/26/2018] [Accepted: 11/14/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The influence of trauma- and surgical stress-induced decrease of CD4 count on anastomotic leaks after penetrating abdominal trauma has to date not been investigated. A prospective study was performed to explore the effect of CD4 count 24 h after surgery on the anastomotic leak rate and to identify risk factors for anastomotic leaks. METHODS This was a prospective study including 98 patients with small or large bowel resection and subsequent anastomosis due to penetrating abdominal trauma. Univariate analysis identified risk factors for the development of anastomotic leak and also investigated the predictive value of the CD4 count for this complication. RESULTS Of the 98 patients 23 patients (23%) were HIV-infected. The overall leak rate was 13%. Univariate analysis including all potential risk factors with p-values<0.05 identified six factors leading to a significantly higher rate of anastomotic complications: postoperative CD4 count<250 cells/μl, postoperative albumin <30 g/L, penetrating abdominal trauma index≥25, gunshot wound as mechanism of injury, blood transfusion requirement >6units and delayed anastomosis after damage control surgery. Survival rates were analysed with the χ2 test and did not show a significantly higher mortality rate in patients with low CD4 count. The negative impact of trauma and subsequent surgery on the cell mediated immunity was demonstrated by the fact that 55 (73%) of the HIV-negative patients had a CD4 count less than 500 cells/μl 24 h postoperatively. HIV-infection had no significant influence on the leak rate, however all HIV infected patients that developed an anastomotic leak died. CONCLUSION A low post-operative CD4 count is a predictor for anastomotic leaks irrespective of HIV-serostatus. Low postoperative serum albumin, high injury severity, gunshot wound as mechanism of injury, blood transfusion requirement >6 units and delayed anastomosis were further risk factors for anastomotic complications. Postoperative CD4 count and serum albumin should be considered in the decision making process of performing an anastomosis or diverting stoma for patients after "clip and drop" of the bowel as part of damage control surgery.
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Affiliation(s)
- Martin Mauser
- Trauma Unit/Department of Surgery, Chris Hani Baragwanath Academic Hospital, 26 Chris Hani Road, Soweto, Gauteng, South Africa.
| | - Christos Bartsokas
- Hippokration General Hospital of Athens, Vas.Sofias 114 ave. Region of Attica, Athens, 11527, South Africa.
| | - Martin Brand
- Department of Surgery, Steve Biko Academic Hospital, University of Pretoria, Gauteng, South Africa.
| | - Frank Plani
- Trauma Unit/Department of Surgery, Chris Hani Baragwanath Academic Hospital, 26 Chris Hani Road, Soweto, Gauteng, South Africa.
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17
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Baker JE, Martin GE, Katsaros G, Lewis HV, Wakefield CJ, Josephs SA, Nomellini V, Makley AT, Goodman MD. Variability of fluid administration during exploratory laparotomy for abdominal trauma. Trauma Surg Acute Care Open 2018; 3:e000240. [PMID: 30623027 PMCID: PMC6307576 DOI: 10.1136/tsaco-2018-000240] [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: 09/25/2018] [Revised: 10/16/2018] [Accepted: 10/30/2018] [Indexed: 11/30/2022] Open
Abstract
Background Approximately 8% of traumatically injured patients require transfusion with packed red blood cells (pRBC) and only 1% to 2% require massive transfusion. Intraoperative massive transfusion was defined as requiring greater than 5 units (u) of pRBC in 4 hours. Despite the majority of patients not requiring transfusion, the appropriate amount and type of crystalloid administered during the era of damage control resuscitation have not been analyzed. We sought to determine the types of crystalloid used during trauma laparotomies and the potential effects on resuscitation. Methods Patients who underwent laparotomy after abdominal trauma from January 2014 to December 2016 at the University of Cincinnati Medical Center were identified. Patients were grouped based on requiring 0u, 1u to 4u, and ≥5u pRBC during intraoperative resuscitation. Demographic, physiologic, pharmacologic, operative, and postoperative data were collected. Statistical analysis was performed with Kruskal-Wallis test and Pearson’s correlation coefficient. Results Lactated Ringer’s (LR) solution was the most used crystalloid type received in the 0u and 1u to 4u pRBC cohorts, whereas normal saline (NS) was the most common in the ≥5u pRBC cohort. Most patients received two types of crystalloid intraoperatively. NS and LR were most frequently the first crystalloids administered, with Normosol infusion occurring later. The amount of crystalloid received correlated with operative length, but did not correlate with the estimated blood loss. Neither the type of crystalloid administered nor the anesthesia provider type was associated with changes in postoperative resuscitation parameters or electrolyte concentrations. Discussion There is a wide variation in the amount and types of crystalloids administered during exploratory laparotomy for trauma. Interestingly, the amount or type of crystalloid given did not affect resuscitation parameters regardless of blood product requirement. Level of evidence Level IV.
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Affiliation(s)
- Jennifer E Baker
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Grace E Martin
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Gianna Katsaros
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Hannah V Lewis
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Connor J Wakefield
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sean A Josephs
- Department of Anesthesia, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vanessa Nomellini
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Amy T Makley
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael D Goodman
- Divisions of Trauma and Research, Section of General Surgery, Department of Surgery, University of Cincinnati, Cincinnati, Ohio, USA
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18
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Jones DG, Nantais J, Rezende-Neto JB, Yazdani S, Vegas P, Rizoli S. Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h. BMC Surg 2018; 18:93. [PMID: 30400852 PMCID: PMC6219036 DOI: 10.1186/s12893-018-0427-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 10/22/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Over-aggressive intravenous fluid therapy with crystalloids has adverse effects in trauma patients. We assessed the role of large-volume (≥5l) administration of crystalloids within 24h of injury as an independent risk-factor for mortality, in-hospital complications, and prolonged mechanical ventilation. METHODS A retrospective cohort analysis of adult trauma patients admitted to a level 1-trauma center between December 2011 and December 2012. Patient demographics, clinical and laboratory values, and total resuscitation fluid administered within the first 24h of injury were obtained. Outcomes included mortality, in-hospital complications and ventilator-days. Multivariable logistic regression and Poisson regression analyses were performed to investigate any association between the administration of ≥5L crystalloids with the aforementioned outcomes while controlling for selected clinical variables. RESULTS A total of 970 patients were included in the analysis. 264 (27%) received ≥5L of crystalloids in the first 24h of injury. 118 (12%) had in-hospital complications and 337 (35%) required mechanical ventilation. The median age was 46 years (interquartile range (IQR) 27-65) years and 73% (n = 708) were males. The median injury severity score (ISS) was 17 (IQR 9-25). Overall mortality rate was 7% (n = 67). Multivariable logistic regression analysis showed several variables independently associated with mortality (p < 0.05), including resuscitation with ≥5L crystalloid in the first 24h (adjusted odds ratio (aOR) 2.55), older age (aOR 1.03), higher ISS (aOR 1.09), and lower temperature (aOR 0.68). The variables independently associated with in-hospital complications (p < 0.05) were older age, longer ICU stay, and platelet transfusion within 24h of the injury. Need for mechanical ventilation was more common in patients who received ≥5L crystalloids (RR 2.31) had higher ISS (RR 1.02), developed in-hospital complications (RR 1.91) and had lower presenting temperature (RR 0.87). CONCLUSION Large-volume crystalloid resuscitation is associated with increased mortality and longer time ventilated, but not with in-hospital complications such as pneumonia and sepsis. Based on this data, we recommend judicious use of crystalloids in the resuscitation of trauma patients.
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Affiliation(s)
- D G Jones
- Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada. .,St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
| | - J Nantais
- Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - J B Rezende-Neto
- Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - S Yazdani
- St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - P Vegas
- St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - S Rizoli
- Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,St. Michael's Hospital Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
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19
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Mahmood I, Mustafa F, Younis B, Ahmed K, El-Menyar A, Asim M, Al-Hassani A, Peralta R, Al-Thani H. Postoperative complications of intestinal anastomosis after blunt abdominal trauma. Eur J Trauma Emerg Surg 2018; 46:599-606. [PMID: 30251153 DOI: 10.1007/s00068-018-1013-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/19/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma. METHOD We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications. RESULTS A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications. CONCLUSION Repair of traumatic blunt bowel injury remains a surgical challenge.
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Affiliation(s)
- Ismail Mahmood
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Mohammad Asim
- Clinical research, Trauma and Vascular Surgery Section, Hamad General Hospital, PO Box 3050, Doha, Qatar
| | - Ammar Al-Hassani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar
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20
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Abstract
Based on the previous experience of war wound treatment, the treatment of colorectal injury has been changing constantly. Also, since the 1980s, the progress of severe trauma treatment such as CT examinations and damage control strategies has had a profound impact on the treatment of colorectal injury. This article systematically reviews the clinical manifestations, imaging findings, and endoscopic examinations of colorectal injuries, and lists injury assessment pitfalls such as neglecting colorectal injury in blunt wounds, being misdirected by negative sign or supine X-rays, strict indications for laparotomy exploration, or intro-operative omission. The progress of emergency surgery such as staged surgery for colorectal injury, surgical way of colorectal injury during damage control strategy, and treatment of rectal injury in extraperitoneal section is also described in detail. In addition, the pitfalls for emergency treatment are described, including ignoring effects of massive crystal fluid resuscitation on colorectal anastomosis, attaching no importance on the technical points of the colonic injury operation, and performing improper suture for abdominal incisions.
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Affiliation(s)
- Lian-Yang Zhang
- Trauma Center of PLA, Institute of Surgery Research, the Third Hospital, Army Military Medical University, State Key Laboratory of Trauma, Burns and Combined Injury, Chongqing 400042, China
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21
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Abstract
Hemorrhage is the leading cause of preventable deaths in trauma patients. After presenting a brief history of hemorrhagic shock resuscitation, this article discusses damage control resuscitation and its adjuncts. Massively bleeding patients in hypovolemic shock should be treated with damage control resuscitation principles including limited crystalloid, whole blood or balance blood component transfusion to permissive hypotension, preventing hypothermia, and stopping bleeding as quickly as possible.
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22
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Hylands M, Toma A, Beaudoin N, Frenette AJ, D’Aragon F, Belley-Côté É, Charbonney E, Møller MH, Laake JH, Vandvik PO, Siemieniuk RA, Rochwerg B, Lauzier F, Green RS, Ball I, Scales D, Murthy S, Kwong JSW, Guyatt G, Rizoli S, Asfar P, Lamontagne F. Early vasopressor use following traumatic injury: a systematic review. BMJ Open 2017; 7:e017559. [PMID: 29151048 PMCID: PMC5701980 DOI: 10.1136/bmjopen-2017-017559] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock. DESIGN Systematic review. DATA SOURCES We searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury. RESULTS Of 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function. CONCLUSIONS Existing data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation. TRIAL REGISTRATION NUMBER CRD42016033437.
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Affiliation(s)
- Mathieu Hylands
- Department of Surgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Augustin Toma
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Beaudoin
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Anne Julie Frenette
- Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Frédérick D’Aragon
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Québec, Canada
| | - Émilie Belley-Côté
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
| | - Emmanuel Charbonney
- Centre de recherche de l’Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Jon Henrik Laake
- Department of Anaesthesiology, Oslo University Hospital, Rikshospitalet Medical Centre, Oslo, Norway
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Reed Alexander Siemieniuk
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Bram Rochwerg
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - François Lauzier
- Centre de Recherche du CHU de Québec, Université Laval, Québec, Canada
| | - Robert S Green
- Department of Emergency Medicine and Critical Care Medicine, Dalhousie University, Halifax, Canada
| | - Ian Ball
- Department of Emergency Medicine and Critical Care Medicine, Queen’s University, Kingston, Canada
| | - Damon Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Murthy
- Department of Pediatrics and Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Joey S W Kwong
- Center for Evidence-Based and Translational Medicine, Wuhan University, Wuhan, Hubei Province, China
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sandro Rizoli
- Department of Trauma and Acute Care Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Asfar
- Centre Hospitalier Universitaire d’Angers, Angers, Pays de la Loire, France
| | - François Lamontagne
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Canada
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23
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Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies. J Trauma Acute Care Surg 2017; 82:328-333. [PMID: 27805990 DOI: 10.1097/ta.0000000000001273] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the related change in outcomes (mortality, complications) in patients undergoing trauma laparotomy (TL) with the implementation of damage control resuscitation (DCR). We hypothesized that the implementation of DCR in patients undergoing TL is associated with better outcomes. METHODS We analyzed 1,030 consecutive patients with TL. Patients were stratified into three phases: pre-DCR (2006-2007), transient (2008-2009), and post-DCR (2010-2013). Resuscitation fluids (crystalloids and blood products), injury severity score (ISS), vital signs, and laboratory (hemoglobin, international normalized ratio, lactate) parameters were recorded. Regression analysis was performed after adjusting for age, ISS, laboratory and vital parameters, comorbidities, and resuscitation fluids to identify independent predictors for outcomes in each phase. RESULTS Patient demographics and ISS remained the same throughout the three phases. There was a significant reduction in the volume of crystalloid (p = 0.001) and a concomitant increase in the blood product resuscitation (p = 0.04) in the post-DCR phase compared to the pre-DCR and transient DCR phases. Volume of crystalloid resuscitation was an independent predictor of mortality in the pre-DCR (OR [95% CI]: 1.071 [1.03-1.1], p = 0.01) and transient (OR [95% CI]: 1.05 [1.01-1.14], p = 0.01) phases; however, it was not associated with mortality in the post-DCR phase (OR [95% CI]:1.01 [0.96-1.09], p = 0.1). Coagulopathy (p = 0.01) and acidosis (p = 0.02) were independently associated with mortality in all three phases. CONCLUSION The implementation of DCR was associated with improved outcome in patients undergoing TL. There was a decrease in the use of damage control laparotomy, with a decrease in the use of crystalloid and an increase in the use of blood products. LEVEL OF EVIDENCE Prognostic study, level III.
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Traumatic colon injury in damage control laparotomy-A multicenter trial: Is it safe to do a delayed anastomosis? J Trauma Acute Care Surg 2017; 82:742-749. [PMID: 28323788 DOI: 10.1097/ta.0000000000001349] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Delayed colonic anastomosis after damage control laparotomy (DCL) is an alternative to colostomies during a single laparotomy (SL) in high-risk patients. However, literature suggests increased colonic leak rates up to 27% with DCL, and various reported risk factors. We evaluated our regional experience to determine if delayed colonic anastomosis was associated with worse outcomes. METHODS A multicenter retrospective cohort study was performed across three Level I trauma centers encompassing traumatic colon injuries from January 2006 through June 2014. Patients with rectal injuries or mortality within 24 hours were excluded. Patient and injury characteristics, complications, and interventions were compared between SL and DCL groups. Regional readmission data were utilized to capture complications within 6 months of index trauma. RESULTS Of 267 patients, 69% had penetrating injuries, 21% underwent DCL, and the mortality rate was 4.9%. Overall, 176 received primary repair (26 in DCL), 90 had resection and anastomosis (28 in DCL), and 26 had a stoma created (10 end colostomies and 2 loop ileostomies in DCL). Thirty-five of 56 DCL patients had definitive colonic repair subsequent to their index operation. DCL patients were more likely to be hypotensive; require more resuscitation; and suffer acute kidney injury, pneumonia, adult respiratory distress syndrome, and death. Five enteric leaks (1.9%) and three enterocutaneous fistulas (ECF, 1.1%) were identified, proportionately distributed between DCL and SL (p = 1.00, p = 0.51). No difference was seen in intraperitoneal abscesses (p = 0.13) or surgical site infections (SSI, p = 0.70) between cohorts. Among SL patients, pancreas injuries portended an increased risk of intraperitoneal abscesses (p = 0.0002), as did liver injuries in DCL patients (p = 0.06). CONCLUSIONS DCL was not associated with increased enteric leaks, ECF, SSI, or intraperitoneal abscesses despite nearly two-thirds having delayed repair. Despite this being a multicenter study, it is underpowered, and a prospective trial would better demonstrate risks of DCL in colon trauma. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Whealon MD, Gahagan JV, Sujatha-Bhaskar S, O’Leary MP, Selleck M, Dumitra S, Lee B, Senthil M, Pigazzi A. Is Fecal Diversion Needed in Pelvic Anastomoses During Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? Ann Surg Oncol 2017; 24:2122-2128. [DOI: 10.1245/s10434-017-5853-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Indexed: 12/14/2022]
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Cheong JY, Keshava A. Management of colorectal trauma: a review. ANZ J Surg 2017; 87:547-553. [DOI: 10.1111/ans.13908] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/14/2016] [Accepted: 12/18/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Ju Yong Cheong
- Department of Colorectal Surgery, Concord Institute of Academic Surgery, Concord Clinical School; The University of Sydney; Sydney New South Wales Australia
| | - Anil Keshava
- Department of Colorectal Surgery, Concord Institute of Academic Surgery, Concord Clinical School; The University of Sydney; Sydney New South Wales Australia
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Hylands M, Toma A, Beaudoin N, Frenette AJ, D'Aragon F, Belley-Côté E, Hylander M, Lauzier F, Siemieniuk RA, Charbonney E, Kwong J, Laake JH, Guyatt G, Vandvik PO, Rochwerg B, Green R, Ball I, Scales D, Murthy S, Rizoli S, Asfar P, Lamontagne F. Vasopressor use following traumatic injury: protocol for a systematic review. BMJ Open 2017; 7:e014166. [PMID: 28246141 PMCID: PMC5337706 DOI: 10.1136/bmjopen-2016-014166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Worldwide, traumatic casualties are projected to exceed 8 million by year 2020. Haemorrhagic shock and brain injury are the leading causes of death following trauma. While intravenous fluids have traditionally been used to support organ perfusion in the setting of haemorrhage, recent investigations have suggested that restricting fluid therapy by tolerating more severe hypotension may improve survival. However, the safety of permissive hypotension remains uncertain, particularly among patients who have suffered a traumatic brain injury. Vasopressors preferentially vasoconstrict blood vessels that supply non-vital organs and capacitance vessels, thereby mobilising the unstressed blood volume. Used as fluid-sparing adjuncts, these drugs can complement resuscitative measures by correcting hypotension without diluting clotting factors or increasing the risk for tissue oedema. METHODS AND ANALYSIS We will identify randomised control trials comparing early resuscitation with vasopressors versus placebo or standard care in adults following traumatic injury. Data sources will include MEDLINE, EMBASE, CENTRAL, clinical trial registries and conference proceedings. Two reviewers will independently determine trial eligibility. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will assess the overall quality of the data for each individual outcome using the GRADE approach. ETHICS AND DISSEMINATION We will report this review in accordance with the PRISMA statement. We will disseminate our findings at critical care and trauma conferences and through a publication in a peer-reviewed journal. We will also use this systematic review to create clinical guidelines (http://www.magicapp.org), which will be disseminated in a standalone publication. TRIAL REGISTRATION NUMBER CRD42016033437.
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Affiliation(s)
- Mathieu Hylands
- Department of Surgery, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Augustin Toma
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Nicolas Beaudoin
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Anne-Julie Frenette
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Frederick D'Aragon
- Department of Anaesthesiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Emilie Belley-Côté
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Morten Hylander
- Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - François Lauzier
- Population Health and Optimal Health Practives Research Unit (Trauma—Emergency—Critical Care Medicine), Centre de Recherche du CHU de Québec—Université Laval, Quebec, Quebec, Canada
| | | | - Emmanuel Charbonney
- Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Quebec, Canada
| | - Joey Kwong
- Wuhan University, Center for Evidence-Based and Translational Medicine Zhongnan Hospital, Wuhan, China
| | | | - Gordon Guyatt
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Per Olav Vandvik
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Bram Rochwerg
- McMaster University, Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
| | - Robert Green
- Department of Critical care, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ian Ball
- London Health Sciences Centre, London, Ontario, Canada
| | - Damon Scales
- Department of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Srinivas Murthy
- Department of Paediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sandro Rizoli
- Division of General Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pierre Asfar
- Centre Hospitalier Universitaire d'Angers, Angers, France
| | - François Lamontagne
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Boland MR, Reynolds I, McCawley N, Galvin E, El-Masry S, Deasy J, McNamara DA. Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery. Ann R Coll Surg Engl 2017; 99:113-116. [PMID: 27659363 PMCID: PMC5392825 DOI: 10.1308/rcsann.2016.0280] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2016] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.
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Affiliation(s)
- M R Boland
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - I Reynolds
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - N McCawley
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - E Galvin
- Department of Anaesthesia, Beaumont Hospital , Dublin 9 , Ireland
| | - S El-Masry
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - J Deasy
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
| | - D A McNamara
- Department of Colorectal Surgery, Beaumont Hospital , Dublin , Ireland
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Deep organ space infection after emergency bowel resection and anastomosis: The anatomic site does not matter. J Trauma Acute Care Surg 2016; 79:805-11. [PMID: 26496105 DOI: 10.1097/ta.0000000000000840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Deep organ space infection (DOSI) is a serious complication after emergency bowel resection and anastomosis. The aim of this study was to identify the incidence and risk factors for the development of DOSI. METHODS National Surgical Quality Improvement Program database study including patients who underwent large bowel or small bowel resection and primary anastomosis. The incidence, outcomes, and risk factors for DOSI were evaluated using univariate and multivariate analyses. RESULTS A total of 87,562 patients underwent small bowel, large bowel, or rectal resection and anastomosis. Of these, 14,942 (17.1%) underwent emergency operations and formed the study population. The overall mortality rate in emergency operations was 12.5%, and the rate of DOSI was 5.6%. A total of 18.0% required ventilatory support in more than 48 hours, and 16.0% required reoperation. Predictors of DOSI included age, steroid use, sepsis or septic shock on admission, severe wound contamination, and advanced American Society of Anesthesiologists classification. The anatomic location of resection and anastomosis was not significantly associated with DOSI. CONCLUSION Patients undergoing emergency bowel resection and anastomosis have a high mortality, risk of DOSI, and systemic complications. Independent predictors of DOSI include wound and American Society of Anesthesiologists classification, sepsis or septic shock on admission, and steroid use. The anatomic location of resection and anastomosis was not significantly associated with DOSI. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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Elofson KA, Eiferman DS, Porter K, Murphy CV. Impact of late fluid balance on clinical outcomes in the critically ill surgical and trauma population. J Crit Care 2015; 30:1338-43. [PMID: 26341457 PMCID: PMC5393270 DOI: 10.1016/j.jcrc.2015.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 07/08/2015] [Accepted: 07/12/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE Management of fluid status in critically ill patients poses a significant challenge due to limited literature. This study aimed to determine the impact of late fluid balance management after initial adequate fluid resuscitation on in-hospital mortality for critically ill surgical and trauma patients. MATERIALS AND METHODS This single-center retrospective cohort study included 197 patients who underwent surgical procedure within 24 hours of surgical intensive care unit admission. Patients with high fluid balance on postoperative day 7 (>5 L) were compared with those with a low fluid balance (≤5 L) with a primary end point of in-hospital mortality. Subgroup analyses were performed based on diuretic administration, diuretic response, and type of surgery. RESULTS High fluid balance was associated with significantly higher in-hospital mortality (30.2 vs 3%, P<.001) compared with low fluid balance; this relationship remained after multivariable regression analysis. High fluid balance was associated with increased mortality, independent of diuretic administration, diuretic response, and type of surgery. CONCLUSIONS Consistent with previous literature, high fluid balance on postoperative day 7 was associated with increased in-hospital mortality. Patients who received and responded to diuretic therapy did not demonstrate improved clinical outcomes, which questions their use in the postoperative period.
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Affiliation(s)
| | | | - Kyle Porter
- The Ohio State University Wexner Medical Center, Columbus, OH
| | - Claire V Murphy
- The Ohio State University Wexner Medical Center, Columbus, OH.
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El-Sharkawy AM, Sahota O, Lobo DN. Acute and chronic effects of hydration status on health. Nutr Rev 2015; 73 Suppl 2:97-109. [DOI: 10.1093/nutrit/nuv038] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Chowdhury AH, Lobo DN. Water and Electrolytes. Clin Nutr 2015. [DOI: 10.1002/9781119211945.ch3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
PURPOSE OF REVIEW This review article explores the recent literature regarding the optimal type and amount of intravenous fluids for the trauma patient from the time of injury through their ICU stay. It discusses damage control principles as well as targeted resuscitation utilizing new technology. RECENT FINDINGS In the prehospital arena, intravenous fluids have been associated with worse patient outcomes due to increased coagulopathy and time to definitive care. Once in the trauma bay, damage control resuscitation principles apply to the severely injured patient. Large volume crystalloid infusion increases mortality. The best patient outcomes have been found with transfusion of blood products in a ratio that closely mimics whole blood. Thrombelastography is a useful adjunct in resuscitation and can help guide the judicious use of blood products. New technology can help providers ascertain when a patient is appropriately resuscitated by determining adequate global and regional perfusion. SUMMARY During the resuscitation of the acutely injured patient, crystalloids should be limited in favor of blood components. Damage control principles apply until definitive hemostasis is obtained, at which point the focus should change to targeted resuscitation using traditional global endpoints of resuscitation in conjunction with determinants of regional perfusion.
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Yeh DD, Van Der Wilden GM, Cropano C, Chang Y, King DR, De Moya M, Fagenholz P, Kaafarani H, Lee J, Velmahos G. Goal-directed diuresis: A case - control study of continuous furosemide infusion in critically ill trauma patients. J Emerg Trauma Shock 2015; 8:34-8. [PMID: 25709251 PMCID: PMC4335155 DOI: 10.4103/0974-2700.150395] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 08/18/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Excessive crystalloid administration is common and associated with negative outcomes in critically ill trauma patients. Continuous furosemide infusion (CFI) to remove excessive fluid has not been previously described in this population. We hypothesized that a goal-directed CFI is more effective for fluid removal than intermittent bolus injection (IBI) diuresis without excess incidence of hypokalemia or renal failure. MATERIALS AND METHODS CFI cases were prospectively enrolled between November 2011 and August 2012, and matched to historic IBI controls by age, gender, Injury Severity Score (ISS), and net fluid balance (NFB) at diuresis initiation. Paired and unpaired analyses were performed to compare groups. The primary endpoints were net fluid balance, potassium and creatinine levels. Secondary endpoints included intensive care unit (ICU) and hospital length of stay (LOS), ventilator-free days (VFD), and mortality. RESULTS 55 patients were included, with 19 cases and 36 matched controls. Mean age was 54 years, mean ISS was 32.7, and mean initial NFB was +7.7 L. After one day of diuresis with CFI vs. IBI, net 24 h fluid balance was negative (-0.55 L vs. +0.43 L, P = 0.026) only for the CFI group, and there was no difference in potassium and creatinine levels. Cumulative furosemide dose (59.4mg vs. 25.4mg, P < 0.001) and urine output (4.2 L vs. 2.8 L, P < 0.001) were also significantly increased with CFI vs. IBI. There were no statistically significant differences in ICU LOS, hospital LOS, VFD, or mortality. CONCLUSIONS Compared to IBI, goal-directed diuresis by CFI is more successful in achieving net negative fluid balance in patients with fluid overload with no detrimental side effects on renal function or patient outcome.
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Affiliation(s)
- Daniel Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Gwendolyn M Van Der Wilden
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Yuchiao Chang
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Marc De Moya
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Haytham Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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New Perioperative Fluid and Pharmacologic Management Protocol Results in Reduced Blood Loss, Faster Return of Bowel Function, and Overall Recovery. Curr Urol Rep 2015; 16:17. [DOI: 10.1007/s11934-015-0490-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Mahara A, Sago M, Yamaguchi H, Ehashi T, Minatoya K, Tanaka H, Nakatani T, Moritan T, Fujisato T, Yamaoka T. Micro-CT evaluation of high pressure-decellularized cardiovascular tissues transplanted in rat subcutaneous accelerated-calcification model. J Artif Organs 2014; 18:143-50. [PMID: 25472919 DOI: 10.1007/s10047-014-0808-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 11/23/2014] [Indexed: 01/25/2023]
Abstract
We have succeeded in reducing the calcification of acellular aortas or valves in porcine allogeneic system by removing the DNA and phospholipids, but its further reduction is desirable. Here, the calcification of the acellular tissue was evaluated in rat subcutaneous transplantation model which is known as calcification model. Acellular samples prepared by high-hydrostatic pressure (HHP) protocols with different washing media were implanted and the calcification was monitored under micro-computed tomography for 1 and 3 months. The amount of the calcium deposition was quantitatively evaluated by atomic absorption spectroscopy. A cell culture medium showed very good cell removal ability but led to severe calcification at 1 month, and surprisingly the calcium deposition increased as the washing period increased. This calcification was suppressed by removing the DNA fraction with high DNase concentration. On the other hand, the calcification was greatly reduced when washed with saline even at low DNase concentration after 2 weeks washing. These results suggest that the ion species in the washing medium and the residual DNase cooperatively affect the tendency of in vivo calcification, which led us to the possibility of reduced calcification of acellular cardiac tissues.
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Affiliation(s)
- Atsushi Mahara
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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Ashes C, Slinger P. Volume Management and Resuscitation in Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0081-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Lolis ED, Theodoridou E, Vogiatzis N, Neonaki D, Markakis C, Daskalakis K. The safety of primary repair or anastomosis in high-risk trauma patients. Surg Today 2014; 45:730-9. [PMID: 25030128 DOI: 10.1007/s00595-014-0982-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/02/2014] [Indexed: 01/09/2023]
Abstract
PURPOSE There is currently not enough data regarding the management of bowel injury and the results of primary repair or resection and anastomosis in high-risk trauma patients. We aimed to determine whether there were any short-term (30 days) postoperative complications relevant to the primary reconstruction of such bowel injuries. METHOD In a retrospective study, all trauma patients who underwent a definite laparotomy after penetrating or blunt injury in our institution during the last decade were identified. The study group consisted of those who underwent primary repair or resection and anastomosis of the small or large bowel or both. Patients who died within 72 h of admission, who had only serosal injuries or who received resection and diversion, were excluded. RESULTS Seventeen of the trauma patients who were treated at our institution during the study period had bowel injuries. Thirteen fit our criteria. All of them had at least one risk factor, and 61.5% of them had at least three risk factors for anastomotic or suture line disruption. Overall, 35 repairs and anastomoses took place. Only one patient developed clinical anastomotic leakage, resulting in a fistula, which did not require re-operation. CONCLUSION Our study contributes to the controversial issue of post-traumatic bowel reconstruction in high-risk trauma patients, and suggests that primary reconstruction is feasible and can provide a good outcome.
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Affiliation(s)
- Evangelos D Lolis
- Surgical Department, General Hospital of Rethymno, Trantalidou 17, 74100, Rethymno, Greece,
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Yeh DD, Tang JF, Chang Y. The use of furosemide in critically ill trauma patients: A retrospective review. J Emerg Trauma Shock 2014; 7:83-7. [PMID: 24812452 PMCID: PMC4013742 DOI: 10.4103/0974-2700.130876] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 08/01/2013] [Indexed: 12/03/2022] Open
Abstract
Introduction: Excessive fluid administration in critically ill post-traumatic patients is common and is associated with poorer outcomes. Once resuscitation is complete; however, assisted diuresis with furosemide is not an option commonly exercised. We hypothesize that diuresis with furosemide in hemodynamically stable, critically ill trauma patients is safe and effective in promoting diuresis. Materials and Methods: In this retrospective chart review, all injured patients admitted to the trauma ICU between March 2007 and June 2009 were identified. Data collection included demographic data, traumatic mechanism, physiologic data, laboratory data, medications, complications, ventilator days, ICU and hospital length of stay. Statistical analyses using two-sample t tests, Wilcoxon rank sum tests, chi-square tests, paired t-tests, and one-sample signed rank tests were performed. Results: Of 162 screened patients, 85 were identified as eligible. Twenty-seven patients (31.8%) received furosemide within the first 14 ICU days, and there were no significant differences in age, ISS, gender, blunt mechanism, co-morbid conditions, overall complications, or mortality when compared to patients who did not receive diuresis. Furosemide administration resulted in a median of 45% increased 24 h urine output and a median of 82% less 24 h net fluid gain without any significant change in HR, MAP, CVP, Hct, creatinine, or potassium. Conclusions: Administration of furosemide in stable, significantly fluid positive critically ill trauma patients results in significantly increased urine output and significantly less net fluid gain with no detrimental effect on hemodynamic parameters or laboratory values.
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Affiliation(s)
- Daniel Dante Yeh
- Massachusetts General Hospital, Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Julin F Tang
- San Francisco General Hospital, Department of Clinical Anesthesia and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yuchiao Chang
- Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA
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Lobo DN, Awad S. Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury?: con. Kidney Int 2014; 86:1096-105. [PMID: 24717302 PMCID: PMC4255073 DOI: 10.1038/ki.2014.105] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/14/2014] [Accepted: 01/24/2014] [Indexed: 02/07/2023]
Abstract
The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent ‘pre-renal' acute kidney injury.
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Affiliation(s)
- Dileep N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - Sherif Awad
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute of Health Research Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
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Kobayashi L, Coimbra R. Planned re-laparotomy and the need for optimization of physiology and immunology. Eur J Trauma Emerg Surg 2014; 40:135-42. [PMID: 26815893 DOI: 10.1007/s00068-014-0396-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/10/2014] [Indexed: 12/31/2022]
Abstract
Planned re-laparotomy or damage control laparotomy (DCL), first described by Dr. Harlan Stone in 1983, has become a widely utilized technique in a broad range of patients and operative situations. Studies have validated the use of DCL by demonstrating decreased mortality and morbidity in trauma, general surgery and abdominal vascular catastrophes. Indications for planned re-laparotomy include severe physiologic derangements, coagulopathy, concern for bowel ischemia, and abdominal compartment syndrome. The immunology of DCL patients is not well described in humans, but promising animal studies suggest a benefit from the open abdomen (OA) and several human trials on this subject are currently underway. Optimal critical care of patients with OA's, including sedation, paralysis, nutrition, antimicrobial and fluid management strategies have been associated with improved closure rates and recovery.
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Affiliation(s)
- L Kobayashi
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
| | - R Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California, San Diego, 200 W. Arbor Dr. #8896, San Diego, CA, 92103-8896, USA.
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Damage control strategies in the management of acute injury. Eur J Trauma Emerg Surg 2014; 40:143-50. [PMID: 26815894 DOI: 10.1007/s00068-014-0386-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 02/13/2014] [Indexed: 01/24/2023]
Abstract
Traumatic injury is the leading cause of death worldwide. The rapid evaluation and correction of injuries in these patients is paramount to preventing uncontrolled decompensation and death. Damage control strategies are a compendium of techniques refined over decades of surgical care that focus on the rapid correction of deranged physiology, control of contamination and blood loss, and resuscitation of critical patients. Damage control resuscitation (DCR) focuses on the replacement of lost blood volume in a manner mimicking whole blood, control of crystalloid administration, and permissive hypotension. Damage control laparotomy controls gastrointestinal contamination and bleeding in the operative suite, allowing rapid egress to the intensive care unit for ongoing resuscitation. Pelvic packing, an adjunct to DCR, provides a means to control hemorrhage from severe pelvic fractures. Temporary vascular shunts restore perfusion, while resuscitation and reconstruction are ongoing. Taken together, these strategies provide the trauma surgeon with a powerful arsenal to preserve life in the transition from injury to the shock trauma room to the intensive care unit.
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Godat L, Kobayashi L, Costantini T, Coimbra R. Abdominal damage control surgery and reconstruction: world society of emergency surgery position paper. World J Emerg Surg 2013; 8:53. [PMID: 24341602 PMCID: PMC3878509 DOI: 10.1186/1749-7922-8-53] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/10/2013] [Indexed: 12/02/2022] Open
Abstract
Damage control laparotomy was first described by Dr. Harlan Stone in 1983 when he suggested that patients with severe trauma should have their primary procedures abbreviated when coagulopathy was encountered. He recommended temporizing patients with abdominal packing and temporary closure to allow restoration of normal physiology prior to returning to the operating room for definitive repair. The term damage control in the trauma setting was coined by Rotondo et al., in 1993. Studies in subsequent years have validated this technique by demonstrating decreased mortality and immediate post-operative complications. The indications for damage control laparotomy have evolved to encompass abdominal compartment syndrome, abdominal sepsis, vascular and acute care surgery cases. The perioperative critical care provided to these patients, including sedation, paralysis, nutrition, and fluid management strategies may improve closure rates and recovery. In the rare cases of inability to primarily close the abdomen, there are a number of reconstructive strategies that may be used in the acute and chronic phases of abdominal closure.
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Affiliation(s)
| | | | | | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, and Burns, University of California, San Diego, 200 West Arbor Dr,, #8896, San Diego CA 92103-8896, United States of America.
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Smorenberg A, Ince C, Groeneveld ABJ. Dose and type of crystalloid fluid therapy in adult hospitalized patients. Perioper Med (Lond) 2013; 2:17. [PMID: 24472418 PMCID: PMC3964340 DOI: 10.1186/2047-0525-2-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 07/04/2013] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE In this narrative review, an overview is given of the pros and cons of various crystalloid fluids used for infusion during initial resuscitation or maintenance phases in adult hospitalized patients. Special emphasis is given on dose, composition of fluids, presence of buffers (in balanced solutions) and electrolytes, according to recent literature. We also review the use of hypertonic solutions. METHODS We extracted relevant clinical literature in English specifically examining patient-oriented outcomes related to fluid volume and type. RESULTS A restrictive fluid therapy prevents complications seen with liberal, large-volume therapy, even though restrictive fluid loading with crystalloids may not demonstrate large hemodynamic effects in surgical or septic patients. Hypertonic solutions may serve the purpose of small volume resuscitation but carry the disadvantage of hypernatremia. Hypotonic solutions are contraindicated in (impending) cerebral edema, whereas hypertonic solutions are probably more helpful in ameliorating than in preventing this condition and improving outcome. Balanced solutions offer a better approach for plasma composition than unbalanced ones, and the evidence for benefits in patient morbidity and mortality is increasing, particularly by helping to prevent acute kidney injury. CONCLUSIONS Isotonic and hypertonic crystalloid fluids are the fluids of choice for resuscitation from hypovolemia and shock. The evidence that balanced solutions are superior to unbalanced ones is increasing. Hypertonic saline is effective in mannitol-refractory intracranial hypertension, whereas hypotonic solutions are contraindicated in this condition.
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Affiliation(s)
- Annemieke Smorenberg
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
| | - AB Johan Groeneveld
- Department of Intensive Care, Erasmus Medical Centre, ‘s-Gravendijkwal 230, 3015, CE, Rotterdam, The Netherlands
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Causey MW, Rivadeneira DE, Steele SR. Historical and current trends in colon trauma. Clin Colon Rectal Surg 2012; 25:189-99. [PMID: 24294119 PMCID: PMC3577616 DOI: 10.1055/s-0032-1329389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.
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Affiliation(s)
- Marlin Wayne Causey
- Department of Surgery, Uniformed Services University of the Health Sciences (USUHS), Madigan Healthcare System, Fort Lewis, Washington
| | - David E. Rivadeneira
- Department of Surgery, St. Catherine of Siena Medical Center, Smithtown, New York
| | - Scott R. Steele
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Georgoff P, Perales P, Laguna B, Holena D, Reilly P, Sims C. Colonic injuries and the damage control abdomen: does management strategy matter? J Surg Res 2012; 181:293-9. [PMID: 22884449 DOI: 10.1016/j.jss.2012.07.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 06/07/2012] [Accepted: 07/03/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal management of colon injury patients requiring damage control laparotomy (DCL) is controversial. The objective of this study was to assess the safety of colonic resection and anastomosis versus fecal diversion in trauma patients requiring DCL. METHODS Patients with traumatic colon injuries undergoing DCL between 2000 and 2010 were identified by the database and chart review. Those who died within 48 h were excluded. Patients were divided into two groups: those undergoing one or more colonic anastomoses with or without distal colostomy (group 1) and those undergoing colostomy only or one or more colonic anastomoses with a protecting proximal ostomy (group 2). Variables were compared using Wilcoxon rank sum, χ2, or Fisher exact tests as appropriate. RESULTS Sixty-one patients were included (group 1, n=28 and group 2, n=33). Fascial closure rates (group 1, 50% versus group 2, 61%; P=0.45), hospital length of stay (29 versus 23 d; P=0.89), and in-patient mortality (11% versus 12%; P=1.0) were similar between groups. There were a total of 11 anastomotic leaks, five of which were related to non-colonic enteric repairs. Colonic anastomosis leak rates were 16% overall (six of the 38 patients), 14% in group 1 (four of the 28 patients), and 20% in group 2 (two of the 10 patients). Compared with patients who did not leak, patients who leaked had a higher median age (37 versus 25 y; P=0.05), greater likelihood of not achieving facial closure before post-injury day 5 (18% versus 2%; P=0.003), and a longer hospital length of stay (46 versus 25 d; P=0.003). CONCLUSIONS Outcomes after colonic injury in the setting of DCL were similar regardless of the surgical management strategy. Based on these findings, a strategy of diversion over anastomosis cannot be strongly recommended.
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Affiliation(s)
- Patrick Georgoff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Lago Oliver J, Arjona Medina I, Martín García-Almenta E, Martín Gil J, Sanz Sánchez M, Pérez Díaz MD, Alonso Poza A, Turégano Fuentes F, Torres García A. [Use of fibrin based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract: preliminary results of the multicentre, prospective, randomised, controlled, and simple blind phase IV clinical trial: Protissucol001]. Cir Esp 2012; 90:647-55. [PMID: 22748849 DOI: 10.1016/j.ciresp.2012.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 04/14/2012] [Accepted: 05/07/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION A multicentre, prospective, randomised, controlled, and simple blind clinical trial was started in January 2007, with the aim of demonstrating the efficacy of fibrin-based biological adhesives in the prevention of anastomotic leaks in the high risk digestive tract. MATERIAL AND METHODS A study on the prevention of anastomotic healing defects by applying biological adhesives along the suture line began in January 2007, and included the hospitals, Gregorio Marañón, Universitario de San Carlos, and Hospital del Sureste, in Madrid. The enrolled patients were randomised to one of 2 groups: the study group in which the adhesive was applied to the suture line, and a control group in which it was not applied. The primary outcome of the study was the presence or absence of leaks. The trial was approved by the corresponding Clinical Research Ethics Committees and the Spanish Medicines Agency (AEMPS) and registered www.clinicaltrials.gov (NCT01306851). The authors declared not to have any conflict of interests with the company, Baxter, which markets the product in Spain. RESULTS A total of 104 patients were recruited between January 2007 and November 2010, of whom 52 were randomised to the study group, and 52 to the control group. A total of 22 anastomotic leaks were recorded, of which 7 (13.4%) were in the study group, and 15 (28.8%) in the control group (P=.046). The leak risk index was 0.384, which means that there was a 61% reduction in leaks in the patients who had the fibrin-based biological adhesive applied. There were 3 (5.7%) further surgeries in the study group, compared to 12 (23%) in the control group (P=.12). On analysing the mortality, it was observed that 3 patients in the study group and 4 patients in the control group died (5.7% vs. 7.7%, P=.5). No other significant differences were found as regards the type of suture, surgical time, or pre-surgical history, except that the use of drainages appeared to be a protective factor of anastomotic leak (P=.041), although the use or not of a drainage was not a controlled factor, but at the discretion of each surgeon. CONCLUSIONS Our study demonstrates, significantly, that in the 104 patients in the study that fibrin based biological adhesives are capable of preventing anastomotic leaks in the high risk digestive tract, reducing the risk of leaks by 61% and a further surgeries. This is the first clinical trial that shows these significant results. If our results are maintained at the end of the study, it will show that anastomotic leaks can be prevented with the application of these adhesives, thus their application may be recommended in all the anastomosis of the high risk digestive tract.
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50
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Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg 2011; 254:598-605. [PMID: 21918426 DOI: 10.1097/sla.0b013e318230089e] [Citation(s) in RCA: 266] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival. BACKGROUND DCR aims at preventing coagulopathy through permissive hypotension, limiting crystalloids and delivering higher ratios of plasma and platelets. Previous work has focused only on the impact of delivering higher ratios (1:1:1). METHODS A retrospective cohort study was performed on all DCL patients admitted between January 2004 and August 2010. Patients were divided into pre-DCR implementation and DCR groups and were excluded if they died before completion of the initial laparotomy. The lethal triad was defined as immediate postoperative temperature less than 95°F, international normalized ratio more than 1.5, or a pH less than 7.30. RESULTS A total of 390 patients underwent DCL. Of these, 282 were pre-DCR and 108 were DCR. Groups were similar in demographics, injury severity, admission vitals, and laboratory values. DCR patients received less crystalloids (median: 14 L vs 5 L), red blood cells (13 U vs 7 U), plasma (11 U vs 8 U), and platelets (6 U vs 0 U) in 24 hours, all P < 0.05. DCR patients had less evidence of the lethal triad upon intensive care unit arrival (80% vs 46%, P < 0.001). 24-hour and 30-day survival was higher with DCR (88% vs 97%, P = 0.006 and 76% vs 86%, P = 0.03). Multivariate analysis controlling for age, injury severity, and emergency department variables, demonstrated DCR was associated with a significant increase in 30-day survival (OR: 2.5, 95% CI: 1.10-5.58, P = 0.028). CONCLUSION In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration. More importantly, DCR is associated with an improvement in 30-day survival.
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