1
|
Madsen JE, Flugsrud GB, Hammer N, Puchwein P. Emergency treatment of pelvic ring injuries: state of the art. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05447-7. [PMID: 38970673 DOI: 10.1007/s00402-024-05447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Abstract
High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.
Collapse
Affiliation(s)
- Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds Vei 3, 0372, Oslo, Norway.
| | | | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
| | - Paul Puchwein
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| |
Collapse
|
2
|
Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
Collapse
Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| |
Collapse
|
3
|
Patterson JT, Wier J, Gary JL. Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury. J Bone Joint Surg Am 2022; 104:1821-1829. [PMID: 35939780 DOI: 10.2106/jbjs.22.00252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury. METHODS Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay. RESULTS In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching. CONCLUSIONS PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Julian Wier
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| |
Collapse
|
4
|
Li P, Liu F, Li Q, Zhou D, Dong J, Wang D. Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis. J Orthop Traumatol 2022; 23:29. [PMID: 35799073 PMCID: PMC9263021 DOI: 10.1186/s10195-022-00647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/29/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of pelvic packing (PP) in pelvic fracture patients with hemodynamic instability. MATERIALS AND METHODS Three databases-PubMed, Embase and the Cochrane Library-were systematically searched to identify studies presenting comparisons between a protocol including PP and a protocol without PP. Mortality, transfusion requirement and length of hospitalization were extracted and pooled for meta-analysis. Relative risk (RR) and standard mean difference (SMD), along with their confidence intervals (CIs), were used as the pooled statistical indices. RESULTS Eight studies involving 480 patients were identified as being eligible for meta-analysis. PP usage was associated with significantly reduced overall mortality (RR = 0.61, 95% CI = 0.47-0.79, p < 0.01) as well as reduced mortality within 24 h after admission (RR = 0.42, 95% CI = 0.26-0.69, p < 0.01) and due to hemorrhage (RR = 0.26, 95% CI = 0.14-0.50, p < 0.01). The usage of PP also decreased the need for pre-operative transfusion (SMD = - 0.44, 95% CI = - 0.69 to - 0.18, p < 0.01), but had no influence on total transfusion during the first 24 h after admission (SMD = 0.05, 95% CI = - 0.43-0.54, p = 0.83) and length of hospitalization (ICU stay and total stay). CONCLUSIONS This meta-analysis indicates that a treatment protocol including PP could reduce mortality and transfusion requirement before intervention in pelvic fracture patients with hemodynamic instability vs. angiography and embolization. This latter technique could be used as a feasible and complementary technique afterwards. LEVEL OF EVIDENCE: 3
Collapse
Affiliation(s)
- Pengyu Li
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, 8 Xishiku Street, Beijing, 100034, China.,Department of Orthopedic, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, 324 Jingwu Road, Jinan, 250021, Shandong, China.,Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Fanxiao Liu
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Qinghu Li
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Dongsheng Zhou
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China
| | - Jinlei Dong
- Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China.
| | - Dawei Wang
- Department of Orthopedic, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, 324 Jingwu Road, Jinan, 250021, Shandong, China. .,Department of Orthopedic, Shandong Provincial Hospital, Affiliated to Shandong First Medical University, 324 Jingwu Road, Jinan, 250021, Shandong, China.
| |
Collapse
|
5
|
Comparative effectiveness of pelvic arterial embolization versus laparotomy in adults with pelvic injuries: A National Trauma Data Bank analysis. Clin Imaging 2022; 86:75-82. [DOI: 10.1016/j.clinimag.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/21/2022]
|
6
|
Li H, Hu P. Letter to the Editor: Non-selective bilateral internal iliac artery embolization is a safe and effective way in hemorrhage control for hemodynamically unstable pelvic fractures. BMC Musculoskelet Disord 2021; 22:355. [PMID: 33853573 PMCID: PMC8048307 DOI: 10.1186/s12891-021-04212-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022] Open
Abstract
A recently published article by Lai et al. in BMC Musculoskeletal Disorders trying to show that patients with pelvic fractures undergoing non-selective internal iliac artery embolization may lead to a higher rate of surgical site infection. The authors also noted that only a small percentage of patients with contrast extravasation detected by emergency contrast-enhanced CT were subsequently confirmed by angiography, thus, considered that the value of enhanced CT in predicting arterial injury was limited. The authors also believe that embolization of the main stem may cause incomplete hemostasis due to the abundant collateral circulations in the pelvic cavity. Although the author’s findings are mentioned in other studies, the article’s data and pictures only partially supported its inferences, and the conclusions cannot be drawn directly. In this Correspondence, we tried to reinterpret the additional findings in the article from our perspective. Through this discussion, we hope that more colleagues can re-understand the safety and effectiveness of non-selective internal iliac artery embolization in treating hemodynamically unstable pelvic fractures during the early resuscitation stage.
Collapse
Affiliation(s)
- Hui Li
- Department of Traumatology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, 1 Jiankang Road, 400014, Yuzhong District, Chongqing, China
| | - Ping Hu
- Department of Traumatology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, 1 Jiankang Road, 400014, Yuzhong District, Chongqing, China.
| |
Collapse
|
7
|
Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma 2021; 12:101-112. [PMID: 33716435 PMCID: PMC7920327 DOI: 10.1016/j.jcot.2020.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022] Open
Abstract
Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.
Collapse
Affiliation(s)
- Ramesh Perumal
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Sivakumar S. P
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Ramesh Kumar Sen
- Institute of Orthopedic Surgery, Max Super Specialty Hospital, Mohali, 160055, India
| | - Vivek Trikha
- Department of Orthopedics, All India Institute of Medical Science, New Delhi, 110029, India
| |
Collapse
|
8
|
Che XR, Wang YJ, Zheng HY. Prognostic value of intracranial pressure monitoring for the management of hypertensive intracerebral hemorrhage following minimally invasive surgery. World J Emerg Med 2020; 11:169-173. [PMID: 32351650 DOI: 10.5847/wjem.j.1920-8642.2020.03.007] [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] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The incidence of hypertensive intracerebral hemorrhage (HICH) has been increasing during the recent years in low- and middle-income countries. With high mortality and morbidity rates, it brings huge burden to the families. It lacks evidence regarding the application of intracranial pressure (ICP) monitoring in HICH. In the current study, the authors aimed to evaluate whether ICP monitoring could make any difference on the prognosis of HICH patients after minimally invasive surgery. METHODS A retrospective review of 116 HICH patients admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine, between 2014 and 2016, was performed. The effects of ICP monitoring on 6-month mortality and favorable outcomes were evaluated by univariate and logistic regression analysis. RESULTS ICP monitors were inserted into 50 patients. Patients with ICP monitoring had a significantly better outcome (P<0.05). The average in-hospital duration in patients with ICP monitoring was shorter than that in the patients without ICP monitoring (16.68 days vs. 20.47 days, P<0.05). Mortality rates between ICP monitoring and no ICP monitoring did not differ significantly (16.0% vs. 15.1%, P=0.901). On univariate analysis, age, Glasgow Coma Scale (GCS) on admission and presence of ICP monitor were independent predictors of 6-month favorable outcomes. CONCLUSION ICP monitoring is associated with a better 6-month functional outcome compared with no ICP monitoring. Future study is still needed to confirm our results and elucidate which subgroup of HICH patients will benefit most from the minimally invasive surgical intervention and ICP monitoring.
Collapse
Affiliation(s)
- Xiao-Ru Che
- Department of Cardiology, Zhejiang Province People's Hospital, Hangzhou, China.,Department of Cardiology, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Yong-Jie Wang
- Department of Neurosurgery, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hai-Yan Zheng
- Department of Cardiology, Zhejiang Province People's Hospital, Hangzhou, China.,Department of Neurosurgery, the Fouth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| |
Collapse
|
9
|
He W, You YY, Sun K, Xie C, Ming Y, Yu LN, Zhang FJ, Yan M. Admission delay is associated with worse surgical outcomes for elderly hip fracture patients: A retrospective observational study. World J Emerg Med 2020; 11:27-32. [PMID: 31893000 DOI: 10.5847/wjem.j.1920-8642.2020.01.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The influence of surgical delay on mortality and morbidity has been studied extensively among elderly hip fracture patients. However, most studies only focus on the timing of surgery when patients have already been hospitalized, without considering pre-admission waiting time. Therefore, the present study aims to explore the influence of admission delay on surgical outcomes. METHODS In this retrospective study, we recorded admission timing and interval from admission to surgery for included patient. Other covariates were also collected to control confounding. The primary outcome was 1-year mortality. The secondary outcomes were 1-month mortality, 3-month mortality, ICU admission and postoperative pneumonia. We mainly used multivariate logistic regression to determine the effect of admission timing on postoperative outcomes. An additional survival analysis was also performed to assess the impact of admission delay on survival status in the first year after operation. RESULTS The proportion of patients hospitalized on day 0, day 1, day 2 after injury was 25.4%, 54.7% and 66.3%, respectively. And 12.6% patients visited hospital one week later after injury. Mean time from admission to surgery was 5.2 days (standard deviation 2.8 days). Hospitalization at one week after injury was a risk factor for 1-year mortality (OR 1.762, 95% CI 1.026-3.379, P=0.041). CONCLUSION Admission delay of more than one week is significantly associated with higher 1-year mortality. As a supplement to the current guidelines which emphasizes early surgery after admission, we also advocate early admission once patients get injured.
Collapse
Affiliation(s)
- Wei He
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Yue-Yang You
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Kai Sun
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chen Xie
- Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou 221004, China
| | - Yue Ming
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Li-Na Yu
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Feng-Jiang Zhang
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Min Yan
- Department of Anesthesiology, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China.,Jiangsu Province Key Laboratory of Anesthesiology, Jiangsu Province Key Laboratory of Anesthesia and Analgesia Application Technology, Xuzhou Medical University, Xuzhou 221004, China
| |
Collapse
|
10
|
Blondeau B, Orlando A, Jarvis S, Banton K, Berg GM, Patel N, Meinig R, Tanner A, Carrick M, Bar-Or D. Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers. Patient Saf Surg 2019; 13:3. [PMID: 30675184 PMCID: PMC6334446 DOI: 10.1186/s13037-019-0183-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mortality from hemodynamically unstable pelvic fractures remains high. Guidelines offer varying care approaches including the use of pelvic packing (PP), which was recently adopted for potential control of bleeding for this condition. However, the implementation of PP is uncertain as the debate on the optimal resuscitation strategy, angioembolization or PP continues. The study was designed to assess current practices among level 1 trauma centers in the US in regard to PP treatment for hemodynamically unstable pelvic fractures. METHODS A cross-sectional survey was created to assess when to apply PP, application approach, and the respondent's anecdotal perception on safety and effectiveness. Trauma Medical Directors at 158 US level 1 trauma centers were sent biweekly email invitations for 3 months. Participants were allowed to skip questions for any reason. The study hypothesis was that PP practices vary by US census bureau region, annual trauma admissions, and length of time in years since each trauma center received their respective level 1 trauma center designation. RESULTS Twenty-five percent (40/158) of trauma medical directors participated and 75% (118/158) of the trauma medical directors did not participate. Of those who took the survey, 36/40 (90%) completed the survey and 4/40 (10%) partially completed the survey. Only 36 trauma medical directors responded on their perception of safety and effectiveness; 72% (26/36) of participants perceived PP as safe, whereas only a third (12/36) of participants perceived PP as effective. There were 25 trauma medical directors who provided the sequence of treatment modalities utilized at their level 1 trauma center, 76% (19/25) of participants reported that PP is utilized as the third or fourth priority. None of the participating level 1 trauma centers reported a preference towards utilization of PP as the first priority treatment. Half of the participants reported a preference towards applying PP only as a last resort to control hemorrhage. Northeastern and Western level 1 trauma centers were significantly more likely than Midwestern and Southern level 1 trauma centers to have reported application of PP to all hemodynamically unstable patients (p = 0.05). Midwestern, Southern, and Western level 1 trauma centers were significantly more likely to have perceived PP as safe than Northeastern level 1 trauma centers (p = 0.04). All low-volume and 38% high-volume level 1 trauma centers perceived PP to increase infection risks, (p = 0.03). We observed no association between the length of time each trauma center was designated a level 1 trauma center, and all participant responses. CONCLUSION Controversy and varying anecdotal perception regarding safety and effectiveness of PP prevails among trauma medical directors at level 1 trauma centers in the US.
Collapse
Affiliation(s)
- Benoit Blondeau
- Research Medical Center, 2316 East Meyer Blvd., Kansas City, MO 64132 USA
- University of Connecticut, Hartford Hospital, Hartford, CT 06106 USA
| | | | - Stephanie Jarvis
- Trauma Research, LLC., 383 Corona St. #319, Denver, CO 80218 USA
| | - Kaysie Banton
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| | - Gina M. Berg
- Wesley Medical Center, 550 N. Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Rick Meinig
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Allen Tanner
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - David Bar-Or
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| |
Collapse
|
11
|
Li YD, Xu JH, Lin JJ, Zhu WF. Application of 4% formaldehyde under electronic colonoscope as a minimally invasive treatment of chronic hemorrhagic radiation proctitis. World J Emerg Med 2019; 10:228-231. [PMID: 31534597 DOI: 10.5847/wjem.j.1920-8642.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To investigate the effectiveness of topical application of 4% formaldehyde as a minimally invasive treatment of rectal bleeding due to chronic radiation proctitis (CRP) under direct vision of electronic colonoscope. METHODS The clinical data of 13 CRP patients complicated with ≥ grade II bleeding admitted to our hospital between January 2003 and December 2018 were retrospectively analyzed. Under the guidance of electronic colonoscope, 4% formaldehyde combined with 5-aminosalicylic acid (5-ASA) suppositories was topically applied. Patients were followed up for two months after treatment, and the therapeutic effectiveness was observed and analyzed. RESULTS The rectal bleeding due to CRP was markedly reduced after topical application of 4% formaldehyde under colonoscope in all 13 patients. The bleeding stopped after one treatment session in 11 patients and after the second session in 2 patients. 5-ASA was also applied along with the use of 4% formaldehyde. The therapeutic effectiveness was satisfactory during the 1- and 2-month follow-up period. CONCLUSION Topical application of 4% formaldehyde under the direct vision of colonoscope as a minimally invasive treatment for CRB-induced bleeding is a simple, effective, affordable, and repeatable technique without obvious complications, which deserves further exploration and promotion.
Collapse
Affiliation(s)
- Yan-Dong Li
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jia-He Xu
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian-Jiang Lin
- Division of Colon& Rectal Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Wei-Fang Zhu
- Division of Dermatology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| |
Collapse
|