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Hylands M, Godbout MP, Mayer SK, Fraser WD, Vanasse A, Leclair MA, Turgeon AF, Lauzier F, Charbonney E, Trottier V, Razek TS, Roy A, D’Aragon F, Belley-Côté E, Day AG, Le Guillan S, Sabbagh R, Lamontagne F. Vasopressor use following traumatic injury - A single center retrospective study. PLoS One 2017; 12:e0176587. [PMID: 28448605 PMCID: PMC5407798 DOI: 10.1371/journal.pone.0176587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/13/2017] [Indexed: 11/19/2022] Open
Abstract
Objectives Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. Methods We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. Results Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5). Conclusions In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.
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Affiliation(s)
- Mathieu Hylands
- Division of General Surgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Marie-Pier Godbout
- Division of General Surgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Sandeep K. Mayer
- Division of General Surgery, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - William D. Fraser
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Obstetrics and Gynecology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Alain Vanasse
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Marc-André Leclair
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Alexis F. Turgeon
- Department of Anesthesiology and Critical Care, Université Laval, Québec, Québec, Canada
- Centre de recherche du Centre hospitalier universitaire de Québec, Québec, Québec, Canada
| | - François Lauzier
- Centre de recherche du Centre hospitalier universitaire de Québec, Québec, Québec, Canada
- Department of Medicine, Université Laval, Québec, Québec, Canada
| | - Emmanuel Charbonney
- Department of Critical Care, Université de Montréal, Montréal, Québec, Canada
- Centre de recherche de l’hôpital du Sacré-Cœur de Montréal, Montréal, Québec, Canada
| | - Vincent Trottier
- Centre de recherche du Centre hospitalier universitaire de Québec, Québec, Québec, Canada
- Department of General Surgery, Université Laval, Québec, Québec, Canada
| | - Tarek S. Razek
- Department of General Surgery/Trauma Surgery, MUHC Montreal General Hospital, Montreal, Quebec, Canada
| | - André Roy
- Department of Physiatry, Université de Montréal, Montréal, Québec, Canada
- Centre de recherche du Centre Hospitalier Universitaire de Montréal, Montréal, Québec, Canada
| | - Frédérick D’Aragon
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Emilie Belley-Côté
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Andrew G. Day
- Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada
| | - Soazig Le Guillan
- Division of Traumatology/General Surgery, Sacré-Coeur Hospital of Montreal, Montreal, Canada
| | - Robert Sabbagh
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Urology, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - François Lamontagne
- Centre de recherche du Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Québec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
- * E-mail:
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Abstract
BACKGROUND/PURPOSE The treatment of long gap esophageal atresia remains a major surgical challenge. Whereas many approaches have been used for this problem, none are ideal. The authors used a technique originally described by Dr John E. Foker and accomplished early repair in 3 infants with long gap atresia. METHODS Three infants with esophageal atresia underwent thoracotomy shortly after birth and had a long gap preventing primary anastomosis. External traction sutures were placed on each esophageal pouch and exteriorized through the thoracic wall. The esophageal ends were approximated 1 to 2 mm daily by traction on the sutures. Anastomosis was performed when the 2 ends came together. RESULTS Three infants were included (31, 34, 37 weeks gestation, weights 1.38 kg, 1.9 kg, and 2.3 kg, respectively). The esophageal gaps were 3, 5, and 4.5 cm, respectively. Definitive anastomosis was performed at 14, 17, and 10 days, respectively. Two patients had anastomotic leaks that were treated conservatively. One patient had an esophageal stenosis that required dilatation. CONCLUSIONS This technique allowed rapid esophageal lengthening in these 3 cases and led to early repair of long gap esophageal atresia, avoiding the need for a prolonged hospitalization or eventual replacement as well as long-term swallowing difficulties.
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Affiliation(s)
- Aayed R Al-Qahtani
- Hôpital Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada, and the Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Abstract
Adrenocortical neoplasms are rare in childhood and adolescence. The prognostic significance of tumor size, weight, and histological grade are still very much unclear. Eleven patients, (3 boys, 8 girls), with a median presentation age of 7 years (range, 0.8 to 16 years) were identified. Six presented with virilizing symptoms, two with cushingoid symptoms, one with both, and two others had nonspecific symptoms. The interval between onset of symptoms and diagnosis was an average of 18 months (median, 8 months). Hormonal profile correlated well with clinical presentation in nine patients. Two patients with nonspecific symptoms had an aldosterone-producing lesion and an androgen-secreting tumor. Ten patients underwent complete surgical excision, with one intraoperative spillage. Median tumor weight was 94.5 g (range, 4 to 750 g). Three lesions were less than 5 cm in maximal width, six were between 5 and 10 cm, and two were greater than 10 cm. Two tumors had capsular or vascular invasion. Three patients received chemotherapy: one who had inoperable metastatic disease, and two based on clinical and histopathologic findings. Ten patients are doing well, without evidence of recurrent disease with a median follow-up of 3 years (range, 9 months to 15 years), eight patients have been followed up for more than 2 years. The medically treated patient who had metastatic disease died 3 years after diagnosis. A review of the pediatric literature, in some cases, indicates that larger tumors have a worse prognosis, while other investigators claim histological grade is more important. The authors' results do not support these conclusions, but rather suggest that in the pediatric population, when excision is complete, guarded optimism is warranted even with tumors larger than 5 cm. Addendum: Since submission of the manuscript, patient 4 has been operated on twice for local recurrences 13 and 16 months after the initial surgery. She was the only patient in the series to have an intraoperative capsular tear. All other surgical patients remain free of disease.
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Affiliation(s)
- S K Mayer
- Division of Pediatric General Surgery, Hôpital Sainte-Justine, Montreal, Quebec, Canada
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