Damage Control for Vascular Injuries

Aucar, John A.; Hirshberg, Asher

doi:10.1016/s0039-6109(05)70589-2

Cited by 58 publications

(19 citation statements)

References 25 publications

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“…10 Experienced surgeons now stress the importance of avoiding these delays by emphasizing that a majority of resuscitative activities can be accomplished simultaneously in the operating room. 9 Modern research has focused on developing resuscitation strategies that serve to reverse those classic physiologic derangements that often lead to death. 17 Predicting the need for massive transfusion, need for a lifesaving intervention or mortality based on vital signs, and presenting physiologic parameters like INR or base deficit can avoid undue delay and justify effective resuscitation plans.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 Standard surgical doctrine and experience has taught surgeons that the operative patient needs to be adequately resuscitated before embarking on a taxing operative course. 8,9 The time needed for adequate resuscitation was the single greatest barrier to limb salvage during the Korean conflict. 10 Convincing modern data show that acidosis and traditional resuscitation techniques using liberal amounts of crystalloid and packed red blood cells (PRBCs) can exacerbate coagulopathy.…”

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confidence: 99%

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The Effectiveness of a Damage Control Resuscitation Strategy for Vascular Injury in a Combat Support Hospital: Results of a Case Control Study

Fox

Gillespie

Cox

et al. 2008

Journal of Trauma: Injury, Infection &Amp; Critical Care

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Objectives:Major vascular injury is a leading cause of potentially preventable hemorrhagic death in modern combat operations. An optimal resuscitation approach for military trauma should offer both rapid hemorrhage control and early reversal of metabolic derangements. The objective of this report is to establish the use and effectiveness of a damage control resuscitation (DCR) strategy in the setting of wartime vascular injury. Methods:A retrospective two-cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with an extremity vascular injury treated at two different points in time: group 1 (n ‫؍‬ 16) from April to June 2006 when DCR concepts were put into practice and group 2 (n ‫؍‬ 24) 1 year later in a period when DCR strategies were not employed.Results: Baseline demographics, injury severity, admission physiology, and operative details were similar between groups 1 and 2. Group 1 patients received more total blood products (23 vs. 12 units, p < 0.05), fresh frozen plasma (16 vs. 7 units, p < 0.01), cryoprecipitate (11 vs. 1.2 units, p < 0.05), whole blood (19% vs. 0%, p ‫؍‬ 0.06), and early recombinant factor VIIa (75% vs. 0%, p < 0.001) than group 2 patients. Group 1 patients had a more complete early physiologic recovery after vascular reconstruction (heart rate: 38 vs. 12, p < 0.001; systolic blood pressure, 39 vs. 14, p < 0.001; base deficit: 7.36 vs.2.72, p < 0.001; International Normalized Ratio, 0.3 vs. 0.1, p < 0.001). There was no significant difference in early amputation rates (group 1: 6.2% vs. group 2: 4.2%) or 7-day mortality (0% in both groups). Conclusions:This study was the first to use the Joint Theater Trauma Registry for follow-up on an established clinical practice guideline. DCR goals appear now to be met during the management of acute wartime vascular injuries with effective correction of physiologic shock. The overall impact of this resuscitation strategy on long-term outcomes such as limb salvage and mortality remains to be determined.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

The Effectiveness of a Damage Control Resuscitation Strategy for Vascular Injury in a Combat Support Hospital: Results of a Case Control Study

Fox

Gillespie

Cox

et al. 2008

Journal of Trauma: Injury, Infection &Amp; Critical Care

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“…Similar to our patient, damage control strategies in the setting of coagulopathy, hemorrhage, and acidosis have been described. 9,10 Based on multiple large series dealing with IVC injuries, management options for less severe infrahepatic IVC injuries include lateral repair, end-to-end anastomosis, vein patch, and vein or synthetic grafting.…”

Section: Discussionmentioning

confidence: 99%

Staged Reconstruction of the Inferior Vena Cava After Gunshot Injury

Droz

Matsuura

2016

Journal of Vascular Surgery

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A 23-year-old man with a gunshot injury to the abdomen and cardiac arrest requiring emergency department thoracotomy had a transection of the distal inferior vena cava (IVC) and small bowel injury. Because of persistent hemorrhagic shock, the IVC was ligated. During the next 3 days, he developed worsening bilateral leg edema. He was taken back for reanastomosis of his small bowel and reconstruction of the IVC using autologous femoral vein harvested from the right leg. We think that patients requiring ligation of the vena cava with worsening leg edema can benefit from a staged reconstruction of the IVC. (J Vasc Surg Cases and Innovative Techniques 2017;3:136-8.) Penetrating injuries of the inferior vena cava (IVC) carry a high mortality. [1][2][3][4][5] In a hemodynamically unstable patient, ligation of the vena cava often becomes necessary as a lifesaving measure. We describe a delayed reconstruction of the IVC using autologous femoral vein after stabilization of the patient. This case demonstrates the value of working with the trauma team in successful resuscitation of severe shock, acidosis, and hypothermia and in control of abdominal contamination before a venous bypass. The patient has consented to this case presentation. CASE REPORTA 23-year-old man arrived in the trauma bay with severe hypotension after a gunshot injury to the abdomen. During emergency department resuscitation, the patient arrested, requiring thoracotomy and aortic cross-clamping. The patient was placed on massive transfusion protocol and transported to the operating room for exploration, with findings of a transected distal IVC involving both origins of the common iliac veins. His aorta and iliac arteries were intact. Because of his persistent hemorrhagic shock, the IVC and both iliac veins were ligated (Fig 1).A segment of small bowel was also injured and treated with we harvested the right femoral vein, between the deep and popliteal veins, and created a bifurcated bypass (Fig 2). The patient was discharged home on clopidogrel and graded compression stockings. His venous duplex ultrasound study at 2 weeks showed a patent bypass. At 1-month follow-up, his incisions were healed and he had no residual leg edema. DISCUSSIONIVC injuries are rare and more often the result of penetrating trauma, occurring in approximately 0.02% of gunshot wounds to the abdomen. 2,6 Mortality of IVC injuries is quoted in most series to be around 50%. 1,2 Factors associated with increased mortality are hypotension on arrival to the emergency department, associated major vascular injury, and level of IVC injury, with proximal injuries carrying the highest mortality (suprahepatic).

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“…[4][5][6][7] As familiarity with complex repair techniques and perioperative resuscitation advanced, limb salvage improved, and vascular injuries previously considered "unsalvageable" or "inadvisable" were successfully repaired. [8][9][10][11] This ultimately led to a selective approach to distal extremity vascular injuries (ie, repair some but not all). However, the effectiveness of this approach as it relates to long-term limb salvage is not known, and the factors influencing the decision on whether or not to revascularize a tibial artery have not been characterized.…”

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confidence: 99%