Infectious complications of extra-peritoneal pelvic packing in emergency room

Abstract

Purpose The Extra-Peritoneal Pelvic Packing (EPP) is a procedure used in emergency conditions to control pelvic hemorrhage. This procedure can be performed in Emergency Room (ER) if the patient is too unstable to be transported into the operating room (OR), with a possible increased risk of infections linked to a less sterile environment. Methods All patients who underwent EPP from 2009 to 2018 were selected from the trauma registry. The patients were divided into two groups according to where EPP was performed (ER or OR). A Propensity Score Matching was realized. EPP was removed in all patients in the OR after obtaining hemodynamic stabilization within 24–48 h and surgical pads were sent to the laboratory for microbiological analysis. Results Eighty-four patients underwent EPP during the period of the study. After PSM, 26 couples of patients were selected. No differences were observed between the two groups in the development of pelvic infection. Patients managed in OR showed a higher rate of associated abdominal injuries (p = 0.027) and an increasing need for external fixation (p = 0,005) as well as an increased proportion of laparotomies (p = 0.023), orthopedic interventions (p = 0.005) and a higher systolic blood pressure on admission (p = 0.003). Conclusions The EPP is a safe procedure, even when performed out of OR. The EPP in ER allows an earlier control of bleeding in patients in extremis. To minimize the risk of infection, EPP should be removed early, as soon as hemodynamics have been stabilized.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

“…In acute unstable haemorrhagic pelvic trauma, ICS may be indicated when management involves an anterior approach and/or an open reduction internal fixation through an infraumbilical laparotomy or with preperitoneal pelvic packing (PPP) [ 191 ]. Observational studies in deferred osteosynthesis of complex fractures of the acetabulum concluded that greater fracture complexity is associated with more bleeding (anterior approach as a risk factor [ 192 ]) and the use of ICS more cost-effective [ 193 ], although in other evaluations no differences in allogeneic transfusion were found [ 194 ].…”

Nine year in-hospital mortality trends in a high-flow level one trauma center in Italy

“…In addition, the study was a retrospective analysis of a nine-year cohort of trauma patients transported and treated in a level one trauma center: a high-flow trauma center with a surgical leadership in trauma management and a staff specifically trained on trauma management and damage-control procedures [ 11 , 21 ]. Although it represented the first Italian report on the topic, it cannot reflect the overall mortality distribution of trauma patients in all the country, as there are differences in trauma management according to the center.…”

Emergency Management of Pelvic Bleeding

“…The surgical technique suggested for EPP is a vertical or transverse incision with a consequent vertical division of the fascia; after the pelvic hematoma is evacuated, laparotomy pads are placed on each side of the bladder adjacent to the pelvic ring to perform a direct compression of the bleeding site. Another recent work from our group demonstrated EPP can be even performed in Emergency Department instead of OR, without an increased risk of an infection complication [ 22 ]. REBOA is considered a damage control technique for patients with severe torso hemorrhage, and it can be placed zone I—from left subclavian to celiac trunk—or zone III—from the lowest renal artery to aortic bifurcation—in case of isolated pelvic bleeding [ 21 ].…”