Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis

Tang, Jun; Shi, Zhanying; Hu, Jian; Wu, Hao; Yang, Chengzhi; Le, Guoping; Zhao, Jinmin

doi:10.1016/j.ajem.2018.06.027

Cited by 18 publications

(6 citation statements)

References 24 publications

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“…These findings are in agreement with previous published studies emphasizing the importance of early pelvic stabilization to reduce pelvic volume and control venous bleeding. 11 Preperitoneal pelvic packing was the most common procedure after REBOA deployment, followed by EF and AE. The lower rates of AE in this study population suggest that most patients were being managed in an operative suite rather than in an Interventional Radiology (IR) suite or a hybrid operating room (hybrid-OR).…”

Section: Discussionmentioning

confidence: 99%

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

Harfouche

Inaba

Cannon

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment. METHODS:A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI). RESULTS:Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036). CONCLUSION:Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care.

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Section: Discussionmentioning

confidence: 99%

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

Harfouche

Inaba

Cannon

et al. 2021

J Trauma Acute Care Surg

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“…In industrialized countries, mortality and disability-adjusted life-years attributable to blunt multiple trauma decreased markedly during the past decades . Advanced Trauma Life Support (ATLS), implementation of trauma centers and networks, hemostatic resuscitation, early pelvic stabilization, point-of-care ultrasonography, resuscitative endovascular balloon occlusion of the aorta, and other complex interventions contributed to this trend . Controversy exists about contrast-enhanced, whole-body computed tomography (WBCT) as a primary screening modality for suspected multiple trauma .…”

Section: Introductionmentioning

confidence: 99%

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

et al. 2020

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Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. OBJECTIVE To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. INTERVENTIONS Standard-or low-dose WBCT. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. RESULTS Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). CONCLUSIONS AND RELEVANCE Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

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“…Therefore, the efficiency of PP remains controversial due to different outcomes. Although two meta-analyses regarding PP were found in our search of the current literature, one study included only three papers comparing PP with angioembolization [28]. The other was a network meta-analysis with a different aim [29].…”

Section: Introductionmentioning

confidence: 99%

Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis

Liu

et al. 2022

J Orthop Traumatol

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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.

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Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis

Cited by 18 publications

References 24 publications

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Role of pelvic packing in the first attention given to hemodynamically unstable pelvic fracture patients: a meta-analysis

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