Pub Date : 2024-06-14DOI: 10.1186/s13017-024-00549-4
Gavin G. Calpin, Sandra Hembrecht, Katie Giblin, Cian Hehir, Gavin P. Dowling, Arnold D.K. Hill
Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes. To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes. A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24–48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed. Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups. Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24–48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.
{"title":"The impact of timing on outcomes in appendicectomy: a systematic review and network meta-analysis","authors":"Gavin G. Calpin, Sandra Hembrecht, Katie Giblin, Cian Hehir, Gavin P. Dowling, Arnold D.K. Hill","doi":"10.1186/s13017-024-00549-4","DOIUrl":"https://doi.org/10.1186/s13017-024-00549-4","url":null,"abstract":"Appendicectomy remains the standard treatment for appendicitis. There is a lack of clarity on the timeframe in which surgery should be performed to avoid unfavourable outcomes. To perform a systematic review and network meta-analysis to evaluate the impact the (1)time-of-day surgery is performed (2), time elapsed from symptom onset to hospital presentation (patient time) (3), time elapsed from hospital presentation to surgery (hospital time), and (4)time elapsed from symptom onset to surgery (total time) have on appendicectomy outcomes. A systematic review was performed as per PRISMA-NMA guidelines. The time-of-day which surgery was done was divided into day, evening and night. The other groups were divided into < 24 h, 24–48 h and > 48 h. The rate of complicated appendicitis, operative time, perforation, post-operative complications, surgical site infection (SSI), length of stay (LOS), readmission and mortality rates were analysed. Sixteen studies were included with a total of 232,678 patients. The time of day at which surgery was performed had no impact on outcomes. The incidence of complicated appendicitis, post-operative complications and LOS were significantly better when the hospital time and total time were < 24 h. Readmission and mortality rates were significantly better when the hospital time was < 48 h. SSI, operative time, and the rate of perforation were comparable in all groups. Appendicectomy within 24 h of hospital admission is associated with improved outcomes compared to patients having surgery 24–48 and > 48 h after admission. The time-of-day which surgery is performed does not impact outcomes.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"8 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141319767","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-08DOI: 10.1186/s13017-024-00551-w
Massimo Sartelli, Carlo Tascini, Federico Coccolini, Fabiana Dellai, Luca Ansaloni, Massimo Antonelli, Michele Bartoletti, Matteo Bassetti, Federico Boncagni, Massimo Carlini, Anna Maria Cattelan, Arturo Cavaliere, Marco Ceresoli, Alessandro Cipriano, Andrea Cortegiani, Francesco Cortese, Francesco Cristini, Eugenio Cucinotta, Lidia Dalfino, Gennaro De Pascale, Francesco Giuseppe De Rosa, Marco Falcone, Francesco Forfori, Paola Fugazzola, Milo Gatti, Ivan Gentile, Lorenzo Ghiadoni, Maddalena Giannella, Antonino Giarratano, Alessio Giordano, Massimo Girardis, Claudio Mastroianni, Gianpaola Monti, Giulia Montori, Miriam Palmieri, Marcello Pani, Ciro Paolillo, Dario Parini, Giustino Parruti, Daniela Pasero, Federico Pea, Maddalena Peghin, Nicola Petrosillo, Mauro Podda, Caterina Rizzo, Gian Maria Rossolini, Alessandro Russo, Loredana Scoccia, Gabriele Sganga, Liana Signorini, Stefania Stefani, Mario Tumbarello, Fabio Tumietto, Massimo Valentino, Mario Venditti, Bruno Viaggi, Fra..
Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients’ safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts’ opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.
{"title":"Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use","authors":"Massimo Sartelli, Carlo Tascini, Federico Coccolini, Fabiana Dellai, Luca Ansaloni, Massimo Antonelli, Michele Bartoletti, Matteo Bassetti, Federico Boncagni, Massimo Carlini, Anna Maria Cattelan, Arturo Cavaliere, Marco Ceresoli, Alessandro Cipriano, Andrea Cortegiani, Francesco Cortese, Francesco Cristini, Eugenio Cucinotta, Lidia Dalfino, Gennaro De Pascale, Francesco Giuseppe De Rosa, Marco Falcone, Francesco Forfori, Paola Fugazzola, Milo Gatti, Ivan Gentile, Lorenzo Ghiadoni, Maddalena Giannella, Antonino Giarratano, Alessio Giordano, Massimo Girardis, Claudio Mastroianni, Gianpaola Monti, Giulia Montori, Miriam Palmieri, Marcello Pani, Ciro Paolillo, Dario Parini, Giustino Parruti, Daniela Pasero, Federico Pea, Maddalena Peghin, Nicola Petrosillo, Mauro Podda, Caterina Rizzo, Gian Maria Rossolini, Alessandro Russo, Loredana Scoccia, Gabriele Sganga, Liana Signorini, Stefania Stefani, Mario Tumbarello, Fabio Tumietto, Massimo Valentino, Mario Venditti, Bruno Viaggi, Fra..","doi":"10.1186/s13017-024-00551-w","DOIUrl":"https://doi.org/10.1186/s13017-024-00551-w","url":null,"abstract":"Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients’ safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts’ opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"314 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141292684","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-08DOI: 10.1186/s13017-024-00552-9
Massimo Sartelli, Philip Barie, Vanni Agnoletti, Majdi N. Al-Hasan, Luca Ansaloni, Walter Biffl, Luis Buonomo, Stijn Blot, William G. Cheadle, Raul Coimbra, Belinda De Simone, Therese M. Duane, Paola Fugazzola, Helen Giamarellou, Timothy C. Hardcastle, Andreas Hecker, Kenji Inaba, Andrew W. Kirkpatrick, Francesco M. Labricciosa, Marc Leone, Ignacio Martin-Loeches, Ronald V. Maier, Sanjay Marwah, Ryan C. Maves, Andrea Mingoli, Philippe Montravers, Carlos A. Ordóñez, Miriam Palmieri, Mauro Podda, Jordi Rello, Robert G. Sawyer, Gabriele Sganga, Pierre Tattevin, Dipendra Thapaliya, Jeffrey Tessier, Matti Tolonen, Jan Ulrych, Carlo Vallicelli, Richard R. Watkins, Fausto Catena, Federico Coccolini
Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient’s clinical condition, and the host’s immune status should be assessed continuously to optimize the management of patients with complicated IAIs.
{"title":"Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery","authors":"Massimo Sartelli, Philip Barie, Vanni Agnoletti, Majdi N. Al-Hasan, Luca Ansaloni, Walter Biffl, Luis Buonomo, Stijn Blot, William G. Cheadle, Raul Coimbra, Belinda De Simone, Therese M. Duane, Paola Fugazzola, Helen Giamarellou, Timothy C. Hardcastle, Andreas Hecker, Kenji Inaba, Andrew W. Kirkpatrick, Francesco M. Labricciosa, Marc Leone, Ignacio Martin-Loeches, Ronald V. Maier, Sanjay Marwah, Ryan C. Maves, Andrea Mingoli, Philippe Montravers, Carlos A. Ordóñez, Miriam Palmieri, Mauro Podda, Jordi Rello, Robert G. Sawyer, Gabriele Sganga, Pierre Tattevin, Dipendra Thapaliya, Jeffrey Tessier, Matti Tolonen, Jan Ulrych, Carlo Vallicelli, Richard R. Watkins, Fausto Catena, Federico Coccolini","doi":"10.1186/s13017-024-00552-9","DOIUrl":"https://doi.org/10.1186/s13017-024-00552-9","url":null,"abstract":"Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient’s clinical condition, and the host’s immune status should be assessed continuously to optimize the management of patients with complicated IAIs.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"80 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141292753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-05DOI: 10.1186/s13017-024-00550-x
A. L. Amati, R. Ebert, L. Maier, A. K. Panah, T. Schwandner, M. Sander, M. Reichert, V. Grau, S. Petzoldt, A. Hecker
The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis. Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis. Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy. A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.
{"title":"Reduced preoperative serum choline esterase levels and fecal peritoneal contamination as potential predictors for the leakage of intestinal sutures after source control in secondary peritonitis","authors":"A. L. Amati, R. Ebert, L. Maier, A. K. Panah, T. Schwandner, M. Sander, M. Reichert, V. Grau, S. Petzoldt, A. Hecker","doi":"10.1186/s13017-024-00550-x","DOIUrl":"https://doi.org/10.1186/s13017-024-00550-x","url":null,"abstract":"The high rate of stoma placement during emergency laparotomy for secondary peritonitis is a paradigm in need of change in the current fast-track surgical setting. Despite growing evidence for the feasibility of primary bowel reconstruction in a peritonitic environment, little data substantiate a surgeons’ choice between a stoma and an anastomosis. The aim of this retrospective analysis is to identify pre- and intraoperative parameters that predict the leakage risk for enteric sutures placed during source control surgery (SCS) for secondary peritonitis. Between January 2014 and December 2020, 497 patients underwent SCS for secondary peritonitis, of whom 187 received a primary reconstruction of the lower gastro-intestinal tract without a diverting stoma. In 47 (25.1%) patients postoperative leakage of the enteric sutures was directly confirmed during revision surgery or by computed tomography. Quantifiable predictors of intestinal suture outcome were detected by multivariate analysis. Length of intensive care, in-hospital mortality and failure of release to the initial home environment were significantly higher in patients with enteric suture leakage following SCS compared to patients with intact anastomoses (p < 0.0001, p = 0.0026 and p =0.0009, respectively). Reduced serum choline esterase (sCHE) levels and a high extent of peritonitis were identified as independent risk factors for insufficiency of enteric sutures placed during emergency laparotomy. A preoperative sCHE < 4.5 kU/L and generalized fecal peritonitis associate with a significantly higher incidence of enteric suture insufficiency after primary reconstruction of the lower gastro-intestinal tract in a peritonitic abdomen. These parameters may guide surgeons when choosing the optimal surgical procedure in the emergency setting.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"101 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-06-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141251719","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-06-04DOI: 10.1186/s13017-024-00542-x
Marco Milone, Pietro Anoldo, Nicola de’Angelis, Federico Coccolini, Jim Khan, Yoram Kluger, Massimo Sartelli, Luca Ansaloni, Luca Morelli, Nicola Zanini, Carlo Vallicelli, Gabriele Vigutto, Ernest E. Moore, Walter Biffl, Fausto Catena
Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.
{"title":"The role of RObotic surgery in EMergency setting (ROEM): protocol for a multicentre, observational, prospective international study on the use of robotic platform in emergency surgery","authors":"Marco Milone, Pietro Anoldo, Nicola de’Angelis, Federico Coccolini, Jim Khan, Yoram Kluger, Massimo Sartelli, Luca Ansaloni, Luca Morelli, Nicola Zanini, Carlo Vallicelli, Gabriele Vigutto, Ernest E. Moore, Walter Biffl, Fausto Catena","doi":"10.1186/s13017-024-00542-x","DOIUrl":"https://doi.org/10.1186/s13017-024-00542-x","url":null,"abstract":"Robotic surgery has gained widespread acceptance in elective interventions, yet its role in emergency procedures remains underexplored. While the 2021 WSES position paper discussed limited studies on the application of robotics in emergency general surgery, it recommended strict patient selection, adequate training, and improved platform accessibility. This prospective study aims to define the role of robotic surgery in emergency settings, evaluating intraoperative and postoperative outcomes and assessing its feasibility and safety. The ROEM study is an observational, prospective, multicentre, international analysis of clinically stable adult patients undergoing robotic surgery for emergency treatment of acute pathologies including diverticulitis, cholecystitis, and obstructed hernias. Data collection includes patient demographics and intervention details. Furthermore, data relating to the operating theatre team and the surgical instruments used will be collected in order to conduct a cost analysis. The study plans to enrol at least 500 patients from 50 participating centres, with each centre having a local lead and collaborators. All data will be collected and stored online through a secure server running the Research Electronic Data Capture (REDCap) web application. Ethical considerations and data governance will be paramount, requiring local ethical committee approvals from participating centres. Current literature and expert consensus suggest the feasibility of robotic surgery in emergencies with proper support. However, challenges include staff training, scheduling conflicts with elective surgeries, and increased costs. The ROEM study seeks to contribute valuable data on the safety, feasibility, and cost-effectiveness of robotic surgery in emergency settings, focusing on specific pathologies. Previous studies on cholecystitis, abdominal hernias, and diverticulitis provide insights into the benefits and challenges of robotic approaches. It is necessary to identify patient populations that benefit most from robotic emergency surgery to optimize outcomes and justify costs.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"307 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-06-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141246550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-31DOI: 10.1186/s13017-024-00537-8
Belinda De Simone, Elie Chouillard, Mauro Podda, Nikolaos Pararas, Gustavo de Carvalho Duarte, Paola Fugazzola, Arianna Birindelli, Federico Coccolini, Andrea Polistena, Maria Grazia Sibilla, Vitor Kruger, Gustavo P Fraga, Giulia Montori, Emanuele Russo, Tadeja Pintar, Luca Ansaloni, Nicola Avenia, Salomone Di Saverio, Ari Leppäniemi, Andrea Lauretta, Massimo Sartelli, Alessandro Puzziello, Paolo Carcoforo, Vanni Agnoletti, Luca Bissoni, Arda Isik, Yoram Kluger, Ernest E Moore, Oreste Marco Romeo, Fikri M Abu-Zidan, Solomon Gurmu Beka, Dieter G Weber, Edward C T H Tan, Ciro Paolillo, Yunfeng Cui, Fernando Kim, Edoardo Picetti, Isidoro Di Carlo, Adriana Toro, Gabriele Sganga, Federica Sganga, Mario Testini, Giovanna Di Meo, Andrew W Kirkpatrick, Ingo Marzi, Nicola déAngelis, Michael Denis Kelly, Imtiaz Wani, Boris Sakakushev, Miklosh Bala, Luigi Bonavina, Joseph M Galante, Vishal G Shelat, Lorenzo Cobianchi, Francesca Dal Mas, Manos Pikoulis, Dimitrios Damaskos, Raul Coimbra, Jugdeep Dhesi, Melissa Red Hoffman, Philip F Stahel, Ronald V Maier, Andrey Litvin, Rifat Latifi, Walter L Biffl, Fausto Catena
Background: The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.
Methods: Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.
Results: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.
Conclusions: The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
{"title":"The 2023 WSES guidelines on the management of trauma in elderly and frail patients.","authors":"Belinda De Simone, Elie Chouillard, Mauro Podda, Nikolaos Pararas, Gustavo de Carvalho Duarte, Paola Fugazzola, Arianna Birindelli, Federico Coccolini, Andrea Polistena, Maria Grazia Sibilla, Vitor Kruger, Gustavo P Fraga, Giulia Montori, Emanuele Russo, Tadeja Pintar, Luca Ansaloni, Nicola Avenia, Salomone Di Saverio, Ari Leppäniemi, Andrea Lauretta, Massimo Sartelli, Alessandro Puzziello, Paolo Carcoforo, Vanni Agnoletti, Luca Bissoni, Arda Isik, Yoram Kluger, Ernest E Moore, Oreste Marco Romeo, Fikri M Abu-Zidan, Solomon Gurmu Beka, Dieter G Weber, Edward C T H Tan, Ciro Paolillo, Yunfeng Cui, Fernando Kim, Edoardo Picetti, Isidoro Di Carlo, Adriana Toro, Gabriele Sganga, Federica Sganga, Mario Testini, Giovanna Di Meo, Andrew W Kirkpatrick, Ingo Marzi, Nicola déAngelis, Michael Denis Kelly, Imtiaz Wani, Boris Sakakushev, Miklosh Bala, Luigi Bonavina, Joseph M Galante, Vishal G Shelat, Lorenzo Cobianchi, Francesca Dal Mas, Manos Pikoulis, Dimitrios Damaskos, Raul Coimbra, Jugdeep Dhesi, Melissa Red Hoffman, Philip F Stahel, Ronald V Maier, Andrey Litvin, Rifat Latifi, Walter L Biffl, Fausto Catena","doi":"10.1186/s13017-024-00537-8","DOIUrl":"10.1186/s13017-024-00537-8","url":null,"abstract":"<p><strong>Background: </strong>The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.</p><p><strong>Methods: </strong>Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.</p><p><strong>Results: </strong>The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared.</p><p><strong>Conclusions: </strong>The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.</p>","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"19 1","pages":"18"},"PeriodicalIF":6.0,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11140935/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141181181","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.
{"title":"Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma and its performance in Japan over the past 18 years: a nationwide descriptive study","authors":"Hiromasa Hoshi, Akira Endo, Ryo Yamamoto, Kazuma Yamakawa, Keisuke Suzuki, Tomohiro Akutsu, Koji Morishita","doi":"10.1186/s13017-024-00548-5","DOIUrl":"https://doi.org/10.1186/s13017-024-00548-5","url":null,"abstract":"Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"22 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141182449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abdominal computed tomography (CT) scan is a crucial imaging modality for creating cross-sectional images of the abdominal area, particularly in cases of abdominal trauma, which is commonly encountered in traumatic injuries. However, interpreting CT images is a challenge, especially in emergency. Therefore, we developed a novel deep learning algorithm-based detection method for the initial screening of abdominal internal organ injuries. We utilized a dataset provided by the Kaggle competition, comprising 3,147 patients, of which 855 were diagnosed with abdominal trauma, accounting for 27.16% of the total patient population. Following image data pre-processing, we employed a 2D semantic segmentation model to segment the images and constructed a 2.5D classification model to assess the probability of injury for each organ. Subsequently, we evaluated the algorithm’s performance using 5k-fold cross-validation. With particularly noteworthy performance in detecting renal injury on abdominal CT scans, we achieved an acceptable accuracy of 0.932 (with a positive predictive value (PPV) of 0.888, negative predictive value (NPV) of 0.943, sensitivity of 0.887, and specificity of 0.944). Furthermore, the accuracy for liver injury detection was 0.873 (with PPV of 0.789, NPV of 0.895, sensitivity of 0.789, and specificity of 0.895), while for spleen injury, it was 0.771 (with PPV of 0.630, NPV of 0.814, sensitivity of 0.626, and specificity of 0.816). The deep learning model demonstrated the capability to identify multiple organ injuries simultaneously on CT scans and holds potential for application in preliminary screening and adjunctive diagnosis of trauma cases beyond abdominal injuries.
{"title":"The application of deep learning in abdominal trauma diagnosis by CT imaging","authors":"Xinru Shen, Yixin Zhou, Xueyu Shi, Shiyun Zhang, Shengwen Ding, Liangliang Ni, Xiaobing Dou, Lin Chen","doi":"10.1186/s13017-024-00546-7","DOIUrl":"https://doi.org/10.1186/s13017-024-00546-7","url":null,"abstract":"Abdominal computed tomography (CT) scan is a crucial imaging modality for creating cross-sectional images of the abdominal area, particularly in cases of abdominal trauma, which is commonly encountered in traumatic injuries. However, interpreting CT images is a challenge, especially in emergency. Therefore, we developed a novel deep learning algorithm-based detection method for the initial screening of abdominal internal organ injuries. We utilized a dataset provided by the Kaggle competition, comprising 3,147 patients, of which 855 were diagnosed with abdominal trauma, accounting for 27.16% of the total patient population. Following image data pre-processing, we employed a 2D semantic segmentation model to segment the images and constructed a 2.5D classification model to assess the probability of injury for each organ. Subsequently, we evaluated the algorithm’s performance using 5k-fold cross-validation. With particularly noteworthy performance in detecting renal injury on abdominal CT scans, we achieved an acceptable accuracy of 0.932 (with a positive predictive value (PPV) of 0.888, negative predictive value (NPV) of 0.943, sensitivity of 0.887, and specificity of 0.944). Furthermore, the accuracy for liver injury detection was 0.873 (with PPV of 0.789, NPV of 0.895, sensitivity of 0.789, and specificity of 0.895), while for spleen injury, it was 0.771 (with PPV of 0.630, NPV of 0.814, sensitivity of 0.626, and specificity of 0.816). The deep learning model demonstrated the capability to identify multiple organ injuries simultaneously on CT scans and holds potential for application in preliminary screening and adjunctive diagnosis of trauma cases beyond abdominal injuries.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"25 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-05-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140845387","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-27DOI: 10.1186/s13017-024-00544-9
Yuhan Qi, Jiarong Wang, Ding Yuan, Pengchao Duan, Li Hou, Tiehao Wang
For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21–0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20–0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75–1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%–27%). Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.
对于创伤性下肢动脉损伤，目前尚不清楚是进行血管内治疗（ET）更好，还是进行开放手术修复（OSR）更好。本研究旨在比较创伤性下肢动脉损伤的 ET 与 OSR 的临床疗效。研究人员在 Medline、Embase 和 Cochrane 数据库中检索了相关研究。报告 ET 或 OSR 结果的队列研究和病例系列研究符合纳入条件。采用Robins-I工具和18项工具评估偏倚风险。主要结果为截肢。次要结果包括筋膜切开术或筋膜室综合征、死亡率、住院时间和下肢神经损伤。我们使用随机效应模型计算汇总估计值。共有32项存在低度或中度偏倚风险的研究被纳入荟萃分析。结果显示，与接受OSR的患者相比，接受ET的患者发生大截肢（OR=0.42，95% CI 0.21-0.85；I2=34%）和筋膜切开术或室间综合征（OR=0.31，95% CI 0.20-0.50，I2=14%）的风险明显降低。两组患者的全因死亡率无明显差异（OR = 1.11，95% CI 0.75-1.64，I2 = 31%）。ET修复术患者的住院时间短于OSR修复术患者（MD=-5.06，95% CI -6.76至-3.36，I2=65%）。据报道，OSR患者术中神经损伤的发生率为15%（95% CI 6%-27%）。血管内治疗可能是外伤性下肢动脉损伤患者的更好选择，因为它可以降低截肢、筋膜切开或筋膜室综合征和神经损伤的风险，并缩短住院时间。
{"title":"Systematic review and meta-analysis of endovascular therapy versus open surgical repair for the traumatic lower extremity arterial injury","authors":"Yuhan Qi, Jiarong Wang, Ding Yuan, Pengchao Duan, Li Hou, Tiehao Wang","doi":"10.1186/s13017-024-00544-9","DOIUrl":"https://doi.org/10.1186/s13017-024-00544-9","url":null,"abstract":"For traumatic lower extremity artery injury, it is unclear whether it is better to perform endovascular therapy (ET) or open surgical repair (OSR). This study aimed to compare the clinical outcomes of ET versus OSR for traumatic lower extremity artery injury. The Medline, Embase, and Cochrane Databases were searched for studies. Cohort studies and case series reporting outcomes of ET or OSR were eligible for inclusion. Robins-I tool and an 18-item tool were used to assess the risk of bias. The primary outcome was amputation. The secondary outcomes included fasciotomy or compartment syndrome, mortality, length of stay and lower extremity nerve injury. We used the random effects model to calculate pooled estimates. A total of 32 studies with low or moderate risk of bias were included in the meta-analysis. The results showed that patients who underwent ET had a significantly decreased risk of major amputation (OR = 0.42, 95% CI 0.21–0.85; I2=34%) and fasciotomy or compartment syndrome (OR = 0.31, 95% CI 0.20–0.50, I2 = 14%) than patients who underwent OSR. No significant difference was observed between the two groups regarding all-cause mortality (OR = 1.11, 95% CI 0.75–1.64, I2 = 31%). Patients with ET repair had a shorter length of stay than patients with OSR repair (MD=-5.06, 95% CI -6.76 to -3.36, I2 = 65%). Intraoperative nerve injury was just reported in OSR patients with a pooled incidence of 15% (95% CI 6%–27%). Endovascular therapy may represent a better choice for patients with traumatic lower extremity arterial injury, because it can provide lower risks of amputation, fasciotomy or compartment syndrome, and nerve injury, as well as shorter length of stay.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"49 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140651541","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-04-25DOI: 10.1186/s13017-024-00545-8
Paula Ferrada, Alberto García, Juan Duchesne, Megan Brenner, Chang Liu, Carlos Ordóñez, Carlos Menegozzo, Juan Carlos Salamea, David Feliciano
Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.
{"title":"Comparing outcomes in patients with exsanguinating injuries: an Eastern Association for the Surgery of Trauma (EAST), multicenter, international trial evaluating prioritization of circulation over intubation (CAB over ABC)","authors":"Paula Ferrada, Alberto García, Juan Duchesne, Megan Brenner, Chang Liu, Carlos Ordóñez, Carlos Menegozzo, Juan Carlos Salamea, David Feliciano","doi":"10.1186/s13017-024-00545-8","DOIUrl":"https://doi.org/10.1186/s13017-024-00545-8","url":null,"abstract":"Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries. A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded. The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries. Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"223 1","pages":""},"PeriodicalIF":8.0,"publicationDate":"2024-04-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140642706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：