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Guided blood transfusion of trauma patients with rotational thromboelastometry: a single-center cohort study. 利用旋转血栓弹性测量法指导创伤患者输血:一项单中心队列研究。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-07-01 DOI: 10.1186/s13017-023-00508-5
Mina Salehi, Rajan Bola, Nenke de Jong, Andrew W Shih, Naisan Garraway, Philip Dawe

Background: Rotational thromboelastometry (ROTEM) is a blood test used to measure in vitro clot strength as a surrogate for a patient's ability to form clots in vivo. This provides information about induction, formation, and clot lysis, allowing goal-directed transfusion therapy for specific hemostatic needs. We sought to evaluate the effect of ROTEM-guided transfusion on blood product usage and in-hospital mortality among patients with a traumatic injury.

Methods: This was a single-center observational cohort analysis of emergency department patients in a Level 1 trauma center. We compared blood usage in trauma patients in whom ratio-based massive hemorrhage protocols were activated in the twelve months before the introduction of ROTEM (pre-ROTEM group) to the twelve months following the introduction of ROTEM (ROTEM-period group). ROTEM was implemented in this center in November 2016. The ROTEM device allowed clinicians to make real-time decisions about blood product therapy in resuscitation for trauma.

Results: The pre-ROTEM group contained 21 patients. Forty-three patients were included from the ROTEM-period, of whom 35 patients received ROTEM-guided resuscitation (81% compliance). The use of fibrinogen concentrate was significantly higher in the ROTEM-period group (pre-ROTEM mean 0.2 vs. ROTEM-period mean 0.8; p = 0.006). There was no significant difference in the number of units of red blood cells, platelets, cryoprecipitate, or fresh frozen plasma transfused between these groups. There was no significant difference in the mortality rate between the pre-ROTEM and ROTEM-period groups (33% vs. 19%; p = 0.22).

Conclusions: The introduction of ROTEM-guided transfusion at this institution was associated with increased fibrinogen usage, but this did not impact mortality rates. There was no difference in the administration of red blood cell, fresh frozen plasma, platelet, and cryoprecipitate. Future research should focus on increased ROTEM compliance and optimizing ROTEM-guided transfusion to prevent blood product overuse among trauma patients.

背景:旋转血栓弹性测定法(ROTEM)是一种血液检测方法,用于测量体外血栓强度,以替代患者体内形成血栓的能力。这提供了有关诱导、形成和凝块溶解的信息,可针对特定止血需求进行目标定向输血治疗。我们试图评估 ROTEM 引导输血对创伤患者血液制品使用和院内死亡率的影响:这是一项针对一级创伤中心急诊科患者的单中心观察性队列分析。我们比较了在引入 ROTEM 前 12 个月(ROTEM 前组)和引入 ROTEM 后 12 个月(ROTEM 期间组)启动基于比例的大出血方案的外伤患者用血情况。该中心于2016年11月实施了ROTEM。ROTEM设备允许临床医生在创伤复苏中实时决定血液制品治疗:ROTEM实施前组共有21名患者。结果:ROTEM前组包括21名患者,ROTEM期间包括43名患者,其中35名患者接受了ROTEM指导下的复苏(依从性为81%)。ROTEM时期组使用浓缩纤维蛋白原的比例明显更高(ROTEM前平均为0.2,ROTEM时期平均为0.8;P = 0.006)。两组间输注的红细胞、血小板、低温沉淀或新鲜冰冻血浆的单位数没有明显差异。ROTEM前组和ROTEM期间组的死亡率无明显差异(33% vs. 19%; p = 0.22):结论:该机构引入 ROTEM 引导输血与纤维蛋白原用量增加有关,但这并不影响死亡率。红细胞、新鲜冰冻血浆、血小板和低温沉淀物的使用量没有差异。未来的研究应侧重于提高 ROTEM 的依从性和优化 ROTEM 指导下的输血,以防止创伤患者过度使用血液制品。
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引用次数: 0
Advantages of using a polymeric clip versus an endoloop during laparoscopic appendectomy in uncomplicated appendicitis: a randomized controlled study. 在无并发症阑尾炎的腹腔镜阑尾切除术中使用聚合夹与内环的优势:一项随机对照研究。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-06-29 DOI: 10.1186/s13017-023-00507-6
Kil-Yong Lee, Jaeim Lee, Youn Young Park, Seong Taek Oh

Background: Polymeric clips are easy to apply, but whether they present more advantages than endoloops is unclear. This single-center, open-label, randomized controlled trial study was conducted to compare the advantages of using a polymeric clip versus an endoloop in terms of the surgical time.

Methods: Adult patients who were diagnosed with acute appendicitis without perforation on preoperative abdominal computed tomography and underwent laparoscopic appendectomy between August 6, 2019, and December 26, 2022, were included. Single-blinded randomization was performed in a 1:1 ratio between the endoloop and polymeric clip groups. The primary endpoint was the difference in surgery time between the polymeric clip and endoloop groups. The secondary endpoints were the difference in the application time of each instrument, difference in operation and anesthesia fees, as well as the frequency of complications.

Results: The completed trial included 104 and 103 patients in the polymeric clip and endoloop groups, respectively. The median surgery time with a polymeric clip was shorter than that with an endoloop; however, the difference was not significant (18 min 56 s vs 19 min 49 s, p = 0.426). Interestingly, the median time from applying the instrument to appendiceal cutting in the polymeric clip group was significantly shorter than that in the endoloop group (49.0 s vs 84.5 s, p < 0.001). No significant difference was observed between the two groups in terms of surgical (p = 0.120) and anesthetic (p = 0.719) costs, as well as the total number of postoperative complications (p > 0.999).

Conclusion: A polymeric clip is a safe instrument that can reduce the time from applying the instrument to appendiceal cutting, although it does not affect the overall surgical time and operation fee when performing laparoscopic appendectomy for uncomplicated appendicitis.

Trial registration: KCT0004154.

背景:聚合物夹子很容易应用,但它们是否比内环更有优势尚不清楚。这项单中心、开放标签、随机对照试验研究旨在比较使用聚合夹与内环在手术时间方面的优势。方法:纳入2019年8月6日至2022年12月26日期间,术前腹部计算机断层扫描诊断为急性阑尾炎且未穿孔并行腹腔镜阑尾切除术的成年患者。在endoloop组和聚合物夹组之间按1:1的比例进行单盲随机化。主要终点是聚合物夹组和endoloop组手术时间的差异。次要终点为各器械使用时间的差异、手术费用和麻醉费用的差异以及并发症的发生频率。结果:完成的试验包括104例和103例患者,分别为聚合物夹组和endoloop组。聚合物夹的中位手术时间比内环短;但差异无统计学意义(18分56秒vs 19分49秒,p = 0.426)。有趣的是,聚合物夹组从应用器械到阑尾切割的中位时间明显短于endoloop组(49.0 s vs 84.5 s, p 0.999)。结论:对于无并发症的阑尾炎进行腹腔镜阑尾切除术时,聚合物夹在不影响手术总时间和手术费用的情况下,是一种安全的器械,可减少从器械到阑尾切割的时间。试验注册号:KCT0004154。
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引用次数: 0
Assessing and managing frailty in emergency laparotomy: a WSES position paper. 评估和管理急诊开腹手术中的虚弱情况:WSES 立场文件。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-06-24 DOI: 10.1186/s13017-023-00506-7
Brian W C A Tian, Philip F Stahel, Edoardo Picetti, Giampiero Campanelli, Salomone Di Saverio, Ernest Moore, Denis Bensard, Boris Sakakushev, Joseph Galante, Gustavo P Fraga, Kaoru Koike, Isidoro Di Carlo, Giovanni D Tebala, Ari Leppaniemi, Edward Tan, Dimitris Damaskos, Nicola De'Angelis, Andreas Hecker, Michele Pisano, YunfengCui, Ron V Maier, Belinda De Simone, Francesco Amico, Marco Ceresoli, Manos Pikoulis, Dieter G Weber, Walt Biffl, Solomon Gurmu Beka, Fikri M Abu-Zidan, Massimo Valentino, Federico Coccolini, Yoram Kluger, Massimo Sartelli, Vanni Agnoletti, Mircea Chirica, Francesca Bravi, Ibrahima Sall, Fausto Catena

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

许多国家都面临着人口老龄化问题。随着人们寿命的延长,外科医生面临着为越来越多的老年患者进行手术的前景。传统观念认为,随着年龄的增长,这些病人面临的死亡和发病风险也会增加,甚至达到无法进行手术的程度。然而,事实并非总是如此。一个活跃的 90 岁患者可能比一个超重、久坐不动且患有合并症的 65 岁患者更健康。最近的文献显示,虚弱--与年龄相关的多个生理系统的累积衰退,因此比单纯的生理年龄更能预测死亡率和发病率。尽管人们认识到虚弱是识别易受伤害手术患者的重要工具,但许多外科医生仍然回避客观的工具。本立场文件旨在对现有文献进行回顾,并就急诊开腹手术和体弱患者的相关问题提出建议。由 37 位专家组成的国际专家组对本立场文件进行了审查,并要求他们对手稿和立场声明进行严格修订。立场文件是根据 WSES 方法编写的。我们将介绍已达成共识的衍生声明,具体说明支持证据的质量,并提出未来的研究方向。
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引用次数: 0
Improving clinical suspicion of acute mesenteric ischemia among patients with acute abdomen: a cross-sectional study from an intestinal stroke center. 提高急腹症患者急性肠系膜缺血的临床怀疑:来自肠卒中中心的横断面研究。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-06-07 DOI: 10.1186/s13017-023-00505-8
Alexandre Nuzzo, Katell Peoc'h, Prabakar Vaittinada Ayar, Alexy Tran-Dinh, Emmanuel Weiss, Yves Panis, Maxime Ronot, Lorenzo Garzelli, Philippine Eloy, Iannis Ben Abdallah, Yves Castier, Olivier Corcos

Background: Early diagnosis of acute mesenteric ischemia (AMI) is essential for a favorable outcome. Selection of patients requiring a dedicated multiphasic computed tomography (CT) scan remains a clinical challenge.

Methods: In this cross-sectional diagnostic study conducted from 2016 to 2018, we compared the presentation of AMI patients admitted to an intestinal stroke center to patients with acute abdominal pain of another origin admitted to the emergency room (controls).

Results: We included 137 patients-52 with AMI and 85 controls. Patients with AMI [median age: 65 years (interquartile range 55-74)] had arterial and venous AMI in 65% and 35% of cases, respectively. Relative to controls, AMI patients were significantly older, more likely to have risk factors or a history of cardiovascular disease, and more likely to present with sudden-onset and morphine-requiring abdominal pain, hematochezia, guarding, organ dysfunction, higher white blood cell and neutrophil counts, and higher plasma C-reactive protein (CRP) and procalcitonin concentrations. On multivariate analysis, two independent factors were associated with the diagnosis of AMI: the sudden-onset (OR = 20, 95%CI 7-60, p < 0.001) and the morphine-requiring nature of the acute abdominal pain (OR = 6, 95%CI 2-16, p = 0.002). Sudden-onset and/or morphine-requiring abdominal pain was present in 88% of AMI patients versus 28% in controls (p < 0.001). The area under the receiver operating characteristic curve for the diagnosis of AMI was 0.84 (95%CI 0.77-0.91), depending on the number of factors.

Conclusions: Sudden onset and the need for morphine are suggestive of AMI in patients with acute abdominal pain and should prompt multiphasic CT scan including arterial and venous phase images for confirmation.

背景:急性肠系膜缺血(AMI)的早期诊断对于预后良好至关重要。选择需要专用多相计算机断层扫描(CT)扫描的患者仍然是一个临床挑战。方法:在2016年至2018年进行的横断面诊断研究中,我们比较了在肠卒中中心住院的AMI患者和在急诊室住院的其他原因的急性腹痛患者(对照组)的表现。结果:我们纳入了137例患者,其中52例为AMI, 85例为对照组。AMI患者[中位年龄:65岁(四分位数范围55-74岁)]分别有65%和35%的病例为动脉和静脉AMI。与对照组相比,AMI患者明显年龄更大,更有可能有危险因素或心血管疾病史,更有可能出现突发性和需要吗啡的腹痛、便血、保护、器官功能障碍、白细胞和中性粒细胞计数较高、血浆c反应蛋白(CRP)和降钙素原浓度较高。在多因素分析中,两个独立因素与AMI的诊断相关:突发性(OR = 20, 95%CI 7-60, p)。结论:急性腹痛患者突发性和吗啡需求提示AMI,应提示多期CT扫描包括动脉和静脉相图像进行确认。
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引用次数: 0
Accuracy of diagnostic tests in cardiac injury after blunt chest trauma: a systematic review and meta-analysis. 钝性胸外伤后心脏损伤诊断试验的准确性:系统回顾和荟萃分析
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-05-27 DOI: 10.1186/s13017-023-00504-9
Ioannis Panagiotis Kyriazidis, Dominik A Jakob, Juliana Alexandra Hernández Vargas, Oscar H Franco, Elias Degiannis, Patrick Dorn, Sjaak Pouwels, Bijendra Patel, Ian Johnson, Christopher John Houdlen, Graham S Whiteley, Marion Head, Anil Lala, Haroon Mumtaz, J Agustin Soler, Katie Mellor, David Rawaf, Ahmed R Ahmed, Suhaib J S Ahmad, Aristomenis Exadaktylos

Introduction: The diagnosis of cardiac contusion, caused by blunt chest trauma, remains a challenge due to the non-specific symptoms it causes and the lack of ideal tests to diagnose myocardial damage. A cardiac contusion can be life-threatening if not diagnosed and treated promptly. Several diagnostic tests have been used to evaluate the risk of cardiac complications, but the challenge of identifying patients with contusions nevertheless remains.

Aim of the study: To evaluate the accuracy of diagnostic tests for detecting blunt cardiac injury (BCI) and its complications, in patients with severe chest injuries, who are assessed in an emergency department or by any front-line emergency physician.

Methods: A targeted search strategy was performed using Ovid MEDLINE and Embase databases from 1993 up to October 2022. Data on at least one of the following diagnostic tests: electrocardiogram (ECG), serum creatinine phosphokinase-MB level (CPK-MB), echocardiography (Echo), Cardiac troponin I (cTnI) or Cardiac troponin T (cTnT). Diagnostic tests for cardiac contusion were evaluated for their accuracy in meta-analysis. Heterogeneity was assessed using the I2 and the QUADAS-2 tool was used to assess bias of the studies.

Results: This systematic review yielded 51 studies (n = 5,359). The weighted mean incidence of myocardial injuries after sustaining a blunt force trauma stood at 18.3% of cases. Overall weighted mean mortality among patients with blunt cardiac injury was 7.6% (1.4-36.4%). Initial ECG, cTnI, cTnT and transthoracic echocardiography TTE all showed high specificity (> 80%), but lower sensitivity (< 70%). TEE had a specificity of 72.1% (range 35.8-98.2%) and sensitivity of 86.7% (range 40-99.2%) in diagnosing cardiac contusion. CK-MB had the lowest diagnostic odds ratio of 3.598 (95% CI: 1.832-7.068). Normal ECG accompanied by normal cTnI showed a high sensitivity of 85% in ruling out cardiac injuries.

Conclusion: Emergency physicians face great challenges in diagnosing cardiac injuries in patients following blunt trauma. In the majority of cases, joint use of ECG and cTnI was a pragmatic and cost-effective approach to rule out cardiac injuries. In addition, TEE may be highly accurate in identifying cardiac injuries in suspected cases.

钝性胸部外伤引起的心挫伤的诊断仍然是一个挑战,因为它引起的非特异性症状和缺乏理想的检测来诊断心肌损伤。如果不及时诊断和治疗,心脏挫伤可能危及生命。一些诊断测试已被用于评估心脏并发症的风险,但识别挫伤患者的挑战仍然存在。研究目的:评估在急诊科或任何一线急诊医生评估的严重胸部损伤患者中,检测钝性心脏损伤(BCI)及其并发症的诊断试验的准确性。方法:采用Ovid MEDLINE和Embase数据库,从1993年至2022年10月进行针对性检索。至少一项以下诊断检查的数据:心电图(ECG)、血清肌酸酐磷酸激酶- mb水平(CPK-MB)、超声心动图(Echo)、心肌肌钙蛋白I (cTnI)或心肌肌钙蛋白T (cTnT)。在荟萃分析中评估心挫伤诊断试验的准确性。使用I2评估异质性,并使用QUADAS-2工具评估研究的偏倚。结果:本系统综述共纳入51项研究(n = 5359)。钝器外伤后心肌损伤的加权平均发生率为18.3%。钝性心脏损伤患者的总体加权平均死亡率为7.6%(1.4-36.4%)。初步心电图、cTnI、cTnT和经胸超声心动图TTE均显示高特异性(> 80%),但敏感性较低(结论:急诊医师对钝性创伤后心脏损伤的诊断面临很大挑战)。在大多数情况下,联合使用ECG和cTnI是一种实用且经济有效的方法来排除心脏损伤。此外,TEE在识别疑似病例的心脏损伤方面可能非常准确。
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引用次数: 1
Complex duodenal fistulae: a surgical nightmare. 复杂十二指肠瘘管:手术噩梦。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-05-19 DOI: 10.1186/s13017-023-00503-w
Ari Leppäniemi, Matti Tolonen, Panu Mentula

Introduction: A common feature of external duodenal fistulae is the devastating effect of the duodenal content rich in bile and pancreatic juice on nearby tissues with therapy-resistant local and systemic complications. This study analyzes the results of different management options with emphasis on successful fistula closure rates.

Methods: A retrospective single academic center study of adult patients treated for complex duodenal fistulas over a 17-year period with descriptive and univariate analyses was performed.

Results: Fifty patients were identified. First line treatment was surgical in 38 (76%) cases and consisted of resuture or resection with anastomosis combined with duodenal decompression and periduodenal drainage in 36 cases, rectus muscle patch, and surgical decompression with T-tube in one each. Fistula closure rate was 29/38 (76%). In 12 cases, the initial management was nonoperative with or without percutaneous drainage. The fistula was closed without surgery in 5/6 patients (1 patient died with persistent fistula). Among the remaining 6 patients eventually operated, fistula closure was achieved in 4 cases. There was no difference in successful fistula closure rates among initially operatively versus nonoperatively managed patients (29/38 vs. 9/12, p = 1.000). However, when considering eventually failed nonoperative management in 7/12 patients, there was a significant difference in the fistula closure rate (29/38 vs. 5/12, p = 0.036). The overall in-hospital mortality rate was 20/50 (40%).

Conclusions: Surgical closure combined with duodenal decompression in complex duodenal leaks offers the best chance of successful outcome. In selected cases, nonoperative management can be tried, accepting that some patients may require surgery later.

导言:十二指肠外瘘的一个共同特征是富含胆汁和胰液的十二指肠内容物对附近组织的破坏性影响,并伴有治疗抵抗性的局部和全身并发症。本研究分析了不同治疗方案的结果,重点是成功的瘘管闭合率。方法:对17年来治疗复杂十二指肠瘘的成人患者进行回顾性研究,并进行描述性和单变量分析。结果:共发现50例患者。一线治疗38例(76%)为手术治疗,36例为再缝合或吻合切除联合十二指肠减压和十二指肠周围引流,1例为直肌贴片,1例为t管手术减压。瘘管闭合率为29/38(76%)。在12例中,最初的治疗方法是非手术,有或没有经皮引流。6例患者中有5例未手术关闭瘘管(1例因瘘管持续存在而死亡)。其余6例患者最终手术,其中4例瘘口闭合。初始手术与非手术治疗患者的瘘管闭合成功率无差异(29/38 vs. 9/12, p = 1.000)。然而,当考虑到7/12患者最终失败的非手术治疗时,瘘管关闭率有显著差异(29/38 vs. 5/12, p = 0.036)。住院总死亡率为20/50(40%)。结论:手术封闭联合十二指肠减压治疗复杂的十二指肠渗漏是获得成功的最佳机会。在选定的病例中,可以尝试非手术治疗,接受一些患者可能需要手术治疗。
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引用次数: 0
WSES consensus guidelines on sigmoid volvulus management. 乙状结肠扭转治疗的WSES共识指南。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-05-15 DOI: 10.1186/s13017-023-00502-x
Brian W C A Tian, Gabriele Vigutto, Edward Tan, Harry van Goor, Cino Bendinelli, Fikri Abu-Zidan, Rao Ivatury, Boris Sakakushev, Isidoro Di Carlo, Gabriele Sganga, Ronald V Maier, Raul Coimbra, Ari Leppäniemi, Andrey Litvin, Dimitrios Damaskos, Richard Ten Broek, Walter Biffl, Salomone Di Saverio, Belinda De Simone, Marco Ceresoli, Edoardo Picetti, Joseph Galante, Giovanni D Tebala, Solomon Gurmu Beka, Luigi Bonavina, Yunfeng Cui, Jim Khan, Enrico Cicuttin, Francesco Amico, Inaba Kenji, Andreas Hecker, Luca Ansaloni, Massimo Sartelli, Ernest E Moore, Yoram Kluger, Mario Testini, Dieter Weber, Vanni Agnoletti, Nicola De' Angelis, Federico Coccolini, Ibrahima Sall, Fausto Catena

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

乙状结肠扭转是一种常见的外科急症,尤其是在老年患者中。患者可以表现出广泛的临床状态:从无症状到继发于结肠穿孔的明显腹膜炎。这些患者通常需要紧急治疗,无论是内镜下结肠减压还是预先结肠切除术。世界急诊外科学会联合了一个世界范围内的国际专家小组,审查了目前的证据,并就乙状结肠扭转的治疗提出了共识指南。
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引用次数: 7
The unrestricted global effort to complete the COOL trial. 完成COOL试验的无限制全球努力。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-05-11 DOI: 10.1186/s13017-023-00500-z
Andrew W Kirkpatrick, Federico Coccolini, Matti Tolonen, Samuel Minor, Fausto Catena, Emanuel Gois, Christopher J Doig, Michael D Hill, Luca Ansaloni, Massimo Chiarugi, Dario Tartaglia, Orestis Ioannidis, Michael Sugrue, Elif Colak, S Morad Hameed, Hanna Lampela, Vanni Agnoletti, Jessica L McKee, Naisan Garraway, Massimo Sartelli, Chad G Ball, Neil G Parry, Kelly Voght, Lisa Julien, Jenna Kroeker, Derek J Roberts, Peter Faris, Corina Tiruta, Ernest E Moore, Lee Anne Ammons, Elissavet Anestiadou, Cino Bendinelli, Konstantinos Bouliaris, Rosemarry Carroll, Marco Ceresoli, Francesco Favi, Angela Gurrado, Joao Rezende-Neto, Arda Isik, Camilla Cremonini, Silivia Strambi, Georgios Koukoulis, Mario Testini, Sandy Trpcic, Alessandro Pasculli, Erika Picariello, Fikri Abu-Zidan, Ademola Adeyeye, Goran Augustin, Felipe Alconchel, Yuksel Altinel, Luz Adriana Hernandez Amin, José Manuel Aranda-Narváez, Oussama Baraket, Walter L Biffl, Gian Luca Baiocchi, Luigi Bonavina, Giuseppe Brisinda, Luca Cardinali, Andrea Celotti, Mohamed Chaouch, Maria Chiarello, Gianluca Costa, Nicola de'Angelis, Nicolo De Manzini, Samir Delibegovic, Salomone Di Saverio, Belinda De Simone, Vincent Dubuisson, Pietro Fransvea, Gianluca Garulli, Alessio Giordano, Carlos Gomes, Firdaus Hayati, Jinjian Huang, Aini Fahriza Ibrahim, Tan Jih Huei, Ruhi Fadzlyana Jailani, Mansoor Khan, Alfonso Palmieri Luna, Manu L N G Malbrain, Sanjay Marwah, Paul McBeth, Andrei Mihailescu, Alessia Morello, Francesk Mulita, Valentina Murzi, Ahmad Tarmizi Mohammad, Simran Parmar, Ajay Pak, Michael Pak-Kai Wong, Desire Pantalone, Mauro Podda, Caterina Puccioni, Kemal Rasa, Jianan Ren, Francesco Roscio, Antonio Gonzalez-Sanchez, Gabriele Sganga, Maximilian Scheiterle, Mihail Slavchev, Dmitry Smirnov, Lorenzo Tosi, Anand Trivedi, Jaime Andres Gonzalez Vega, Maciej Waledziak, Sofia Xenaki, Desmond Winter, Xiuwen Wu, Andee Dzulkarnean Zakaria, Zaidi Zakaria
<p><strong>Background: </strong>Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.</p><p><strong>Methods: </strong>The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer.</p><p><strong>Discussion: </strong>OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention.</p><p><strong>Trial registrat
背景:严重并发症腹腔内脓毒症(SCIAS)的发病率不断上升,在某些情况下死亡率超过80%。死亡通常由胃肠道破坏、进行性和自我延续的生物介质产生、全身性炎症和多器官衰竭引起。另一种治疗选择可能是采用腹腔负压疗法(NPPT)进行开腹(OA)治疗,以消除炎症性腹水并减轻SCIAS的全身损伤,尽管在可能关闭的情况下保持腹部开放存在一定的风险。这种潜在的治疗模式是在剖腹手术后闭合或打开(COOL试验)中评估的基本原理(https://clinicaltrials.gov/ct2/show/NCT03163095)。最初,COOL试验获得了行业赞助;然而,这笔资金要求在分配到干预(开放)组的一半患者中使用特定的商标和昂贵的NPPT设备。2022年8月,3m /Acelity公司未经协商,但在合同条款内取消了对试验的财政支持。虽然造成了财政困难,但现在对特定的NPPT设备没有限制,并且取消了成本高昂的干预措施,这为将COOL试验扩大到真正的全球基础创造了机会。本文件描述了COOL试验的发展,重点是该研究在全球发展的未来机会。方法:COOL试验是最大的前瞻性随机对照试验,检查术中随机分配SCIAS患者进行正式关闭筋膜或使用OA并应用NPPT敷料。如果患者有游离的不受控制的腹腔污染和生理紊乱,例如感染性休克或严重不良的预测临床结果,则符合条件。主要结果旨在通过最终评估90天生存率来明确告知全球实践。最初的招募人数低于预期,但令人满意,COOL指导委员会和试验研究人员打算在全球范围内获得更多支持,继续招募,直到招募确保了明确的答案。讨论:OA在许多SCIAS病例中是强制性的,例如与闭合相关的腹部隔室综合征的风险,或计划的第二次检查,例如“损害控制”的一部分;然而,改进的源代码控制(局部的和系统的)是OA最不确定的指示。COOL试验旨在扩大潜在的部位,并继续评估与设备无关的NPPT,以适当地检验这种治疗减轻全身损伤和提高生存率的假设。这种方法不会影响内部效度,并应提高干预的任何观察结果的外部效度。试验注册:美国国立卫生研究院(https://clinicaltrials.gov/ct2/show/NCT03163095)。
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Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) ( https://clinicaltrials.gov/ct2/show/NCT03163095 ). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. 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引用次数: 2
Trauma deaths of hospitalized patients in Abu Dhabi Emirate: a retrospective descriptive study. 阿布扎比酋长国住院病人创伤死亡:一项回顾性描述性研究。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-04-28 DOI: 10.1186/s13017-023-00501-y
David O Alao, Arif Alper Cevik, Fikri M Abu-Zidan

Aim: To study the epidemiology and pattern of trauma-related deaths of hospitalized patients in Abu Dhabi Emirate, United Arab Emirates, in order to improve trauma management and injury prevention.

Methods: The Abu Dhabi Trauma Registry prospectively collects data of all hospitalized trauma patients from seven major trauma centres in Abu Dhabi Emirate. We studied all patients who died on arrival or after admission to these hospitals from January 2014 to December 2019.

Results: There were 453 deaths constituting 13.5% of all trauma deaths in the Abu Dhabi Emirate. The median (IQR) age of the patients was 33 (25-45) years, and 82% were males. 85% of the deaths occurred in the emergency department (ED) and the intensive care unit (ICU). Motor vehicle collision (63.8%) was the leading cause of death. 45.5% of the patients had head injury. Two of the seven hospitals admitted around 50% of all patients but accounted for only 25.8% of the total deaths (p < 0.001). Those who died in the ward (7%) were significantly older, median (IQR) age: of 65.5 (31.75-82.25) years, (p < 0.001), 34.4% of them were females (p = 0.09). The median (IQR) GCS of those who died in the ward was 15 (5.75-15) compared with 3 (3-3) for those who died in ED and ICU (P < 0.001).

Conclusions: Death from trauma predominantly affects young males with motor traffic collision as the leading cause. Over 85% of in-hospital deaths occur in the ICU and ED, mainly from head injuries. Injury prevention of traffic collisions through enforcement of law and improved hospital care in the ED and ICU will reduce trauma death.

目的:了解阿拉伯联合酋长国阿布扎比酋长国住院患者创伤相关死亡的流行病学和模式,以提高创伤管理和损伤预防水平。方法:阿布扎比创伤登记处前瞻性地收集了阿布扎比酋长国七个主要创伤中心的所有住院创伤患者的数据。我们研究了2014年1月至2019年12月期间抵达这些医院时或入院后死亡的所有患者。结果:阿布扎比酋长国有453例死亡,占所有创伤死亡的13.5%。患者的中位(IQR)年龄为33岁(25-45岁),82%为男性。85%的死亡发生在急诊科(ED)和重症监护病房(ICU)。机动车碰撞(63.8%)是主要死亡原因。45.5%的患者有头部损伤。7家医院中的2家接收了约50%的患者,但仅占总死亡人数的25.8% (p结论:创伤死亡主要发生在年轻男性中,机动车交通碰撞是主要原因。超过85%的院内死亡发生在ICU和ED,主要是头部受伤。通过执法和改善急诊科和ICU的医院护理来预防交通碰撞伤害,将减少创伤性死亡。
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引用次数: 0
The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study. 急诊外科手术新时机(新TACS)分类:一项WSES Delphi共识研究。
IF 8 1区 医学 Q1 EMERGENCY MEDICINE Pub Date : 2023-04-28 DOI: 10.1186/s13017-023-00499-3
Belinda De Simone, Yoram Kluger, Ernest E Moore, Massimo Sartelli, Fikri M Abu-Zidan, Federico Coccolini, Luca Ansaloni, Giovanni D Tebala, Salomone Di Saverio, Isidoro Di Carlo, Boris E Sakakushev, Luigi Bonavina, Michael Sugrue, Joseph M Galante, Rao Ivatury, Edoardo Picetti, Mircea Chirica, Imtiaz Wani, Miklosh Bala, Ibrahima Sall, Andrew W Kirkpatrick, Vishal G Shelat, Emmanouil Pikoulis, Ari Leppäniemi, Edward Tan, Richard P G Ten Broek, Solomon Gurmu Beka, Andrey Litvin, Elie Chouillard, Raul Coimbra, Yunfeng Cui, Nicola De' Angelis, Gabriele Sganga, Philip F Stahel, Vanni Agnoletti, Alessia Rampini, Mario Testini, Francesca Bravi, Ronald V Maier, Walter L Biffl, Fausto Catena

Background: Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The "timing in acute care surgery" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts.

Methods: This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease.

Results: Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority.

Conclusion: The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a "safe" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

背景:在全球范围内,急诊普通外科(EGS)指征的及时进入手术室仍然是一个挑战,主要受手术室可用性和人员配备限制的驱动。“急性护理手术时机”(TACS)分类此前已发布,旨在引入一种新工具,对EGS患者及时、适当地进入手术室进行分类。然而,TACS分类的临床和操作有效性尚未在随后的验证研究中进行调查。本研究旨在通过与国际专家的标准化德尔菲法,改进TACS分类,并就新TACS分类的适当使用提供进一步的共识。方法:这是一项新的TACS的验证研究,由选定的国际专家小组使用德尔菲法。TACS问卷设计为基于网络的调查。一致同意水平为≥75%。集体共识协议被定义为所有参与者中李克特量表最高水平(4-5)的百分比之和。外科急诊疾病和相关的临床情况被定义为每一个建议的类别。随后进行了几轮谈判,直到达成了明确的协商一致意见。计算频率和百分比以确定每种外科疾病的一致程度。结果:进行了四轮投票。新的TACS分类提供了6种颜色编码,与手术的精确时间、定义的场景和手术条件相关。白色代码班被引入到快速(在一周内)重新安排取消或推迟的外科手术。血流动力学稳定性是判定患者是否存在败血症/感染性休克时立即手术的主要工具。51种外科疾病被列入不同颜色编码的优先类别。结论:新的TACS分类是一种全面、简单、清晰、可重复的分诊系统,可用于评估患者和外科疾病的严重程度,减少进入手术室的时间,在“安全”的时间内管理急诊外科患者。通过德尔福共识(Delphi consensus)验证,以不同颜色编码的优先级包括定义明确的外科疾病,新的TACS改善了外科医生之间、外科医生和麻醉师之间的沟通,减少了急诊外科患者进入手术室的冲突、浪费和等待时间。
{"title":"The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study.","authors":"Belinda De Simone,&nbsp;Yoram Kluger,&nbsp;Ernest E Moore,&nbsp;Massimo Sartelli,&nbsp;Fikri M Abu-Zidan,&nbsp;Federico Coccolini,&nbsp;Luca Ansaloni,&nbsp;Giovanni D Tebala,&nbsp;Salomone Di Saverio,&nbsp;Isidoro Di Carlo,&nbsp;Boris E Sakakushev,&nbsp;Luigi Bonavina,&nbsp;Michael Sugrue,&nbsp;Joseph M Galante,&nbsp;Rao Ivatury,&nbsp;Edoardo Picetti,&nbsp;Mircea Chirica,&nbsp;Imtiaz Wani,&nbsp;Miklosh Bala,&nbsp;Ibrahima Sall,&nbsp;Andrew W Kirkpatrick,&nbsp;Vishal G Shelat,&nbsp;Emmanouil Pikoulis,&nbsp;Ari Leppäniemi,&nbsp;Edward Tan,&nbsp;Richard P G Ten Broek,&nbsp;Solomon Gurmu Beka,&nbsp;Andrey Litvin,&nbsp;Elie Chouillard,&nbsp;Raul Coimbra,&nbsp;Yunfeng Cui,&nbsp;Nicola De' Angelis,&nbsp;Gabriele Sganga,&nbsp;Philip F Stahel,&nbsp;Vanni Agnoletti,&nbsp;Alessia Rampini,&nbsp;Mario Testini,&nbsp;Francesca Bravi,&nbsp;Ronald V Maier,&nbsp;Walter L Biffl,&nbsp;Fausto Catena","doi":"10.1186/s13017-023-00499-3","DOIUrl":"https://doi.org/10.1186/s13017-023-00499-3","url":null,"abstract":"<p><strong>Background: </strong>Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The \"timing in acute care surgery\" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts.</p><p><strong>Methods: </strong>This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease.</p><p><strong>Results: </strong>Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority.</p><p><strong>Conclusion: </strong>The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a \"safe\" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.</p>","PeriodicalId":48867,"journal":{"name":"World Journal of Emergency Surgery","volume":"18 1","pages":"32"},"PeriodicalIF":8.0,"publicationDate":"2023-04-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10147354/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9418885","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}
引用次数: 1
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World Journal of Emergency Surgery
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