Operating Room Use of Hypertonic Solutions: A Clinical Review

Hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. Recently, there has been a growing interest in intra-operative use of hypertonic solutions. We reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. Well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies

Recombinant factor VIIA is associated with an improved 24‐hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients

Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients

OBJECTIVE: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications. INTRODUCTION: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use. METHODS: Consecutive massively transfused (>; 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival. RESULTS: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events. CONCLUSIONS: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients

COAGULOPATIA NO TRAUMA

Trauma is one of the most important causes of deaths worldwide. Massive bleeding is the leading cause of trauma deaths in the first 24 hours following an injury. Major trauma patients frequently develop coagulopathy, which is related to huge bleedings, fluid therapy with crystalloids and red blood cells, acidosis and hypothermia. The control of this situation is a challenge to surgeons and intensivists. In addition, trauma victims are one of the most important consumers of blood components. Recently, the adequacy of this massive transfusion has been put into question, particularly due to the lack of well-developed and clinically-proved guidelines. The objective of this article is to provide an overview of the pathophysiology of the trauma coagulopathy, discussing current strategies available for its management and new developments in the field.Trauma é uma das principais causas de mortalidade no mundo. A principal causa de óbitos das vítimas de trauma, nas primeiras 24 horas após a lesão, é o sangramento maciço. Os pacientes politraumatizados podem desenvolver graves distúrbios de coagulação relacionados à perda de grandes volumes de sangue e fatores de coagulação, à reposição volêmica com cristalóides e com concentrados de hemácias, à acidose e à hipotermia. O controle deste tipo de situação tem sido um grande desafio para cirurgiões e intensivistas. Além disto, as vítimas de trauma formam um dos maiores grupos de consumidores de sangue e seus derivados. Recentemente, a adequação destes grandes volumes de transfusão tem sido questionada, principalmente em decorrência da ausência de protocolos bem definidos e testados clinicamente. O objetivo deste artigo foi rever a literatura atual conceituando coagulopatia do trauma e descrevendo as mais recentes orientações para a hemoterapia direcionada às vitimas de trauma

Evidence-based telemedicine: trauma & acute care surgery (EBT-TACS)

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Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers

Fresh frozen plasma (FFP) is indicated for the management of massive bleedings. Recent audits suggest physician knowledge of FFP is inadequate and half of the FFP transfused in critical care is inappropriate. Trauma is among the largest consumers of FFP. Current trauma resuscitation guidelines recommend FFP to correct coagulopathy only after diagnosed by laboratory tests, often when overt dilutional coagulopathy already exists. The evidence supporting these guidelines is limited and bleeding remains a major cause of trauma-related death. Recent studies demonstrated that coagulopathy occurs early in trauma. A novel early formula-driven haemostatic resuscitation proposes addressing coagulopathy early in massive bleedings with FFP at a near 1:1 ratio with red blood cells. Recent retrospective reports suggest such strategy significantly reduces mortality, and its use is gradually expanding to nontraumatic bleedings in critical care. The supporting studies, however, have bias limiting the interpretation of the results. Furthermore, logistical considerations including need for immediately available universal donor AB plasma, short life after thawing, potential waste and transfusion-associated complications have challenged its implementation. The present review focuses on FFP transfusion in massive bleeding and critically appraises the evidence on formula-driven resuscitation, providing resources to allow clinicians to develop informed opinion, given the current deficient and conflicting evidence

Selective nonoperative management of high grade splenic trauma

The Evidence-based Telemedicine - Trauma & Acute Care Surgery (EBT-TACS) Journal Club performed a critical review of the literature and selected three up-to-date articles on the management of splenic trauma. Our focus was on high-grade splenic injuries, defined as AAST injury grade III-V. The first paper was an update of the 2003 Eastern Association for the Surgery of Trauma (EAST) practice management guidelines for nonoperative management of injury to the spleen. The second paper was an American Association for the Surgery of Trauma (AAST) 2012 plenary paper evaluating the predictive role of contrast blush on CT scan in AAST grade IV and V splenic injuries. Our last article was from Europe and investigates the effects of angioembolization of splenic artery on splenic function after high-grade splenic trauma (AAST grade III-V). The EBT-TACS Journal Club elaborated conclusions and recommendations for the management of high-grade splenic trauma.A reunião de revista Telemedicina baseada em evidências - Cirurgia do Trauma e Emergência (TBE-CiTE) realizou uma revisão crítica da literatura e selecionou três artigos atuais sobre o tratamento do trauma de baço. O foco foi em lesão de baço grave, definida pela American Association for the Surgery of Trauma (AAST) como graus III a V. O primeiro artigo foi uma atualização do protocolo de 2003 da Eastern Association for the Surgery of Trauma (EAST) para o tratamento não operatório de trauma do baço. O segundo artigo foi apresentado na plenária de 2012 da AAST avaliando o papel do extravasamento de contraste na tomografia computadorizada em pacientes com lesão grave de baço (AAST IV-V). O último artigo é europeu e investigou o efeito da angioembolização da artéria esplênica na função do baço após lesão esplênica grave (AAST III-V). A reunião de revista TBE-CiTE elaborou conclusões e recomendações para o tratamento de lesão grave do baço.24625

Management of retained hemothoraces after chest tube thoracostomy for trauma

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Sequential closure of the abdominal wall with continuous fascia traction (using mesh or suture) and negative pressure therapy

The last decade was marked by a multiplication in the number of publications on (and usage of) the concept of damage control laparotomy, resulting in a growing number of patients left with an open abdomen (or peritoneostomy). Gigantic hernias are among the dreaded consequences of damage control and the impossibility of closing the abdomen during the initial hospital admission. To minimize this sequela, the literature has proposed many different strategies. In order to explore this topic, the Evidence-based Telemedicine - Trauma & Acute Care Surgery (EBT -TACS) conducted a literature review and critically appraised the most relevant articles on the topic. No commercially available systems for the closure of peritoneostomies were analyzed, except for negative pressure therapy. Three relevant and recently published studies on the sequential closure of the abdominal wall (with mesh or sutures) plus negative pressure therapy were appraised. For this appraisal 2 retrospective and one prospective study were included. The EBT-TACS meeting was attended by representatives of 6 Universities and following recommendations were generated: (1) the association of negative pressure therapy and continuous fascia traction with mesh or suture and adjusted periodically appears to be a viable surgical strategy to treat peritoneostomies. (2) the primary dynamic abdominal closure with sutures or mesh appears to be more efficient and economically sound than leaving the patient with a gigantic hernia to undergo complex repair at a later date. New studies including larger number of patients classified according to their different presentations and diseases are needed to better define the best surgical treatment for patients with peritoneostomies.Na última década multiplicaram-se as publicações e a utilização da cirurgia de controle de danos, resultando num número crescente de pacientes deixados com o abdome aberto (ou peritoneostomia). Uma das consequências nefastas do abdome aberto são as hérnias ventrais gigantes que resultam da impossibilidade de se fechar o abdome durante a internação hospitalar do paciente. Para minimizar esta sequela têm surgido na literatura diferentes tipos de abordagem. Para abordar este tópico, a reunião de revista Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência (TBE-CiTE) optou por não analisar sistemas comerciais de fechamento abdominal dinâmico, com exceção da terapia de pressão negativa ou vácuo. O grupo fez uma avaliação crítica dirigida de três artigos mais relevantes publicados recentemente sobre fechamento sequencial da parede abdominal (com tela ou sutura) mais vácuo. Nesta avaliação foram incluídos dois estudos retrospectivos mais um estudo prospectivo. Baseados na análise crítica desses 3 estudos mais a discussão que contou com a participação de representantes de 6 Universidades e realizada via telemedicina, são feitas as seguintes recomendações: (1) a associação de terapia de pressão negativa com tração fascial constante mediada por tela ou sutura, ajustada periodicamente, parece ser uma ótima estratégia cirúrgica para o tratamento de peritoneostomias. (2) O fechamento abdominal primário dinâmico com sutura e mediada por tela parece ser mais econômico e eficiente do que deixar o paciente com uma hérnia gigante e planejar uma reconstrução complexa tardiamente. Novos estudos com grupos maiores de pacientes separados de acordo com as diferentes apresentações e doenças são necesários para definir qual o melhor método cirúrgico para o tratamento de peritoneostomias.858