Variation in the use of damage control (DC) surgery across trauma centers may partially be driven by uncertainty as to when the procedure is indicated. We sought to scope the literature on DC surgery ...and DC interventions, identify their reported indications, and examine the content and evidence upon which they are based.
We searched MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and the Cochrane Library (1950-February 14, 2014) and the grey literature for original and nonoriginal citations reporting indications for DC surgery or DC interventions in civilian trauma patients.
Among 27,732 citations identified, we included 270 peer-reviewed articles in the scoping review. Of these, 156 (57.8%) represented original research, primarily (75.0%) cohort studies. The articles reported 1,099 indications for DC surgery and 418 indications for 15 different DC interventions. The majority of indications for DC interventions were for abdominal (56.5%) procedures, including therapeutic perihepatic packing (56.5%), temporary abdominal closure/open abdominal management (40.7%), and staged pancreaticoduodenectomy (2.8%). Most DC surgery indications were based on intraoperative findings (71.7%) and represented characteristics of the injured patient (94.5%), including their physiology (57.6%), injuries (38.9%), and/or the amount or type of resuscitation provided (14.3%). Others were dependent on characteristics of the treating surgeon (12.1%), the patient's physiologic response to trauma care (9.6%), and/or the trauma care environment (1.5%). Approximately half (49.5%) included a decision threshold (e.g., pH < X) and, while most (74.7%) were based on a single clinical finding/injury, 25.3% required the presence of multiple findings concurrently. Only 87 indications were evaluated in original research studies and only 9 by more than one study.
The vast number, varying underlying content, and lack of original research relating to indications for DC suggests that substantial uncertainty exists around when the procedure is indicated and highlights the need to establish evidence-informed consensus indications.
Patients with occult pneumothorax (OPTX) requiring positive-pressure ventilation (PPV) face uncertain risks of tension pneumothorax or chest drainage complications.
Adults with traumatic OPTXs ...requiring PPV were randomized to drainage/observation, with the primary outcome of composite “respiratory distress” (RD)).
Seventy-five (75) patients were randomized to observation, 67 to drainage. RD occurred in 38% observed and 25% drained (p = 0.14; Power = 0.38), with no mortality differences. One-quarter of observed patients failed, reaching 40% when ventilated >5 days. Twenty-three percent randomized to drainage had complications or ineffectual drains.
RD was not significantly different with observation. Thus, OPTXs may be cautiously observed in stable patients undergoing short-term PPV when prompt “rescue drainage” is immediately available. As 40% of patients undergoing prolonged (≥5 days) ventilation (PPPV) require drainage, we suggest consideration of chest drainage performed with expert guidance to reduce risk of chest tube complications.
Therapeutic study, level II.
•The composite primary endpoint of Respiratory Distress was not significantly different in either treatment group.•One-quarter of those allocated to observation failed and required drainage.•Nearly 40% of those ventilated for more than 5 days required pleural drainage.•Six percent of those being observed underwent an urgent pleural drainage.
Background
Physiological instability and confounding factors may interfere with the clinical diagnosis of brain death. Computed tomography angiography (CTA) has been suggested as a potential ...ancillary test for confirmation of brain death, but its diagnostic accuracy remains unclear.
Methods
We searched MEDLINE, EMBASE, and CENTRAL for studies comparing CTA with other accepted methods of diagnosing brain death (clinical or radiographic). Summary estimates of diagnostic accuracy were computed using random effects models. Subgroup analyses and meta-regression were performed to assess associations between CTA sensitivity and study or patient characteristics.
Results
Twelve studies, involving 541 patients, were included. If the CTA criterion for brain death was complete lack of opacification of intracranial vessels, then the pooled sensitivity was 62 % (50–74 %) for venous phase and 84 % (75–94 %) for arterial phase imaging. The sensitivity of CTA was higher when the criterion for brain death involved absence of opacification of internal cerebral veins, either alone (99 %, 97–100 %) or in combination with lack of flow to the distal middle cerebral artery branches (85 %, 77–93 %). CTA sensitivity was not influenced by different reference standards (clinical vs. radiographic) or predominant diagnostic category (stroke vs. brain trauma). Specificity of CTA could not be adequately determined from the existing data.
Conclusion
Many patients who progress to brain death by accepted clinical or radiographic criteria have persistent opacification of proximal intracranial vessels when CTA is performed. The specificity of CTA in the diagnosis of brain death has not been adequately assessed. Routine use of CTA as an ancillary test in the diagnosis of brain death is therefore not recommended until diagnostic criteria have undergone further refinement and prospective validation. Absence of opacification of the internal cerebral veins appears to be the most promising angiographic criterion.
Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when ...indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).
We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.
Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold, nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.
Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
Controlling the microstructure of materials by means of phase separation is a versatile tool for optimizing material properties. Phase separation has been exploited to fabricate intricate ...microstructures in many fields including cell biology, tissue engineering, optics, and electronics. The aim of this study was to use phase separation to tailor the spatial location of drugs and thereby generate release profiles of drug payload over periods ranging from 1 week to months by exploiting different mechanisms: polymer degradation, polymer diluent dissolution, and control of microstructure. To achieve this, we used drop-on-demand inkjet three-dimensional (3D) printing. We predicted the microstructure resulting from phase separation using high-throughput screening combined with a model based on the Flory–Huggins interaction parameter and were able to show that drug release from 3D-printed objects can be predicted from observations based on single drops of mixtures. We demonstrated for the first time that inkjet 3D printing yields controllable phase separation using picoliter droplets of blended photoreactive oligomers/monomers. This new understanding gives us hierarchical compositional control, from droplet to device, allowing release to be “dialled up” without manipulation of device geometry. We exemplify this approach by fabricating a biodegradable, long-term, multiactive drug delivery subdermal implant (“polyimplant”) for combination therapy and personalized treatment of coronary heart disease. This is an important advance for implants that need to be delivered by cannula, where the shape is highly constrained and thus the usual geometrical freedoms associated with 3D printing cannot be easily exploited, which brings a hitherto unseen level of understanding to emergent material properties of 3D printing.
Surgical site infections (SSIs) are a common and potentially preventable complication of lower limb revascularization surgery associated with increased healthcare resource utilization and patient ...morbidity. We conducted a systematic review to evaluate multivariable prediction models designed to forecast risk of SSI development after these procedures.
After protocol registration (CRD42022331292), we searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception to April 4th, 2023) for studies describing multivariable prediction models designed to forecast risk of SSI in adults after lower limb revascularization surgery. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risk of bias. A narrative synthesis was performed to summarize predictors included in the models and their calibration and discrimination, validation status, and clinical applicability.
Among the 6,671 citations identified, we included 5 studies (n = 23,063 patients). The included studies described 5 unique multivariable prediction models generated through forward selection, backward selection, or Akaike Information Criterion-based methods. Two models were designed to predict any SSI and 3 Szyilagyi grade II (extending into subcutaneous tissue) SSI. Across the 5 models, 18 adjusted predictors (10 of which were preoperative, 3 intraoperative, and 5 postoperative) significantly predicted any SSI and 14 adjusted predictors significantly predict Szilagyi grade II SSI. Female sex, obesity, and chronic obstructive pulmonary disease significantly predicted SSI in more than one model. All models had a "good fit" according to the Hosmer-Lemeshow test (P > 0.05). Model discrimination was quantified using the area under the curve, which ranged from 0.66 to 0.75 across models. Two models were internally validated using non-exhaustive twofold cross-validation and bootstrap resampling. No model was externally validated. Three studies had a high overall risk of bias according to the Prediction model Risk Of Bias ASsessment Tool (PROBAST).
Five multivariable prediction models with moderate discrimination have been developed to forecast risk of SSI development after lower limb revascularization surgery. Given the frequency and consequences of SSI after these procedures, development and external validation of novel prediction models and comparison of these models to the existing models evaluated in this systematic review is warranted.
Inferior mesenteric artery (IMA) aneurysms account for approximately 1% of visceral artery aneurysms and can occur secondary to high flow because of occlusive disease in other mesenteric arteries. We ...describe the case of a 79-year-old man who presented with a 3.3-cm IMA aneurysm and chronic total occlusions of the celiac artery and superior mesenteric artery (SMA). After an unsuccessful attempt at endovascular SMA recanalization, he underwent an uncomplicated retrograde aorta to SMA bypass and antegrade aorta to IMA bypass. We propose that an aorta to IMA bypass after SMA revascularization is safe and effective to treat suspected high-flow IMA aneurysms.
Objectives
Ruptured abdominal aortic aneurysm (rAAA) is a life‐threatening condition, and rapid diagnosis is necessary to facilitate early surgical intervention. We sought to evaluate the accuracy of ...presenting symptoms, physical examination signs, computed tomography with angiography (CTA), and point‐of‐care ultrasound (PoCUS) for diagnosis of rAAA.
Methods
We searched six databases from inception through April 2021. We included studies investigating the accuracy of any of the above tests for diagnosis of rAAA. The primary reference standard used in all studies was intraoperative diagnosis or death from rAAA. Because PoCUS cannot detect rupture, we secondarily assessed its accuracy for the diagnosis of AAA, using the reference standard of intraoperative or CTA diagnosis. We used GRADE to assess certainty in estimates.
Results
We included 20 studies (2,077 patients), with 11 of these evaluating signs and symptoms, seven evaluating CTA, and five evaluating PoCUS. Pooled sensitivities of abdominal pain, back pain, and syncope for rAAA were 61.7%, 53.6%, and 27.8%, respectively (low certainty). Pooled sensitivity of hypotension and pulsatile abdominal mass were 30.9% and 47.1%, respectively (low certainty). CTA had a sensitivity of 91.4% and specificity of 93.6% for diagnosis of rAAA (moderate certainty). In our secondary analysis, PoCUS had a sensitivity of 97.8% and specificity of 97.0% for diagnosing AAA in patients suspected of having rAAA (moderate certainty).
Conclusions
Classic clinical symptoms associated with rAAA have poor sensitivity, and their absence does not rule out the condition. CTA has reasonable accuracy, but misses some cases of rAAA. PoCUS is a valuable tool that can help guide the need for urgent transfer to a vascular center in patients suspected of having rAAA.
In addition to standard open surgical techniques, major hemorrhage is increasingly being managed using hybrid (open and endovascular) surgery. We present a case of hybrid management of a carotid ...artery injury secondary to an oropharyngeal gunshot wound. After performing balloon catheter tamponade with an inflated intraoral Foley catheter, on-table transfemoral angiography demonstrated extravasation from the external carotid artery with arteriovenous fistulization to the internal jugular vein. An endovascular stent graft was deployed, spanning from the common carotid to the internal carotid artery. This facilitated surgical neck exploration and ligation of the external carotid artery and jugular vein injury in zone II/III of the neck while maintaining antegrade cerebral blood flow. The approach presented represents a feasible and effective means to manage these types of difficult-to-access injuries in the endovascular and hybrid surgical era.
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