Blunt aortic injury-traumatic aortic isthmus pseudoaneurysm with right iliac artery dissection aneurysm: A case report.

BACKGROUND: Blunt aortic injury is a special type of aortic disease. Due to its low incidence, high prehospital mortality and high probability of leakage diagnosis, the timely identification of patients with blunt aortic injury who survive the initial injury has always been a clinical challenge. CASE SUMMARY: We report a case of traumatic aortic pseudoaneurysm with right iliac artery dissection aneurysm that was diagnosed 3 mo after a traffic accident. The patient is a 76-year-old male who was knocked down by a fast-moving four-wheel motor vehicle while crossing the road (the damage mechanism was side impact). He received chest, cranial computed tomography (CT) and whole abdomen enhanced CT in the local hospital. The images suggested subarachnoid hemorrhage, right frontoparietal scalp hematoma, fracture of the right clavicle and second rib, lump-shaped mediastinal shadow outside the anterior descending thoracic aorta (mediastinal hematoma), mesenteric vascular injury with hematoma formation, pelvic fracture, and subluxation of the left sacroiliac joint. After the pelvic fracture was fixed with an external stent, he was sent to our hospital for further treatment. In our hospital, he successfully underwent partial resection of the small intestine and CT-guided screw internal fixation of the left sacroiliac joint and returned to the local hospital for rehabilitation treatment. However, since the accident, the patient has been suffering from mild chest pain, which has not aroused the attention of clinicians. During rehabilitation, his chest pain gradually worsened, and the thoracic aorta computed tomography angiography performed in the local hospital showed a pseudoaneurysm in the initial descending segment of the aortic arch. After transfer to our hospital, a dissecting aneurysm of the right external iliac artery was incidentally found in the preoperative evaluation. Finally, endovascular stent graft repair was performed, and he was discharged on the 10th day after the operation. No obvious endo-leak was found after 4 years of follow-up. CONCLUSION: We highlight that emergency trauma centers should consider the possibility of aortic injury in patients with severe motor vehicle crashes and repeat the examination when necessary to avoid missed diagnoses.

Effect of goal-directed fluid therapy on renal function in critically ill patients: a systematic review and meta-analysis.

OBJECTIVE: To evaluate whether goal-directed fluid therapy (GDFT) reduces the risk of renal injury in critical illness. METHODS: MEDLINE via PubMed, EMBASE, CENTRAL and CBM was searched from inception to 13 March 2022, for studies comparing the effect of GDFT with usual care on renal function in critically ill patients. GDFT was defined as a protocolized intervention based on hemodynamic and/or oxygen delivery parameters. A fixed or random effects model was applied to calculate the pooled odds ratio (OR) based on heterogeneity through the included studies. RESULTS: A total of 28 studies with 9,019 patients were included. The pooled data showed that compared with usual care, GDFT reduced the incidence of acute kidney injury (AKI) in critical illness (OR 0.62, 95% confidence interval (CI) 0.47 to 0.80, p< 0.001). Sensitivity analysis with only low risk of bias studies showed the same result. Subgroup analyses found that GDFT was associated with a lower AKI incidence in both postoperative and medical patients. The reduction was significant in GDFT aimed at dynamic indicators. However, no significant difference was found between groups in RRT support (OR 0.88, 95% CI 0.74 to 1.05, p= 0.17). GDFT tended to increase fluid administration within the first 6 h, decrease fluid administration after 24 h, and was associated with more vasopressor requirements. CONCLUSIONS: This meta-analysis suggests that GDFT aimed at dynamic indicators may be an effective way to prevent AKI in critical illness. This may indicate a benefit from early adequate fluid resuscitation and the combined effect of vasopressors.

[Comparison of the effect of fluid resuscitation as guided either by lactate clearance rate or by central venous oxygen saturation in patients with sepsis].

OBJECTIVE: To compare the efficacy of fluid resuscitation as guided by lactate clearance rate (LCR) and central venous oxygen saturation (ScvO2) in patients with sepsis. METHODS: A prospective randomized control study was conducted. Fifty patients diagnosed with severe sepsis or septic shock from January 2011 to February 2012 in department of critical care medicine of Fourth Hospital of Hebei Medical University were enrolled in the study. The patients were randomly divided into two groups according to the sequence (each n=25): ScvO2 group and LCR group. After ICU admission, the patients were treated symptomatically timely, and fluid resuscitation was started as early as possible according to Surviving Sepsis Campaign guidance for management of severe sepsis and septic shock 2008. Central venous pressure (CVP)≥8 mm Hg (1 mm Hg=0.133 kPa), mean arterial pressure (MAP)≥65 mm Hg and ScvO2≥0.70 served as goal values to accomplish the fluid resuscitation therapy in ScvO2 group, while CVP≥8 mm Hg, MAP≥65 mm Hg, LCR≥10% served as goal value to accomplish the fluid resuscitation therapy in LCR group. The general condition and clinical characteristics on arrival in ICU, changes in CVP, MAP, ScvO2, lactate level and/or LCR before (0 hour) and 3, 6, 72 hours after the start of fluid resuscitation and the other related conditions during the therapy were recorded. RESULTS: There was no significant difference in general data or clinical characteristics before the start of therapy, occurrence of organ dysfunction, or treatment measures during different time periods after start of fluid resuscitation. Compared with the condition immediately before fluid resuscitation, at 3 hours after start of fluid resuscitation, CVP were improved in LCR and ScvO2 groups (8.58±1.17 mm Hg vs. 6.33±1.21 mm Hg, 9.08±2.43 mm Hg vs. 5.33±0.98 mm Hg, both P<0.05); at 6 hours after start of fluid resuscitation, heart rate (HR) and respiratory rate (RR) were lowered in LCR and ScvO2 groups (HR: 96±18 bpm vs. 127±13 bpm, 98±13 bpm vs. 116±19 bpm, RR: 23±3 times/min vs. 33±9 times/min, 24±5 times/min vs. 35±6 times/min, all P<0.05), oxygenation index (PaO2/FiO2) was increased in LCR and ScvO2 groups (179±41 mm Hg vs. 86±21 mm Hg, 202±33 mm Hg vs. 95±17 mm Hg, both P<0.05), and there was no significant difference in MAP in both groups. There was no significant difference in all indexes between two groups. In LCR group, 3 hours after start of fluid resuscitation, lactate level was significantly decreased (2.81±0.18 mmol/L vs. 3.43±1.31 mmol/L, P<0.05). Compared with the value 3 hours after start of fluid resuscitation, LCR was significantly improved at 6 hours and 72 hours after start of fluid resuscitation in LCR group [(42.69±8.75)%, (48.87±9.69)% vs. (20.32±4.58)%, both P<0.05]. Compared with that immediately before fluid resuscitation, ScvO2 was significant improved in ScvO2 group at 3 hours after start of fluid resuscitation (0.65±0.04 vs. 0.53±0.06, P<0.05). There was no significant difference in success rate of fluid resuscitation comparing that of 6 hours and that of 72 hours [6 hours: 72% (18/25) vs. 64% (16/25), χ(2)=0.368, P=0.762; 72 hours: 88% (22/25) vs. 88% (22/25) ,χ(2)=0.000, P=1.000], length of ICU stay (8±3 days vs. 10±4 days, t=0.533, P=0.874), length of hospital stay (29±11 days vs. 35±16 days, t=0.692, P=0.531), improvement rate [84% (21/25) vs. 76%(19/25), χ(2)=0.500, P=0.480] or 28-day mortality [20% (5/25) vs. 28% (7/25), χ(2)=0.439, P=0.742] between LCR and ScvO2 groups. CONCLUSIONS: Both LCR and ScvO2 can be taken as the index in confirming the endpoint of fluid resuscitation for patients with severe sepsis and septic shock. Fluid resuscitation therapy under the guidance of LCR is accurate and reliable in patients with severe sepsis and septic shock.