RESUMEN
The utility of 4-factor prothrombin complex concentrate (4F-PCC) for reversal in patients on factor Xa inhibitors (XaI) is unclear, specifically in mild traumatic brain injury (mTBI). This is a retrospective review over 6 years at a level 1 trauma center of patients presenting with mTBI on XaI comparing outcomes for those that received 4F-PCC to those that did not. 140 patients were included, 103 (74%) of these patients received 4F-PCC while 37 (26%) did not. There was no significant difference in neurologic decline within 48 hours of admission or need for neurosurgical intervention. Interestingly, there was no difference in ICH progression (16% vs 14%, P = .77). In this study, 4F-PCC given after mild traumatic brain injury did not impact ICH progression, neurologic decline, or need for neurosurgical intervention. Although limited in numbers, this study suggests that 4F-PCC is not necessarily required in mTBI and further studies are indicated.
Asunto(s)
Factores de Coagulación Sanguínea , Inhibidores del Factor Xa , Hemorragia Intracraneal Traumática , Humanos , Estudios Retrospectivos , Inhibidores del Factor Xa/uso terapéutico , Masculino , Femenino , Factores de Coagulación Sanguínea/uso terapéutico , Persona de Mediana Edad , Hemorragia Intracraneal Traumática/etiología , Hemorragia Intracraneal Traumática/cirugía , Adulto , Anciano , Resultado del Tratamiento , Conmoción Encefálica/complicacionesRESUMEN
Social determinants of health (SDOH) influence patient outcomes and risk assessment. This study focuses on interpersonal violence, trauma outcomes, and SDOH. We hypothesized patients with lower SDOH experience worse trauma outcomes and present from higher-risk communities. Demographics, SDOH, and outcomes for patients admitted to surgical trauma suffering interpersonal violence were collected and analyzed. Home addresses were plotted, identifying areas of need compared with Area Deprivation Index (ADI). Only 18.8% of patients had documented SDOH, yielding small sample size. Analysis revealed no statistically significant associations (P < .05) between SDOH and trauma outcomes, including ICU length of stay and stress concern (P = .0804). Heat mapping revealed several hot spots across our catchment area, correlating with higher-ranked ADIs and increased deprivation. This study demonstrated SDOH can bring value in determining patient risk, emphasizing resource dedication to documenting these factors. Home addresses in conjunction with ADIs can ascertain areas for resource allocation within communities.
Asunto(s)
Determinantes Sociales de la Salud , Humanos , Femenino , Masculino , Persona de Mediana Edad , Adulto , Violencia/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Heridas y Lesiones/cirugía , Estudios Retrospectivos , Medición de Riesgo , AncianoRESUMEN
BACKGROUND: Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast." However, a simplified, effective LCBDE technique as part of a "surgery first" strategy could drive wider adoption in the specialty most often managing these patients. To determine efficacy and safety, we sought to compare our initial ACS-driven experience with a simple, fluoroscopy-guided, catheter-based LCBDE approach during laparoscopic cholecystectomy (LC) to LC with endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We reviewed ACS patients who underwent LCBDE or LC + ERCP (pre-/postoperative) at a tertiary care center in the 4 years since starting this surgery first approach. Demographics, outcomes, and length of stay (LOS) were compared on an intention to treat basis. Laparoscopic common bile duct exploration was performed via using wire/catheter Seldinger techniques under fluoroscopic guidance with flushing or balloon dilation of the sphincter as needed. Our primary outcomes were LOS and successful duct clearance. RESULTS: One hundred eighty patients were treated for choledocholithiasis with 71 undergoing LCBDE. The success rate of catheter-based LCBDE was 70.4%. Length of stay was significantly reduced for the LCBDE group compared with the LC + ERCP group (48.8 vs. 84.3 hours, p < 0.01). Of note, there were no intraoperative or postoperative complications in the LCBDE group. CONCLUSION: A simplified catheter-based approach to LCBDE is safe and associated with decreased LOS when compared with LC + ERCP. This simplified step-up approach may help facilitate wider LCBDE utilization by ACS providers who are well positioned for a timely surgery first approach in the management of uncomplicated choledocholithiasis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
Asunto(s)
Colecistectomía Laparoscópica , Coledocolitiasis , Cálculos Biliares , Humanos , Coledocolitiasis/cirugía , Cálculos Biliares/cirugía , Colangiopancreatografia Retrógrada Endoscópica/métodos , Colecistectomía Laparoscópica/métodos , Fluoroscopía , Estudios Retrospectivos , Tiempo de InternaciónRESUMEN
A ruptured omental pseudoaneurysm is a rare cause of intra-abdominal hemorrhage. Herein, we present a case of bleeding ruptured omental pseudoaneurysm in a patient on systemic anticoagulation and successful treatment with surgery. A 72-year-old female on warfarin for atrial fibrillation presented with worsening abdominal pain. Cross-sectional imaging was obtained and was consistent with a large omental pseudoaneurysm (measuring 2.2 cm) as well as blood products within the abdomen. The patient was taken to the operating room where a pseudoaneurysm with evidence of active bleeding was identified. A diagnostic laparoscopy converted to exploratory laparotomy with partial omentectomy was performed. An omental pseudoaneurysm is a rare but potentially life-threatening cause of intra-abdominal hemorrhage. Given the risk of re-bleed, these lesions should be addressed promptly. In a facility that has the expertise, a catheter based approach with embolization may be considered, however, the mainstay of therapy should remain surgical resection.
RESUMEN
Whole blood transfusion (WBT) began in 1667 as a treatment for mental illness, with predictably poor results. Its therapeutic utility and widespread use were initially limited by deficiencies in transfusion science and antisepsis. James Blundell, a British obstetrician, was recognized for the first allotransfusion in 1825. However, WBT did not become safe and therapeutic until the early 20th century, with the advent of reliable equipment, sterilization, and blood typing. The discovery of citrate preservation in World War I allowed a separation of donor from recipient and introduced the practice of blood banking. During World War II, Elliott and Strumia were the first to separate whole blood into blood component therapy (BCT), producing dried plasma as a resuscitative product for "traumatic shock." During the 1970s, infectious disease, blood fractionation, and financial opportunities further drove the change from WBT to BCT, with few supporting data. Following a period of high-volume crystalloid and BCT resuscitation well into the early 2000s, measures to avoid the resulting iatrogenic resuscitation injury were developed under the concept of damage control resuscitation. Modern transfusion strategies for hemorrhagic shock target balanced BCT to reapproximate whole blood. Contemporary research has expanded the role of WBT to therapy for the acute coagulopathy of trauma and the damaged endothelium. Many US trauma centers are now using WBT as a front-line treatment in tandem with BCT for patients suffering hemorrhagic shock. Looking ahead, it is likely that WBT will once again be the resuscitative fluid of choice for patients in hemorrhagic shock.
Asunto(s)
Transfusión Sanguínea/historia , Choque Hemorrágico/historia , Sistema del Grupo Sanguíneo ABO/historia , Bancos de Sangre/historia , Transfusión de Componentes Sanguíneos/historia , Conservación de la Sangre/historia , Transfusión Sanguínea/instrumentación , Soluciones Cristaloides/historia , Historia del Siglo XVII , Historia del Siglo XIX , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Resucitación/historia , Choque Hemorrágico/terapia , Choque Traumático/historia , Choque Traumático/terapia , Reacción a la Transfusión/historia , Primera Guerra Mundial , Segunda Guerra MundialRESUMEN
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
RESUMEN
It is increasingly recognized that non-erythroid spectrins have roles remote from the plasma membrane, notably in endomembrane trafficking. The large spectrin isoform, ßH, partners with Annexin B9 to modulate endosomal processing of internalized proteins. This modulation is focused on the early endosome through multivesicular body steps of endocytic processing and loss of either protein appears to cause a traffic jam before removal of ubiquitin at the multivesicular body. We previously reported that ßH/Annexin B9 influenced EGF receptor signaling. While investigating this effect we noticed that mSptiz, the membrane bound precursor of the secreted EGF receptor ligand sSpitz, is located in striking intrusions of the nuclear membrane. Here we characterize these structures and identify them as 'cytoplasmic capes', which were previously identified in old ultrastructural studies and probably coincide with recently recognized sites of non-nuclear-pore RNA export. We show that cytoplasmic capes contain multiple endosomal markers and that their existence is dependent upon ßH and Annexin B9. Diminution of these structures does not lead to a change in mSpitz processing. These results extend the endosomal influence of ßH and its partner Annexin B9 to this unusual compartment at the nuclear envelope.