Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) could prevent lethal exsanguination and support cardiopulmonary resuscitation. In prehospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. The aim of this study was to establish consensus on the use and implementation of REBOA in civilian prehospital settings for noncompressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. METHODS: A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA experts with different medical specialties, backgrounds, and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. RESULTS: Panel members reached consensus on potential (contra)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and prehospital REBOA. CONCLUSION: The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of noncompressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For prehospital REBOA and early femoral artery access, consensus was reached on (contra)indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of prehospital REBOA for noncompressible truncal hemorrhage. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Whole blood transfusion in the treatment of acute hemorrhage, a systematic review and meta-analysis.

BACKGROUND: Whole blood (WB) transfusion received renewed interest after recent armed conflicts. The effectiveness as compared with blood component transfusion (BCT) is, however, still topic of debate. Therefore, this study investigated the effect of WB ± BCT as compared with BCT transfusion on survival in trauma patients with acute hemorrhage. METHODS: Studies published up to January 16, 2023, including patients with traumatic hemorrhage comparing WB ± BCT and BCT were included in meta-analysis. Subanalyses were performed on the effectiveness of WB in the treatment of civilian or military trauma patients, patients with massive hemorrhage and on platelet (PLT)/red blood cell (RBC), plasma/RBC and WB/RBC ratios. Methodological quality of studies was interpreted using the Cochrane risk of bias tool. The study protocol was registered in PROSPERO under number CRD42022296900. RESULTS: Random effect pooled odds ratio (OR) for 24 hours mortality in civilian and military patients treated with WB as compared with BCT was 0.72 (95% confidence interval [CI], 0.53-0.97). In subanalysis of studies conducted in civilian setting (n = 20), early (4 hours, 6 hours, and emergency department) and 24 hours mortality was lower in WB groups compared with BCT groups (OR, 0.65; 95% CI, 0.44-0.96 and OR, 0.71; 95% CI, 0.52-0.98). No difference in late mortality (28 days, 30 days, in-hospital) was found. In military settings (n = 7), there was no difference in early, 24 hours, or late mortality between groups. The WB groups received significant higher PLT/RBC ( p = 0.030) during early treatment and significant higher PLT/RBC and plasma/RBC ratios during 24 hours of treatment ( p = 0.031 and p = 0.007). The overall risk of bias in the majority of studies was judged as serious due to serious risk on confounding and selection bias, and unclear information regarding cointerventions. CONCLUSION: Civilian trauma patients with acute traumatic hemorrhage treated with WB ± BCT as compared to BCT had lower odds on early and 24-hour mortality. In addition, WB transfusion resulted in higher PLT/RBC and plasma/RBC ratios. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level III.

The effectiveness of Foley catheter balloon tamponade versus expanding sponges and hemostatic granules for catastrophic penetrating groin hemorrhage with small skin defect: A comparative study in a live tissue porcine model with evaluation of a concise training program.

BACKGROUND: Prompt bleeding control in the prehospital phase is essential to improve survival from catastrophic junctional hemorrhage. This study aimed to compare the effectiveness and practicality of Foley catheter balloon tamponade (FCBT), Celox-A, and XSTAT for the treatment of catastrophic hemorrhage from penetrating groin injuries with a small skin defect in a live-tissue porcine model. In addition, this study aimed to determine whether a training program could train military personnel in application of these advanced bleeding control adjuncts. METHODS: A standardized wound was created in 18 groins from 9 anesthetized swine. Eighteen military medics participated in the training program and performed a bleeding control procedure after randomization over the swine and test products and after transection of the femoral neurovascular bundle. Primary endpoints were bleeding control, time to bleeding control, rebleeding, blood loss, medic performance, and user product rating. RESULTS: No significant differences were found in vital signs and laboratory values between the groups. In the Celox-A group, 3/6 groins achieved hemorrhage control. This was 6/6 in the XSTAT and FCBT groups. XSTAT scored best on application time, time to obtain hemorrhage control, hemorrhage control score, and practicality. No significant differences were found between groups for rebleeding, amount of blood loss, and medic performance. Military medics had a significant higher preference for XSTAT over Celox-A. This was not significant for FCBT. CONCLUSION: All tested products proved effective in obtaining hemorrhage control. XSTAT has the highest effectivity and shortest application time for the treatment of catastrophic bleeding from nonpackable, penetrating junctional groin injuries with a small skin defect, compared with Celox-A and FCBT. XSTAT scored best on practicality. This study shows that our training curriculum can be used to train military medics with limited prior experience in the use of advanced bleeding control techniques for penetrating junctional groin injuries with small skin defect.

Recurrent diabetic foot ulcers: Results of a maximal multidisciplinary approach including reconstructive foot/ankle surgery.

The diabetic foot ulcer (DFU) and Charcot Neuroarthropathy (CN) are serious complications of diabetes mellitus in which wound closure is complex to achieve. Treating recurrent DFU in patients with a combination of infection, ischemia, and deformities is extremely challenging and this group of patients has a very poor outcome. This case series describes the outcomes of patients with a recurrent DFU and CN, with a mean SINBAD score of 4 and of which 40% had a TCS of D3, using a multidisciplinary protocol that includes reconstructive foot and ankle surgery. In 24/35 (69%) of patients, wound closure was achieved after a mean of 75 days postoperatively. The mean ulcer-free period was 358 days. The mean number of interventions was 6.7 (range 3-9). Post treatment 27/35 (77%) of patients was mobile, without additional amputation or ulcer recurrence. This study shows that wound closure and a long ulcer-free period can be achieved in patients with a DFU and CN and its multifactorial underlying diseases when treated in a multidisciplinary team, including reconstructive foot and ankle surgery.

Advanced bleeding control in combat casualty care: An international, expert-based Delphi consensus.

BACKGROUND: Hemorrhage from truncal and junctional injuries is responsible for the vast majority of potentially survivable deaths in combat casualties, causing most of its fatalities in the prehospital arena. Optimizing the deployment of the advanced bleeding control modalities required for the management of these injuries is essential to improve the survival of severely injured casualties. This study aimed to establish consensus on the optimal use and implementation of advanced bleeding control modalities in combat casualty care. METHODS: A Delphi method consisting of three rounds was used. An international expert panel of military physicians was selected by the researchers to complete the Delphi surveys. Consensus was reached if 70% or greater of respondents agreed and if 70% or greater responded. RESULTS: Thirty-two experts from 10 different nations commenced the process and reached consensus on which bleeding control modalities should be part of the standard equipment, that these modalities should be available at all levels of care, that only trained physicians should be allowed to apply invasive bleeding control modalities, but all medical and nonmedical personnel should be allowed to apply noninvasive bleeding control modalities, and on the training requirements for providers. Consensus was also reached on the necessity of international registries and guidelines, and on certain indications and contraindications for resuscitative endovascular balloon occlusion of the aorta (REBOA) in military environments. No consensus was reached on the role of a wound clamp in military settings and the indications for REBOA in patients with chest trauma, penetrating axillary injury or penetrating neck injury in combination with thoracoabdominal injuries. CONCLUSION: Consensus was reached on the contents of a standard bleeding control toolbox, where it should be available, providers and training requirements, international registries and guidelines, and potential indications for REBOA in military environments.

A contemporary assessment of devices for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): resource-specific options per level of care.

PURPOSE: Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as adjunct for temporary hemorrhage control in patients with exsanguinating torso hemorrhage is increasing. Characteristics of aortic occlusion balloons (AOB) are diverse and evolving as efforts are made to improve the technology. It is important to select a device that fits the requirements of the medical situation to minimize the risk of failure and complications. The aim of this study is to appraise guidance in the choice of an AOB in a specific situation. METHODS: We assessed 29 AOB for differences and outline possible advantages and disadvantages of each. Bending stiffness was measured with a three-point bending device. RESULTS: Diameter of the AOB ranged from 6 (ER-REBOA™) to 10 (Coda®-46) French. However, some need large-bore access sheaths up to 22 French (Fogarty®-45 and LeMaitre®-45) or even insertion via cut-down (Equalizer™-40). Bending stiffness varied from 0.08 N/mm (± 0.008 SD; Coda®-32) to 0.72 N/mm (± 0.024 SD; Russian prototype). Rescue Balloon™ showed kinking of the shaft at low bending pressures. The only non-compliant AOB is REBOA Balloon®. ER-REBOA™, Fogarty®, LeMaitre®, REBOA Balloon®, and Rescue Balloon™ are provided with external length marks to assist blind positioning. CONCLUSION: In resource-limited settings, a guidewire- and fluoroscopy-free, rather stiff device, such as ER-REBOA™, Fogarty®, and LeMaitre®, is warranted. Of these devices, ER-REBOA™ is the only catheter compatible with seven French sheaths and specifically designed for emergency hemorrhage control. Of the over-the-wire devices, Q50® has several features that facilitate use and reduce the risk of malplacement or vessel damage.

For debate: advanced bleeding control potentially saves lives in armed forces and should be considered.

INTRODUCTION: Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel. METHODS: The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control. RESULTS: There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61). CONCLUSION: Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

Prevalence of foot ulcers in dialysis-dependent patients.

Hemodialysis patients are at high risk for foot ulceration. The aim of this prospective study was to describe the prevalence and risk factors for foot ulcers in hemodialysis-dependent patients. From 2012 until 2015, all hemodialysis patients (n = 66) above18 years of age, treated at the Alrijne Hospital (Leiderdorp, the Netherlands), were included. Demographics and medical history were collected and the quality of life was measured. Data were collected on common risk factors for foot ulceration: peripheral arterial disease, peripheral neuropathy with or without foot deformities, diabetes mellitus (DM), hypertension, smoking, previous foot ulcer, edema, pedicure attendance, and orthopedic footwear. Sixty-six hemodialysis patients were evaluated; the prevalence of foot ulcer was 21/66 (31.8%). Risk factors were history of foot ulceration in 27/66 (40.9%), ankle-brachial index (ABI) <0.9, and toe pressure < 80 mmHg in 38/66 (57.6%). The percentage of DM in the group of foot-ulcers was higher 13/21 (61.9%) vs. 20/45 (44.4%) in the non-ulcer group, this was not significant (p = 0.183). No differences were found in ABI, toe pressure, peripheral neuropathy and foot deformity, between the DM and non DM group. The mortality between ulcer vs. no ulcer was significant different: 13/21 (61.9%) vs. 11/45 (24.4%) (p = 0.003). Approximately, one-third of hemodialysis patient have a foot ulcer 21/66 (32%). Arterial insufficiency is associated with an increased risk of foot ulcers. In patients with a foot ulcer, survival is significantly lower than in patients without a foot ulcer; interventions to reduce foot ulceration should be implemented for all hemodialysis patients and include frequent inspection, and prompt treatment. Further research should focus on the prevention of foot ulcers in dialysis-dependent patients.

Do antipsychotics prevent postoperative delirium? A systematic review and meta-analysis.

OBJECTIVE: To summarize the effect of antipsychotics for preventing postoperative delirium. DESIGN: We conducted a literature search using Medline, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and clinicaltrials.gov. We included randomized controlled trials of adults undergoing surgery who were given antipsychotics to prevent postoperative delirium. Quality was assessed via the Cochrane risk of bias tool. Random-effects meta-analysis and meta-regression were conducted. Q-statistics and I(2) were used for assessment of heterogeneity. The main outcome was delirium incidence using validated definitions. RESULTS: A total of 1710 subjects were included, with a mean age ranging from 60.7 to 86.4 years. Antipsychotics reduced the incidence of postoperative delirium with the global effect-size estimate (weighted odds ratio) using the random effects model of 0.44 (95% confidence interval: 0.28-0.70; N = 6; Q-value: 16, p-value 0.0005; I(2) = 69%). Significant heterogeneity existed with the pooled global effect of delirium incidence; however, meta-regression allowed us to test both treatment-level and patient-level explanations for significant between-study variance. Baseline risk for delirium was found to be a significant contributor to study heterogeneity, and meta-regression suggested that antipsychotic type and dosage were two of the several treatment-level factors that also may have led to heterogeneity. Our analysis implied the presence of a breakeven baseline level of delirium risk below which preventive treatment with antipsychotics might prove ineffective. CONCLUSIONS: Within the limits of few randomized controlled trials, antipsychotics appeared to reduce the incidence of postoperative delirium in several surgical settings, predominantly orthopedic and for those at higher risk for delirium.

Contralateral hip fractures and other osteoporosis-related fractures in hip fracture patients: incidence and risk factors. An observational cohort study of 1,229 patients.

PURPOSE: To report risk factors, 1-year and overall risk for a contralateral hip and other osteoporosis-related fractures in a hip fracture population. METHODS: An observational study on 1,229 consecutive patients of 50 years and older, who sustained a hip fracture between January 2005 and June 2009. Fractures were scored retrospectively for 2005-2008 and prospectively for 2008-2009. Rates of a contralateral hip and other osteoporosis-related fractures were compared between patients with and without a history of a fracture. Previous fractures, gender, age and ASA classification were analysed as possible risk factors. RESULTS: The absolute risk for a contralateral hip fracture was 13.8 %, for one or more osteoporosis-related fracture(s) 28.6 %. First-, second- and third-year risk for a second hip fracture was 2, 1 and 0 %. Median (IQR) interval between both hip fractures was 18.5 (26.6) months. One-year incidence of other fractures was 6 %. Only age was a risk factor for a contralateral hip fracture, hazard ratio (HR) 1.02 (1.006-1.042, p = 0.008). Patients with a history of a fracture (33.1 %) did not have a higher incidence of fractures during follow-up (16.7 %) than patients without fractures in their history (14 %). HR for a contralateral hip fracture for the fracture versus the non-fracture group was 1.29 (0.75-2.23, p = 0.360). CONCLUSION: The absolute risk of a contralateral hip fracture after a hip fracture is 13.8 %, the 1-year risk was 2 %, with a short interval between the 2 hip fractures. Age was a risk factor for sustaining a contralateral hip fracture; a fracture in history was not.