Circulatory Trauma: A Paradigm for Understanding the Role of Endovascular Therapy in Hemorrhage Control.

ABSTRACT: The pathophysiology of traumatic hemorrhage is a phenomenon of vascular disruption and the symptom of bleeding represents one or more vascular injuries. In the Circulatory Trauma paradigm traumatic hemorrhage is viewed as injury to the circulatory system and suggests the underlying basis for endovascular hemorrhage control techniques. The question "Where is the patient bleeding?" is replaced by "Which blood vessels are disrupted?" and stopping bleeding becomes a matter of selective vessel access and vascular flow control. Control of traumatic hemorrhage has traditionally been performed via external access to the end organ that is bleeding followed by the application of direct pressure, packing, or clamping and repair of directly affected blood vessels. In the circulatory trauma paradigm, bleeding is seen as disruption to vessels which may be accessed internally, from within the vascular system. A variety of endovascular treatments such as balloon occlusion, embolization, or stent grafting can be used to control hemorrhage throughout the body. This narrative review presents a brief overview of the current role of endovascular therapy in the management of circulatory trauma. The authors draw on their personal experience combined with the last decade of published experiences with the use of endovascular techniques in trauma and present general recommendations for their evolving use. The focus of the review is on the use of endovascular techniques as specific vascular treatments using the circulatory trauma paradigm.

Challenges and Opportunities for Endovascular Treatment of Hemorrhage in Combat Casualty Care.

ABSTRACT: The care of the hemorrhaging patient continues to evolve. The use of endovascular techniques to treat hemorrhage has increased significantly in civilian trauma care over the past 15 years and is identified as a major national trauma care research priority. Endovascular techniques are being increasingly employed to treat major thoracoabdominal arterial injuries and resuscitative endovascular balloon occlusion of the aorta is being adopted at trauma centers as a supportive adjunct to resuscitation in the exsanguinating patient. Emerging endovascular technology offers the opportunity to provide temporary or permanent control of non-compressible torso hemorrhage, which remains a vexing problem in combat casualty care. Endovascular advances have not been translated to the care of combat casualties to any significant degree, however. This review provides a summary and analysis of the gap between civilian endovascular hemorrhage control and combat casualty care practice to better align future research and development efforts.

The Role of TEG and ROTEM in Damage Control Resuscitation.

ABSTRACT: Trauma-induced coagulopathy is associated with very high mortality, and hemorrhage remains the leading preventable cause of death after injury. Directed methods to combat coagulopathy and attain hemostasis are needed. The available literature regarding viscoelastic testing, including thrombelastography (TEG) and rotational thromboelastometry (ROTEM), was reviewed to provide clinically relevant guidance for emergency resuscitation. These tests predict massive transfusion and developing coagulopathy earlier than conventional coagulation testing, within 15 min using rapid testing. They can guide resuscitation after trauma, as well. TEG and ROTEM direct early transfusion of fresh frozen plasma when clinical gestalt has not activated a massive transfusion protocol. Reaction time and clotting time via these tests can also detect clinically significant levels of direct oral anticoagulants. Slowed clot kinetics suggest the need for transfusion of fibrinogen via concentrates or cryoprecipitate. Lowered clot strength can be corrected with platelets and fibrinogen. Finally, viscoelastic tests identify fibrinolysis, a finding associated with significantly increased mortality yet one that no conventional coagulation test can reliably detect. Using these parameters, guided resuscitation begins within minutes of a patient's arrival. A growing body of evidence suggests this approach may improve survival while reducing volumes of blood products transfused.

Limitations of Available Blood Products for Massive Transfusion During Mass Casualty Events at US Level 1 Trauma Centers.

INTRODUCTION: Exsanguination remains a leading cause of preventable death in traumatically injured patients. To better treat hemorrhagic shock, hospitals have adopted massive transfusion protocols (MTPs) which accelerate the delivery of blood products to patients. There has been an increase in mass casualty events (MCE) worldwide over the past two decades. These events can overwhelm a responding hospital's supply of blood products. Using a computerized model, this study investigated the ability of US trauma centers (TCs) to meet the blood product requirements of MCEs. METHODS: Cross-sectional survey data of on-hand blood products were collected from 16 US level-1 TCs. A discrete event simulation model of a TC was developed based on historic data of blood product consumption during MCEs. Each hospital's blood bank was evaluated across increasingly more demanding MCEs using modern MTPs to guide resuscitation efforts in massive transfusion (MT) patients. RESULTS: A total of 9,000 simulations were performed on each TC's data. Under the least demanding MCE scenario, the median size MCE in which TCs failed to adequately meet blood product demand was 50 patients (IQR 20-90), considering platelets. Ten TCs exhaust their supply of platelets prior to red blood cells (RBCs) or plasma. Disregarding platelets, five TCs exhausted their supply of O- packed RBCs, six exhausted their AB plasma supply, and five had a mixed exhaustion picture. CONCLUSION: Assuming a TC's ability to treat patients is limited only by their supply of blood products, US level-1 TCs lack the on-hand blood products required to adequately treat patients following a MCE. Use of non-traditional blood products, which have a longer shelf life, may allow TCs to better meet the blood product requirement needs of patients following larger MCEs.

The Colombian Experience in Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): The Progression From a Large Caliber to a Low-Profile Device at a Level I Trauma Center.

PURPOSE: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is now performed in many trauma centers, it is used at more than 250 hospitals in the United States and there is an increase rate of publications with the experience in these centers, but there is a gap of knowledge regarding the use of REBOA in Latin-America. This paper endeavors to describe the utilization of REBOA at a high level Latin-American Trauma Center and the transition from a large caliber to a low-profile device with the concomitant reduction in the groin access complications. METHODS: A prospective, observational, single-center study was conducted. We included all trauma patients who underwent REBOA. We recorded data from admission parameters, complications, and clinical outcomes. RESULTS: Fifty patients were included. Most of the REBOA catheters were inserted in the operating room [47 (94%)], and the arterial access was done by surgical cutdown [40 (80%)]. All the complications were associated with the catheter of 11 Fr Sheath used in 36 patients [n = 8/36 (22%) vs. n = 0/14 (0%); P = 0.05]. CONCLUSION: REBOA can be used safely in blunt or penetrating thoracic, abdominal, and pelvic trauma. The insertion of a 7 Fr Sheath was associated with lower complications, so its use should be preferred over larger calibers.

Prehospital Mortality Due to Hemorrhagic Shock Remains High and Unchanged: A Summary of Current Civilian EMS Practices and New Military Changes.

ABSTRACT: Mortality secondary to trauma-related hemorrhagic shock has not improved for several decades. Underlying the stall in progress is the conundrum of effective prehospital interventions for hemorrhage control. As we know, neither pressing hard on the gas nor "stay and play" has changed mortality over the last 20 years. For this reason, when dealing with effective changes that will improve severe hemorrhage mortality outcomes, there is a need for the creation of a hybrid prehospital model. Improvements in mortality outcomes for patients with severe hemorrhage based on evidence for common civilian prehospital procedures such as in-field intubation and immediate fluid resuscitation with crystalloid solution are weak at best. The use of tourniquets, once considered too risky to use, however, has risen dramatically in large part due to success seen during their use in the military. Their use in the civilian setting shows promising results. Recently updated military Advanced Resuscitative Care guidelines propose the use of prehospital whole blood transfusion as well as in-field use of Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. Several case studies from Europe suggest these strategies are feasible for use in the civilian population, but could they be implemented in the US?

Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation.

ABSTRACT: In recent years there has been a tremendous increase in hemorrhage control by endovascular methods. Traumatic and non-traumatic hemorrhage is being more frequently managed with endografts, embolization agents, and minimal invasive methods. These methods initially were used in hemodynamically stable patients only, whereas now these are being implemented in acute settings and hemodynamically unstable patients. The strategy of using endovascular and combined open-endo methods approach for hemodynamic instability in trauma and non-trauma patients has been named EVTM- EndoVascular resuscitation and Trauma Management. The EVTM concept will be presented in this article, describing how it is developed and used, as well as its limitations and future aspects.

Back to the Future: Whole Blood Resuscitation of the Severely Injured Trauma Patient.

ABSTRACT: Following advances in blood typing and storage, whole blood transfusion became available for the treatment of casualties during World War I. While substantially utilized during World War II and the Korean War, whole blood transfusion declined during the Vietnam War as civilian centers transitioned to blood component therapies. Little evidence supported this shift, and recent conflicts in Iraq and Afghanistan have renewed interest in military and civilian applications of whole blood transfusion. Within the past two decades, civilian trauma centers have begun to study transfusion protocols based upon cold-stored, low anti-A/B titer type O whole blood for the treatment of severely injured civilian trauma patients. Early data suggests equivalent or improved resuscitation and hemostatic markers with whole blood transfusion when compared to balanced blood component therapy. Additional studies are taking place to define the optimal way to utilize low-titer type O whole blood in both prehospital and trauma center resuscitation of bleeding patients.

Primary total hip replacement in Ficat-Arlet stage 3 and 4 osteonecrosis: a retrospective study at a minimum 12-year follow-up.

INTRODUCTION: Results of total hip replacement (THR) for aseptic osteonecrosis are controversial and conflicting according to implant type and generation. The present study consisted in a retrospective assessment of implant survival in primary THR for aseptic osteonecrosis, using a cemented stem, standard polyethylene press-fit acetabular component, and metal-metal bearing. The study hypothesis was that THR results are equivalent between aseptic osteonecrosis and osteoarthritis of the hip. MATERIAL AND METHOD: A single-center retrospective study included 54 patients with metal-on-metal THR for femoral head osteonecrosis. The main endpoint was revision surgery for all causes, whether implant related or procedure related; secondary endpoints were complications and progression in clinical scores. RESULTS: Mean follow-up was 13.9 ± 1.6 years (range 12.0-17.1 years). Eighteen of the 54 patients (33.3%) died. Implant survival at last follow-up was 93.8% (95% CI, 87.1-100). There were 12 complications (22.2%): 1 intraoperative, 5 (9.3%) immediate postoperative, and 6 (11.1%) long term. Clinical assessment found a significant 43.1 point improvement in mean Harris score (p = 8.4E-33) and a 5.6 point improvement in mean PMA score (p = 2.9E-22). CONCLUSION: Survival in primary THR for aseptic osteonecrosis was good. Follow-up needs to be rigorous to screen for onset of complications. Primary THR is thus justified in Ficat-Arlet stage 3 and 4 aseptic osteonecrosis of the hip. LEVEL OF EVIDENCE: IV.

Evaluation of the efficacy of an interdialytic "ethanol 40% v/v - enoxaparin 1000 U/mL" lock solution to prevent tunnelled catheter infections in chronic hemodialysis patients: a multi-centre, randomized, single blind, parallel group study.

BACKGROUND: Tunnelled dialysis catheter (TC) infections are a major health complication and are associated with increased antibiotic consumption, hospital stays, health costs and mortality. Experimental data provide evidence that Ethenox, a mixture of enoxaparine 1000 U/mL in 40% v/v ethanol, could be a promising lock solution. The aim of the study is to compare an interdialytic lock solution of Ethenox with reference lock solutions, unfractionated heparin (UFH) or citrate 4% for the prevention of TCI in hemodialysis patients. METHOD: This study will monitor a multicentre, prospective, single blind, randomized, controlled, parallel group trial. The main inclusion criteria are patients > 18 years old with end-stage renal disease, treated with chronic hemodialysis/hemodiafiltration three times a week, with incident or prevalent non-impregnated internal jugular TCs inserted for at least 2 weeks and able to give informed consent. Exclusion criteria are TCI in the previous 4 weeks and anti-infective treatment for TCI in the previous 2 weeks. Patients will be randomized to receive either study treatment Ethenox in the intervention group or reference solutions in the control group, unfractionated heparin (UFH) or citrate 4% w/v according to usual practice. The primary outcome measure will be time to first TCIs assessed by an endpoint adjudication committee blinded to the study arm according to predefined criteria. Patients will receive the study treatment for up to 12 months. Intention-to-treat analysis of the primary endpoint will be performed with a marginal Cox proportional hazard model. Prospective power calculations indicate that the study will have 90% statistical power to detect a clinical significant two-fold increase in median infection-free survival if 200 patients are recruited into each arm over a period of 24 months. DISCUSSION: Firm evidence of the efficacy of the Ethenox lock in preventing TCI could be of major clinical benefit for patients. The results of this study will allow the development of new guidelines based on a high level of evidence. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03083184 , date of registration March 17 2017 and European Clinical Trials Database Identifier: EudraCT 2016-A00180-51), date of registration July 11 2016.

Augmented reality in gynecologic surgery: evaluation of potential benefits for myomectomy in an experimental uterine model.

BACKGROUND: Augmented Reality (AR) is a technology that can allow a surgeon to see subsurface structures. This works by overlaying information from another modality, such as MRI and fusing it in real time with the endoscopic images. AR has never been developed for a very mobile organ like the uterus and has never been performed for gynecology. Myomas are not always easy to localize in laparoscopic surgery when they do not significantly change the surface of the uterus, or are at multiple locations. OBJECTIVE: To study the accuracy of myoma localization using a new AR system compared to MRI-only localization. METHODS: Ten residents were asked to localize six myomas (on a uterine model into a laparoscopic box) when either using AR or in conditions that simulate a standard method (only the MRI was available). Myomas were randomly divided in two groups: the control group (MRI only, AR not activated) and the AR group (AR activated). Software was used to automatically measure the distance between the point of contact on the uterine surface and the myoma. We compared these distances to the true shortest distance to obtain accuracy measures. The time taken to perform the task was measured, and an assessment of the complexity was performed. RESULTS: The mean accuracy in the control group was 16.80 mm [0.1-52.2] versus 0.64 mm [0.01-4.71] with AR. In the control group, the mean time to perform the task was 18.68 [6.4-47.1] s compared to 19.6 [3.9-77.5] s with AR. The mean score of difficulty (evaluated for each myoma) was 2.36 [1-4] versus 0.87 [0-4], respectively, for the control and the AR group. DISCUSSION: We developed an AR system for a very mobile organ. This is the first user study to quantitatively evaluate an AR system for improving a surgical task. In our model, AR improves localization accuracy.

Efficacy and safety of sedation with dexmedetomidine in critical care patients: a meta-analysis of randomized controlled trials.

INTRODUCTION: Dexmedetomidine may help physicians target a low level of sedation. Unfortunately, the impact of dexmedetomidine on major endpoints remains unclear in intensive care unit (ICU). MATERIAL AND METHODS: To evaluate the association between dexmedetomidine use with efficacy and safety outcomes, two reviewers independently identified randomized controlled trials comparing dexmedetomidine with other sedative agents in non-post-cardiac surgery critically ill patients in the PubMed and Cochrane databases. Random effects models were considered if heterogeneity was detected using the DerSimonian and Laird estimation method. Statistical heterogeneity between results was assessed by examining forest plots, confidence intervals (CI) and by using the I(2) statistic. The risk of bias was assessed using the risk of bias tool. RESULTS: This meta-analysis included 1994 patients from 16 randomized controlled trials. Comparators were lorazepam, midazolam and propofol. Dexmedetomidine was associated with a reduction in ICU length of stays (WMD=-0.304; 95% CI [-0.477, -0.132]; P=0.001), mechanical ventilation duration (WMD=-0.313, 95% CI [-0.523, -0.104]; P=0.003) and delirium incidence (RR=0.812, 95% CI [0.680, 0.968]; P=0.020). Dexmedetomidine is also associated with an increase in the incidence of bradycardia (RR=1.947, 95% CI [1.387, 2.733]; P=0.001) and hypotension (RR=1.264; 95% CI [1.013, 1.576]; P=0.038). CONCLUSIONS AND RELEVANCE: In this first meta-analysis including only randomized controlled trials related to ICU patients, dexmedetomidine was associated with a 48h reduction in ICU length of stay, mechanical ventilation duration and delirium occurrence despite a significant heterogeneity among studies. Dexmedetomidine was also associated with an increase in bradycardia and hypotension.