Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma.

This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings.

A Near-Fatal Encounter with Acute Suicidal Behavior in Anti-N-methyl-D-aspartate Autoimmune Encephalitis.

Anti-N-methyl-D-aspartate receptor encephalitis (anti-NMDARE) is a complex neuropsychiatric syndrome known for its diverse neurological manifestations, often involving psychiatric symptoms and seizures that elevate the risk of suicidal ideation and behavior. We present a case illustrating the potentially lethal nature of anti-NMDARE, wherein an unexpected suicide attempt occurred 10 days after the onset of seizures in a 21-year-old man. Upon arrival at the emergency room, immediate interventions addressed hypovolemic shock, followed by subsequent neurosurgical and orthopedic procedures. Six days after cessation of sedation, the patient exhibited atypical focal seizures, behavioral arrest, psychotic responses, and delusions. Despite normal brain magnetic resonance imaging and cerebrospinal fluid (CSF) analysis results, a high CSF immunoglobulin G index and posterior hypometabolism on brain F-fluorodeoxyglucose positron emission tomography raised suspicion of autoimmune encephalitis. Steroids and intravenous immunoglobulins were administered. A comprehensive evaluation ruled out other conditions. Serum and CSF tests confirmed the presence of anti-NMDAR antibodies. This case highlights the potential lethality of the acute stage of anti-NMDARE, emphasizing the absence of apparent psychiatric symptoms before a suicide attempt. Further studies on suicidality associated with anti-NMDARE are crucial, underscoring the importance of vigilance in cases involving newly diagnosed seizures or psychoses.

Evaluation of red blood cell transfusion threshold in the management of brain-dead organ donors.

The disparity between the demand and supply of organs has necessitated an expansion of the criteria for organ donation. Consequently, numerous guidelines have been proposed for managing brain-dead organ donors (BDODs) to improve their organ function and the organ procurement rate. Therefore, we aimed to evaluate the previously recommended threshold for red blood cell transfusion in BDODs. Medical records of BDODs were retrospectively reviewed from January 2012 to December 2021. We enrolled BDODs who stayed for more than 24 hours at an hospital organ procurement organization. We analyzed their organ function and the rate of organ procurement according to the hemoglobin concentration. A total of 111 BDODs were enrolled and divided into the following 2 groups: hemoglobin (Hb) ≥ 10 g/dL (45.0 %) and Hb < 10 g/dL (55.0 %). There were no significant differences between the groups in the total bilirubin, creatinine, arterial blood lactate, and the rate of organ procurement. A correlation analysis did not reveal any association between the hemoglobin concentration and organ function of the BDODs. Hemoglobin concentration of 10 g/dL cannot be considered a threshold for red blood cell transfusion. Furthermore, organ function is not correlated with a hemoglobin concentration > 7 g/dL. Restrictive transfusion strategy is appropriate for BDOD management.

Risk factors for end-stage renal disease in patients with trauma and stage 3 acute kidney injury.

ABSTRACT: Research on long-term renal outcomes in patients with acute kidney injury (AKI) and trauma, especially those with traumatic brain injury (TBI), has been limited.In this study, we enrolled patients with stage 3 AKI as per the Kidney Disease Improving Global Outcomes guidelines, who initiated renal replacement therapy (RRT). These patients were divided into 2 groups depending on the presence of TBI. Comparing the baseline characteristics and management strategies of each group, we analyzed whether TBI affects the progression of kidney disease.Between January 1, 2014 and June 30, 2020, 51 patients who initiated RRT due to AKI after trauma were enrolled in this study. TBI was identified in 20 patients, and the clinical conditions were not related to TBI in the remaining 31. The study endpoint was set to determine whether the patients of each group needed RRT persistently at discharge and at the time of recent outpatient clinic. Six (30.0%) out of 20 patients with TBI and 2 (6.5%) out of 31 patients without TBI required conventional hemodialysis, as per the most recent data. No significant within-group differences were found in terms of the baseline characteristics and management strategies. In the logistic regression analysis, TBI was independently associated with disease progression to end-stage renal disease.TBI is a risk factor for end-stage renal disease in patients with trauma and stage 3 AKI who initiate RRT.

Feasibility of the Ultrasound-Guided Insertion of the Peripherally Inserted Central Catheter (PICC) by the Vascular Surgeon at the Bedside in the Trauma Intensive Care Unit.

BACKGROUND: This study analyzed the outcomes of the ultrasound-guided insertion of the peripherally inserted central venous catheter (PICC) by experienced vascular surgeons at the bedside of the trauma intensive care unit (ICU) and compared the outcomes with those of fluoroscopy-guided PICC performed by radiologists in the interventional suite. METHODS: Between May 1, 2016, and April 30, 2021, 97 patients who were hospitalized in the trauma ICU and underwent PICC insertion were enrolled in the study. Forty-two out of the 97 patients underwent PICC insertion by interventional radiologists in the interventional radiology suite under fluoroscopy guidance, while the remaining 55 cases underwent ultrasound-guided PICC insertion by the vascular surgeon at the trauma ICU bedside. RESULTS: The technical failure (P = 0.504) and malposition (P = 0.127) rates were not significantly different between the 2 groups. However, it took significantly less time for the vascular surgeon to complete the PICC insertion procedure (P < 0.001). Significantly more patients of the ultrasound-guided group required inotropes (P = 0.012) and mechanical ventilation (P = 0.003) at the time of the procedure. In addition, the ultrasound-guided group appeared to be in critical condition in terms of kidney function according to laboratory data (P = 0.014). Meanwhile, the ultrasound-guided group maintained the central line catheter for a shorter time (P < 0.001). CONCLUSIONS: In trauma patients, ultrasound-guided PICC insertion at the bedside by experienced vascular surgeons at the trauma ICU was feasible compared to fluoroscopy-guided insertion performed by interventional radiologists.

Current status of initial antibiotic therapy and analysis of infections in patients with solitary abdominal trauma: a multicenter trial in Korea.

PURPOSE: Proper use of antibiotics during emergency abdominal surgery is essential in reducing the incidence of surgical site infection. However, no studies have investigated the type of antibiotics and duration of therapy in individuals with abdominal trauma in Korea. We aimed to investigate the status of initial antibiotic therapy in patients with solitary abdominal trauma. METHODS: From January 2015 to December 2015, we retrospectively analyzed the medical records of patients with solitary abdominal trauma from 17 institutions including regional trauma centers in South Korea. Both blunt and penetrating abdominal injuries were included. Time from arrival to initial antibiotic therapy, rate of antibiotic use upon injury mechanism, injured organ, type, and duration of antibiotic use, and postoperative infection were investigated. RESULTS: Data of the 311 patients were collected. The use of antibiotic was initiated in 96.4% of patients with penetrating injury and 79.7% with blunt injury. Initial antibiotics therapy was provided to 78.2% of patients with solid organ injury and 97.5% with hollow viscus injury. The mean day of using antibiotics was 6 days in solid organ injuries, 6.2 days in hollow viscus. Infection within 2 weeks of admission occurred in 36 cases. Infection was related to injury severity (Abbreviated Injury Scale of >3), hollow viscus injury, operation, open abdomen, colon perforation, and RBC transfusion. There was no infection in cases with laparoscopic operation. Duration of antibiotics did not affect the infection rate. CONCLUSION: Antibiotics are used extensively (84.2%) and for long duration (6.2 days) in patients with abdominal injury in Korea.

Liver Steatosis in Brain-Dead Donors: Progression Pattern and Affecting Factors.

OBJECTIVES: No study has investigated the short-term effect of acute insulin resistance on liver steatosis in critically ill condition. We analyzed the effects of critically ill conditions of brain-dead donors (BDDs) on the development and progression of liver steatosis to investigate the influencing factors. METHODS: This study was conducted retrospectively between January 2003 and December 2017. BDDs were for organ procurement. BDDs with body mass indexes (BMIs) < 18.5 kg/m2 and ≥ 30 kg/m2 were excluded. Liver steatosis was defined as ≥5% of the fat vacuole. The serum glucose level (SGL) was used to reflect insulin resistance. RESULTS: Of the 179 BDDs, 87 (48.6%) had liver steatosis. BMI (r = 0.176, P = .019) and SGL (r = 0.267, P < .001) were correlated with steatosis. The length of the predonation period (LPDP) was negatively correlated with steatosis (r = -0.379, P < .001). BMI (odds ratio 1.266, P = .002), SGL ≥180 mg/dL (odds ratio 2.825, P = .003), and LPDP (odds ratio 0.885, P = .001) were independent risk factors for liver steatosis. CONCLUSION: Liver steatosis is related to the SGL and BMI. Liver steatosis develops acutely in the early phase of critical illness and patients recover gradually.

Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea.

OBJECTIVE: To investigate the effects of trauma center establishment on the clinical characteristics and outcomes of trauma patients with traumatic brain injury (TBI). METHODS: We enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma. RESULTS: Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICU) admissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment. CONCLUSION: We confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary.

Rapidly growing pediatric trampoline-related injuries in Korea: a 10-year single center retrospective study.

PURPOSE: Several published policy statements have warned against the risks associated with trampoline use and recommended safety guidelines. However, few studies have focused on trampoline-related injuries in Korea. This study aimed to assess the incidence and characteristics of pediatric trampoline-related injuries presented to Ulsan University Hospital. METHODS: We retrospectively reviewed the medical records of children aged <16 years with trampoline-related injuries who visited our Emergency Department between 2008 and 2017. RESULTS: Over the 10-year period, 178 trampoline-related injuries were reported, which represented a significant increase (P=0.016). Most (87.6%) of the injuries occurred during the last 5 study years, and a rapid increase in injuries was observed in children aged <6 years. Lower extremity injuries (62.4%) were the most common, followed by injuries of the upper extremities, head and face, and trunk, including injuries to the neck and spine. Sixty-seven children (37.6%) had fractures, and proximal tibia fractures were the most common. Fractures were significantly more common in younger children (<6 years old) than in older children (P=0.026). CONCLUSION: In Korea, the mechanism of trampoline injury is similar to that of injuries incurred in indoor trampoline parks but is characterized by smaller spaces and multiple users. Trampoline use and the incidence of trampoline-related injuries in children aged <6 years are increasing rapidly. Prohibiting the use of trampolines for children aged <6 years, restricting simultaneous use by multiple children, and ensuring adult supervision should be strictly emphasized. Public awareness and policy guidelines are needed to reduce the incidence of trampoline-related injuries.

The duration of intra-abdominal hypertension strongly predicts outcomes for the critically ill surgical patients: a prospective observational study.

INTRODUCTION: Intra-abdominal hypertension (IAH) is associated with morbidity and mortality in critically ill patients. The present study analyzed the clinical significance of IAH in surgical patients with severe sepsis. METHODS: This was a prospective study carried out in the surgical intensive care unit (SICU). Intra-abdominal pressure (IAP) was measured three times a day via a urinary catheter filled with 25 mL of saline. IAH was defined as an IAP ≥ 12 mmHg, and the peak IAP was recorded as the IAP for the day. Data were analyzed in terms of IAH development and the IAH duration. RESULTS: Of the 46 patients enrolled in the study, 42 developed IAH while in the SICU. The development of IAH aggravated the clinical outcomes; such as longer SICU stay, requirement of ventilator support, and delayed initiation of enteral feeding (EF). The IAH duration showed a significant correlation with pulmonary, renal, and cardiovascular function, and enteral feeding. The IAH duration was an independent predictor of 60-day mortality (odds ratio: 1.196; p = 0.014). CONCLUSIONS: The duration of IAH is a more important prognostic factor than the development of IAH; thus every effort should be made to reduce the IAH duration in critically ill patients. TRIAL REGISTRATION: NCT01784458.

Beneficial effect of low caloric intake in the early period after orthotopic liver transplantation: a new concept using graft weight.

BACKGROUND/AIMS: Although various factors are correlated with early graft function after orthotopic liver transplantation (OLT), caloric supplementation is not considered in postoperative period. This retrospective study investigated the correlation between caloric intake and early graft function and compared calorie/ body weight ratio (CBWR) and calorie/graft weight ratio (CGWR) as standards for nutritional provision. METHODOLOGY: Patients were divided into the low caloric group (<18 kcal/kg/day) and eucaloric group (≥18 kcal/kg/day) according to caloric intake until 48 hours post-OLT. Graft function was assessed according to aminotransferase level, bilirubin level, and international normalised ratio (INR) on postoperative days (POD) 0, 2, and 7. The variables associated with caloric intake were compared to identify the superiority between CBWR and CGWR. RESULTS: There were 32 and 8 patients in the low caloric and eucaloric groups. INR on POD 2 was significantly lower in the low caloric group (p = 0.018). CGWR was more strongly correlated with INR than CBWR on POD 2 (r = 0.08, p = 0.63 vs. r = 0.36, p = 0.024). CONCLUSIONS: Low caloric intake has a beneficial effect on the restoration of early graft function. CGWR is superior to CBWR as a standard for nutritional supplementation.

Acute limb ischemia: surgical thromboembolectomy and the clinical course of arterial revascularization at ankle.

Surgical thromboembolectomy for acute limb ischemia using Fogarty catheter is basically a blind procedure. Therefore, the complete removal of thromboemboli in all calf arteries is difficult even if completion angiography or radiological intervention is performed. The purpose of this study is to identify whether limb salvage could be achieved if at least one ankle artery was revascularized by surgical thromboembolectomy. We also observed the effectiveness of below-knee popliteal approach. Over 1 year, surgical thromboembolectomy via below-knee popliteal artery was performed on 18 acutely ischemic limbs in 14 consecutive patients. All patients were diagnosed based on clinical symptoms and computed tomography (CT) angiography. Surgical thromboembolectomy was terminated when a pulse was detected by a handheld vascular Doppler device in at least one ankle artery after closing the arteriotomy. Patients were observed during postoperative anticoagulation therapy. Of the 14 patients, 1 died and 1 underwent amputation due to the already necrotized lesion in the foot. After 1 week of anticoagulation therapy, two or more arterial pulses were detected at the ankles in all 15 limbs from the remaining 12 patients. During the 6 to 18 months of follow-up, all 15 limbs were salvaged successfully. In acute limb ischemia, successful limb salvage could be achieved by the revascularization of at least one ankle artery by surgical thromboembolectomy with concomitant anticoagulation therapy. Below-knee popliteal approach is an effective method and is worth for further study compared with other approaches.

Enteral nutrition associated non-occlusive bowel ischemia.

We describe two patients, with no previous history of vascular problems but poor lung function, who experienced septic shock due to bowel ischemia. Both were fed an enteral formula rich in fiber using a feeding tube and experienced septic shock with regular enteral feeding. Surgical finding showed hemorrhagic ischemia in the bowel. The pathologic finding suggests these changes may have been due to inspissations of bowel contents, which may put direct pressure on the mucosa of the bowel wall, leading to local impairment of mucosal and submucosal blood flow with subsequent bowel necrosis. Bowel ischemia may have been precipitated by an increased mesenteric blood flow requirement in combination with a metabolically stressed bowel. Patients in the intensive care unit fed a fiber-rich enteral formula may have inspissated bowel contents, leading to bowel ischemia, suggesting that the use of fiber-rich formula should be limited in patients at high-risk of bowel ischemia.

Non-invasive ventilation for surgical patients with acute respiratory failure.

PURPOSE: Acute respiratory failure is a relatively common complication in surgical patients, especially after abdominal surgery. Non-invasive ventilation (NIV) is increasingly used in the treatment of acute respiratory failure. We have assessed the usefulness of NIV in surgical patients with acute respiratory failure. METHODS: We retrospectively reviewed the medical charts of patients who were admitted to a surgical intensive care unit between March 2007 and February 2008 with acute respiratory failure. The patients who have got respiratory care for secondary reason such as sepsis and encephalopathy were excluded from this study. RESULTS: Of the 74 patients who were treated with mechanical ventilation, 15 underwent NIV and 59 underwent invasive ventilation. The causes of acute respiratory failure in the NIV group were atelectasis in 5 patients, pneumonia in 5, acute lung injury in 4, and pulmonary edema in 1, this group included 3 patients with acute respiratory failure after extubation. Overall success rate of NIV was 66.7%. CONCLUSION: NIV may be an alternative to conventional ventilation in surgical patients with acute respiratory failure. Use of NIV may avoid re-intubation in patients who develop respiratory failure after intubation.