Comparison of lower limb lifting and squeeze exsanguination before tourniquet inflation during total knee arthroplasty.

BACKGROUND: During total knee arthroplasty(TKA), tourniquet is widely used by most surgeons whereas the optimal application is still controversial. With this prospective randomized controlled study, we intend to investigate the effect of lower limb lifting and squeeze exsanguination methods on clinical outcomes in a series of TKAs. METHODS: Prospectively enrolled a total of 236 TKA patients from March, 2012 to November, 2016. Of which 118 patients randomly constitute Group A with lower limb lifting exsanguination technique; and the other 118 patients comprise Group B with squeeze exsanguination method. A year's follow-up measurements were recorded in detail for analysis. RESULTS: The pre-tourniquet time of Group A was significantly shorter than that in Group B (P < 0.001). Significant difference was found on skin tension blister, 3 happened in Group A and 11 happened in Group B (P = 0.031), which resulted in a difference in total complications (P = 0.039). The VAS score was significantly lower in Group A at one and seven days postoperatively, P < 0.001 and P = 0.011, respectively. No significant differences were found regarding all other clinical outcome measurements. CONCLUSION: The lower limb lifting exsanguination is a safe and effective technique. Compared with squeeze exsanguination method, it could decrease the incidence of skin tension blister and alleviate early postoperative pain reaction, no additional risks occurred regarding other clinical outcomes. Thus, it might have the potentiality to be commonly utilized in TKA procedure. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: ChiCTR1800020471. Registered on 31 December 2018 Retrospectively registered.

HEAVEN Criteria: Derivation of a New Difficult Airway Prediction Tool.

OBJECTIVE: Airway management is vitally important in the management of critically ill and injured patients. Current tools to predict the difficult airway have limited application in the emergency airway situation. The aim of this study was to derive a novel difficult airway prediction tool for emergency intubation. METHODS: A retrospective descriptive analysis was performed in a population of air medical rapid sequence intubation patients requiring more than 1 attempt. The Delphi technique was used to classify the etiology for airway failure as reported by providers as part of a performance improvement database. Etiologies were organized into 6 categories, and an acronym was derived for ease of recall. RESULTS: A total of 504 patients were screened, with 63 (12%) patients identified in whom the initial intubation attempt was unsuccessful. All 63 patients (100%) were placed into 1 or more categories (HEAVEN criteria = Hypoxemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination/anemia, and Neck mobility issues). The database was relatively modest in size, and many patients had more than 1 criterion present, limiting our ability to perform prevalence calculations. CONCLUSION: The HEAVEN criteria represent a set of difficult airway predictors that may be applied prospectively by emergency airway personnel, facilitating airway decision making. These criteria should be validated prospectively.

The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination.

BACKGROUND: After the Sandy Hook shootings and the resulting Hartford Consensus, as well as the recent Boston Marathon bombing, the need for a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol became clear. We hypothesized that most states within the United States lack a detailed uniform protocol. METHODS: We performed a systematic nationwide assessment of emergency medical services (EMS) prehospital extremity exsanguination control protocols. An online search (updated February 7, 2015) identified state-, region-, or county-specific EMS protocols in all 50 states. If unavailable online, protocols were retrieved directly by contacting each state's Department of Public Health (or other appropriate agency). Two investigators independently screened each extremity exsanguination control protocol. Protocols were first grouped into three categories: I, tourniquet not mentioned; II, tourniquet mentioned, without specific guidance; III, tourniquet mentioned, with specific guidance related to type, indications, application technique, and safety concerns. Each protocol was then scored on a five-point scale for comparison. RESULTS: Forty-two states (84%) had statewide and 14 (28%) had at least one county-specific protocol. Seven states (16%) had no statewide protocol but at least one county-specific protocol (range, 1-10). Mississippi had neither statewide nor county-specific protocols. Of statewide protocols, 4 (9.5%) were in Category I, 23 (54.8%) in Category II, and 15 (35.7%) in Category III. The mean score for statewide tourniquets was 2.4/5 (SD, 1.25; range, 0-5). Thirteen (31%) statewide protocols referred to "commercial" or "approved" tourniquets; only three (7%) recommended a particular commercial device. The mean score for the county-specific protocols of states with no statewide protocol was 3.10 (SD, 1.56; range, 0-5) CONCLUSIONS: Throughout the United States, there is considerable variability in EMS protocols addressing the management of extremity exsanguination and an alarming absence of specific guidance for tourniquet use. Most states do not have a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol. LEVEL OF EVIDENCE: Epidemiologic and prognostic study, level III.

Life-threatening hemorrhage associated with dental implant surgery: a review of the literature.

OBJECTIVES: Life-threatening bleeding may occur during implant placement. PURPOSE: The present review was conducted to evaluate the localization, the symptoms, and therapies of life-threatening bleedings associated with implant placement. MATERIAL AND METHODS: A literature review including 590 articles was performed in PubMed, Medline, and Cochrane database. Any article reporting on life-threatening bleeding was included which additionally reported on the site of implant surgery. RESULTS: Twenty-seven cases were extracted. In the majority of the cases, bleeding occurred in the anterior interforaminal region. Aside local management stopping the bleedings, most cases required intubation or tracheotomy. CONCLUSIONS: Surgeons must be aware of the risk of severe bleedings during implant surgery and should immediately refer patients to a specialized clinic in suspicious or proved cases.

Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population.

BACKGROUND: Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. METHODS: Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. RESULTS: MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9-95.8). The area under the receiver operating characteristic curve for the model was 0.859. CONCLUSION: From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation. LEVEL OF EVIDENCE: Prognostic study, level III.

The STOP the Bleeding Campaign.

According to the World Health Organization, traumatic injuries worldwide are responsible for over 5 million deaths annually. Post-traumatic bleeding caused by traumatic injury-associated coagulopathy is the leading cause of potentially preventable death among trauma patients. Despite these facts, awareness of this problem is insufficient and treatment options are often unclear. The STOP the Bleeding Campaign therefore aims to increase awareness of the phenomenon of post-traumatic coagulopathy and its appropriate management by publishing European guidelines for the management of the bleeding trauma patient, by promoting and monitoring the implementation of these guidelines and by preparing promotional and educational material, organising activities and developing health quality management tools. The campaign aims to reduce the number of patients who die within 24 hours after arrival in the hospital due to exsanguination by a minimum of 20% within the next 5 years.

Hemorragias obstétricas exanguinantes / Exsanguinating obstetric haemorrhages

Objetivo evaluar la etiología, el tratamiento y la morbilidad en un grupo de gestantes con hemorragias obstétricas exanguinantes, así como proponer medidas para su prevención. Material y método estudio retrospectivo y descriptivo efectuado sobre 25 gestantes con edad de 35±5 años que ingresaron desde marzo de 1991 hasta febrero de 2008 en la División de Cuidados Intensivos por presentar hemorragias de origen obstétrico (con un monto estimado superior a 4.000ml) y que requirieron transfusiones iguales o mayores de 10 U de glóbulos rojos. Resultados hubo 11 desgarros cervicovaginales y roturas uterinas. El 88% de los casos presentó shock hemorrágico. El promedio de hematíes sedimentados transfundidos fue de 14,8±5,1U, y el hematocrito alcanzado al cabo de las siguientes 24h fue del 20,6±6,2%. En el caso de 20 enfermas se recurrió a la histerectomía como última medida para controlar la hemorragia masiva. Siete de las mujeres histerectomizadas presentaron hemorragia retroperitoneal o intraperitoneal, y hubo que reintervenirlas quirúrgicamente por hemorragias persistentes. Veintidós enfermas presentaron coagulopatía por consumo; 6 de ellas, coagulación intravascular diseminada. En la mitad de las puérperas se presentaron complicaciones graves. Cinco mujeres sufrieron lesiones quirúrgicas: 2 mujeres sufrieron lesiones rectosigmoideas, 2 mujeres sufrieron lesiones vasculares y una mujer sufrió lesión vesical. Ocho mujeres presentaron distrés pulmonar; 2 de ellas, disfunción multiorgánica. Las 25 puérperas sobrevivieron sin secuelas. Conclusiones a) Los desgarros cervicovaginales y las roturas uterinas representaron las causas más frecuentes de hemorragias exanguinantes; b) la histerectomía, aunque necesaria, no resolvió la hemorragia en el 40% de los casos; c) hubo un elevado índice de complicaciones, y d) la supervivencia materna fue óptima (AU)

Objective: To evaluate etiology, treatment and morbidity in a group of pregnant women with exsanguinating obstetric haemorrhage and to propose measures for its prevention. Material and methods: We performed a retrospective, descriptive study of 25 pregnant women, aged 3575 years, admitted to the Intensive Care Division from March 1991 to February 2008 with obstetric haemorrhage exceeding 4000 ml and transfusion requirement equal to or greater than 10 units of red blood cells. Results: There were 11 cervico-vaginal lacerations and uterine ruptures. Haemorrhagic shock occurred in 88% of the patients. The mean red cell transfusion requirement was14.875.1 units, and the hematocrit after 24 h was 20.676.2%. Hysterectomy wasperformed as the last option to stop massive bleeding in 20 patients. Retro and/or intraperitoneal bleeding occurred in seven patients with hysterectomy, who underwent reintervention for persistent bleeding. Coagulation factor defects were found in 22 patients, of whom six had disseminated intravascular coagulation. Serious complications occurred in 50% of the patients. Five patients had recto sigmoid(2), vascular (2) and bladder (1) surgical lesions. Eight had respiratory distress; of these, two had multiple organ dysfunction. The 25 puerperal women survived without recurrences. Conclusions: a). The most frequent causes of exsanguinating bleeding were cervicovaginal lacerations and uterine ruptures. b). Hysterectomy, although necessary, did not resolve the bleeding in 40% of the patients. c). There was a high rate of maternal complications d). Survival was optimal (AU)