Comparison of the impact of applications of Targeted Transfusion Protocol and Massive Transfusion Protocol in trauma patients / 대한마취과학회지

BACKGROUND: The current study assessed a recently developed resuscitation protocol for bleeding trauma patients called the Targeted Transfusion Protocol (TTP) and compared its results with those of the standard Massive Transfusion Protocol (MTP). METHODS: Per capita utilization of blood products such as packed red blood cells (RBCs), fresh frozen plasma (FFP), and platelet concentrates was compared along with mortality rates during two 6-month periods, one in 2011 (when the standard MTP was followed) and another in 2014 (when the TTP was used). In the TTP, patients were categorized into three groups based on the presence of head injuries, long bone fractures, or penetrating injuries involving the trunk, extremities, or neck who were resuscitated according to separate algorithms. All cases had experienced motor vehicle accidents and had injury severity scores over 16. RESULTS: No statistically significant differences were observed between the study groups at hospital admission. Per capita utilization of RBC (4.76 ± 0.92 vs. 3.37 ± 0.55; P = 0.037), FFP (3.71 ± 1.00 vs. 2.40 ± 0.52; P = 0.025), and platelet concentrate (1.18 ± 0.30 vs. 0.55 ± 0.18; P = 0.006) blood products were significantly lower in the TTP epoch. Mortality rates were similar between the two study periods (P = 0.74). CONCLUSIONS: Introduction of the TTP reduced the requirements for RBCs, FFP, and platelet concentrates in severely injured trauma patients.

Which One is Better? Comparison of the Acute Inflammatory Response, Raja Isteri Pengiran Anak Saleha Appendicitis and Alvarado Scoring Systems

PURPOSE: Acute appendicitis (AA) is one of the most common causes of an acute abdomen. The accuracies of the Alvarado and the acute inflammatory response (AIR) scores in the diagnosis of appendicitis is very low in Asian populations, so a new scoring system, the Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) system, was designed recently. We applied and compared the Alvarado, AIR, and RIPASA scores in the diagnoses of appendicitis in the Iranian population. METHODS: We prospectively compared the RIPASA, Alvarado, and AIR systems by applying them to 100 patients. All the scores were calculated for patients who presented with right quadrant pain. Appendectomies were performed; then, the postoperative pathology reports were correlated with the scores. Scores of 8, 7, and 5 or more are optimal cutoffs for the RIPASA, Alvarado, and AIR scoring systems, respectively. The sensitivities, specificities, positive predictive values, negative predictive values (NPVs), positive and negative likelihood ratios (LRs) for the 3 systems were determined. RESULTS: The sensitivity and the specificity of the RIPASA score were 93.18% and 91.67%, respectively. The sensitivities of the Alvarado and the AIR scores were both 78.41%. The specificities of the Alvarado and the AIR scores were 100% and 91.67%, respectively. The RIPASA score correctly classified 93% of all patients confirmed with histological AA compared with 78.41% for the Alvarado and the AIR scores. CONCLUSION: The RIPASA scoring system had more sensitivity, better NPV, a positive LR, and a less negative LR for the Iranian population whereas the Alvarado scoring system was more specific.

Tube thoracostomy [chest tube] removal in traumatic patients: what do we know? What can we do?

Chest tube [CT] or tube thoracostomy placement is often indicated following traumatic injuries. Premature movement of the chest tube leads to increased hospital complications and costs for patients. Placement of a chest tube is indicated in drainage of blood, bile, pus, drain air, and other fluids. Although there is a general agreement for the placement of a chest tube, there is little consensus on the subsequent management. Chest tube removal in trauma patients increases morbidity and hospital expense if not done at the right time. A review of relevant literature showed that the best answers to some questions about time and decision-making have been long sought. Issues discussed in this manuscript include chest tube removal conditions, the need for chest radiography before and after chest tuberemoval, the need to clamp the chest tube prior to removal, and drainage rate and acceptability prior to removal

Perihepatic packing versus primary surgical repair in patients with blunt liver trauma; an 8-year experience

Objective: To explore the pros and cons of early versus delayed intervention when dealing with severe blunt liver injury with significant hemoperitoneum and hemodynamic instability

Methods: This retrospective cross-sectional study was performed at the Nemazi hospital, Shiraz, Southern Iran, level I trauma Center affiliated with Shiraz University of Medical Sciences. The study population comprised of all patients who were operated with the impression of blunt abdominal trauma and confirmed diagnosis of liver trauma during an 8-year period. All data were extracted from patients' hospital medical records during the study period. The patients' outcome was compared between those who underwent perihepatic packing or primary surgical repair

Results: Medical records of 76 patients with blunt abdominal liver trauma who underwent surgical intervention were evaluated. Perihepatic packing was performed more in patients who have been transferred to operation room due to unstable hemodynamics [p<0.001] as well as in patients with more than 1000 milliliters of hemoperitoneum based on pre-operative imaging studies [e.g. CT/US] [p=0.002]

Conclusion: We recommend that trauma surgeons should approach perihepatic packing earlier in patients who have been developed at least two of these three criteria; unstable hemodynamics, more than 1000 milliliters hemoperitoneum and more than 1600 milliliters of intra-operative estimated blood loss. We believe that considering these criteria will help trauma surgeons to diagnose and treat high risk patients in time so significant hemorrhage [e.g. caused by dilatational coagulopathy, hypothermia and acidosis, etc.] can ultimately be prevented and more lives can be saved

Determinants of successful non-operative management of intra- peritoneal bleeding following blunt abdominal trauma

Objectives: To identify the predictive factors of successful non-operative management of patients with intraperitoneal bleeding following blunt abdominal trauma

Methods: This was cross-sectional study being performed in our Level I trauma center in southern Iran between 2010 and 2011. We included adult [>14 years] patients with blunt abdominal trauma and intraperitoneal hemorrhage detected by CT-Scan who were hemodynamically stable and did not require any surgical intervention. Patients were managed conservatively in ICU. Those who required laparotomy during the study period were named as non-operative management failure [NOM-F] while the other were nonoperative management success [NOM-S]. The baseline, clinical and laboratory characteristics were compared between two study groups in order to detect the predictors of successful NOM of intra-peritoneal bleeding

Results: Overall we included 80 eligible patients among whom there were 55 [68.7%] men and 25 [31.3%] women with mean age of 30.63.6 +/- years. Finally, 43 [53.8%] were successfully managed conservatively [NOM-S] while 37 [46.2%] required laparotomy [NOM-F]. We found that those who underwent emergency laparotomy had significantly higher [delta]Hb [p=0.016] and lower base deficit [p=0.005] when compared to those who were successfully managed conservatively. Those who required surgical intervention had significantly lower baseline systolic blood pressure [p<0.001] and higher shock index [p=0.002]. The other parameters such as pulse rate and respiratory rate were comparable between two study groups

Conclusion: In patients with intra-peritoneal bleeding following blunt abdominal trauma, the most reliable predictive clinical and para-clinical factor of successful non-operative management are shock index and systolic blood pressure on arrival, base deficit and hemoglobin drop within first 12 hours of admission

Short-term outcome of early tracheostomy in the trauma patients admitted to intensive care unit: a comparative study

Objectives: To compare the results of early versus late tracheostomy in trauma patients admitted to intensive care unit [ICU]

Methods: This was case control study being performed at a major trauma centre in Shiraz, Iran including 120 trauma patients admitted to ICU during a 2-year period and underwent tracheostomy during their ICU stay. The patients were categorized into two groups of the early tracheostomy who underwent tracheostomy within the first 7 days of initiation of mechanical ventilation [n=60], and the late tracheostomy group, in which tracheostomy was performed after 7 days [n=60]. The duration of mechanical ventilation, ICU stay and hospital stay as well as mortality rates in ICU and hospital were recorded and compared between two study groups

Results: The baseline characteristics such as age [p=0.325], sex [p=0.071] Glasgow coma scale [GCS] [p=0.431] and the mechanism of injury [p=0.822] were comparable between two study groups. Early tracheostomy was associated with a significantly shorter duration of mechanical ventilation [p=0.008] and shorter ICU stay [p=0.003]. Hospital stay [p=0.165], ICU mortality [p=0.243], and hospital mortality [p=0.311] were not different between the two study groups

Conclusion: Early tracheostomy is associated with reduced ICU stay and shorter duration of mechanical ventilation. Adopting a standardized strategy may improve resource utilization