腹膜前盆腔填塞可降低因不稳定骨盆骨折导致危及生命出血患者的死亡率。
Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures.
作者信息
Burlew Clay Cothren, Moore Ernest E, Stahel Philip F, Geddes Andrea E, Wagenaar Amy E, Pieracci Fredric M, Fox Charles J, Campion Eric M, Johnson Jeffrey L, Mauffrey Cyril
机构信息
From the Department of Surgery (C.C.B., E.E.M., A.E.G., A.E.W., F.M.P., C.J.F., E.M.C., and J.L.J.), Denver Health Medical Center and the University of Colorado Denver, Denver, CO, and the Department of Orthopedics (P.F.S., C.M.), Denver Health Medical Center, Denver, CO.
出版信息
J Trauma Acute Care Surg. 2017 Feb;82(2):233-242. doi: 10.1097/TA.0000000000001324.
BACKGROUND
A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality.
METHODS
In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage.
RESULTS
During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival.
CONCLUSIONS
PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion.
LEVEL OF EVIDENCE
Therapeutic study, level IV.
背景
2015年美国创伤外科协会的一项试验报告称，骨盆骨折休克患者的死亡率为32%。血管栓塞术（AE）是最常见的干预措施；马里兰小组显示，至血管栓塞术的平均时间为5小时。本研究的目的是评估另一种骨盆出血治疗方法的干预时间和疗效。我们假设腹膜前骨盆填塞（PPP）可缩短干预时间并降低死亡率。
方法
2004年，我们启动了一项针对骨盆骨折出血的PPP方案。
结果
在为期11年的研究中，2293例患者因骨盆骨折入院；128例（6%）患者接受了PPP（平均年龄44±2岁；损伤严重度评分（ISS）48±1.2）。急诊科最低收缩压为74 mmHg，最高心率为120次/分。手术中位时间为44分钟，109例（85%）患者还接受了3次额外手术。入住外科重症监护病房（SICU）前与术后24小时的红细胞输注中位数分别为8单位和3单位（p<0.05）。PPP术后，16例（13%）患者接受了有记录的动脉造影剂外渗的血管栓塞术。该高危组的死亡率为21%。死亡原因包括脑损伤（9例）、多器官功能衰竭（4例）、肺或心力衰竭（6例）、放弃支持（4例）、不良生理状况（3例）和毛霉菌感染（1例）。在那些出现生理耗竭的患者中，2例在到达后89分钟和100分钟死于手术室，1例在到达后9小时死亡。
结论
与采用血管栓塞术的现代系列研究相比，PPP可缩短干预时间并降低死亡率。在死亡率方面，只有3例（2%）死亡归因于出血的直接后遗症和生理功能衰竭。2例患者死亡时间在100分钟以内，血管栓塞术不太可能可行。对于尽管初始输血仍不稳定的骨盆骨折相关出血患者，应采用PPP。
证据水平
治疗性研究，IV级。
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