Mathew Sarah, Smith Brian P, Cannon Jeremy W, Reilly Patrick M, Schwab C William, Seamon Mark J
From the Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
J Trauma Acute Care Surg. 2017 Mar;82(3):512-517. doi: 10.1097/TA.0000000000001334.
Arterial shunting is a well-described method to control hemorrhage and rapidly reestablish flow, but optimal shunt dwell times remain controversial. We hypothesized that prolonged shunt dwell times of more than 6 hours are related to adverse outcomes after major arterial injury.
A review (2005-2013) of all patients with arterial shunts placed after traumatic injury at our urban Level I trauma center was undertaken. Patients who died prior to shunt removal (n = 7) were excluded. Shunt complications were defined as dislodgement, thrombosis, and distal ischemia. Patients were compared on the basis of shunt complications with respect to clinical parameters.
The 42 patients who underwent arterial shunting after major vascular injury were primarily young (median, 26 years; interquartile range [IQR], 22-31 years) males (97.6%), severely injured (Injury Severity Score, 17.5 [IQR, 14-29]; shunted vessel Abbreviated Injury Scale score, 4 [IQR, 3-4]) by gunshot (85.7%) requiring neck/torso (33.3%) or upper-extremity (19.1%) or lower-extremity (47.6%) shunts. Thirty-five patients survived until shunt removal, and 5 (14.3%) of 35 developed shunt complications. Demographics and clinical characteristics were compared between those with shunt dwell times of less than 6 hours (n = 19) and more than 6 hours (n = 16). While patients appeared to have a greater injury burden overall in the group with dwell times of more than 6 hours, there were no statistical differences between groups with respect to age, gender, initial systolic blood pressure or hemodynamics during the shunt dwell period, use of vasopressors, Abbreviated Injury Scale score of the shunted vessel, Injury Severity Score, or outcomes including limb amputation or mortality. No patients (0/19) with shunt dwell times of less than 6 hours developed complications, whereas 5 (31.3%) of 16 patients with dwell times of more than 6 hours developed shunt complications (p = 0.05).
In this civilian series, 14% of patients with arterial shunts developed shunt complications. Our data suggest that limiting shunt dwell times to less than 6 hours when clinically feasible may decrease adverse outcomes.
Therapeutic/care management study, level IV.
动脉分流术是一种广为人知的控制出血和迅速重建血流的方法，但最佳分流停留时间仍存在争议。我们推测，主要动脉损伤后分流停留时间延长超过6小时与不良预后相关。
对我们城市一级创伤中心2005年至2013年所有创伤后放置动脉分流管的患者进行回顾性研究。排除分流管移除前死亡的患者（n = 7）。分流并发症定义为移位、血栓形成和远端缺血。根据分流并发症情况对患者的临床参数进行比较。
42例主要血管损伤后接受动脉分流术的患者主要为年轻男性（中位年龄26岁；四分位间距[IQR]，22 - 31岁）（97.6%），受伤严重（损伤严重程度评分，17.5[IQR，14 - 29]；分流血管简明损伤量表评分，4[IQR，3 - 4]），因枪伤（85.7%）需要在颈部/躯干（33.3%）、上肢（19.1%）或下肢（47.6%）进行分流。35例患者存活至分流管移除，其中35例中有5例（14.3%）发生分流并发症。对分流停留时间小于6小时（n = 19）和大于6小时（n = 16）的患者的人口统计学和临床特征进行比较。虽然分流停留时间大于6小时的患者总体损伤负担似乎更大，但两组在年龄、性别、分流停留期间的初始收缩压或血流动力学、血管升压药的使用、分流血管的简明损伤量表评分、损伤严重程度评分或包括肢体截肢或死亡率在内的预后方面无统计学差异。分流停留时间小于6小时的患者中无1例（0/19）发生并发症，而分流停留时间大于6小时的16例患者中有5例（31.3%）发生分流并发症（p = 0.05）。
在这个 civilian 系列中，14%的动脉分流患者发生了分流并发症。我们的数据表明，在临床可行时将分流停留时间限制在小于6小时可能会减少不良预后。
治疗/护理管理研究，IV级。
