Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China; Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China.
Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China.
Am J Emerg Med. 2019 Apr;37(4):571-578. doi: 10.1016/j.ajem.2018.06.027. Epub 2018 Jun 20.
The mortality rate of patients with hemodynamic instability due to severe pelvic fracture remains substantial and massive transfusion happens frequently. Angio-embolization, external fixation and preperitoneal pelvic packing of the pelvis are the main managements used to control bleeding in these patients. In this paper, we aimed at characterizing the rationale of these surgical managements, and placed them in optimal management algorithm to compose a new guideline.
We selected controlled trials, assessing safety of management for the intervention of hemorrhagic shock from mortality data, and assessing efficacy from volume of first 24 h blood transfusion following hospitalization. Six single and combined managements were extracted as comparison. A pairwise meta-analysis was conducted using a random effect model, and then the analysis was extended to a network meta-analysis. Pooled effect sizes were ranked and demonstrated the probability of being the best treatments for safety and efficacy.
13 clinical trials and 24,396 participants were identified for this analysis. The assessment of rank probability indicated that pelvic packing presented the greatest likelihood of improving safety, while external fixation was indicated most efficient among the interventions for controlling hemorrhage.
Clinical protocols for guidelines of hemodynamically unstable pelvic fracture patients have been multidirectionally developed. We strongly support the initial application of an external fixator. Provided that patients remain hemodynamically unstable after application of an external fixation, pelvic packing is the next procedure to consider. Angio-embolization is the complementary but not alternative method of choice subsequently.
由于严重骨盆骨折导致血流动力学不稳定的患者死亡率仍然很高，且经常需要大量输血。血管栓塞、外固定和骨盆前腹膜填塞是用于控制这些患者出血的主要治疗方法。在本文中，我们旨在描述这些手术治疗的原理，并将其放入最佳管理算法中，以制定新的指南。
我们选择了对照试验，从死亡率数据评估干预治疗出血性休克的安全性，并从住院后 24 小时内的首次输血量评估疗效。提取了 6 种单一和联合治疗方法作为比较。使用随机效应模型进行了成对荟萃分析，然后将分析扩展到网络荟萃分析。对汇总的效应大小进行了排名，并展示了其作为安全性和疗效最佳治疗方法的概率。
本分析共纳入了 13 项临床试验和 24396 名参与者。等级概率评估表明，骨盆填塞在改善安全性方面最有可能，而外固定在控制出血方面是最有效的干预措施之一。
针对血流动力学不稳定骨盆骨折患者的指南临床方案已经得到了多方位的发展。我们强烈支持初始应用外固定器。如果患者在应用外固定器后仍然血流动力学不稳定，那么接下来考虑的是骨盆填塞。血管栓塞是随后的补充但不是首选方法。
