Abstract:Background:Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury.Methods:Adu… Show more
“…After the removal of duplicates, screening abstracts, and a full-text review applying the inclusion and exclusion criteria, 8 articles remained and were included in this systematic review. 12-19 6 were retrospective cohort studies, one was a prospective study, and 1 was a quasi-randomized clinical trial. A PRISMA table summarizing search results can be found in Figure 1.Figure 1.PRISMA flow diagram of included studies in the systematic review.…”
Section: Resultsmentioning
confidence: 99%
“…12-17 Six studies reported no statistical difference in in-hospital mortality between either cohort (Table 4). 13-17,19 One study reported an increase in mortality in the PPP cohort (Table 4). 12 Four studies reported the rate of DVT in patients following PPP or AE (Table 4).…”
Section: Resultsmentioning
confidence: 99%
“…Six studies reported transfusions of packed red blood cells within 24 hours following PPP or AE (Table 4). [13][14][15][16][17]19 None of these studies identified a statistically significant difference in PRBC requirements for either cohort (Table 4). [13][14][15][16][17]19 Seven studies evaluated in-hospital mortality for patients undergoing PPP or AE (Table 4).…”
Section: Systematic Reviewmentioning
confidence: 99%
“…[13][14][15][16][17]19 None of these studies identified a statistically significant difference in PRBC requirements for either cohort (Table 4). [13][14][15][16][17]19 Seven studies evaluated in-hospital mortality for patients undergoing PPP or AE (Table 4). [12][13][14][15][16][17] Six studies reported no statistical difference in in-hospital mortality between either cohort (Table 4).…”
Section: Systematic Reviewmentioning
confidence: 99%
“…12 Four studies reported the rate of DVT in patients following PPP or AE (Table 4). 13,[17][18][19] One study reported a significantly greater risk of DVT in the PP group. 19…”
Background Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE). Methods A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate. Results Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = −1.0, 95% CI: −1.8 to −.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups. Conclusion The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.
“…After the removal of duplicates, screening abstracts, and a full-text review applying the inclusion and exclusion criteria, 8 articles remained and were included in this systematic review. 12-19 6 were retrospective cohort studies, one was a prospective study, and 1 was a quasi-randomized clinical trial. A PRISMA table summarizing search results can be found in Figure 1.Figure 1.PRISMA flow diagram of included studies in the systematic review.…”
Section: Resultsmentioning
confidence: 99%
“…12-17 Six studies reported no statistical difference in in-hospital mortality between either cohort (Table 4). 13-17,19 One study reported an increase in mortality in the PPP cohort (Table 4). 12 Four studies reported the rate of DVT in patients following PPP or AE (Table 4).…”
Section: Resultsmentioning
confidence: 99%
“…Six studies reported transfusions of packed red blood cells within 24 hours following PPP or AE (Table 4). [13][14][15][16][17]19 None of these studies identified a statistically significant difference in PRBC requirements for either cohort (Table 4). [13][14][15][16][17]19 Seven studies evaluated in-hospital mortality for patients undergoing PPP or AE (Table 4).…”
Section: Systematic Reviewmentioning
confidence: 99%
“…[13][14][15][16][17]19 None of these studies identified a statistically significant difference in PRBC requirements for either cohort (Table 4). [13][14][15][16][17]19 Seven studies evaluated in-hospital mortality for patients undergoing PPP or AE (Table 4). [12][13][14][15][16][17] Six studies reported no statistical difference in in-hospital mortality between either cohort (Table 4).…”
Section: Systematic Reviewmentioning
confidence: 99%
“…12 Four studies reported the rate of DVT in patients following PPP or AE (Table 4). 13,[17][18][19] One study reported a significantly greater risk of DVT in the PP group. 19…”
Background Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE). Methods A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate. Results Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = −1.0, 95% CI: −1.8 to −.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups. Conclusion The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.
Objectives:
To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing (PPP) in patients with pelvic ring injuries and hemodynamic instability (HDI).
Methods:
Design: Retrospective review
Setting:
Urban level one trauma center
Patients Selection Criteria:
Severely injured (Injury severity score (ISS) >15) patients with pelvic ring injuries treated before and after increasing threshold to perform PPP from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure (SBP) <90 mmHg.
Outcome Measures and Comparisons:
Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms (VTE) before and after increasing PPP threshold.
Results:
166 patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n=43) of the historical protocol group and 49.3% (n=36) of the updated protocol group (p=0.69). The median age of HDI patients was 35.0 years (IQR 26.0 and 52.0), 74.7% (n=59) were males, and the median ISS was 41.0 (IQR 29.0 to 50.0). HDI patients in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; p=0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, p=0.03), and did not differ in age, ISS, SBP on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta (REBOA), resuscitative thoracotomy (RT), angioembolization (AE), or anterior pelvis open reduction internal fixation (p>0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, p<0.0001) and there were fewer anterior pelvic infections (0.0% vs. 13.9%, p=0.02), fewer VTEs (8.3% vs. 30.2%; p=0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, p=1.00).
Conclusions:
Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage.
Level of Evidence:
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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