Preperitoneal Pelvic Packing: How and When

Abstract

Pelvic fractures can lead to life-threatening hemorrhage, particularly as they tend to occur in the setting of polytrauma. Several approaches to hemorrhage control have been employed in pelvic fracture patients over the years. This review describes the indications, operative technique, and outcomes for preperitoneal pelvic packing (PPP). Pelvic packing should be considered for every hemodynamically unstable patient with a significant pelvic fracture. We describe how this can be accomplished in coordination with other resuscitative efforts and operative needs.

Extraperitoneal pelvic packing in trauma of the pelvis: A standard practice? A general review

“…Regarding the effectiveness of this technique, when properly applied, it reduced both the transfusion requirement and the number of deaths by exsanguination data confirmed by Osvaldo et al and Nina et al [19,20]. Reducing the need for transfusion is an important aspect that requires attention because it has been identified as an independent factor that causes multiple organ failure and death, so reducing the number of transfusions implies better survival after the first 24 hours [24].…”

“…Osvaldo et al proposed that extraperitoneal packing in trauma of the pelvis and hemodynamic instability should be used only as a bridging solution that ensures the survival of the patient until definitive treatment is available and allows the surgeon to complete the paraclinical investigations that can locate the source of the bleeding [19]. This concept has been also mentioned and confirmed by the group study of Nina et al This technique has a real benefit in small hospitals, as it offers a window of time for the patient to be transferred to a larger trauma center [20]. His group found a better survival in the arm of patients with extraperitoneal packing when compared with the arm without extraperitoneal packing, with the mention that this procedure had to be accompanied by an effective resuscitation in the emergency room such as administration of blood components according to the European 1: 1: 1 protocol [19].…”

The Concept of Damage Control Laparotomy

“…Pelvic fractures are treated by applying pelvic binders. If there is expanding haematoma and patient is unstable then preperitoneal pelvic packing can be done in which laparotomy pads are placed in preperitoneal space via a small suprapubic incision to stop bleeding [26].…”

Análise dos resultados do tratamento multidisciplinar de pacientes com fratura pélvica e choque, submetidos ao tamponamento extraperitoneal de pelve, no Hospital das Clínicas da FMUSP

“…Como desvantagens desta técnica, estão o fato de não assegurar estabilidade adequada em fraturas posteriores e, quando utilizada em fraturas por cisalhamento vertical, necessitar associação de tração esquelética no fêmur homolateral à hemipelve deslocada cranialmente. Além disso, embora fraturas devam ser reduzidas, o excesso de pressão para aproximar os elementos anteriores, em fraturas tipo livro aberto (CAP) que apresentem disjunção de sacroilíaca, pode resultar em agravamento da disjunção e consequente sangramento (49) . Quando o paciente já está com a pelve imobilizada temporariamente, por lençol ou faixa pélvica, é recomendado que este seja substituído pela fixação externa o quanto antes (81) .…”

“…A principal complicação do TXP é a infecção no espaço extraperitoneal, que pode ocorrer em 5,7% a 33% dos casos (32,37) . Os principais fatores associados ao maior risco de infecção são fraturas expostas com feridas abertas, presença de lesão de uretra, bexiga ou reto associada, e a necessidade de novo tamponamento (49) . A realização deste segundo TXP é necessária em 10% a 32% dos pacientes, e o estudo com maior número de pacientes submetidos ao TXP reportou aumento significativo de infecção do espaço extraperitoneal (45% vs. 6%) neste subgrupo (20) .…”