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Resuscitation 10/2012; · 3.60 Impact Factor
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ABSTRACT: BACKGROUND: The current military paradigm for blood transfusion in major trauma favours high plasma:RBC ratios. This study aimed determine whether high plasma:red blood cell (RBC) ratios during massive transfusion for trauma decrease mortality, using meta-analysis of contemporaneous groups matched for injury severity score. METHODS: A systemic review of the published literature for massive blood transfusions in trauma was performed. Patients were categorised into groups based on plasma:RBC transfusion ratios. Meta-analysis was only performed when there were no significant differences in Injury Severity Score (ISS) between ratio groups within studies. The main endpoint was 30-day mortality. RESULTS: Six observational studies reporting outcomes for 1885 patients were included in this meta-analysis. Five studies were from civilian environments and one from a military setting. Ratio cut-offs at 1:2 were the most commonly reported, demonstrating a survival advantage with higher ratios (OR 0.49, 95% CI 0.31-0.80, p=0.004). Ratios≥1:2 showed a significant reduction in mortality compared to lower ratios (OR 0.56, 95% CI 0.40-0.78, p<0.001). Reducing the cut-off level was still protective (ratios between 1:2.5 and 1:4, OR 0.41), although the confidence interval was wide (0.16-1.00, p=0.05) and data heterogenous (I(2)=78%). Ratios of 1:1 were not proven to confer additional benefit beyond ratios of 1:2 (OR 0.50, 95% CI 0.37-0.68, p<0.001). CONCLUSIONS: In groups matched for ISS, there was a survival benefit with high plasma:RBC resuscitation ratios. No additional benefits of 1:1 over 1:2 ratios were identified.
Injury 09/2012; · 1.98 Impact Factor
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ABSTRACT: BACKGROUND: Provision of transfusion support is an important element of contemporary military operations, but presents a considerable logistic burden. Intraoperative blood salvage (IBS) offers the potential to reduce dependency on donated red blood cell (RBC) supply. The aim of this study was to assess the feasibility of IBS in an operational environment. STUDY DESIGN AND METHODS: A "salvage-only" IBS feasibility study was undertaken in a deployed, Anglo-American combat support hospital. All adult patients admitted with combat-related injuries likely to require more than 10 units of RBCs in 12 hours were included. The volume of salvaged blood available for reinfusion was collated with injury type. RESULTS: A total of 130 patients were admitted having sustained combat-related injury. Twenty-nine fulfilled the criteria, of which 27 were identified on admission. Eighteen cases were selected for IBS and salvage was completed in 17. From these 17, the mechanism of injury was 24% gunshot wound (GSW) and 76% blast injury, and injury type was 47% body cavity and 53% extremity. A total of 5578 g RBC mass was salvaged and prepared for reinfusion, representing 7.6% of total requirement. The proportion of RBC mass salvaged to that required was greatest in those with GSWs and cavity injuries, being 39% (673 g/1733 g) and 16% (243 g/1497 g), respectively. CONCLUSION: Salvage is most successful in patients with GSWs and cavity injuries and less appropriate for limb and blast injuries. However, the results of this study present more arguments against IBS than for it, and further research is needed to determine its safety in combat settings.
Transfusion 08/2012; · 3.22 Impact Factor
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ABSTRACT: We read with interest the article by Saeed et al on the incidence of hernia at the site of temporary loop ileostomy closure(1) . Although at one year follow-up they did not visualise any case of a hernial sac, 37% (16/43) had either muscle atrophy or a defect. It should be noted that the post-operative surveillance computed tomography (CT) scans used were not optimised to detect hernia formation, in contrast to some previously published studies(2) . No patient was reported as requiring surgical repair of a hernia at the stoma closure site. © 2012 The Authors Colorectal Disease © 2012 The Association of Coloproctology of Great Britain and Ireland.
Colorectal Disease 06/2012; · 2.93 Impact Factor
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ABSTRACT: The incidence of incisional hernias at the site of stoma closure is surprisingly unclear. A review of the current literature was undertaken to determine how commonly this complication may occur and to assess the quality of evidence available.
A systematic review was performed to identify studies reporting the incidence of incisional hernia after closure of an ileostomy or colostomy. Studies including children (<16 years old) and studies in which >10% of the total number were trauma patients were excluded.
Thirty-four studies provided outcomes for 2,729 closed stomas. Median follow-up time was 36 months but was only described in seven studies. Closure of loop ileostomies was the most commonly performed procedure (48%). The overall reported hernia rate was 7%, but with a wide range among studies (0-48%). Most studies based their hernia rates on retrospective clinical findings only. A separate analysis of three studies that were specifically designed to assess for stoma site hernias found the clinical hernia rate to be 30% (28/93) and the combined clinical/radiological hernia rate to be 35% (33/93). From 11 studies reporting reoperation rates, 51% of patients who developed a hernia required a surgical repair (34/66). There was a lower risk of hernia following reversal of ileostomy versus colostomy (odds ratio 0.28, 95% confidence interval 0.12-0.65).
One in three patients may develop a hernia after stoma closure, and around half of hernias that are detected require repair. Risk of hernia is greater after colostomy closure than after ileostomy closure. Clinical measures to reduce the development of these hernias warrant consideration.
World Journal of Surgery 02/2012; 36(5):973-83. · 2.36 Impact Factor
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ABSTRACT: The primary aim of this study was to assess the accuracy of clinical coding in identifying negative appendicectomies. The secondary aim was to analyse trends over time in rates of simple, complex (gangrenous or perforated) and negative appendicectomies.
Retrospective review of 1210 patients undergoing emergency appendicectomy during a five year period (2006-2010). Histopathology reports were taken as gold standard for diagnosis and compared to clinical coding lists. Clinical coding is the process by which non-medical administrators apply standardised diagnostic codes to patients, based upon clinical notes at discharge. These codes then contribute to national databases. Statistical analysis included correlation studies and regression analyses.
Clinical coding had only moderate correlation with histopathology, with an overall kappa of 0.421. Annual kappa values varied between 0.378 and 0.500. Overall 14% of patients were incorrectly coded as having had appendicitis when in fact they had a histopathologically normal appendix (153/1107), whereas 4% were falsely coded as having received a negative appendicectomy when they had appendicitis (48/1107). There was an overall significant fall and then rise in the rate of simple appendicitis (B coefficient -0.239 (95% confidence interval -0.426, -0.051), p = 0.014) but no change in the rate of complex appendicitis (B coefficient 0.008 (-0.015, 0.031), p = 0.476).
Clinical coding for negative appendicectomy was unreliable. Negative rates may be higher than suspected. This has implications for the validity of national database analyses. Using this form of data as a quality indictor for appendicitis should be reconsidered until its quality is improved.
International journal of surgery (London, England) 02/2012; 10(3):144-7.
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ABSTRACT: This study aimed to analyse predictive factors and outcomes of failure of non-operative management (NOM) following blunt splenic trauma.
A systematic review of the literature was performed for studies comparing failed NOM (fNOM) to successful NOM (sNOM) in adults (≥ 16 years). The main endpoints were fNOM and associated mortality. Between-study heterogeneity was assessed. Meta-analysis of high quality studies, identified using the Newcastle-Ottawa Scale, was performed using fixed or random models.
Four prospective and 21 retrospective studies were included. From 24,615 unselected patients, 3025 experienced fNOM (12%, range 4-52%). Meta-analysis of the high quality studies revealed that mortality was significantly higher with fNOM in unselected age groups (odds ratio 1.93, 95% confidence interval 1.04-3.57, p = 0.04, I(2) = 0%), in those <55 years old (OR 3.42, 95% CI 1.73-6.77, p = 0.02, I(2) = 0%) and in those ≥ 55 years old (OR 2.65, 95% CI 1.20-5.82, p = 0.02, I(2) = 0%). There was a significant improvement in sNOM following introduction of angioembolisation protocols (OR 0.26, 95% CI 0.13-0.53, p<0.002, I(2) = 51%), although these five studies were non-randomised. American Association for the Surgery of Trauma injury grades 4-5, the presence of moderate or large haemoperitoneum, increasing injury severity score and increasing age were all significantly associated with increased risk of fNOM. fNOM led to significantly longer intensive care unit and overall lengths of stay.
fNOM leads to increased resource use and increased mortality. Methods of preventing fNOM, such as angioembolisation, warrant further assessment. Patients with increasing age, AAST scores and moderate or large haemoperitoneums may benefit from closer monitoring.
Injury 10/2011; 43(9):1337-46. · 1.98 Impact Factor
