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The world of trauma working together
Rizoli Sandro,Lepp?niemi Ari
World Journal of Emergency Surgery , 2012, DOI: 10.1186/1749-7922-7-s1-s2
Pro/Con Debate: Does recombinant factor VIIa have a role to play in the treatment of patients with acute nontraumatic hemorrhage?
Paola Pieri, Deborah M Stein, Sandro Scarpelini, Sandro Rizoli
Critical Care , 2006, DOI: 10.1186/cc4940
Abstract: A 49-year-old male has been managed in the intensive care unit for 5 days after a large left diaphragmatic hernia repair and is currently being weaned from mechanical ventilation. He suddenly has significant hematemesis and becomes hemodynamically unstable, with alteration to his coagulation. You start to resuscitate him with fluid, blood and plasma, in order to reverse the hemorrhagic shock and correct the coagulopathy. An endoscopy reveals diffuse gastric erosions but fails to stop the bleeding. He continues to be unstable and surgical intervention is not an option. You are aware that factor VIIa (FVIIa) has been used in acute traumatic hemorrhage to stop bleeding. You wonder whether it has a role to play in this type of patient.Paola Pieri and Deborah M SteinFVIIa (NovoSeven?) was developed by Novo Nordisk for use in patients with congenital and acquired hemophilia and inhibitors of factor VIII or IX. Since it was licensed in Europe in the 1990s and in the USA in 1999 it has been utilized off-label in an increasing number of nonhemophiliac patients with severe bleeding, such as the patient described in the scenario above. At present the precise role of FVIIa in treating life-threatening hemorrhage has not been determined. However, numerous studies have demonstrated benefit from off-label use.Several case series have been published that describe successful use of FVIIa in severely injured patients [1-4]. Additionally, in a recently published prospective randomized placebo-controlled double blind trial [5], a reduction in transfusion requirement was observed in trauma patients, as was a decrease in overall morbidity and mortality when early deaths were excluded from the analysis. There are numerous other reports of successful use of FVIIa in the noninjured patient with acute hemorrhage, such as that secondary to esophageal varices, hemorrhagic pancreatitis, and hemorrhage occurring during cardiac surgery and liver transplantation. Case reports of FVIIa use to treat
Operating room use of hypertonic solutions: a clinical review
Azoubel, Gustavo;Nascimento, Bartolomeu;Ferri, Mauricio;Rizoli, Sandro;
Clinics , 2008, DOI: 10.1590/S1807-59322008000600021
Abstract: hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. recently, there has been a growing interest in intra-operative use of hypertonic solutions. we reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies.
The utility of recombinant factor VIIa as a last resort in trauma
Mamtani Rishi,Nascimento Bartolomeu,Rizoli Sandro,Pinto Ruxandra
World Journal of Emergency Surgery , 2012, DOI: 10.1186/1749-7922-7-s1-s7
Abstract: Introduction The use of recombinant factor VII (rFVIIa) as a last resort for the management of coagulopathy when there is severe metabolic acidosis during large bleedings in trauma might be deemed inappropriate. The objective of this study was to identify critical degrees of acidosis and associated factors at which rFVIIa might be considered of no utility. Methods All massively transfused (≥ 8 units of red blood cells within 12 hours) trauma patients from Jan 2000 to Nov 2006. Demographic, baseline physiologic and rFVIIa dosage data were collected. Rate of red blood cell transfusion in the first 6 hours of hospitalization (RBC/hr) was calculated and used as a surrogate for bleeding. Last resort use of rFVIIa was defined by a pH≤ 7.02 based on ROC analysis for survival. In-hospital mortality was analyzed in last resort and non-last resort groups. Univariate analysis was performed to assess for differences between groups and identify factors associates with no utility of rFVIIa. Results 71 patients who received rFVIIa were analyzed. The pH> 7.02 had 100% sensitivity for the identification of potential survivors. All 11 coagulopathic, severely acidotic (pH ≤ 7.02) patients with high rates of bleeding (4RBC/hr) died despite administration of rFVIIa. The financial cost of administering rFVIIa as a last resort to these 11 severely acidotic and coagulophatic cases was $75,162 (CA). Conclusions Our study found no utility of rFVIIa in treating severely acidotic, coagulopathic trauma patients with high rates of bleeding; and thus restrictions should be set on its usage in these circumstances.
TEG and ROTEM in trauma: similar test but different results?
Sankarankutty Ajith,Nascimento Bartolomeu,Teodoro da Luz Luis,Rizoli Sandro
World Journal of Emergency Surgery , 2012, DOI: 10.1186/1749-7922-7-s1-s3
Abstract: Introduction Transfusion in trauma is often empiric or based on traditional lab tests. Viscoelastic tests such as thromboelastography (TEG ) and rotational thromboelastometry (ROTEM ) have been proposed as superior to traditional lab tests. Due to the similarities between the two tests, general opinion seems to consider them equivalent with interchangeable interpretations. However, it is not clear whether the results can be similarly interpreted. This review evaluates the comparability between TEG and ROTEM and performs a descriptive review of the parameters utilized in each test in adult trauma patients. Methods PUBMED database was reviewed using the keywords “thromboelastography” and “compare”, between 2000 and 2011. Original studies directly comparing TEG with ROTEM in any area were retrieved. To verify the individual test parameter used in studies involving trauma patients, we further performed a review using the keywords “thromboelastography” and “trauma” in the PUBMED database. Results Only 4 studies directly compared TEG with ROTEM . One in liver transplantation found that transfusion practice could differ depending on the device in use. Another in cardiac surgery concluded that all measurements are not completely interchangeable. The third article using commercially available plasma detected clinically significant differences in the results from the two devices. The fourth one was a head-to-head comparison of the technical aspects. The 24 articles reporting the use of viscoelastic tests in trauma patients, presented considerable heterogeneity. Conclusion Both tests are potentially useful as means to rapidly diagnose coagulopathy, guide transfusion and determine outcome in trauma patients. Differences in the activators utilized in each device limit the direct comparability. Standardization and robust clinical trials comparing the two technologies are needed before these tests can be widely recommended for clinical use in trauma.
Telemedicina baseada em evidência: cirurgia do trauma e emergência (TBE-CITE) Evidence-based telemedicine: trauma & acute care surgery (EBT-TACS)
Gustavo Pereira Fraga,Bartolomeu Nascimento Jr,Sandro Rizoli
Revista do Colégio Brasileiro de Cirurgi?es , 2012, DOI: 10.1590/s0100-69912012000100002
Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers
Bartolomeu Nascimento, Jeannie Callum, Gordon Rubenfeld, Joao Neto, Yulia Lin, Sandro Rizoli
Critical Care , 2010, DOI: 10.1186/cc8205
Abstract: Fresh frozen plasma (FFP) is a blood product that has been available since 1941 [1]. Initially used as a volume expander, it is currently indicated for the management and prevention of bleeding in coagulopathic patients [1-3]. The evidence on FFP transfusion is scant and of limited quality [4].Estimates state that 25 to 30% of all critical care patients receive FFP transfusions [5,6]. Despite its commonality, only 37% of the physicians in a recent study correctly responded to basic questions about FFP, including the volume of one unit [7]. An audit on transfusion practices suggested that one-half of all FFP transfused to critical care patients is inappropriate [5].Massive haemorrhage is among the most challenging issues in critical care, affecting trauma patients, surgical patients, obstetric patients and gastrointestinal patients [3,8,9]. In trauma, a recent series of retrospective clinical studies suggests that early and aggressive use of FFP at a 1:1 ratio with red blood cells (RBC) improves survival in cases of massive haemorrhage [10-19]. Because bleeding is directly responsible for 40% of all trauma-related deaths, this strategy - also known as haemostatic damage control or formula-driven resuscitation - has received substantial attention worldwide. This early formula-driven haemostatic resuscitation proposes transfusion of FFP at a near 1:1 ratio with RBC, thus addressing coagulopathy from the beginning of the resuscitation and potentially reducing mortality. Nevertheless, this strategy requires immediate access to large volumes of thawed universal donor FFP, which is challenging to implement.Despite conflict with existing guidelines, early formula-driven haemostatic resuscitation use is expanding and is gradually being used in nontraumatic bleedings in critical care [20]. Both the existing guidelines and early formula-driven haemostatic resuscitation are supported by limited evidence, generating controversies and challeng ing clinical decisions in critical c
Recombinant factor VIIa is associated with an improved 24-hour survival without an improvement in inpatient survival in massively transfused civilian trauma patients
Nascimento, Bartolomeu;Lin, Yulia;Callum, Jeannie;Reis, Marciano;Pinto, Ruxandra;Rizoli, Sandro;
Clinics , 2011, DOI: 10.1590/S1807-59322011000100018
Abstract: objective: to determine whether recombinant factor viia (rfviia) is associated with increased survival and/or thromboembolic complications. introduction: uncontrollable hemorrhage is the main cause of early mortality in trauma. rfviia has been suggested for the management of refractory hemorrhage. however, there is conflicting evidence about the survival benefit of rfviia in trauma. furthermore, recent reports have raised concerns about increased thromboembolic events with rfviia use. methods: consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. data on demographics, injury severity scores, baseline laboratory values and use of rfviia were collected. rate of transfusion in the first 6 h was used as surrogate for bleeding. study outcomes included 24-hour and in-hospital survival, and thromboembolic events. a multivariable logistic regression analysis was used to determine the impact of rfviia on 24-hour and in-hospital survival. results: three-hundred and twenty-eight patients were massively transfused. of these, 72 patients received rfviia. as expected, patients administered rfviia had a greater degree of shock than the non-rfviia group. using logistic regression to adjust for predictors of death in the regression analysis, rfviia was a significant predictor of 24-hour survival (odds ratio (or) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (or = 1.63; confidence interval 0.79-3.37; p = 0.19). no differences were seen in clinically relevant thromboembolic events. conclusions: despite being associated with improved 24-hour survival, rfviia is not associated with a late survival to discharge in massively transfused civilian trauma patients.
Fatal motorcycle crashes: a serious public health problem in Brazil
Carrasco Carlos,Godinho Mauricio,Berti de Azevedo Barros Marilisa,Rizoli Sandro
World Journal of Emergency Surgery , 2012, DOI: 10.1186/1749-7922-7-s1-s5
Abstract: Introduction The numbers of two-wheel vehicles are growing across the world. In comparison to other vehicles, motorcycles are cheaper and thus represent a significant part of the automobile market. Both the mobility and speed are attractive factors to those who want to use them for work or leisure. Crashes involving motorcyclists have become an important issue, especially fatal ones. Specific severe injuries are responsible for the deaths. Defining them is necessary in order to offer better prevention and a more suitable medical approach. Methods All fatal motorcycle crashes between January 2001 and December 2009 in Campinas, Brazil, were analyzed in this study. Official data have been collected from police incident reports, hospitals’ registers and autopsies. Both incidents and casualties were analyzed according to relevant variables. The Injury Severity Score (ISS) was calculated, describing the most potentially fatal injuries. Results There were 479 deaths; 90.8% were male; the mean age was 27.8 (range 0-73); 86.4% were conductors of the vehicles; blood alcohol was positive in 42.3%; 49.7% died at a hospital; 32.6% died at the scene; 26.1% of the accidents occurred at night, 69.1% were urban and 30.9% occurred on highways. The main causes of injury were collisions (63%) and falls (14%). The mean ISS was 38.5 (range 9-75). With regard to injuries, head trauma (67%) and thoracic trauma (40%) were the most common, followed by abdominal trauma (35%). Traumatic brain injury (67%) and hypovolemic shock (38%) were the most frequent causes of death. Conclusions Alcohol was a significant factor in relation to the accidents. Head trauma was the most frequent and severe injury. Half of the victims died before receiving adequate medical attention, suggesting that prevention programs and laws should be implemented and applied in order to save future lives.
Classifica o de gravidade na pancreatite aguda Classification of severity of acute pancreatitis
Tercio De Campos,José Gustavo Parreira,José Cesar Assef,Sandro Rizoli
Revista do Colégio Brasileiro de Cirurgi?es , 2013,
Abstract: De acordo com a Classifica o de Atlanta a pancreatite aguda pode ser dividida, baseado em sua severidade, em uma forma leve ou grave. Uma série de aspectos têm sido discutidos nos últimos anos, tais como, quantas categorias de gravidade devem ser consideradas; se o doente com falência organica é igual ao doente com necrose infectada; qual o papel da falência organica transitória; e como avaliar a falência organica. A reuni o de revista"Telemedicina Baseada em Evidência - Cirurgia do Trauma e Emergência" (TBE-CiTE) realizou uma avalia o crítica de artigos relacionados a este tema, considerando três artigos recentes que delinearam duas grandes revis es publicadas nos últimos meses. Estes artigos sugerem a classifica o de gravidade em três ou quatro categorias, ao invés de pancreatite aguda leve ou grave, além de discutir qual o melhor escore para avaliar a falência organica. As seguintes recomenda es foram propostas: (1) A pancreatite aguda deve ser classificada em quatro categorias: leve, moderada, grave e crítica, o que permite uma melhor determina o das características dos doentes; (2) Avalia o de falência organica com um escore de gravidade, preferencialmente algum que avalie diretamente cada falência organica, tais como o SOFA e o MODS (Marshall). O SOFA parece ter maior acurácia, mas o MODS tem melhor aplicabilidade devido à facilidade de uso. Based on the Atlanta Classification, acute pancreatitis is classified according to its severity in either mild or severe acute pancreatitis. In recent years, several issues regarding acute pancreatitis have been discussed in the literature. These issues include how many categories of severity should be considered; whether or not a patient with organ failure holds similar holds severity of disease and prognosis of a patient with infected necrosis; the role of transient organ failure; and how to evaluate organ failure. The"Evidence-based Telemedicine - Trauma and Acute Care Surgery" (EBT-TACS) conducted a review of the recent literature on the topic, and critically appraised its most relevant pieces of evidence.. The articles discussed suggested classifying the severity of acute pancreatitis in three or four categories, rather than mild or severe only, and addressed which is the best score to assess organ failure. The following recommendations were proposed: (1) Acute pancreatitis should be classified into four categories: mild, moderate, severe and critical, which allows a better determination of the characteristics of patients, (2) Evaluation of organ failure with a severity score that preferably evaluat
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