Pre-hospital Management in Trauma Patients: a Comparison Between Austria and Germany

ObjectivesTo compare the pre-hospital treatment and intervention regimen for major trauma patients with comparable injury patterns between Austria (AUT) and Germany (GER). Patients and MethodsThis analysis is based on data retrieved from the TraumaRegister DGU®. Data included severely injured trauma patients with an Injury Severity Score (ISS) ≥ 16, an age ≥ 16, and who were primary admitted to an Austrian (n=4.186) or German (n=41.670) Level I Trauma Center from 2008 to 2017. Endpoints included pre-hospital times and interventions performed until final hospital admission. The analyzed data include patients’ demographics, mode of transportation, pre-hospital time management, hemodynamic stability, and various pre-hospital interventions.ResultsThe cumulative time for transportation from the site of accident to the hospital did not significantly differ between the countries (62 min. in AUT, 65 min. in GER). Overall, 53% of all trauma patients in AUT were transported to the hospital with a helicopter compared to 37% in GER (P<0.001). The rate of intubation - 48% in both countries, the number of chest tubes placed (5.7% GER, 4.9% AUT), and the frequency of administered catecholamines (13.4% GER, 12.3% AUT) was comparable (Φ=0.00). Hemodynamic instability upon arrival in the TC was higher in AUT, (20.6% vs. 14.7% in GER; P<0.001). A median of 500mL of fluid was administered in AUT, whereas in GER 1000mL were infused (P<0.001). Patient demographics did not reveal a relationship (Φ=0.00) and the majority of patients sustained a blunt trauma (96%). ConclusionA significant higher number of Helicopter EMS transports (HEMS) were carried out in AUT. This can be explained by the overall lack of a unified transport algorithm. The authors suggest implementing an international guideline to explicitly use the HEMS system for trauma patients only a) for the rescue/care of people who have had an accident or are in life-threatening situations, b) for the transport of emergency patients with ISS>16, c) for transport of rescue personnel to hard-to-reach regions or, d) for the transport of medicinal products. Further, the amount of administered fluid in the pre-clinical setting should follow the concept of permissive hypotension/ hypotensive resuscitation, however the data are still inconclusive and mandate further research.

Comparison of Permissive Hypotension vs. Conventional Resuscitation Strategies in Adult Trauma Patients with Hemorrhagic Shock: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BackgroundThere is still an ongoing battle against the Permissive Hypotension (PH) through Conventional Resuscitation Strategies (CR). Active fluid resuscitation in patients with traumatic shock can bring many problems, as it is known that standard high-volume resuscitation can exacerbate the lethal triad of acidemia, hypothermia, and coagulopathy. As a part of damage control resuscitation strategy, it can reduce mortality and shorten hospital stay, compared with the use of standard liquids. Moreover, its application is gradually receiving wider attention (1) . This review evaluated the effectiveness and safety of permissive hypotension resuscitation in adult patients with traumatic hemorrhagic shock.MethodsThe systematic review and meta-analysis were conducted according to PRISMA guidelines. We searched PubMed, EMBASE and Cochrane databases for randomized controlled trials (RCTs) from the beginning to March 2021 to compare the therapeutic effects of controlled fluid resuscitation and conventional fluid resuscitation on patients with traumatic hemorrhagic shock. Two reviewers independently conducted screening, data extraction and bias assessment. Data analysis was performed using Cochrane Collaboration Software Revman 5.2. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood routine index, coagulation function, resuscitation fluid use, complications, and length of hospital stay. Pooling was performed with a random-effects model.Results8 randomized controlled trials were screened out of 898 studies and 1593 patients were evaluated. The target blood pressure of the intervention group ranged from 50-90 mmHg in systolic pressure or mean arterial pressure ≥ 50 mmHg, while that of the control group was 65-110 mmHg systolic pressure or mean arterial pressure ≥ 60 mmHg. Only patients with penetrating injuries were evaluated in two studies, while the remaining six included blunt injuries. A statistically significant reduction in mortality was observed in the intervention group (RR = 0.70; 95%CI= 0.58-0.84; P < 0.05). Small heterogeneity was observed in the included articles (χ2 = 8.9; P = 0.18; I2 = 33%). The loss of platelet (PLT), hemoglobin (Hb) and body fluid was properly protected, the amount of resuscitation fluid was reduced, and the incidence of some adverse events was effectively reduced. There was no significant difference in coagulation time and hospital stay between the two groups.ConclusionsThis meta-analysis reveals the survival benefits of hypotension resuscitation in patients with traumatic hemorrhagic shock. The significant advantage is to promote the recovery of patients' physical function and reduce the incidence of treatment-related complications such as acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and multiple organ dysfunction syndrome (MODS), which reduces the mortality. Convincing evidences are provided based on these results, but larger, multicenter, randomized trials are needed to confirm the findings.

The “Fountain of Death”: A Case Series on Tracheo-innominate Artery Fistula

Tracheo-innominate artery fistula (TIF) is a very rare complication related to tracheostomy and has been reported in 0.7% of patients, but certainly is one of the most life-threatening conditions. It is of paramount importance to maintain a high index of suspicion in evaluating patients with TIF and to anticipate occurrence of massive haemorrhage even during simple procedures related to tracheostomy such as tube change. We report 3 cases of TIF, each with a unique and unsuspecting history of the condition and review the emergency protocol in arresting the bleeding. We’ve also highlighted the potential role of permissive hypotension with sedation in improving survival outcomes of patients with TIF.

Anesthetic management of a patient with hollow viscus perforation due to blunt abdominal trauma with grade IV hemorrhagic shock

Hemorrhagic shock is a form of hypovolemic shock in which severe blood loss leads to inadequate oxygen delivery at the cellular level. Death from hemorrhage represents a substantial global problem, with more than 60,000 deaths per year in the United States and an estimated 1.9 million deaths per year worldwide, 1.5 million of which result from physical trauma. This case report aims to stress the need of handling cases of hemorrhagic shock in accordance with damage control protocol. Hemorrhagic shock management using permissive hypotension management, bleeding control, massive transfusion protocol (MTP), minimal crystalloid therapy, and adjuvant therapy is the best approach to get optimal outcome to prevent triad of death. In this case, the application of damage control resuscitation has not been fully implemented because of several constraints. Key words: Hemorrhage; Hemorrhagic shock; Permissive hypotension; Massive Transfusion Protocol; MTP; Resuscitation; Damage control Citation: Pohan DK, Sudjud RW, Kurniawan MB, Ramila HN. Anesthetic management on patient with hollow viscus perforation due to blunt abdominal trauma with grade IV hemorrhagic shock. Anaesth. pain intensive care 2021;25(2):217-221. DOI: 10.35975/apic.v25i2.1474 Received: 11 January 2021, Reviewed: 15 January 2021, Accepted: 16 February 2021

Reduced exposure to vasopressors through permissive hypotension to reduce mortality in critically ill people aged 65 and over: the 65 RCT

Background Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death. However, they work by causing vasoconstriction, which may reduce blood flow and cause other adverse effects. A mean arterial pressure target typically guides administration. An individual patient data meta-analysis (Lamontagne F, Day AG, Meade MO, Cook DJ, Guyatt GH, Hylands M, et al. Pooled analysis of higher versus lower blood pressure targets for vasopressor therapy septic and vasodilatory shock. Intensive Care Med 2018;44:12–21) suggested that greater exposure, through higher mean arterial pressure targets, may increase risk of death in older patients. Objective To estimate the clinical effectiveness and cost-effectiveness of reduced vasopressor exposure through permissive hypotension (i.e. a lower mean arterial pressure target of 60–65 mmHg) in older critically ill patients. Design A pragmatic, randomised clinical trial with integrated economic evaluation. Setting Sixty-five NHS adult general critical care units. Participants Critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension. Interventions Intervention – permissive hypotension (i.e. a mean arterial pressure target of 60–65 mmHg). Control (usual care) – a mean arterial pressure target at the treating clinician’s discretion. Main outcome measures The primary clinical outcome was 90-day all-cause mortality. The primary cost-effectiveness outcome was 90-day incremental net monetary benefit. Secondary outcomes included receipt and duration of advanced respiratory and renal support, mortality at critical care and acute hospital discharge, and questionnaire assessment of cognitive decline and health-related quality of life at 90 days and 1 year. Results Of 2600 patients randomised, 2463 (permissive hypotension, n = 1221; usual care, n = 1242) were analysed for the primary clinical outcome. Permissive hypotension resulted in lower exposure to vasopressors than usual care [mean duration 46.0 vs. 55.9 hours, difference –9.9 hours (95% confidence interval –14.3 to –5.5 hours); total noradrenaline-equivalent dose 31.5 mg vs. 44.3 mg, difference –12.8 mg (95% CI –18.0 mg to –17.6 mg)]. By 90 days, 500 (41.0%) patients in the permissive hypotension group and 544 (43.8%) patients in the usual-care group had died (absolute risk difference –2.85%, 95% confidence interval –6.75% to 1.05%; p = 0.154). Adjustment for prespecified baseline variables resulted in an odds ratio for 90-day mortality of 0.82 (95% confidence interval 0.68 to 0.98) favouring permissive hypotension. There were no significant differences in prespecified secondary outcomes or subgroups; however, patients with chronic hypertension showed a mortality difference favourable to permissive hypotension. At 90 days, permissive hypotension showed similar costs to usual care. However, with higher incremental life-years and quality-adjusted life-years in the permissive hypotension group, the incremental net monetary benefit was positive, but with high statistical uncertainty (£378, 95% confidence interval −£1347 to £2103). Limitations The intervention was unblinded, with risk of bias minimised through central allocation concealment and a primary outcome not subject to observer bias. The control group event rate was higher than anticipated. Conclusions In critically ill patients aged ≥ 65 years receiving vasopressors for vasodilatory hypotension, permissive hypotension did not significantly reduce 90-day mortality compared with usual care. The absolute treatment effect on 90-day mortality, based on 95% confidence intervals, was between a 6.8-percentage reduction and a 1.1-percentage increase in mortality. Future work Future work should (1) update the individual patient data meta-analysis, (2) explore approaches for evaluating heterogeneity of treatment effect and (3) explore 65 trial conduct, including use of deferred consent, to inform future trials. Trial registration Current Controlled Trials ISRCTN10580502. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 14. See the NIHR Journals Library website for further project information.

Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65): protocol and statistical analysis plan for a randomised clinical trial

IntroductionVasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60–65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years.Methods and analysisOVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation.Ethics and disseminationThis protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums.Trial registration numberNCT03431181.

Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Protocol for the 65 randomised clinical trial

Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragmatic, multi-centre, parallel-group, open-label, randomised clinical trial of permissive hypotension (a mean arterial pressure target of 60 -65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial is conducted in 2600 patients from 65 United Kingdom adult, general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. The 65 trial received favourable ethical opinion from the South Central - Oxford C Research Ethics Committee and approval from the Health Research Authority. The results will be presented at national and international conferences and published in peer-reviewed medical journals. Trial registration: ISRCTN10580502

Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Statistical and health economic analysis plan for the 65 trial in article

The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65 United Kingdom adult general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. This paper describes the proposed statistical and health economic analysis for the 65 trial.