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The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis.

ABSTRACT: Traumatic bowel mesenteric injury (TBMI) is a challenge in trauma care. The presence of free peritoneal fluid (FF) in computed tomography (CT) was considered the indication for surgical intervention. However, conservative treatment should be applied for minor injuries. We conduct a systematic review to analyze how reliable the FF is to assess the TBMI. Publications were retrieved by structured searching among databases, review articles and major textbooks. For statistical analysis, summary receiver operating characteristic curves (SROCs) were computed using hierarchical models. Fourteen studies enrolling 4336 patients were eligible for final qualitative analysis. The SROC line was created by a hierarchical summary receiver operating characteristic model. The summary sensitivity of FF to predict surgical TBMI was 0.793 (95% CI: 0.635-0.894), and the summary specificity of FF to predict surgical TBMI was 0.733 (95% CI: 0.468-0.896). The diagnostic odds ratio was 10.531 (95% CI: 5.556-19.961). This study represents the most robust evidence (level 3a) to date that FF is not the absolute but an acceptable indicator for surgically important TBMI. However, there is still a need for randomized controlled trials to confirm.

SUBMITTER: Chen SA

PROVIDER: S-EPMC8620381 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. METHODS:This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients 14 years or older treated at our Level I trauma center between January 1, 2010, and November 1, 2015, with pericardial fluid on admission CT scan. RESULTS:For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount, 3.99, 95% confidence interval, 1.47-10.81) but not of mortality. CONCLUSION:There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. LEVEL OF EVIDENCE:Therapeutic/care management study, level IV.

Project description:ObjectivesControversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points.MethodsWe will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations.Ethics and disseminationEthics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals.Prospero registrationCRD42020187852.

Project description:ImportanceAlthough several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit.ObjectiveTo determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach.Design, setting, and participantsA retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017.ExposuresPatients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans.Main outcomes and measuresThe primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit).ResultsOf the 42?912 children included in the study (median age [interquartile range], 9 [5-12] years; 27?861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, -0.2%; 95% CI, -0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality.Conclusions and relevanceAmong children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.

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The Current Diagnostic Accuracy on Free Peritoneal Fluid in Computed Tomography to Determinate the Necessity of Surgery in Blunt Bowel and Mesenteric Trauma-Systemic Review and Meta-Analysis.

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