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Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review.

ABSTRACT: Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this narrative review, we summarize the available evidence in this setting, focusing on perioperative brain protection, cardiorespiratory optimization, and preservation of the coagulative function. An overview on simultaneous multisystem surgery (SMS) is also presented.

SUBMITTER: Picetti E

PROVIDER: S-EPMC8745292 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

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Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review.

Picetti Edoardo E Rosenstein Israel I Balogh Zsolt J ZJ Catena Fausto F Taccone Fabio S FS Fornaciari Anna A Votta Danilo D Badenes Rafael R Bilotta Federico F

Journal of clinical medicine 20211221 1

Managing the acute phase after a severe traumatic brain injury (TBI) with polytrauma represents a challenging situation for every trauma team member. A worldwide variability in the management of these complex patients has been reported in recent studies. Moreover, limited evidence regarding this topic is available, mainly due to the lack of well-designed studies. Anesthesiologists, as trauma team members, should be familiar with all the issues related to the management of these patients. In this ...[more]

PMID: 35011760

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Project description:Background and objectiveThoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.MethodsWe searched PubMed and Google Scholar databases from inception to May 2021 using the terms "thoracic surgery", "thoracic surgery AND pain management", "thoracic surgery AND analgesia", "thoracic surgery AND regional anesthesia", "thoracic surgery AND epidural". We considered articles written in English and available to the reader.Key content and findingsThere is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate.ConclusionsThe optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.

Project description:BackgroundAntithrombotic drugs increase the risk of bleeding, especially in patients who need urgent surgery without an adequate wash-out period. This review aims to evaluate perioperative bleeding complications in patients on dual antiplatelet therapy (DAPT) or direct-acting oral anticoagulants (DOACs) undergoing high-bleeding risk cardiovascular surgery and to present currently available potential solutions to mitigate antithrombotic therapy-related bleeding complications.MethodsAs a first step, we searched for relevant articles, over the last 10 years, in Medline (PubMed) and abstracted clinical information based on pre-defined criteria for bleeding complications. In the next step, an additional search evaluating potential solutions to mitigate bleeding complications was performed. The literature screening and selection process followed the principles derived from the PRISMA statement.ResultsFrom all reviewed studies, a total of 19 articles could be included evaluating the risk for bleeding in cardiac surgery related to DAPT or DOACs and 10 papers evaluating antithrombotic drug reversal or removal in the setting of cardiovascular surgery. Reported bleeding rates ranged between 18% and 41%. The variability of the reported data is remarkable. Idarucizumab is reported to provide optimal perioperative hemostasis in up to 93% of patients. It has been observed that andexanet alfa causes unresponsiveness to the anticoagulant effects of heparin. Antithrombotic removal by intraoperative hemoadsorption is found to be associated with a significant decrease in re-thoracotomy rate, overall procedure duration, administered transfusion volumes, chest-tube drainage, and length of hospitalization.DiscussionBleeding complications in patients treated with DAPT or DOACs in cardiac surgery are high. New costly reversal agents are available but have not been sufficiently tested in the cardio-surgical setting so far. Interestingly, bleeding-related complications seem to be effectively reduced by applying innovative intraoperative hemoadsorption techniques. Expected results from the ongoing trials should provide better insights concerning the efficacy and safety of several potential solutions. Currently, the variability of reports and the deficit of high-quality studies in this specific setting represent the major limitation for the unbiased conclusion of this review.

Project description:IntroductionPreoperative anemia is a common finding among surgical patients. It is associated with an increased risk of perioperative morbidity and mortality. Outcomes among emergency surgical patients are not established. This study aimed to assess the effect of preoperative anemia on perioperative outcomes among patients undergoing emergency surgery in selected Southern Ethiopia governmental teaching hospitals, Southern Ethiopia, 2022.MethodA multicenter prospective cohort study was conducted. Data were collected at selected hospitals, after obtaining ethical approval from the institutional review board. Descriptive statistics, cross-tabulation, and multivariable binary logistic regression analysis were performed. A P-value less than 0.05 were taken as statistically significant.ResultA total of 200 patients who underwent emergency surgery were grouped into the anemia group (100 patients) while the rest were in the non-anemia group. There was no statistically significant difference between the groups regarding socio-demographic and intraoperative patient characteristics. Based on multivariate logistic regression, anemia group had a significant risk of perioperative transfusion requirement (Relative Risk (RR) = 4.030, p < 0.001), developing postoperative complications (RR = 1.868, p = 0.017), occurring in-hospital mortality (RR = 5.763, p = 0.045), prolong the length of hospital stay (RR = 4.028, p < 0.001), and requiring postoperative intensive care unit admission (RR = 6.332, p = 0.003) compared with non-anemia groups.ConclusionPreoperative anemia was associated with a higher rate of perioperative transfusion requirements, along with increased postoperative complication, increased in-hospital mortality, increased Intensive Critical Care Unit admission rate, and prolonged length of hospital stay. We recommend adequate preoperative assessment and correction of hemoglobin concentrations to normal values to improve surgical outcomes and reduce complications.

Dataset Information

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review.

Publications

Perioperative Management of Polytrauma Patients with Severe Traumatic Brain Injury Undergoing Emergency Extracranial Surgery: A Narrative Review.

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