Search Results (28)

Introduction: Severe traumatic brain injury (sTBI) frequently coexists with polytrauma and often necessitates damage control neurosurgery (DCNS), where rapid decompression and temporary stabilization take precedence over definitive reconstruction. Within this context, anesthetic management must balance cerebral protection with ongoing resuscitation, yet high-quality DCNS-specific evidence remains limited. Materials and Methods: A comprehensive search of PubMed, Scopus, and Google Scholar (2015–2025) was conducted using MeSH terms and keywords related to neurotrauma, anesthesia, intracranial pressure, and perioperative management. Studies were included if they examined anesthetic or hemodynamic strategies in severe TBI or DCNS and reported relevant clinical or physiologic outcomes. Results: Nineteen articles addressing perioperative strategies for optimizing DCNS outcomes were analyzed. Discussion: Preoperative care emphasizes hemodynamic stabilization and permissive hypertension, damage control resuscitation including massive transfusion protocols, optimization of cerebral perfusion pressure (CPP) and neuromonitoring, and the use of hyperosmolar therapy. Transexamic acid can be used in sTBI safely but with unclear improvement in outcomes. Intraoperatively, propofol-based total intravenous anesthesia is generally preferred over volatile agents due to favorable effects on intracranial pressure (ICP), cerebral blood flow (CBF), autoregulation, and emergence. While historically contraindicated, ketamine and etomidate are now increasingly used as hemodynamically protective induction agents. Analgesic and sedative strategies prioritize dexmedetomidine and carefully titrated opioids to minimize respiratory depression and reduce postoperative complications. CPP and ICP-directed management relies on individualized blood pressure targets, vasopressor selection, lung-protective ventilation, and strict temperature control. Conclusions: Emerging evidence has suggested the benefit of DCNS for patient survival. Overall, perioperative care is guided largely by physiology and extrapolation, highlighting the need for standardized protocols. Full article

Background/Objectives: The United States is facing a national blood shortage, which is a function of the reduced number of donors since the COVID-19 pandemic and the increasing use of balanced hemostatic resuscitation for severely bleeding trauma patients. As a result, recent attempts to define futility based on clinical and laboratory criteria have been proposed. There is no literature on the frequency of institutional futility protocols, either at hospitals or blood collection centers. Methods: The Association for the Advancement of Blood & Biotherapies sent out a survey to 800 United States hospitals and blood collection centers to determine the frequency of trauma futility protocols and the need to limit blood for non-trauma patients due to high use in trauma patients. Results: 213 (26.6%) institutions responded. 10.8% of hospitals and blood collection centers reported having a trauma futility protocol, and those hospitals and blood collection centers with futility protocols were more likely to have needed to limit blood to non-trauma patients due to high consumption by trauma patients. Conclusions: Trauma futility protocols at hospitals and blood collection centers are uncommon. Because of the national shortage of blood products available for trauma and non-trauma cases, implementing institutional trauma futility protocols may help to curb the incidence of blood limitation to non-trauma patients. Increased awareness and communication between blood bankers and traumatologists during the declaration of futility may reduce blood wastage and enhance the nation’s blood supply reservoirs. Full article

Background: Massive intraoperative blood loss (IBL) is a serious complication in complex spine surgeries such as deformity correction, multilevel fusion, tumor resection, and revision procedures. While no strict definition exists, blood loss exceeding 1500 mL or 20% of estimated blood volume is generally considered clinically significant. Excessive bleeding increases the risk of hemodynamic instability, transfusion-related complications, postoperative infection, and prolonged hospitalization. Methods: This narrative review summarizes the current understanding of the incidence, risk factors, anatomical vulnerabilities, and evidence-based strategies for managing IBL in spine surgery through comprehensive literature analysis of recent studies and clinical guidelines. Results: Key risk factors include patient characteristics (anemia, obesity, advanced age, medication use), surgical variables (multilevel instrumentation, revision status, operative time), and pathological conditions (hypervascular tumors, severe deformity). Perioperative medication management is critical, requiring discontinuation of NSAIDs (5–7 days), antiplatelet agents (5–7 days), and NOACs (48–72 h) preoperatively to minimize bleeding risk. The thoracolumbar junction and hypervascular spinal lesions are especially prone to bleeding due to dense vascular anatomy. Evidence-based management strategies include comprehensive preoperative optimization, intraoperative hemostatic techniques, antifibrinolytic agents, topical hemostatic products, cell salvage technology, and structured transfusion protocols. Conclusions: Effective management of massive IBL requires a multimodal approach combining preoperative risk assessment and medication optimization, intraoperative hemostatic strategies including tranexamic acid administration, advanced monitoring techniques, and coordinated transfusion protocols. Particular attention to perioperative management of anticoagulant and antiplatelet medications is essential for bleeding risk mitigation. Understanding patient-specific risk factors, surgical complexity, and anatomical considerations enables surgeons to implement targeted prevention and management strategies, ultimately improving patient outcomes and reducing complications in high-risk spine surgery procedures. Full article

Background/Objectives: Open thoracoabdominal aortic aneurysm (TAAA) repair remains essential despite expanded endovascular options, yet the contemporary open-surgery case-mix has shifted as minimally invasive therapies became widespread. The objective was to evaluate temporal changes in patient demographics, pathology, and perioperative outcomes of open TAAA repair across two decades. Methods: Retrospective, cross border cohort of all open TAAA repairs performed at two high-volume tertiary centers (Aachen, Germany; Maastricht, Netherlands) from 2000–2024. Patients were stratified into Early Era (2004–2013) and Late Era (2014–2024). Primary endpoints were shifts in demographics and perioperative mortality/morbidity; secondary endpoints included major complications (spinal cord ischemia, acute kidney injury, pulmonary and cardiac events). Results: Among 577 open repairs, 376 (65.2%) occurred in the Early Era and 201 (34.8%) in the Late Era, with annual volumes declining to <12 cases/year after 2020. Late Era patients were younger (median 55.9 vs. 63.0 years, $p<0.001$) and had more genetic aortopathy (Marfan 26.9% vs. 11.7%, $p<0.01$) and post-dissection pathology (64.7% vs. 43.1%, $p<0.01$), alongside more prior aortic surgery (59.2% vs. 43.4%, $p<0.01$). Massive transfusion and incidental splenectomy decreased (37.8% vs. 54.5%, $p<0.01$; 5.0% vs. 14.9%, $p<0.01$). In-hospital mortality was similar (18.4% Late vs. 21.8% Early, $p=0.34$); spinal cord ischemia showed a non-significant reduction (5.5% vs. 8.0%, $p=0.26$); myocardial infarction decreased (1.0% vs. 4.3%, $p=0.03$); and ARDS increased (15.9% vs. 5.1%, $p<0.01)$. Conclusions: Despite the shift towards endovascular repair and the changing demographics of patients selected for open TAAA repair, specialized centers can maintain stable outcomes through standardized protocols and concentrated expertise. The preservation of open surgical capabilities remains crucial for specific patient populations, emphasizing the need for a balanced approach that integrates both open and endovascular techniques to provide optimal, individualized care. Full article

Background: We present a multidisciplinary training experience based on simulation techniques and critical resource management implemented in the emergency department. Methods: Simulation courses/workshops were conducted with a multidisciplinary team from the Hospital Emergency Department. The timeline for their development includes a preliminary analysis of needs, objectives, and scenario design, development of the simulation course, and finally, areas of implementation. In this last phase, the teaching team prepares a document and/or report/summary of the activity in which, among other things, the aspects with the greatest capacity for improvement or the areas for implementation of safety measures are determined. A total of 112 healthcare professionals (doctors, nurses, and care assistants) participated in this training program. Its design consisted of the following stages: a preliminary analysis of training needs, the establishment of objectives and scenario design, the development of the simulation workshop, and finally, a report on areas for improvement in patient safety identified during the workshop learning process. Results: The workshops enabled us to identify areas for improvement and develop local protocols/recommendations aimed at improving patient safety in the emergency department, such as standardizing a protocol to guide us in managing resources in crisis situations, a protocol for airway management, a protocol for massive transfusion, and a review of the triage process. In addition, we added value by incorporating cognitive aids and visual tools into the standardization of processes. Conclusions: For resource management in this type of crisis in the hospital emergency setting, it is essential to use a debriefing process guided by experienced instructors after a specific experiential learning experience through simulation scenarios. This helps to contextualize and analyze the advantages and disadvantages of general recommendations. Full article

Background/Objectives: Hemorrhage remains a leading cause of early mortality in trauma patients, and timely transfusion guided by a structured massive transfusion protocol (MTP) is critical for improving outcomes. Although regional trauma centers have been established, standardized MTPs remain insufficiently developed in many settings. This study aimed to evaluate current MTP practices across five major trauma centers within a national trauma care system. Methods: Participating institutions provided written protocols and completed a structured survey addressing key domains, including activation criteria, transfusion strategies, laboratory monitoring, adjunct therapies, termination processes, and performance improvement measures. Findings were analyzed and compared against established international recommendations. Results: All centers had implemented MTPs and were capable of delivering initial blood products within 15 min. However, considerable variation was observed in activation triggers, transfusion ratios, and laboratory monitoring protocols. None of these centers maintained thawed plasma or whole blood in immediate readiness. Only one of five centers had a formal performance improvement monitoring system. Tranexamic acid was included in all institutional protocols. Conclusions: This review highlights significant variability and critical gaps in MTP implementation across trauma centers. Inconsistent activation criteria, the absence of essential components, and limited quality monitoring may compromise the efficacy of current practices. To improve patient outcomes, a standardized, evidence-based MTP framework should be developed and implemented nationwide. Full article

Background: In 2015, Spanish scientific societies published a consensus document on managing massive hemorrhage (MH). This study aimed to evaluate the knowledge and application of the Massive Hemorrhage Protocol (MHP) among healthcare professionals and to assess whether an educational intervention could improve compliance and patient outcomes. Methods: A two-phase observational study was conducted in four Spanish university hospitals. In phase one, compliance with MHP recommendations was surveyed. Based on the findings, educational sessions were implemented, focusing on the least known or followed recommendations. Compliance was then reassessed. Primary outcome was adherence to MHP; secondary outcomes included morbidity and 24 h and in-hospital mortality. Results: The MHP was activated in 303 MH episodes, mostly of surgical (42.6%) or traumatic (25%) origin. The most followed recommendation before the intervention was protocol activation (94%), which improved to 98.3% post-intervention (p = 0.049). Lesser-followed recommendations such as requesting a hemorrhage lab panel and correcting hypothermia improved after intervention from 39% to 50.4% (p = 0.05) and 31.3% to 43.8% (p = 0.027), respectively. Overall compliance increased from 68% to 73% (p = 0.05). Mortality remained high in both phases, 24 h (25.4%) and in-hospital (42.2%). Patients who required massive transfusion had higher mortality (53.6%) than those who did not (35.9%, p = 0.03). Survivors had higher protocol compliance (p = 0.003 at 24 h; p = 0.049 in-hospital). Conclusions: Educational intervention modestly improved adherence to MHP recommendations. Higher compliance was associated with better survival outcomes, supporting the need for targeted educational strategies to enhance protocol implementation and improve care in MH cases. Full article

Background and Objectives: Blood shortages are a national crisis, creating dangerous scenarios for patients requiring the use of a massive transfusion protocol (MTP). A judicious use of blood products is critical to rescue salvageable patients while refraining from unnecessary MTP to save precious resources. This study examines effect of trauma characteristics, socioeconomic variables and markers of futility on the likelihood of activating and receiving MTP in the trauma setting. Materials and Methods: In this retrospective study, emergency department (ED) trauma activations from a database of an urban Level I trauma center were analyzed from 1 January 2017 to 30 June 2022, inclusive. In-ED mortality, RBC transfusion volumes during initial resuscitation, patient sociodemographic data, and trauma event factors were analyzed. The primary outcomes were the dichotomous outcomes of MTP activation and MTP transfusion. Univariable analyses and logistic regressions were conducted, with class balancing sensitivities applied to the multivariable regressions to adjust for imbalance in the data. p < 0.05 was considered statistically significant. Results: Among the 8670 trauma activations, there was a 0.3% in-ED mortality rate. MTP activation and MTP transfusion were associated with higher in-ED mortality rates (3.8% and 15.4%, respectively, compared to 0.2% without MTP). Younger patients, male patients, and Medicaid recipients were more likely to undergo MTP activation; Medicare patients were less likely. Penetrating trauma substantially increased the likelihood of both MTP activation (odds ratio (OR) 5.81) and transfusion (OR 3.63). The logistic regression models identified the presence of penetrating trauma, lower probability of survival, and age as the most important covariates. Models demonstrated high discriminatory value (area under the curve (AUC) of the receiver operating characteristic curve (ROC) of 0.876 for MTP activation, 0.935 for MTP transfusion) and precision (0.974 for activation, 0.994 for transfusion), with class balancing further improving model performance and precision scores. Conclusions: These results are significant as assessing the futility of MTP should be equitable, and future transfusion guidelines should consider salvageability in cases with a low probability of survival despite age and mechanism. Full article

Perioperative blood management strategies include evidence-based guidelines to efficiently manage blood products and transfusions while minimizing blood loss and improving patient outcomes. Perioperative Medicine has made evident that anemia is often under-recognized and not appropriately addressed prior to surgery. Early recognition and correction of anemia is imperative for better surgical optimization, fewer transfusions perioperatively, and improved outcomes. Patient blood management utilize evidence-based guidelines for the establishment of a framework to promote treatment of the causes of anemia, reduce blood loss and coagulopathy as well as to improve patient safety and outcomes by efficiently managing blood products, decrease complications associated with blood transfusions and reduce overall costs. Both liberal and restrictive strategies for blood transfusions established thresholds for hemoglobin: restrictive transfusion threshold of hemoglobin 7–8 g/dL in stable patients, and a higher transfusion threshold of hemoglobin > 8 g/dL may be considered in patients with cardiac disease. Intraoperatively, tests such as viscoelastic testing, including rotational thromboelastometry and thrombelastography, offer real-time analysis of a patient’s clotting ability, allowing for targeted transfusions of fresh frozen plasma, platelets, cryoprecipitate or antifibrinolytic drugs. Complications associated with blood transfusions include allergic reactions, delayed hemolytic reactions, transfusion related acute lung injury, transfusion-associated circulatory overload, and the transmission of infectious diseases such as Hepatitis B, Hepatitis C, and Human-immunodeficiency virus. This review will discuss the management of blood products for surgical patients in the entire perioperative setting, with specific considerations for the peri-, intra- and post-operative stages. Full article

Background: We aimed to evaluate the clinical significance of abnormal rotational thromboelastometry (ROTEM) findings in trauma patients and investigate the relationships between FIBTEM-maximum clot firmness (MCF), fibrinogen concentration and patient outcomes. Methods: A retrospective cohort analysis was conducted on adult trauma patients who underwent on-admission ROTEM testing between January 2020 and January 2021. Univariate analyses compared data based on injury severity, ROTEM findings (normal vs. abnormal), and initial fibrinogen concentration (normal vs. hypofibrinogenemia). ROC curve analysis was performed to determine the diagnostic performance of FIBTEM A10/MCF for its association with hypofibrinogenemia. Results: A total of 1488 patients were included in this study; the mean age was 36.4 ± 14.2 years and 92% were male. In total, 376 (25.3%) patients had ROTEM abnormalities. Severe injuries (ISS ≥ 16) were associated with a higher shock index, positive troponin T levels, standard coagulation abnormalities, hypofibrinogenemia, and abnormal ROTEM parameters (p < 0.05). These patients also had higher rates of massive transfusions and in-hospital mortality (p = 0.001). Coagulation alterations were significantly associated with higher injury severity score (ISS), shock index, head abbreviated injury score (AIS), hypofibrinogenemia, transfusion need, and mortality (p < 0.05). Hypofibrinogenemic patients were younger, sustained severe injuries, had higher shock indices and coagulation marker levels, required more intensive treatments, had longer hospital stays, and had higher mortality (p < 0.05). A significant positive correlation was found between plasma fibrinogen concentration and FIBTEM-MCF (r = 0.294; p = 0.001). Conclusions: Approximately one-fourth of the patients had early traumatic coagulopathy, as assessed by ROTEM. The FIBTEM A10/MCF may serves as a surrogate marker for plasma fibrinogen concentration. While prior studies have established the link between ROTEM and injury severity, our findings reinforce its relevance across varying trauma severity levels. However, prospective studies are warranted to validate its role within diverse trauma systems and evolving resuscitation protocols. Full article

Background and Objectives: Trauma, particularly uncontrolled bleeding, is a major cause of death. Recent evidence-based guidelines recommend the use of a tourniquet when life-threating limb bleeding cannot be controlled with direct pressure. Prehospital hemorrhage management, according to the XABCDE protocol, emphasizes the critical role of tourniquets in controlling massive bleeding. The aim of this systematic review and meta-analysis was to summarize data from the available scientific literature on the effectiveness of prehospital tourniquet use for extremity bleeding. Materials and Methods: A systematic review and meta-analysis was performed between March 2022 and March 2024, adhering to PRISMA guidelines, to determine whether prehospital tourniquets are clinically effective. The protocol was published on PROSPERO (ID number: CRD42023450373). Results: A comprehensive literature search yielded 925 articles and 11 studies meeting the inclusion criteria. The analysis showed a non-statistically significant reduction in mortality risk with tourniquet application (4.02% vs. 6.43%, RR 0.70, 95% CI 0.46–1.07). Analysis of outcomes of amputation of the traumatized limb indicated a statistically higher incidence of initial amputation in the tourniquet group (19.32% vs. 6.4%, RR 2.07, 95% CI 1.21–3.52), while delayed amputation showed no difference (9.39% vs. 3.66%, RR 0.93, 95% CI 0.42–2.07). Tourniquet use demonstrated a non-significant reduction in the number of blood components transfused (MD = −0.65; 95% CI −5.23 to 3.93 for pRBC, MD = −0.55; 95% CI −4.06 to 2.97 for plasma). Conclusions: Despite increasing use in civilian settings, this systematic review and meta-analysis showed no significant reduction in mortality or blood product use associated with prehospital tourniquet use. Further research, including high-quality randomized controlled trials, is required, as well as awareness and education campaigns relating to proper tourniquet use in the prehospital setting. Full article

Patients with severe traumatic brain injury (STBI) often experience an abnormal hemostasis that contributes to mortality and unfavorable neurological outcomes. Objectives: We aimed to analyze epidemiologic, clinical, and laboratory factors associated with mortality in patients with STBI during the first 48 h after in-hospital admission. Methods: We performed an observational retrospective study of STBI patients with associated extracranial trauma [defined as Injury Severity Score (ISS) ≥ 16 with an Abbreviated Injury Scale (AIS) head and neck ≥ 3 and Glasgow Coma Scale (GCS) ≤ 8] admitted to a Level II trauma center over seven years (2015–2021). Patients were divided into two groups: survivors and dead. We assessed differences regarding demographics, trauma severity, hemodynamics, disability, need for surgery, length of stay, transfusions, need for massive transfusion protocol, and hemostatic laboratory parameters at different time points. Results: A total of 134 STBI patients were included. Patients who died were older, mostly men, and showed higher trauma severity and disability. Hemoglobin, platelets, and clotting parameters deteriorated after admission to the emergency department (ED) with significant differences between groups within the first 24 h after admission. Platelet count < 150 × 10³/μL at ED arrival, GCS, and age were independent risk factors for mortality. Conclusions: Older age, GCS, and platelet count at ED arrival were independent risk factors for mortality in STBI patients with associated extracranial trauma. Early thrombocytopenia < 150 × 10³/μL at ED arrival may be used as a simple prognostic tool to early predict mortality between non-isolated STBI. Full article

Rapid and reliable Rhesus D typing is crucial for blood donation centers. In instances of massive blood transfusion or reduced antigen expression, DNA-based phenotype prediction becomes mandatory. Our molecular RHD typing approach involves an initial real-time PCR for the most common aberrant RHD types in our region, RHD*01W.1 (weak D type 1), RHD*01W.2 (weak D type 2), RHD*01W.3 (weak D type 3), and RHD*07.01 (DVII). For comprehensive coverage, Sanger sequencing of RHD coding regions is performed in the case of PCR target-negative results. We evaluated the specificity and accuracy of these methods using the recently launched LightCycler^® PRO real-time platform. All findings demonstrated remarkable accuracy. Notably, the LightCycler^® PRO instrument offers a distinct advantage in data interpretation and integration via the HL7 interface. This study underlines the importance of including advanced molecular techniques in blood typing protocols, especially in scenarios where conventional serological methods may be insufficient. Full article

Androgens have long been recognized as oncogenic agents. They can induce both benign and malignant hepatocellular neoplasms, including hepatocellular adenoma (HCA) and hepatocellular carcinoma, though the underlying mechanisms remain unclear. Androgen-induced liver tumors are most often solitary and clinically silent. Herein, we reported an androgen-induced HCA complicated by spontaneous rupture. The patient was a 24-year-old male presenting with fatigue, diminished libido, radiology-diagnosed hepatocellular adenomatosis for 3 years, and sudden-onset, severe, sharp, constant abdominal pain for one day. He used Aveed (testosterone undecanoate injection) from age 17 and completely stopped one year before his presentation. A physical exam showed touch pain and voluntary guarding in the right upper quadrant of the abdomen. An abdominal CT angiogram demonstrated multiple probable HCAs, with active hemorrhage of the largest one (6.6 × 6.2 × 5.1 cm) accompanied by large-volume hemoperitoneum. After being stabilized by a massive transfusion protocol and interventional embolization, he underwent a percutaneous liver core biopsy. The biopsy specimen displayed atypical hepatocytes forming dense cords and pseudoglands. The lesional cells diffusely stained β-catenin in nuclei and glutamine synthetase in cytoplasm. Compared to normal hepatocytes from control tissue, the tumor cells were positive for nuclear AR (androgen receptor) expression but had no increased EZH2 (Enhancer of Zeste 2 Polycomb Repressive Complex 2 Subunit) protein expression. The case indicated that androgen-induced hepatocellular neoplasms should be included in the differential diagnosis of acute abdomen. Full article