Current Literature

Finding Optimal Prehospital Crystalloid Resuscitation Volume in Hemorrhagic Shock Trauma Patients

Deeb A-P, Lu L, Guyette FX, et al. Optimal Prehospital Crystalloid Resuscitation Volume in Trauma Patients at Risk for Hemorrhagic Shock. J Am Coll Surg, 2023, in press.

The guiding principles for achieving optimal outcomes for injured patients with hemorrhagic shock include rapid control of bleeding and resuscitation, preferably using whole blood or packed red blood cells and clotting factors (hemostatic resuscitation). Logistics often prevent use of hemostatic resuscitation in the prehospital phase of care, and crystalloid fluid administration is often the only available alternative.

Data cited in this article confirmed that use of crystalloid resuscitation in patients with penetrating trauma is associated with increased mortality. Additional data showed that use of crystalloid resuscitation in blunt injury patients is associated with improved outcomes.

The objective of this study was to determine the volume range of prehospital crystalloid fluid administration that was associated with the lowest mortality in a cohort (n = 405) of patients who sustained blunt force injuries and had clinical evidence of hemorrhagic shock. After statistical analysis of the data and propensity matching of patient characteristics and risk factors, a range of 250 mL–1250 mL of prehospital crystalloid fluid was the fluid volume range associated with the lowest mortality risk. In addition, administration of fluids in the chosen range was associated with reduced systemic inflammation (lower levels of IL-6 and syndecan-1).

The authors concluded that use of the recommended fluid volumes in the prehospital phase of care would potentially reduce mortality risk and avoid fluid overload. They recommended adjusting the total fluid volume administered based on the anticipated transport time, stressing that additional studies are needed to determine if the recommended fluid volume range is associated with improved outcomes in patients with traumatic brain injury. These findings provide useful guidance for prehospital care providers but will need to be adjusted based on individual patient factors and diligent hemodynamic monitoring.

Article Examines Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia

Shishehbor MH, Powell RJ, Montero-Baker MF, et al. Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia. N Engl J Med 2023;388(13):1171-80. doi: 10.1056/NEJMoa2212754

Patients with chronic limb-threatening ischemia are usually treated with endovascular or surgical reconstruction of arterial inflow. Approximately 20% of these patients present for care having exhausted all options for arterial reconstruction and are usually subjected to above-ankle amputation. This study presented data on the use of a percutaneous approach that employed an endovascular stent to connect arterial inflow to the deep venous system of the extremity, thus restoring oxygen delivery to the ischemic tissue. The technique is clearly illustrated in the article.

A cohort of patients (n = 105) with chronic, limb-threatening ischemia and no remaining options for arterial reconstruction were prospectively chosen for transcatheter arterialization of the deep veins in the approved PROMISE II trial. The endpoints of interest were freedom from mortality or above ankle amputation at 6 months after the procedure. Secondary endpoints included limb salvage, wound healing, and technical success of the procedure.

Initial success of the procedure was achieved in 99% of the patients. Amputation-free survival was 66.1% at 6 months; complete wound healing occurred in 25% of patients and wound healing was progressing satisfactorily in an additional 51% of patients. No procedure-related adverse events were noted, but reintervention was necessary to preserve tissue oxygen delivery in 36.5% of patients. The authors concluded that transcatheter arterialization of deep veins was feasible and effective.

Editorial

Drachman DE. Arterial Gerrymandering—Converting Veins to Arteries to Save Ischemic Limbs. N Engl J Med 2023;388(13):1223-24. doi: 10.1056/NEJMe2216380

In the editorial that accompanied the article, Douglas E. Drachman, MD, noted that these results were encouraging, but long-term follow-up is necessary to determine whether vessel patency can be maintained, and symptoms of venous congestion can be avoided.