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Poster # 1 THREE SEQUENTIAL REBOA CATHETERS for VASCULAR EXCLUSION of the LIVER: a HEMORRHAGE CONTROL STRATEGY in JUXTAHEPATIC VENA CAVA INJURIES JOAO B

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Poster # 1 THREE SEQUENTIAL REBOA CATHETERS for VASCULAR EXCLUSION of the LIVER: a HEMORRHAGE CONTROL STRATEGY in JUXTAHEPATIC VENA CAVA INJURIES JOAO B Poster # 1 THREE SEQUENTIAL REBOA CATHETERS FOR VASCULAR EXCLUSION OF THE LIVER: A HEMORRHAGE CONTROL STRATEGY IN JUXTAHEPATIC VENA CAVA INJURIES JOAO B. REZENDE-NETO* MD,Ph.D., Ghassan Al-Kefeiri MD, Matt Strickland MD, Vikram Prabhudesai MD, Sandro Rizoli* MD,Ph.D., St. Michael's Hospital Introduction: Injuries to the retrohepatic inferior vena cava (RH-IVC) and juxtahepatic IVC (JH-IVC) have a mortality rate in the order of 80% despite several treatment options. Surgeons are confronted with a combination of challenges including hemodynamic instability, difficult exposure, and rapid exsanguination. Thus, temporary hemorrhage control is important prior to surgical exploration. There is evidence that hepatic vascular exclusion could potentially facilitate injury repair. The emergence of resuscitative endovascular balloon occlusion of the aorta (REBOA) resulted in renewed interest in the use of this technology to temporize traumatic hemorrhage. We hypothesized that sequential deployment of three REBOA devices, inserted in the aorta and in the inferior vena cava, and application of the Pringle maneuver would provide complete hepatic vascular exclusion. Methods: Five swine underwent intravascular hemodynamic monitoring, cutdown of the femoral vessels, and splenectomy. Three REBOA devices were positioned under fluoroscopic guidance in the thoracic aorta, suprahepatic IVC, and infrahepatic IVC above the renal veins. Shock was induced by blood withdrawal to a target of 30% of the total blood volume in 20 minutes. Subsequently, complete hepatic vascular exclusion was performed in the following sequence: inflation of the aortic balloon, followed by Pringle maneuver, inflation of the balloon in the infrahepatic IVC, and ultimately inflation of the balloon in the suprahepatic IVC. Hemodynamic parameters and laboratory tests were recorded after 15 minutes of liver isolation. Afterward, hepatic revascularization was performed by: deflation of the balloon in the suprahepatic IVC, deflation of the infrahepatic IVC balloon, release of the Pringle, and deflation of the aortic balloon. Subsequently, hepatic vascular exclusion was performed again in the presence of an injury to the JH-IVC (Figure). Results: Hepatic vascular exclusion by sequential inflation of three REBOA devices and Pringle maneuver effectively temporized the bleeding from the JH-IVC injury. Hepatic vascular exclusion significantly increased MAP compared to shock (40±3.7mmHg vs. 68.4 ±3.8mmHg, p 0.0001), and continued after the injury to the JH-IVC (66 ± 5.8mmHg, p 0.0001). Hepatic vascular exclusion did not aggravate shock assessed by pH, lactate and base excess, as well as additional hemodynamic parameters CVP and heart rate ( p>0.05). Deflation of the balloons led to immediate exsanguination from the JH-IVC injury; MAP (10mmHg ± 7.5mmHg) at 1min after balloon deflation. Conclusion: Sequential deployment of three REBOA devices combined with the Pringle maneuver enabled total vascular exclusion of the liver and effectively temporized hemorrhage from a juxtahepatic IVC injury. This procedure is potentially less invasive than other strategies previously described. Poster # 2 PREPERITONEAL PELVIC PACKING FOR THE TREATMENT OF HEMODYNAMICALLY UNSTABLE PELVIC TRAUMA: FIVE YEARS EXPERIENCE WITH A TIMELY AND EFFICIENT TOOL. Stefano Magnone* MD, Marco Ceresoli MD, Federico Coccolini MD, Luca Ansaloni MD, Papa Giovanni XXIII Hospital Introduction: Hemodynamically unstable pelvic trauma has been a great challenge for a long time even in most experienced Trauma Centers. Most of them still consider angiography as the first option to treat these patients. Preperitoneal Pelvic Packing (PPP) is another option. In 2011 PPP was introduced in our Hospital as the first maneuver, with or without External Fixation (EF). Aims of this study are to review time to treatment and mortality in this group of patients. Methods: A retrospective review of our database was performed from September 2011 to December 2016. Patients with hemodynamic instability (defined as Systolic Blood Pressure SBP < 90 mmHg at the arrival in the Emergency Department, ED, or during the initial phase of resuscitation) and a pelvic or acetabular fracture were included. Values were expressed in median and interquartile range (IR). Continuous variables were compared with Mann-Whitney test. Results: In the index period, we treated 34 patients (25 males and 9 females). Median age was 51 years (40-65) and Injury Severity Score (ISS) 37 (34-43). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess -8 (-11.5/-4.8), pH 7.23 (7.20-7.27). First 24 hours transfusion rate was 13 U (8-18.8) of packed red blood cell, 9 U (4-15) of fresh frozen plasma and 2 U (1-3) of platelets. Length of stay in the ED was 58 min (30-130) and time to emergency treatment was 66 min (54-160). 31 (91.2%) patients underwent PPP, while in 2 external fixation was sufficient to control bleeding and in another one angiography was the only procedure. Time to PPP was 63 min (51-113). 17 patients (54.8%) underwent angiography after PPP for persistent instability and 11 of these (35.5%) underwent therapeutic embolization. Early mortality was 26.5%, (8 due to physiologic exhaustion and one to traumatic brain injury). All patients died within the first 24 hours from trauma. There were not significant differences between survivors and non- survivors groups. (Tab. 1) Conclusion: Hemodynamically unstable pelvic trauma remains a big challenge for trauma centers. In our experience PPP proved to be quick to achieve even by the single surgeon in charge. No death occurred from direct pelvic bleeding. Poster # 3 AFTER THE EMBO: PREDICTING NON-HEMORRHAGIC INDICATIONS FOR SPLENECTOMY AFTER ANGIOEMBOLIZATION IN BLUNT TRAUMA PATIENTS John F. Bilello* MD, Victoria Sharp DO, Rachel Dirks Ph.D., Krista Kaups* MD, James W. Davis* MD, UCSF Fresno Introduction: Successful non-operative management (NOM) of blunt splenic trauma has increased with the use of splenic angioembolization (SAE); however, patients may still require splenectomy (SPLEN) post-SAE for total splenic infarction and/or abscess. Prompt recognition of this complication may be challenging. We hypothesized that changes in laboratory values indicating complete splenic infarction may expedite the management of these patients. Methods: Trauma patients admitted to an ACS verified Level 1 trauma center, from 1/07-1/17, who underwent SAE were identified from the trauma registry. Patients with successful NOM after SAE (SAE/NOM) were compared to those requiring splenectomy (SAE/SPLEN). Data included demographics, splenic injury grade, ISS, time to SAE and splenectomy, ICU and hospital LOS, and CBC values. Laboratory values were analyzed immediately post-SAE (time1), and day#5 post-SAE (or day of discharge) for SAE/NOM patients or day of splenectomy for SAE/SPLEN patients (time2). Data was analyzed using Mann Whitney U and Chi square tests with significance attributed to p<0.05. Results: 116 patients underwent SAE; one patient with chronic lymphocytic leukemia and splenomegaly was excluded. 16 (14%) later required SPLEN for infarction/abscess, at a median of 5 days post SAE (IQR: 4-10 days). No differences existed between SAE/SPLEN and SAE/NOM patients in age, gender, ISS, or grade of splenic injury. SAE/SPLEN patients had longer hospital LOS (24 vs 10, p = 0.001). WBC, PLT, and PLT/WBC ratio did not differ between the groups at time1. At time2, WBC was higher and PLT/WBC ratio was lower in SAE/SPLEN patients. Conclusion: Patients requiring splenectomy for abscess/infarction after SAE develop significant leukocytosis and thrombocytosis, and the PLT/WBC ratio is indicative of total splenic infarction. Monitoring of these parameters allows for more prompt diagnosis and operative intervention. Poster # 4 LEAKY LIVERS? ROUTINE HIDA AS A SCREENING TOOL FOR BILIARY LEAK IN HIGH-GRADE LIVER LACERATIONS Joseph S. Farhat MD, Loren Bach MD, Jonathan Gipson MD, Michaela A. West* MD,Ph.D., North Memorial Health Care Introduction: Bile leak is a serious complication of major liver injury that can result in substantial morbidity and even death. Our Level 1 Trauma Center instituted early (48-72 hours post-injury) routine HIDA scans in grade 4-5 liver lacerations to screen for bile leaks. We hypothesized that routine HIDA scans would identify subclinical bile leaks that could be prospectively managed to minimize complications. Methods: The trauma registry was used to retrospectively identify all patients (pts) with grade 4-5 liver lacerations from blunt trauma between July 2011 and Dec 2016. Medical records were reviewed to identify pts who underwent screening HIDA scans. Total bilirubin, Injury Severity Score (ISS), interventions, and length of stay (LOS) were recorded. Pts with positive HIDA scan (HIDA+) were compared to those with negative HIDA scan (HIDA-). Mean and standard deviation (SD) were calculated. Statistical analysis was performed by Student t-test or Chi-square. Results: We identified 35 pts with blunt grade 4-5 liver lacerations during the study period. Seven pts were excluded (4 required emergent exploratory laparotomy, 1 left AMA, 2 pts did not get screening HIDA), leaving 28 pts who met inclusion criteria. Study pts were severely injured, with a mean ISS of 27. HIDA scans were completed on median post injury day 3. Of the 28 HIDA scans performed, 5 (17.8%) were positive for bile leak. All 5 pts with HIDA+ underwent ERCP, 4 also had laparoscopic washout, and 2 required IR drainage. No HIDA- pts required additional interventions. HIDA+ pts had significantly higher total bilirubin and a greater hospital LOS. Conclusion: We showed that HIDA scans were a useful tool in high-grade blunt liver lacerations to aid in early identification of bile leak. Patients with HIDA+ were able to undergo ERCP, biliary stenting, washout, and/or IR drainage prior to overt clinical signs of biliary leak or bile peritonitis. We also found that early negative HIDA scans seemed to reliably identify patients without bile leak after high grade liver trauma. Poster # 5 SPLENIC INJURY MANAGEMENT OUTCOMES FROM TQIP = SOS - SAVE OUR SPLEENS! Bryce N.
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