Dispelling Dogma: American Association for Surgery of Trauma Prospective, Multicenter Trial of Index vs Delayed Fasciotomy after Extremity Trauma.
Journal
Journal of the American College of Surgeons
ISSN: 1879-1190
Titre abrégé: J Am Coll Surg
Pays: United States
ID NLM: 9431305
Informations de publication
Date de publication:
01 05 2023
01 05 2023
Historique:
medline:
18
4
2023
pubmed:
4
2
2023
entrez:
3
2
2023
Statut:
ppublish
Résumé
Surgical dogma states that "if you think about doing a fasciotomy, you do it," yet the benefit of this approach remains unclear. We hypothesized that early fasciotomy during index operative procedures for extremity vascular trauma would be associated with improved patient outcomes. This prospective, observational multicenter (17 level 1, 1 level 2) analysis included patients ≥15 years old with extremity vascular injury requiring operative management. Clinical variables were analyzed with respect to fasciotomy timing for correlation with outcomes, including muscle necrosis and limb amputation. Associated variables (p < 0.05) were input into multivariable logistic regression models evaluating these endpoints. Of 436 study patients, most were male (87%) with penetrating (57%), lower extremity (77%), arterial (73%), vein (40%), and bony (53%) injury with prolonged hospital length of stay (11 days). Patients who had index fasciotomy (66%) were compared with those who did not (34%), and no differences were appreciated with respect to age, initial systolic blood pressure, tourniquet time, "hard" signs of vascular injury, massive transfusion protocol activation, or Injury Severity Score (all p < 0.05). Of the 289 patients who underwent index fasciotomy, 49% had prophylactic fasciotomy, 11% developed muscle necrosis, 4% required an additional fasciotomy, and 8% required amputation, although only 28 of 147 (19%) required delayed fasciotomy in those without index fasciotomy. Importantly, forgoing index fasciotomy did not correlate (p > 0.05) with additional muscle necrosis or amputation risk in the delayed fasciotomy group. After controlling for confounders, index surgery fasciotomy was not associated with either muscle necrosis or limb salvage in multivariable models. Routine, index operation fasciotomy failed to demonstrate an outcome benefit in this prospective, multicenter analysis. Our data suggest that a careful observation and fasciotomy-when-needed approach may limit unnecessary surgery and its resulting morbidity in extremity vascular trauma patients.
Sections du résumé
BACKGROUND
Surgical dogma states that "if you think about doing a fasciotomy, you do it," yet the benefit of this approach remains unclear. We hypothesized that early fasciotomy during index operative procedures for extremity vascular trauma would be associated with improved patient outcomes.
STUDY DESIGN
This prospective, observational multicenter (17 level 1, 1 level 2) analysis included patients ≥15 years old with extremity vascular injury requiring operative management. Clinical variables were analyzed with respect to fasciotomy timing for correlation with outcomes, including muscle necrosis and limb amputation. Associated variables (p < 0.05) were input into multivariable logistic regression models evaluating these endpoints.
RESULTS
Of 436 study patients, most were male (87%) with penetrating (57%), lower extremity (77%), arterial (73%), vein (40%), and bony (53%) injury with prolonged hospital length of stay (11 days). Patients who had index fasciotomy (66%) were compared with those who did not (34%), and no differences were appreciated with respect to age, initial systolic blood pressure, tourniquet time, "hard" signs of vascular injury, massive transfusion protocol activation, or Injury Severity Score (all p < 0.05). Of the 289 patients who underwent index fasciotomy, 49% had prophylactic fasciotomy, 11% developed muscle necrosis, 4% required an additional fasciotomy, and 8% required amputation, although only 28 of 147 (19%) required delayed fasciotomy in those without index fasciotomy. Importantly, forgoing index fasciotomy did not correlate (p > 0.05) with additional muscle necrosis or amputation risk in the delayed fasciotomy group. After controlling for confounders, index surgery fasciotomy was not associated with either muscle necrosis or limb salvage in multivariable models.
CONCLUSIONS
Routine, index operation fasciotomy failed to demonstrate an outcome benefit in this prospective, multicenter analysis. Our data suggest that a careful observation and fasciotomy-when-needed approach may limit unnecessary surgery and its resulting morbidity in extremity vascular trauma patients.
Identifiants
pubmed: 36735489
doi: 10.1097/XCS.0000000000000612
pii: 00019464-202305000-00013
doi:
Types de publication
Observational Study
Multicenter Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1037-1044Investigateurs
Jane Keating
(J)
Joanelle Bailey
(J)
Robert Jean
(R)
M Victoria P Miles
(MVP)
Nathan Klingensmith
(N)
Amanda Leung
(A)
David Swift
(D)
Kevin Schuster
(K)
Randi Smith
(R)
Jeffry Nahmias
(J)
Alexis Moren
(A)
Robert A Maxwell
(RA)
Fabio Saccomanno
(F)
Joshua Hazelton
(J)
David Skarupa
(D)
Anna Goldenberg-Sandau
(A)
Jennifer Mull
(J)
Khaled Jawad
(K)
Anthony Loria
(A)
Howard Lieberman
(H)
Michael Vella
(M)
Joseph Fernandez Moure
(JF)
Zoe Maher
(Z)
Adrian Ong
(A)
Sarah Annie Moore
(SA)
Camilla Nettleton
(C)
Michael C Smith
(MC)
Pawan Mathew
(P)
Commentaires et corrections
Type : CommentIn
Type : CommentIn
Informations de copyright
Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.
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