Aziz, HA, Bugaev, N, Baltazar, G, et al. Management of adult renal trauma: a practice management guideline from the eastern association for the surgery of trauma. BMC Surg 23, 22 (2023)
Relevant Background: Renal trauma is the most common form of genitourinary trauma. Several guidelines from multiple societies exist, often with conflicting recommendations.
PICOs: PICO 1: In hemodynamically stable adult patients with renal trauma and evidence of active bleeding clinically or radiographically (P), should angioembolization (I) versus observation (C) be performed to decrease mortality, nephrectomy, or delayed hemorrhage necessitating intervention and the need for long term renal replacement therapy (RRT) (O)? PICO 2: In hemodynamically unstable adult patients with a stable zone II hematoma diagnosed intraoperatively (P), should renal exploration (I) versus no renal exploration (C) be performed to decrease mortality, nephrectomy, or delayed hemorrhage necessitating intervention, need for long term RRT, and angioembolization (O)? PICO 3: In hemodynamically unstable adult patients found to have an expanding zone II hematoma necessitating exploration (P) should total nephrectomy (I) versus renal preserving surgery (partial nephrectomy or primary repair) (C) be performed to decrease mortality, delayed hemorrhage necessitating intervention, or need for long term renal replacement therapy (RRT) and angioembolization (O)? PICO 4: In hemodynamically stable adult patients with high grade (AAST III-V) renal trauma managed non-operatively (P), should routine follow up CT abdomen (I) versus symptom-based CT abdomen (C) be performed to decrease delayed hemorrhage necessitating intervention (O)?
Recommendations: PICO 1: No recommendation made regarding the use of angioembolization vs observation in hemodynamically stable patients with signs of active bleeding. PICO 2: Conditional recommendation against renal exploration in favor of no renal exploration in hemodynamically unstable patients with stable zone II retroperitoneal hematoma diagnosed intraoperatively. PICO 3: Conditional recommendation against total nephrectomy in favor of renal preserving surgery in hemodynamically unstable patients. PICO 4: No recommendation made regarding routine repeat follow up CT abdomen vs symptom based CT abdomen in hemodynamically stable patients with high grade renal injury.
Clinical Application:
The clinical application of these guidelines is limited by the lack of quality evidence available. No recommendation can be made on the use of angioembolization vs observation in stable patients with signs of active extravasation or other signs of bleeding. Likewise, no recommendation can be made on the utility of routine follow up CT scan in high grade renal trauma. If a zone II retroperitoneal hematoma is discovered at laparotomy in an unstable patient, this hematoma should be left in place according to the guidelines. If renal exploration is undertaken for an expanding hematoma or active bleeding from defects in Gerota's fascia, reasonable attempts should be made to perform kidney preserving operations.
Additional Thoughts or Information: Unfortunately, these guidelines are severely limited by the lack of available evidence for the PICO questions. No recommendation could be made for 2 of the questions and the 2 questions that did lead to recommendations were based on very limited evidence. The authors admit that the quality of evidence for both of the recommendations is very low and that the certainty of the effects seen in the studies utilized to make those recommendations is likewise very low. Caution must be exercised when utilizing these guidelines to make clinical decisions. This dearth of evidence underscores the need for better designed, larger scale studies to answer these questions. _____________________________________________________________________________________________________
Teichman AL, Bonne S, Rattan R, Dultz L, Qurashi FA, Goldenberg A, Polite N, Liveris A, Freeman JJ, Colosimo C, Chang E, Choron RL, Edwards C, Arabian S, Haines KL, Joseph D, Murphy PB, Schramm AT, Jung HS, Lawson E, Fox K, Mashbari HNA, Smith RN. Screening and intervention for intimate partner violence at trauma centers and emergency departments: an evidence-based systematic review from the Eastern Association for the Surgery of Trauma. Trauma Surg Acute Care Open. 2023 Mar 16;8(1):e001041. doi: 10.1136/tsaco-2022-001041. PMID: 36967863; PMCID: PMC10030790.
Relevant Background: Intimate partner violence (IPV) is a significant public health issue contributing directly to mental health, physical injury and the financial healthcare burden. One in nine trauma patients are at risk for intimate partner or sexual violence; thus trauma and ED providers are uniquely poised to assist in identification of IPV. Victim identification and the effective distribution of resources remains a major barrier to reducing morbidity and mortality related to IPV.
PICOs: PICO 1: Does an institutional formal IPV screening tool used to screen adult trauma victims (>/= 18 years of age) increase identification of IPV victims? PICO 2: Does an institutional formal IPV intervention protocol reduce mortality and adverse outcomes related to IPV?
Recommendations: Regarding PICO 1: We conditionally recommend implementation of universal screening to identify victims of IPV in adult trauma and ED patients. Regarding PICO 2: There are no studies addressing outcomes related to interventions around IPV and therefore a recommendation cannot be made.
Clinical Application: Clinicians should screen ED patients and trauma victims for IPV as it has the ability to identify more victims. Direct questioning was shown to capture the greatest number of victims. Interviews with possible victims should occur when the patient is alone and not in the presence of a potential abuser. Clinicians should recall that many IPV victims do not present to the ED for injury and thus screening should be performed on all patients regardless of presentation or complaint.
Additional Thoughts or Information: The field of intimate partner violence needs further research regarding methods of IPV intervention, timeliness of identification and overall effects of screening on morbidity and mortality. While all populations are at risk, literature reports that LGBTQ+ individuals may be disproportionately affected and thus there is a need for continued research in this specific domain. The trauma community has a unique opportunity to positively affect the lives of those suffering from IPV and it is our duty to assist in identification of these individuals. ______________________________________________________________________________________________________
Ra JH, Rattan R, Patel NJ, Bhattacharya B, Butts CA, Gupta S, Asfaw SH, Como JJ, Sahr SM, Bugaev N. Duration of antimicrobial treatment for complicated intra-abdominal infections after definitive source control: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2023 Oct 1;95(4):603-612. doi: 10.1097/TA.0000000000003998. Epub 2023 Jun 15. PMID: 37316989.
Relevant Background: Antimicrobial treatment is an important aspect of the clinical management of complicated intra-abdominal infections (cIAIs), but the duration of antimicrobial treatment after definitive source control (DSC) has remained quite variable among providers over the years. More recently, studies investigating outcomes associated with duration of antibiotic treatment for cIAI have suggested a shorter course of antibiotics after DSC. This EAST PMG group aimed to incorporate this new evidence from recent studies and make clinical recommendations using the GRADE methodology.
PICOs: In adult patients with cIAIs who have undergone DSC, should a short vs. long duration of antibiotic treatment be used to reduce the risk of surgical site infections, unplanned radiological or surgical interventions, hospital length of stay, readmissions, and mortality?
Recommendations: In adults with cIAIs who have undergone DSC, the authors of this PMG recommend a short (4 days) vs. long (8 days) duration of antibiotic treatment.
Clinical Application: This EAST PMG recommends a short duration of antibiotic therapy after DSC of a cIAI. This was based on the noninferior effect of a short vs. long antibiotic course duration, taking into account the lower risk of antibiotic related complications along with reduced cost. The exact antibiotic agent should be considered according to the surgical pathology, individual patient characteristics, and local institutional protocols.
Additional Thoughts or Information: Majority of the studies included in this meta-analysis were observational, and 6 out of 16 studies only looked at the treatment of appendicitis. Further high-quality studies are warranted looking specifically at the duration of treatment in fungal intra-abdominal infections or infections with resistant pathogens, and in immunocompromised or patients with comorbid conditions.