Альманах клинической медицины. 2017; 45: 416-422
Консервативное ведение закрытой травмы живота: положительные прогностические критерии
https://doi.org/10.18786/2072-0505-2017-45-5-416-422Аннотация
Актуальность. В последние годы в ведущих мировых специализированных центрах избирательное консервативное ведение (NOM – nonoperative management) входит в стандартные протоколы лечения закрытой травмы. В основе успеха применения данной тактики лежит тщательный отбор пострадавших. Критерии селекции до настоящего времени четко не определены. Целью исследования стало определение прогностических критериев успешного NOM и разработка лечебно-диагностического алгоритма его применения.
Материал и методы. В исследование включены 209 пострадавших с травмой живота, в лечении которых в период с января 2006 по сентябрь 2015 г. применена лапароскопия либо консервативное ведение. Анализировались объем гемоперитонеума и степень повреждения органов по данным ультразвукового исследования и компьютерной томографии, уровень гемоглобина, уровень артериального давления и пульс. Произведен сравнительный анализ прогностической ценности различных критериев отбора пациентов для NOM, описанных в литературе: 1) ультразвуковых шкал количественной оценки гемоперитонеума Huang и McKenney, 2) гемодинамических показателей, 3) уровня гемоглобина, 4) различных вариантов сочетания вышеуказанных факторов, 5) ультразвуковой шкалы отбора пациентов на операцию при травме – шкалы SSORTT.
Результаты. Положительная прогностическая ценность использованных в исследовании показателей по отдельности, их комбинаций, а также различных вариантов балльной оценки каждого из факторов варьировала от 88 до 91,7%. При этом не выявлено статистически значимых различий между положительной прогностической ценностью всех вариантов сочетания факторов и оценкой только ультразвуковых данных по шкале McKenney.
Заключение. Предложенные нами прогностические критерии и выработанный лечебно-диагностический алгоритм просты и доступны для применения в клинической практике.
Список литературы
1. Cirocchi R, Boselli C, Corsi A, Farinella E, Listorti C, Trastulli S, Renzi C, Desiderio J, Santoro A, Cagini L, Parisi A, Redler A, Noya G, Fingerhut A. Is non-operative management safe and effective for all splenic blunt trauma? A systematic review. Crit Care. 2013;17(5):R185. doi: 10.1186/cc12868.
2. Jim J, Leonardi MJ, Cryer HG, Hiatt JR, Shew S, Cohen M, Tillou A. Management of highgrade splenic injury in children. Am Surg. 2008;74(10):988–92.
3. Pereira BM. Non-operative management of hepatic trauma and the interventional radiology: an update review. Indian J Surg. 2013;75(5): 339–45. doi: 10.1007/s12262-012-0712-4.
4. Sikhondze WL, Madiba TE, Naidoo NM, Muckart DJ. Predictors of outcome in patients requiring surgery for liver trauma. Injury. 2007;38(1): 65–70. doi: 10.1016/j.injury.2006.08.064.
5. Asensio JA, Petrone P, García-Núñez L, Kimbrell B, Kuncir E. Multidisciplinary approach for the management of complex hepatic injuries AAST-OIS grades IV-V: a prospective study. Scand J Surg. 2007;96(3):214–20. doi: 10.1177/145749690709600306.
6. van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, Jacobs L, Gross R, Agarwal S, Burke P, Maung AA, Johnson DC, Winchell R, Gates J, Cholewczynski W, Rosenblatt M, Chang Y. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg. 2012;147(5):423–8. doi: 10.1001/archsurg.2012.147.
7. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244(4):620–8. doi: 10.1097/01.sla.0000237743.22633.01.
8. Manka M, Moscati R, Raghavendran K, Priya A. Sonographic scoring for operating room triage in trauma. West J Emerg Med. 2010;11(2): 138–43.
9. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323–4.
10. Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. Ultrasonography for the evaluation of hemoperitoneum during resuscitation: a simple scoring system. J Trauma. 1994;36(2):173–7.
11. McKenney KL, McKenney MG, Cohn SM, Compton R, Nunez DB, Dolich M, Namias N. Hemoperitoneum score helps determine need for therapeutic laparotomy. J Trauma. 2001;50(4): 650–4.
Almanac of Clinical Medicine. 2017; 45: 416-422
Non-operative management of blunt abdominal trauma: positive predictors
https://doi.org/10.18786/2072-0505-2017-45-5-416-422Abstract
Background: Over the last years a non-operative management (NOM) of blunt abdominal trauma has been included into the standard treatment guidelines in leading trauma centers all over the world. The success of NOM is based on careful patient selection. Nevertheless, the selection criteria have not been clearly determined up to now.
Aim: To identify predictors of successful NOM and to create a diagnostic and treatment algorithm for its implementation.
Materials and methods: 209 patients with abdominal trauma who underwent laparoscopy or NOM from January 2006 to September 2015 were included in the study. The hemoperitoneum volume and organ injury rate evaluated by using ultrasonography and computed tomography scan, as well as hemoglobin level, blood pressure, and peripheral pulse were analyzed. We performed comparative analysis of prognostic values of various selection criteria for NOM, such as: 1) Huang and McKenney ultrasound scoring systems for hemoperitoneum quantification; 2) hemodynamic parameters; 3) hemoglobin levels; 4) various combinations of the above mentioned factors; 5) Sonographic Scoring for Operating Room Triage in Trauma (SSORTT) scoring system.
Results: Positive prognostic values of parameters included into the study varied from 88 to 91.7% when used separately or in combination with other scored factors. Furthermore, there was no significant difference between positive predictive value of all combinations of factors and McKenney ultrasound hemoperitoneum scoring system used alone.
Conclusion: The proposed predictors as well as diagnostic and treatment algorithm are easy-to-use and available in clinical practice.
References
1. Cirocchi R, Boselli C, Corsi A, Farinella E, Listorti C, Trastulli S, Renzi C, Desiderio J, Santoro A, Cagini L, Parisi A, Redler A, Noya G, Fingerhut A. Is non-operative management safe and effective for all splenic blunt trauma? A systematic review. Crit Care. 2013;17(5):R185. doi: 10.1186/cc12868.
2. Jim J, Leonardi MJ, Cryer HG, Hiatt JR, Shew S, Cohen M, Tillou A. Management of highgrade splenic injury in children. Am Surg. 2008;74(10):988–92.
3. Pereira BM. Non-operative management of hepatic trauma and the interventional radiology: an update review. Indian J Surg. 2013;75(5): 339–45. doi: 10.1007/s12262-012-0712-4.
4. Sikhondze WL, Madiba TE, Naidoo NM, Muckart DJ. Predictors of outcome in patients requiring surgery for liver trauma. Injury. 2007;38(1): 65–70. doi: 10.1016/j.injury.2006.08.064.
5. Asensio JA, Petrone P, García-Núñez L, Kimbrell B, Kuncir E. Multidisciplinary approach for the management of complex hepatic injuries AAST-OIS grades IV-V: a prospective study. Scand J Surg. 2007;96(3):214–20. doi: 10.1177/145749690709600306.
6. van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, Jacobs L, Gross R, Agarwal S, Burke P, Maung AA, Johnson DC, Winchell R, Gates J, Cholewczynski W, Rosenblatt M, Chang Y. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. Arch Surg. 2012;147(5):423–8. doi: 10.1001/archsurg.2012.147.
7. Demetriades D, Hadjizacharia P, Constantinou C, Brown C, Inaba K, Rhee P, Salim A. Selective nonoperative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244(4):620–8. doi: 10.1097/01.sla.0000237743.22633.01.
8. Manka M, Moscati R, Raghavendran K, Priya A. Sonographic scoring for operating room triage in trauma. West J Emerg Med. 2010;11(2): 138–43.
9. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995;38(3):323–4.
10. Huang MS, Liu M, Wu JK, Shih HC, Ko TJ, Lee CH. Ultrasonography for the evaluation of hemoperitoneum during resuscitation: a simple scoring system. J Trauma. 1994;36(2):173–7.
11. McKenney KL, McKenney MG, Cohn SM, Compton R, Nunez DB, Dolich M, Namias N. Hemoperitoneum score helps determine need for therapeutic laparotomy. J Trauma. 2001;50(4): 650–4.
