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Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis

Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China; Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China. Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China. Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China. Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China. Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China. Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China. Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China. Electronic address: 407683545@qq.com.

The American Journal of Emergency Medicine. 2018
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Abstract
BACKGROUND The mortality rate of patients with hemodynamic instability due to severe pelvic fracture remains substantial and massive transfusion happens frequently. Angio-embolization, external fixation and preperitoneal pelvic packing of the pelvis are the main managements used to control bleeding in these patients. In this paper, we aimed at characterizing the rationale of these surgical managements, and placed them in optimal management algorithm to compose a new guideline. METHODS We selected controlled trials, assessing safety of management for the intervention of hemorrhagic shock from mortality data, and assessing efficacy from volume of first 24h blood transfusion following hospitalization. Six single and combined managements were extracted as comparison. A pairwise meta-analysis was conducted using a random effect model, and then the analysis was extended to a network meta-analysis. Pooled effect sizes were ranked and demonstrated the probability of being the best treatments for safety and efficacy. RESULTS 13 clinical trials and 24,396 participants were identified for this analysis. The assessment of rank probability indicated that pelvic packing presented the greatest likelihood of improving safety, while external fixation was indicated most efficient among the interventions for controlling hemorrhage. CONCLUSIONS Clinical protocols for guidelines of hemodynamically unstable pelvic fracture patients have been multidirectionally developed. We strongly support the initial application of an external fixator. Provided that patients remain hemodynamically unstable after application of an external fixation, pelvic packing is the next procedure to consider. Angio-embolization is the complementary but not alternative method of choice subsequently.
Study details
Study Design : Systematic Review
Language : English
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine