Publications by authors named "Alberto Garcia"

133 Publications

COVID-19 Vaccine Acceptability Among Clients and Staff of Homeless Shelters in Detroit, Michigan, February 2021.

Health Promot Pract 2021 Oct 23:15248399211049202. Epub 2021 Oct 23.

Detroit Health Department, Detroit, MI, USA.

Understanding COVID-19 vaccine acceptability among clients and staff of homeless shelters can inform public health efforts focused on communicating with and educating this population about COVID-19 vaccines and thus improve vaccine uptake. The objective of this study was to assess COVID-19 vaccine acceptability and uptake among people in homeless shelters in Detroit, Michigan. A cross-sectional study was conducted from February 9 to 23, 2021. Seventeen homeless shelters were surveyed: seven male-only, three male/female, and seven women and family shelters. All clients and staff aged ≥18 years and able to complete a verbal survey in English or with a translator were eligible to participate; of the 168 individuals approached, 26 declined, leaving a total sample of 106 clients and 36 staff participating in the study. The median client and staff ages were 44 and 54 years, respectively. Most participants (>80%) identified as non-Hispanic Black or African American. Sixty-one (57.5%) clients and 27 (75.5%) staff had already received or planned to receive a COVID-19 vaccination. Twelve (11.3%) clients and four (11.1%) staff were unsure, and 33 (31.1%) clients and five (13.9%) staff did not plan to get vaccinated. Reasons for hesitancy were concerns over side effects (29 clients [64.4%] and seven staff [77.8%]) and unknown long-term health impacts (26 clients [57.8%] and six staff [66.7%]). More than half of the clients had already received or planned to receive the vaccine. Continuing efforts such as vaccine education for hesitant clients and staff and having accessible vaccine events for this population may improve acceptability and uptake.
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http://dx.doi.org/10.1177/15248399211049202DOI Listing
October 2021

Rectal damage control: when to do and not to do.

Colomb Med (Cali) 2021 May 20;52(2):e4124776. Epub 2021 May 20.

Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA.

Rectal trauma is uncommon, but it is usually associated with injuries in adjacent pelvic or abdominal organs. Recent studies have changed the paradigm behind military rectal trauma management, showing better morbidity and mortality. However, damage control techniques in rectal trauma remain controversial. This article aims to present an algorithm for the treatment of rectal trauma in a patient with hemodynamic instability, according to damage control surgery principles. We propose to manage intraperitoneal rectal injuries in the same way as colon injuries. The treatment of extraperitoneal rectum injuries will depend on the percentage of the circumference involved. For injuries involving more than 25% of the circumference, a colostomy is indicated. While injuries involving less than 25% of the circumference can be managed through a conservative approach or primary repair. In rectal trauma, knowing when to do or not to do it makes the difference.
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http://dx.doi.org/10.25100/cm.v52i2.4776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216057PMC
May 2021

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Colomb Med (Cali) 2021 Apr 27;52(2):e4114425. Epub 2021 Apr 27.

Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.
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http://dx.doi.org/10.25100/cm.v52i2.4425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216049PMC
April 2021

Damage control in penetrating duodenal trauma: less is better - the sequel.

Colomb Med (Cali) 2021 May 3;52(2):e4104509. Epub 2021 May 3.

Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.
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http://dx.doi.org/10.25100/cm.v52i2.4509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216054PMC
May 2021

Damage Control for renal trauma: the more conservative the surgeon, better for the kidney.

Colomb Med (Cali) 2021 May 13;52(2):e4094682. Epub 2021 May 13.

Parma Maggiore Hospital, Department of Emergency Surgery, Parma, Italy.

Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.
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http://dx.doi.org/10.25100/cm.v52i2.4682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216050PMC
May 2021

Damage control surgery for splenic trauma: "preserve an organ - preserve a life".

Colomb Med (Cali) 2021 May 7;52(2):e4084794. Epub 2021 May 7.

Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.

The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.
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http://dx.doi.org/10.25100/cm.v52i2.4794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216056PMC
May 2021

Damage control surgery in lung trauma.

Colomb Med (Cali) 2021 May 10;52(2):e4044683. Epub 2021 May 10.

University of Pittsburgh, Critical Care Medicine. Pittsburgh, PA, USA.

Damage control techniques applied to the management of thoracic injuries have evolved over the last 15 years. Despite the limited number of publications, information is sufficient to scatter some fears and establish management principles. The severity of the anatomical injury justifies the procedure of damage control in only few selected cases. In most cases, the magnitude of the physiological derangement and the presence of other sources of bleeding within the thoracic cavity or in other body compartments constitutes the indication for the abbreviated procedure. The classification of lung injuries as peripheral, transfixing, and central or multiple, provides a guideline for the transient bleeding control and for the definitive management of the injury: pneumorraphy, wedge resection, tractotomy or anatomical resection, respectively. Identification of specific patterns such as the need for resuscitative thoracotomy, or aortic occlusion, the existence of massive hemothorax, a central lung injury, a tracheobronchial injury, a major vascular injury, multiple bleeding sites as well as the recognition of hypothermia, acidosis or coagulopathy, constitute the indication for a damage control thoracotomy. In these cases, the surgeon executes an abbreviated procedure with packing of the bleeding surfaces, primary management with packing of some selected peripheral or transfixing lung injuries, and the postponement of lung resection, clamping of the pulmonary hilum in the most selective way possible. The abbreviation of the thoracotomy closure is achieved by suturing the skin over the wound packed, or by installing a vacuum system. The management of the patient in the intensive care unit will allow identification of those who require urgent reintervention and the correction of the physiological derangement in the remaining patients for their scheduled reintervention and definitive management.
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http://dx.doi.org/10.25100/cm.v52i2.4683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216053PMC
May 2021

Damage control in penetrating cardiac trauma.

Colomb Med (Cali) 2021 Apr 3;52(2):e4034519. Epub 2021 Apr 3.

University of Cape Town, Faculty of Health Sciences, Groote Schuur Hospital, Trauma Center, Anzio Road, Observatory, Cape Town, South Africa.

Definitive management of hemodynamically stable patients with penetrating cardiac injuries remains controversial between those who propose aggressive invasive care versus those who opt for a less invasive or non-operative approach. This controversy even extends to cases of hemodynamically unstable patients in which damage control surgery is thought to be useful and effective. The aim of this article is to delineate our experience in the surgical management of penetrating cardiac injuries via the creation of a clear and practical algorithm that includes basic principles of damage control surgery. We recommend that all patients with precordial penetrating injuries undergo trans-thoracic ultrasound screening as an integral component of their initial evaluation. In those patients who arrive hemodynamically stable but have a positive ultrasound, a pericardial window with lavage and drainage should follow. We want to emphasize the importance of the pericardial lavage and drainage in the surgical management algorithm of these patients. Before this concept, all positive pericardial windows ended up in an open chest exploration. With the coming of the pericardial lavage and drainage procedure, the reported literature and our experience have shown that 25% of positive pericardial windows do not benefit and/or require further invasive procedures. However, in hemodynamically unstable patients, damage control surgery may still be required to control ongoing bleeding. For this purpose, we propose a surgical management algorithm that includes all of these essential clinical aspects in the care of these patients.
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http://dx.doi.org/10.25100/cm.v52i2.4519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216058PMC
April 2021

Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach.

Colomb Med (Cali) 2021 Apr 8;52(2):e4024592. Epub 2021 Apr 8.

Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.

Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.
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http://dx.doi.org/10.25100/cm.v52i2.4592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216055PMC
April 2021

Damage control in the emergency department, a bridge to life.

Colomb Med (Cali) 2021 May 30;52(2):e4004801. Epub 2021 May 30.

Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.

Patients with hemodynamic instability have a sustained systolic blood pressure less or equal to 90 mmHg, a heart rate greater or equal to 120 beats per minute and an acute compromise of the ventilation/oxygenation ratio and/or an altered state of consciousness upon admission. These patients have higher mortality rates due to massive hemorrhage, airway injury and/or impaired ventilation. Damage control resuscitation is a systematic approach that aims to limit physiologic deterioration through strategies that address the physiologic debt of trauma. This article aims to describe the experience earned by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia in the management of the severely injured trauma patient in the emergency department following the basic principles of damage control surgery. Since bleeding is the main cause of death, the management of the severely injured trauma patient in the emergency department requires a multidisciplinary team that performs damage control maneuvers aimed at rapidly controlling bleeding, hemostatic resuscitation, and/or prompt transfer to the operating room, if required.
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http://dx.doi.org/10.25100/cm.v52i2.4801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8216048PMC
May 2021

Genetic connectivity between Atlantic bluefin tuna larvae spawned in the Gulf of Mexico and in the Mediterranean Sea.

PeerJ 2021 14;9:e11568. Epub 2021 Jun 14.

Centro Oceanográfico de Málaga, Instituto Español de Oceanografía, Consejo Superior de Investigaciones Científicas, Fuengirola, Málaga, Spain.

The highly migratory Atlantic bluefin tuna (ABFT) is currently managed as two distinct stocks, in accordance with natal homing behavior and population structuring despite the absence of barriers to gene flow. Larval fish are valuable biological material for tuna molecular ecology. However, they have hardly been used to decipher the ABFT population structure, although providing the genetic signal from successful breeders. For the first time, cooperative field collection of tuna larvae during 2014 in the main spawning area for each stock, the Gulf of Mexico (GOM) and the Mediterranean Sea (MED), enabled us to assess the ABFT genetic structure in a precise temporal and spatial frame exclusively through larvae. Partitioning of genetic diversity at nuclear microsatellite loci and in the mitochondrial control region in larvae spawned contemporarily resulted in low significant fixation indices supporting connectivity between spawners in the main reproduction area for each population. No structuring was detected within the GOM after segregating nuclear diversity in larvae spawned in two hydrographically distinct regions, the eastern GOM (eGOM) and the western GOM (wGOM), with the larvae from eGOM being more similar to those collected in the MED than the larvae from wGOM. We performed clustering of genetically characterized ABFT larvae through Bayesian analysis and by Discriminant Analysis of Principal Components (DAPC) supporting the existence of favorable areas for mixing of ABFT spawners from Western and Eastern stocks, leading to gene flow and apparent connectivity between weakly structured populations. Our findings suggest that the eastern GOM is more prone for the mixing of breeders from the two ABFT populations. Conservation of this valuable resource exploited for centuries calls for intensification of tuna ichthyoplankton research and standardization of genetic tools for monitoring population dynamics.
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http://dx.doi.org/10.7717/peerj.11568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210807PMC
June 2021

Quality of Education and Late-Life Cognitive Function in a Population-Based Sample From Puerto Rico.

Innov Aging 2021 9;5(2):igab016. Epub 2021 May 9.

Department of Psychology, University of Alabama at Birmingham, USA.

Background And Objectives: We examined quality of education, literacy, and years of education in relation to late-life cognitive function and decline in older Puerto Ricans.

Research Design And Methods: Our sample consisted of 3,385 community-dwelling adults aged 60 years and older from the Puerto Rican Elderly: Health Conditions study. Quality of education was based on principal component analysis of variables gathered from Department of Education and Census reports. Literacy (yes/no) and years of education were self-reported. Cognitive function was assessed in participants' homes at baseline and 4 years later using a previously validated Spanish-language 20-point global screening measure for dementia, the minimental Cabán. Regression models were adjusted for sociodemographic and life course covariates.

Results: Quality of education was positively correlated with both educational attainment and cognitive performance. Independent of years of education, literacy, childhood economic hardship, and adult economic hardship, compared to participants in the lowest quartile of education quality, those in the highest quartile had significantly better baseline cognitive performance ( = 0.09, < .001). Quality of education did not consistently show an association with change in cognitive function over 4 years. Literacy and greater educational attainment were each independently associated with better cognitive function at baseline and less cognitive decline.

Discussion And Implications: Quality of education, literacy, and years of education, while interrelated, also show independent associations with cognitive functioning in older Puerto Ricans. The downstream factors of literacy and years of education were more closely related to age-related cognitive decline than quality of education.
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http://dx.doi.org/10.1093/geroni/igab016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8219031PMC
May 2021

Videothoracoscopic approach to the extraction of a cardiac retainer missile.

Trauma Case Rep 2021 Jun 22;33:100489. Epub 2021 Apr 22.

Department of Cardiovascular Surgery, Centro Médico Imbanaco - Clínica Farallones, Cali, Colombia.

The presence of foreign bodies (FB) retained in the heart or pericardium secondary to penetrating trauma in stable patients is a very rare event and its management is controversial. We present the case of a 19-year-old patient who was admitted to our trauma center hemodynamically stable because of two gunshot wounds in the lumbar region. A chest x-ray (CXR) revealed a blurred foreign body over the right heart chamber, thoracoabdominal computed tomography (CT) scan showed a free projectile over the left atrial wall, and transesophageal echocardiogram (TEE) showed a hyperrefringent pericardial sac image near the right ventricle. Finally, the patient went to surgery where a missile was removed from the pericardial sac by video-assisted thoracoscopic surgery (VATS).
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http://dx.doi.org/10.1016/j.tcr.2021.100489DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099773PMC
June 2021

Effect of continuous positive airway pressure versus nasal cannula on late preterm and term infants with transient tachypnea of the newborn.

J Perinatol 2021 07 13;41(7):1675-1680. Epub 2021 May 13.

Department of Pediatrics, Baylor Scott & White McLane Children's Medical Center, Temple, TX, USA.

Objective: To compare continuous positive airway pressure (CPAP) with nasal cannula (NC) as primary noninvasive respiratory therapy in hypoxic infants for transient tachypnea of the newborn (TTN).

Study Design: Retrospective cohort study of infants born at ≥34 weeks of gestation between January 1, 2015 and December 31, 2018.

Result: After adjusting for gestational age and birth weight, the maximum fractional inspired oxygen (FiO) was significantly lower in the CPAP group with an incidence rate ratio (IRR) of 0.85 (95% CI: 0.76-0.96). Although nonsignificant, the CPAP group needed 32% fewer hours on oxygen with an IRR of 0.68 (95% CI: 0.38-1.22). The duration of respiratory support and the incidence of pneumothorax were similar between both groups.

Conclusion: Comparing CPAP with NC as initial noninvasive respiratory therapy for TTN, significantly lower maximum FiO was observed in the infants of CPAP group without increase in the incidence of pneumothorax.
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http://dx.doi.org/10.1038/s41372-021-01068-9DOI Listing
July 2021

Emergency surgery workforce and its inverse relationship with multidimensional poverty in Colombia.

Eur J Trauma Emerg Surg 2021 May 7. Epub 2021 May 7.

Department of Surgery, Fundacion Valle del Lili, Cali, Colombia.

Purpose: General surgeons, anesthesiologists, obstetricians and gynecologists (ob-gyns), and orthopedic surgeons are the vital disciplines to provide emergency surgery within a healthcare system. This paper aims to examine the relationship (if any) between multidimensional poverty (MDP) and GDP per-capita with the emergency surgery workforce density in Colombia.

Methods: We performed an ecological study, where the observation units were the 32 Colombian departments. The total numbers of general surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons were obtained from the "Registro Unico Nacional de Talento Humano en Salud" (ReTHUS) registry. The 2020 population projections, the incidence of MDP and the GDP per capita were obtained from the Colombian National Administrative Department of Statistics. A spearman's correlation coefficient was calculated to measure the strength of the correlations between the surgical workforce density with MDP and GDP per-capita.

Results: There were significant moderate inverse linear correlations between the incidence of multidimensional poverty and workforce density. The correlation coefficients for the incidence of multidimensional poverty and the workforce density were - 0.5273, - 0.5620, - 0.4704, and - 0.4612 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively. Conversely, the correlation coefficients for the GDP per-capita and the workforce density were 0.4045, 0.3822, 0.4404, and 0.3742 for surgeons, anesthesiologists, ob-gyns, and orthopedic surgeons, respectively.

Conclusion: This study found that Colombian trauma and emergency surgery workforce density was inversely and directly correlated with multidimensional poverty and GDP per-capita levels, respectively. The relationship of these economic indicators with the surgical capacity deserves further investigation.
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http://dx.doi.org/10.1007/s00068-021-01690-4DOI Listing
May 2021

Impact of red blood cell transfusion on oxygen transport and metabolism in patients with sepsis and septic shock: a systematic review and meta-analysis.

Rev Bras Ter Intensiva 2021 Jan-Mar;33(1):154-166

Fundación Valle del Lili - Cali, Valle del Cauca, Colômbia.

Red blood cell transfusion is thought to improve cell respiration during septic shock. Nevertheless, its acute impact on oxygen transport and metabolism in this condition remains highly debatable. The objective of this study was to evaluate the impact of red blood cell transfusion on microcirculation and oxygen metabolism in patients with sepsis and septic shock. We conducted a search in the MEDLINE®, Elsevier and Scopus databases. We included studies conducted in adult humans with sepsis and septic shock. A systematic review and meta-analysis were performed using the DerSimonian and Laird random-effects model. A p value < 0.05 was considered significant. Nineteen manuscripts with 428 patients were included in the analysis. Red blood cell transfusions were associated with an increase in the pooled mean venous oxygen saturation of 3.7% (p < 0.001), a decrease in oxygen extraction ratio of -6.98 (p < 0.001) and had no significant effect on the cardiac index (0.02L/minute; p = 0,96). Similar results were obtained in studies including simultaneous measurements of venous oxygen saturation, oxygen extraction ratio, and cardiac index. Red blood cell transfusions led to a significant increase in the proportion of perfused small vessels (2.85%; p = 0.553), while tissue oxygenation parameters revealed a significant increase in the tissue hemoglobin index (1.66; p = 0.018). Individual studies reported significant improvements in tissue oxygenation and sublingual microcirculatory parameters in patients with deranged microcirculation at baseline. Red blood cell transfusions seemed to improve systemic oxygen metabolism with apparent independence from cardiac index variations. Some beneficial effects have been observed for tissue oxygenation and microcirculation parameters, particularly in patients with more severe alterations at baseline. More studies are necessary to evaluate their clinical impact and to individualize transfusion decisions.
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http://dx.doi.org/10.5935/0103-507X.20210017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075342PMC
November 2021

Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality.

Colomb Med (Cali) 2020 Dec 30;51(4):e4214510. Epub 2020 Dec 30.

University of Colorado, Denver Health Medical Center, Department of Surgery, Denver, CO USA.

Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.
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http://dx.doi.org/10.25100/cm.v51i4.4510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968423PMC
December 2020

Pancreatic damage control: the pancreas is simple don't complicate it.

Colomb Med (Cali) 2020 Dec 30;51(4):e4164361. Epub 2020 Dec 30.

Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.

Pancreatic trauma is a rare but potentially lethal injury because often it is associated with other abdominal organ or vascular injuries. Usually, it has a late clinical presentation which in turn complicates the management and overall prognosis. Due to the overall low prevalence of pancreatic injuries, there has been a significant lack of consensus among trauma surgeons worldwide on how to appropriately and efficiently diagnose and manage them. The accurate diagnosis of these injuries is difficult due to its anatomical location and the fact that signs of pancreatic damage are usually of delayed presentation. The current surgical trend has been moving towards organ preservation in order to avoid complications secondary to exocrine and endocrine function loss and/or potential implicit post-operative complications including leaks and fistulas. The aim of this paper is to propose a management algorithm of patients with pancreatic injuries via an expert consensus. Most pancreatic injuries can be managed with a combination of hemostatic maneuvers, pancreatic packing, parenchymal wound suturing and closed surgical drainage. Distal pancreatectomies with the inevitable loss of significant amounts of healthy pancreatic tissue must be avoided. General principles of damage control surgery must be applied when necessary followed by definitive surgical management when and only when appropriate physiological stabilization has been achieved. It is our experience that viable un-injured pancreatic tissue should be left alone when possible in all types of pancreatic injuries accompanied by adequate closed surgical drainage with the aim of preserving primary organ function and decreasing short and long term morbidity.
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http://dx.doi.org/10.25100/cm.v51i4.4361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968433PMC
December 2020

Damage Control in Penetrating Liver Trauma: Fear of the Unknown.

Colomb Med (Cali) 2020 Dec 30;51(4):e4134365. Epub 2020 Dec 30.

Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA.

The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.
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http://dx.doi.org/10.25100/cm.v51i4.4422.4365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968427PMC
December 2020

Damage control of laryngotracheal trauma: the golden day.

Colomb Med (Cali) 2020 Dec 30;51(4):e4124599. Epub 2020 Dec 30.

Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.

Laryngotracheal trauma is rare but potentially life-threatening as it implies a high risk of compromising airway patency. A consensus on damage control management for laryngotracheal trauma is presented in this article. Tracheal injuries require a primary repair. In the setting of massive destruction, the airway patency must be assured, local hemostasis and control measures should be performed, and definitive management must be deferred. On the other hand, management of laryngeal trauma should be conservative, primary repair should be chosen only if minimal disruption, otherwise, management should be delayed. Definitive management must be carried out, if possible, in the first 24 hours by a multidisciplinary team conformed by trauma and emergency surgery, head and neck surgery, otorhinolaryngology, and chest surgery. Conservative management is proposed as the damage control strategy in laryngotracheal trauma.
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http://dx.doi.org/10.25100/cm.v51i4.4422.4599DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968428PMC
December 2020

REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients.

Colomb Med (Cali) 2020 Dec 30;51(4):e4064506. Epub 2020 Dec 30.

15 Örebro University Hospital, Faculty of Medicine, Department of Cardiothoracic and Vascular Surgery, Örebro, Sweden.

Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the esuscitative ndovascular alloon cclusion of the orta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.
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http://dx.doi.org/10.25100/cm.v51i4.4422.4506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968426PMC
December 2020

Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient.

Colomb Med (Cali) 2020 Dec 30;51(4):e4054362. Epub 2020 Dec 30.

Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.

Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.
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http://dx.doi.org/10.25100/cm.v51i4.4362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968424PMC
December 2020

Whole blood for blood loss: hemostatic resuscitation in damage control.

Colomb Med (Cali) 2020 Dec 30;51(4):e4044511. Epub 2020 Dec 30.

University of Pittsburgh, Critical Care Medicine. Pittsburgh, PA, USA.

Hemorrhagic shock and its complications are a major cause of death among trauma patients. The management of hemorrhagic shock using a damage control resuscitation strategy has been shown to decrease mortality and improve patient outcomes. One of the components of damage control resuscitation is hemostatic resuscitation, which involves the replacement of lost blood volume with components such as packed red blood cells, fresh frozen plasma, cryoprecipitate, and platelets in a 1:1:1:1 ratio. However, this is a strategy that is not applicable in many parts of Latin America and other low-and-middle-income countries throughout the world, where there is a lack of well-equipped blood banks and an insufficient availability of blood products. To overcome these barriers, we propose the use of cold fresh whole blood for hemostatic resuscitation in exsanguinating patients. Over 6 years of experience in Ecuador has shown that resuscitation with cold fresh whole blood has similar outcomes and a similar safety profile compared to resuscitation with hemocomponents. Whole blood confers many advantages over component therapy including, but not limited to the transfusion of blood with a physiologic ratio of components, ease of transport and transfusion, less volume of anticoagulants and additives transfused to the patient, and exposure to fewer donors. Whole blood is a tool with reemerging potential that can be implemented in civilian trauma centers with optimal results and less technical demand.
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http://dx.doi.org/10.25100/cm.v51i4.4511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968429PMC
December 2020

Prehospital Damage Control: The Management of Volume, Temperature… and Bleeding!

Colomb Med (Cali) 2020 Dec 30;51(4):e4024486. Epub 2020 Dec 30.

Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.

Damage control resuscitation should be initiated as soon as possible after a trauma event to avoid metabolic decompensation and high mortality rates. The aim of this article is to assess the position of the Trauma and Emergency Surgery Group (CTE) from Cali, Colombia regarding prehospital care, and to present our experience in the implementation of the "Stop the Bleed" initiative within Latin America. Prehospital care is phase 0 of damage control resuscitation. Prehospital damage control must follow the guidelines proposed by the "Stop the Bleed" initiative. We identified that prehospital personnel have a better perception of hemostatic techniques such as tourniquet use than the hospital providers. The use of tourniquets is recommended as a measure to control bleeding. Fluid management should be initiated using low volume crystalloids, ideally 250 cc boluses, maintaining the principle of permissive hypotension with a systolic blood pressure range between 80- and 90-mm Hg. Hypothermia must be management using warmed blankets or the administration of intravenous fluids warmed prior to infusion. However, these prehospital measures should not delay the transfer time of a patient from the scene to the hospital. To conclude, prehospital damage control measures are the first steps in the control of bleeding and the initiation of hemostatic resuscitation in the traumatically injured patient. Early interventions without increasing the transfer time to a hospital are the keys to increase survival rate of severe trauma patients.
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http://dx.doi.org/10.25100/cm.v51i4.4486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968431PMC
December 2020

Damage control resuscitation: REBOA as the new fourth pillar.

Colomb Med (Cali) 2020 Dec 30;51(4):e4014353. Epub 2020 Dec 30.

University of Alabama Center for Injury Science, Department of Surgery, Birmingham. AL, USA.

Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm "The Fourth Pillar": Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.
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http://dx.doi.org/10.25100/cm.v51i4.4353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968430PMC
December 2020

A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

J Trauma Acute Care Surg 2021 02;90(2):388-395

From the Méderi Hospital Universitario Mayor (R.M.-N., D.E., J.G., J.G.R.-N., A.C.C., A.G., J.O., V.O.-M., F.B., F.G.); Escuela de Medicina y Ciencias de la Salud (R.M.-N., D.E., J.G., J.G.R.-N., A.C.C., A.G., J.O., V.O.-M., F.B., F.G.), Universidad del Rosario, Bogotá, DC; Fundacion Valle del Lili, Clinical Research Center (A.G., M.S.-R.), Cali; Hospital Occidente de Kennedy (A.C.R., P.C.), Bogotá, DC; Sección de Urología, Departamento de Cirugía, (A.G.-H., H.A.G.-P.), Universidad del Valle; and Department of Surgery (A.F.G.), Fundación Valle del Lili, Cali, Colombia.

Background: We performed a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

Methods: A literature search in five databases identified relevant articles for inclusion in this SR and MA. Studies were eligible if they evaluated the diagnostic accuracy of chest US, compared with a PW, for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients presenting with penetrating thoracic trauma. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. We performed a MA of binary diagnostic test accuracy within the bivariate mixed-effects logistic regression modeling framework.

Results: We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results.

Conclusion: This SR and MA found that, compared with PW, US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. Caution interpretation of pericardial US results is suggested in the presence of left hemothorax. In these cases, a second diagnostic test should be performed.

Level Of Evidence: Systematic Review and Meta-analysis, level II.
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http://dx.doi.org/10.1097/TA.0000000000003006DOI Listing
February 2021

A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum.

J Trauma Acute Care Surg 2021 05;90(5):807-816

From the Placenta Accreta Spectrum Clinic (A.J.N.-C., F.R., C.A.O., A.F.G., J.V., J.P.C., A.M.B., M.P.E., M.F.E., J.C., J.P.B.-C., J.M.B.), Clinical Research Center (L.M.V.-G., M.C.L., R.M.); Division of Trauma and Acute Care Surgery, Department of Surgery (F.R., C.A.O., A.F.G.); and Interventional Radiology Department (J.V., J.P.C.), Fundación Valle del Lili, Cali, Colombia.

Introduction: The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team.

Methodology: A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way.

Results: A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise.

Conclusion: Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills.

Level Of Evidence: Therapeutic care management, level III.
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http://dx.doi.org/10.1097/TA.0000000000003090DOI Listing
May 2021

Arterial thrombosis after REBOA use in placenta accreta spectrum: a case series.

J Matern Fetal Neonatal Med 2020 Nov 18:1-4. Epub 2020 Nov 18.

Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.

Background: The use of resuscitative endovascular balloon of the aorta (REBOA) is a useful strategy for bleeding control in placenta accreta spectrum (PAS) management. The incidence of complications associated with this procedure is variable. We report three cases of arterial thrombosis associated with REBOA, and we also analyze the factors that facilitated its occurrence.

Case Report: Three women with PAS, presented common femoral and external iliac arterial thrombosis after REBOA use. Among the contributing factors probably associated with thrombosis, we identified the absence of ultrasound guidance for vascular access and the not using of heparin during aortic occlusion.

Conclusions: REBOA use is not exempt from complications and must be performed by experienced groups applying strategies to reduce the risks of complications.
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http://dx.doi.org/10.1080/14767058.2020.1846178DOI Listing
November 2020

Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management: Proposal of a New Decision-Making Algorithm.

World J Surg 2021 Apr 5;45(4):1043-1052. Epub 2020 Nov 5.

Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.

Background: Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice.

Methods: Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups.

Results: 290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3-8) vs. DISM group: 3 (IQR: 1-6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS.

Conclusion: DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.
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http://dx.doi.org/10.1007/s00268-020-05854-yDOI Listing
April 2021
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