title: Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability: do they make a difference?
abstract: BACKGROUND
  The management of patients with hemodynamic instability related to pelvic fracture is a major challenge, with high morbidity and mortality. Evidence-based institutional practice guidelines (PG) were developed as a strategy to optimize the care of these patients. The aims of this study were to evaluate the adherence to the new PG and compare the outcomes before and after their implementation.
  
  
  METHODS
  Major blunt trauma patients (Injury Severity Score [ISS] > 15) with hemodynamic instability (initial base deficit > 6 mEq/L or received > 6 units of packed red blood cells [PRBCs] during the first 12 hours) related to pelvic fracture were investigated. Patients presenting with ongoing bleeding from other regions or with severe head injury (Glasgow Coma Scale score < 9) were excluded. The pre-PG group (n = 17) were patients managed during the 18 months ending on December 31, 2001. The post-PG group (n = 14) consisted of patients managed during the subsequent 18 months. Demographics, ISS, shock severity, resuscitation, and outcome data were prospectively collected. The adherence to the key steps of PG was evaluated retrospectively in the pre-PG and prospectively in the post-PG group, including abdominal clearance (AC) with diagnostic peritoneal aspiration/lavage or ultrasound (<15 minutes), noninvasive pelvic binding (PB) (<15 minutes), pelvic angiography (PA) (<90 minutes after admission), and minimally invasive orthopedic fixation (MIOF) (<24 hours). Data are presented as mean +/- SEM or percentages.
  
  
  RESULTS
  The pre-PG and post-PG groups were similar regarding age (40 +/- 4 years vs. 42 +/- 6 years), gender (both 71% male), ISS (39 +/- 3 vs. 37 +/- 4), admission base deficit (9 +/- 1 vs. 10 +/- 1) admission systolic blood pressure (116 +/- 7 vs. 112 +/- 6 mm Hg), Glasgow Coma Scale score (12 +/- 1 vs. 12 +/- 1), and PRBC transfusion in the first 12 hours (9 +/- 2 U vs. 9 +/- 2 U). The adherence to the guidelines in the post-PG period was as follows: AC, 100%; PB, 86% (p < 0.05 based on t test or chi test); PA, 93% (p < 0.05 based on t test or chi test); and MIOF, 86%. In the pre-PG period, adherence to the guidelines was as follows: AC, 65%; PB, 0%; PA, 30%; and MIOF 52%. In the post-PG period, the 24-hour PRBC transfusion decreased from 16 +/- 2 U to 11 +/- 1 U and the mortality decreased from 35% to 7% (p < 0.05 based on t test or chi test for both).
  
  
  CONCLUSIONS
  The adherence to the PG as a reflection of optimal management was significantly improved. PG focusing particular on timely hemorrhage control reduced the 24-hour transfusion requirements and the mortality rate in the post-PG group.
authors.affiliation: Department of Trauma, Liverpool Health Service, Sydney, New South Wales, Australia.
authors.forename: Zsolt
authors.initials: Z
authors.lastname: Balogh
authors.forename: Erica
authors.initials: E
authors.lastname: Caldwell
authors.forename: Martin
authors.initials: M
authors.lastname: Heetveld
authors.forename: Scott
authors.initials: S
authors.lastname: D'Amours
authors.forename: Glen
authors.initials: G
authors.lastname: Schlaphoff
authors.forename: Ian
authors.initials: I
authors.lastname: Harris
authors.forename: Michael
authors.initials: M
authors.lastname: Sugrue
mesh_terms: D000328:Adult; D019091:Critical Pathways; D005260:Female; D050723:Fractures, Bone / Q000150:complications*; D019983:Guideline Adherence; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D010384:Pelvic Bones / Q000293:injuries*; D017410:Practice Guidelines as Topic; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000628:therapy*