SMARTQCIncreasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality

Objectives: To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing (PPP) in patients with pelvic ring injuries and hemodynamic instability (HDI). Methods: Design: Retrospective review Setting: Urban level one trauma center Patients Selection Criteria: Severely injured (Injury severity score (ISS) >15) patients with pelvic ring injuries treated before and after increasing threshold to perform PPP from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure (SBP) <90 mmHg. Outcome Measures and Comparisons: Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms (VTE) before and after increasing PPP threshold. Results: 166 patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n=43) of the historical protocol group and 49.3% (n=36) of the updated protocol group (p=0.69). The median age of HDI patients was 35.0 years (IQR 26.0 and 52.0), 74.7% (n=59) were males, and the median ISS was 41.0 (IQR 29.0 to 50.0). HDI patients in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; p=0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, p=0.03), and did not differ in age, ISS, SBP on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta (REBOA), resuscitative thoracotomy (RT), angioembolization (AE), or anterior pelvis open reduction internal fixation (p>0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, p<0.0001) and there were fewer anterior pelvic infections (0.0% vs. 13.9%, p=0.02), fewer VTEs (8.3% vs. 30.2%; p=0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, p=1.00). Conclusions: Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.