Patient Safety in Surgery

Featured article: Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers.

For patients with hemodynamically unstable pelvic ring injuries, survival depends on the early recognition and control of the associated retroperitoneal hemorrhage. A protocolized approach of pelvic packing in conjunction with pelvic external fixation has been shown to significantly reduce the unacceptably high mortality rates in patients with severe pelvic ring disruptions. The concept of pelvic packing was initially described in the 1980s and 1990s in Germany and Switzerland as a technique of transabdominal open pelvic packing through a “damage control” explorative laparotomy. Later on, the pelvic packing technique was modified in the United States towards a concept of “direct” preperitoneal pelvic packing (PPP) by applying a distinct surgical technique through a suprapubic midline incision that allows packing directly into the preperitoneal space without the necessity of a laparotomy. In spite of the proven benefits of pelvic packing towards improved patient outcomes, there is a widespread residual reluctance in the surgical and orthopaedic community for adopting the concept of PPP as a fundamental strategy for acute trauma management. In the current featured article, the authors report the preferences of trauma medical directors (TMDs) at 157 level 1 trauma centers in the United States related to utilizing PPP as a measure for acute hemorrhage control in hemodynamically unstable pelvic ring disruptions. The TMDs were surveyed as to their perception related to safety and effectiveness of PPP in a 15-item online questionnaire. Intriguingly, there appears to exist an ongoing unwillingness for adopting pelvic packing in many U.S. level 1 trauma centers due to perceived concerns related to safety and infection risk, in spite of published international best practice guidelines related the effectiveness of PPP for acute bleeding control and reduced mortality after severe trauma. The insights form this study imply an educational void and an opportunity for additional research to further corroborate the safety and effectiveness of pelvic packing.