Invited Commentary
November 30, 2022
Nationwide Variation of Care for Patients With Bleeding Pelvic Fracture—An Opportunity to Rescue Better?
Lydia R. Maurer, Haytham M. Kaafarani
JAMA Surg. Published online November 30, 2022. doi:10.1001/jamasurg.2022.5778
Most studies in the trauma literature have examined the mortality of all patients with pelvic fractures, estimating it at around 10%.1,2 In this nationwide study, Anand and colleagues3 examined the outcomes of severely injured patients with pelvic fracture, those with hemodynamic instability requiring at least 4 units of blood transfusion and at least 1 major hemorrhage control intervention. The authors report a high overall mortality rate of 36%, lower mortality for patients who undergo angioembolization (AE), and increased complications in patients who undergo preperitoneal pelvic packing (PP).
The authors included patients with severe injuries in other body regions beyond the pelvis. Including these multiple-trauma patients with a median Injury Severity Score of 24 can perhaps explain the high mortality rate and the median of 9 units of blood transfused, but the authors elegantly performed a sensitivity analysis in which they excluded the subset of patients with an Abbreviated Injury Severity score of 2 or greater for head or chest and confirmed their findings. Previous studies have also suggested that, in the presence of other major injuries, pelvic fracture is associated with an independent risk of mortality.4 Perhaps more importantly, the authors demonstrate considerable variation across the United States in the management of these critically ill patients, specifically with respect to the choice and combination of interventions used, such as AE, preperitoneal PP, and resuscitative endovascular balloon angioplasty of the aorta (REBOA).
Despite the authors’ great statistical efforts at managing confounders, it is likely that residual confounding remains in this population-based study, and patients who undergo preperitoneal PP are inherently physiologically different from those who can wait for the interventional radiology team to arrive, but the obvious question from these data remains: what can we do to better rescue these patients and decrease their high mortality rate? In our opinion, the real important finding of this study is the significant variation in management strategies across different hospitals. This variation deserves exploration in subsequent studies. Although some variation is always warranted to provide patient-centered, personalized care, literature suggests that variation in processes of care often reflects variation in the quality of care provided.5,6
We congratulate the authors for bringing these data to light and invite the major trauma societies in the United States to standardize care in this high-risk population. We see no real barrier for the American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, and the Western Trauma Association to come together and not only create 1 specific evidence-based set of guidelines, but also catalyze an effort to implement it widely across the nation. With 1 in 3 of these patients dying, the opportunity to save lives is evident.
