Abhijit S. Pathak

Injuries of the inferior vena cava

Injuries of the IVC, whether caused by blunt or penetrating mechanisms, are usually fatal. Patients who arrive in shock and fail to respond to initial resuscitative measures, those who are still actively bleeding at the time of laparotomy, and those with wounds of the retrohepatic vena cava have a low probability of survival. Death most commonly is caused by intraoperative exsanguination. Knowledge of the anatomy and exposure techniques for the five different segments of the intra-abdominal vena cava is very important to trauma surgeons. Although some wounds of the vena cava, especially those of the retrohepatic vena cava, are best left unexplored, most injuries inferior to this level can be exposed and repaired by lateral suture technique. Preservation of a lumen of at least 25% of normal is probably important in the suprarenal vena cava but is of no provable value inferior to the renal veins. No evidence supports the need to expose and repair vena caval wounds that have spontaneously stopped bleeding. Such wounds, especially in the retrohepatic area, may be managed expectantly provided that there is no strong suspicion of an associated injury to a major artery or hollow viscus.

Emergency Department Thoracotomy: Still Useful After Abdominal Exsanguination?

BACKGROUND Although literature regarding emergency department thoracotomy (EDT) outcome after abdominal exsanguination is limited, numerous reports have documented poor EDT survival in patients with anatomic injuries other than cardiac wounds. As a result, many trauma surgeons consider prelaparotomy EDT futile for patients dying from intra-abdominal hemorrhage. Our primary study objective was to prove that prelaparotomy EDT is beneficial to patients with exsanguinating abdominal hemorrhage. METHODS A retrospective review of 237 consecutive EDTs for penetrating injury (2000-2006) revealed 50 patients who underwent EDT for abdominal exsanguination. Age, gender, injury mechanism and location, field and emergency department (ED) signs of life, prehospital time, initial ED cardiac rhythm, vital signs, Glasgow Coma Score, blood transfusion requirements, predicted mortality, primary abdominal injuries, and the need for temporary abdominal closure were analyzed. The primary study endpoint was neurologically intact hospital survival. RESULTS The 50 patients who underwent prelaparotomy EDT for abdominal exsanguination were largely young (mean, 27.3 +/- 8.2 years) males (94%) suffering firearm injuries (98%). Patients presented with field (84%) and ED signs of life (78%) after a mean prehospital time of 21.2 +/- 9.8 minutes. Initial ED cardiac rhythms were variable and Glasgow Coma Score was depressed (mean, 4.2 +/- 3.2). Eight (16%) patients survived hospitalization, neurologically intact. Of these eight, all were in hemorrhagic shock because of major abdominal vascular (75%) or severe liver injuries (25%) and all required massive blood transfusion (mean, 28.6 +/- 17.3 units) and extended intensive care unit length of stay (mean, 36.3 +/- 25.7 days). CONCLUSIONS Despite critical injuries, 16% survived hospitalization, neurologically intact, after EDT for abdominal exsanguination. Our results suggest that prelaparotomy EDT provides survival benefit to penetrating trauma victims dying from intra-abdominal hemorrhage.

Portal vein injuries.

Wounds of the portal vein are caused most commonly by penetrating trauma and carry a very high mortality rate. Most deaths are caused by exsanguination, occurring intraoperatively as surgeons struggle to control the hemorrhage from the portal vein and associated vascular injuries. A thorough knowledge of the anatomy of the area and of the likely patterns of wounding is important. At surgery, surgeons must be prepared to deal with multiple vessel wounding. Although most investigators have advocated lateral repair of the portal vein when it can be accomplished, portal ligation seems to be a safe alternative. Complex repairs are justified only when a contraindication to ligation exists. Postoperative care must recognize the need for extraordinary fluid replacement and the small risk for postoperative bowel infarction after repair or ligation of the portal vein.

''SCIP''ping antibiotic prophylaxis guidelines in trauma: The consequences of noncompliance

OBJECTIVE The Surgical Care Improvement Project (SCIP) established surgical antibiotic prophylaxis guidelines as part of a national patient safety initiative aimed at reducing surgical complications such as surgical site infection (SSI). Although these antibiotic prophylaxis guidelines have become well established in surgical patients, they remain largely unstudied in patients with injury from trauma undergoing operative procedures. We sought to determine the role of these antibiotic prophylaxis guidelines in preventing SSI in patients undergoing trauma laparotomy. METHODS A retrospective review of all patients who underwent emergency trauma laparotomy at two Level I trauma centers (2007–2008) revealed 306 patients who survived more than 4 days after injury. Demographics and clinical risk SSI factors were analyzed, and patients were compared on the basis of adherence to the following SCIP guidelines: (1) prophylactic antibiotic given, (2) antibiotic received within 1 hour before incision, (3) correct antibiotic selection, and (4) discontinuation of antibiotic within 24 hours after surgery. The primary study end point was the development of SSI. RESULTS The study sample varied by age (mean [SD], 32 [16] years) and injury mechanism (gunshot wound 44%, stab wound 27%, blunt trauma 30%). When patients with perioperative antibiotic management complying with the four SCIP antibiotic guidelines (n = 151) were compared with those who did not comply (n = 155), no difference between age, shock, small bowel or colon resection, damage control procedures, and skin closure was detected (p > 0.05). After controlling for injury severity score, hypotension, blood transfusion, enteric injury, operative duration, and other potential confounding variables in a multivariate analysis, complete adherence to these four SCIP antibiotic guidelines independently decreased the risk of SSI (odds ratio, 0.43; 95% confidence interval, 0.20–0.94; p = 0.035). Patients adhering to these guidelines less often developed SSI (17% vs. 33%, p = 0.001) and had shorter overall hospital duration of antibiotics (4 [6] vs. 9 [11] days, p < 0.001) and hospital length of stay (14 [13] vs. 19 [23] days, p = 0.016), although no difference in mortality was detected (p > 0.05). CONCLUSIONS Our results suggest that SCIP antibiotic prophylaxis guidelines effectively reduce the risk of SSI in patients undergoing trauma laparotomy. Despite the emergent nature of operative procedures for trauma, efforts to adhere to these antibiotic guidelines should be maintained. LEVEL OF EVIDENCE Therapeutic study, level II.

HIV and hepatitis in an urban penetrating trauma population: unrecognized and untreated.

BACKGROUND Despite limited prospective data, it is commonly believed that human immunodeficiency virus (HIV) and hepatitis infections are widespread in the penetrating trauma population, placing healthcare workers at risk for occupational exposure. Our primary study objective was to measure the prevalence of HIV (anti-HIV), hepatitis B (HB surface antigen [HBsAg]), and hepatitis C virus (anti-HCV) in our penetrating trauma population. METHODS We prospectively analyzed penetrating trauma patients admitted to Temple University Hospital between August 2008 and February 2010. Patients (n = 341) were tested with an oral swab for anti-HIV and serum evaluated for HBsAg and anti-HCV. Positives were confirmed with western blot, neutralization immunoassay, and reverse transcription polymerase chain reaction, respectively. Demographics, risk factors, and clinical characteristics were analyzed. RESULTS Of 341 patients, 4 patients (1.2%) tested positive for anti-HIV and 2 had a positive HBsAg (0.6%). Hepatitis C was the most prevalent measured infection as anti-HCV was detected in 26 (7.6%) patients. Overall, 32 (9.4%) patients were tested positive for anti-HIV, HBsAg, or anti-HCV. Twenty-eight (75%) of these patients who tested positive were undiagnosed before study enrollment. When potential risk factors were analyzed, age (odds ratio, 1.07, p = 0.031) and intravenous drug use (odds ratio 14.4, p < 0.001) independently increased the likelihood of anti-HIV, HBsAg, or anti-HCV-positive markers. CONCLUSIONS Greater than 9% of our penetrating trauma study population tested positive for anti-HIV, HBsAg, or anti-HCV although patients were infrequently aware of their seropositive status. As penetrating trauma victims frequently require expedient, invasive procedures, universal precautions are essential. The prevalence of undiagnosed HIV and hepatitis in penetrating trauma victims provides an important opportunity for education, screening, and earlier treatment of this high-risk population.

Noncardiac surgery in patients on mechanical circulatory support.

This study examined outcomes in patients with left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO) requiring noncardiac surgical procedures and identified factors that influence outcomes. All patients with mechanical circulatory support (MCS) devices at our institution from 2002 to 2013 undergoing noncardiac surgical procedures were reviewed. There were 148 patients requiring MCS during the study period, with 40 (27.0%) requiring 62 noncardiac surgical procedures. Of these, 29 (72.5%) had implantable LVAD and 11 (27.5%) were supported with ECMO. The two groups were evenly matched with regard to age (53.6 vs. 54.5 years, p = 0.87), male sex (71.4 vs. 45.5%, p = 0.16), and baseline creatinine (1.55 vs. 1.43 mg/dl, p = 0.76). Patients on ECMO had greater demand for postoperative blood products (0.8 vs. 2.8 units of packed red blood cells, p = 0.002) and greater postoperative increase in creatinine (0.07 vs. 0.44 mg/dl, p = 0.047). Median survival was markedly worse in ECMO patients. Factors associated with mortality included ECMO support, history of biventricular assist device, and postoperative blood transfusion. Preoperative aspirin was associated with survival. These findings demonstrate the importance of careful surgical hemostasis and minimizing perioperative blood transfusions in patients on MCS undergoing noncardiac surgical procedures. In addition, low-dose antiplatelet therapy should be continued perioperatively.

Does payer status matter in predicting penetrating trauma outcomes

BACKGROUND Few data exist regarding payer status as a predictor of outcomes in penetrating trauma. This study determined whether insurance status impacts in-hospital complications and mortality in gunshot and stab wound patients at our inner-city, level I trauma center. METHODS Penetrating trauma admissions from 2005 to 2009 were reviewed for patient demographics, insurance, Injury Severity Score, complications, duration of stay, and mortality. RESULTS A total of 1,347 penetrating trauma patients were admitted with 652 (48.4%) uninsured. Although uninsured patients were more likely to be male (93.3% vs 89.8%, P = .030), there was no difference in age, ISS, or number of radiologic, operative, or interventional procedures. Uninsured patients had lesser intensive care unit (4.4 vs 3.3 days; P = .049) and total hospital length of stay (10.2 vs 8.3; P = .049). No uninsured patients were placed into a rehabilitation facility at the time of discharge (0.0% vs 1.6%, P < .001). There was no difference in frequency of pulmonary complications, thromboembolic complications, sepsis, urinary tract infection, or wound infections. On multivariate analysis, being uninsured was not an independent predictor of in-hospital complications (1.010, 95% confidence interval 0.703-1.450, P = .959) or mortality (odds ratio 0.905, 95% confidence interval 0.523-1.566, P = .722). CONCLUSION This is the first study to show that penetrating trauma patients who are uninsured have lesser duration of stay and decreased placement into a rehabilitation facility. Being uninsured added no additional risk of in-hospital complications or mortality.

Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model.

BACKGROUND: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage. METHODS: After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag‐valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14‐gauge catheter, and a Swan‐Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10‐minute intervals. RESULTS: There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase. CONCLUSION: Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag‐valve mask ventilation.

Skin closure after trauma laparotomy in high-risk patients: opening opportunities for improvement.

BACKGROUND Although many surgeons leave laparotomy incisions open after colon injury to prevent surgical site infection (SSI), other injured patient subsets are also at risk. We hypothesized that leaving trauma laparotomy skin incisions open in high-risk patients with any enteric injury or requiring damage control laparotomy (DCL) would not affect superficial SSI and fascial dehiscence rates. METHODS Patients who underwent trauma laparotomy (2004–2008) at two Level I centers were reviewed. To ensure a high-risk sample, only patients with transmural enteric injuries or need for DCL surviving 5 days or more were included. SSIs were categorized by the CDC (Centers for Disease Control and Prevention) criteria and risk factors were analyzed by skin closure (open vs. any closure). Significant (p < 0.05) univariate variables were applied to two multivariate analyses examining superficial SSI and fascial dehiscence. RESULTS Of 1,501 patients who underwent laparotomy, 503 met inclusion criteria. Patients were young (median, 28.0 years; range, 22.0–40.0 years) with penetrating (74%) or enteric (80%) injuries, and DCL (36%) and SSI (44%; superficial, 25%; deep, 3%; organ/space, 25%) were common. While no difference in superficial SSI after loose (n = 136) or complete skin closure (n = 224) was detected (p = 0.64), superficial SSIs were less common with open skin incisions (9.8%), despite multiple risk factors, than with any skin closure (31.1%, p < 0.001). Predictors of superficial SSIs and fascial dehiscence were each evaluated with multiple-variable logistic regression analysis. After adjusting for multiple potential confounding variables, any skin closure increased the risk of superficial SSIs approximately nine times (odds ratio, 8.6; p < 0.001) and fascial dehiscence six times (odds ratio, 5.7; p = 0.013). CONCLUSION Management of skin incisions takes careful consideration like any other step of a laparotomy. Our results suggest that the decision to leave skin open is one simple method to improve outcomes in high-risk patients. LEVEL OF EVIDENCE Therapeutic study, level III.

Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68–1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06–2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.