Agathoklis Konstantinidis

Outcomes of proximal versus distal splenic artery embolization after trauma: a systematic review and meta-analysis.

The objective of this systematic review and meta-analysis was to assess the outcomes after angioembolization in blunt trauma patients with splenic injuries and to examine specifically the impact of the technique used. Studies evaluating adult trauma patients who sustained blunt splenic injuries managed by angioembolization were systematically evaluated. The following data were required for inclusion: grade of splenic injury, indication for embolization, and site of embolization (proximal [main splenic artery] or distal [selective]). In addition, major (requiring splenectomy) or minor (not requiring splenectomy) rebleeding, infarction, and infection in relation to the site of embolization (proximal vs. distal) was required. Pooled outcomes were compared between proximal and distal embolizations. To eliminate between-study heterogeneity, a sensitivity analysis was conducted on three reduced sets of studies. Fifteen of 147 evaluated studies were included for analysis. All were retrospective cohort studies and incorporated a total of 479 embolized patients. The overall failure rate of angioembolization was 10.2% (range, 0.0-33.3%). Injury severity and basic demographics did not differ among the study populations. However, the indications for angioembolization (contrast extravasation, large amount of hemoperitoneum, or high-grade splenic injury) differed between the populations but were not associated with a change in the failure rates. Rebleeding was the most common reason for failure; however, it did not differ statistically between the used techniques, and with the 95% confidence interval crossing the 5% zone of clinical indifference, this result was inconclusive. Minor complications occurred statistically and clinically more often after distal than after proximal embolization. The available literature is inconclusive regarding whether proximal or distal embolization should be used to avoid significant rebleeding and larger prospective cohort studies are required. However, both techniques have an equivalent rate of infarctions and infections requiring splenectomy. Minor complications occur more often after distal embolization. This is primarily explained by the higher rate of segmental infarctions after distal embolization.

Management of post-traumatic retained hemothorax: a prospective, observational, multicenter AAST study.

Background: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. Methods: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 hours of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. Results: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH ⩽300 cc (odds ratio [OR], 3.7 [2.0–7.0]; p < 0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6–13.7]; p = 0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2–9.0]; p = 0.023), and volume of RH ⩽900 cc (OR, 3.9 [1.4–13.2]; p = 0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4–9.9]; p < 0.001), RH >900 cc (OR, 3.2 [1.4–7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; p = 0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. Conclusion: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy. Level of Evidence: II, prospective comparative study.

Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy: Results From the Prospective AAST Open Abdomen Registry

IMPORTANCE Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. OBJECTIVE To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. DESIGN The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. SETTING Fourteen level I trauma centers. PARTICIPANTS A total of 517 patients with an open abdomen following damage control laparotomy. MAIN OUTCOMES AND MEASURES Complication of ECF, EAF, or IAS. RESULTS More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). CONCLUSIONS AND RELEVANCE Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

Necrotizing soft tissue infections: delayed surgical treatment is associated with increased number of surgical debridements and morbidity.

BACKGROUND Early surgical treatment is crucial in the management of necrotizing soft tissue infections (NSTI), a severe, potentially life threatening, rapidly progressive infection. The purpose of this study was to determine the influence of surgical procedure timing on the number of surgical debridements required. METHODS A retrospective study including 47 patients with the diagnosis of NSTI admitted to a large academic hospital from December 2004 to December 2010 was conducted. Demographics, basic laboratories on admission, medical comorbidities, site of infection, and intraoperative culture results were compared between patients with early (≤12 hour) and late (>12 hour) surgical treatment. The x-y plot for the study population and linear regression analyses were used to define the time cut point. Outcomes included the total number of debridements, mortality, hospital length of stay, and complications. Adjustment for confounding factors was done with binary regression logistic model for categorical outcomes and analysis of covariants for continuous outcomes. RESULTS Overall mortality was 17.0%. The average number of surgical debridements in patients with delay surgical treatment >12 hours from the time of emergency department admission was significantly higher than those who had an operation within 12 hours after admission (7.4 ± 2.5 vs. 2.3 ± 1.2; p < 0.001). Delayed surgical debridement was associated with significantly higher mortality, higher incidence of septic shock and renal failure, and more surgical debridements than patients with early surgical debridements. After adjusting for possible confounding factors, the average number of surgical debridements and the presence of septic shock and acute renal failure were still significantly higher in patients in whom surgery was delayed >12 hours. CONCLUSION In patients with NSTI, a delay of surgical treatment of >12 hours is associated with an increased number of surgical debridements and higher incidence of septic shock and acute renal failure.

Blunt splenic trauma: splenectomy increases early infectious complications: a prospective multicenter study.

Background: The purpose of this study was to evaluate the effect of the method of splenic injury management on early infectious complications. Methods: Prospective observational, multicenter study which included all patients with blunt splenic injury surviving at least 72 hours. Epidemiologic and clinical data, grade of splenic injury, method of splenic management, and infectious complications during the initial hospitalization were collected according to a standardized collecting datasheet. Logistic regression analysis was used to identify independent risk factors for infectious complications. Results: During a 22-month period, 269 eligible patients were enrolled in the study. Overall, 105 (39.0%) patients were observed; 48 (17.8%) underwent successful angioembolization, 19 (7.1%) underwent splenorrhaphy, and 97 (36.1%) underwent splenectomy. Multivariate analysis adjusting for age, hypotension on admission, Glasgow Coma Scale, Injury Severity Score, Abbreviated Injury Scale, laparotomy, grade of splenic injury, and associated solid and hollow viscus injuries, showed that splenectomy had a significantly higher incidence of infectious complications than splenic preservation (adjusted odds ratio [95% confidence interval], 9.62 [3.04–30.30]; p < 0.001). A regression model analysis identified splenectomy, hypotension on admission, associated hollow viscus injury, and high Injury Severity Score as independent risk factors for infectious complications. Forward logistic regression analysis, which included only the 176 patients with grades III to V splenic injuries, identified splenectomy as the most significant independent risk factors for infection (adjusted odds ratio [95% confidence interval], 16.67 [3.76–71.43]; p < 0.001). Conclusions: Splenectomy is an independent risk factor for early infectious complications. Splenic-preserving techniques should be considered more liberally. Level of Evidence: II, therapeutic study.

Ethanol Intoxication Is Associated with a Lower Incidence of Admission Coagulopathy in Severe Traumatic Brain Injury Patients

The aim of this study was to determine the impact of ethanol (ETOH) on the incidence of severe traumatic brain injury (sTBI)-associated coagulopathy and to examine the effect of ETOH on in-hospital outcomes in patients sustaining sTBI. Patients admitted to the surgical intensive care unit from June 2005 through December 2008 following sTBI, defined as a head Abbreviated Injury Scale (AIS) score ≥3, were retrospectively identified. Patients with a chest, abdomen, or extremity AIS score >3 were excluded to minimize the impact of extracranial injuries. Criteria for sTBI-associated coagulopathy included thrombocytopenia and/or elevated International Normalized Ratio (INR) and/or prolonged activated partial thromboplastin time (aPTT). The incidence of admission coagulopathy, in-hospital complications, and mortality were compared between patients who were ETOH positive [ETOH (+)] and ETOH negative [ETOH (-)]. During the study period, there were 439 patients with ETOH levels available for analysis. Overall, 46.5% (n=204) of these patients were ETOH (+), while 53.5% (n=235) were ETOH (-). Coagulopathy was significantly less frequent in the ETOH (+) patients compared to their ETOH (-) counterparts (5.4% versus 15.3%; adjusted p<0.001). In the forward logistic regression analysis, a positive ETOH level proved to be an independent protective factor for admission coagulopathy [OR (95% CI)=0.24 (0.10,0.54; p=0.001]. ETOH (+) patients had a significantly lower in-hospital mortality rate than ETOH (-) patients [9.8% versus 16.6%; adjusted p=0.011; adjusted OR (95% CI)=0.39 (0.19,0.81)]. For brain-injured patients arriving alive to the hospital, ETOH intoxication is associated with a significantly lower incidence of early coagulopathy and in-hospital mortality. Further research to establish the pathophysiologic mechanisms underlying any potential beneficial effect of ETOH on the coagulation system following sTBI is warranted.

The impact of nontherapeutic hypothermia on outcomes after severe traumatic brain injury.

INTRODUCTION In patients with isolated severe traumatic brain injury (TBI), the effect of controlled, therapeutic hypothermia on outcomes has been studied extensively. What is not well understood, however, and the purpose of this study, was to examine the impact of noninduced, nontherapeutic hypothermia on outcomes in these patients. METHODS A retrospective review of the institutional trauma registry at the Los Angeles County + University of Southern California Medical Center was performed to identify all trauma patients admitted to the surgical intensive care unit (SICU) with isolated severe TBI from January 2000 to December 2008. Patients were classified as hypothermic (core temperature [Tc] ≤35°C) or normothermic (Tc >35°C) based on their first Tc recorded on SICU admission. The primary outcome measure was in-hospital mortality, and secondary outcomes included SICU and hospital length of stay. RESULTS During the study period, 1,403 patients sustaining an isolated severe TBI were admitted to the SICU. After excluding 122 patients with missing temperature data, 1,281 patients were analyzed. Hypothermia (Tc ≤35°C) on SICU admission was identified in 10.9% (n = 140) of the study population, with the remaining 89.1% (n = 1,141) being normothermic (Tc >35°C). After adjusting for differences in baseline characteristics between the two groups, patients who were hypothermic on SICU admission were found to be significantly less likely to survive (odds ratio, 2.9; 95% confidence interval, 1.3, 6.7; p < 0.013). A penetrating mechanism of injury, Injury Severity Score ≥25, and undergoing an exploratory laparotomy before admission were found to be independent risk factors for the development of hypothermia on SICU admission. CONCLUSION For patients who have sustained isolated severe TBI, the presence of noninduced, nontherapeutic hypothermia on SICU admission is associated with a significant increase in mortality. The impact of preventative measures used to avoid the development of hypothermia and the effectiveness of measures for restoring normothermia warrant further investigation.

Vascular trauma in geriatric patients: a national trauma databank review.

BACKGROUND The epidemiology of vascular injuries in the geriatric patient population has not been described. The purpose of this study was to examine nationwide data on vascular injuries in the geriatric patients and to compare this with the nongeriatric adult patients with respect to the incidence, injury mechanisms, and outcomes. METHODS Geriatric patients aged 65 or older with at least one traumatic vascular injury were compared with an adult cohort aged 16 years to 64 years with a vascular injury using the National Trauma Databank version 7.0. RESULTS During the study period, 29,736 (1.6%) patients with a vascular injury were identified. Of those, geriatric patients accounted for 7.6% (2,268) and the nongeriatric adult patients accounted for 83.1% (n=24,703). Compared with the nongeriatric adult patients, the geriatric vascular patients had a significantly higher Injury Severity Score (26.6±17.0 vs. 21.3±16.7; p<0.001) and less frequently sustained penetrating injuries (16.1% vs. 54.1%; p<0.001). The most commonly injured vessels in the elderly were vessels of the chest (n=637, 40.2%), including the thoracic aorta and innominate and subclavian vessels. The overall incidence of thoracic aorta injuries was significantly higher in geriatric patients (33.0% vs. 13.9%; p<0.001) and increased linearly with progressing age. After adjusting for confounding factors, geriatric patients demonstrated a fourfold increase in mortality following vascular injuries (adjusted odds ratio, 3.9; 95% confidence interval, 3.32-4.58; p<0.001). CONCLUSION Vascular trauma is rare in the geriatric patient population. These injuries are predominantly blunt, with the thoracic aorta being the most commonly injured vessel. Although vascular injuries occur less frequently than in the nongeriatric cohort, in the geriatric patient, vascular injury is associated with a fourfold increase in adjusted mortality.

Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank analysis ☆

BACKGROUND Few studies of pediatric cardiac injuries have been conducted in large cohorts. We, therefore, investigated the epidemiology of these injuries in the United States. METHODS We identified patients with traumatic cardiac injury from the National Trauma Data Bank, using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinical data, and inhospital outcomes were compared among 5 age groups. A logistic regression model was used to determine adjusted mortality among these groups. RESULTS Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion; 36%, laceration. Penetrating injuries proved more severe than blunt, having lower average Glasgow Coma Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68% vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%), hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%, thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%), most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%), compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significant differences that were lost after adjustment for confounding variables. CONCLUSIONS The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults), frequently paired with contusion. Pediatric cardiac injury is associated with excessive inhospital mortality (40%), with no age-related difference in adjusted mortality.

The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.

BACKGROUND A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. METHODS This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. RESULTS During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. CONCLUSION C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.