David S. Morris

The Perioperative Management of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery

OBJECTIVE To describe the perioperative management of patients with left ventricular assist devices (LVADs) who require general anesthesia while undergoing noncardiac surgery (NCS) at a single, large tertiary referral center. PATIENTS AND METHODS Electronic medical records from September 2, 2005, through May 31, 2012, were retrospectively reviewed to evaluate the perioperative management and outcomes in LVAD patients undergoing NCS. Patients were included only if they required a general anesthetic and had previously been discharged from the hospital after initial LVAD implantation. RESULTS Thirty-three patients with LVADs underwent general anesthesia for 67 noncardiac operations. The mean ± SD time from LVAD implantation to NCS was 317 ± 349 days. All but 1 patient had axial flow LVADs. Anticoagulation or antiplatelet agents were present within 7 days before NCS in 49 procedures (73%) and reversed in 32 of 49 (65%). No perioperative thrombotic complications related to anticoagulation or antiplatelet reversal were noted. Red blood cell, fresh frozen plasma, and platelet transfusions were administered during 10, 6, and 4 operations, respectively. The only intraoperative complication was surgical bleeding. Postoperative complications were present in 12 patients after NCS and were mainly composed of bleeding. Three patients died within 30 days of NCS, with the causes of death not attributed to NCS. CONCLUSION Patients with LVAD safely underwent NCS in a multidisciplinary setting that included preoperative optimization by cardiologists familiar with LVADs when feasible. Anticoagulation or antiplatelet agents were present preoperatively in most patients with LVADs and were safely reversed when necessary for NCS. The relatively high occurrence of postoperative bleeding is consistent with previous series.

Evolution of general surgical problems in patients with left ventricular assist devices

BACKGROUND Left ventricular assist devices (LVADs) are increasingly used to treat patients with end-stage heart failure. These patients may develop acute noncardiac surgical problems around the time of LVAD implantation or, as survival continues to improve, chronic surgical problems as ambulatory patients remote from the LVAD implant. Previous reports of noncardiac surgical problems in LVAD patients included patients with older, first-generation devices and do not address newer, second-generation devices. We describe the frequency and management of noncardiac surgical problems encountered during LVAD support with these newer-generation devices to assist noncardiac surgeons involved in the care of patients with LVADs. METHODS We retrospectively reviewed the medical records of consecutive patients receiving LVADs at our institution. We collected data for any consultation by noncardiac surgeons within the scope of general surgery during LVAD support and subsequent treatment. RESULTS Ninety-nine patients received implantable LVADs between 2003 and 2009 (first-generation, n = 19; second-generation, n = 80). Excluding intestinal hemorrhage, general surgical opinions were rendered for 34 patients with 49 problems, mostly in the acute recovery phase after LVAD implantation. Of those, 27 patients underwent 28 operations. Respiratory failure and intra-abdominal pathologies were the most common problems addressed, and LVAD rarely precluded operation. Patients with second-generation LVADs were more likely to survive hospitalization (P = .04) and develop chronic, rather than emergent, surgical problems. CONCLUSION Patients with LVADs frequently require consultation from noncardiac surgeons within the scope of general surgeons and often require operation. Patients with second-generation LVADs are more likely to become outpatients and develop more elective surgical problems. Noncardiac surgeons will be increasingly involved in caring for patients with LVADs and should anticipate the problems unique to this patient population.

Increased anatomic severity predicts outcomes: Validation of the American Association for the Surgery of Trauma's Emergency General Surgery score in appendicitis

BACKGROUND Determination and reporting of disease severity in emergency general surgery lacks standardization. Recently, the American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system. We aimed to validate this system in patients with appendicitis and determine if cross-sectional imaging correlates with disease severity at operation. METHODS Patients 18 years or older undergoing treatment for acute appendicitis between 2013 and 2015 were identified. Baseline demographics, procedure types were recorded, and AAST grades were assigned based on intraoperative and radiologic findings. Outcomes including length of stay, 30-day mortality, and complications based on Clavien-Dindo categories and National Surgical Quality Improvement Program variables. Summary statistical univariate, nominal logistic, and standard least squares analyses were performed comparing AAST grade with key outcomes. Bland-Altman analysis compared operative findings with preoperative cross-sectional imaging to compare assigning grades. RESULTS Three hundred thirty-four patients with mean (±SD) age of 39.3 years (±16.5) were included (53% men), and all patients had cross-sectional imaging. Two hundred ninety-nine underwent appendectomy, and 85% completed laparoscopic. Thirty-day mortality rate was 0.9%, complication rate was 21%. Increased (median [interquartile range, IQR]) AAST grade was recorded in patients with complications (2 [1–4]) compared with those without (1 [1–1], p = 0.001). For operative management, (median [IQR]) AAST grades were significantly associated with procedure type: laparoscopic (1 [1–1]), open (4 [2–5]), conversion to open (3 [1–4], p = 0.001). Increased (median [IQR]) AAST grades were significantly associated in nonoperative management: patients having a complication had a higher median AAST grade (4 [3–5]) compared with those without (3 [2–3], p = 0.001). Bland-Altman analysis comparing AAST grade and cross-sectional imaging demonstrated no difference (−0.02 ± 0.02; p = 0.2; coefficient of repeatability 0.9). CONCLUSIONS The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. The AAST emergency general surgery grade determined by preoperative imaging strongly correlated to operative findings. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.

Hemorrhagic cholecystitis in an elderly patient taking aspirin and cilostazol.

Hemorrhage is a rare complication of acute cholecystitis. Patients who develop this complication often are receiving anticoagulation therapy or have a pathologic coagulopathy. We present a case of an elderly patient who developed hemorrhagic cholecystitis while taking aspirin and cilostazol, a phosphodiesterase inhibitor. The patient underwent an emergent abdominal exploration. A large, blood-filled gallbladder was found along with a large hematoma between the liver and gallbladder. We also briefly review the literature regarding hemorrhagic cholecystitis, hemorrhage into the biliary tree, and hemorrhage as a complication of aspirin and phosphodiesterase inhibitor therapy.

Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience

BACKGROUND Surgical stabilization of rib fracture (SSRF) is increasingly used for treatment of rib fractures. There are few data on the incidence, risk factors, outcomes, and optimal management strategy for hardware infection in these patients. We aimed to develop and propose a management algorithm to help others treat this potentially morbid complication. METHODS We retrospectively searched a prospectively collected rib fracture database for the records of all patients who underwent SSRF from August 2009 through March 2014 at our institution. We then analyzed for the subsequent development of hardware infection among these patients. Standard descriptive analyses were performed. RESULTS Among 122 patients who underwent SSRF, most (73%) were men; the mean (SD) age was 59.5 (16.4) years, and median (interquartile range [IQR]) Injury Severity Score was 17 (13–22). The median number of rib fractures was 7 (5–9) and 48% of the patients had flail chest. Mortality at 30 days was 0.8%. Five patients (4.1%) had a hardware infection on mean (SD) postoperative day 12.0 (6.6). Median Injury Severity Score (17 [range, 13–42]) and hospital length of stay (9 days [6–37 days]) in these patients were similar to the values for those without infection (17 days [range, 13–22 days] and 9 days [6–12 days], respectively). Patients with infection underwent a median (IQR) of 2 (range, 2–3) additional operations, which included wound debridement (n = 5), negative-pressure wound therapy (n = 3), and antibiotic beads (n = 4). Hardware was removed in 3 patients at 140, 190, and 192 days after index operation. Cultures grew only gram-positive organisms. No patients required reintervention after hardware removal, and all achieved bony union and were taking no narcotics or antibiotics at the latest follow-up. CONCLUSIONS Although uncommon, hardware infection after SSRF carries considerable morbidity. With the use of an aggressive multimodal management strategy, however, bony union and favorable long-term outcomes can be achieved. LEVEL OF EVIDENCE Therapeutic study, level V.

Successful laparoscopic cholecystectomy after percutaneous cholecystostomy tube placement.

BACKGROUND Interval cholecystectomy (IC) after percutaneous cholecystostomy tube (PCT) placement is the definitive treatment for cholecystitis in patients who are operative candidates after optimization of medical comorbidities. It is not clear, however, which patients will be able to have a laparoscopic IC after PCT placement. We aimed to identify factors associated with successful laparoscopic IC in these patients. METHODS This is a retrospective review of patients who had a PCT from 2009 to 2011. Patient’s baseline demographics, clinical data, and outcomes were analyzed. Univariable and multivariable comparisons were performed between patients who did and did not undergo IC. A subgroup analysis of patients who had laparoscopic IC and open IC was performed. Data are presented as percentages, medians with interquartile ranges (IQRs), or odds ratios with 95% confidence interval as appropriate. RESULTS A total of 245 patients had PCT placement, with a median age of 71 years (IQR, 59–80 years); 63% were male, of whom 72 (29%) underwent IC. The median time from PCT placement to IC was 55 days (IQR, 42–75 days). IC patients had a lower Charlson Comorbidity Index (5 [4–6] vs. 6 [4–8], p = 0.005) at the time of PCT placement. When controlling for other factors, lower Charlson Comorbidity Index and fewer previous abdominal operations were associated with performance of IC. Laparoscopic surgery was planned for 89% of the patients and completed successfully in 78%. The only factor associated with successful laparoscopic IC was fewer previous abdominal operations. CONCLUSION Patients who have been medically optimized following PCT can undergo laparoscopic IC with a high rate of success. The degree of illness at the time of PCT placement did not seem to influence the rate of success of laparoscopic IC. LEVEL OF EVIDENCE Therapeutic/care management study, level III.

Definitive airway management after pre-hospital supraglottic airway insertion: Outcomes and a management algorithm for trauma patients

Background: Prehospital airway management increasingly involves supraglottic airway insertion and a paucity of data evaluates outcomes in trauma populations. We aim to describe definitive airway management in traumatically injured patients who necessitated prehospital supraglottic airway insertion. Methods: We performed a single institution retrospective review of multisystem injured patients (≥ 15 years) that received prehospital supraglottic airway insertion during 2009 to 2016. Baseline demographics, number and type of: supraglottic airway insertion attempts, definitive airway and complications were recorded. Primary outcome was need for tracheostomy. Univariate and multivariable statistics were performed. Results: 56 patients met inclusion criteria and were reviewed, 78% were male. Median age [IQR] was 36 [24–56] years. Injuries comprised blunt (94%), penetrating (4%) and burns (2%). Median ISS was 26 [22–41]. Median number of prehospital endotracheal intubation (PETI) attempts was 2 [1–3]. Definitive airway management included: (n = 20, 36%, tracheostomy), (n = 10, 18%, direct laryngoscopy), (n = 6, 11%, bougie), (n = 9, 15%, Glidescope), (n = 11, 20%, bronchoscopic assistance). 24‐hour mortality was 41%. Increasing number of PETI was associated with increasing facial injury. On regression, increasing cervical and facial injury patterns as well as number of PETI were associated with definitive airway control via surgical tracheostomy. Conclusions: After supraglottic airway insertion, operative or non‐operative approaches can be utilized to obtain a definitive airway. Patients with increased craniofacial injuries have an increased risk for airway complications and need for tracheostomy. We used these factors to generate an evidence based algorithm that requires prospective validation. Level of evidence: Level IV – Retrospective study. Study type: Retrospective single institution study.

Swallowing dysfunction in elderly trauma patients

Purpose: Newly diagnosed swallowing dysfunction is rare, with an incidence < 1% in hospitalized patients. The purpose of this study was to evaluate the incidence and clinical characteristics of dysphagia in elderly trauma patients specifically. Methods: Patients ≥ 75 years who had newly diagnosed swallowing dysfunction were identified by retrospective review of our institutional trauma database from 2009–2012. A comparison group without dysphagia was also identified that was matched by age, gender, injury mechanism, and injury severity score (ISS). Relevant demographics, injury characteristics, and potential factors associated with dysphagia were collected. Results: 1323 patients met criteria. Of these, 56(4.2%) had newly identified dysphagia. Cases and controls were similar in regards to regional injury pattern (AIS). Patients with dysphagia had a mean Charlson Comorbidity Index (CCI) of 3.7 vs. 1.9 for patients without dysphagia (p < 0.01). Patients with dysphagia also had longer hospital (11.4 vs. 5.8 days, p < 0.01) and ICU LOS (5.6 vs 1.9 days, p < 0.01). On multivariable regression, CCI greater than 3 (OR 7.2, p < 0.001), in‐hospital complications (OR 9.6, p < 0.01), and ICU LOS greater than 2 days (OR 1.5, p < 0.05) were independently associated with the diagnosis of dysphagia. Conclusions: Elderly trauma patients with a high comorbidity burden or with prolonged ICU lengths of stay should be screened for dysphagia.

Validation of the AAST EGS acute cholecystitis grade and comparison with the Tokyo guidelines

Background. Acute cholecystitis presents with heterogeneous severity. The Tokyo Guidelines 2013 is a validated method to assess cholecystitis severity, but the variables are multifactorial. The American Association for the Surgery of Trauma (AAST) developed an anatomically based severity grading system for surgical diseases, including cholecystitis. Because the Tokyo Guidelines represent the gold standard to estimate acute cholecystitis severity, we wished to validate the AAST emergency general surgery scoring system and compare the performance of both systems for several patient outcomes. Methods. Adults (≥18 years) with acute cholecystitis during 2013–2016 were identified. Baseline demographic characteristics, comorbidity severity as defined by Charlson Comorbidity Index score, procedure types, and AAST and Tokyo Guidelines 2013 grades were abstracted. Outcomes included duration of stay, 30‐day mortality, and complications. Comparison of the Tokyo Guidelines and AAST grading system was performed using receiver operating characteristic (AUROC) curve C statistics. Results. There were 443 patients, with a mean (±standard deviation) age of 64.8 (±18) years, 59% male. The median (interquartile ratio) Charlson Comorbidity score was 3 (0–6). Management included laparoscopic (n = 307, 69.3%), open (n = 26, 6%), laparoscopy converted to laparotomy (n = 53, 12%), and cholecystostomy (n = 57, 12.7%). Comparison of AAST with Tokyo Guidelines AUROC C statistics indicated (P < .05) mortality (0.86 vs 0.73), complication (0.76 vs 0.63), and cholecystostomy tube utilization (0.80 vs 0.68). Conclusion. Emergency general surgery grading systems improve disease severity assessment, may improve documentation, and guide management. Discrimination of disease severity using the AAST grading system outperforms the Tokyo Guidelines for key clinical outcomes. The AAST grading system requires prospective validation and further comparison.

Weight-based enoxaparin dosing and deep vein thrombosis in hospitalized trauma patients: A double-blind, randomized, pilot study

Background: Venous thromboembolism is a cause of morbidity and mortality in trauma patients. Chemoprophylaxis with low‐molecular‐weight heparin at a standardized dose is recommended. Conventional chemoprophylaxis may be inadequate. We hypothesized that a weight‐adjusted enoxaparin prophylaxis regimen would reduce the frequency of venous thromboembolism in hospitalized trauma patients and at 90‐day follow‐up. Methods: This prospective, randomized pilot study enrolled adult patients admitted to a level 1 trauma center between July 2013 and January 2015. Subjects were randomized to receive either standard (30 mg subcutaneously every 12 hours) or weight‐based (0.5mg/kg subcutaneously every 12 hours) enoxaparin. Surveillance duplex ultrasound for lower extremity deep vein thrombosis was performed on hospital days 1, 3, and 7, and weekly thereafter. The primary outcome was deep vein thrombosis during hospitalization. Secondary outcomes included venous thromboembolism at 90 days and significant bleeding events. Results: Two hundred thirty‐four (124 standard, 110 weight‐based) subjects were enrolled. There was no difference between standard and weight‐based regarding age, body mass index, percentage female gender, injury severity score, or percentage that had surgery. There was a trend toward less in‐hospital deep vein thrombosis in weight‐based (12 [9.7%] standard vs 4 [3.6%] weight‐based, P = .075). At 90 days, there was no difference in venous thromboembolism (12 [9.7%] standard vs 6 [5.5%] weight‐based, P =.34). There was 1 bleeding event, which occurred in a standard subject. Conclusion: Weight‐based enoxaparin dosing for venous thromboembolism chemoprophylaxis in trauma patients may provide better protection against venous thromboembolism than standard. A definitive study is necessary to determine whether weight‐based dosing is superior to standard.