Efstathios Karamanos

Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study

OBJECT The Brain Trauma Foundation (BTF) has established guidelines for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). This study assessed compliance with these guidelines and the effect on outcomes. METHODS This is a prospective, observational study including patients with severe blunt TBI (Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score ≥ 3) between January 2010 and December 2011. Demographics, clinical characteristics, laboratory profile, head CT scans, injury severity indices, and interventions were collected. The study population was stratified into 2 study groups: ICP monitoring and no ICP monitoring. Primary outcomes included compliance with BTF guidelines, overall in-hospital mortality, and mortality due to brain herniation. Secondary outcomes were ICU and hospital lengths of stay. Multiple regression analyses were deployed to determine the effect of ICP monitoring on outcomes. RESULTS A total of 216 patients met the BTF guideline criteria for ICP monitoring. Compliance with BTF guidelines was 46.8% (101 patients). Patients with subarachnoid hemorrhage and those who underwent craniectomy/craniotomy were significantly more likely to undergo ICP monitoring. Hypotension, coagulopathy, and increasing age were negatively associated with the placement of ICP monitoring devices. The overall in-hospital mortality was significantly higher in patients who did not undergo ICP monitoring (53.9% vs 32.7%, adjusted p = 0.019). Similarly, mortality due to brain herniation was significantly higher for the group not undergoing ICP monitoring (21.7% vs 12.9%, adjusted p = 0.046). The ICU and hospital lengths of stay were significantly longer in patients subjected to ICP monitoring. CONCLUSIONS Compliance with BTF ICP monitoring guidelines in our study sample was 46.8%. Patients managed according to the BTF ICP guidelines experienced significantly improved survival.

Impact of fibrinogen levels on outcomes after acute injury in patients requiring a massive transfusion.

BACKGROUND For critically injured patients requiring a massive transfusion, the optimal plasma fibrinogen level is unknown. The purpose of this study was to examine the impact of the fibrinogen level on mortality. We hypothesized that decreasing fibrinogen levels are associated with worse outcomes. STUDY DESIGN All patients undergoing a massive transfusion from January 2000 through December 2011 were retrospectively identified. Those with a fibrinogen level measured on admission to the surgical ICU were analyzed according to their fibrinogen level (normal [≥180 mg/dL], abnormal [≥101 to <180 mg/dL], and critical [≤100 mg/dL]). Primary outcome was death. Multivariate analysis evaluated the impact of fibrinogen on survival. RESULTS There were 260 patients who met inclusion criteria. Ninety-two patients had normal admission fibrinogen levels, 114 had abnormal levels, and 54 patients had critical levels. Patients with a critical fibrinogen level had significantly higher mortality at 24 hours compared with patients with abnormal (31.5% vs 5.3%; adj. p < 0.001) and normal fibrinogen levels (31.5% vs 4.3%; adjusted p < 0.001). Patients with a critical fibrinogen level had significantly higher in-hospital mortality compared with patients with abnormal (51.9% vs 25.4%; adjusted p = 0.013) and normal fibrinogen levels (51.9% vs 18.5%; adjusted p < 0.001). A critical fibrinogen level was the most important independent predictor of mortality (p = 0.012). CONCLUSIONS For patients undergoing a massive transfusion after injury, as the fibrinogen level increased, a stepwise improvement in survival was noted. A fibrinogen level ≤100 mg/dL was a strong independent risk factor for death. The impact of an aggressive fibrinogen replacement strategy using readily available products warrants further prospective evaluation.

Early operation is associated with a survival benefit for patients with adhesive bowel obstruction.

Objective:To evaluate the effect of surgical delay on the outcomes of patients with adhesive small bowel obstruction (ASBO). Background:It is generally accepted that patients with uncomplicated ASBO failing nonoperative management should be operated on within 5 days. However, the optimal time of operation within this 5-day period is unknown. Methods:Patients requiring surgery for ASBO were identified from the National Surgical Quality Improvement Program database. Linear regression was performed to evaluate the impact of incremental surgical delay in mortality and complications. The study population was stratified by time to intervention (24-hour intervals), and logistic regression was performed to adjust for premorbid conditions and presentation physiology. The outcomes included 30-day mortality and infectious complications. Results:A total of 4163 patients underwent laparotomy for ASBO. Mortality and complications increased significantly with operative delay. Delay of 24 hours or more was associated with significantly higher mortality: 6.5% vs 3.0%; adjusted odds ratio (AOR) [95% confidence interval (CI), 1.58 (1.12–2.24)]; P = 0.009. The delayed operation group (≥24 hours) also had significantly higher rates of surgical site infections [12.9% vs 10.0%; AOR (95% CI), 1.33 (1.08–1.62); P = 0.007], pneumonia (7.9% vs 5.2%; AOR (95% CI), 1.36 (1.04–1.78); P = 0.025], sepsis [7.6% vs 5.1%; AOR (95% CI), 1.45 (1.10–1.90); P = 0.007], and septic shock [6.2% vs 3.5%; AOR (95% CI), 1.47 (1.07–2.02); P = 0.018]. Early operation was associated with significantly shorter hospital stay [8.4 ± 8.3 vs 14.4±13.5 days; adjusted mean difference (95% CI), −5.2 (−5.9 to −4.4); P<0.001]. Conclusions:Early operative intervention for patients with ASBO is associated with a significant survival benefit, lower incidence of local and systemic complications, and shorter hospitalization.

Emergency surgery for acute diverticulitis: which operation? A National Surgical Quality Improvement Program study.

BACKGROUND The optimal surgical management of acute diverticulitis is still a controversial and unresolved issue. While the Hartmann’s procedure (`) is the most commonly performed operation, primary anastomosis (PA), with or without proximal diversion, has also been used with increasing frequency. METHODS This is a National Surgical Quality Improvement Program database study including all patients requiring emergency surgery for acute diverticulitis. Three operative approaches were analyzed: HP, colectomy with PA, and colectomy with PA with proximal diversion (PAPD). Mortality and postoperative outcomes were compared between the three groups using a logistical regression model. RESULTS There were 1,314 patients who required emergent operation for acute diverticulitis, 75.4% underwent HP, 21.7% underwent PA, and 2.9% underwent PAPD. Thirty-day mortality was 7.3%, 4.6%, and 1.6% for HP, PA, and PAPD respectively (p = 0.163), while surgical site infections occurred in 19.7%, 17.9%, and 13.2%, respectively (p = 0.59). After multivariable analysis adjusting for age, alcohol consumption, comorbidities, steroid use, preoperative laboratory values, hemorrhage at admission and laparoscopic surgery, the adjusted odds ratio for 30-day mortality comparing PA with HP was 0.77 (95% confidence interval [CI], 0.38–1.56; p = 0.465), 0.47 (95% CI, 0.06–3.74; p = 0.479) comparing PAPD with HP, and 1.62 (95% CI, 0.19–13.78; p = 0.658) comparing PA with PAPD. In addition, the three groups did not have significantly different adjusted odds ratio for the development of surgical infectious complications, acute kidney injury, cardiovascular incidents, or venous thromboembolism after surgery. CONCLUSION Resection and PA in patients undergoing an emergency operation for acute diverticulitis is a safe alternative to the HP, with no significant difference in mortality or postoperative surgical site infections. LEVEL OF EVIDENCE Therapeutic study, level IV.

Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis

INTRODUCTION Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant. HYPOTHESIS Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied. METHODS This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS). RESULTS Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS. CONCLUSION In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.

Clinical Relevance of Magnetic Resonance Imaging in Cervical Spine Clearance: A Prospective Study

IMPORTANCE A missed cervical spine (CS) injury can have devastating consequences. When CS injuries cannot be ruled out clinically using the National Emergency X-Radiography Utilization Study low-risk criteria because of either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial. OBJECTIVE To investigate the accuracy of computed tomography (CT) and magnetic resonance imaging (MRI) for CS clearance. DESIGN, SETTING, AND PARTICIPANTS A prospective observational study was conducted from January 1, 2010, through May 31, 2011, at a level I trauma center. Participants included 830 adults who were awake, alert, and able to be examined who experienced blunt trauma with resultant midline CS tenderness and/or neurologic deficits and were undergoing CT of the CS. Initial examinations, all CS imaging results, interventions, and final CS diagnoses were documented. The criterion standard for the sensitivity and specificity calculations was final diagnosis of CS injury at the time of discharge. MAIN OUTCOMES AND MEASURES Clinically significant CS injuries, defined as injuries requiring surgical stabilization or halo placement. RESULTS Overall, 164 CS injuries (19.8%) were diagnosed, and 23 of these (2.8%) were clinically significant. All clinically significant injuries were detected by CT. Fifteen of 681 patients (2.2%) with a normal CT scan had a newly identified finding on MRI; however, none of the injuries required surgical intervention or halo placement. There was no change in management on the basis of MRI findings. The sensitivity and specificity of CT for detecting CS injury was 90.9% and 100%, respectively. For clinically significant CS injuries, the sensitivity was 100% and specificity was 100%. CONCLUSIONS AND RELEVANCE Computed tomography is effective in the detection of clinically significant CS injuries in adults deemed eligible for evaluation who had a neurologic deficit or CS pain. Magnetic resonance imaging does not provide any additional clinically relevant information.

The persistent diagnostic challenge of thoracoabdominal stab wounds

BACKGROUND Penetrating thoracoabdominal trauma, with potential injury to two anatomic cavities, significantly challenges surgical management, yet this injury pattern has not been reviewed across a large patient series. METHODS The trauma registry of a major level 1 center was queried for all adult patients admitted with thoracoabdominal stab wounds between January 1996 and December 2011. RESULTS The study identified 617 patients; 11% arrived hypotensive (systolic blood pressure < 90 mm Hg), 6.5% had Glasgow Coma Scale (GCS) score less than 8, and 3.6% were in cardiac arrest. Of those arriving alive, 350 (59%) of 595 underwent surgery (88% laparotomy, 3% thoracotomy, and 9% both procedures). Nontherapeutic laparotomy was performed on 12.3% of these patients. Cardiac injury occurred in 71% (29 of 41) of the patients arriving alive undergoing thoracotomy. Among this group, only 1 (2.4%) of 41 had a major thoracic vessel or aortic injury without cardiac trauma. Diaphragmatic injury (DI) occurred in 224 (38%) of 595, with 72 (32.1%) of these 224 demonstrating no computed tomographic evidence of DI. Either hollow viscus injury or DI occurred in 50%. Only 36.8% of liver, 58% of spleen, and 29.8% of kidney injuries required surgical repair. The need for dual-cavitary intervention was associated with a precipitous increase in patient mortality. CONCLUSION Patients with thoracoabdominal stab wounds present considerable clinical challenges due to high surgical need, high occult DI incidence, persistently high rates of negative laparotomy, and significant mortality with dual-cavitary intervention. Many patients with solid-organ injuries do not require intervention. High incidence of hollow viscus injury and DI ultimately limits nonoperative management. Laparoscopy is necessary to exclude occult DI. In unstable patients, determination of which anatomic cavity to explore primarily requires exclusion of cardiac injury. In those with equivocal clinical or ultrasonographic evidence of cardiac trauma, laparotomy, with transdiaphragmatic pericardial window, if a causative abdominal injury is not immediately apparent, seems the most effective strategy. LEVEL OF EVIDENCE Epidemiologic study, level III.

Effect of delaying same-admission cholecystectomy on outcomes in patients with diabetes

Recent studies have suggested that same‐admission delayed cholecystectomy is a safe option. Patients with diabetes have been shown to have less favourable outcomes after cholecystectomy, but the impact of timing of operation for acute cholecystitis during the same admission is unknown.

Relationship of creatine kinase elevation and acute kidney injury in pediatric trauma patients.

BACKGROUND Rhabdomyolysis following trauma has been associated with renal impairment. Nevertheless, the literature is scant in risk assessment of acute kidney injury (AKI) and survival in children experiencing posttraumatic rhabdomyolysis. METHODS After institutional review board approval was obtained, the registry of an urban trauma center was reviewed for pediatric (age < 18 years) trauma admissions with available creatine kinase (CK) values. Variables extracted included demographics and trauma severity indices along with serum creatine, CK, and Blood Urea Nitrogen (BUN) values. AKI was defined per pediatric RIFLE (Risk, Injury, Failure, Loss, End stage) definition. Regression models were deployed to determine the independent risk factors for AKI and CK levels. RESULTS Overall, 521 patients constituted the study sample. AKI occurred in 70 patients (13.4%), with correlation to CK values in excess of 3,000 IU/L (41.4% vs. 4.9%, adjusted p < 0.001). Independent risk factors for AKI proved to be CK level of 3,000 or greater (adjusted odds ratio [AOR], 11.02; 95% confidence interval [CI], 4.56–26.64; p < 0.001), Injury Severity Score (ISS) of 15 or less (AOR, 0.25; 95% CI, 0.10–0.61), Glasgow Coma Scale (GCS) score of 8 or less (AOR, 15.00; 95% CI, 4.98–44.94), abdominal Abbreviated Injury Scale (AIS) score of 3 or less (AOR, 3.14; 95% CI, 1.04–5.36), imaging studies with contrast of 3 or less (AOR, 3.81; 95% CI, 1.37–10.57), blunt mechanism of injury (AOR, 2.76; 95% CI, 1.17–6.49), administration of nephrotoxic agents (AOR, 4.81; 95% CI, 1.23–18.79), and requirement for fluids administration in the emergency department (AOR, 2.36; 95% CI, 1.04–5.36). Mortality in the study sample with CK values of 3,000 or greater versus less than 3,000 IU/L did not reach statistical significance (25.0% vs. 9.3%, adjusted p = 0.787). CONCLUSION AKI in pediatric posttraumatic rhabdomyolysis occurs in 13% of trauma patients. CK values of 3,000 IU/L or greater pose a significant adjusted risk for AKI. Aggressive monitoring of CK values in pediatric trauma patients is warranted. LEVEL OF EVIDENCE Prognostic study, level III.

The peril of thoracoabdominal firearm trauma: 984 civilian injuries reviewed

BACKGROUND Thoracoabdominal firearm injuries present major diagnostic and therapeutic challenges because of the risk for potential injury in multiple anatomic cavities and the attendant dilemma of determining the need for and correct sequencing of cavitary intervention. Injury patterns, management strategies, and outcomes of thoracoabdominal firearm trauma remain undescribed across a large population. METHODS All patients with thoracoabdominal firearm injury admitted to a major Level I trauma center during a 16-year period were reviewed. RESULTS The 984 study patients experienced severe injury burden; 25% (243 of 984) presented in cardiac arrest, and 75% (741 of 984) had an Abbreviated Injury Scale (AIS) score of 3 or greater in both the chest and the abdomen. Operative management occurred in 86% (638 of 741). Of the patients arriving alive, 68% (507 of 741) underwent laparotomy alone, 4% (27 of 741) underwent thoracotomy alone, and 14% (104 of 741) underwent dual-cavitary intervention. Negative laparotomy occurred in 3%. Diaphragmatic injury (DI) occurred in 63%. Seventy-five percent had either DI or hollow viscus injury. Cardiac injury was present in 33 patients arriving alive. Despite the use of trauma bay ultrasound, 44% of the patients with cardiac injury underwent initial laparotomy. In half of this group, ultrasound did not detect pericardial blood. The need for thoracotomy, either alone or as part of dual-cavitary intervention, was the strongest independent risk factor for mortality in those arriving alive. CONCLUSION Greater kinetic destructive potential drives the peril of thoracoabdominal firearm trauma, producing clinical challenges qualitatively and quantitatively different from nonfirearm injuries. Severe injury, on both sides of the diaphragm, generates high operative need with low rates of negative exploration. The need for emergent intervention and a high incidence of DI or hollow viscus injury limit opportunity for nonoperative management. Even with ultrasound, emergent preoperative diagnosis remains challenging, as the complex combination of intra-abdominal, thoracic, and diaphragmatic injuries can provoke misinterpretation of both radiologic and clinical data. Successful emergent management requires thorough assessment of all anatomic spaces, integrating ultrasonographic, radiologic, and clinical findings. LEVEL OF EVIDENCE Epidemiologic study, level III.