Evren Dilektasli

The prognostic value of neutrophil to lymphocyte ratio on mortality in critically Ill trauma patients.

BACKGROUND Recent studies suggest that the neutrophil-lymphocyte ratio (NLR) as a marker of inflammation is associated with mortality in surgical patients. The aim of this study was to determine the prognostic impact of NLR in critically ill trauma patients. METHODS This is a retrospective cohort study involving all trauma patients 16 years or older admitted to the surgical intensive care unit of a Level 1 trauma center (January 2013 to January 2014). The predictive capacity of NLR on mortality was assessed using a receiver operating characteristic curve analysis. To identify the effect of the NLR on survival, a separate log-rank test was used. Multivariable Cox proportional hazard modeling was used to identify independent predictors of mortality. RESULTS During the study period, 1,356 patients met inclusion criteria. Of these, 74% were male, 86% sustained blunt trauma, and the median age was 49 years (interquartile range [IQR], 35). The median Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were 15 (IQR, 3) and 13 (IQR, 14), respectively. With the use of the receiver operating characteristic curve analyses at intensive care unit Days 2 and 5, optimal NLR cutoff values of 8.19 and 7.92 were calculated by maximizing the Youden index. Kaplan-Meier curves revealed an NLR greater than or equal to these cutoff values as a marker for increased in-hospital mortality (p < 0.001, log-rank test). The Cox regression model demonstrated that an NLR greater than 8.19 and 7.92 are independently associated with in-hospital mortality at Days 2 and 5, respectively (hazard ratio, 1.602 [p = 0.019] and 3.758 [p < 0.001]). CONCLUSION NLR is associated with mortality in critically ill trauma patients. Prospective validation of its role as a predictive marker for outcomes is warranted. LEVEL OF EVIDENCE Prognostic study, level III.

The effects of body mass index on complications and mortality after emergency abdominal operations: The obesity paradox

BACKGROUND Recent literature suggests that obesity is protective in critically illness. This study addresses the effect of BMI on outcomes after emergency abdominal surgery (EAS). METHODS Retrospective, ACS-NSQIP analysis. All patients that underwent EAS were included. The study population was divided into five groups based on BMI; regression models were used to evaluate the role of obesity in morbidity and mortality. RESULTS 101,078 patients underwent EAS; morbidity and mortality were 19.5% and 4.5%, respectively. Adjusted mortality was higher in underweight patients (AOR 1.92), but significantly lower in all obesity groups (AORs 0.73, 0.66, 0.70, 0.70 respectively). Underweight and class III obesity was associated with increased complications (AOR 1.47 and 1.30), while mild obesity was protective (AOR 0.92). CONCLUSIONS Underweight patients undergoing EAS have increased morbidity and mortality. Although class III obesity is associated with increased morbidity, overweight and class I obesity were protective. All grades of obesity may be protective against mortality after EAS relative to normal weight patients.

Airway management following repair of cervical tracheal injuries: A retrospective, multicenter study

BACKGROUND Optimal airway management following repair of cervical tracheal injuries is unknown. This study aimed to determine the optimal airway strategy following cervical tracheal injury repair. METHODS Patients with cervical tracheal injuries admitted from January 2000 to January 2014 at seven US Level I trauma centers were identified. Patients were grouped depending on postoperative airway management: immediate or early extubation (⩽24 hours, EXT), prolonged intubation (>24 hours, INT), and immediate tracheostomy (TRACH). Following univariate analysis, a multivariate model was then developed to evaluate for surgical site infection (SSI) and intensive care unit–free and ventilator-free days, comparing INT and TRACH with EXT as the reference. RESULTS A total of 120 cervical tracheal injuries were treated at seven Level I trauma centers. Ten patients were excluded for incomplete data, and seven died within 24 hours of admission, leaving 103 patients included in the study. Patients were grouped based on airway management: 40 (39%) in the EXT, 30 (29%) in the INT, and 33 (32%) in the TRACH group. There were no differences in demographics or injury mechanism. The INT and TRACH groups were more severely injured than the EXT group (median Injury Severity Score [ISS]: INT, 25; TRACH, 17 vs. EXT, 16; p < 0.01). Despite a higher SSI rate (TRACH, 21% vs. INT, 13% vs. EXT, 2%; p = 0.11), the TRACH group had a lower mortality rate (TRACH, 0% vs. INT, 13% vs. EXT, 0%, p < 0.01) and more ventilator-free days compared with the INT cohort. On multivariate analysis, tracheostomy was associated with an increased risk in the odds of SSI (odds ratio, 9.56; 95% confidence interval, 1.35–67.95) compared with both EXT and INT, while INT was associated with fewer ventilator-free days (correlation coefficient, −9.24; 95% confidence interval, −12.30 to −6.18) compared with both EXT and TRACH. CONCLUSION In patients with a cervical tracheal injury, immediate or early extubation was common and safe. However, among those with more severe injuries, immediate tracheostomy versus prolonged intubation presents a risk-benefit decision. Immediate tracheostomy is associated with increased risk of SSI, while prolonged intubation is associated with higher risk of mortality and fewer ventilator-free days. LEVEL OF EVIDENCE Therapeutic study, level IV.

Pediatric resuscitative thoracotomy: a far from futile intervention

RESULTS: We evaluated 484 children with head injury during the study period. From this cohort, 361 had SF, of which 122 were isolated. Of the isolated SF group, 101 (83%) were NDSFs of which 80 (79%) presented with GCS of 15. None of the patients with isolated NDSF and GCS 15 necessitated neurosurgical intervention or developed any neurologic deficit. 21 children had DSFs, of which 17 presented with GCS of 15 (80%). Likewise, none of those with DSF and GCS 15 developed a persistent neurologic deficit; however, 3 did undergo neurosurgical intervention (these were cranial elevations). 2,097 children identified in the NTDB with isolated SF and admission GCS of 15 had no TBI related mortality and no patients required neurosurgical intervention.

High Density Free Fluid on Computed Tomography: A Predictor of Surgical Intervention in Patients with Adhesive Small Bowel Obstruction

Background Patients with adhesive small bowel obstruction (ASBO) often develop intraabdominal free fluid (IFF). While IFF is a finding on abdominopelvic computed tomography (CT) associated with the need for surgical intervention, many patients with IFF can be still managed non-operatively. A previous study suggested that a higher red blood cell count of IFF is highly predictive of strangulated ASBO. We hypothesized that radiodensity in IFF (Hounsfield unit (HU)) on CT would predict the need for surgical intervention.