Faisal Jehan

Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: What is the role of Plasma Hemoglobin A1c?

BACKGROUND Plasma hemoglobin A1c (HbA1c) reflects quality of glucose control in diabetic patients. Literature reports that patients undergoing surgery with an elevated HbA1c level are associated with increased postoperative morbidity and mortality. The aim of our study was to evaluate the impact of HbA1c level on outcomes after emergency general surgery (EGS). METHODS We performed a 3-year analysis of our prospectively maintained EGS database. Patients who had HbA1c levels measured within 3 months before surgery were included. Patients were divided into two groups (HbA1c < 6 and HbA1c ≥ 6). Our primary outcome measures included in-hospital complications (major and minor complications), hospital and intensive care unit length of stay, and mortality. Secondary outcomes measures were 30-day complications, readmissions, and mortality. Multivariate and linear regressions were performed. RESULTS Of the 402 study patients, mean age was 61 ± 12 years, 53% were females, and 63.8% were diabetics. Overall, 49% had an HbA1c ≥ 6%; the mortality rate was 6%. Those with hypertension, history of coronary artery disease, and body mass index of 30 kg/m2 or greater were more likely to have HbA1c of 6.0% or greater. 7.9% patients experienced major complications. Patients with HbA1c of 6% or greater had a higher complication rate (36% vs 11%, p < 0.001) than those with HbA1c less than 6%. However there was no difference in mortality between two groups (p = 0.09). After controlling for confounders, HbA1c ≥ 6.0% (odds ratio [OR], 2.9; p < 0.01) and a postoperative random blood sugar (RBS) of 200 mg/dL or greater (OR, 2.3; p < 0.01) were independent predictors of major complications. Patients with both HbA1c of 6.0% or greater and postoperative RBS of 200 or greater had higher odds (OR, 4.2; p < 0.01) of developing major complication. After adjusting for confounders, a higher HbA1c was independently correlated with a higher postoperative RBS (b = 0.494, [19.7–28.4], p = 0.02), but there was no correlation with the preoperative RBS. CONCLUSION Patients with HbA1c of 6.0% or greater and a postoperative RBS of 200 mg/dL or greater have a four times higher risk of developing major complications after EGS. A preoperative HbA1c can stratify patients prone to develop postoperative hyperglycemia, regardless of their preoperative RBS. LEVEL OF EVIDENCE Prognostic, level III.

The Mobility and Impact of Frailty in the Intensive Care Unit

Prevalence of pre-existing frailty in patients admitted to the intensive care unit (ICU) is increasing. Critical illness leads to a catabolic state that further diminishes body reserves and contributes to frailty independent of age and prehospital functional status. Because early mobilization of patients in the ICU results in accelerated recovery and improvement in functional status and quality of life, frailty can severely affect the mobility of patients in ICU ultimately prolonging recovery. Understanding the concept of frailty and the association of frailty and its impact on mobility in the ICU, identifying patients, and timely resource allocation helps in optimum care and improves clinical outcomes.

Trauma Systems: Standardization and Regionalization of Care Improve Quality of Care

Purpose of ReviewThis review focuses on how the development and regionalization of trauma systems improve outcomes and quality of care.Recent FindingsA comprehensive trauma system integrates and coordinates many different key components, resulting in cost-effective services for injury prevention and high-quality patient care without breaking the continuum of care. Developments of trauma systems along with the regionalization of care have led to the concentration of care in relatively few dedicated centers, which results in increase institutional resources, experience, and volume, leading to improved outcomes and a high-quality, cost-efficient health care for large populations. Data has started to emerge on the improvement in functional and long-term outcomes along with mortality.SummaryRegionalization of care has resulted in changes in the delivery of care both in the pre-hospital and in-hospital setting leading to improved utilization of resources and improved outcomes.

How does marijuana affect outcomes after trauma in ICU patients? A propensity-matched analysis

INTRODUCTION In the United States, marijuana abuse and dependence are becoming more prevalent among adult and adolescent trauma patients. Unlike several studies that focus on the effects of marijuana on the outcomes of diseases, our aim was to assess the relationship between a positive toxicology screen for marijuana and mortality in such patients. METHODS A 5-year (2008–2012) analysis of adult trauma patients (older than 18 years old) in Arizona State Trauma Registry. We included patients admitted to the intensive care unit (ICU) with a positive toxicology screen for marijuana. We excluded patients with positive alcohol or other substance screening. Outcome measures were mortality, ventilator days, ICU, and hospital length of stay. We matched patients who tested positive for marijuana (marijuana positive) to those who tested negative (marijuana negative) using propensity score matching in a 1:1 ratio controlling for age, injury severity score, and Glasgow Coma Scale. RESULTS We included a total of 28,813 patients, of which 2,678 were matched (1,339, marijuana positive; 1,339, marijuana negative). The rate of positive screening for marijuana was 7.4% (2,127/28,813). Mean age was 31 ± 9 years, and injury severity score was 13 (8–20). There was no difference between the two groups in hospital (6.4 days vs. 5.4 days, p = 0.08) or ICU (3 days vs. 4 days, p = 0.43) length of stay. Of the marijuana-positive patients, 55.3% received mechanical ventilation, while 32% of marijuana-negative patients received mechanical ventilation (p < 0.001). On subanalysis of patients who received mechanical ventilation, the marijuana-positive patients had a higher number of ventilator days (2 days vs. 1 day, p = 0.02) and a lower mortality rate (7.3% vs. 16.1%, p < 0.001) than those who were marijuana negative. CONCLUSION A positive marijuana screen is associated with decreased mortality in adult trauma patients admitted to the ICU. This association warrants further investigation of the possible physiologic effects of marijuana in trauma patients. LEVEL OF EVIDENCE Prognostic studies, level III.

Decompressive craniectomy versus craniotomy only for intracranial hemorrhage evacuation: A propensity matched study

BACKGROUND Decompressive craniectomy (DC) is often performed in conjunction with evacuation of intracranial hemorrhage (ICH) to control intracranial pressure (ICP) in patients with a traumatic brain injury (TBI). The efficacy of DC in lowering ICP is well established; however, its effect on clinical outcomes remains controversial. The aim of our study is to assess outcomes in TBI patients undergoing DC versus craniotomy only (CO) for the evacuation of ICH. METHODS We performed a 5-year retrospective analysis of TBI patients with ICH who underwent craniotomy or craniectomy for traumatic ICH. Patients were divided into two groups, those who underwent CO and those who underwent DC. Propensity scoring matched patients in a 1:2 ratio for demographics, admission Glasgow Coma Scale (GCS) score, severity of injury, type and size of ICH, and anticoagulant use. Outcome measures included mortality, adverse discharge disposition (skilled nursing facility), discharge GCS and Glasgow Outcome Scale scores, and complications. RESULTS We reviewed 1,831 patients with TBI, of which 155 underwent craniotomy and/or craniectomy. After propensity score matching, we included 99 of those patients in our study (DC, 33; CO, 66). Matched groups were similar in age (p = 0.68), admission GCS score (p = 0.50), Injury Severity Score (p = 0.70), head Abbreviated Injury Scale score (p = 0.32), and intracranial bleeding characteristics. Overall, 26.3% (n = 26) of the patients died and 62.6% (n = 62) were discharged to Rehab/skilled nursing facility. There was no difference in the mortality rate (27.3% vs. 25.0%; p = 0.99), adverse discharge disposition (45% vs. 33%; p = 0.66), GCS score (p = 0.53), and Glasgow Outcome Scale (p = 0.80) at discharge between the DC and the CO groups. However, patients in DC group had higher complication rates and ventilator days. CONCLUSION This study showed no significant difference in clinical outcomes for patients undergoing evacuation of ICH regardless of the procedure performed. DC did not appear to be superior to craniotomy alone for the treatment of acute ICH. LEVEL OF EVIDENCE Therapeutic, level III.

Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program

Background Advancement in trauma care has led to the evolution of emergency resuscitative thoracotomy (ERT) for the revival of trauma patients. We now have more precise understanding of selecting suitable patients for achieving optimal outcomes. The aim of our study was to analyze the utilization and survival trends during the past 5 years, as well as factors that influence survival after ERT. Methods A 5-year (2010-2014) analysis of all trauma patients ≥18 years who underwent ERT in the American College of Surgeons Trauma Quality Improvement Program. Outcome measures were utilization rates and survival trends after ERT during the 5-year period. Regression analysis was performed. Results 2229 patients underwent ERT, mean age was 37±17 years, 81% were male. Overall 56% patients had penetrating mechanism, location of major injury was thorax in 48, and 71% had signs of life (SOL) on arrival. The overall survival rate was 9.6%. From 2010–2014 ERT utilization has decreased from 331/100 000 to 243/100 000 trauma admissions (p=0.002) and the survival rate has improved from 7.9% to 11.3% (p<0.001). On regression, the independent predictors of survival were penetrating mechanism, age<60 years, SOL on arrival, no prehospital CPR and ISS. No patient aged >60 years with a blunt mechanism of injury (MOI) survived, and there were no survivors above the age of 70 years, regardless of injury mechanism. Discussion Utilization of ERT has been decreased during the study period along with improved survival rates. The results of our study demonstrate that performing ERT on patients aged >60 years with a blunt MOI or on any patient aged ≥70 years, regardless of MOI, is futile and should be avoided. Level of evidence Level III, prognostic studies.

A modified frailty index predicts adverse outcomes among patients with colon cancer undergoing surgical intervention

INTRODUCTION Assessing outcomes in patients with colon cancer (CC) undergoing surgical intervention is challenging. Frailty has been as established tool for assessing patient outcomes. The aim was of this study was to assess role of frailty in patients with CC. METHODS National estimates for patients with CC were abstracted from the National Inpatient Sample (NIS) database (2011). Frailty was calculated using a 11 variable CCFI. Patient was stratified as frail (FL) (mFI≥0.25) and non-frail (Non-FL). Outcome measures were: in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS), discharge disposition, and mortality. Regression analysis was performed. RESULTS A total of 53,652 patients with CC who underwent surgery were analyzed. The mean age was 69 ± 19 years with 62% males and mean CCFI being 0.13. 34% of patients were frail. 22.3% patients had in-hospital complications and mortality rate was 3.2%. Frail patients were more likely to have in-hospital complications (p = 0.001), longer hospital LOS (p = 0.001), more likely to be discharged to a facility (p = 0.001). On regression analysis after controlling for age, gender, type of procedure, hospital status, insurance status, frail status was independently associated with in-hospital complications (OR[95% CI]: 1.8[1.1-2.9], p = 0.035) and adverse discharge disposition (OR[95% CI]: 1.3[1.08-3.5], p = 0.043). CONCLUSION Frailty status is an independent predictor of adverse outcomes (complications, discharge disposition, and LOS) in CC patient undergoing surgical intervention. Age was not independently associated with outcome and had poor correlation with frailty status. Pre-operative assessment of frailty in CC patient may help early identifications and risk stratification to help improve outcomes and discharge planning.

The burden of excess length of stay in trauma patients

BACKGROUND Disposition of trauma patients frequently results in excessive hospital-stay. The aim of this study was to assess the risk of developing complications due to excessive stay in the hospital. METHODS Over a period of 4 years (2012-2015) we analyzed all trauma patients with hospital length-of-stay (h-LOS) >30 days. Outcome measures were complications after termination of medical care. RESULTS 416 patients were identified having h-LOS>30 days of which 61.0% (254) had an excess hospital stay and were included. The most common causes of excess hospital stay were placement in SNiF followed by placement in Inpatient-Rehabilitation. Excessive hospital-stay was independently associated with the development of complications (p = 0.004). Each excess day in the hospital after completion of medical care was associated with 5% higher odds of complications (OR [95%CI]: 1.05[1.02-1.09]) independent of presenting condition of the patient. CONCLUSION Each extra day spent in the hospital after completion of medical care was associated with higher odds of developing complications.

Big for Small; Validating Brain Injury Guidelines in Pediatric Traumatic Brain Injury

BACKGROUND Brain injury guidelines (BIG) were developed to reduce overutilization of neurosurgical consultation (NC) as well as computed tomography (CT) imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without NC (no-NC). METHODS We prospectively implemented the BIG-1 category (normal neurologic examination, ICH ⩽ 4 mm limited to one location, no skull fracture) to identify pediatric TBI patients (age, ⩽ 21 years) that were to be managed no-NC. Propensity score matching was performed to match these no-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention. RESULTS A total of 405 pediatric TBI patients were enrolled, of which 160 (NC, 80; no-NC, 80) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n = 85) were male, the median Glasgow Coma Scale score was 15 (13–15), and the median head Abbreviated Injury Scale score was 2 (2–3). A subanalysis based on stratifying patients by age groups showed a decreased in the use of repeat head CT (p = 0.02) in the no-NC group, with no difference in progression (p = 0.34) and the need for neurosurgical intervention (p = 0.9) compared with the NC group. CONCLUSION The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups. LEVEL OF EVIDENCE Therapeutic/care management, level III.

The burden of firearm violence in the United States: stricter laws result in safer states

Abstract: Background: Increasing firearm violence has resulted in a strong drive for stricter firearm legislations. Aim of this study was to determine the relationship between firearm legislations and firearm-related injuries across states in the United States. Methods: We performed a retrospective analysis of all patients with trauma related hospitalization using the 2011 Nationwide Inpatient Sample database. Patients with firearm-related injury were identified using E-codes. States were dichotomized into strict firearm laws [SFL] or non-strict firearm laws [Non-SFL] states based on Brady Center score. Outcome measures were the rate of firearm injury and firearm mortality. Linear Regression and correlation analysis were used to assess outcomes among states. Results: 1,277,250 patients with trauma related hospitalization across 44 states were included of which, 2,583 patients had firearm-related injuries. Ten states were categorized as SFL and 34 states as Non-SFL. Mean rate of firearm related injury per 1000 trauma patients was lower in SFL states (1.3±0.5 vs. 2.1±1.4; p=0.006) and negatively correlated with Brady score (R2 linear=-0.07; p=0.04). SFL states had a 28% lower incidence of firearm related injuries compared to Non-SFL states (Beta coefficient, -0.28; 95% CI, -1.7- -0.06; p=0.04). Firearm related mortalities resulted in overall 9,722 potential life years lost and more so in the non-SFL states (p=0.001). Conclusions: States without SFL have higher firearm related injury rates, higher firearm related mortality rate, and significant potential years of life lost compared to SFL states. Further analysis of differences in the legislation between SFL and non-SFL states may help reduce firearm related injury rate.