Gustavo Recinos

Endovascular stenting for the treatment of traumatic internal carotid injuries: expanding experience.

BACKGROUND The role of endovascular techniques in the treatment of traumatic vascular injuries, including injury to the internal carotid artery, continues to evolve. Despite growing experience with the usage of these techniques in the setting of artherosclerotic disease, published results in traumatic carotid injuries remain sporadic and confined to case reports and case series. METHODS We conducted a review of the medical literature from 1990 to the present date using the Pubmed and OVID Medline databases to search for all reports documenting the use of endovascular stenting for the treatment of carotid injuries. Thirty-one published reports were analyzed to abstract data regarding mechanism, location, and type of injury; use and type of anticoagulation used in conjunction with stenting; type and timing of radiographic and clinical follow-up; and radiographic and clinical outcomes. RESULTS The use of endovascular stenting for the treatment of internal carotid injuries was reported for only 113 patients from 1994 to the present date. Stenting was most commonly used after a blunt mechanism of injury (77.0%). The injury types treated by stenting included pseudoaneurysm (60.2%), arteriovenous fistula (16.8%), dissection (14.2%), partial transection (4.4%), occlusion (2.7%), intimal flap (0.9%), and aneurysm (0.9%). Initial endovascular stent placement was successful in 76.1% of patients. Radiographic and clinical follow-up periods ranging from 2 weeks to 2 years revealed a follow-up patency of 79.6%. No stent-related mortalities were reported. New neurologic deficits after stent placement occurred in 3.5%. CONCLUSION Endovascular treatment of traumatic internal carotid artery injury continues to evolve. Early results are encouraging, but experience with this modality and data on late follow-up are still very limited. A large prospective randomized trial is warranted to further define the role of this treatment modality in the setting of trauma.

Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma

Background: The optimal chest tube size for the drainage of traumatic hemothoraces and pneumothoraces is unknown. The purpose of this study was to compare the efficacy of small versus large chest tubes for use in thoracic trauma. Our hypothesis was that (1) there would be no difference in clinically relevant outcomes including retained hemothoraces, the need for additional tube insertion, and invasive procedures and (2) there would be an increase in pain with the insertion of large versus small tubes. Methods: This is a prospective, institutional review board-approved observational study. All patients requiring open chest tube drainage within 12 hours of admission (January 2007–January 2010) were identified at a Level I trauma center. Clinical demographic data and outcomes including efficacy of drainage, complications, retained hemothoraces, residual pneumothoraces, need for additional tube insertion, video-assisted thoracoscopy, and thoracotomy were collected and analyzed by tube size. Small chest tubes (28–32 Fr) were compared with large (36–40 Fr). Results: During the study period, a total of 353 chest tubes (small: 186; large: 167) were placed in 293 patients. Of the 275 chest tubes inserted for a hemothorax, 144 were small (52.3%) and 131 were large (47.7%). Both groups were similar in age, gender, and mechanism; however, large tubes were placed more frequently in patients with a Glasgow Coma Scale ⩽8, severe head injury, a systolic blood pressure <90 mm Hg, and Injury Severity Score ⩽25. The volume of blood drained initially and the total duration of tube placement were similar for both groups (small: 6.3 ± 3.9 days vs. large: 6.2 ± 3.6 days; adjusted (adj.) p = 0.427). After adjustment, no statistically significant difference in tube-related complications, including pneumonia (4.9% vs. 4.6%; adj. p = 0.282), empyema (4.2% vs. 4.6%; adj. p = 0.766), or retained hemothorax (11.8% vs. 10.7%; adj. p = 0.981), was found when comparing small versus large chest tubes. The need for tube reinsertion, image-guided drainage, video-assisted thoracoscopy, and thoracotomy was likewise the same (10.4% vs. 10.7%; adj. p = 0.719). For patients with a pneumothorax requiring chest tube drainage (n = 238), there was no difference in the number of patients with an unresolved pneumothorax (14.0% vs. 13.0%; adj. p = 0.620) or those needing reinsertion of a second chest tube. The mean visual analog pain score was similar for small and large tubes (6.0 ± 3.3 and 6.7 ± 3.0; p = 0.237). Conclusions: For injured patients with chest trauma, chest tube size did not impact the clinically relevant outcomes tested. There was no difference in the efficacy of drainage, rate of complications including retained hemothorax, need for additional tube drainage, or invasive procedures. Furthermore, tube size did not affect the pain felt by patients at the site of insertion. Level of Evidence: II.

Local complications following pancreatic trauma

BACKGROUND Major trauma to the pancreas is uncommon, but associated with significant overall morbidity and mortality. A vast majority of these adverse outcomes can be attributed to the presences of associated injuries. Among those patients who survive the initial injury, however, the subsequent development of pancreas-related complications represents a significant source of adverse outcomes. METHODS AND RESULTS A total of 257 patients admitted from January 1996 to April 2007 were identified from the trauma registry database at our institution. One hundred and eighty-three patients surviving more than 48 h after admission were selected for analysis. These patients were grouped according to the surgical management utilised to address their pancreatic injuries: either resection or operative drainage. After exclusion of patients with associated vascular injuries, those undergoing drainage had lower rate of associated hollow viscus injuries (51.9% vs. 69.9%; p = 0.016) and lower rates of associated solid organ injuries (44.2% vs. 70.9%; p < or = 0.001). Patients undergoing drainage were noted to have a higher incidence of pseudocyst formation (19.5% vs. 9.0%; OR: 2.47, 95% CI, 0.92-6.67; p = 0.068), but lower hospital lengths of stay (18.7+/-18.5 vs. 33.8+/-63.5; p = 0.001). No difference in mortality was noted between the two populations (5.7% vs. 3.0%; p = 0.700). After multivariate analysis pseudocyst formation was the only complication that proved different between the two management groups, with patients undergoing operative drainage more commonly developing this adverse sequela (OR: 2.93, 95% CI, 1.02-8.36; p = 0.041). CONCLUSIONS In the absence of vascular injury, the choice of surgical management did not affect adjusted mortality or the overall occurrence of pancreas-related complications. Individuals treated with operative drainage alone, however, were significantly more likely to develop a post-operative pseudocyst than their resectional counterparts.

ACS trauma centre designation and outcomes of post-traumatic ARDS: NTDB analysis and implications for trauma quality improvement

BACKGROUND Several authors have examined the relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation. Little is known, however, about the association between ACS level and outcomes following complications of trauma. METHODS The National Trauma Databank (NTDB, v. 5.0) was queried to identify adult (age > or =18) trauma patients developing post-traumatic ARDS, who were admitted to either ACS level 1 or level 2 trauma centres from 2000 to 2004. Patients transferred between institutions and injuries following burns were excluded. Univariate analysis was used to assess differences between those patients admitted to ACS level 1 and level 2 facilities. Adjusted mortality was derived using logistic regression analysis. RESULTS A total of 902 adult trauma patients with ARDS after 48 h of mechanical ventilation were identified from the NTDB. Five hundred and thirty six patients were admitted to a level 1 ACS verified centre and 366 to a level 2 facility. Univariate analysis revealed no statistical differences in clinical and demographic characteristics between the two groups. On univariate comparison, patients admitted to level 1 facilities had longer mean hospital and ICU length of stay and higher hospital related charges than level 2 counterparts. Patients admitted to a level 1 centre were, however, significantly more likely to achieve discharge to home. Using multivariate logistic regression, ACS level designation was shown to have no statistical effect on mortality. Hypotension on admission and age greater than 55 were the only independent predictors of mortality. CONCLUSION ACS trauma centre designation level is not an independent predictor of mortality following post-traumatic ARDS.

Prospective evaluation of ambient operating room temperature on the core temperature of injured patients undergoing emergent surgery

BACKGROUND Although uncomfortable for the operating team, trauma operating room (OR) temperatures have traditionally been kept warm in an attempt to mitigate intraoperative heat loss. The purpose of this study was to examine how ambient OR temperatures impact core temperature in patients undergoing emergent surgery for trauma. METHODS Injured adult patients requiring emergent surgery at a Level 1 trauma center were prospectively enrolled between July 2008 and January 2010. Standardized warming measures were used for all patients. Ambient OR temperature was recorded in 5-minute intervals with the Fourier Microlog EC600 temperature data logger. Intraoperative core patient temperatures were compared with ambient OR temperature. Patients experiencing intraoperative core temperature decreases were compared with those who did not, to examine the impact of ambient temperature changes on the risk of perioperative hypothermia. RESULTS During the 18-month study period, 118 patients requiring emergent surgery (73% laparotomy, 5% thoracotomy, 7% combined, 15% other) were enrolled. Incidence of hypothermia (<35°C) at admission to the OR was 29.7%. Crude mortality increased as the final patient core temperature achieved in the OR decreased (4.2% for temperatures >35°C and as high as 50% for temperatures ⩽32°C). Overall, core temperature decreased in 46 patients (39.0%) but remained stable or increased by the end of the procedure in 72 (61%). There were no significant differences in the admission temperature, clinical demographics, or volume of fluids and blood products between the two groups. In a forward logistic regression analysis, a lower ambient OR temperature was not associated with a drop in the patient’s core temperature. CONCLUSION In this prospective study, the ambient OR temperature did not affect the core temperature of injured patients undergoing emergent surgery. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

The relationship between post-traumatic ventilator-associated pneumonia outcomes and American College of Surgeons trauma centre designation

INTRODUCTION The relationship between outcomes following severe trauma and American College of Surgeons (ACS) trauma centre designation has been studied. Little is known, however, about the association between ACS level and outcomes associated with ventilator-associated pneumonia (VAP). METHODS The National Trauma Databank (NTDB, Version 5.0) was queried to identify adult (age 18)trauma patients who (1) developed VAP and (2) were admitted to either an ACS level I or level II centre.Transfer and burn patients were excluded. Univariate analysis defined differences between patient cohorts. Logistic regression analysis was utilised to identify independent risk factors for mortality. RESULTS A total of 3465 patients were identified where 65.6% were admitted to a level I facility and 34.4%to a level II centre. Patients admitted to a level I centre were more likely to have an age > 55 (71.5% vs.66.8%, p = 0.004) and to be hypotensive (SBP < 90) on admission (16.2% vs. 13.6%, p = 0.042). They were also more likely to have a longer duration of mechanical ventilation (18.5 days vs. 16.5 days, p = 0.001),longer hospital LOS (34.2 days vs. 29.6 days, p < 0.001) and a higher rate of early (±7 days) tracheostomy(33.1% vs. 29.1%, p = 0.017). Level I admission was, however, associated with lower mortality rates (10.8%vs. 14.7%, p = 0.001) and a higher likelihood of achieving discharge to home (20.2% vs. 16.1%, p < 0.001).Logistic regression analysis identified admission to a level II facility as an independent risk factor for mortality (OR 1.34, 95% CI 1.08–1.66; p = 0.008) in patients developing post-traumatic VAP. CONCLUSION For adults who develop VAP after trauma, admission to a level I facility is associated with improved survival. Further prospective study is needed.

Reference Accuracy in the General Surgery Literature

BackgroundReference inaccuracy in scientific articles brings the scientific validity of the research into question and may create difficulty when accessing the cited background data. The objective of this study was to examine the reference accuracy in the general surgery literature and its correlation with the journal impact factor.MethodsFive general surgery journals were chosen with varying impact factors. From the year 2007, one issue was randomly chosen from each journal, and from each issue 180 citations were randomly chosen for review. Three investigators evaluated the chosen references for primary, citational, and quotational errors. The impact factor of each journal was compared to the percentage of errors detected.ResultsThe total number of errors per journal ranged from 31.3 to 39.3%, with a total of 35.4% of all citations reviewed containing some type of error. The most common error type detected was incorrect citation of the primary source supporting a statement, the incidence of which ranged from 13.8 to 25.2%, depending on the journal, and accounting for 53.6% of the total errors found. Citational errors, which included incorrect author names, pagination, dates, and issue and volume numbers, ranged from 1.8 to 18.1% and accounted for 20.4% of the total errors detected. Qualitative errors, which occurred when the author misquoted another author’s written assertions or conclusions, ranged from 7.4 to 16.0% and accounted for 34.7% of the total errors detected. Quantitative errors (misquoted numerical data) ranged from 3.1 to 8.6% and accounted for 17.9% of the total errors detected. No association between impact factor and error rate was demonstrated.ConclusionsReference inaccuracy is common in the general surgery literature. The impact factor has no clear association with the error rate, demonstrating that journal quality does not necessarily correlate with reference quality. Further investigation into potential methods for improving reference accuracy in the general surgery literature is warranted.

American College of Surgeons trauma centre designation and mechanical ventilation outcomes

OBJECTIVE The association between hospital volume and outcomes following mechanical ventilation has been previously examined in diverse patient populations. The American College of Surgeons (ACS) Committee on Trauma has outlined criteria for trauma centre level designations with specific requirements for both specialty capabilities and hospital volume. Our objective is to determine the relationship between ACS centre designation and outcomes for trauma patients undergoing mechanical ventilation. METHODS We conducted a retrospective cohort study using the National Trauma Databank (NTDB), identifying 13,933 adult (age>or=18) trauma patients receiving mechanical ventilation for greater than 48 h from 2000 to 2004 who were admitted to either an ACS Level I or Level II trauma centre. The primary endpoints examined were mortality, pneumonia and Acute Respiratory Distress Syndrome (ARDS). Univariate analysis defined differences between those patients admitted to ACS Level I and Level II facilities. Logistic regression analysis was used to identify if ACS level designation was an independent risk factor for the goal outcomes. RESULTS Patients admitted to a Level I facility and mechanically ventilated for greater than 48 h were more commonly greater than age 55 (71.3% vs. 67.9%, p<0.01), hypotensive (SBP<90) (16.1% vs. 12.8%, p<0.01), and likely to have sustained injury due to penetrating mechanism (11.1% vs. 5.1%, p<0.01). On univariate analysis, mortality and the incidence of pneumonia did not differ between the two groups. Level I admission was, however, less commonly associated with the development of ARDS (5.8% vs. 7.7%, p<0.01) and patients admitted to Level I facilities were significantly more likely to be discharged to home than Level II counterparts (29.7% vs. 22.9%, p<0.01). Logistic regression revealed that, while ACS Level designation was not a predictive factor for mortality or the development of pneumonia, admission to an ACS Level II facility was an independent predictor for the development of ARDS [p<0.01, odds ratio, 95% CI: 1.35 (1.18-1.59)]. CONCLUSION For trauma patients requiring mechanical ventilation for >48 h, ACS trauma centre designation had no effect on overall mortality or the incidence of pneumonia. Compared to Level I counterparts, however, patients admitted to an ACS Level II facility were significantly more likely to develop ARDS following trauma. This finding needs further investigation in a large, prospective analysis.

Risk factors for empyema after diaphragmatic injury: Results of a National Trauma Databank analysis

BACKGROUND Empyema is a rare, but morbid complication of diaphragmatic injury. The purpose of this study was to use the National Trauma Databank of the American College of Surgeons to determine (1) the incidence of empyema after diaphragmatic injury, (2) risk factors for development of empyema after these injuries, and (3) the effect of empyema on mortality, hospital, and intensive care unit (ICU) length of stay (LOS) after diaphragm injury. METHODS The National Trauma Databank (v. 5.0) was used to identify adult patients sustaining diaphragmatic injury and surviving for greater than 48 hours. Demographics, injury characteristics, associated abdominal injuries, thoracic procedures, and outcomes data were abstracted for comparison of patients who did and did not develop empyema after these injuries. Stepwise logistic regression analysis was used to identify independent risk factors for the development of empyema. Subsequent adjusted analysis was used to determine the effect of empyema on outcomes (hospital LOS, ICU LOS, mortality). RESULTS Among 4,153 patients with diaphragmatic injury who survived more than 48 hours from admission, 57 (1.4%) developed empyema. Demographics did not differ significantly between the two groups. Empyema was associated with longer adjusted mean hospital (35.9 vs. 16.1, p < 0.001) and ICU (18.1 vs. 8.5, p < 0.001) LOS, but was not associated with increased mortality. Patients with empyema more commonly had associated hollow viscus (63.2% vs. 35.6%, p < 0.001), gastric (40.4% vs. 18.8%, p < 0.001), and splenic injuries (49.1% vs. 33.3%, p = 0.01). After multivariable analysis, two independent risk factors for the development of empyema after diaphragmatic injury were identified: gastric injury (adjusted odds ratio = 2.90; 95% confidence interval: 1.69-5.00; p < 0.001) and Injury Severity Score > or = 20 (adjusted odds ratio = 2.99; 95% confidence interval: 1.61-5.59; p = 0.001). Concomitant colonic injury did not significantly increase the risk of empyema in the study population. CONCLUSIONS Empyema is an uncommon sequela of diaphragm injury that contributes to the need for prolonged hospital and ICU LOSs. Associated gastric trauma and Injury Severity Score > or = 20 were independently associated with empyema development after diaphragmatic injury.

Pharmacological Thromboembolic Prophylaxis in Traumatic Brain Injuries: Low Molecular Weight Heparin Is Superior to Unfractionated Heparin

Objective: We hypothesized that low molecular weight heparin (LMWH) is superior to unfractionated heparin (UH) for venous thromboembolism (VTE) prophylaxis in patients with severe traumatic brain injuries (TBI). Summary Background Data: Pharmacological VTE prophylaxis with LMWH or UH is the current standard of care in TBI. Clinical work suggests that LMWH may be more effective than UH for VTE prophylaxis in trauma patients. Experimental work shows that heparinoids may have neuroprotective properties. Methods: ACS TQIP database study including patients with blunt severe TBI (AIS ≥ 3), those that received LMWH or UH VTE prophylaxis. Patients with severe extracranial injuries (AIS ≥ 3), death within 72 hours, or hospital stay <48 hours were excluded. Demographic and clinical data on admission was collected, as well as head, thorax, and abdomen AIS, and timing of prophylaxis (within 48 hours, 49–72 hours, and >72 hours). Outcomes included VTE complications, mortality, and unplanned return to the operating room. Multivariate analysis was performed to compare outcomes between patients receiving LMWH and UH. Results: Overall, 20,417 patients met the criteria for inclusion in the study, 10,018 (49.1%) received LMWH and 10,399 (50.9%) UH. Multivariate analysis showed that LMWH was an independent protective factor against mortality and thromboembolic complications, regardless of timing of prophylaxis initiation. The type of prophylaxis had no effect on the need for unplanned return to the operating room. Conclusions: LMWH prophylaxis in severe TBI is associated with better survival and lower thromboembolic complications than UH.