Henry C. Veldenz

Prophylactic Greenfield filter placement in selected high-risk trauma patients

PURPOSE Pulmonary embolus (PE) remains a major factor in morbidity and death in severely injured patients, especially those in specific high-risk groups. PEs have been documented to occur despite routine deep venous thrombosis prophylaxis. The purpose of this study was to evaluate the safety and efficacy of prophylactic Greenfield filter (PGF) placement in patients who have multiple trauma with known high-risk injuries for PE. METHODS From January 1992 to June 1994, PGF were prospectively placed in 108 patients who had an injury severity score greater than 9 and met one of the following criteria: (1) severe head injury with prolonged ventilator dependence, (2) severe head injury with multiple lower extremity fractures, (3) spinal cord injury with or without paralysis, (4) major abdominal or pelvic penetrating venous injury, (5) pelvic fracture with lower extremity fractures. These patients were compared with 216 patients, historically matched for age, sex, mechanism of injury, injury severity score, and days in the intensive care unit. Data analysis was done with chi-squared and Students t testing. RESULT There were no statistical differences between the PGF and control group with regard to age (35.9 +/- 1.5 vs 38.3 +/- 1.4), sex (male 76% vs 75.5%), days in the intensive care unit (21.2 +/- 1.4 vs 18.1 +/- 1.5), ISS (28.0 +/- 1.0 vs 25.4 +/- 0.8) and mechanism of injury (blunt 85% vs 81%). None of the patients in the PGF group had a PE. In the control group, however, 13 patients had a PE, nine of which were fatal. These differences were statistically significant for both PE (p < 0.009) and PE-related death (p < 0.03). The overall mortality rate was reduced in the PGF group (18 of 108, 16%) versus the control group (47 of 216, 22%); however, this did not achieve statistical significance. CONCLUSION PGF insertion in selected patients at high risk who had trauma effectively prevented both fatal and nonfatal PE. The lower incidence of fatal PE in the PGF group may have contributed to a reduction in the overall mortality rate. Patients who have trauma with high risk for PE should be considered for PGF placement.

Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up.

PURPOSE To establish by long-term follow-up the safety and efficacy of nonoperative management of clinically occult arterial injuries and the use of physical examination (PE) alone in determining treatment of penetrating extremity trauma (PET). METHODS Two groups of patients were studied: (1) all patients with PET, arterial abnormalities on arteriograms, and no hard signs of vascular injury treated nonoperatively from 1986 to 1989; and (2) all patients with PET to the extremities managed by PE alone from 1989 to 1991. Telephone contact, PE, and duplex ultrasonography (US) were attempted in all group 1 patients, and telephone interviews were attempted in all group 2 patients. RESULTS Group 1 had 43 patients with 44 clinically occult penetrating injuries to extremity arteries. Arteriography identified 21 intimal flaps/irregularities, 19 narrowings, 2 pseudoaneurysms, and 1 arteriovenous fistula. Four patients (9%) had clinical deterioration within 1 month and required surgery, with good results. Twenty-three of the other 39 patients (58%) were able to be contacted, and 17 (43%) with 18 injuries underwent PE and US. All were asymptomatic and had normal PE, and one had mild residual narrowing on US. The other 6 patients (four in prison, two out of state) reported no symptoms of vascular insufficiency and never sought medical attention for vascular problems. Mean follow-up was 9.1 years (range, 8.6-11.1 years). Group 2 had 287 patients (309 injuries) with PET treated by observation based on PE alone. Four patients (1.3%) required delayed surgery within the first week, and 78 with 90 injuries (29%) were able to be contacted. No patient reported any vascular symptoms or ever saw a physician for vascular problems. Mean follow-up was 5.4 years (range, 2.2-6.0 years). CONCLUSION This is the first long-term follow-up of nonoperative management of clinically occult arterial injuries of the extremities and the use of PE alone in the initial management of PET. The results show these approaches to be safe, effective, and now a proven standard of care.

Confirmation of the safety and accuracy of physical examination in the evaluation of knee dislocation for injury of the popliteal artery: a prospective study.

BACKGROUND Knee dislocation, which poses a significant risk for injury of the popliteal artery, prompts many surgeons to evaluate these patients with arteriography routinely. Our hypothesis was that physical examination alone (without arteriography) accurately confirms or excludes surgically significant vascular injuries associated with knee dislocation. METHODS All patients diagnosed with a knee dislocation by an attending orthopedic surgeon between January 1990 and January 2000 were prospectively managed by protocol at our Level I trauma center according to their physical examination. Those with hard signs (active hemorrhage, expanding hematoma, absent pulse, distal ischemia, bruit/thrill) underwent arteriography followed immediately by surgical repair if indicated. Patients with no hard signs (negative physical examination) were admitted for 23 hours, underwent serial physical examination, and then followed as outpatients. RESULTS There were 35 knee dislocations in 35 patients during this 10-year period. The average age was 31 years; 18 dislocations were on the right knee and 17 were on the left. Two patients died from closed head injuries and multisystem trauma. Eight patients were found to have hard signs (positive physical examination) either at presentation (six patients) or during their hospitalization after reduction of their dislocation (two patients). All eight patients demonstrated a loss of pulses only. Six of these patients showed occlusion of the popliteal artery on arteriography and underwent surgical repair without complication (five vein grafts, one primary repair), one demonstrated spasm of the popliteal artery, and one showed a normal artery that required no treatment. None of the 27 patients with negative physical examination during their hospitalization ever developed limb ischemia, needed an operation for vascular injury, or experienced limb loss. Sixteen patients were available for follow-up (46%). Twelve patients with negative physical examination (44%) were contacted (mean, 13 months; range, 2-35 months), and four of the eight patients with positive physical examination (50%) and surgical repair were contacted (mean, 19 months; range, 6-49 months). None of the patients in either group developed any vascular-related symptoms or suffered from a vascular repair complication over the follow-up interval. CONCLUSION This limited series suggests that the presence or absence of an injury of the popliteal artery after knee dislocation can be safely and reliably predicted, with a 94.3% positive predictive value and 100% negative predictive value. Arteriography appears to be unnecessary when physical examination is negative but may avert negative vascular exploration when physical examination is positive. This approach substantially reduces cost and resource use without adverse impact on the patient.

Relationship of Trauma Patient Volume to Outcome Experience: Can a Relationship Be Defined?

OBJECTIVES Five years experience recorded in a multi-institutional pediatric trauma registry was analyzed to define the relationship between case volume and outcome as measured by mortality. METHODS A total of 30,930 records with complete data were categorized by contributing hospital. Patients with fatal injury as indicated by an injury severity score of 75 or any abbreviated injury scale of 6 were excluded. Each centers experience was stratified by injury severity using injury severity score > or = 15 as indicative of severe injury. Centers were then classified as low volume (LV, 100-500 cases), mid volume (MV, 501-1,000 cases), or high volume (HV, > 1,000 cases). Proportion of patients with severe injury (injury severity score > 15) and mortality were compared among groups using the chi(2) test with significance accepted at p < 0.05. Using the Pediatric Risk Indicator to adjust for mortality risk, the combined hospital experience of each volume group was further analyzed to assess performance with specific levels of increasing injury severity. RESULTS Findings demonstrated a trend of increasing mortality with increasing volume, despite a consistent proportion of severe injury. Risk adjusted mortality for each volume class indicates best outcome in the mid level group. CONCLUSIONS Regardless of overall volume of patients encountered, there is a consistent proportion of severe injury. The increasing mortality with the most severe injuries seen in the high volume centers may reflect overdemand on resources.

A three-year follow-up on standard versus thin wall ePTFE grafts for hemodialysis

PURPOSE Expanded polytetraflouroethylene (ePTFE) grafts are the most popular prosthetic grafts for hemodialysis patients in whom autogenous fistulas cannot be constructed. Long-term studies to study the durability and complication rate of the different wall configurations of ePTFE grafts have not been carried out. The primary, secondary, and cumulative patency and other complications between standard thickness (STD) and thin wall (THN) 6 mm stretch ePTFE grafts (WL Gore & Assoc, Flagstaff, AZ) was prospectively evaluated. METHODS From September 1993 to August 1995, 108 patients receiving new grafts were randomized into 2 groups: those receiving STD grafts (n = 56) or those receiving THN (n = 52) grafts. Data prospectively collected included day of first access, primary patency, interventions required, and long-term results. Infections, pseudoaneurysms, and mortality were also documented. Students unpaired t-test was used to compare the 2 groups, and log-rank life tables were constructed and compared. RESULTS Mean follow-up examination time was 38.1 +/- 0.8 months for STD grafts and 35.1 +/- 1.0 months for THN grafts (P<.03). Longer patency was noted in the STD group of grafts (18.2 months for STD vs. 12.1 months for THN). Biographical data and complications, including pseudoaneurysm (6% vs. 5%), infection (2% vs. 3%), and mortality (22% vs. 19%), between STD and THN groups were not different statistically. Mean primary (18.2 months vs. 12.1 months), secondary (20.9 months vs. 13.7 months), and cumulative patency times (22.2 months vs. 15.2 months) for the STD group were significantly more than those for the THN group (P<.000 by log rank of life tables). Other complications were not different between groups. CONCLUSION Standard thickness ePTFE is the graft of choice when placing ePTFE arteriovenous grafts for hemodialysis.

Elderly injury: a profile of trauma experience in the Sunshine (Retirement) State

OBJECTIVE By using mandatory discharge data from a state agency, the records of 116,687 patients hospitalized for treatment of injury were evaluated to develop an epidemiologic and demographic profile of this population and to compare outcomes of patients treated in state-designated trauma centers (TC) with those treated in nontrauma centers (NTC). METHODS Injury severity was calculated by using the International Classification Injury Severity Score methodology to compute individual diagnosis survival risk ratios from 698,187 reported diagnoses, and then by using these survival risk ratios to determine probability of survival for every patient. The population was then categorized by age, injury type, treatment facility designation, injury severity as indicated by probability of survival, and discharge disposition. Incidence of potentially preventable death was compared between TC and NTC, as was the effect on outcome of noninjury comorbidity. RESULTS The average age of this population was 58 +/- 26 years with significant skew toward the elderly in NTC (mean age, 62 +/- 26 years). The most commonly encountered injuries likewise reflected the elderly nature of this population. Although 71.3% received care in NTC, the majority of severely injured were treated in TC. Potentially preventable mortality (>0.5) was significantly lower in TC. The effect of noninjury comorbidity on outcome was better managed by TC, both in terms of decreased mortality and in proportion of patients discharged home. CONCLUSION These data demonstrate the unique characteristics of injury victims treated in the state of Florida and indicate that the developing trauma system is demonstrating productivity in terms of avoidance of preventable death, efficient management of noninjury comorbid problems, and more complete recovery as indicated by proportion of patients discharged to home.

Two careers in one: an analysis of the earning power of certification in surgical critical care.

BACKGROUND The core of general surgery supports multiple disciplines, each of which entails similar operative care for different diseases. The purpose of this study was to compare variations of practice patterns of four general surgeons to define the general surgical core that each shared in common, and to determine the effect of subspecialization in surgical critical care on the scope of practice and efficiency of revenue production. METHODS The charges and collections of four members of the same surgical faculty were analyzed for the 6 months beginning July 1, 2000. Three members practiced general surgery with additional specialization in surgical oncology, surgical endoscopy, and trauma/critical care. The fourth covered all aspects of general surgery, including in-house trauma call, but not surgical critical care. Data were stratified by Current Procedural Terminology code and categorized as operative, bedside care (which included minor procedures), and evaluation/consultation care. Scope of practice was defined as the proportion of operative cases represented by the 10 most frequently performed procedures. General surgical core was defined as those cases that were preformed by all four surgeons at the same frequency. Efficiency of revenue generation was defined as collection rate for these procedures divided by the established, budgeted collection rate for each practitioner. All results were compared using chi(2) with significance accepted at p < 0.05. RESULTS Fifteen operative procedures were performed with equal frequency by each surgeon and represented a broad spectrum of surgical disease. These procedures constituted a similar proportion of operative practice for all specialists (mean, 45.2%; 90% confidence limit, 3.5%), yet occupied 70% of the trauma surgeons 10 most frequent surgical procedures versus 36% for the surgical oncology and surgical endoscopy. Charges generated by the provision of surgical critical care, especially in bedside procedures commonly performed in the intensive care unit, exceeded all of the other three surgeons and equaled the revenue generated by operative care. Although overall revenue-generating efficiency was less for the trauma surgeons (57% of eventual collections vs. 67%, chi(2) p = 0.1), immediate reimbursement for critical care was higher than for any other clinical services. CONCLUSION These data demonstrate that subspecialization in surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional operative care, and fees generated can actually exceed revenue from operative care. With impending decreases in global reimbursement, and attempts to unbundle operative fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs.