Jayun Cho

Intracranial pressure monitoring in severe blunt head trauma: does the type of monitoring device matter?

OBJECTIVE Intracranial pressure (ICP) monitoring has become the standard of care in the management of severe head trauma. Intraventricular devices (IVDs) and intraparenchymal devices (IPDs) are the 2 most commonly used techniques for ICP monitoring. Despite the widespread use of these devices, very few studies have investigated the effect of device type on outcomes. The purpose of the present study was to compare outcomes between 2 types of ICP monitoring devices in patients with isolated severe blunt head trauma. METHODS This retrospective observational study was based on the American College of Surgeons Trauma Quality Improvement Program database, which was searched for all patients with isolated severe blunt head injury who had an ICP monitor placed in the 2-year period from 2013 to 2014. Extracted variables included demographics, comorbidities, mechanisms of injury, head injury specifics (epidural, subdural, subarachnoid, intracranial hemorrhage, and diffuse axonal injury), Abbreviated Injury Scale (AIS) score for each body area, Injury Severity Score (ISS), vital signs in the emergency department, and craniectomy. Outcomes included 30-day mortality, complications, number of ventilation days, intensive care unit and hospital lengths of stay, and functional independence. RESULTS During the study period, 105,721 patients had isolated severe traumatic brain injury (head AIS score ≥ 3). Overall, an ICP monitoring device was placed in 2562 patients (2.4%): 1358 (53%) had an IVD and 1204 (47%) had an IPD. The severity of the head AIS score did not affect the type of ICP monitoring selected. There was no difference in the median ISS; ISS > 15; head AIS Score 3, 4, or 5; or the need for craniectomy between the 2 device groups. Unadjusted 30-day mortality was significantly higher in the group with IVDs (29% vs 25.5%, p = 0.046); however, stepwise logistic regression analysis showed that the type of ICP monitoring was not an independent risk factor for death, complications, or functional outcome at discharge. CONCLUSIONS This study demonstrated that compliance with the Brain Trauma Foundation guidelines for ICP monitoring is poor. In isolated severe blunt head injuries, the type of ICP monitoring device does not have any effect on survival, systemic complications, or functional outcome.

Comparison of outcomes in severe pediatric trauma at adult trauma centers with different trauma case volumes

BACKGROUND In addition to trauma center levels and types, trauma volume may be an important factor impacting outcomes in severe pediatric trauma. METHODS All severely injured pediatric patients treated at adult trauma centers were identified from the National Trauma Data Bank. All qualifying centers were stratified into four groups based on the cumulative pediatric trauma case volumes with ISS >15: lowest (group 1), lower (group 2), higher (group 3), and highest (group 4) volume centers. Mortality rates among the groups were compared. RESULTS A total of 3747 patients were stratified into group 1 (n=2122, median annual pediatric trauma volume 3 cases/year), group 2 (n=842, 15 cases/year), group 3 (n=494, 24 cases/year), and group 4 (n=289, 43 cases/year). In the hierarchical logistic regression analysis, the highest volume centers (group 4) were shown to have improved mortality (odds ratio 0.474, 95% confidence interval [CI] 0.301-0.747) compared to the lowest volume centers (group 1). Odds ratios of group 4 against group 1 for subgroups were 0.634 (age<10, 95% CI 0.335-1.198), 0.491 (blunt injury, 95% CI 0.310-0.777), and 0.495 (level 1 center, 95% CI 0.312-0.785). CONCLUSIONS In severe pediatric trauma treated at adult trauma centers, higher volume centers were associated with improved mortality in comparison to the lower volume centers. LEVEL OF EVIDENCE Level III, therapeutic/care management, retrospective comparative study without negative criteria.

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury

Objective The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries. Methods Patients in the National Trauma Data Bank (NTDB; 2007‐2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries. Results Overall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30‐day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30‐day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries (P < .001). Patients with isolated iliac vein injuries had morbidity rates of deep venous thrombosis (repair, 14.6%; ligation, 14.1%; P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08‐4.66). Conclusions Isolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible.

Operative outcomes of infantile hypertrophic pyloric stenosis in patients with congenital heart disease

PURPOSE This study aims to compare the outcomes of pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) in children with and without congenital heart disease (CHD). METHODS A retrospective, single pediatric center, case-control, matched cohort study was performed over 10years. A case of IHPS with CHD was paired with control patients of IHPS without CHD, matched by age and gender. Perioperative morbidity, 30-day mortality, length of hospital stay, and hospital cost were compared. Subgroups were analyzed based on the severity of CHD and the reason for admission. RESULTS Twenty-six patients who underwent pyloromyotomy for IHPS with CHD (CHD group) were matched with 78 patients with IHPS without CHD (Non-CHD group). No 30-day mortality was identified in either group. Overall perioperative complications were not significantly different between groups (11.5% vs 5.2%, p=0.163). However, postoperative length of stay was longer in CHD group (6 vs 1days, p<0.001) and any subgroups of CHD as compared to Non-CHD group. CHD group patients admitted only for IHPS had short postoperative LOS, whereas those who developed pyloric stenosis during a hospital admission stayed longer postoperatively (1.5 vs 26.5days, p<0.001). Mean hospital costs in patients admitted for IHPS were

A high-volume trauma intensive care unit can be successfully staffed by advanced practitioners at night

16,270 and

Isolated Iliac Vascular Injuries: Morbidity of Repair Versus Ligation of Iliac Vein Injury

3591 for CHD group and Non-CHD group, respectively (p<0.001). CONCLUSIONS IHPS patients with CHD have prolonged postpyloromyotomy course, especially when inpatients with CHD incidentally develop IHPS.

Peak creatinine kinase level is a key adjunct in the evaluation of critically ill trauma patients.

PURPOSE It remains unknown whether critically ill trauma patients can be successfully managed by advanced practitioners (APs). The purpose of this study was to examine the impact of night coverage by APs in a high-volume trauma intensive care unit (ICU) on patient outcomes and care processes. MATERIALS AND METHODS During the study period, our ICU was staffed by APs during the night shift (7 pm-7 am) from Sunday to Wednesday and by resident physicians (RPs) from Thursday to Saturday. On-call trauma fellows and attending surgeons in house supervised both APs and RPs. Patient outcomes and care processes by APs was compared with those admitted by RPs. RESULTS A total of 289 patients were identified between July 2013 and February 2014. Median lactate clearance rate within 24 hours of admission was similar between study groups (10.0% vs 9.1%; P = .39). Advanced practitioners and RPs transfused patients requiring massive transfusion with a similar blood product ratio (packed red blood cell:fresh frozen plasma) (2.1:1 vs 1.7:1; P = .32). In a multiple logistic regression analysis, AP coverage was not associated with any clinical outcome differences. CONCLUSIONS Our data suggest that, with adequate supervision, a high-volume trauma ICU can be safely staffed by APs overnight.

Therapeutic anticoagulation in patients with traumatic brain injury

Objective: The advantage of an arteriovenous graft in reducing infectious complication over a tunneled hemodialysis catheter for patients without native fistula options has been established. Standard arteriovenous graft access requires 2 weeks before cannulation to avoid complications from early access. Limited studies are available to evaluate the efficacy of bovine carotid artery graft (BCAG) for subsequent early access. We report our experience with BCAG in patients who underwent early access at our institution. Methods: All patients who underwent placement of BCAG for hemodialysis access were reviewed from November 2013 to February 2016. Early access was defined as <7 days after implantation. Outcome variables included primary and secondary patency rates and graft-related complications. Kaplan-Meier survival analysis was performed to evaluate primary and secondary patency. Results: During the study period, 70 patients underwent BCAG implantation. Thirty-one (44%) patients underwent successful early access. Of those patients, 18 (58%) patients has successful dialysis on postoperative day 1. Indications for primary BCAG placement were the presence of disadvantaged vein with no previous access and infected or nonfunctional catheters. Twelve (38%) patients had primary graft BCAG placement for disadvantaged veins. Secondary graft placement was done in 19 (61%) patients, with the most common indication being aneurysmal degeneration of the fis-