Kevin M. Schuster

Selective Nonoperative Management of Blunt Splenic Injury: An Eastern Association for the Surgery of Trauma Practice Management Guideline

BACKGROUND During the last century, the management of blunt force trauma to the spleen has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the Practice Management Guidelines for Non-operative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the current EAST guideline. METHODS The National Library of Medicine and the National Institute of Health MEDLINE database was searched using Pub Med (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords splenic injury and blunt abdominal trauma. RESULTS One hundred seventy-six articles were reviewed, of which 125 were used to create the current practice management guideline for the selective nonoperative management of blunt splenic injury. CONCLUSION There has been a plethora of literature regarding nonoperative management of blunt splenic injuries published since the original EAST practice management guideline was written. Nonoperative management of blunt splenic injuries is now the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury, patient age, or the presence of associated injuries. Its use is associated with a low overall morbidity and mortality when applied to an appropriate patient population. Nonoperative management of blunt splenic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and has an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt splenic injuries. Repeat imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography with embolization are increasingly important adjuncts to nonoperative management of splenic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt splenic injuries remain without conclusive answers in the literature.

Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline

Background During the last century, the management of blunt force trauma to the liver has changed from observation and expectant management in the early part of the 1900s to mainly operative intervention, to the current practice of selective operative and nonoperative management. These issues were first addressed by the Eastern Association for the Surgery of Trauma in the Practice Management Guidelines for Nonoperative Management of Blunt Injury to the Liver and Spleen published online in 2003. Since that time, a large volume of literature on these topics has been published requiring a reevaluation of the previous Eastern Association for the Surgery of Trauma guideline. Methods The National Library of Medicine and the National Institutes of Health MEDLINE database were searched using PubMed (www.pubmed.gov). The search was designed to identify English-language citations published after 1996 (the last year included in the previous guideline) using the keywords liver injury and blunt abdominal trauma. Results One hundred seventy-six articles were reviewed, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. Conclusion Most original hepatic guidelines remained valid and were incorporated into the greatly expanded current guidelines as appropriate. Nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. Nonoperative management of blunt hepatic injuries should only be considered in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. Patients presenting with hemodynamic instability and peritonitis still warrant emergent operative intervention. Intravenous contrast enhanced computed tomographic scan is the diagnostic modality of choice for evaluating blunt hepatic injuries. Repeated imaging should be guided by a patient’s clinical status. Adjunctive therapies like angiography, percutaneous drainage, endoscopy/endoscopic retrograde cholangiopancreatography and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. Despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.

The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?

BACKGROUND: Massive transfusion protocol (MTP) utilization and makeup is unknown.

Factors Predicting Morbidity and Mortality in Emergency Colorectal Procedures in Elderly Patients

OBJECTIVE To identify rapidly modifiable risk factors that would improve surgical outcomes in elderly patients undergoing emergent colorectal procedures who are at high risk for morbidity and mortality. DESIGN Retrospective review. Patients were identified on the basis of Current Procedural Terminology codes and admission through the emergency department. Medical records were reviewed and data were abstracted for comorbidities, procedural details, and in-hospital morbidity and mortality. SETTING University tertiary referral center. PATIENTS Two hundred ninety-two patients 65 years or older undergoing emergency colorectal procedures from January 1, 2000, through December 31, 2006. MAIN OUTCOME MEASURES Postoperative morbidity (intensive care unit days, ventilator days, pneumonia, deep venous thrombosis, pulmonary embolus, myocardial infarction, and cerebrovascular accident) and mortality. RESULTS The most frequent presenting diagnoses were obstructing or perforated colorectal carcinoma (30%) and perforated diverticulitis (25%). Average age at presentation was 78.1 years, and in-hospital mortality was 15%. One hundred one patients (35%) experienced a total of 195 complications. Pneumonia (25%), persistent or recurrent respiratory failure (15%), and myocardial infarction (12%) were the most frequent complications. Operative time, shock, renal insufficiency, and significant intra-abdominal contamination or frank peritonitis were associated with morbidity. Age, septic shock at presentation, large estimated intraoperative blood loss, delay to operation, and development of a complication were associated with in-hospital mortality. CONCLUSIONS Emergent colorectal procedures in the elderly are associated with significant morbidity and mortality. Minimizing the delay to definitive operative care may improve outcomes. These procedures frequently involve locally advanced colorectal cancer, emphasizing the need for improved colorectal cancer screening.

Non‐operative management of acute cholecystitis in the elderly

Although cholecystectomy is the standard therapy for acute cholecystitis (AC), operative morbidity in the elderly may be high owing to medical co‐morbidities and decreased physiological reserve. Outcomes of AC in the elderly have not been fully defined with regard to operative and long‐term non‐operative management.

Contrast-induced nephropathy in elderly trauma patients.

BACKGROUND Computed tomography (CT) is the gold standard for the identification of occult injuries, but the intravenous (IV) contrast used in CT scans is potentially nephrotoxic. Because elderly patients have decreased renal function secondary to aging and chronic disease, we sought to determine the rate of acute kidney injury (AKI) in elderly trauma patients exposed to IV contrast. METHODS Medical records of patients older than 55 years evaluated at a level-one trauma center between January 2003 and July 2008 were reviewed. Contrast was nonionic, isosmolar, and administered in standard volumes. Groups were based on administration of contrast. AKI was defined as a 25% relative or 0.5 mg/dL absolute increase in serum creatinine within 72 hours of presentation [corrected]. RESULTS During the study period 1,371 patients older than 55 years were evaluated, and 1,152 met the inclusion criteria. CT was performed on 1,071 patients (96%); 71% of this group received IV contrast. There was no significant difference between the contrast and noncontrast groups in terms of baseline characteristics. Criteria for AKI were satisfied in 2.1% of all patients, including 1.9% the contrast group versus 2.4% in the noncontrast group. AKI diagnosed within 72 hours of patient presentation was an independent risk factor for in-hospital mortality and prolonged length of stay. CONCLUSIONS IV contrast media in elderly trauma patients is not associated with an increased risk of AKI. Development of AKI within 72 hours of admission is associated with mortality and increased length of stay.

Ischemic colitis: risk factors for eventual surgery.

BACKGROUND Ischemic colitis is a common disorder often without clear indications for surgical management. The aim of this study was to identify risk factors that predict the need for surgery. METHODS Patients were identified retrospectively based on International Classification of Disease codes and admission over an 8-year period. RESULTS A total of 253 patients presented with ischemic colitis. A total of 205 patients were managed nonsurgically, 12 underwent immediate surgery (within 12 hours of presentation), and 36 had delayed surgery. On univariate analysis, risk factors that predicted delayed surgery were peripheral vascular disease, atrial fibrillation, hypotension, tachycardia, absence of bleeding per rectum, free intraperitoneal fluid on computed tomography scan, intensive care unit admission, vasopressors, mechanical ventilation, and increased lactate level on admission. Intraperitoneal fluid on computed tomography scan and absence of bleeding per rectum were predictive of surgical intervention on multivariate analysis. CONCLUSIONS In patients with ischemic colitis, several risk factors were associated with the need for subsequent surgery during the same admission. These factors could be used to select patients for immediate surgery before worsening of their clinical condition.

Risk of venous thromboembolism after spinal cord injury: not all levels are the same.

BACKGROUND Venous thromboembolism (VTE), a diagnosis that includes both deep vein thrombosis and pulmonary embolism, is a well-recognized complication following injury. Previous studies have identified multiple risk factors including spinal cord injury (SCI). We hypothesized that the level of SCI also influences the likelihood of VTE. METHODS The National Trauma Data Bank was queried to identify all patients with SCI admitted in 2007 and 2008. Rates of VTE, demographics, admitting comorbidities, in-hospital complications, level of SCI (divided by National Trauma Data Bank into five groups), associated injuries, and outcome variables were abstracted. Multiple regression was used to identify independent risk factors for VTE. RESULTS During the 2-year period, 18,302 patients were admitted with SCI. The overall rate of VTE was 4.3% but varied significantly depending on the level of SCI injury (χ(2), 44.8; p < 0.05). Patients with high cervical spine (C1-4) injury had a rate VTE of 3.4%, whereas patients with high thoracic spine (T1-6) injury had the highest rate of VTE at 6.3%. The lowest rate of VTE was in patients with lumbar injury (3.2%). There were no significant differences in the preexisting comorbidities or in-hospital complications among the five SCI groups with the exception of pneumonia. In a multiple logistic regression model, the level of SCI was an independent risk factor for VTE as was increasing age, increasing Injury Severity Score, male gender, traumatic brain injury, and chest trauma. CONCLUSIONS The rate of VTE differs with various SCI levels. Patients with high thoracic (T1-6) injury seem to be at the highest risk and patients with high cervical (C1-4) injury at one of the lowest. A higher index of suspicion for VTE should therefore be maintained in patients with a high thoracic SCI. Further studies are required to elucidate the underlying mechanisms.

Glial cell line-derived neurotrophic factor defines the path of developing and regenerating axons in the lateral line system of zebrafish

How the peripheral axons of sensory neurons are guided to distant target organs is not well understood. Here we examine this question in the case of the posterior lateral line (PLL) system of zebrafish, where sensory organs are deposited by a migrating primordium. Sensory neurites accompany this primordium during its migration and are thereby guided to their prospective target organs. We show that the inactivation of glial cell line-derived neurotrophic factor (GDNF) signaling leads to defects of innervation and that these defects are due to the inability of sensory axons to track the migrating primordium. GDNF signaling is also used as a guidance cue during axonal regeneration following nerve cut. We conclude that GDNF is a major determinant of directed neuritic growth and of target finding in this system, and we propose that GDNF acts by promoting local neurite outgrowth.

Trauma team oversight improves efficiency of care and augments clinical and economic outcomes.

BACKGROUND The purpose of this study was to determine whether trauma team oversight of patient management would positively affect efficiency of care as defined by improved patient throughput, with augmentation of both clinical and economic outcomes. METHODS All patients activating the trauma team at a level I trauma center during two time periods (last 6 months of 2005 and 2006) were reviewed. Trauma team activation criteria remained constant across the two time periods. During period one, patients were admitted to multiple services depending on injury pattern, whereas in period two, most patients were admitted to the trauma service for trauma team oversight of their management. In period two, improved documentation and appropriate coding were encouraged. Data are reported as mean +/- SD, and median. RESULTS Patient demographics, number of full-time trauma surgeons, and payer mix were similar during the two time periods. Trauma activations increased 150% (p < 0.05). The percentage of patients admitted to the trauma service increased (68% vs. 86%, p < 0.001). Median injury severity score (ISS) of admitted patients was unchanged, although mean ISS decreased (15 +/- 15 vs. 12 +/- 11, p < 0.0001). Hospital length of stay decreased (12 +/- 55 vs. 6 +/- 11, p < 0.0001). Linear regression analysis identified ISS and admission during the later time period as significant predictors of decreased length of stay. Changes in billings and coding practices resulted in statistically significant increases in trauma surgeon work-related relative value units (182% increase), charges (360% increase), and collections (280% increase). The increased system efficiency resulted in significant decreases in the actual hospital costs per patient and led to the generation of an overall net positive hospital contribution margin per patient. CONCLUSIONS Implementation of trauma team oversight of patient care resulted in increased efficiency of care delivery, with shorter hospital lengths of stay despite increased patient volume. This paradigm change, coupled with improved documentation and coding, resulted in improved reimbursement for the physician, and lower cost per discharge for the hospital.