Madhukar S. Patel

A Diagnostic Delay of 5 Hours Increases the Risk of Death After Blunt Hollow Viscus Injury

BACKGROUNDnHollow viscus injuries (HVI) are uncommon after blunt trauma, and accomplishing a timely diagnosis can be difficult. Time to operative intervention has been implicated as a risk factor for mortality, but reports are conflicting.nnnMETHODSnAll blunt trauma admissions to an academic level 1 trauma center from January 1992 to September 2005 were retrospectively reviewed. Patients with a diagnosis of blunt HVI were included. Patients who died within 24 hours were excluded. Data regarding patient demographics, injuries, time from admission until laparotomy, length of stay, and mortality were recorded, and a multivariate analysis to determine independent risk factors for mortality was carried out. A p < 0.05 was considered significant.nnnRESULTSnOf 35,033 blunt trauma admissions, there were 195 (0.6%) HVI patients with the following characteristics (data expressed as mean +/- 1 SD): mean age of 35 years +/- 16 years, Injury Severity Score of 17 +/- 11, time from admission to laparotomy of 5.9 hours +/- 5.8 hours, operative blood loss of 1500 mL +/- 1800 mL, and length of stay of 19 days +/- 23 days. Twelve percent presented with a systolic pressure <90 mm Hg and 9% died. Independent risk factors for mortality were age (odds ratio [OR] = 1.04, p = 0.005), Abdominal Abbreviated Injury Score (OR = 2.5, p = 0.011), the presence of a significant extra-abdominal injury (OR = 3.4, p = 0.043), and a delay of more than 5 hours between admission and laparotomy (OR = 3.2, p = 0.0499). Eighty-six percent of the deaths in patients who had a delay of >5 hours were because of abdominal-related sepsis.nnnCONCLUSIONnHVI occurred in less than 1% of all blunt trauma admissions. Delays in operative intervention are associated with an increased mortality. A high index of suspicion is needed to make a timely diagnosis and minimize risk.

Achieving donor management goals before deceased donor procurement is associated with more organs transplanted per donor.

BACKGROUNDnThere is a national shortage of organs available for transplantation. Implementation of preset donor management goals (DMGs) to improve outcomes is recommended, but uniform practices and data are lacking. We hypothesized that meeting DMGs before organ procurement would result in more organs transplanted per donor (OTPD).nnnMETHODSnThe eight organ procurement organization in United Network for Organ Sharing Region 5 selected 10 critical care end points as DMGs. Each organ procurement organization submitted retrospective data from 40 standard criteria donors. DMGs met was defined as achieving any eight DMGs before procurement. The primary outcome was ≥4 OTPD. Binary logistic regression was used to determine independent predictors of ≥4 OTPD with a p<0.05.nnnRESULTSnThree hundred twenty standard criteria donors had 3.6±1.6 OTPD. Donors with DMGs met had more OTPD (4.4 vs. 3.3, p<0.001) and were more likely to have ≥4 OTPD (70% vs. 39%, p<0.001). Independent predictors of ≥4 OTPD were age (odds ratio [OR]=0.94), serum creatinine (OR=0.65), thyroid hormone use (OR=2.0), DMGs met (OR=4.4), and achieving the following individual DMGs: central venous pressure 4 mm Hg to 10 mm Hg (OR=1.9), ejection fraction>50% (OR=4.0), Pao2:FIO2>300 (OR=4.6), and serum sodium 135 to 160 mEq/L (OR=3.4).nnnCONCLUSIONSnMeeting DMGs before procurement resulted in more OTPD. Donor factors and critical care end points are independent predictors of organ yield. Prospective studies are needed to determine the true impact of each DMG on the number and function of transplanted organs.

Early Intervention to Promote Medical Student Interest in Surgery and the Surgical Subspecialties

OBJECTIVEnConcerns about projected workforce shortages are growing, and attrition rates among surgical residents remain high. Early exposure of medical students to the surgical profession may promote interest in surgery and allow students more time to make informed career decisions. The objective of this study was to evaluate the impact of a simple, easily reproducible intervention aimed at increasing first- and second-year medical student interest in surgery.nnnDESIGNnSurgery Saturday (SS) is a student-organized half-day intervention of four faculty-led workshops that introduce suturing, knot tying, open instrument identification, operating room etiquette, and basic laparoscopic skills. Medical students who attended SS were administered pre-/post-surveys that gauged change in surgical interest levels and provided a self-assessment (1-5 Likert-type items) of knowledge and skills acquisition.nnnPARTICIPANTSnFirst- and second-year medical students.nnnOUTCOME MEASURESnChange in interest in the surgical field as well as perceived knowledge and skills acquisition.nnnRESULTSnThirty-three first- and second-year medical students attended SS and completed pre-/post-surveys. Before SS, 14 (42%) students planned to pursue a surgical residency, 4 (12%) did not plan to pursue a surgical residency, and 15 (46%) were undecided. At the conclusion, 29 (88%) students indicated an increased interested in surgery, including 87% (13/15) who were initially undecided. Additionally, attendees reported a significantly (p < 0.05) higher comfort level in the following: suturing, knot tying, open instrument identification, operating room etiquette, and laparoscopic instrument identification and manipulation.nnnCONCLUSIONSnSS is a low resource, high impact half-day intervention that can significantly promote early medical student interest in surgery. As it is easily replicable, adoption by other medical schools is encouraged.

The Impact of Select Chronic Diseases on Outcomes after Trauma: A Study from the National Trauma Data Bank

BACKGROUNDnData regarding pre-existing comorbidities is often poorly recorded in trauma registries, and reports of their impact on outcomes are conflicting. Additionally, many previous reports, when conducting data analysis, do not reliably account for differences in case and control cohorts. Our objective was to identify a subset of patients with reliable comorbidity and complication data in the National Trauma Data Bank (NTDB) in order to determine the impact of select chronic organ system dysfunction on morbidity and mortality using case-control methodology.nnnSTUDY DESIGNnWe analyzed a refined dataset from NTDB 7.1 (2002 to 2006) containing admissions to Level 1 and 2 trauma centers, which specified using chart abstraction to document comorbidities and complications. Patients with a history of cirrhosis, dialysis, HIV, and warfarin therapy were compared with a 2:1 case-matched control group. Data regarding age; Injury Severity Score (ISS); ventilator, ICU, and hospital lengths of stay; complications; and mortality were obtained. Pearsons chi-square, Fishers exact test, and the t-test were used to compare demographics and outcomes of each comorbidity group. A p value < 0.05 was considered significant.nnnRESULTSnAfter case-control matching, pre-existing cirrhosis, dialysis, and warfarin therapy were found to be risk factors for both complications and mortality; HIV/AIDS was found to be a risk factor only for complications.nnnCONCLUSIONSnChronic hepatic failure, end-stage renal disease, immunodeficiency, and acquired coagulopathy are associated with higher resource use, complication rates, and mortality in a refined subset of NTDB patients.

Risk factors for venous thromboembolism in critically ill trauma patients who cannot receive chemical prophylaxis

BACKGROUNDnStandard venous thromboembolism (VTE) prevention for critically ill trauma patients includes sequential compression devices and chemical prophylaxis. When contraindications to anticoagulation are present, prophylactic inferior vena cava filters (IVCF) may be used to prevent pulmonary emboli (PE) in high-risk patients, but specific indications are lacking. We sought to identify independent predictors of VTE in critically-ill trauma patients who cannot receive chemical prophylaxis in order to identify a subset of patients who may benefit from aggressive screening and/or prophylactic IVCF placement.nnnMETHODSnAll trauma patients in the surgical ICU from 2008 to 2009 were prospectively followed. Patients with an ICU length of stay ≥2 days who had contraindications to prophylactic anticoagulation were included. Screening duplex exams were obtained within 48 h of admission and then weekly. CT-angiography for PE was obtained if clinically indicated. Patients were excluded if they did not receive a duplex or if they had a post-injury VTE prior to ICU admission. Data regarding VTE rates (lower extremity [LE] DVT or PE), demographics, past medical history (PMH), injuries, and surgeries were collected. Univariate and multivariable analyses were performed to identify independent predictors of VTE with a p<0.05.nnnRESULTSn411 trauma patients with a mean age of 48 (SD 22) years and 8 (SD 9) ICU days were included. 72% were male and the mean ISS was 22 (SD 13). 30 (7.3%) patients developed VTE: 28 (6.8%) with LEDVT and 2 (0.5%) with PE. Risk factors for VTE with a p<0.2 on univariate analysis included: PMH of DVT, injury severity score (ISS), extremity fractures (Fx), and a pelvis or LE extremity Fx repair. After logistic regression, only PMH of DVT (OR=22.6) and any extremity Fx (OR=2.4) remained as independent predictors.nnnCONCLUSIONnVTE occur in 7% of critically injured trauma patients who cannot receive chemical prophylaxis. Aggressive screening and/or prophylactic IVCF placement may be considered in patients with a PMH of DVT or extremity fractures when anticoagulation is prohibited.

Impact of Compliance with the American College of Surgeons Trauma Center Verification Requirements on Organ Donation-Related Outcomes

BACKGROUNDnIn order to maximize organ donation opportunities, the American College of Surgeons (ACS) requires verified trauma centers to have a relationship with an organ procurement organization (OPO), a policy for notification of the OPO, a process to review organ donation rates, and a protocol for declaring neurologic death. We hypothesized that meeting the ACS requirements will be associated with improved donation outcomes.nnnSTUDY DESIGNnTwenty-four ACS-verified Level I and Level II trauma centers were surveyed for the following registry data points from 2004 to 2008: admissions, ICU admissions, patients with a head Abbreviated Injury Score ≥ 5, deaths, and organ donors. Centers were also queried for the presence of the ACS requirements as well as other process measures and characteristics. The main outcomes measure was the number of organ donors per center normalized for patient volume and injury severity. The relationship between center characteristics and outcomes was determined.nnnRESULTSnTwenty-one centers (88%) completed the survey and referred 2,626 trauma patients to the OPO during the study period, 1,008 were eligible to donate, and 699 became organ donors. Compliance with the 4 ACS requirements was not associated with increased organ donation outcomes. However, having catastrophic brain injury guidelines (CBIGs) and the presence of a trauma surgeon on a donor council were associated with significantly more organ donors per 1,000 trauma admissions (6.3 vs 4.2 and 6.0 vs 4.2, respectively, p < 0.05).nnnCONCLUSIONSnAlthough the ACS trauma center organ donation-related requirements were not associated with improved organ donor outcomes, involvement of trauma surgeons on donor councils and CBIGs were and should be encouraged. Additionally, incorporation of quantitative organ donation measures into the verification process should be considered.

Predictors of Hazardous Drinking Behavior in 1,340 Adult Trauma Patients: A Computerized Alcohol Screening and Intervention Study

BACKGROUNDnAlcohol screening and brief intervention (SBI) is used to decrease alcohol consumption, health care costs, and injury recidivism in trauma patients. Despite SBI being mandated for trauma centers, various concerns have led many centers to conduct SBI only on patients with a detectable blood alcohol concentration (BAC). We sought to determine the predictive nature of BAC on hazardous drinking behavior.nnnSTUDY DESIGNnAdult trauma patients were included if they received an SBI before discharge. SBI was administered using a computerized alcohol screening and intervention (CASI) system with the Alcohol Use Disorder Identification Test (AUDIT). Data regarding demographics, injuries, and BAC were prospectively collected. Multivariate analyses were performed to identify independent predictors of hazardous drinking behavior.nnnRESULTSnData were complete for 1,340 patients, with a mean age of 43 years (SD 20 years). Sixty-eight percent were male, 33% had detectable BAC, and 19% had hazardous drinking behavior. Multivariate analysis identified age (odds ratio [OR] 0.97 per year), male sex (OR 3.1), BAC (OR 1.009 per mg/dL), detectable BAC (OR 3.9), and legal intoxication (OR 7.8) as independent predictors of hazardous drinking behavior. Asian/Pacific Islander ethnicity was a significant negative predictor (OR 0.53) compared with white. Thirty-eight percent of patients with hazardous drinking behavior had no detectable BAC.nnnCONCLUSIONSnYounger age, male sex, and higher BAC are early predictors of hazardous drinking behavior in adult trauma patients. Asian/Pacific Islander patients are half as likely to report hazardous drinking behavior compared with white patients. More than one-third of patients with hazardous drinking behavior do not have detectable BAC on admission and are not receiving interventions in centers that screen solely based on BAC.

The natural history of upper extremity deep venous thromboses in critically ill surgical and trauma patients: what is the role of anticoagulation?

BACKGROUNDnThe natural history and optimal treatment of upper extremity (UE) deep venous thromboses (DVTs) remains uncertain as does the clinical significance of catheter-associated (CA) UE DVTs. We sought to analyze predictors of UE DVT resolution and hypothesized that anticoagulation will be associated with quicker UE DVT clot resolution and that CA UE DVTs whose catheters are removed will resolve more often than non-CA UE DVTs.nnnMETHODSnAll patients on the surgical intensive care unit service were prospectively followed from January 2008 to May 2010. A standardized DVT prevention protocol was used and screening bilateral UE and lower extremity duplex examinations were obtained within 48 hours of admission and then weekly. Computed tomography angiography for pulmonary embolism was obtained if clinically indicated. Patients with UE DVT were treated according to attending discretion. Data regarding patient demographics and UE DVT characteristics were recorded: DVT location, catheter association, occlusive status, treatment, and resolution. The primary outcome measure was UE DVT resolution before hospital discharge. Interval decrease in size on the subsequent duplex after UE DVT detection was also noted. UE DVTs without a follow-up duplex were excluded from the final analysis. Univariate and multivariate analyses were used to identify independent predictors of UE DVT resolution.nnnRESULTSnThere were 201 UE DVTs in 129 patients; 123 DVTs had a follow-up duplex and were included. Fifty-four percent of UEDVTs improved on the next duplex, 60% resolved before discharge, and 2% embolized. The internal jugular was the most common site (52%) and 72% were nonocclusive. Sixty-four percent were CAUEDVTs and line removal was associated with more frequent improvement on the next duplex (55% vs. 17%, p = 0.047, mid-P exact). Sixty-eight percent of UEDVTs were treated with some form of anticoagulation, but this was not associated with improved UE DVT resolution (61% vs. 60%). Independent predictors of clot resolution were location in the arm (odds ratio = 4.1 compared with the internal jugular, p = 0.031) and time from clot detection until final duplex (odds ratio =1.052 per day, p = 0.032).nnnCONCLUSIONnA majority of UE DVTs are CA, more than half resolve before discharge, and 2% embolize. Anticoagulation does not appear to affect outcomes, but line removal does result in a quicker decrease in clot size.

Inhibition of intraluminal pancreatic enzymes with nafamostat mesilate improves clinical outcomes after hemorrhagic shock in swine

BACKGROUNDnRecent studies suggest that intraluminal pancreatic enzymes play a major role in the initiation of the inflammatory cascade by the gut after hemorrhagic shock. Previous animal models have shown that the inhibition of enteral pancreatic enzymes with a serine protease inhibitor, nafamostat mesilate (NM), decreases leukocyte activation and transfusion requirements after hemorrhagic shock. The objective of this study was to determine whether enteroclysis with NM would improve the clinical outcomes in swine after hemorrhagic shock and intestinal hypoperfusion.nnnMETHODSnThirty-three male Yucatan minipigs weighing 25 kg to 30 kg underwent a controlled hemorrhage of 25 mL/kg with mesenteric clamp for further gut ischemia. Animals were allocated to three groups: (1) shock only (n = 15), (2) shock + enteroclysis with 100 mL/kg GoLYTELY (GL) as a carrier (n = 11), and (3) shock + enteroclysis with GL + 0.37 mmol/L NM (GL+NM, n = 7). Animals were resuscitated, recovered from anesthesia, observed for 3 days, and graded on a daily 4-point clinical scoring system. A score of 0 indicated a moribund state or early death, and a score of 4 indicated normal behavior.nnnRESULTSnPigs treated with GL + NM had significantly higher mean postoperative recovery scores (3.8 +/- 0.4, essentially normal behavior with no early deaths) compared with animals within the shock only and shock + GL groups (2.1 +/- 1 with one early death and 2.2 +/- 1.2 with two early deaths, respectively, analysis of variance p < 0.003).nnnCONCLUSIONnThe inhibition of intraluminal pancreatic enzymes using enteroclysis with the serine protease inhibitor, NM, after hemorrhagic shock significantly improves the clinical outcome.

Penetrating oesophageal injury: A contemporary analysis of the National Trauma Data Bank

BACKGROUNDnOesophageal trauma is uncommon. The aim of this study was to conduct a descriptive analysis of penetrating oesophageal trauma and determine risk factors for oesophageal related complications and mortality in the National Trauma Data Bank (NTDB).nnnMETHODSnPatients with penetrating oesophageal trauma from Levels 1 and 2 trauma centres in the NTDB (2007 and 2008) that specified how complication and comorbidity data were recorded were selected. Data collected included age, injury severity score (ISS), abbreviated injury scores (AIS), lengths of stay (LOS) and ventilation days, systolic blood pressure (SBP) in the emergency department (ED), comorbidities, oesophageal related procedures, and oesophageal related complications. Univariate and multivariable analyses were conducted to identify significant predictors of oesophageal-related complications and mortality in patients with LOS>24 h.nnnRESULTSn227 patients from 107 centres were studied. The mean number of patients per centre was 2 (range 1-15). Overall mortality was found to be 44% with 92% of these deaths in less than 24 h. In patients with LOS>24 h, 62% had primary repair, 13% drainage, 4% resection, 1% diversion, and 20% unspecified. No significant difference in mortality was found in patients with oesophageal related complications. The time to first oesophageal related procedure was not significantly different in those with oesophageal related complications or those who died. Significant predictors of oesophageal related complications were age and AIS of the abdomen or pelvic contents ≥3 and the only significant predictor of mortality was ISS.nnnCONCLUSIONSnMost deaths in penetrating oesophageal trauma occur in the first 24 h due to severe associated injuries. Primary repair was the most common intervention, followed by drainage and resection. Oesophageal related complications were not found to significantly increase mortality and time to first oesophageal related procedure did not affect outcomes in this subset of patients from the NTDB.