Margaret H. Lauerman

Nontrauma open abdomens: A prospective observational study.

BACKGROUND Damage-control surgery with open abdomen (OA) is described for trauma, but little exists regarding use in the emergency general surgery. This study aimed to better define the following: demographics, indications for surgery and OA, fascial and surgical site complications, and in-hospital/long-term mortality. We hypothesize that older patients will have increased mortality, patients will have protracted stays, they will require specialized postdischarge care, and the indications for OA will be varied. METHODS A prospective observational study of emergency general surgery OA patients from June 2013 to June 2014 was performed. Demographics, clinical/operative variables, comorbidities, indications for procedure and OA, wound/fascial complications, and disposition were collected. Patients were stratified into age groups (⩽60, 61–79, and ≥80 years). Six-month and 1-year mortality was determined by query of the Social Security Death Index. RESULTS A total of 338 laparotomies were performed, of which 96 (28%) were managed with an OA. Median age was 61 years (interquartile range [IQR], 0–68 years), and 51% were male. The median Charlson Comorbidity Index was 2 (IQR, 1.5–5.1), and the median hospital stay was 25 days (IQR, 15–50 days). The most common indications for operation were perforated viscus/free air (20%), mesenteric ischemia (17%), peritonitis (16%), and gastrointestinal hemorrhage (12%). The most common indication for OA was damage control (37%). In the 63 patients with fascial closure, there were 9 (14%) wound infections and 6 (10%) fascial dehiscences. A total of 30% of the patients died in the hospital, and an additional six patients died 6 months after discharge. Patients in the oldest age stratum were more likely to die at 6 months than those in the lower strata. CONCLUSION Older patients were more likely to die by 6 months, the median hospital stay was 3 weeks, and there were multiple indications for OA management. With a 6-month mortality of 36% and 70% of survivors requiring postdischarge care, this population represents a critically ill population meriting additional study. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Long-term follow-up of blunt cerebrovascular injuries: Does time heal all wounds?

BACKGROUND The short-term natural history of blunt cerebrovascular injuries (BCVIs) has been previously described in the literature, but the purpose of this study was to analyze long-term serial follow-up and lesion progression of BCVI. METHODS This is a single institutions retrospective review of a prospectively collected database over four years (2009–2013). All patients with a diagnosis of BCVI by computed tomographic (CT) scan were identified, and injuries were graded based on modified Denver scale. Management followed institutional algorithm: initial whole-body contrast-enhanced CT scan, followed by CT angiography at 24 to 72 hours, 5 to 7 days, 4 to 6 weeks, and 3 months after injury. All follow-up imaging, medication management, and clinical outcomes through 6 months following injury were recorded. RESULTS There were 379 patients with 509 injuries identified. Three hundred eighty-one injuries were diagnosed as BCVI on first CT (Grade 1 injuries, 126; Grade 2 injuries, 116; Grade 3 injuries, 69; and Grade 4 injuries, 70); 100 “indeterminate” on whole-body CT; 28 injuries were found in patients reimaged only for lesions detected in other vessels. Sixty percent were male, mean (SD) age was 46.5 (19.9) years, 65% were white, and 62% were victims of a motor vehicle crash. Most frequently, Grade 1 injuries were resolved at all subsequent time points. Up to 30% of Grade 2 injuries worsened, but nearly 50% improved or resolved. Forty-six percent of injuries originally not detected were subsequently diagnosed as Grade 3 injuries. Greater than 70% of all imaged Grade 3 and Grade 4 injuries remained unchanged at all subsequent time points. CONCLUSIONS This study revealed that there are many changes in grade throughout the six-month time period, especially the lesions that start out undetectable or indeterminate, which become various grade injuries. Low-grade injuries (Grades 1 and 2) are likely to remain stable and eventually resolve. Higher-grade injuries (Grades 3 and 4) persist, many up to six months. Inpatient treatment with antiplatelet or anticoagulation did not affect BCVI progression. LEVEL OF EVIDENCE Prognostic study, level III; therapeutic study, level IV.

Multicompartment management of patients with severe traumatic brain injury.

Purpose of review Intracranial pressure (ICP) control is a mainstay of traumatic brain injury (TBI) management. However, development of intracranial hypertension (ICH) may be affected by factors outside of the cranial vault in addition to the local effects of the TBI. This review will examine the pathophysiology of multiple compartment syndrome (MCS) and current treatment considerations for patients with TBI given the effects of MCS. Recent findings Elevated intra-abdominal pressure (IAP) is associated with ICP elevation, and decompressive laparotomy in patients with concurrent elevations in IAP and ICP can reduce ICP. Elevated intrathoracic pressure may be similarly associated with ICP elevation, although the ideal ventilator management strategy for TBI patients when considering MCS is unclear. Summary In MCS, intracranial, intrathoracic and intra-abdominal compartment pressures are interrelated. TBI patient care should include ICP control as well as minimization of intrathoracic and intra-abdominal pressure as clinically possible.

Lethal now or lethal later: The natural history of Grade 4 blunt cerebrovascular injury.

BACKGROUND Grade 4 blunt cerebrovascular injury (BCVI4) has a known, significant rate of stroke. However, little is known about the natural history of BCVI4 and the pathophysiology of subsequent stroke formation. METHODS A 4-year review of patients with BCVI4 at the R Adams Cowley Shock Trauma Center was performed. Rates of BCVI4-related stroke, stroke-related mortality, and overall mortality were calculated. The relationship of change in vessel characteristics and BCVI4-related stroke was examined, as was the mechanism of stroke formation. RESULTS There were 82 BCVI4s identified, with 13 carotid artery (ICA) and 69 vertebral artery BCVI4s. BCVI4-related stroke rate was 2.9% in vertebral artery BCVI4 and 70% in ICA BCVI4 patients surviving to reimaging. Stroke mechanisms included embolic strokes, thrombotic strokes, and combined embolic and thrombotic strokes. Peristroke vessel recanalization and an embolic stroke mechanism were seen in 100% of ICA BCVI4-related strokes developing after admission. BCVI4-related stroke occurred within 10 hours of hospital admission in 67% of the patients with strokes. Contraindications to anticoagulation were present in most patients with BCVI4-related stroke developing after admission. CONCLUSION Multiple etiologies of stroke formation exist in BCVI4. Early risk-benefit analysis for initiation of anticoagulation or antiplatelet agents should be performed in all patients with BCVI4, and the use of endovascular vessel occlusion should be considered in those with true contraindications to anticoagulation. However, more aggressive medical therapy may be needed to lessen BCVI4-related stroke development. LEVEL OF EVIDENCE Prognostic study, level IV; therapeutic study, level V.

Less is more? Antibiotic duration and outcomes in Fournier’s gangrene

BACKGROUND Antibiotic management of Fournier’s gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown. METHODS A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration. RESULTS Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms. CONCLUSION Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG. LEVEL OF EVIDENCE Therapeutic, level IV.

Are frailty markers associated with serious thoracic and spinal injuries among motor vehicle crash occupants

BACKGROUND While age is a known risk factor in trauma, markers of frailty are growing in their use in the critically ill. Frailty markers may reflect underlying strength and function more than chronologic age, as many modern elderly patients are quite active. However, the optimal markers of frailty are unknown. METHODS A retrospective review of The Crash Injury Research and Engineering Network (CIREN) database was performed over an 11-year period. Computed tomographic images were analyzed for multiple frailty markers, including sarcopenia determined by psoas muscle area, osteopenia determined by Hounsfield units (HU) of lumbar vertebrae, and vascular disease determined by aortic calcification. RESULTS Overall, 202 patients were included in the review, with a mean age of 58.5 years. Median Injury Severity Score was 17. Sarcopenia was associated with severe thoracic injury (62.9% vs. 42.5%; p = 0.03). In multivariable analysis controlling for crash severity, sarcopenia remained associated with severe thoracic injury (p = 0.007) and osteopenia was associated with severe spine injury (p = 0.05). While age was not significant in either multivariable analysis, the association of sarcopenia and osteopenia with development of serious injury was more common with older age. CONCLUSIONS Multiple markers of frailty were associated with severe injury. Frailty may more reflect underlying physiology and injury severity than age, although age is associated with frailty. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level IV.

Perioperative Use of Nonsteroidal Anti-Inflammatory Drugs and the Risk of Anastomotic Failure in Emergency General Surgery

BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis. METHODS Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed. RESULTS Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04–4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03). CONCLUSION Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. LEVEL OF EVIDENCE Therapeutic study, level III.BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. NSAID administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal anastomotic failure in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis. METHODS Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula or abscess. Patients utilizing NSAIDS were compared to those without. Summary, univariate and multivariable analyses were performed. RESULTS 533 patients met inclusion criteria with a mean (±SD) age of 60 ±17.5years, 53% male. There were 46% (n=244) patients utilizing perioperative NSAIDs. Gastrointestinal anastomotic failure (AF) rate between NSAID and no NSAID was (13.9% vs 10.7%, p=0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs 13.8%, p=0.34), or mortality (7.39 vs 6.92%, p=0.84). Multivariable analysis demonstrated that perioperative corticosteroid (OR 2.28, CI 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with anastomotic failure. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared to enteroenteric or enterocolonic anastomoses (30.0% vs 13.0%, p=0.03). CONCLUSION Perioperative NSAID utilization appears to be safe in emergency general surgery patients undergoing small bowel resection and anastomosis. NSAIDs administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF. LEVEL OF EVIDENCE Therapeutic study, level III.

Blunt cerebrovascular injury

A 38-year-old man was transferred to the R Adams Cowley Shock Trauma center after a motorcycle collision. He was evaluated at a non-trauma hospital, intubated for a depressed mental status, and inability to protect the airway. Computerized tomography (CT) scans were performed and the patient was transferred. Details of the collision and clinical status at the scene were not provided. He arrived at our trauma center intubated, in a cervical collar; temperature 37.6 C, heart rate 122 beats per minute, blood pressure 152/80mmHg, SaO2 98% on 40% FiO2 on the ventilator. Pertinent findings on physical examination were agitation and significant facial swelling with ecchymosis. The neurologic examination off sedation revealed bilateral reactive pupils, a Glasgow Coma Scale (GCS) 8T (E2, V1T, M5), the right upper extremity was weaker than the left. No further past medical or surgical history could be obtained given his mental status. Initial chest and pelvic radiographs were unremarkable. A focused abdominal ultrasonography for trauma (FAST) was negative.

RESHAPES: Increasing AAST EGS grade is associated with anastomosis type

INTRODUCTION Threatened, perforated, and infarcted bowel is managed with conventional resection and anastomosis (hand sewn [HS] or stapled [ST]). The SHAPES analysis demonstrated equivalence between HS and ST techniques, yet surgeons appeared to prefer HS for the critically ill. We hypothesized that HS is more frequent in patients with higher disease severity as measured by the American Association for the Surgery of Trauma Emergency General Surgery (AAST EGS) grading system. METHODS We performed a post hoc analysis of the SHAPES database. Operative reports were submitted by volunteering SHAPES centers. Final AAST grade was compared with various outcomes including duration of stay, physiologic/laboratory data, anastomosis type, anastomosis failure (dehiscence, abscess, or fistula), and mortality. RESULTS A total of 391 patients were reviewed, with a mean age (±SD) of 61.2 ± 16.8 years, 47% women. Disease severity distribution was as follows: grade I (n = 0, 0%), grade II (n = 106, 27%), grade III (n = 113, 29%), grade IV (n = 123, 31%), and grade V (n = 49, 13%). Increasing AAST grade was associated with acidosis and hypothermia. There was an association between higher AAST grade and likelihood of HS anastomosis. On regression, factors associated with mortality included development of anastomosis complication and vasopressor use but not increasing AAST EGS grade or anastomotic technique. CONCLUSION This is the first study to use standardized anatomic injury grades for patients undergoing urgent/emergent bowel resection in EGS. Higher AAST severity scores are associated with key clinical outcomes in EGS diseases requiring bowel resection and anastomosis. Anastomotic-specific complications were not associated with higher AAST grade; however, mortality was influenced by anastomosis complication and vasopressor use. Future EGS studies should routinely include AAST grading as a method for reliable comparison of injury between groups. LEVEL OF EVIDENCE Prognostic, level III.

Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial

BACKGROUND Following blunt splenic injury, there is conflicting evidence regarding the natural history and appropriate management of patients with vascular injuries of the spleen such as pseudoaneurysms or blushes. The purpose of this study was to describe the current management and outcomes of patients with pseudoaneurysm or blush. METHODS Data were collected on adult (aged ≥18 years) patients with blunt splenic injury and a splenic vascular injury from 17 trauma centers. Demographic, physiologic, radiographic, and injury characteristics were gathered. Management and outcomes were collected. Univariate and multivariable analyses were used to determine factors associated with splenectomy. RESULTS Two hundred patients with a vascular abnormality on computed tomography scan were enrolled. Of those, 14.5% were managed with early splenectomy. Of the remaining patients, 59% underwent angiography and embolization (ANGIO), and 26.5% were observed. Of those who underwent ANGIO, 5.9% had a repeat ANGIO, and 6.8% had splenectomy. Of those observed, 9.4% had a delayed ANGIO, and 7.6% underwent splenectomy. There were no statistically significant differences between those observed and those who underwent ANGIO. There were 111 computed tomography scans with splenic vascular injuries available for review by an expert trauma radiologist. The concordance between the original classification of the type of vascular abnormality and the expert radiologist’s interpretation was 56.3%. Based on expert review, the presence of an actively bleeding vascular injury was associated with a 40.9% risk of splenectomy. This was significantly higher than those with a nonbleeding vascular injury. CONCLUSIONS In this series, the vast majority of patients are managed with ANGIO and usually embolization, whereas splenectomy remains a rare event. However, patients with a bleeding vascular injury of the spleen are at high risk of nonoperative failure, no matter the strategy used for management. This group may warrant closer observation or an alternative management strategy. LEVEL OF EVIDENCE Prognostic study, level III.