Miren A. Schinco

The effect of early spine fixation on non-neurologic outcome.

INTRODUCTION It has been shown that spinal fracture fixation within 3 days can reduce the incidence of pneumonia, length of stay, number of ventilator days, and hospital charges. Our institutional protocol calls for surgical stabilization of spinal fractures within 3 days of admission. We hypothesized that compliance with an early spinal fracture fixation protocol (within 3 days of admission) would improve non-neurologic outcome in patients with spinal fractures. METHODS The trauma registry was queried for the period January 1988 through October 2001 to identify patients with spinal fractures requiring surgical stabilization. Patients were analyzed to determine the compliance with our protocol and to determine whether early spinal fixation can reduce the incidence of pneumonia, reduce length of stay, and reduce mortality. RESULTS 1,741 patients with spinal fractures were identified. 299 (17.2%) required surgical stabilization. 174 (58.2%) had surgical stabilization within 3 days while 125 (41.8%) had surgical stabilization greater than 3 days from admission. There were no significant differences between the two groups with regards to age (37.9 versus 42.5), admission GCS (14.1 versus 13.9), or ISS (22 versus 20.8). The incidence of pneumonia was similar in both groups (21.8 versus 25.6%). The mortality was higher in the early group as compared with the late group (6.9 versus 2.5%), although it did not reach statistical significance. The hospital length of stay was significantly shorter (14.3 versus 21.1) for patients who had early spine fixation, however there was no statistically significant difference between the two groups with regards to intensive care unit length of stay (7.2 versus 7.9) or number of ventilator days (5.02 versus 1.9). Patients who were severely injured (ISS > 25) also had a significantly shorter hospital length of stay (19.6 versus 29.1) if they underwent early spinal fixation. Patients with thoracic spine injury and associated spinal cord injury had a significantly shorter HLOS (10.1 versus 30.5), ICULOS (2.3 versus 13.1), and lower incidence of pneumonia (6.5 versus 33.3%). CONCLUSIONS Reasonable compliance with an early spinal fracture fixation protocol produced some outcome improvements in non-neurologic outcome. Early spine stabilization reduced hospital length of stay in all patients. Patients with thoracic spine trauma and a spinal cord injury had the greatest benefit in reduction of morbidity, HLOS and ICULOS from early stabilization. There was a trend toward poorer outcome in some groups with early spine stabilization. A rigid protocol requiring early surgical spine stabilization in all patients does not appear justified. Although early spine stabilization should be performed whenever possible to reduce hospital length of stay, the timing of this procedure should be individualized to allow patients with the most severe physiologic derangements to be optimized preoperatively.

The use of 23.4% hypertonic saline for the management of elevated intracranial pressure in patients with severe traumatic brain injury: a pilot study.

BACKGROUND Oncotic agents are a therapeutic mainstay for the management of intracranial hypertension. Both mannitol and varied concentrations of hypertonic saline (HTS) have been shown to be effective at reducing elevated intracranial pressure (ICP). We compared the safety and efficacy of 23.4% HTS to mannitol for acute management of elevated ICP after traumatic brain injury (TBI). METHODS After approval from our institutional review board, the records of patients admitted with severe TBI who received mannitol or HTS were reviewed. Demographic and physiologic data were recorded. ICP, cerebral perfusion pressure, reduction of ICP after dose administration, serum sodium, osmolality, and magnitude of dose response during the subsequent 60 minutes were analyzed. Efficacy was determined by comparison of proportion of patients with any response and mean change in ICP after dosing with either agent. Safety was determined by recording any new postinfusion electrolyte or neurologic anomalies. Data were compared using chi2 test, accepting p < 0.05 as significant. RESULTS Twenty-two patients with severe TBI received 210 doses of either mannitol or HTS. All patients suffered severe blunt injury (mean Injury Severity Score 28 +/- 11). HTS patients had a significantly higher ICP at the initiation of therapy than that of mannitol group (30.7 +/- 7.94 mm Hg vs. 28.3 +/- 8.07 mm Hg, respectively). There was no difference in initial cerebral perfusion pressure. Mean ICP reduction in the hour after administration of 102 doses of mannitol and 108 doses of HTS was greater for patients receiving HTS (9.3 +/- 7.37 mm Hg vs. 6.4 +/- 6.57 mm Hg, respectively; p = 0.0028, chi2). More patients responded to HTS (92.6% HTS vs. 74% mannitol; p = 0.0002, chi2). There was no significant difference between groups in the duration of ICP reduction after dose administration (4.1 hours vs. 3.8 hours, respectively). No adverse events after administration of either agent were identified. CONCLUSION Based on this retrospective analysis, 23.4% HTS is more efficacious than mannitol in reducing ICP. If these results are confirmed in a prospective, randomized study, 23.4% HTS may become the agent of choice for the management of elevated ICP after TBI.

Definitive Establishment of Airway Control is Critical for Optimal Outcome in Lower Cervical Spinal Cord Injury

BACKGROUND Respiratory complications can undermine outcome from low cervical spinal cord injury (SCI) (C5-T1). Most devastating of these is catastrophic loss of airway control. This study sought to determine the incidence and effect of catastrophic airway loss (CLA) and to define the need for elective intubation with subsequent tracheostomy to prevent potentially fatal outcomes. METHODS A database of 54,838 consecutive patients treated in a level I trauma center between January 1988 and December 2004 was queried to identify patients with low cervical SCI, without traumatic brain injury. Patients were then stratified into complete or incomplete SCI groups, based on clinical assessment of their SCI. Mortality, age, injury severity, need for intubation, and tracheostomy were analyzed for each group using Fishers exact test or Students t test, as appropriate, accepting p < 0.05 as significant. RESULTS One hundred eighty-six patients met inclusion criteria. The majority of low cervical spinal cord injuries were complete (58%). Overall, 127 (68%) patients required intubation, 88 (69%) required tracheostomy, and 27 died (15% of study population). Between each group there were significant differences in age and Injury Severity Score, however, within each group there were no significant differences in either. Eleven CSCI patients were not intubated; four of whom were at family request. Six of the remaining seven patients encountered fatal catastrophic airway loss. One patient was discharged to rehabilitation. Patients with incomplete SCI required intubation less frequently (38%); however, 50% of those required tracheostomy for intractable pulmonary failure. CONCLUSIONS These data indicate that regardless of severity of low cervical SCI, immediate, thorough evaluation for respiratory failure is necessary. Early intubation is mandatory for CSCI patients. For incomplete patients evidence of respiratory failure should prompt immediate airway intervention, half of whom will require tracheostomy.

The effect of early surgical treatment of traumatic spine injuries on patient mortality.

INTRODUCTION The ideal timing of spinal fixation is controversial. A recent study showed that early spine fixation reduced morbidity and resource utilization. We previously noted a trend toward higher mortality in patients undergoing early spinal fixation. This study was done to analyze whether the timing of spinal fixation had a significant effect on mortality. METHODS The registry of our Level I trauma program was queried for all patients with at least one spinal vertebral injury. Anatomic and physiologic variables included age, initial Glasgow Coma Scale score, systolic blood pressure, heart rate, and Injury Severity Score. Outcome was evaluated in terms of ventilator days, intensive care unit length of stay, hospital length of stay (HLOS), and mortality. Patients were stratified by day of spinal operative fixation as early when done within 48 hours and late when done after 48 hours. Data were analyzed using chi and an unpaired t test, accepting p < 0.05 as significant. RESULTS Three hundred sixty-one patients between January 1988 and February 2003 required operative spinal fixation (158 early, within 48 hours vs. 203 late, beyond 48 hours). There was no significant difference between the two groups except mortality, which was significantly higher in the early group (7.6 vs. 2.5%; p = 0.0257), and HLOS, which was significantly shorter in the early group (14.42 vs. 17.64 days; p = 0.025). CONCLUSION Spinal fixation within 48 hours after vertebral fractures and dislocations appears to increase mortality despite similar anatomic and physiologic parameters in the later operative group. Incomplete resuscitation of patients before surgery may have contributed to this result. The shorter HLOS may have been because of the higher number of early deaths. Prospective studies to identify the optimal timing of spinal fixation and the reason for these outcome differences are warranted.

Best practice determination of timing of spinal fracture fixation as defined by analysis of the National Trauma Data Bank

BACKGROUND To examine the efficacy of early versus late spinal fracture fixation, we reviewed National Trauma Data Bank (NTDB) records to identify the breakpoint in reported timing of operative fixation. Using this breakpoint we then analyzed outcome for those treated early versus late, hypothesizing that the early group would experience better outcome as reflected by resource utilization and complications. METHODS The NTDB was queried for patients with any level spinal fracture that required surgical stabilization. Histogram analysis of the postinjury day of initial operative fixation was used to determine the point at which the majority of operative procedures had been performed, thereby defining early (E) and late (L) groups. Patients in E were matched to a cohort from L with similar age, Injury Severity Score, and Glasgow Coma Scale. Outcome data included hospital length of stay, intensive care unit length of stay, ventilator days, charges, incidence of complications, and mortality. The groups were compared using Students t test for continuous variables and Fishers exact test for categorical variables, accepting p < or = 0.05 as significant. RESULTS Of 16,812 patients who underwent operative fixation, 59% were completed within 3 days of injury and formed E. The 374 L patients whose dataset was complete enough to allow analysis were matched to 497 E patients. There was no significant difference in the presence of spinal cord injury between E and L (51 vs. 48%; p = 0.3735). Complications were significantly higher in L (30% vs. 17.5%; p < 0.0001) yet mortality was similar in both groups (2.0% vs.1.9%; p > 0.05). CONCLUSIONS NTDB records indicate that the majority of patients with spinal fractures undergo operative fixation within 3 days, and that these patients had less complications and required less resources. Use of a national data bank to compare groups with similar injury severity and presenting physiology can validate best practice and define opportunities for improvement in care.

Pediatric trauma is very much a surgical disease.

ObjectiveThe evolution of nonoperative management of certain solid visceral injuries has stimulated speculation that management of the severely injured child is no longer a surgical exercise. The authors hypothesized that the incidence of injuries that require surgical evaluation is disproportionately high in children at risk of death or disability from significant injury. MethodsNational Pediatric Trauma Registry data were queried for all patients with ICDA-9-CM diagnoses requiring at least surgical evaluation. Selected diagnoses included CNS: 800 to 804, 850 to 854; thoracoabdominal: 860 to 870; pelvic fracture: 808; and acute vascular disruption: 900 to 904. Operative intervention was identified by ICDA-9-CM operative codes less than 60 and selected operative orthopedic codes between 79.8 and 84.4. At-risk patients were identified as those with at least one of the following: Glasgow Coma Scale score less than 15, Glasgow Coma Scale motor score less than 6, initial systolic blood pressure less than 90, or Injury Severity Scale score more than 10. The incidence of a surgical diagnosis in at-risk children was compared to the incidence in the population with no identifiable risk. Within the population undergoing surgical evaluation, resource utilization, as reflected by operative intervention and ICU days, and outcome, as reflected by mortality, were compared between the at-risk group and the group with no identifiable risk. ResultsFrom 1987 to 2000, 87,424 records were complete enough for analysis. Of those, 48,687 (55.6%) patients sustained at least one injury requiring a surgical evaluation and 28,645 (32.7%) children were determined to be at risk. Mortality for at-risk children was 5.8% versus 0.02% for those with no identifiable risk. Of the children at risk, 24,706 (86.2%) had at least one injury requiring a surgical evaluation. Of the 58,779 children with no risk, 23,981 (40.8%) also had at least one injury requiring a surgical evaluation. Operative intervention for surgical injuries was required in 20.5% of cases (n = 10,015). Of these, 5,562 (56%) were at-risk children, and they had a mortality rate of 11.5%. Of the children not at risk, 4,453 required operative care, and they had a mortality of 0.1%. At-risk children undergoing surgery required an average of 5.02 days of ICU care compared to 1.2 for cases performed on children without risk. ConclusionsThese data clearly demonstrate the primacy of surgical pathology as the major determinant of outcome in pediatric injury. Operative intervention and the option of timely operative care remain major components of clinical management of children with injuries that pose a significant risk of morbidity or mortality.

The role and value of surgical critical care, an essential component of Acute Care Surgery, in the Affordable Care Act: A report from the Critical Care Committee and Board of Managers of the American Association for the Surgery of Trauma

Heidi L. Frankel, MD, Karyn L. Butler, MD, Joseph Cuschieri, MD, Randall S. Friese, MD, Toan Huynh, MD, Alicia M. Mohr, MD, Miren A. Schinco, MD, Lena M. Napolitano, MD, L.D. Britt, MD, MPH, Raul Coimbra, MD, PhD, Martin A. Croce, MD, James W. Davis, MD, Gregory J. Jurkovich, MD, Ernest E. Moore, MD, John A. Morris, Jr., MD, Andrew B. Peitzman, MD, Basil A. Pruitt, MD, Grace S. Rozycki, MD, MBA, Thomas M. Scalea, MD, and J. Wayne Meredith, MD, Baltimore, Maryland

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.

Inhaled epoprostenol improves oxygenation in severe hypoxemia.

BACKGROUND Epoprostenol (Flolan), an inhalational epoprostenol vasodilator, increases pulmonary arterial flow and decreases pulmonary pressures, thereby improving gas exchange and arterial oxygenation. We evaluated the benefits of inhaled epoprostenol as a less expensive alternative to nitric oxide in ventilated surgical intensive care patients with severe hypoxemia. METHODS After institutional review board approval was obtained, the records of mechanically ventilated surgical intensive care unit patients who received epoprostenol as a therapy for severe hypoxia (SaO2 < 90%) in a tertiary care referral center were retrospectively reviewed. Initial PaO2/FIO2 (P/F) ratio and oxygen saturation were compared with values at 12 and 48 hours after the administration of epoprostenol. One-way repeated-measures analysis of variance compared improvements in oxygenation. Further subgroup analyses evaluated differences among trauma, nontrauma patient subgroups, time to initiation of epoprostenol, and age. RESULTS During a 20 month-interval beginning February 2009, 36 patients (23 trauma and 13 nontrauma; age, 15–80 years) were treated. Epoprostenol significantly improved both P/F ratio and oxygen saturation in both trauma and nontrauma patients. There was no difference between subgroups. Larger improvements in P/F ratio were seen when epoprostenol was started within 7 days. Response between age groups did not differ significantly. Subgroup analysis of mortality (trauma, 60.9% vs. nontrauma, 61.5%) failed to show any differences. CONCLUSION Treatment with inhaled epoprostenol improved gas exchange in severely hypoxemic surgical patients. Earlier intervention (within 7 days of intubation) was more efficacious at improving oxygenation. LEVEL OF EVIDENCE Therapeutic study, level IV.

Beyond the golden hour Avoiding the pitfalls from resuscitation to critical care

The transition from resuscitation bay to intensive care unit is wrought with potential problems that can significantly affect patient outcome. Among these are hypothermia, injudicious fluid management, hypocarbia, incorrect drug dosing, and incomplete evaluation. Based on a comprehension of the ongoing pathophysiology associated with injury, steps can be taken to ensure that this process positions the patient on the beginning of the path to recovery and not further into the spiral of worsening organ system dysfunction.