Nicolas Melo

Gender impacts mortality after traumatic brain injury in teenagers

BACKGROUND Gender may influence outcomes following traumatic brain injury (TBI) although the mechanism is unknown. Animal TBI studies suggest that gender differences in endogenous hormone production may be the source. Limited retrospective clinical studies on gender present varied conclusions. Pediatric patients represent a unique population as pubescent children experience up-regulation of endogenous hormones that varies dramatically by gender. Younger children do not have these hormonal differences. The aim of this study was to compare pubescent and prepubescent females with males after isolated TBI to identify independent predictors of mortality. METHODS We performed a retrospective review of the National Trauma Data Bank Research Data Sets from 2007 and 2008 looking at all blunt trauma patients 18 years or younger who required hospital admission after isolated, moderate-to-severe TBI, defined as head Abbreviated Injury Scale (AIS) score 3 or greater. We excluded all individuals with AIS score of 3 or greater for any other region to limit the confounding effect of comorbidities. Based on the median age of menarche, we defined two age groups as follows: prepubescent (0–12 years) and pubescent (>12 years). Analysis was performed to compare trauma profiles and outcomes between groups. Our primary outcome measure was in-hospital mortality. RESULTS A total of 20,280 patients met inclusion criteria; 10,135 were prepubescent, and 10,145 were pubescent. Overall mortality was 6.9%, and lower mortality was noted among prepubescent patients compared with pubescent (5.2% vs. 8.6%, p < 0.0001). Although female gender did not predict reduced mortality in the prepubescent cohort (adjusted odds ratio, 1.05; 95% confidence interval, 0.85–1.30; p = 0.63), female gender was associated with reduced mortality in the pubescent (adjusted odds ratio, 0.78; 95% confidence interval, 0.65–0.93; p = 0.007). CONCLUSION In contrast to prepubescent female gender, pubescent female gender predicts reduced mortality following isolated, moderate-to-severe TBI. Endogenous hormonal differences may be a contributing factor and require further investigation. LEVEL OF EVIDENCE Prognostic study, level III.

Measurable outcomes of quality improvement using a daily quality rounds checklist: Two-year prospective analysis of sustainability in a surgical intensive care unit

BACKGROUND The use of a “quality rounds checklist” (QRC) is an effective tool for improving compliance with evidence-based preventative measures and outcomes in the surgical intensive care unit (SICU). Our aim was to evaluate the long-term sustainability and outcome impact of this quality improvement strategy. METHODS Prospective observational study evaluates the use of the QRC in the SICU from July 2009 to June 2011. Daily compliance with evidence-based prophylactic measures was assessed using the QRC and reviewed monthly at a multidisciplinary meeting. Logistic regression was performed to evaluate patterns of compliance over time. Current compliance was compared with previously reported rates, and the impact on outcomes including catheter-related blood stream infection and ventilator-associated pneumonia rates was examined. RESULTS Over 2 years, 2,472 patients were admitted to the SICU. Mean (SD) age was 42.2 (22.4) years, 79% were male, and 35% had an Injury Severity Score (ISS) of greater than 15. The rate of compliance with head-of-bed elevation significantly improved during the study period (p = 0.01 for trend), with an overall compliance of 97%. Both deep venous thrombosis prophylaxis and gastrointestinal bleed prophylaxis compliance remained stable, with overall rates of 98% and 96%, respectively. The use of sedation holidays also remained stable, with an overall compliance rate of 94%. Compared with our previously published data, the compliance rates with preventative measures were stable or significantly improved; the incidence of catheter-related blood stream infections was lower (0.85/1,000 vs. 4.98/1,000 catheter days, p < 0.001); and the incidence of ventilator-associated pneumonia downtrended (1.66/1,000 vs. 8.74/1,000 ventilator days, p = 0.07). CONCLUSION Two years after implementation of a QRC, sustainable high rates of compliance with clinically relevant preventative measures in a SICU was demonstrated with minimal fading of clinically relevant outcomes. LEVEL OF EVIDENCE Therapeutic study, level IV.

Prospective Evaluation of the Role of Computed Tomography in the Assessment of Abdominal Stab Wounds

IMPORTANCE An important adjunct in the management of abdominal gunshot wounds, the role of computed tomography (CT) in the diagnostic workup of abdominal stab wounds remains controversial. OBJECTIVE To prospectively compare CT against serial physical examination in the evaluation of patients who have sustained a stab wound to the abdomen. DESIGN, SETTING, AND PATIENTS Prospective single-center observational study of all patients sustaining abdominal stab wounds from March 1, 2009, through March 31, 2011. Patients who were hemodynamically unstable, unevaluable, peritonitic, or eviscerated proceeded directly to laparotomy (n = 249). The remainder underwent CT evaluation. The impact of CT findings and physical examination on the decision to operate was analyzed. MAIN OUTCOMES AND MEASURES Diagnostic accuracy of CT vs physical examination in determining the need for therapeutic laparotomy. RESULTS A total of 249 patients were enrolled (94% male; mean [SD]: age, 30.8 [12.9] years [range, 16-87 years]; systolic blood pressure, 128 [28] mm Hg; Glasgow Coma Scale score, 14 [2]; Injury Severity Score, 6.8 [6.5]). Forty-five patients (18.1%) underwent immediate laparotomy, 27 (10.8%) had superficial injuries allowing immediate discharge, and the remaining 177 (71.1%) underwent CT. Of these, 154 (87.0%) were successfully observed, with 20 (11.3%) requiring laparotomy, 2 (1.1%) thoracotomy, and 1 (0.6%) sternotomy. Of the 20 laparotomies, 16 (80.0%) were therapeutic. All patients who underwent therapeutic laparotomy did so based on their physical examination. The most common finding leading to laparotomy was the development of peritonitis in 70%. The CT scan findings did not alter clinical decision making. The sensitivity and specificity of physical examination were 100.0% and 98.7%, respectively, while those of CT were 31.3% and 84.2%, respectively. CONCLUSIONS AND RELEVANCE In this prospective evaluation of abdominal stab wound management, serial physical examination was able to discriminate between patients requiring a therapeutic laparotomy and those who could be safely observed. A physical examination-based diagnostic algorithm was effective and decreased radiation burden in the management of abdominal stab wounds.

Early propranolol after traumatic brain injury is associated with lower mortality.

BACKGROUND &bgr;-Adrenergic receptor blockers (BBs) administered after trauma blunt the cascade of immune and inflammatory changes associated with injury. BBs are associated with improved outcomes after traumatic brain injury (TBI). Propranolol may be an ideal BB because of its nonselective inhibition and ability to cross the blood-brain barrier. We determined if early administration of propranolol after TBI is associated with lower mortality. METHODS All adults (age ≥ 18 years) with moderate-to-severe TBI (head Abbreviated Injury Scale [AIS] score, 3–5) requiring intensive care unit (ICU) admission at a Level I trauma center from January 1, 2013, to May 31, 2015, were prospectively entered into a database. Administration of early propranolol was dosed within 24 hours of admission at 1 mg intravenous every 6 hours. Patients who received early propranolol after TBI (EPAT) were compared with those who did not (non-EPAT). Data including demographics, hospital length of stay (LOS), ICU LOS, and mortality were collected. RESULTS Over 29 months, 440 patients with moderate-to-severe TBI met inclusion criteria. Early propranolol was administered to 25% (109 of 440) of the patients. The EPAT cohort was younger (49.6 years vs. 60.4 years, p < 0.001), had lower Glasgow Coma Scale (GCS) score (11.7 vs. 12.4, p = 0.003), had lower head AIS score (3.6 vs. 3.9, p = 0.001), had higher admission heart rate (95.8 beats/min vs. 88.4 beats/min, p = 0.002), and required more days on the ventilator (5.9 days vs. 2.6 days, p < 0.001). Similarities were noted in sex, Injury Severity Score (ISS), admission systolic blood pressure, hospital LOS, ICU LOS, and mortality rate. Multivariate regression showed that EPAT was independently associated with lower mortality (adjusted odds ratio, 0.25; p = 0.012). CONCLUSION After adjusting for predictors of mortality, early administration of propranolol after TBI was associated with improved survival. Future studies are needed to identify additional benefits and optimal dosing regimens. LEVEL OF EVIDENCE Therapeutic study, level IV.

Body mass index strongly impacts the diagnosis and incidence of heparin-induced thrombocytopenia in the surgical intensive care unit.

BACKGROUND The obese state has been linked to several immune-mediated conditions. Our objective was to examine the association of body mass index (BMI) with the diagnosis of heparin-induced thrombocytopenia (HIT). METHODS Prospectively collected data on patients in the surgical and cardiac intensive care unit suspected of having HIT between January 2007 and August 2014 were analyzed. Patients were categorized into five discrete BMI (kg/m2) groups and compared. Data collected included Warkentin 4-T scores, antiplatelet factor 4 (anti-PF4OD) values, serotonin release assay values, and thromboembolic diseases. HIT positivity was defined as serotonin release assay value greater than 20%. RESULTS Of 304 patients meeting inclusion criteria, mean (SD) age was 62.1 (16.5) years, 59% were male, and mean (SD) BMI was 27 (6) kg/m2. Thirty-six (12%) were positive for HIT. Incidence of HIT increased progressively with BMI (0%, 8%, 11%, 19%, 36%; p < 0.001). Compared with patients with normal BMI, patients with a BMI of 30 kg/m2 to 39.9 kg/m2 had a 200% increase in the odds for HIT (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.20–7.54; p = 0.019), while patients with a BMI of 40 kg/m2 or greater had a 600% increase (OR, 6.98; 95% CI, 1.59–28.2; p = 0.012). After regression analysis, BMI remained an independent predictor of the development of HIT (adjusted OR per kg/m2, 1.08; 95% CI, 1.02–1.14; p = 0.010). Anti-PF4OD values greater than or equal to 2.0 also increased with BMI (p < 0.001). In-hospital mortality increased significantly with BMI above normal (p = 0.026). Warkentin 4-T scores, deep venous thrombosis, pulmonary embolism, and stroke incidence did not correlate with changes in BMI. CONCLUSION Increasing BMI seems to be strongly associated with increased rates of HIT in intensive care unit patients. Obesity is an important new clinical variable for estimating the pretest probability of HIT, and patient “thickness” could be considered a fifth “T” of the 4-T scoring system. Additional biochemical work is indicated to decipher the role of obesity in this immune-mediated condition. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Midodrine: A Novel Therapeutic for Refractory Chylothorax

Thoracic duct injury is a rare but serious complication following surgery of the neck or chest that leads to uncontrolled chyle leak. Conventional management includes drainage, nutritional modification, or aggressive surgical interventions such as thoracic duct ligation, flap coverage, fibrin glue, or talc pleurodesis; few successful medical therapeutics are available. We report a case of a high-output chylothorax refractory to aggressive medical and surgical interventions. Chyle output decreased substantially after initiating midodrine, an α1-adrenergic agonist that causes vasoconstriction of the lymph system, reducing chyle flow. This case report suggests that midodrine may be a novel therapeutic for refractory chyle leaks.

Needs assessment for a focused radiology curriculum in surgical residency: a multicenter study

BACKGROUND Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. METHODS We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. RESULTS Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. CONCLUSIONS Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation.

Impact of body mass index on injury in abdominal stab wounds: implications for management.

BACKGROUND Although it is assumed that obese patients are naturally protected against anterior abdominal stab wounds, the relationship has never been formally studied. We sought to examine the impact of body mass index (BMI) on severity of sustained injury, need for operation, and patient outcomes. MATERIALS AND METHODS We conducted a review of all patients presenting with abdominal stab wounds at an urban level I trauma center from January 2000-December 2012. Patients were divided into groups based on their BMI (<18.5, 18.5-29.9, 30-35, and >35). Data abstracted included baseline demographics, physiologic data, and characterization of whether the stab wound had violated the peritoneum, caused intra-abdominal injury, or required an operation that was therapeutic. The one-sided Cochran-Armitage trend test was used for significance testing of the protective effect. RESULTS Of 281 patients with abdominal stab wounds, 249 had complete data for evaluation. Chest and abdomen abbreviated injury scale trends decreased with increasing BMI, as did overall injury severity score, the percent of patients severely injured (injury severity score ≥ 25), and length of intensive care unit stay. Rates of peritoneal violation (100%, 84%, 77%, and 74%; P = 0.077), visceral injury (83%, 56%, 50%, and 30%; P = 0.022), and injury requiring a therapeutic operation (67%, 45%, 40%, and 20%; P = 0.034) all decreased with increasing BMI. Patients in the thinnest group required an operation three times more often than those in the most obese. CONCLUSIONS Increased BMI protects patients with abdominal stab wounds and is associated with lower incidence of severe injury and need for operation. Heavier patients may be more suitable to observation and serial examinations, whereas very thin patients are more likely to require an operation and be critically injured.

Injuries sustained by bicyclists

Although generally a safe activity with considerable health benefit, the wide social prevalence of cycling, its performance by both young and elderly riders, and the increasing operation of bicycles in complex urban environments results in a significant incidence of trauma. Orthopedic injuries, followed by head and facial trauma, are most frequent but all anatomic regions can be affected and the spectrum of injury ranges from minor to severe and potentially fatal. Clinicians need to be aware of the range of injuries and causative mechanisms as many patients may present with relatively minor signs and symptoms despite significant underlying pathology. Non-commuter, recreational cyclists are also at risk for injury due to: variable terrain and environmental conditions; increased competitive and risk-taking behavior; technical equipment failure; and poor compliance with protective equipment. Numerous injury preventative strategies have been advocated including: increased rider training; creation of dedicated traffic lanes for commuting cyclists; bike-awareness education for motorists and interventions to improve cyclist visibility; increased utilization of protective equipment and programs to reduce concomitant drug or alcohol use. Of all preventative strategies, bicycle helmets have received the most study, leading to legislated use in some jurisdictions. As urban environments become more congested for commuter cyclists, and interest in recreational and competitive cycling grows, bicycle injury is likely to become more prevalent.

Care of the Elderly Critical Care Patient

Critical care poses significant challenges for all patients. However, the elderly population requires extra vigilance owing to age-related changes in physiology, multiple medical comorbidities, polypharmacy, and deconditioning. The elderly, defined here as persons 65 years or older, account for 14.5% of the population and account for 42–52% of ICU admissions. The impact of the elderly will dramatically increase as their population will double to 70 million in 2030. Given increasing life expectancy (78.8 years in the United States), and the fact that this segment of the population accounts for 42–52% of ICU admissions [1, 2], the impact on health care and critical care is immense. Mortality is increased in the elderly, and studies demonstrate an 18.7% mortality for surgical patients, up to 26.5% ICU mortality for medical cause, and up to 50% mortality 1 year after discharge [1–3]. Aging affects every system in the body, and combined with comorbidities, multiple medications, and frequent end-of-life ethical issues, caring for these patients poses significant challenges in today’s health-care environment [4–13]. Knowing how to care for this special population with age-related physiologic changes and a lack of physiologic reserve compared to the general population is of paramount importance.