Pieter Joosse

Consensus strategies for the nonoperative management of patients with blunt splenic injury: A Delphi study

BACKGROUND Nonoperative management is the standard of care in hemodynamically stable patients with blunt splenic injury. However, a number of issues regarding the management of these patients are still unresolved. The aim of this study was to reach consensus among experts concerning optimal treatment and follow-up strategies. METHODS The Delphi method was used to reach consensus among 30 expert trauma surgeons and interventional radiologists from around the world. An online survey was used in the two study rounds. Consensus was defined as an agreement of 80% or greater. RESULTS Response rates of the first and second rounds were 90% and 80%, respectively. Consensus was reached for 43% of the (sub)questions. The American Association for the Surgery of Trauma organ injury scale for grading splenic injury is used by 93% of the experts. In hemodynamically stable patients, observation or splenic artery embolization (SAE) can be applied in the presence of a small or no hemoperitoneum combined with an intraparenchymal contrast extravasation or no contrast extravasation, regardless of the presence of an arteriovenous (AV) fistula/pseudoaneurysm. Hemodynamic instability is an indication for operative management, irrespective of computed tomographic characteristics and grade of splenic injury (≥82% of the experts). Operative management is also indicated in the presence of associated intra-abdominal injuries and/or the need for five or more packed red blood cell transfusions (22 of 27 experts, 82%). Recommended time span to start SAE in a stable patient with an intraparenchymal contrast extravasation is 60 minutes (19 of 24 experts). Patients should be admitted 1 to 3 days to a monitored setting (27 of 27 experts, 100%). Serial hemoglobin checks are performed by all experts, every 4 to 6 hours in the first 24 hours and once or twice a day after that (21 of 24 experts, 88%), in nonoperative management as well as after SAE. Routine postdischarge imaging is not indicated (21 of 24 experts, 88%). CONCLUSION Although treatment should always be adjusted to the specific patient, the results of this study may serve as general guidelines.

Prognostic factors for failure of nonoperative management in adults with blunt splenic injury: a systematic review.

BACKGROUND Contradictory findings are reported in the literature concerning prognostic factors for failure of nonoperative management (NOM) in the treatment of adults with blunt splenic injury. The objective of this systematic review was to identify prognostic factors for failure of NOM, with or without angiography and embolization. METHODS MEDLINE, Embase, and the Cochrane Library databases were searched. Prospective or retrospective cohort studies addressing failure of nonoperative treatment, with and/or without angiography and embolization, of blunt abdominal injuries were included. Methodological quality of the studies was assessed. RESULTS A total of 335 titles and abstracts were screened, of which 31 fulfilled the inclusion criteria. No randomized controlled trials were found. Ten articles were qualified as high-quality articles and used for data extraction (best-evidence synthesis). A total of 25 prognostic factors were investigated, of which 14 were statistically significant in one or more studies. Strong evidence exists that age of 40 years or above, Injury Severity Score (ISS) of 25 or greater, and splenic injury grade of 3 or greater are prognostic factors for failure of NOM. Moderate evidence was found for a splenic Abbreviated Injury Scale score of 3 or greater, trauma and ISS of less than 0.80, the presence of an intraparenchymal contrast blush, as well as transfusion of 1 unit of packed red blood cells or more. Limited evidence was found for large hemoperitoneum, lower Revised Trauma Score, lower Glasgow Coma Scale score, lower systolic blood pressure, male sex, the presence of traumatic brain injury, and splenic embolization as protective factor for failure of NOM. CONCLUSION Awareness for failure of NOM is required in patients aged 40 years or older, in patients with an ISS of 25 or higher or those with splenic injury grade 3 or higher. The prognostic factors for failure that we identified should be confirmed in future prospective cohort studies or meta-analyses using individual patient data. LEVEL OF EVIDENCE Systematic review, level III.

Trauma outcome analysis of a Jakarta University Hospital using the TRISS method: validation and limitation in comparison with the major trauma outcome study. Trauma and Injury Severity Score.

BACKGROUND In this prospective study, the TRISS methodology is used to compare trauma care at a University Hospital in Jakarta, Indonesia, with the standards reported in the Major Trauma Outcome Study (MTOS). METHODS Between February 24, 1999, and July 1, 1999, all consecutive patients with multiple and severe trauma were included in the study (n = 105). Survival analysis was completed for 97 (92%) patients. RESULTS The majority of patients were men (81%), and the average age was 28 years. Ninety-five patients (98%) sustained blunt trauma, with motor vehicle crashes being the most common (68%). The predicted mortality was 14% and the observed mortality was 29%. The Z and M statistics were 7.87 and 0.843, respectively. CONCLUSION We conclude that in developing countries both institution-bound factors and specific limitations in the TRISS methodology are responsible for the difference between predicted and observed mortality, indicating the need for a regional database.

Impact of secondary transfer on patients with severe traumatic brain injury.

Background: Within a trauma network in the Netherlands, neurosurgical facilities are usually limited to Level I hospitals. Initial transport to a district hospital of patients who are later found to require neurosurgical intervention may cause delay. The purpose of this study was to assess the influence on outcome and time intervals of secondary transfer in trauma patients requiring emergency neurosurgical intervention. Methods: In a 3-year period, all patients who sustained a severe traumatic brain injury and underwent a neurosurgical intervention within 6 hours after admission to a Level I trauma center were included. Patients were classified into two groups: direct presentation to the Level I trauma center (TC) group or requiring secondary transport after having been diagnosed for neurosurgical intervention in other hospitals (transfer group). Results: Eighty patients were included for analyses. Twenty-four patients in the transfer group had a better Glasgow Coma Scale on-scene but a higher 30-day mortality compared with patients who were primarily presented to the Level I trauma center (33% vs. 27%; p = 0.553). In the transfer group, time to operation was 304 minutes compared with 151 minutes in the TC group (p < 0.001). Most delay occurred during the initial trauma evaluation and the interval between the first computed tomography and the transfer ambulance departure at the referring hospital. Conclusion: Patients requiring an emergency neurosurgical intervention appear to have a clinically relevant worse outcome after secondary transfer to a neurosurgical service. Therefore, patient care can probably be improved by better triage on-scene and standardized procedures in case of a secondary transfer.

Comparison of the predictive performance of the BIG, TRISS and PS09 score in an adult trauma population derived from multiple international trauma registries

BackgroundThe BIG score (Admission base deficit (B), International normalized ratio (I), andGlasgow Coma Scale (G)) has been shown to predict mortality on admission inpediatric trauma patients. The objective of this study was to assess itsperformance in predicting mortality in an adult trauma population, and to compareit with the existing Trauma and Injury Severity Score (TRISS) and probability ofsurvival (PS09) score.Materials and methodsA retrospective analysis using data collected between 2005 and 2010 from seventrauma centers and registries in Europe and the United States of America wasperformed. We compared the BIG score with TRISS and PS09 scores in a population ofblunt and penetrating trauma patients. We then assessed the discrimination abilityof all scores via receiver operating characteristic (ROC) curves and compared theexpected mortality rate (precision) of all scores with the observed mortalityrate.ResultsIn total, 12,206 datasets were retrieved to validate the BIG score. The mean ISSwas 15 ± 11, and the mean 30-day mortality rate was 4.8%. With an AUROC of0.892 (95% confidence interval (CI): 0.879 to 0.906), the BIG score performed wellin an adult population. TRISS had an area under ROC (AUROC) of 0.922 (0.913 to0.932) and the PS09 score of 0.825 (0.915 to 0.934). On a penetrating-traumapopulation, the BIG score had an AUROC result of 0.920 (0.898 to 0.942) comparedwith the PS09 score (AUROC of 0.921; 0.902 to 0.939) and TRISS (0.929; 0.912 to0.947).ConclusionsThe BIG score is a good predictor of mortality in the adult trauma population. Itperformed well compared with TRISS and the PS09 score, although it hassignificantly less discriminative ability. In a penetrating-trauma population, theBIG score performed better than in a population with blunt trauma. The BIG scorehas the advantage of being available shortly after admission and may be used topredict clinical prognosis or as a research tool to risk stratify trauma patientsinto clinical trials.

External fixation of the pelvic ring: An experimental study on the role of pin diameter, pin position, and parasymphyseal fixator pins

Background The mechanical properties of current external fixator systems for unstable (type C) pelvic ring fractures are inferior to internal fixation, and are not optimal for definitive treatment. We explored methods to increase stability of external fixator constructs. Methods An experimental model was used for load tests. The same pelvic fixator was used while different pin diameters, pin positions, and modes of pubic symphysis fixation were tested. Results Changing of the pin diameter of the unthreaded part from 6 to 8 mm resulted in an increase in stiffness of 20%. An increase in stiffness by a factor of 1.9 was found by placing a pin on the iliac crest and one supra-acetabular. An additional increase by a factor of 3.6 was obtained by adding pubic symphysis plate fixation. Parasymphyseal pin fixation instead reduced stiffness, but not so much as when parasymphyseal pins were connected to the external fixator of the pelvic ring. The final configuration was at least 6 times stiffer than the initial configuration. Interpretation The new concept of parasymphyseal pin fixation connected to an external fixator of the pelvic ring produces a considerable increase in stability for the treatment of type C pelvic ring injuries, as does an increase in pin diameter and alternative pin positioning.

External Validation of the Emergency Trauma Score for Early Prediction of Mortality in Trauma Patients

Objectives:The Emergency Trauma Score has been developed for early estimation of mortality risk in adult trauma patients with an Injury Severity Score of 16 or higher. Emergency Trauma Score combines four early predictors available at the trauma resuscitation room: age, Glasgow Coma Scale, base excess, and prothrombin time. Our goal was to validate the Emergency Trauma Score in two large external cohorts. As the Injury Severity Score is not accurately known at the time patients present at the resuscitation room, we evaluated the performance of Emergency Trauma Score in all trauma patients. Design:External validation study using data from two prospectively collected trauma registries. Setting:Two academic level 1 trauma centers. Patients:Adult patients admitted to the hospital after treatment at the trauma resuscitation room. InterventionCalibration and discrimination of the original Emergency Trauma Score were assessed within each cohort separately. Measurement and Main Results:A total of 4,418 consecutive patients were evaluated. Discrimination was good in both validation cohorts, with areas under the receiver-operating curve curves that were even higher (0.94 and 0.92, respectively) than that in the original cohort (0.83). Predicted mortality was systematically too high compared with actual mortality in patients with low-to-medium expected risk (< 25%). Calibration improved in the lower expected risk range after exclusion of patients with Injury Severity Score less than 16. Conclusions:The Emergency Trauma Score model performs well in discriminating between trauma patients who will survive and who will not. If applied to all trauma patients, predicted mortality risks are too high in the low-risk category.

The effect of the introduction of the Amsterdam Trauma Workflow Concept on mortality and functional outcome of patients with severe traumatic brain injury.

The purpose of this study was to analyze the effect of the introduction of an all-in workflow concept that included direct computed tomography (CT) scanning in the trauma room on mortality and functional outcome of trauma patients with severe traumatic brain injury (TBI) admitted to a level-1 trauma center. To this end, a retrospective comparison was made of a 1-year cohort prior to the implementation of the all-in workflow concept (Pre-CT in trauma room cohort [Pre-TRCT]) and a 1-year cohort after the implementation (Post-TRCT). All severely injured TBI patients aged 16 years or older that were presented in our level-1 trauma center and that underwent a CT of the head were initially included. Severe TBI was defined as an Abbreviated Injury Scale (AIS) score of >2 of the head region following trauma. Primary outcome parameter was TBI-related mortality during primary hospital admission. Secondary outcome parameter was the functional outcome based on GOS-Extended. A total of 59 patients were included in the Pre-TRCT and 49 in the Post-TRCT. Median age was 49 years in the Post-TRCT and 44 years in the Pre-TRCT (not significant [NS]). Median ISS was similar (ISS = 25). Median Head-AIS was higher in the Post-TRCT (5 vs. 4, NS). Initial CT scanning was completed faster in the Post-TRCT. There was a significant difference of 23% mortality in favor of the Post-TRCT for TBI-related mortality during primary hospital admission (p < 0.05). For acute neurosurgical interventions, time until intervention tended to be faster in the Post-TRCT (NS). Functional outcomes for survivors were higher in the Post-TRCT (6 vs. 5, NS).

Effect of Antibiotic Prophylaxis on Surgical Site Infections Following Removal of Orthopedic Implants Used for Treatment of Foot, Ankle, and Lower Leg Fractures: A Randomized Clinical Trial

Importance Following clean (class I, not contaminated) surgical procedures, the rate of surgical site infection (SSI) should be less than approximately 2%. However, an infection rate of 12.2% has been reported following removal of orthopedic implants used for treatment of fractures below the knee. Objective To evaluate the effect of a single dose of preoperative antibiotic prophylaxis on the incidence of SSIs following removal of orthopedic implants used for treatment of fractures below the knee. Design, Setting, and Participants Multicenter, double-blind, randomized clinical trial including 500 patients aged 18 to 75 years with previous surgical treatment for fractures below the knee who were undergoing removal of orthopedic implants from 19 hospitals (17 teaching and 2 academic) in the Netherlands (November 2014-September 2016), with a follow-up of 6 months (final follow-up, March 28, 2017). Exclusion criteria were an active infection or fistula, antibiotic treatment, reimplantation of osteosynthesis material in the same session, allergy for cephalosporins, known kidney disease, immunosuppressant use, or pregnancy. Interventions A single preoperative intravenous dose of 1000 mg of cefazolin (cefazolin group, n = 228) or sodium chloride (0.9%; saline group, n = 242). Main Outcomes and Measures Primary outcome was SSI within 30 days as measured by the criteria from the US Centers for Disease Control and Prevention. Secondary outcome measures were functional outcome, health-related quality of life, and patient satisfaction. Results Among 477 randomized patients (mean age, 44 years [SD, 15]; women, 274 [57%]; median time from orthopedic implant placement, 11 months [interquartile range, 7-16]), 470 patients completed the study. Sixty-six patients developed an SSI (14.0%): 30 patients (13.2%) in the cefazolin group vs 36 in the saline group (14.9%) (absolute risk difference, −1.7 [95% CI, −8.0 to 4.6], P = .60). Conclusions and Relevance Among patients undergoing surgery for removal of orthopedic implants used for treatment of fractures below the knee, a single preoperative dose of intravenous cefazolin compared with saline did not reduce the risk of surgical site infection within 30 days following implant removal. Trial Registration clinicaltrials.gov Identifier: NCT02225821

Bone mineral density in developing children with osteogenesis imperfecta: a longitudinal study with 9 years of follow-up.

Background and purpose — Osteogenesis imperfecta (OI) is a heritable disorder of connective tissue caused by a defect in collagen type I synthesis. For bone, this includes fragility, low bone mass, and progressive skeletal deformities, which can result in various degrees of short stature. The purpose of this study was to investigate development of bone mineral density in children with OI. Patients and methods — Development of lumbar bone mineral density was studied retrospectively in a cohort of 74 children with OI. Mean age was 16.3 years (SD 4.3). In 52 children, repeated measurements were available. Mean age at the start of measurement was 8.8 years (SD 4.1), and mean follow-up was 9 years (SD 2.7). A longitudinal data analysis was performed. In the total cohort (74 children), a cross-sectional analysis was performed with the latest-measured BMD. Age at the latest BMD measurement was almost equal for girls and boys: 17.4 and 17.7 years respectively. Result — Mean annual increase in BMD in the 52 children was 0.038 g/cm2/year (SD 0.024). Annual increase in BMD was statistically significantly higher in girls, in both the unadjusted and adjusted analysis. In cross-sectional analysis, in the whole cohort the latest-measured lumbar BMD was significantly higher in girls, in the children with OI of type I, in walkers, and in those who were older, in both unadjusted and adjusted analysis. Interpretation — During 9 years of follow-up, there appeared to be an increase in bone mineral density, which was most pronounced in girls. One possible explanation might be a later growth spurt and older age at peak bone mass in boys.