Quinton Hatch

Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients.

Objective:To determine whether implementation of damage control resuscitation (DCR) in patients undergoing damage control laparotomy (DCL) translates into improved survival. Background:DCR aims at preventing coagulopathy through permissive hypotension, limiting crystalloids and delivering higher ratios of plasma and platelets. Previous work has focused only on the impact of delivering higher ratios (1:1:1). Methods:A retrospective cohort study was performed on all DCL patients admitted between January 2004 and August 2010. Patients were divided into pre-DCR implementation and DCR groups and were excluded if they died before completion of the initial laparotomy. The lethal triad was defined as immediate postoperative temperature less than 95°F, international normalized ratio more than 1.5, or a pH less than 7.30. Results:A total of 390 patients underwent DCL. Of these, 282 were pre-DCR and 108 were DCR. Groups were similar in demographics, injury severity, admission vitals, and laboratory values. DCR patients received less crystalloids (median: 14 L vs 5 L), red blood cells (13 U vs 7 U), plasma (11 U vs 8 U), and platelets (6 U vs 0 U) in 24 hours, all P < 0.05. DCR patients had less evidence of the lethal triad upon intensive care unit arrival (80% vs 46%, P < 0.001). 24-hour and 30-day survival was higher with DCR (88% vs 97%, P = 0.006 and 76% vs 86%, P = 0.03). Multivariate analysis controlling for age, injury severity, and emergency department variables, demonstrated DCR was associated with a significant increase in 30-day survival (OR: 2.5, 95% CI: 1.10–5.58, P = 0.028). Conclusion:In patients undergoing DCL, implementation of DCR reduces crystalloid and blood product administration. More importantly, DCR is associated with an improvement in 30-day survival.

Impact of closure at the first take back: Complication burden and potential overutilization of damage control laparotomy

BACKGROUND Damage control laparotomy (DCL) is a lifesaving technique initially employed to minimize the lethal triad of coagulopathy, hypothermia, and acidosis. Recently, it has been recognized that DCL itself carries significant morbidity and may be overutilized. The purpose of this study was to determine (1) whether early fascial closure is associated with a reduction in postoperative complications and (2) whether patients at our institution met traditional DCL indications (acidosis, hypothermia, and coagulopathy). METHODS This is a retrospective review of all patients undergoing immediate laparotomy at a Level I trauma center between 2004 and 2008. DCL was defined as temporary abdominal closure at the initial surgery. Early closure was defined as primary fascial closure at initial take back laparotomy. Patients were excluded if they died before first take back. Acidosis (pH <7.30), hypothermia (temperature <95.0°F), and coagulopathy (international normalized ratio >1.5) were measured on intensive care unit (ICU) arrival. RESULTS Totally, 925 patients were eligible. Thirty percent had DCL employed. Of these, 86 subjects (34%) were closed at first take back while 161 (66%) were not. Both groups were similar in demographics, injury severity score, resuscitation volumes, blood products, and prehospital, emergency department, and operating room vital signs. Univariate analyses noted that intra-abdominal abscesses (8.4% vs. 21.3%), respiratory failure (14.4% vs. 37.1%), sepsis (8.4% vs. 25.1%), and renal failure (3.6% vs. 25.1%) were lower in patients closed at first take back (all <0.05). Controlling for age, gender, injury severity score, and transfusions, logistic regression analysis noted that closure at the first take back was associated with a reduction in infectious (odds ratio, 0.28; 95% confidence interval [CI], 0.12-0.66; p = 0.004) and noninfectious abdominal complications (odds ratio, 0.23; 95% CI, 0.09-0.56; p = 0.001) as well as wound (odds ratio, 0.31; 95% CI, 0.13-0.72; p = 0.007) and pulmonary complications (odds ratio, 0.35; CI, 0.20-0.62; p < 0.001). Of patients closed at the initial take back, 78% were acidotic (35%), coagulopathic (49%), or hypothermic (44%) on initial ICU admission. CONCLUSION Early fascial closure is an independent predictor of reduced complications in DCL patients. One in five patients closed at initial take back did not meet any of the traditional indications for DCL upon initial ICU admission. This may represent an overutilization of this valuable technique, exposing patients to increased complications. Further efforts should be directed at achieving both early facial closure as well as redefining the appropriate indications for DCL.

Current use of damage-control laparotomy, closure rates, and predictors of early fascial closure at the first take-back.

BACKGROUND Damage-control laparotomy (DCL) is a lifesaving technique but carries significant morbidity. If DCL is over used and the factors that predict early fascial closure have not been fully evaluated. The purpose of the current study was to determine (1) the current rate of DCL, (2) the percentage of DCLs that are closed at first take-back, and (3) possible physiologic and resuscitative parameters predicting early fascial closure. METHODS A retrospective review of all trauma laparotomies from a Level I trauma center between January 2004 and December 2008 was performed. Patients were excluded if they died before first take-back. Univariate and multivariate analyses were performed. RESULTS Nine hundred thirty patients were eligible, 278 (30%) underwent DCL, 36 excluded for death before first take-back. Of the remaining 242 DCL patients, 83 (34%) were closed at first take-back and 159 (66%) were not closed at first take-back. These two groups were similar in injury severity, demographics, and prehospital and emergency department fluids and vitals. Median emergency department international normalized ratio (INR; 1.13 vs. 1.29, p = 0.010), post-op INR (1.4 vs. 1.5, p = 0.028), 24-hour fluids (11.9 L vs. 15.5 L, p = 0.006), peak post-op intra-abdominal pressure (IAP; 15 vs. 18, p < 0.001), and mortality (1.2% vs. 8.2%, p = 0.027) were different between groups. Multivariate analysis noted vacuum-assisted closure at initial laparotomy (Odds ratio, 3.1; 95% confidence interval [CI], 1.42-6.63; p = 0.004) was an independent predictor of closure at first take-back. However, post-op INR (Odds ratio, 0.18; 95% CI, 0.03-0.97; p = 0.04) and post-op peak IAP (Odds ratio, 0.85; 95% CI, 0.76-0.95; p = 0.005) predicted failure to close fascia at first take-back. CONCLUSION In similarly injured DCL patients, increased post-op INR and IAP predicted inability to achieve primary fascial closure on first take-back, while use of the vacuum-assisted closure was associated with increased likelihood of early fascial closure. At a busy academic Level I trauma center, the current rate of DCL among those undergoing emergent laparotomy is 30%. Whether this represents optimal use or overutilization of this technique still needs to be determined.

Identifying Risk Factors for Renal Failure and Myocardial Infarction Following Colorectal Surgery

BACKGROUND The development of acute renal failure and myocardial infarction (MI) following colectomy prolongs recovery and is associated with worse outcomes. The purpose of this study is to identify perioperative factors that predispose patients to an adverse cardiac or renal complication. MATERIALS AND METHODS We conducted a retrospective review of colectomies from 2001 to 2009. Patients were evaluated based upon the electronic inpatient record and followed to determine the incidence of acute renal failure (creatinine elevation over 50% of baseline) and myocardial injury. RESULTS A total of 339 inpatient records were reviewed, of which 134 were female (40%) and 205 male (60%). The mean age was 61.96 ± 16.2 years with 39.5% right hemicolectomies, 22.7% sigmoidectomy, 13.9% Left hemicolectomy, 11.5% total abdominal colectomy, and 6.2% for ileocectomy and transverse colectomy. Within the cohort, 13.9% had baseline renal insufficiency (Cr > 1.4), 7.1% sustained anastomotic leak, 23.9% required postoperative intubation, 15% sustained postoperative sepsis, 11.2% postoperative MI, and 5% clinically significant acidosis. Excluding patients with an anastomotic leak, postoperative intubation, and sepsis, we found that the need for blood product transfusion was associated with postoperative acute renal failure (OR= 7.15 [2.4-20.7]). Preoperative creatinine > 1.5, limited functional capacity, and preoperative systolic blood pressure < 90 mm Hg were all associated with increased MI rates (OR= 15.7 [3.6-66.8], 9.5 [2.1-42.2], 12.0 [5.523-26.072], and 40.6 [1.7-968], respectively). CONCLUSION This study demonstrates that several potentially modifiable preoperative and intraoperative factors exist that predispose patients to postoperative cardiac and renal dysfunction in the absence of major surgical complications.

Outcomes after colon trauma in the 21st century: An analysis of the U.S. National Trauma Data Bank

INTRODUCTION Most colon trauma data arise from institutional series that provide descriptive analysis. We investigated the outcome of these patients by analyzing a nationwide database. METHODS We queried the U.S. National Trauma Data Bank (2007-2009) using primary International Classification of Diseases, 9th edition, Clinical Modification codes to identify colon injuries. Outcomes were stratified by injury mechanism (blunt versus penetrating), segment of colon injured, and management strategy (diversion versus in continuity). RESULTS There were 6,817 patients who suffered primary colon injuries; 82% were male and 48% experienced blunt injuries. Blunt colon trauma patients were older, had lengthier intensive care stays, and greater rates of morbidity and mortality than those with penetrating injuries (all P < .05). Nonspecified injuries were the most common (36%), followed by transverse colon injuries (24%). The overall fecal diversion rate was 9%, with the highest rates seen in patients with sigmoid colon injuries (15%). Diverted patients were older, had higher injury severity scores, and increased mortality (22% vs 12%; P < .001). Multivariate analysis found that neither mechanism nor fecal diversion were independently associated with increased morbidity or mortality. CONCLUSION Sigmoid colon injuries seem to be managed with fecal diversion more often than other segmental injuries. Neither blunt mechanism nor fecal diversion were independently associated with adverse outcomes in colon trauma.

The use of temporary abdominal closure in low-risk trauma patients: helpful or harmful?

BACKGROUND: Temporary abdominal closure (TAC) has become a widely used technique in severely injured patients. However, there is growing concern that TAC is being overutilized. We sought to identify less severely injured patients who underwent TAC and to compare their outcomes with patients managed with a single-stage laparotomy (SSL). METHODS: This is a analysis of all trauma patients who underwent immediate laparotomy from 2005 to 2009. Risk modeling identified TAC patients who met all low-risk criteria: systolic blood pressure >90, no severe head injury, no combined solid + hollow viscus injury, or vascular injury. The low-risk cohort (LR-TAC) was compared with a matched similarly injured cohort managed with SSL using univariate and multivariate regression analysis. RESULTS: Among the 282 patients undergoing TAC, 62 (22%) met low-risk criteria and were included in the LR-TAC group. There were 566 patients identified in the SSL group. There was no significant difference between groups for age, mechanism, Injury Severity Scores, associated injuries, base deficit, temperature, blood transfusion, solid organ injury, or bowel resection. The LR-TAC group had more hospital and ventilator days and increased complications rates (all p < 0.05). This included a higher rate of bowel ischemia/perforation with LR-TAC (7% vs. 0.7%). The use of TAC in the low-risk group was independently associated with increased complications (odds ratio 3.0, p = 0.01) and prolonged hospital stays (odds ratio 9.6, p < 0.01). CONCLUSIONS: TAC was associated with increased morbidity and resource utilization when applied to less severely injured patients. Further study is indicated to clarify populations that may be harmed or benefitted by TAC. LEVEL OF EVIDENCE: III, therapeutic study.

The impact of pregnancy on surgical Crohn disease: an analysis of the Nationwide Inpatient Sample

BACKGROUND The impact of pregnancy on the course of Crohn disease is largely unknown. Retrospective surveys have suggested a variable effect, but there are limited population-based clinical data. We hypothesized pregnant women with Crohn disease will have similar rates of surgical disease as a nonpregnant Crohn disease cohort. MATERIAL AND METHODS International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify female Crohn patients from all patients admitted using the Nationwide Inpatient Sample (1998-2009). Women were stratified as either pregnant or nonpregnant. We defined Crohn-related surgical disease as peritonitis, gastrointestinal hemorrhage, intra-abdominal abscess, toxic colitis, anorectal suppuration, intestinal-intestinal fistulas, intestinal-genitourinary fistulas, obstruction and/or stricture, or perforation (excluding appendicitis). RESULTS Of the 92,335 women admitted with a primary Crohn-related diagnosis, 265 (0.3%) were pregnant. Pregnant patients were younger (29 versus 44 y; P<0.001) and had lower rates of tobacco use (6% versus 13%; P<0.001). Pregnant women with Crohn disease had higher rates of intestinal-genitourinary fistulas (23.4% versus 3.0%; P<0.001), anorectal suppuration (21.1% versus 4.1%; P<0.001), and overall surgical disease (59.6% versus 39.2%; P<0.001). On multivariate logistic regression analysis controlling for malnutrition, smoking, age, and prednisone use, pregnancy was independently associated with higher rates of anorectal suppuration (odds ratio [OR], 5.2; 95% confidence interval [CI], 3.8-7.0; P<0.001), intestinal-genitourinary fistulas (OR, 10.4; 95% CI, 7.8-13.8; P<0.001), and overall surgical disease (OR, 2.9; 95% CI, 2.3-3.7; P<0.001). CONCLUSIONS Pregnancy in women with Crohn disease is a significant risk factor for Crohn-related surgical disease, in particular, anorectal suppuration and intestinal-genitourinary fistulas.

The impact of race on outcomes following emergency surgery: an American College of Surgeons National Surgical Quality Improvement Program assessment

BACKGROUND Despite significant evolutions in health care, outcome discrepancies exist among demographic cohorts. We sought to determine the impact of race on emergency surgery outcomes. METHODS This is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005 through 2009) for all patients aged ≥16 years undergoing emergency abdominal surgery. Primary outcomes included morbidity and mortality. RESULTS We identified 75,280 patients (mean age 48.2 ± 19.9 years, 51.7% female; 79% white, 9.9% black, 5.0% Hispanic, 3.7% Asian, 1.3% American Indian or Alaskan, .2% Pacific Islander). Annual rates of emergency operations ranged from 7.3% to 8.5% (P = .22). The overall complication (18.6%) and mortality rate (4.6%) was highest in the black population (24.3%, 5.3%) followed by whites (18.7%, 4.6%), with the lowest rate in Hispanic (11.7%, 1.8%) and Pacific Islander populations (10.2%, 1.8%; P < .001). Compared with whites, blacks had a 1.25-fold (1.17 to 1.34; P < .001) increased risk of complications, but similar mortality (P = .168). When combining minorities, overall complications were 1.059-fold (1.004 to 1.12; P = .034) higher, however, mortality was reduced 1.7-fold (1.07 to 1.34; P = .001). CONCLUSIONS Following emergency abdominal surgery, minority race is independently associated with increased complications and reduced mortality.

Crohn's disease and pregnancy: the impact of perianal disease on delivery methods and complications.

BACKGROUND: The optimal delivery method in patients with Crohn’s disease is unknown, and there is no large-scale evidence on which to base decisions. OBJECTIVE: The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn’s disease. DESIGN AND PATIENTS: The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn’s disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). SETTINGS: A large population-cohort database was used for the analysis. MAIN OUTCOME MEASURES: The primary outcomes measured were cesarean delivery and perineal lacerations. RESULTS: Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn’s disease. Rates of cesarean delivery were higher in patients who had Crohn’s disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn’s disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn’s disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3–4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5–1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn’s disease was not independently associated with 4th degree laceration. LIMITATIONS: This was a retrospective study with the inherent limitations of large databases. CONCLUSIONS: Patients with Crohn’s disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn’s disease. In the absence of perianal disease, the method of delivery in women with Crohn’s disease should be predicated on obstetric indication.

Tranexamic acid corrects fibrinolysis in the presence of acidemia in a swine model of severe ischemic reperfusion.

BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic with anti-inflammatory properties associated with improved outcomes when administered to trauma patients at risk for bleeding; however, its efficacy is unknown in acidemia. We evaluated the efficacy of TXA on hyperfibrinolysis using an established porcine traumatic hemorrhage ischemic shock model. METHODS Ten Yorkshire swine underwent a controlled hemorrhage followed by supraceliac aortic cross-clamping. During standard resuscitation, control animals received recombinant tissue plasminogen activator (rtPA) after cross-clamp removal, and experimental animals received rtPA followed by TXA. Rotational thromboelastometry analysis was performed at baseline, 5 minutes and 15 minutes after rtPA dosing, and 4 hours after cross-clamp removal. RESULTS Control and experimental animals had similar hemodynamics and routine laboratory values at baseline and throughout resuscitation. At the time of TXA administration, average pH was 7.2. Clot formation time was prolonged from baseline and all resuscitation time points in both groups, with no difference at any time point. Maximum clot firmness decreased from baseline at all resuscitation time points in both groups. Maximum lysis increased from baseline (9% control vs. 9% TXA) after tissue plasminogen activator administration in both groups (100% control vs. 99% TXA). In experimental animals, maximum lysis returned to baseline 10 minutes after TXA administration (92% vs. 9%, p < 0.001). CONCLUSION TXA rapidly and fully reverses hyperfibrinolysis despite severe acidemia in a porcine trauma model. TXA is a promising adjunct to trauma resuscitation that is easily administered in austere or prehospital settings.