Rajan Gupta

Hepatic angiography in patients undergoing damage control laparotomy.

OBJECTIVE Patients undergoing damage control (DC) laparotomy require intensive and aggressive resuscitation, and may require additional maneuvers to control parenchymal bleeding. Those patients suffering significant liver injury are at high risk for arterial bleeding deep within the liver, and many require hepatic angiography in addition to hepatic packing. We reviewed our experience with hepatic angiography, and sought to determine its safety in the DC population of penetrating and blunt trauma patients. METHODS A 3-year (June 1997-May 2000) retrospective review generated 37 DC patients. Patients sustaining hepatic trauma constituted the study group. Patients undergoing angiography in addition to DC laparotomy were compared with the group of patients not undergoing angiography. Data regarding mechanism of injury, patient demographics, extent of hepatic injury, and presence of associated injuries were collected. Physiologic parameters including vital signs at admission, lowest pH and base excess in the operating room, and lactate levels in the intensive care unit, as well as volumes of fluid resuscitation throughout all phases of DC were examined. Complications including death, intra-abdominal processes, acute respiratory distress syndrome and/or multiple organ dysfunction syndrome, and acute renal failure were reviewed. RESULTS Nineteen patients (51%) had hepatic trauma and underwent perihepatic packing as a part of DC laparotomy. Eleven had sustained penetrating injury and 8 had blunt injury. There was 1 American Association for the Surgery of Trauma grade I, 5 grade II, 3 grade III, and 10 grade IV injuries. Nine patients in the study population underwent angiography, and eight of these were hepatic artery angiograms. One hepatic angiogram was obtained before operation and seven were obtained in the immediate postoperative period. Six underwent embolization of bleeding hepatic vessels, for a therapeutic liver angiography rate of 75%. There was no statistical difference in physiologic parameters or fluid requirements between the patients who underwent angiography and those who did not. There were no mishaps or complications from angiography or while in the angiography suite. CONCLUSION Hepatic angiography is a safe adjunct to the principles of damage control. It has a high therapeutic ratio, with no significant untoward effect in this small study population.

Management of the Most Severely Injured Spleen A Multicenter Study of the Research Consortium of New England Centers for Trauma (ReCONECT)

OBJECTIVE To determine the rate and predictors of failure of nonoperative management (NOM) in grade IV and V blunt splenic injuries (BSI). DESIGN Retrospective case series. SETTING Fourteen trauma centers in New England. PATIENTS A total of 388 adult patients with a grade IV or V BSI who were admitted between January 1, 2001, and August 31, 2008. MAIN OUTCOME MEASURES Failure of NOM (f-NOM). RESULTS A total of 164 patients (42%) were operated on immediately. Of the remaining 224 who were offered a trial of NOM, the treatment failed in 85 patients (38%). At the end, 64% of patients required surgery. Multivariate analysis identified 2 independent predictors of f-NOM: grade V BSI and the presence of a brain injury. The likelihood of f-NOM was 32% if no predictor was present, 56% if 1 was present, and 100% if both were present. The mortality of patients for whom NOM failed was almost 7-fold higher than those with successful NOM (4.7% vs 0.7%; P = .07). CONCLUSIONS Nearly two-thirds of patients with grade IV or V BSI require surgery. A grade V BSI and brain injury predict failure of NOM. This data must be taken into account when generalizations are made about the overall high success rates of NOM, which do not represent severe BSI.

Inefficiencies in a rural trauma system: the burden of repeat imaging in interfacility transfers.

BACKGROUND Local hospitals (LHs) transferring patients to regional trauma centers (TCs) often obtain CT scans to diagnose injuries and justify transfer. However, these imaging studies are often repeated at the receiving TCs. This study was performed to examine how frequently computed tomography (CT) scans were repeated in interfacility transfers in a rural trauma system and to identify the most common reason for repeating the studies. METHODS Patients transferred to a rural Level I TC from October 2007 through February 2008 were prospectively evaluated. Data abstracted included CT scans performed at LHs and CT scans repeated at the TC. Additionally, the reason for repeating each study was recorded as follows: (1) scan not sent, (2) software not compatible, (3) inadequate technique (no intravenous contrast), (4) inadequate technique (no reconstructions), and (5) clinically indicated. RESULTS During the study period, 138 patients were transferred to the TC. Of these, 104 (75%) underwent CT imaging before transfer. Sixty of these patients (58%) underwent repeat CT imaging at the TC. Overall, 98 of 243 (40%) scans were repeated. Head CT scans were repeated predominantly because of clinical indications. All other body region CT scans were repeated predominantly because of inadequate technique at the LHs. CONCLUSIONS CT scans were repeated in 58% of interfacility transfers. Repeat CT scans inevitably result in increased radiation exposure to patients as well as additional charges and may be an important patient safety and cost issue for trauma systems.

Integrating emergency general surgery with a trauma service: impact on the care of injured patients.

BACKGROUND There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service. METHODS Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fishers exact, and t tests provided between-group comparisons. RESULTS The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions. CONCLUSION Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.

Critical Care Nurse Practitioners Improve Compliance With Clinical Practice Guidelines in “semiclosed” Surgical Intensive Care Unit

This prospective study examined whether the integration of acute care nurse practitioners (ACNP) in a “semiclosed” surgical intensive care unit (SICU) model increased compliance with clinical practice guidelines (CPG). Patients were admitted to critical care services with a (a) “semiclosed”/ACNP team or (b) “mandatory consultation”/non-ACNP team. CPG compliance was significantly higher (P < .05) on the “semiclosed”/ACNP team for all 3 CPGs examined in the study.

Blunt pancreatoduodenal injury: A multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT)

OBJECTIVES To evaluate the safety of nonoperative management (NOM), to examine the diagnostic sensitivity of computed tomography (CT), and to identify missed diagnoses and related outcomes in patients with blunt pancreatoduodenal injury (BPDI). DESIGN Retrospective multicenter study. SETTING Eleven New England trauma centers (7 academic and 4 nonacademic). PATIENTS Two hundred thirty patients (>15 years old) with BPDI admitted to the hospital during 11 years. Each BPDI was graded from 1 (lowest) to 5 (highest) according to the American Association for the Surgery of Trauma grading system. MAIN OUTCOME MEASURES Success of NOM, sensitivity of CT, BPDI-related complications, length of hospital stay, and mortality. RESULTS Ninety-seven patients (42.2%) with mostly grades 1 and 2 BPDI were selected for NOM: NOM failed in 10 (10.3%), 10 (10.3%) developed BPDI-related complications (3 in patients in whom NOM failed), and 7 (7.2%) died (none related to failure of NOM). The remaining 133 patients were operated on urgently: 34 (25.6%) developed BPDI-related complications and 20 (15.0%) died. The initial CT missed BPDI in 30 patients (13.0%); 4 of them (13.3%) died but not because of the BPDI. The mortality rate in patients without a missed diagnosis was 8.8% (P = .50). There was no correlation between time to diagnosis and length of hospital stay (Spearman r = 0.06; P = .43). The sensitivity of CT for BPDI was 75.7% (76% for pancreatic and 70% for duodenal injuries). CONCLUSIONS The NOM of low-grade BPDI is safe despite occasional failures. Missed diagnosis of BPDI continues to occur despite advances in CT but does not seem to cause adverse outcomes in most patients.

Training in trauma surgery: quantitative and qualitative aspects of a new paradigm for fellowship.

Objective: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship. Summary Background Data: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models. Methods: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale. Results: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows’ feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience “great -5” or “exceptional– 6.” Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship. Conclusion: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review.

New developments in massive transfusion in trauma.

Purpose of review Trauma patients requiring massive transfusion represent a population at high risk for potentially preventable death. This review describes recent advances in the early recognition and treatment of the coagulopathy of trauma, as well as ongoing work to define optimal resuscitation strategies. Recent findings Damage control resuscitation involves the rapid correction of hypothermia and acidosis, direct treatment of coagulopathy, and early transfusion in trauma patients. Recent evidence demonstrates improved mortality and lower overall blood product usage with higher ratios of plasma and platelets to red blood cells transfused. Adjuncts to damage control resuscitation such as factor VIIa may also be beneficial. Thrombelastography and advances in point-of-care testing may provide timely measurements to help guide massive transfusion in patients based on their individual needs. Summary As optimal resuscitation strategies continue to evolve, recent efforts have focused on early and aggressive treatment of coagulopathy, with higher ratios of plasma and platelets to red blood cells transfused. Early evidence suggests that such strategies have a beneficial outcome in regards to trauma-related mortality.

Seasonal Variation in Undiagnosed HIV Infection on the General Medicine and Trauma Services of Two Urban Hospitals

OBJECTIVE: To examine the seroprevalence of undiagnosed HIV and variation by season among patients admitted to the general internal medicine (GIM) and trauma services of two urban hospitals.DESIGN: A cross-sectional blinded HIV-1 seroprevalence survey.SETTING: A 725-bed academic medical center’s hospital and an affiliated 324-bed tertiary care hospital.PARTICIPANTS: Residual serological specimens were obtained for unique patients aged 17 to 65 to study services in summer (June 16 to September 4, 2001) and fall to winter (November 1, 2001 to January 8, 2002).METHODS: Hospital files provided data on demographics, service type, and discharge clinical categories (fall-winter group only). HIV ELISA (enzyme-linked immunosorbent assay) tests with confirmatory Western blot were linked to subjects’ de-identified files. We excluded 34 subjects with known HIV. Of the remaining unique admissions in summer (n=604) and fall-winter (n=978), 60% and 55% were tested, respectively. Predictors of undiagnosed HIV infection were examined using multivariate analysis.RESULTS: The summer cohort (n=362) had significantly lower unadjusted seroprevalence of undiagnosed HIV infection (1.4%; 95% confidence interval [CI], 0.4% to 3.2%) than the fall-winter cohort (n=539; 3.7%; 95% CI, 2.3% to 5.7%; P=.04). Overall, undiagnosed HIV was somewhat less likely in women (adjusted odds ratio [AOR], 0.45; 95% CI, 0.19 to 1.07) but more likely in black patients (AOR, 3.46; 95% CI, 0.70 to 17.06). In the fall-winter cohort, undiagnosed HIV was more likely for discharges with the following clinical categories versus those with a cardiac condition: dermatologic/breast (AOR, 14.90; 95% CI, 1.20 to 184.77), renal/urological (AOR, 22.43; 95% CI, 2.12 to 236.75), or infectious (AOR, 31.08; 95% CI, 2.40 to 402.98).CONCLUSIONS: The higher seroprevalence of undiagnosed HIV in the fall-winter admissions to GIM and trauma services supports especially targeting HIV testing in these months.

Evolution of Operative Interventions by Two University-Based Surgical Teams in Haiti during the First Month following the Earthquake

BACKGROUND The earthquake that struck Haiti on 10 January 2010, killed 200,000 persons and injured thousands more. Working with Partners in Health, a non-governmental organization already present in Haiti, Dartmouth College, and the University of Pennsylvania sent multidisciplinary surgical teams to hospitals in the villages of Hinche and Cange. The purpose of this report is to describe the injuries seen and evolution of treatments rendered at these two outlying regional hospitals during the first month following the earthquake. METHODS A retrospective review of the database maintained by each team was performed. In addition to a list of equipment taken to Haiti, information collected included patient age, American Society of Anesthesiology (ASA) physical status, injuries sustained, procedures performed, wound management strategy, antibiotic therapy, and early outcomes. RESULTS A total of 113 surgical procedures were performed in 15 days by both teams. The average patient age was 25 years and average ASA score was 1.4. The majority of injuries involved large soft tissue wounds and closed fractures, although 21-40% of the patients at each hospital had either an open fracture or amputation wound. Initially, wound debridement was the most common procedure performed, but after two weeks, skin grafting, fracture fixation, and amputation revision were the more commonly needed operations. CONCLUSIONS Academic surgical teams can ameliorate the morbidity and mortality following disasters caused by natural hazards by partnering with organizations that already have a presence in the affected region. A multidisciplinary team of surgeons and nurses can improve both mortality and morbidity following a disaster.