Rifat Latifi

Early high ratio platelet transfusion in trauma resuscitation and its outcomes

Introduction: The optimal ratio of platelets (PLTs) to packed red blood cell (PRBC) in trauma patients requiring massive transfusion protocol (MTP) is still controversial. This report aims to describe the effect of attaining a high PLT:PRBC ratio (≥1:1.5) within 4 h postinjury on the outcomes of trauma patients receiving MTP. Methods: Over a 24-month period, records of all adult patients with traumatic injury who received MTP were retrospectively reviewed. Data were analyzed with respect to PLT:PRBC ratio ([high-MTP ≥1:1.5] [HMTP] vs. [low-MTP <1:1.5] [LMTP]) given within the first 4 h postinjury and also between (>4 and 24 h). Baseline demographic, clinical characteristics, complications, and outcomes were compared according to HMTP and LMTP. Results: Of the total 3244 trauma patients, PLT:PRBC ratio was attainable in 58 (1.2%) patients who fulfilled the inclusion criteria. The mean age was 32.3 ± 10.7 years; the majority were males (89.6%) with high mean Injury Severity Score (ISS): 31.9 ± 11.5 and Revise Trauma Score (RTS): 5.1 ± 2.2. There was no significant association between age, gender, type of injury, presenting hemoglobin, International Normalized Ratio, ISS, and RTS. The rate of ventilator-associated pneumonia (38.9% vs. 10.8%; P = 0.02) and wound infection (50% vs. 10.8%; P = 0.002) were significantly higher in the HMTP group. However, HMTP was associated with lower rate of multiple organ failure (MOF) (42.1% vs. 87.2%, P = 0.001) and mortality (36.8% vs. 84.6%, P = 0.001) within the first 30 days postinjury. Conclusions: Our study revealed that early attainment of high PLT/PRBC ratio within 4 h postinjury is significantly associated with lower MOF and mortality in trauma patients.

Early versus late intramedullary nailing for traumatic femur fracture management: Meta-analysis

IntroductionThere is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN).MethodsEnglish language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used across studies to distinguish between early and late IMN, but 24xa0h was the most frequently used cutoff. The quality assessment of the reviewed studies was performed with two instruments. Observational studies were assessed with the Newcastle-Ottawa Quality Assessment Scale. RCTs were assessed with the Cochrane Risk of Bias Tool.ResultsWe have searched 1151 references. Screening of titles and abstracts eliminated 1098 references. We retrieved 53 articles for full-text screening, 15 of which met study eligibility criteria.ConclusionsThis meta-analysis addresses the utility of IMN in patients with FF based on the current evidence; however, the modality and timing to intervene remain controversial. While we find large pooled effects in favor of early IMN, for reasons discussed, we have little confidence in the effect estimate. Moreover, the available data do not fill all the gaps in this regard; therefore, a tailored algorithm for management of FF would be of value especially in polytrauma patients.

Telemedicine for Neurotrauma in Albania: Initial Results from Case Series of 146 Patients

BACKGROUNDnUse of telemedicine for neurotrauma when performed by neurosurgeons is an innovative care option for traumatic brain injury patients, particularly in countries with limited neurosurgery expertise resources. In recent years, Albania has developed a robust telemedicine program and teleneurotrauma is the flagship of the program. We aimed to evaluate the outcomes of the first neurotrauma patients managed via telemedicine in Albania.nnnMETHODSnA retrospective analysis of prospectively collected data on all telemedicine consultations for isolated neurotrauma was performed from 2014 through 2016. Patient demographics, mechanism of injury, modes of teleneurotrauma consultation (store-and-forward vs. live video consultation), outcomes of teleconsultation (whether the patient was transferred or kept at the regional hospital), operative procedures for those transferred, length of hospital stay, and discharge status were analyzed.nnnRESULTSnOf the 146 teleconsultations for neurotrauma, asynchronous technology (store-and-forward) accounted for the majority of teleconsultations (84%), while the live plus store-and-forward technique was employed in 15% of cases. Median time of response to teleconsultation was 20 minutes. Sixty-six percent of patients remained at the referring hospital for further observation and did not require transfer to a trauma center. Of the patients transferred to the tertiary care, 91% were treated nonoperatively, 85% percent were discharged to home, 9% were transferred to another hospital, and 6% died in the hospital.nnnCONCLUSIONnTelemedicine for neurotrauma, when structured appropriately and led by neurosurgeons, is a valuable service for the entire country, prevents unnecessary transfers to trauma center, and saves resources, particularly in low- and middle-income countries.

The clinical utility of shock index to predict the need for blood transfusion and outcomes in trauma

BACKGROUNDnWe aimed to evaluate the clinical utility of shock index (SI) to assess the need for blood transfusion and predict the outcomes in trauma.nnnMATERIALS AND METHODSnWe conducted a retrospective analysis for trauma patients between 2012 and 2016 in a level-1 trauma center. Data included patient demographics, vital signs, mechanism of injury, Injury Severity Score (ISS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS), blood transfusion, hospital length of stay (HLOS), and mortality. Patients were classified into group I (SIxa0<xa00.8) and group II (SIxa0≥xa00.8).nnnRESULTSnOut of 8710 admitted patients, 1535 (22%) had SIxa0≥xa00.8 and 976 (12.5%) received blood transfusion (89 received massive transfusion, following massive blood transfusion protocol [MTP]). In comparison to lower SI, patients with SIxa0≥xa00.8 were mostly female patients, 8xa0y younger (43xa0±xa022 versus 51xa0±xa023), had greater ISS (15xa0±xa012 versus 10.5xa0±xa08), higher NISS (19xa0±xa015 versus 14xa0±xa011), lower pulse pressure (43xa0±xa014 versus 62xa0±xa018), lower TRISS (0.892xa0±xa00.20 versus 0.953xa0±xa00.11), and received more blood transfusion (28.6% versus 9.0%) or MTP (17.7% versus 3%), Pxa0=xa00.001. Also, they had mostly exploratory laparotomy (13.3% versus 6.6%, Pxa0=xa00.001), longer HLOS (11.3 versus 7.0xa0d, Pxa0=xa00.001), and higher mortality (7.0% versus 3.1%, Pxa0=xa00.001). SI was correlated with age (rxa0=xa0-0.188), pulse pressure (rxa0=xa0-0.51), HLOS (rxa0=xa00.168), ISS (rxa0=xa00.251), NISS (rxa0=xa00.211), amount of blood transfused (rxa0=xa00.27), Glasgow Coma Scale (rxa0=xa0-0.96), and TRISS (rxa0=xa0-0.230). After adjusting for age and sex, ISS, and Glasgow Coma Scale in two multivariable analyses, high SI was found to be an independent predictor for mortality (odd ratio, 2.553; 95% confidence intervals: 1.604-4.062) and blood transfusion (odd ratio, 3.57; 95% confidence intervals: 3.012-4.239). The cutoff point of SI for predicting MTP is 0.81 (sensitivity, 85%; specificity, 64%; positive predictive value, 16%; and negative predictive value, 98%).nnnCONCLUSIONSnThe SI after injury can be used early to predict the need for MTP and laparotomy and mortality. It correlates with other physiological and anatomical variables. However, its cutoff values for risk stratification and prognostication need further evaluation.

Correction to: Early versus late intramedullary nailing for traumatic femur fracture management: meta-analysis

Following the publication of this article [1], the authors reported that they had submitted an incorrect version of Figs.xa02, 3 and 4.

Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism missions: A retrospective cohort study

BACKGROUNDnSurgical volunteer missions (SVMs) have become a popular approach for reducing the burden of surgical disease worldwide. The aim of this study was to evaluate the outcomes of 12 surgical missions between 2006 and 2018 from the mission entitled Operation Giving Back Bohol Tagbilaran, Philippines and discuss the lessons learned during these missions in particular seven challenges that every volunteer surgeon should be familiar with.nnnMETHODSnThis was a retrospective descriptive study of prospectively collected data on all patients treated during one SVM. The data collected included gender, age, diagnosis, types of surgeries performed, and perioperative adverse events.nnnRESULTSnDuring the study period 1327 operations were performed (842 females (63.4%) and 485 males (36.6%); (male-to-female ratio 0.59); mean age 37u202f±u202f18 years. The majority of operations were for thyroid disease (31.6%), followed by hernia (17.3%), hysterectomies/salpingo-oophorectomies (12.2%), soft tissue tumors (9.9%), cleft lip/palate repairs (7.2%), breast (6.4%), gallbladder disease (4.7%), cataract (2.9%), parotid masses (1.4%) and others (6.4%). For each mission, there were an average 5.5 days of operating, performing a median of 105.5 (80-148) cases per mission. There were 27 complications (2%), of which, 22 were postoperative bleeding and two temporary tracheostomies. The mortality rate was 0.15% (2/1327). In one patient, the family withdrew care following compassionate last ditch effort thyroidectomy for advanced cancer and one patient died as a result of intracranial bleeding from a brain tumor, which was unrecognized before mastectomy.nnnCONCLUSIONSnSurgical volunteerism missions are safe and valuable in lessening the burden of surgical disease globally when performed in an organized fashion and with continuity of care. However, there is need for standardization of surgical care provided during SVMs and creation of a world-wide database of all SVMs, and each surgeon and others who participate in these mission should be familiar with critical elements and challenges for the successful mission.

The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections

PurposeSevere necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs.MethodsA retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded.ResultsThere were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55u2009±u200918 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (<u20096xa0h). There were no significant differences between groups in baseline characteristics. The late group (≥u20096xa0h) had prolonged hospital stay (38 vs. 23 days, pu2009<u20090.008) in comparison to the early group (<u20096xa0h). With every 1xa0h delay in time to surgery, there is a 0.268xa0day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality.ConclusionsEarly surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Abdominal Wall Reconstruction in Patients with Complex Defects: A Nine-Step Treatment Strategy

With advances in abdominal surgery and the management of major trauma, abdominal wall defects have become the new surgical disease, and the need for complex abdominal wall reconstruction has increased dramatically. Subsequently, how to recreate the new abdominal wall in patients with large defects has become a new surgical question. One particular group of patients that exemplify “complex” are those with contaminated wounds, enterocutaneous fistulas (ECFs), enteroatmospheric fistulas (EAFs), and/or stoma(s), where synthetic mesh is to be avoided if at all possible. Most recently, biologic mesh has become standard in high-risk patients with contaminated and dirty-infected wounds. While biologic mesh is the most common tissue engineered in this field of surgery, Level I evidence is needed on its indication for use and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described; however, the long-term outcomes for most of these studies are rarely reported. This chapter presents a nine-step strategy: ISOWATS PL where I = Identification and diagnosis of postoperative fistulae; S = Sepsis and Source Control; O = Optimization of Nutrition; W = Providing and Ensuring Wound Care; A = Redefining the anatomy and understanding the pathology at hand; T = Timing of definitive surgery and/or takedown of fistulas; S = Definitive surgery and surgical approach; P = Postoperative care; and L = Long-term follow-up for management of ECFs.

A Difficult Abdomen: Temporary Closure and Management of the Consequences

When performing damage control surgery (DCS), the surgeon has several options for temporary closure of the abdomen, most notably an intestinal bag, wound vacuum-assisted closure (VAC), or a moist gauze that serves as the “poor man’s wound VAC.” However, if the patient has enough skin and subcutaneous tissue, then closing the skin offers the best temporary closure. Temporary closure of the fascia should be avoided for fear of injuring the edges of the fascia and subsequently creating a hernia and dehiscence. This chapter reviews various techniques of temporary closure following DCS and recent study findings.

The Surgical Nightmare: Dealing with Infected Mesh

The use of mesh has become standard in abdominal wall hernia repair. Infection of the implanted mesh in surgery of hernias and other major and complex abdominal wall reconstruction is one of the most significant consequences of this type of surgery. In most cases antibiotics and mesh-saving conservative operations may not be sufficient to eradicate the infection thus require mesh explanations, resulting in additional surgery, morbidity, and significant cost. How surgeons should approach this serious issue is the topic of this chapter.