Robert T. Russell

Coagulopathy after severe pediatric trauma

ABSTRACT Trauma remains the leading cause of morbidity and mortality in the United States among children aged 1 to 21 years. The most common cause of lethality in pediatric trauma is traumatic brain injury. Early coagulopathy has been commonly observed after severe trauma and is usually associated with severe hemorrhage and/or traumatic brain injury. In contrast to adult patients, massive bleeding is less common after pediatric trauma. The classical drivers of trauma-induced coagulopathy include hypothermia, acidosis, hemodilution, and consumption of coagulation factors secondary to local activation of the coagulation system after severe traumatic injury. Furthermore, there is also recent evidence for a distinct mechanism of trauma-induced coagulopathy that involves the activation of the anticoagulant protein C pathway. Whether this new mechanism of posttraumatic coagulopathy plays a role in children is still unknown. The goal of this review is to summarize the current knowledge on the incidence and potential mechanisms of coagulopathy after pediatric trauma and the role of rapid diagnostic tests for early identification of coagulopathy. Finally, we discuss different options for treating coagulopathy after severe pediatric trauma.

The glycocalyx and Trauma: A Review

ABSTRACT In the United States trauma is the leading cause of mortality among those under the age of 45, claiming approximately 192,000 lives each year. Significant personal disability, lost productivity, and long-term healthcare needs are common and contribute 580 billion dollars in economic impact each year. Improving resuscitation strategies and the early acute care of trauma patients has the potential to reduce the pathological sequelae of combined exuberant inflammation and immune suppression that can co-exist, or occur temporally, and adversely affect outcomes. The endothelial and epithelial glycocalyx has emerged as an important participant in both inflammation and immunomodulation. Constituents of the glycocalyx have been used as biomarkers of injury severity and have the potential to be target(s) for therapeutic interventions aimed at immune modulation. In this review, we provide a contemporary understanding of the physiologic structure and function of the glycocalyx and its role in traumatic injury with a particular emphasis on lung injury.

Surgical wound misclassification: A multicenter evaluation

BACKGROUND Surgical wound classification (SWC) is used by hospitals, quality collaboratives, and Centers for Medicare and Medicaid to stratify patients for their risk for surgical site infection. Although these data can be used to compare centers, the validity and reliability of SWC as currently practiced has not been well studied. Our objective was to assess the reliability of SWC in a multicenter fashion. We hypothesized that the concordance rates between SWC in the electronic medical record and SWC determined from the operative note review is low and varies by institution and operation. STUDY DESIGN Surgical wound classification concordance was assessed at 11 participating institutions between SWC from the electronic medical record and SWC from operative note review for 8 common pediatric surgical operations. Cases with concurrent procedures were excluded. A maximum of 25 consecutive cases were selected per operation from each institution. A designated surgeon reviewed the included operative notes from his/her own institution to determine SWC based on a predetermined algorithm. RESULTS In all, 2,034 cases were reviewed. Overall SWC concordance was 56%, ranging from 47% to 66% across institutions. Inguinal hernia repair had the highest overall median concordance (92%) and appendectomy had the lowest (12%). Electronic medical records and reviewer SWC differed by up to 3 classes for certain cases. CONCLUSIONS Surgical site infection risk stratification by SWC, as currently practiced, is an unreliable methodology to compare patients and institutions. Surgical wound classification should not be used for quality benchmarking. If SWC continues to be used, individual institutions should evaluate their process of assigning SWC to ensure its accuracy and reliability.

Correlation of Health-Related Quality of Life After Liver Transplant With the Model for End-Stage Liver Disease Score

OBJECTIVE To determine whether a correlation exists between the Model for End-Stage Liver Disease (MELD) score and health-related quality of life (HRQOL) after liver transplant (LT). DESIGN Prospective cohort. SETTING University hospital. PATIENTS Adult LT recipients (N = 209). MAIN OUTCOME MEASURES Postoperative HRQOL over a 1-year period after LT as measured via multiple regression-based path analysis testing the effects of the MELD score, preoperative variables, and postoperative variables on scores on the physical component summary and mental component summary scales of the 36-Item Short Form Health Survey and on composite physical and mental HRQOL scores derived from multiple scales. RESULTS The MELD score (beta = .16), cholestatic cirrhosis (beta = .12), autoimmune/metabolic disease (beta = .18), neoplasm (beta = .23), time after LT (beta = .16), and the Karnofsky score (beta = .49) had significant effects on the physical component summary scale score. Autoimmune/metabolic disease (beta = .16) and the Karnofsky score (beta = .25) had significant effects on the mental component summary scale score. The MELD score (beta = .15), high school education (beta = .15), college education (beta = .17), autoimmune/metabolic disease (beta = .15), neoplasm (beta = .23), time after LT (beta = .11), and the Karnofsky score (beta = .51) had significant effects on the composite physical HRQOL score. Autoimmune/metabolic disease (beta = .23), neoplasm (beta = .15), and the Karnofsky score (beta = .42) had significant effects on the composite mental HRQOL score. CONCLUSIONS An increasing MELD score, when computed without any diagnosis-based exception points, was associated with improved physical HRQOL in the first year after LT. The MELD score did not affect mental HRQOL.

Profile of health-related quality of life outcomes after liver transplantation: univariate effects and multivariate models

AIM To test the effects of pre- and post-transplant clinical covariates on post-transplant health-related quality of life (HRQOL) score profiles in liver transplant recipients. MATERIAL AND METHODS HRQOL was measured before and after transplantation using the SF-36 Health Survey. Clinical data [diagnosis, model of end-stage liver disease (MELD) score, post-transplant rejection and infection episodes], pre-transplant functional performance (FP), and demographics were collected. Multivariate models for the eight SF-36 scales and two summary components were developed using multiple regression. Discriminant analysis was used to test whether the score profiles differentiated among recipients with and without hepatitis C virus (HCV) infection. RESULTS 104 adults reported pre- and post-transplant HRQOL. Time post-transplant averaged 9+/-8 months (range 1-39). Scores on all SF-36 measures improved from pre- to post-transplant (p<0.001), and 7 of 10 models were significant (p<0.05). After controlling for pre-transplant HRQOL and time post-transplant, HCV infection had a negative effect on the role physical, bodily pain, and role emotional scales. History of a rejection episode had a negative effect on the bodily pain and vitality scales. MELD scores > or = 18 had a positive effect on the role physical scale. Pre-transplant FP and post-transplant infection episodes did not affect post-transplant HRQOL. HCV infection had a significant effect on the SF-36 score profile (canonical correlation=0.50; p<0.001). CONCLUSIONS Pre-transplant HCV infection, MELD score, and post-transplant rejection episodes have significant independent effects on HRQOL after liver transplantation. Their specific effects vary among the individual SF-36 scales, and HRQOL score profiles differ among HCV+ and HCV- recipients.

Esophageal button battery ingestions: Decreasing time to operative intervention by level I trauma activation

PURPOSE The incidence of button battery ingestions is increasing and injury due to esophageal impaction begins within minutes of exposure. We changed our management algorithm for suspected button battery ingestions with intent to reduce time to evaluation and operative removal. METHODS A retrospective study was performed to identify and evaluate time to treatment and outcome for all esophageal button battery ingestions presenting to a major childrens hospital emergency room from February 1, 2010 through February 1, 2012. During the first year, standard emergency room triage (ST) was used. During the second year, the triage protocol was changed and Trauma I triage (TT) was used. RESULTS 24 children had suspected button battery ingestions with 11 having esophageal impaction. One esophageal impaction was due to 2 stacked coins. Time from arrival in emergency room to battery removal was 183minutes in ST group (n=4) and 33minutes in TT group (n=7) (p=0.04). One patient in ST developed a tracheoesophageal fistula. There were no complications in the TT group. CONCLUSIONS The use of Trauma 1 activations for suspected button battery ingestions has led to more expedient evaluation and shortened time to removal of impacted esophageal batteries.

Use of real-time ultrasound during central venous catheter placement: Results of an APSA survey

PURPOSE The purpose of this study was to document the attitudes and practice patterns of pediatric surgeons regarding use of RTUS with CVC placement. METHODS An analytic survey composed of 20 questions was sent via APSA headquarters to all practicing members. Answers were summarized as frequency and percentage. Distributions of answers were compared using the chi-square tests. P-values ≤0.05 were considered statistically significant. RESULTS 361 of 1072 members chose to participate for a response rate of 34%. Most placed CVCs into the subclavian veins (SCV) of patients without coagulopathy, with the left SCV chosen approximately four times more often than the right. Conversely, RTUS use at the internal jugular vein (IJV) was significantly greater than that for the SCV (p<0.001). Coagulopathy, multiple previous catheters, and morbid obesity were identified as patient characteristics that would encourage RTUS use. The most commonly cited potential barriers to RTUS use were lack of formal ultrasound training and the belief that ultrasound is not necessary. CONCLUSIONS Variability exists among pediatric surgeons regarding use of RTUS during CVC placement. Additional studies are needed to document actual frequency of use, how RTUS is implemented, and its efficacy of preventing adverse events in children.

Tracheoesophageal fistula following button battery ingestion: Successful non-operative management

The incidence of devastating complications from button battery ingestions is increasing. Battery impactions may result in erosive esophagitis, tracheoesophageal fistula (TEF), esophageal strictures, spondylodiscitis, vocal cord paralysis due to paralysis of recurrent laryngeal nerve(s), and aortoesophageal fistulas with significant morbidity and mortality. We present a case of a 15 month old boy who developed an acquired TEF secondary to ingestion of a 20mm button battery lodged at the level of the carina. The clinical course and imaging findings are reviewed. Serial limited CT imaging with 3-D reconstruction was helpful in noninvasive assessment of healing and clinical decision making. Of special interest are the negative initial esophagram and the healing of the fistula without the need for surgical intervention.

Utility of immature granulocyte percentage in pediatric appendicitis

BACKGROUND Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis. MATERIALS AND METHODS We identified all patients with appendicitis from July 2012-June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t-tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis. RESULTS A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count (P=0.0063), C-reactive protein (CRP) (P<0.0001), and IG% (P=0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40-8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09-6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis. CONCLUSIONS IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.

Histone-Complexed DNA Fragments Levels are Associated with Coagulopathy, Endothelial Cell Damage, and Increased Mortality after Severe Pediatric Trauma

Background: The release of damage-associated molecular pattern molecules in the extracellular space secondary to injury has been shown to cause systemic activation of the coagulation system and endothelial cell damage. We hypothesized that pediatric trauma patients with increased levels of histone-complexed DNA fragments (hcDNA) would have evidence of coagulopathy and endothelial damage that would be associated with poor outcomes. Methods: We conducted a prospective observational study of 149 pediatric trauma patients and 62 control patients at two level 1 pediatric trauma centers from 2013 to 2016. Blood samples were collected upon arrival and at 24 h, analyzed for hcDNA, coagulation abnormalities, endothelial damage, and clinical outcome. Platelet aggregation was assessed with impedance aggregometry (Multiplate) and coagulation parameters were assessed by measuring prothrombin time ratio in plasma and the use of viscoelastic techniques (Rotational Thromboelastometry) in whole blood. Results: The median age was 8.3 years, the median injury severity score (ISS) was 20, and overall mortality was 10%. Significantly higher levels of hcDNA were found on admission in patients with severe injury (ISS > 25), coagulopathy, and/or abnormal platelet aggregation. Patients with high hcDNA levels also had significant elevations in plasma levels of syndecan-1, suggesting damage to the endothelial glycocalyx. Finally, significantly higher hcDNA levels were found in non-survivors. Conclusion: hcDNA is released following injury and correlates with coagulopathy, endothelial glycocalyx damage, and poor clinical outcome early after severe pediatric trauma. These results indicate that hcDNA may play an important role in development of coagulation abnormalities and endothelial glycocalyx damage in children following trauma.