Shahin Mohseni

Coagulopathy after isolated severe traumatic brain injury in children.

INTRODUCTION Few previous studies have been conducted on the severe traumatic brain injury (sTBI)-associated coagulopathy in children. The purpose of this study was to evaluate the incidence and risk factors of sTBI coagulopathy in a pediatric cohort and to evaluate its impact on outcomes. METHODS Retrospective analysis of pediatric patients (younger than 18 years) sustaining isolated sTBI [head Abbreviated Injury Scale (AIS) score ≥3 and extracranial injuries AIS score <3]. Criteria for sTBI-associated coagulopathy included thrombocytopenia (platelet count <100,000 per mm(3)) and/or elevated international normalized ratio >1.2 and/or prolonged activated partial thromboplastin time >36 seconds. Incidence and risk factors of sTBI coagulopathy and its impact on in-hospital outcomes were analyzed. RESULTS Overall, 42.8% (n = 137) of the 320 patients studied developed coagulopathy, with increasing incidence in a stepwise fashion with escalating head AIS score (31.1, 46.2, and 88.6% for head AIS score 3, 4, and 5, respectively; p < 0.001). Depressed GCS, increasing age, an ISS ≥16, and brain contusions/lacerations were independently associated with the presence of coagulopathy. The case fatality rate was 7.8% (n = 25); 17.5% versus 0.5% in coagulopathic versus noncoagulopathic patients, respectively. After logistic regression to adjust for confounders, no statistical significant mortality difference in patients with and without coagulopathy was noted (adjusted p = 0.912). CONCLUSIONS Incidence of coagulopathy in children suffering isolated sTBI is exceedingly high at 40% and reflect the head injury severity. A low GCS, increasing age, ISS ≥16 and intraparenchymal lesions proved to be independently associated with TBI coagulopathy.

Preinjury β-blockade is protective in isolated severe traumatic brain injury

BACKGROUND The purpose of this study was to investigate the effect of preinjury &bgr;-blockade in patients experiencing isolated severe traumatic brain injury (TBI). We hypothesized that &bgr;-blockade before TBI is associated with improved survival. METHODS The trauma registry of an urban academic trauma center was queried to identify patients with an isolated severe TBI between January 2007 and December 2011. Isolated severe TBI was defined as an intracranial injury with an Abbreviated Injury Scale (AIS) score of 3 or greater excluding all extracranial injuries AIS score of 3 or greater. Patient demographics, clinical characteristics on admission, injury profile, Injury Severity Score (ISS), AIS score, in-hospital morbidity, and &bgr;-blocker exposure were abstracted for analysis. The primary outcome evaluated was in-hospital mortality stratified by preinjury &bgr;-blockade exposure. RESULTS Overall, a total of 662 patients met the study criteria. Of these, 25% (n = 159) were exposed to &bgr;-blockade before their traumatic insult. When comparing the demographics and injury characteristics between the groups, the sole difference was age, with the &bgr;-blocked group being older (69 [12] years vs. 63 [13] years, p < 0.001). &bgr;-blocked patients had a higher rate of infectious complications (30% vs. 19%, p = 0.04), with no difference in cardiac or pulmonary complications between the cohorts. Patients exposed to &bgr;-blockade versus no &bgr;-blockade experienced 13% and 22% mortality, respectively (p = 0.01). Stepwise logistic regression predicted the absence of &bgr;-blockade exposure as a risk factor for mortality (odds ratio, 2.7; 95% confidence interval, 1.5–4.8; p = 0.002). After adjustment for significant differences between the groups, patients not exposed to &bgr;-blockade experienced twofold increased risk of mortality (adjusted odds ratio, 2.2; 95% confidence interval, 1.3–3.7; p = 0.004). CONCLUSION Preinjury &bgr;-blockade improves survival following isolated severe TBI. The role of prophylactic &bgr;-blockade and the timing of initiation of such therapy after TBI warrant further investigations. LEVEL OF EVIDENCE Therapeutic study, level III; prognostic study, level II.

The impact of liver cirrhosis on outcomes in trauma patients: a prospective study.

BACKGROUND The adverse effects of liver cirrhosis on outcomes following trauma has been established in retrospective series. In this study, however, we set out to evaluate prospectively the in-hospital outcome measures in this subgroup of trauma patients. METHODS Prospective observational study of all patients admitted to the surgical intensive care unit of a Level I trauma center from January 2008 to December 2011. Cirrhotic trauma cases were matched with noncirrhotic controls in a 1:2 ratio. Matching criteria included age, sex, injury mechanism, vital signs at admission, Abbreviated Injury Scale (AIS) score for all body regions, and Injury Severity Score (ISS). Outcomes included in-hospital morbidity and mortality. RESULTS During the 4-year study period, 92 (0.8%) of the 12,102 trauma admissions had liver cirrhosis. After matching, no differences with regard to demographic and clinical injury characteristics were noted comparing the cases and controls. The overall complication rate in cases and controls was 31.5% and 7.1%, respectively (p < 0.001). In-hospital mortality was significantly higher for cirrhotic patients compared with their noncirrhotic counterparts (20.7 vs. 6.5%, p = 0.001). Within the cirrhotic group, mortality increased significantly from 8.0% in Child-Pugh Class A to 32.3% in Class B and 45.5% in Class C (p = 0.003). Likewise, mortality was significantly higher for patients with a Model for End-Stage Liver Disease (MELD) score of 10 or greater versus less than 10 (30.0% vs. 9.5%; odds ratio, 4.07; 95% confidence interval, 1.23–13.45; p = 0.016). CONCLUSION In this prospective investigation, liver cirrhosis is associated with adverse outcomes following trauma. Both stepwise increasing Child-Pugh and MELD scores predicted adjusted adverse outcomes. Injured patients with cirrhosis warrant aggressive monitoring and instant treatment after injury. LEVEL OF EVIDENCE Prognostic study, level III.

Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression?

INTRODUCTION Depressive symptoms occur in approximately half of trauma patients, negatively impacting on functional outcome and quality of life following severe head injury. Pontine noradrenaline has been shown to increase upon trauma and associated β-adrenergic receptor activation appears to consolidate memory formation of traumatic events. Blocking adrenergic activity reduces physiological stress responses during recall of traumatic memories and impairs memory, implying a potential therapeutic role of β-blockers. This study examines the effect of pre-admission β-blockade on post-traumatic depression. METHODS All adult trauma patients (≥18 years) with severe, isolated traumatic brain injury (intracranial Abbreviated Injury Scale score (AIS) ≥3 and extracranial AIS <3) were recruited from the trauma registry of an urban university hospital between 2007 and 2011. Exclusion criteria were in-hospital deaths and prescription of antidepressants up to one year prior to admission. Pre- and post-admission β-blocker and antidepressant therapy data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. Patients with and without pre-admission β-blockers were matched 1:1 by age, gender, Glasgow Coma Scale, Injury Severity Score and head AIS. Analysis was carried out using McNemars and Students t-test for categorical and continuous data, respectively. RESULTS A total of 545 patients met the study criteria. Of these, 15% (n=80) were prescribed β-blockers. After propensity matching, 80 matched pairs were analyzed. 33% (n=26) of non β-blocked patients developed post-traumatic depression, compared to only 18% (n=14) in the β-blocked group (p=0.04). There were no significant differences in ICU (mean days: 5.8 (SD 10.5) vs. 5.6 (SD 7.2), p=0.85) or hospital length of stay (mean days: 21 (SD 21) vs. 21 (SD 20), p=0.94) between cohorts. CONCLUSION β-blockade appears to act prophylactically and significantly reduces the risk of post-traumatic depression in patients suffering from isolated severe traumatic brain injuries. Further prospective randomized studies are warranted to validate this finding.

Positive blood alcohol level in severe traumatic brain injury is associated with better long-term functional outcome

Abstract Objective: To investigate the association between positive blood alcohol level (BAL) and functional outcome in patients suffering severe traumatic brain injury. Study design: The brain trauma registry of an academic trauma centre was queried for patients admitted between January 2007 and December 2011. All patients (≥ 18 years) with a neurosurgical intensive care length of stay beyond 2 days were included. Patient demographics, clinical characteristics, injury profile, laboratory test and outcomes were abstracted for analysis. Primary outcome was unfavourable functional outcome defined as Glasgow Outcome Score (GOS) ≤ 3. Multivariable regression models were used for analysis. Results: Of the 352 patients, 39% were BAL (+) at admission. Patients with (+) BAL were significantly younger with less co-morbidities. The cohorts exhibited no significant difference in the severity of the intra-cranial injury and the use of intra-cranial monitoring or surgical interventions. Further, the groups presented no difference in in-hospital mortality (p = 0.1) or 1-year mortality (p = 0.5). There was a worse long-term functional outcome in (–) BAL patients compared to their BAL (+) counterparts after adjustment for confounders (GOS ≤ 3: AOR = 2.0, 95% CI = 1.1–3.5, p = 0.02). Conclusion: Positive BAL on admission is associated with a better long-term functional outcome in patients suffering severe traumatic brain injury.

Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury : A trauma quality improvement (TQIP) databank analysis

BACKGROUND High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma. METHODS A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection. RESULTS A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68. CONCLUSION Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.

Risk factors for depression following traumatic injury: An epidemiological study from a scandinavian trauma center

INTRODUCTION A significant proportion of patients suffer depression following traumatic injuries. Once manifested, major depression is challenging to overcome and its presence risks impairing the potential for physical rehabilitation and functional recovery. Risk stratification for early detection and intervention in these instances is important. This study aims to investigate patient and injury characteristics associated with an increased risk for depression. METHODS All patients with traumatic injuries were recruited from the trauma registry of an urban university hospital between 2007 and 2012. Patient and injury characteristics as well as outcomes were collected for analysis. Patients under the age of eighteen, prescribed antidepressants within one year of admission, in-hospital deaths and deaths within 30days of trauma were excluded. Pre- and post-admission antidepressant data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. To isolate independent risk factors for depression a multivariable forward stepwise logistic regression model was deployed. RESULTS A total of 5981 patients met the inclusion criteria of whom 9.2% (n=551) developed post-traumatic depression. The mean age of the cohort was 42 [standard deviation (SD) 18] years and 27.1% (n=1620) were females. The mean injury severity score was 9 (SD 9) with 18.4% (n=1100) of the patients assigned a score of at least 16. Six variables were identified as independent predictors for post-traumatic depression. Factors relating to the patient were female gender and age. Injury-specific variables were penetrating trauma and GCS score of≤8 on admission. Furthermore, intensive care admission and increasing hospital length of stay were predictors of depression. CONCLUSION Several risk factors associated with the development of post-traumatic depression were identified. A better targeted in-hospital screening and patient-centered follow up can be offered taking these risk factors into consideration.

Closed suction drain after isolated hollow viscus injury: a friend or foe?

BACKGROUND The objective of this study was to investigate associations between closed suction intra-abdominal drain placement in isolated hollow viscus injury (HVI) and intra-abdominal deep surgical site infections (DSSI). PATIENTS Patients undergoing emergent trauma laparotomy at a Level I trauma center after isolated HVI from January 2006 to December 2008 were identified. Study variables extracted from institutional trauma registry and patient electronic medical records included demographics, clinical characteristics, abdominal injuries, drain placement, DSSI, septic events, intensive care unit and hospital length of stay, and mortality. Diagnosis of DSSI was based on abdominal computed tomography scan demonstrating an intra-abdominal collection combined with fever and increased white blood cell count. Patients were analyzed according to the HVI severity and the type of intervention performed: primary repair versus resection and primary reanastomosis. To identify independent associations between surgical management of HVI and DSSI, logistic regression analysis was used. RESULTS Overall, 131 patients met the study criteria; 20% (n = 26) received an intra-abdominal drain. The incidence of DSSI was significantly higher in patients who received a drain (31% vs. 9%, p = 0.001). No associated risk for development of DSSI in patients who underwent drain placement after primary repair versus resection and primary reanastomosis was demonstrated. Stepwise logistic regression analysis identified the following independent risk factors for development of DSSI: drain utilization (adjusted odds ratio, 3.7; 95% confidence interval, 1.15-11.9; p < 0.028), and Injury Severity Score ≥16 (adjusted odds ratio, 5.6; 95% confidence interval, 1.9-16.9; p < 0.002). In-hospital survival was unchanged with respective interventions. CONCLUSION Intra-abdominal drain placement after isolated HVI repair is associated with almost fourfold adjusted increased incidence of DSSI. Prospective validation of drain utilization in these instances is warranted.

Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery: Beta-blocker therapy and mortality after emergency colonic cancer surgery

Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta‐blockade reduced mortality after emergency colonic cancer surgery.

Early selenium treatment for traumatic brain injury: Does it improve survival and functional outcome?

BACKGROUND Traumatic brain injury (TBI) is a major cause of death and debility following trauma. The initial brain tissue insult is worsened by secondary reactive responses including oxidative stress reactions, inflammatory changes and subsequent permanent neurologic deficits. Effective agents to improve functional outcome and survival following TBI are scarce. Selenium is an antioxidant which has shown to reduce oxidative stress. This study examines the effect of intravenous selenium (Selenase®) treatment in patients with severe TBI on functional outcome and survival in a prospective study design. METHODS Patients sustaining TBI were prospectively identified during a 12-month period at an academic urban trauma center. Study inclusion criteria applied were: age ≥18 years, blunt injury mechanism and admission to neurosurgical intensive care unit (NICU). Early deaths (≤48h) and patients suffering extracranial injuries requiring invasive interventions or surgery were excluded. All consecutive admissions during a six-month period were administered intravenous Selenase® for a maximum 10-day period and constituted cases. Patient demographics and outcomes up to six-months post-discharge were collected for analysis. RESULTS A total of 307 patients met inclusion criteria of which 125 were administered Selenase®. Stepwise Poisson regression analysis identified five common predictors of poor functional outcome and in-hospital mortality: GCS ≤8, age ≥55 years, hypotension at admission, high Rotterdam score and invasive neurosurgical intervention. Selenase® significantly reduced the risk of unfavourable functional outcomes, defined as GOS-E ≤4, at both discharge (adjusted RR 0.69, 95% CI 0.51-0.92, p=0.012) and at six months follow-up (adjusted RR 0.61, 95% CI 0.44-0.83, p=0.002). Following adjustment for significant group differences similar results were seen for functional outcome. Selenase® did not improve survival (adjusted RR 1.12, 95% CI 0.62-2.02, p=0.709). CONCLUSION Intravenous Selenase® treatment demonstrates a significant improvement in functional neurologic outcome. This effect is sustained at six months following discharge.