Stephanie R. Goldberg

Independent Predictors of Enteric Fistula and Abdominal Sepsis After Damage Control Laparotomy: Results From the Prospective AAST Open Abdomen Registry

IMPORTANCE Enterocutaneous fistula (ECF), enteroatmospheric fistula (EAF), and intra-abdominal sepsis/abscess (IAS) are major challenges for surgeons caring for patients undergoing damage control laparotomy after trauma. OBJECTIVE To determine independent predictors of ECF, EAF, or IAS in patients undergoing damage control laparotomy after trauma, using the AAST Open Abdomen Registry. DESIGN The AAST Open Abdomen registry of patients with an open abdomen following damage control laparotomy was used to identify patients who developed ECF, EAF, or IAS and to compare these patients with those without these complications. Univariate analyses were performed to compare these groups of patients. Variables from univariate analyses differing at P < .20 were entered into a stepwise logistic regression model to identify independent risk factors for ECF, EAF, or IAS. SETTING Fourteen level I trauma centers. PARTICIPANTS A total of 517 patients with an open abdomen following damage control laparotomy. MAIN OUTCOMES AND MEASURES Complication of ECF, EAF, or IAS. RESULTS More patients in the ECF/EAF/IAS group than in the group without these complications underwent bowel resection (63 of 111 patients [57%] vs 133 of 406 patients [33%]; P < .001). Within the first 48 hours after surgery, the ECF/EAF/IAS group received more colloids (P < .03) and total fluids (P < .03) than did the group without these complications. The ECF/EAF/IAS group underwent almost twice as many abdominal reexplorations as did the group without these complications (mean [SD] number, 4.1 [4.1] vs 2.2 [3.4]; P < .001). After multivariate analysis, the independent predictors of ECF/EAF/IAS were a large bowel resection (adjusted odds ratio [AOR], 3.56 [95% CI, 1.88-6.76]; P < .001), a total fluid intake at 48 hours of between 5 and 10 L (AOR, 2.11 [95% CI, 1.15-3.88]; P = .02) or more than 10 L (AOR, 1.93 [95% CI, 1.04-3.57]; P = .04), and an increasing number of reexplorations (AOR, 1.14 [95% CI, 1.06-1.21]; P < .001). CONCLUSIONS AND RELEVANCE Large bowel resection, large-volume fluid resuscitation, and an increasing number of abdominal reexplorations were statistically significant predictors of ECF, EAF, or IAS in patients with an open abdomen after damage control laparotomy.

Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay

BACKGROUND We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients. METHODS All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups. RESULTS A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p < 0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03). CONCLUSION LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation. LEVEL OF EVIDENCE Therapeutic study, level II.

Health care-associated infections in surgical patients undergoing elective surgery: are alcohol use disorders a risk factor?

BACKGROUND Health care-associated infections (HAI) result in 100,000 deaths/year. Alcohol use disorders (AUD) increase the risk of community-acquired infections and HAI. Small studies have shown that AUD increase the risk of HAI and surgical site infections (SSI). We sought to determine the risk of HAI and SSI in surgical patients undergoing elective inpatient joint replacement, coronary artery bypass grafting, laparoscopic cholecystectomy, colectomy, and hernia repair. STUDY DESIGN The Nationwide Inpatient Sample was analyzed (years 2007 and 2008). HAI were defined as health care-associated pneumonia, sepsis, SSI, and urinary tract infection. Primary outcomes were risk of HAI and SSI in patients with AUD. Secondary outcomes were mortality and hospital length of stay in patients with HAI and SSI, alpha = 10(-6). RESULTS There were 1,275,034 inpatient admissions analyzed; 38,335 (3.0%) cases of HAI were documented, and 5,756 (0.5%) cases of SSI were identified. AUD was diagnosed in 11,640 (0.9%) of cases. Multivariable analysis demonstrated that AUD was an independent predictor of developing HAI: odds ratio (OR) 1.70, p < 10(-6), and this risk was independent of type of surgery. By multivariable analysis, the risk of SSI in patients with AUD was also higher: OR 2.73, p < 10(-6). Hospital mortality in patients with HAI or SSI was not affected by AUD. However, hospital length of stay was longer in patients with HAI who had AUD (multivariable analysis 2.4 days longer, p < 10(-6)). Among patients with SSI, those with AUD did not have longer hospital length of stay. CONCLUSIONS Patients with AUD who undergo a variety of elective operations have an increased risk of infectious postoperative morbidity.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest.

A 3D scanning confocal imaging method measures pit volume and captures the role of Rac in osteoclast function

Modulation of Rho GTPases Rac1 and Rac2 impacts bone development, remodeling, and disease. In addition, GTPases are considered treatment targets for dysplastic and erosive bone diseases including Neurofibromatosis type 1. While it is important to understand the effects of Rac modulation on osteoclast function, two-dimensional resorption pit area measurements fall short in elucidating the volume aspect of bone resorption activity. Bone marrow from wild-type, Rac1 and Rac2 null mice was isolated from femora. Osteoclastogenesis was induced by adding M-CSF and RANKL in culture plates containing dentin slices and later stained with Picro Sirius Red to image resorption lacunae. Osteoclasts were also plated on glass cover slips and stained with phalloidin and DAPI to measure their surface area and the number of nuclei. Volumetric images were collected on a laser-scanning confocal system. Sirius Red confocal imaging provided an unambiguous, continuous definition of the pit boundary compared to reflected and transmitted light imaging. Rac1- and Rac2-deficient osteoclasts had fewer nuclei in comparison to wild-type counterparts. Rac1-deficient osteoclasts showed reduced resorption pit volume and surface area. Lacunae made by single Rac2 null osteoclasts had reduced volume but surprisingly surface area was unaffected. Surface area measures are deceiving since volume changed independently in resorption pits made by individual Rac2 null osteoclasts. Our innovative confocal imaging technique allows us to derive novel conclusions about Rac1 and Rac2 in osteoclast function. The data and method can be applied to study effects of genes and drugs including Rho GTPase modulators on osteoclast function and to develop pharmacotherapeutics to treat bone lytic disorders.

Open extremity fractures: impact of delay in operative debridement and irrigation.

BACKGROUND Early (<8 hours) operative debridement and irrigation (D&I) of open fractures are considered essential to reduce the risk of deep infection. With the advent of powerful antimicrobials, this axiom has been challenged. The current study evaluates the rates of deep infections of open fractures in relation to the time to the first D&I. METHODS A list of all blunt open fractures during a 6-year period was obtained from the trauma registry. Patients were evaluated for age, Injury Severity Score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to the first D&I was calculated. All patients received appropriate prophylactic antimicrobials. Infection rates were calculated and correlated to the time to the first D&I (<8 hours vs. >8 hours). Regression analysis was performed to identify independent predictors of infection. RESULTS During the 72-month study period, 404 patients met entry criteria, with 415 open extremity fractures (upper, 129; lower, 287). Early (<8 hours) and delayed (>8 hours) groups were well matched, although the age was lower and ISS was higher in the group with greater than 8 hours. The rates of infection were 35 (11%) of 328 (<8 hour) and 17 (19%) of 87 (>8 hours) (p < 0.05). When fractures were subgrouped by extremity, for the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection. In the upper extremity, only higher Gustilo type correlated, and a delay to the first D&I did not increase the incidence of infection. Regression analysis revealed that higher ISS (odd ratio [OR], 1.052; 95% confidence interval [CI], 1.019–1.086), Gustilo grade, and a delay of greater than 8 hours (OR, 2.035; 95% CI, 1.022–4.054) were independent predictors of infection for the all-extremity model. Separate models for upper and lower extremities showed that the same three parameters were independent predictors for the lower extremity (ISS: OR, 1.045; 95% CI, 1.004–1.087; Gustilo type and >8-hour delay: OR, 3.006; 95% CI, 1.280–7.059), but none for the upper extremity. CONCLUSION Delay of greater than 8 hours to the first D&I for open fractures of the lower extremity increases the likelihood of infection but not for the upper extremity. Higher Gustilo type open fractures have a higher incidence of infection for both upper and lower extremities. The results have important implications in an era of decreasing surgeon availability, especially in off hours. LEVEL OF EVIDENCE Therapeutic study, level IV.

Creation of a Novel Recuperative Pain Medicine Service to Optimize Postoperative Analgesia and Enhance Patient Satisfaction

Many patients have difficulty with pain control after transition from patient-controlled analgesia modalities to oral analgesics. The creation of a Recuperative Pain Medicine (RPM) service was intended to bridge this gap in pain management at the Hospital for Special Surgery. Specific goals were to improve patient and staff satisfaction with management of postoperative oral analgesics by improving clinical care, administrative policies, and patient and staff education. Primary outcome measures for improved satisfaction were Press Ganey surveys and staff surveys. From inception in Aug 2007 to Dec 2008, RPM has seen 6,305 patients for discharge planning and education and 997 patients for pain management consultation. Administrative and educational accomplishments have included creation of a patient “Helpline” for emergent phone questions regarding postdischarge home pain medications, a policy for prescribing pain medications for home discharge, patient education booklets, a pain management webpage on the Hospital for Special Surgery website, and direct education of staff. Press Ganey measurements of patient satisfaction increased from 87th percentile up to the 99th percentile among peer institutions since the implementation of RPM. Staff satisfaction was 92% positive regarding the RPM service’s function and patient management. An RPM appears to be an effective means to optimize postoperative pain management after transition off patient-controlled analgesia devices. Further research is needed to ascertain the exact cost–benefit and potential impact on postoperative quality-of-life measurements.

Prevention of firearm-related injuries with restrictive licensing and concealed carry laws: an Eastern Association for the Surgery of Trauma systematic review

BACKGROUND In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the US Restrictive Licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons. METHODS A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions. RESULTS A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3,623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3,379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2. CONCLUSION PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries. PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries. This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7% to 40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines. LEVEL OF EVIDENCE Systematic review, level III.

Role of PTPα in the Destruction of Periodontal Connective Tissues

IL-1β contributes to connective tissue destruction in part by up-regulating stromelysin-1 (MMP-3), which in fibroblasts is a focal adhesion-dependent process. Protein tyrosine phosphatase-α (PTPα) is enriched in and regulates the formation of focal adhesions, but the role of PTPα in connective tissue destruction is not defined. We first examined destruction of periodontal connective tissues in adult PTPα+/+ and PTPα−/− mice subjected to ligature-induced periodontitis, which increases the levels of multiple cytokines, including IL-1β. Three weeks after ligation, maxillae were processed for morphometry, micro-computed tomography and histomorphometry. Compared with unligated controls, there was ∼1.5–3 times greater bone loss as well as 3-fold reduction of the thickness of the gingival lamina propria and 20-fold reduction of the amount of collagen fibers in WT than PTPα−/− mice. Immunohistochemical staining of periodontal tissue showed elevated expression of MMP-3 at ligated sites. Second, to examine mechanisms by which PTPα may regulate matrix degradation, human MMP arrays were used to screen conditioned media from human gingival fibroblasts treated with vehicle, IL-1β or TNFα. Although MMP-3 was upregulated by both cytokines, only IL-1β stimulated ERK activation in human gingival fibroblasts plated on fibronectin. TIRF microscopy and immunoblotting analyses of cells depleted of PTPα activity with the use of various mutated constructs or with siRNA or PTPαKO and matched wild type fibroblasts were plated on fibronectin to enable focal adhesion formation and stimulated with IL-1β. These data showed that the catalytic and adaptor functions of PTPα were required for IL-1β-induced focal adhesion formation, ERK activation and MMP-3 release. We conclude that inflammation-induced connective tissue degradation involving fibroblasts requires functionally active PTPα and in part is mediated by IL-1β signaling through focal adhesions.

Practice Patterns for the Use of Antibiotic Agents in Damage Control Laparotomy and Its Impact on Outcomes

BACKGROUND The purpose of this study was to identify practice patterns associated with the use of antimicrobial agents with damage control laparotomy (DCL) and the relationship with post-operative intra-abdominal infection (IAI) rates. PATIENTS AND METHODS The study was a retrospective review of trauma patients undergoing laparotomy at a Level 1 trauma center in 2010. Patients undergoing DCL versus those primarily closed (PCL) were compared for antimicrobial use (ABX) and its correlation with IAI rates (p < 0.05). Deaths with length of stay <5 days were excluded. RESULTS A total of 121 patients were identified (28 DCL, 93 PCL). The DCL group was more severely injured (Injury Severity Score [ISS]: 31.4 ± 15 DCL vs. 18 ± 12.7 PCL, p < 0.001) with more small and large bowel injuries (SLBI), although not statistically significant (53.6% DCL vs. 35.5% PCL, p = 0.12). Practice patterns of ABX administration in terms of pre-operative (94.6% PCL vs. 69.2% DCL, p = 0.0012) and post-operative administration (PCL: 50.5% none, 21.5% one day, 28% long term >1 d; DCL: 21.4% none, 25.0% one day, 53.6% long term >1 day, p = 0.0130) were significant. Regression analyses demonstrated that neither ISS nor DCL was an independent predictor of infection, but pre-operative ABX was a negative predictor (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.05-0.91, p = 0.037), while post-operative ABX (OR 6.7, 95%CI 1.33-33.8, p = 0.044) and SLBI (OR 3.45, CI 1.03-11.5, p = 0.02) were positive predictors of infection with an receiver operating characteristic of 0.81. CONCLUSION Significant variations exist in the use of ABX in DCL and PCL. These variations may lead to deleterious results from both lack of initial pre-operative coverage and prolonged ABX use. The decrease in infection rates with pre-operative ABX yet significant increase with continued post-operative use even in the presence of SLBI suggests the need for a more standardized approach. With the increase in DCL and the open abdomen, more research is needed to clearly establish ABX protocols in this patient population.