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Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Croce MA, Fabian TC. How to Increase the Burden on Trauma Centers: Implement the 80-hour Work Week. Am Surg 2020. [DOI: 10.1177/000313481408000719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.
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Farrar JE, Garner KM, Swanson JM, Magnotti LJ, Croce MA, Wood GC. Tigecycline to treat Stenotrophomonas maltophilia ventilator-associated pneumonia in a trauma intensive care unit as a result of a drug shortage: A case series. J Clin Pharm Ther 2020; 45:836-839. [PMID: 32406951 DOI: 10.1111/jcpt.13158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Stenotrophomonas maltophilia is an intrinsically multidrug-resistant (MDR) organism which commonly presents as a respiratory tract infection. S. maltophilia is typically treated with high-dose sulfamethoxazole/trimethoprim (SMX/TMP). However, SMX/TMP and other treatment options for S. maltophilia can be limited because of resistance, allergy, adverse events or unavailability of the drug; use of novel agents may be necessary to adequately treat this MDR infection and overcome these limitations. CASE DESCRIPTION This small case series describes two patients who underwent treatment with tigecycline for ventilator-associated pneumonia (VAP) caused by S. maltophilia after admission to a trauma intensive care unit. At the time of admission for the two reported patients, a national drug shortage of intravenous (IV) SMX/TMP prevented its use. Tigecycline was chosen as a novel agent to treat S. maltophilia VAP based on culture and susceptibility data, and it was used successfully. Both patients showed clinical signs of improvement with eventual cure and discharge from the hospital after treatment with tigecycline, and one patient demonstrated confirmed microbiological cure with a negative repeat bronchoscopic bronchoalveolar lavage (BAL). WHAT IS NEW AND CONCLUSION To our knowledge, this small case series is the first documentation of utilizing tigecycline to treat S. maltophilia VAP in the United States. Although it likely should not be considered as a first-line agent, tigecycline proved to be an effective treatment option in the two cases described in the setting of a national drug shortage of the drug of choice.
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Filiberto DM, Afzal MO, Sharpe JP, Seger C, Shankar S, Croce MA, Fabian TC, Magnotti LJ. Radiographic predictors of therapeutic operative intervention after blunt abdominal trauma: the RAPTOR score. Eur J Trauma Emerg Surg 2020; 47:1813-1817. [PMID: 32300849 DOI: 10.1007/s00068-020-01371-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/06/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Bowel and mesenteric injuries are rare in patients following blunt abdominal trauma. Computed tomography (CT) imaging has become a mainstay in the work-up of the stable trauma patient. The purpose of this study was to identify radiographic predictors of therapeutic operative intervention for mesenteric and/or bowel injuries in patients after blunt abdominal trauma. METHODS All patients with a discharge diagnosis of bowel and/or mesenteric injury after blunt trauma were identified over a 5-year period. Admission CT scans were reviewed to identify potential predictors of bowel and/or mesenteric injury. Patients were then stratified by operative intervention [therapeutic laparotomy (TL) vs. non-therapeutic laparotomy (NTL)] and compared. All potential predictors included in the initial regression model were assigned one point and a score based on the number of predictors was calculated: the radiographic predictors of therapeutic operative intervention (RAPTOR) score. RESULTS 151 patients were identified. 114 (76%) patients underwent operative intervention. Of these, 75 patients (66%) underwent TL. Multifocal hematoma, acute arterial extravasation, bowel wall hematoma, bowel devascularization, fecalization, pneumoperitoneum and fat pad injury, identified as potential predictors on univariable analysis, were included in the initial regression model and comprised the RAPTOR score. The optimal RAPTOR score was identified as ≥ 3, with a sensitivity, specificity and positive predictive value of 67%, 85% and 86%, respectively. Acute arterial extravasation (OR 3.8; 95% CI 1.2-4.3), bowel devascularization (OR 14.5; 95% CI 11.8-18.4) and fat pad injury (OR 4.5 95% CI 1.6-6.2) were identified as independent predictors of TL (AUC 0.91). CONCLUSIONS CT imaging remains vital in assessing for potential bowel and/or mesenteric injuries following blunt abdominal trauma. The RAPTOR score provides a simplified approach to predict the need for early therapeutic operative intervention.
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Tsao MW, Delozier OM, Stiles ZE, Magnotti LJ, Behrman SW, Deneve JL, Glazer ES, Shibata D, Yakoub D, Dickson PV. The impact of race and socioeconomic status on the presentation, management and outcomes for gastric cancer patients: Analysis from a metropolitan area in the southeast United States. J Surg Oncol 2020; 121:494-502. [PMID: 31902137 DOI: 10.1002/jso.25827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Socioeconomic disparities in gastric cancer have been associated with differences in care and inferior outcomes. We evaluated the presentation, treatment, and survival for patients with gastric cancer (GC) in a metropolitan setting with a large African American population. METHODS Retrospective cohort analysis of patients with GC (2003-2018) across a multi-hospital system was performed. Associations between socioeconomic and clinicopathologic data with the presentation, treatment, and survival were examined. RESULTS Of 359 patients, 255 (71%) were African American and 104 (29%) Caucasian. African Americans were more likely to present at a younger age (64.0 vs 72.5, P < .001), have state-sponsored or no insurance (19.7% vs 6.9%, P = .02), reside within the lowest 2 quintiles for median income (67.4% vs 32.7%, P < .001), and have higher rates of Helicobacter pylori (14.9% vs 4.8%, P = .02). Receipt of multi-modality therapy was not impacted by race or insurance status. On multivariable analysis, only AJCC T class (HR 1.68) and node positivity (HR 2.43) remained significant predictors of disease-specific survival. CONCLUSION Despite socioeconomic disparities, African Americans, and Caucasians with GC had similar treatment and outcomes. African Americans presented at a younger age with higher rates of H. pylori positivity, warranting further investigation into differences in risk factors and tumor biology.
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Schroeppel TJ, Sharpe JP, Shahan CP, Clement LP, Magnotti LJ, Lee M, Muhlbauer M, Weinberg JA, Tolley EA, Croce MA, Fabian TC. Beta-adrenergic blockade for attenuation of catecholamine surge after traumatic brain injury: a randomized pilot trial. Trauma Surg Acute Care Open 2019; 4:e000307. [PMID: 31467982 PMCID: PMC6699724 DOI: 10.1136/tsaco-2019-000307] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/24/2019] [Accepted: 07/05/2019] [Indexed: 12/02/2022] Open
Abstract
Background Beta-blockers have been proven in multiple studies to be beneficial in patients with traumatic brain injury. Few prospective studies have verified this and no randomized controlled trials. Additionally, most studies do not titrate the dose of beta-blockers to therapeutic effect. We hypothesize that propranolol titrated to effect will confer a survival benefit in patients with traumatic brain injury. Methods A randomized controlled pilot trial was performed during a 24-month period. Patients with traumatic brain injury were randomized to propranolol or control group for a 14-day study period. Variables collected included demographics, injury severity, physiologic parameters, urinary catecholamines, and outcomes. Patients receiving propranolol were compared with the control group. Results Over the study period, 525 patients were screened, 26 were randomized, and 25 were analyzed. Overall, the mean age was 51.3 years and the majority were male with blunt mechanism. The mean Injury Severity Score was 21.8 and median head Abbreviated Injury Scale score was 4. Overall mortality was 20.0%. Mean arterial pressure was higher in the treatment arm as compared with control (p=0.021), but no other differences were found between the groups in demographics, severity of injury, severity of illness, physiologic parameters, or mortality (7.7% vs. 33%; p=0.109). No difference was detected over time in any variables with respect to treatment, urinary catecholamines, or physiologic parameters. Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation scores all improved over time. GCS at study end was significantly higher in the treatment arm (11.7 vs. 8.9; p=0.044). Finally, no difference was detected with survival analysis over time between groups. Conclusions Despite not being powered to show statistical differences between groups, GCS at study end was significantly improved in the treatment arm and mortality was improved although not at a traditional level of significance. The study protocol was safe and feasible to apply to an appropriately powered larger multicenter study. Level of evidence Level 2—therapeutic.
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Manley NR, Croce MA, Fischer PE, Crowe DE, Goines JH, Sharpe JP, Fabian TC, Magnotti LJ. Evolution of Firearm Violence over 20 Years: Integrating Law Enforcement and Clinical Data. J Am Coll Surg 2019; 228:427-434. [DOI: 10.1016/j.jamcollsurg.2018.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 12/17/2018] [Indexed: 11/24/2022]
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Huang X, Magnotti LJ, Fabian TC, Croce MA, Sharpe JP. Does lack of thoracic trauma attenuate the severity of pulmonary failure? An 8-year analysis of critically injured patients. Eur J Trauma Emerg Surg 2019; 46:3-9. [PMID: 30712060 PMCID: PMC7223815 DOI: 10.1007/s00068-019-01081-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/30/2019] [Indexed: 11/03/2022]
Abstract
PURPOSE Patients with thoracic trauma are presumed to be at higher risk for pulmonary dysfunction, but adult respiratory distress syndrome (ARDS) may develop in any patient, regardless of associated chest injury. This study evaluated the impact of thoracic trauma and pulmonary failure on outcomes in trauma patients admitted to the intensive-care unit (ICU). METHODS All trauma patients admitted to the ICU over an 8-year period were identified. Patients that died within 48 h of arrival were excluded. Patients were stratified by baseline characteristics, injury severity, development of ARDS, and infectious complications. Multiple logistic regression was used to determine variables significantly associated with the development of ARDS. RESULTS 10,362 patients were identified. After exclusions, 4898 (50%) patients had chest injury and 4975 (50%) did not. 200 (2%) patients developed ARDS (3.6% of patients with chest injury and 0.5% of patients without chest injury). Patients with ARDS were more likely to have chest injury than those without ARDS (87% vs 49%, p < 0.001). However, of the patients without chest injury, the development of ARDS still led to a significant increase in mortality compared to those patients without ARDS (58% vs 5%, p < 0.001). Multiple logistic regression found ventilator-associated pneumonia (VAP) to be the only independent predictor for the development of ARDS in ICU patients without chest injury. CONCLUSIONS ARDS development was more common in patients with thoracic trauma. Nevertheless, the development of ARDS in patients without chest injury was associated with a tenfold higher risk of death. The presence of VAP was found to be the only potentially preventable and treatable risk factor for the development of ARDS in ICU patients without chest injury.
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Gibson BH, Sharpe JP, Lewis RH, Newell JS, Swanson JM, Wood GC, Fabian TC, Croce MA, Magnotti LJ. Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients. Am Surg 2018. [DOI: 10.1177/000313481808401236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.
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Gibson BH, Sharpe JP, Lewis RH, Newell JS, Swanson JM, Wood GC, Fabian TC, Croce MA, Magnotti LJ. Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients. Am Surg 2018; 84:1906-1912. [PMID: 30606347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.
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Evans CR, Sharpe JP, Swanson JM, Wood GC, Fabian TC, Croce MA, Magnotti LJ. Keeping it Simple: Impact of a Restrictive Antibiotic Policy for Ventilator-Associated Pneumonia in Trauma Patients on Incidence and Sensitivities of Causative Pathogens. Surg Infect (Larchmt) 2018; 19:672-678. [DOI: 10.1089/sur.2018.087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Schroeppel TJ, Clement LP, Barnard DL, Guererro W, Ferguson MD, Sharpe JP, Magnotti LJ, Croce MA, Fabian TC. Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol. Am Surg 2018. [DOI: 10.1177/000313481808400848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.
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Schroeppel TJ, Clement LP, Barnard DL, Guererro W, Ferguson MD, Sharpe JP, Magnotti LJ, Croce MA, Fabian TC. Propofol Infusion Syndrome: Efficacy of a Prospective Screening Protocol. Am Surg 2018; 84:1333-1338. [PMID: 30185312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Propofol infusion syndrome (PIS) is a potentially lethal complication of propofol marked by rhabdomyolysis, metabolic acidosis, and cardiac arrhythmias or collapse. The objective of this study was to determine the effectiveness of a prospective screening protocol to prevent PIS. All trauma patients admitted who received propofol as a continuous infusion were prospectively screened from November 1, 2013 to December 31, 2015. Variables studied included demographics, injury severity, laboratory values, infusion rates, and mortality. Serum creatine phosphokinase (CPK) and lactate were drawn daily. Propofol was stopped for a positive screen defined as an increase in CPK to greater than 5000 IU/L or lactate greater than 4 mmol/L. Positive and negative cohorts were compared. Two hundred and twenty-five patients met the inclusion criteria and 12 patients (5.3%) had propofol stopped because of elevated CPK. No differences were identified in demographics, transfusions, injury severity, hospital length of stay, or propofol dose. The positive screened group had longer intensive care unit length of stay (20 vs 13 days; P = 0.002) and increased vent days (14.5 vs 10 days; P = 0.008). Max serum osmolality (334 vs 305 mosm/kg; P = 0.049) and max serum CPK (6782 vs 1058 IU/L; P < 0.0001) were higher in the positive cohort. No cases of PIS occurred, and mortality (16.7 vs 15.5%; P = 0.999) was not different between the cohorts. The screening protocol was effective in eliminating PIS. Serial CPK evaluations provided an effective screening tool and serum lactate can be dropped from screening.
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Manley NR, Magnotti LJ, Fabian TC, Cutshall MB, Croce MA, Sharpe JP. Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma. Am Surg 2018. [DOI: 10.1177/000313481808400742] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
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Manley NR, Magnotti LJ, Fabian TC, Cutshall MB, Croce MA, Sharpe JP. Factors Contributing to Morbidity after Combined Arterial and Venous Lower Extremity Trauma. Am Surg 2018; 84:1217-1222. [PMID: 30064592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The purpose of this study was to evaluate the impact of management of venous injury on clinical outcomes in patients with combined lower extremity arterial and venous trauma. Patients with common and external iliac, common and superficial femoral, and popliteal artery injuries were identified. Patients who underwent vein repair and those who received vein ligation were compared. The analysis was repeated for those patients who required secondary intervention for their arterial injury and those who did not require secondary intervention. Seventy patients were identified with both arterial and venous injuries: 40 underwent vein ligation and 30 received vein repair. There was no difference in ischemic time between patients undergoing vein repair compared with ligation. Vein ligation did not produce a higher incidence of muscle debridement (10% vs 15%, P = 0.72), necessity for secondary intervention (10% vs 7.5%, P = 0.99), or amputation (3.3% vs 7.5%, P = 0.63). Patients who required secondary intervention had a greater degree of shock on presentation (packed red blood cells (PRBC), 13 units vs 6 units, P = 0.02) and were more likely to require muscle debridement (50% vs 9%, P = 0.02) and amputation (33% vs 3%, P = 0.03). Vein ligation did not impact muscle ischemia or success of arterial repair in patients with combined venous and arterial trauma in the lower extremities. Patient morbidity after extremity vascular trauma is most related to degree of shock.
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Shahan CP, Stavely TC, Croce MA, Fabian TC, Magnotti LJ. Long-Term Functional Outcomes after Blunt Cerebrovascular Injury: A 20-Year Experience. Am Surg 2018; 84:551-556. [PMID: 29712605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Since blunt cerebrovascular injury (BCVI) became increasingly recognized more than 20 years ago, significant improvements have been made in both diagnosis and treatment. Little is known regarding long-term functional outcomes in BCVI. The purpose of this study was to evaluate the impact of BCVI on those long-term outcomes. All patients with BCVI from 1996 to 2014 were identified from the trauma registry. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care. Multiple regression analysis was performed to identify potential predictors of outcomes. A total of 509 patients were identified. Overall mortality was 18 per cent (BCVI-related = 1%). Of the 415 survivors, follow-up was obtained in 77 (19%). Mean follow-up was five years, with a maximum of 19 years. Mean age and injury severity score were 47 and 25, respectively. Six (8%) patients suffered strokes. Mean Activity Measure for Post-Acute Care scores were 59 (mobility), 58 (activity), and 44 (cognitive function), each indicating significant impairment compared with normal. Multiple regression models identified 1) age as a predictor of decreased mobility, 2) injury severity score as a predictor of decreased mobility, activity, and cognitive function, and 3) stroke as a predictor of decreased activity, cognitive function, and likely mobility. Development of stroke and increased injury severity resulted in worse long-term functional outcomes after BCVI. Thus, stroke prevention with optimal diagnostic and treatment algorithms remains critical in the successful treatment of BCVI because it has significant impact on long-term functional outcomes and is the only modifiable predictor of outcomes in patients after BCVI.
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Shahan CP, Stavely TC, Croce MA, Fabian TC, Magnotti LJ. Long-Term Functional Outcomes after Blunt Cerebrovascular Injury: A 20-Year Experience. Am Surg 2018. [DOI: 10.1177/000313481808400430] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since blunt cerebrovascular injury (BCVI) became increasingly recognized more than 20 years ago, significant improvements have been made in both diagnosis and treatment. Little is known regarding long-term functional outcomes in BCVI. The purpose of this study was to evaluate the impact of BCVI on those long-term outcomes. All patients with BCVI from 1996 to 2014 were identified from the trauma registry. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care. Multiple regression analysis was performed to identify potential predictors of outcomes. A total of 509 patients were identified. Overall mortality was 18 per cent (BCVI-related = 1%). Of the 415 survivors, follow-up was obtained in 77 (19%). Mean follow-up was five years, with a maximum of 19 years. Mean age and injury severity score were 47 and 25, respectively. Six (8%) patients suffered strokes. Mean Activity Measure for Post-Acute Care scores were 59 (mobility), 58 (activity), and 44 (cognitive function), each indicating significant impairment compared with normal. Multiple regression models identified 1) age as a predictor of decreased mobility, 2) injury severity score as a predictor of decreased mobility, activity, and cognitive function, and 3) stroke as a predictor of decreased activity, cognitive function, and likely mobility. Development of stroke and increased injury severity resulted in worse long-term functional outcomes after BCVI. Thus, stroke prevention with optimal diagnostic and treatment algorithms remains critical in the successful treatment of BCVI because it has significant impact on long-term functional outcomes and is the only modifiable predictor of outcomes in patients after BCVI.
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Wood GC, Jonap BL, Maish GO, Magnotti LJ, Swanson JM, Boucher BA, Croce MA, Fabian TC. Treatment of Achromobacter Ventilator-Associated Pneumonia in Critically Ill Trauma Patients. Ann Pharmacother 2017; 52:120-125. [PMID: 28906137 DOI: 10.1177/1060028017730838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Achromobacter sp are nonfermenting Gram-negative bacilli (NFGNB) that rarely cause severe infections, including ventilator-associated pneumonia (VAP). Data on the treatment of Achromobacter pneumonia are very limited, and the organism has been associated with a high mortality rate. Thus, more data are needed on treating this organism. OBJECTIVE To evaluate the treatment of Achromobacter VAP in critically ill trauma patients. METHODS This retrospective, observational study evaluated critically ill trauma patients who developed Achromobacter VAP. A previously published pathway for the diagnosis and management of VAP was used according to routine patient care. This included the use of quantitative bronchoscopic bronchoalveolar lavage cultures to definitively diagnose VAP. RESULTS A total of 37 episodes of Achromobacter VAP occurred in 34 trauma intensive care unit patients over a 15-year period. The most commonly used definitive antibiotics were imipenem/cilastatin, cefepime, or trimethoprim/sulfamethoxazole. The primary outcome of clinical success was achieved in 32 of 37 episodes (87%). This is similar to previous studies of other NFGNB VAP (eg, Pseudomonas, Acinetobacter) from the study center. Microbiological success was seen in 21 of 28 episodes (75%), and VAP-related mortality was 9% (3 of 34 patients). CONCLUSIONS Achromobacter is a rare but potentially serious cause of VAP in critically ill patients. In this study, there was an acceptable success rate compared with other causes of NFGNB VAP in this patient population.
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Sharpe JP, Magnotti LJ, Fabian TC, Croce MA. Evolution of the operative management of colon trauma. Trauma Surg Acute Care Open 2017; 2:e000092. [PMID: 29766094 PMCID: PMC5877907 DOI: 10.1136/tsaco-2017-000092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 04/03/2017] [Indexed: 11/24/2022] Open
Abstract
For any trauma surgeon, colon wounds remain a relatively common, yet sometimes challenging, clinical problem. Evolution in operative technique and improvements in antimicrobial therapy during the past two centuries have brought remarkable improvements in both morbidity and mortality after injury to the colon. Much of the early progress in management and patient survival after colon trauma evolved from wartime experience. Multiple evidence-based studies during the last several decades have allowed for more aggressive management, with most wounds undergoing primary repair or resection and anastomosis with an acceptably low suture line failure rate. Despite the abundance of quality evidence regarding management of colon trauma obtained from both military and civilian experience, there remains some debate among institutions regarding management of specific injuries. This is especially true with respect to destructive wounds, injuries to the left colon, blunt colon trauma and those wounds requiring colonic discontinuity during an abbreviated laparotomy. Some programs have developed data-driven protocols that have simplified management of destructive colon wounds, clearly identifying those high-risk patients who should undergo diversion, regardless of mechanism or anatomic location. This update will describe the progression in the approach to colon injuries through history while providing a current review of the literature regarding management of the more controversial wounds.
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Sharpe JP, Khan NR, Chatterjee AR, Huang J, Magnotti LJ, Croce MA, Fabian TC. Investigating Cyclooxygenase Inhibition in a Rat Pulmonary Contusion Model: A Laboratory Study Finding No Improvement with Ibuprofen. Am Surg 2017. [DOI: 10.1177/000313481708300635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimal advances have been made in the management of pulmonary contusions (PCs). The purpose of this study was to evaluate the impact of cyclooxygenase inhibition on outcomes following PC in a rat model. PC was induced in anesthetized adult rats. Ibuprofen was given to the treatment group (TG) and water was given to the control group (CG). Lung injury was assessed with pulse oximetry, arterial blood gases, CT, and histopathologic examination. Inflammation was measured with both serum and bronchoalveolar lavage (BAL) levels of tumor necrosis factor a and interleukin-6. Rats in the TG did not differ from rats in the CG with respect to oxygenation. Pathologic examination demonstrated a trend toward more inflammatory infiltrate in the CG, yet the sizes of the contusions were larger in the TG. The CG trended toward decreased levels of interleukin-6 in the serum and BAL at both three and seven days. While BAL levels of tumor necrosis factor a were increased in the TG at three days compared to the CG, they trended toward a reduced amount at seven days. Our data do not support cyclooxygenase inhibition for treatment to decrease the respiratory compromise associated with PC in this model of rat PCs.
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Shahan CP, Croce MA, Fabian TC, Magnotti LJ. Impact of Continuous Evaluation of Technology and Therapy: 30 Years of Research Reduces Stroke and Mortality from Blunt Cerebrovascular Injury. J Am Coll Surg 2017; 224:595-599. [PMID: 28111193 DOI: 10.1016/j.jamcollsurg.2016.12.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 12/12/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blunt cerebrovascular injury (BCVI) was underdiagnosed until the 1990s when blunt carotid injuries were found to be more common than historically described. Technological advancements and regionalization of trauma care have resulted in increased screening and improved diagnosis of BCVI. The aim of this study was to demonstrate that systematic evaluation of the screening and diagnosis of BCVI, combined with early and aggressive treatment, have led to reductions in BCVI-related stroke and mortality. STUDY DESIGN Patients with BCVI from 1985 to 2015 were identified and stratified by age, sex, and Injury Severity Score. BCVI-related stroke and mortality rates were then calculated and compared. Patients were divided into 5 eras based on changes in technology, screening, or treatment algorithms at our institution. RESULTS Five hundred and sixty-four patients were diagnosed with BCVI: 508 carotid artery and 267 vertebral artery injuries. Sixty-five percent of patients were male, mean age was 41 years, and mean Injury Severity Score was 27. Incidence of BCVI diagnosis increased from 0.33% to approximately 2% of all blunt trauma (p < 0.001) during the study period. Ninety (14%) patients suffered BCVI-related stroke, with the incidence of stroke significantly decreasing over time from 37% to 5% (p < 0.001). Twenty-eight (5%) patients died as a direct result of BCVI, and BCVI-related mortality also decreased significantly over time from 24% to 0% (p < 0.001). CONCLUSIONS Although increased screening has resulted in a higher incidence of injuries over time, BCVI-related stroke and mortality have decreased significantly. Continuous critical evaluation of evolving technology and diagnostic and treatment algorithms has contributed substantially to those improved outcomes. Appraisals of technological advances, preferably through prospective multi-institutional studies, should advance our understanding of these injuries and lead to even lower stroke rates.
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Hendrick LE, Schroeppel TJ, Sharpe JP, Alsbrook D, Magnotti LJ, Weinberg JA, Johnson BP, Lewis RH, Clement LP, Croce MA, Fabian TC. Impact of Beta-Blockers on Nonhead Injured Trauma Patients. Am Surg 2016. [DOI: 10.1177/000313481608200721] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Catecholamine surge after traumatic injury may lead to dysautonomia with increased morbidity. Small retrospective studies have shown potential benefit of beta-blockers (BB) in trauma patients with and without traumatic brain injury (TBI). This study evaluates a large multiply injured cohort without TBI that received BB. Patients were identified from the trauma registry from January 1, 2003 to December 31, 2011. Patients who received >1 dose of BB were compared to controls. Patients with TBI, length of stay (LOS) < 2 days, and prehospital BB were excluded. Outcomes were mortality, intensive care unit (ICU) LOS, and LOS. Stepwise multivariable regression was used to identify variables significantly associated with mortality. During the study period, 19,151 eligible patients were admitted. The mean age was 39 years. Most were male (74%) and most sustained blunt mechanism (75%). A total of 1854 (11%) patients received BB. BB patients had longer LOS (16 vs 6 days), ICU LOS (7 vs 1 days), and higher mortality (2.8 vs 0.5%) (all P < 0.001). Multivariable regression demonstrated no benefit to BB after adjusting for potential confounding characteristics [odds ratio (OR) 0.952; confidence interval (CI) 0.620–1.461]. In conclusion, in this largest study to date, patients receiving BB were older, more severely injured, and had a higher mortality. Unlike TBI patients, multivariable regression showed no benefit from BB in this population.
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Hendrick LE, Schroeppel TJ, Sharpe JP, Alsbrook D, Magnotti LJ, Weinberg JA, Johnson BP, Lewis RH, Clement LP, Croce MA, Fabian TC. Impact of Beta-Blockers on Nonhead Injured Trauma Patients. Am Surg 2016; 82:575-579. [PMID: 27457854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Catecholamine surge after traumatic injury may lead to dysautonomia with increased morbidity. Small retrospective studies have shown potential benefit of beta-blockers (BB) in trauma patients with and without traumatic brain injury (TBI). This study evaluates a large multiply injured cohort without TBI that received BB. Patients were identified from the trauma registry from January 1, 2003 to December 31, 2011. Patients who received >1 dose of BB were compared to controls. Patients with TBI, length of stay (LOS) < 2 days, and prehospital BB were excluded. Outcomes were mortality, intensive care unit (ICU) LOS, and LOS. Stepwise multivariable regression was used to identify variables significantly associated with mortality. During the study period, 19,151 eligible patients were admitted. The mean age was 39 years. Most were male (74%) and most sustained blunt mechanism (75%). A total of 1854 (11%) patients received BB. BB patients had longer LOS (16 vs 6 days), ICU LOS (7 vs 1 days), and higher mortality (2.8 vs 0.5%) (all P < 0.001). Multivariable regression demonstrated no benefit to BB after adjusting for potential confounding characteristics [odds ratio (OR) 0.952; confidence interval (CI) 0.620-1.461]. In conclusion, in this largest study to date, patients receiving BB were older, more severely injured, and had a higher mortality. Unlike TBI patients, multivariable regression showed no benefit from BB in this population.
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Newgard CD, Sanchez BJ, Bulger EM, Brasel KJ, Byers A, Buick JE, Sheehan KL, Guyette FX, King RV, Mena‐Munoz J, Minei JP, Schmicker RH, Kerby JD, Wang HE, Gray R, Christenson J, Christenson J, Andrusiek D, Heest R, Goulding J, Balfour N, Rainier‐Pope N, Beeson J, Gamber M, Simonson R, Gandhi R, Witham W, Simonson R, Ramsay M, Fabian TC, Croce MA, Magnotti LJ, Maish GO, Schroeppel TJ, Zarzaur BL, Weinberg JA, Holley J, Ludwig G, Burnett A, Barnes D, Aufderheide TP, Pirrallo RG, Colella R, Forster R, Pukansky L, Sternig K, Chin E, Krueger K, Szewczuga D, Funk R, Jacobsen G, Spitzer J, Cohn J, Jankowski M, Whitaker R, Rohlfing M, Rosandish T, Remington A, Knitter J, Ugaste R, Saidler T, Reminga T, Shepherd D, Holzhauer P, Rubin J, Skold C, Alvarez O, Harkins H, Barthell E, Haselow W, Yee A, Whitcomb J, Castro EE, Motarjeme S, Coogan P, Rader K, Glaspy J, Gerschke G, Croft H, Brin M, Wilson C, Johnson A, Kumprey W, Ateyyah KA, Gourlay D, Kaslow O, Stiell I, Vaillancourt C, Dreyer J, Munkley D, Prpic J, Maloney J, Affleck A, Bradford P, Trickett J, Sykes N, Graham E, Hedges C, MacPhee R, Nolan L, McLeod S, Luke R, Michaud S, Broughton M, Klass C, Morassutti P, Callaway C, Tisherman S, Daya M, Wittwer L, Jui J, Muhr MD, Griffith J, Free C, Warden CR, Gorman K, Beeler T, Conway W, Newton C, Geiger C, Colvin J, Hollingsworth M, Shertz M, Malone S, Keim E, Sahni R, DeHart S, Freedman S, Moreno R, Chin J, Snyder S, Boyce D, Charleston M, Stevens M, Schult E, Sullivan S, Getsfrid J, Barnes R, Schreiber M, Karmy‐Jones R, Dean Gubler K, Davis DP, Vilke GM, Garcia EM, Coimbra R, Sise MJ, Copass M, Rea T, Eisenberg M, Morrison LJ, Nathens A, Verbeek R, Cheskes S, Rizoli SB, Slutsky A, Mokedanz D, Austin D, Moran P, Wright G, Martin M, Sanderson M, MacDonald R, McConnell S, Jones V, Beckett W, Baker A, Hutchinson J, Choong K, Welsford M, Sne N, Rizoli S. A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes. Acad Emerg Med 2016; 23:554-65. [PMID: 26836571 DOI: 10.1111/acem.12930] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 12/04/2015] [Accepted: 12/06/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes. METHODS This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering. RESULTS There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters. CONCLUSIONS Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence.
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Dickerson RN, Voss JR, Schroeppel TJ, Maish GO, Magnotti LJ, Minard G, Croce MA. Feasibility of jejunal enteral nutrition for patients with severe duodenal injuries. Nutrition 2015; 32:309-14. [PMID: 26704967 DOI: 10.1016/j.nut.2015.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the feasibility of enteral nutrition (EN) for critically ill trauma patients with severe traumatic duodenal injuries who received placement of concurrent decompressing and feeding jejunostomies. METHODS Adult patients admitted to the trauma intensive care unit from January 2010 to December 2013, given concurrent afferent decompressing and efferent feeding jejunostomies for severe duodenal injury and provided EN or parenteral nutrition (PN), were retrospectively evaluated. Enteral feeding intolerance was defined as an increase in the decompressing jejunostomy drainage volume output, worsening abdominal distension, or cramping/pain unrelated to surgical incisions. Patients who failed initial EN were transitioned to PN. RESULTS Twenty-six patients were enrolled. Of the 24 patients given EN within the first 2 wk posthospitalization, 18 (75%) failed EN within 2 ± 2 d of initiating EN. EN was discontinued when increases were seen in decompressing jejunostomy drainage volume output (n = 11) and output with abdominal pain and/or distension (n = 6), or abdominal pain/distension was seen without an increase in output (n = 1). Jejunostomy drainage volume output increased from 474 ± 425 mL/d to 1168 ± 725 mL/d (P < 0.001) during EN intolerance. More patients with blunt intestinal injury than those with penetrating injuries (75% versus 15%, respectively; P = 0.035) tolerated EN. Patients initially given PN (n = 13) received more calories (P < 0.005) and protein (P < 0.001) than those given initial EN (n = 13). CONCLUSION The majority of patients with severe duodenal injuries and concurrent decompressing/feeding tube jejunostomies failed initial EN therapy.
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Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Croce MA, Fabian TC. How to Further Decrease the Efficiency of Care at a Level I Trauma Center: Implement the Amended Resident Work Hours. Am Surg 2015. [DOI: 10.1177/000313481508100719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Work-hour restrictions were amended in 2011 to limit interns to 16 continuous duty hours, essentially requiring a night float system of 12-hour shifts. We hypothesize that there has been no improvement in outcomes after implementation of the amended work-hour restrictions. Outcomes from trauma admissions were queried from the trauma registry from 2009 to 2011 (PRE) and 2011 to 2013 (POST). The primary outcome was mortality with secondary outcomes intensive care unit length of stay (LOS) and LOS. Patients were stratified based on age, mechanism, gender, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Scale, Base Deficit). Outcomes were then compared from admissions PRE to POST. A total of 9178 patients were included in the study population. The mean age was 42 with most being male (72%) and blunt mechanism (81%). Patient populations were well matched except patients in the POST period were slightly older (43 vs 42 years; P = 0.01). Intensive care unit LOS and LOS were higher in the POST period. After adjusted analysis, admission in the POST period was not a predictor of mortality (odds ratio 0.857; confidence interval 0.655–1.12). The POST period was an independent predictor for LOS (β = 0.74; P = 0.002). This study adds to the mounting evidence that the implementation of the amended limits on work hours leads to furthermore decreased efficiency of care.
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Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Croce MA, Fabian TC. How to Further Decrease the Efficiency of Care at a Level I Trauma Center: Implement the Amended Resident Work Hours. Am Surg 2015; 81:698-703. [PMID: 26140890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Work-hour restrictions were amended in 2011 to limit interns to 16 continuous duty hours, essentially requiring a night float system of 12-hour shifts. We hypothesize that there has been no improvement in outcomes after implementation of the amended work-hour restrictions. Outcomes from trauma admissions were queried from the trauma registry from 2009 to 2011 (PRE) and 2011 to 2013 (POST). The primary outcome was mortality with secondary outcomes intensive care unit length of stay (LOS)and LOS. Patients were stratified based on age, mechanism, gender, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Scale, Base Deficit). Outcomes were then compared from admissions PRE to POST. A total of 9178 patients were included in the study population. The mean age was 42 with most being male (72%) and blunt mechanism (81%). Patient populations were well matched except patients in the POST period were slightly older (43 vs 42 years; P = 0.01). Intensive care unit LOS and LOS were higher in the POST period. After adjusted analysis, admission in the POST period was not a predictor of mortality (odds ratio 0.857; confidence interval 0.655-1.12). The POST period was an independent predictor for LOS (β = 0.74; P = 0.002). This study adds to the mounting evidence that the implementation of the amended limits on work hours leads to furthermore decreased efficiency of care.
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McClellan N, Swanson JM, Magnotti LJ, Griffith TW, Wood GC, Croce MA, Boucher BA, Mueller EW, Fabian TC. Adjunctive intraventricular antibiotic therapy for bacterial central nervous system infections in critically ill patients with traumatic brain injury. Ann Pharmacother 2015; 49:515-22. [PMID: 25690904 DOI: 10.1177/1060028015570466] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Limited data exist on the role of adjunctive intraventricular (IVT) antibiotics for the treatment of central nervous system (CNS) infections in traumatic brain injury (TBI) patients. OBJECTIVE To evaluate differences in CNS infection cure rates for TBI patients who received adjunctive IVT antibiotics compared with intravenous (IV) antibiotics alone. METHODS We retrospectively identified patients with TBI and bacterial CNS infections admitted to the trauma intensive care unit (ICU) from 1997 to 2013. Study patients received IV and IVT antibiotics, and control patients received IV antibiotics alone. Clinical and microbiological cure rates were determined from patient records, in addition to ICU and hospital lengths of stay (LOSs), ventilator days, and hospital mortality. RESULTS A total of 83 patients were enrolled (32 study and 51 control). The duration of IV antibiotics was similar in both groups (10 vs 12 days, P = 0.14), and the study group received IVT antibiotics for a median of 9 days. Microbiological cure rates were 84% and 82% in study and control groups, respectively (P = 0.95). Clinical cure rates were similar at all time points. No significant differences were seen in days of mechanical ventilation, ICU or hospital LOS, or hospital mortality. When only patients with external ventricular drains were compared, cure rates remained similar between groups. CONCLUSIONS TBI patients with CNS infections had similar microbiological and clinical cure rates whether they were treated with adjunctive IVT antibiotics or IV antibiotics alone. Shorter than recommended durations of antibiotic therapy still resulted in acceptable cure rates and similar clinically relevant outcomes.
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Sharpe JP, Magnotti LJ, Weinberg JA, Swanson JM, Wood GC, Fabian TC, Croce MA. Impact of pathogen-directed antimicrobial therapy for ventilator-associated pneumonia in trauma patients on charges and recurrence. J Am Coll Surg 2014; 220:489-95. [PMID: 25572796 DOI: 10.1016/j.jamcollsurg.2014.12.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) represents one of the driving forces behind antibiotic use in the ICU. In a previous study, we established a defined algorithm for treatment of hospital-acquired VAP dictated by the causative pathogen. The purpose of the current study was to evaluate the impact of this algorithm for hospital-acquired VAP on recurrence and charges in trauma patients. STUDY DESIGN Patients with VAP secondary to MRSA, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, or Enterobacteriaceae during 5 years subsequent to the previous study were evaluated. All VAP were diagnosed using quantitative cultures of the bronchoalveolar lavage effluent. Duration of antimicrobial therapy was dictated by the causative pathogen. If microbiologic resolution, defined as <10(3) colony-forming units/mL, was achieved, therapy was stopped by day 10. The remainder received 14 days of therapy. Recurrence was defined as >10(5) colony-forming units/mL on subsequent bronchoalveolar lavage performed within 2 weeks after completion of appropriate therapy. RESULTS Five hundred and twenty-nine VAP episodes were identified in 381 patients. Overall recurrence was unchanged compared with the previous study (1.5% vs 2%; p = 0.3). There was a decrease in the number of bronchoalveolar lavages performed per patient compared with the previous study (1.6 vs 2.3; p = 0.24) and a reduction of 4.8 antibiotic days per VAP episode compared with the previous study. Both changes resulted in a cumulative reduction of $3,535.04 per patient, for a savings of $1.35 million during the study period. CONCLUSIONS Hospital-acquired VAP can be managed effectively by a defined course of therapy dictated by the causative pathogen. Adherence to an established algorithm simplified the management of VAP and contributed to a cumulative reduction in patient charges without impacting recurrence.
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Paulus EM, Weinberg JA, Magnotti LJ, Sharpe JP, Schroeppel TJ, Fabian TC, Croce MA. Admission red cell distribution width: a novel predictor of massive transfusion after injury. Am Surg 2014; 80:685-689. [PMID: 24987901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Admission red cell distribution width (aRDW) has been shown to predict mortality in trauma patients by an unclear mechanism. It has been speculated that aRDW is a marker of chronic health status, but elevated RDW may also reflect recent hemorrhage. We hypothesized that aRDW is a predictor of major hemorrhage in trauma patients. Shock trauma patients at a Level I trauma center over 6.5 years were evaluated. Patients were stratified by aRDW quintile (Q1: less than 13%, Q2: 13.1 to 13.5%, Q3: 13.6 to 14.0%, Q4: 14.1 to 14.9%, Q5: 15.0% or greater). Massive transfusion (MT) was defined as 10 or more packed red blood cells in the first 24 hours. From multiple logistic regression, odds ratios with 95 per cent confidence intervals (CIs) were determined to evaluate the association between aRDW quintile and MT. Three thousand nine hundred ninety-four met study criteria. Overall MT incidence was 10 per cent and in-hospital mortality was 17 per cent. MT and mortality increased in a stepwise fashion by aRDW quintile (P < 0.0001). From logistic regression, a threefold increased odds of MT was associated with aRDW Q4 (CI, 1.81 to 4.92), and a 3.5-fold increased odds of MT was associated with aRDW Q5 (CI, 2.70 to 5.83). aRDW independently predicted MT, suggesting that elevated aRDW is an indicator of major hemorrhage in trauma patients. The association between aRDW and mortality in trauma patients may be explained by acute hemorrhage rather than chronic health status.
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Paulus EM, Weinberg JA, Magnotti LJ, Sharpe JP, Schroeppel TJ, Fabian TC, Croce MA. Admission Red Cell Distribution Width: A Novel Predictor of Massive Transfusion after Injury. Am Surg 2014. [DOI: 10.1177/000313481408000724] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Admission red cell distribution width (aRDW) has been shown to predict mortality in trauma patients by an unclear mechanism. It has been speculated that aRDW is a marker of chronic health status, but elevated RDW may also reflect recent hemorrhage. We hypothesized that aRDW is a predictor of major hemorrhage in trauma patients. Shock trauma patients at a Level I trauma center over 6.5 years were evaluated. Patients were stratified by aRDW quintile (Q1: less than 13%, Q2: 13.1 to 13.5%, Q3: 13.6 to 14.0%, Q4: 14.1 to 14.9%, Q5: 15.0% or greater). Massive transfusion (MT) was defined as 10 or more packed red blood cells in the first 24 hours. From multiple logistic regression, odds ratios with 95 per cent confidence intervals (CIs) were determined to evaluate the association between aRDW quintile and MT. Three thousand nine hundred ninety-four met study criteria. Overall MT incidence was 10 per cent and in-hospital mortality was 17 per cent. MT and mortality increased in a stepwise fashion by aRDW quintile ( P < 0.0001). From logistic regression, a threefold increased odds of MT was associated with aRDW Q4 (CI, 1.81 to 4.92), and a 3.5-fold increased odds of MT was associated with aRDW Q5 (CI, 2.70 to 5.83). aRDW independently predicted MT, suggesting that elevated aRDW is an indicator of major hemorrhage in trauma patients. The association between aRDW and mortality in trauma patients may be explained by acute hemorrhage rather than chronic health status.
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Schroeppel TJ, Sharpe JP, Magnotti LJ, Weinberg JA, Croce MA, Fabian TC. How to increase the burden on trauma centers: implement the 80-hour work week. Am Surg 2014; 80:659-663. [PMID: 24987896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The 80-hour week was implemented in 2003 to improve outcomes and limit errors. We hypothesize that there has been no change in outcomes postimplementation of the restrictions. Outcomes were queried from the trauma registry from 1997 to 2002 (PRE) and 2004 to 2009 (POST). Primary outcomes were mortality, intensive care unit length of stay (ICU LOS), and length of stay (LOS). Patients were stratified based on demographics, blood pressure, heart rate, and injury severity (Injury Severity Score, Glasgow Coma Score, base deficit). Outcomes were then compared PRE with POST. A total of 41,770 patients were admitted during the study period. The mean age was 38 years with most being male (73%) and blunt mechanism (78%). Although patients admitted in the POST period had a slightly higher blood pressure, they were older and had higher injury severity. ICU LOS, LOS, self-pay, and mortality were higher in the POST period. After adjusted analysis, admission in the POST period was no longer a predictor of mortality (odds ratio, 1.02; confidence interval, 0.92 to 1.14). Whereas patients were more slightly more injured in the POST period, the adjusted analysis shows no difference in mortality and both a longer LOS and ICU LOS. Whether the increase is the result of more severe injury in the POST period or less efficient disposition remains to be elucidated. This study adds to the mounting evidence that the implementation of the limits on work hours does not lead to better outcomes.
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Shafi S, Barnes SA, Millar D, Sobrino J, Kudyakov R, Berryman C, Rayan N, Dubiel R, Coimbra R, Magnotti LJ, Vercruysse G, Scherer LA, Jurkovich GJ, Nirula R. Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries. J Neurosurg 2014; 120:773-7. [PMID: 24438538 DOI: 10.3171/2013.12.jns132151] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.
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Schroeppel TJ, Fabian TC, Clement LP, Fischer PE, Magnotti LJ, Sharpe JP, Lee M, Croce MA. Propofol infusion syndrome: a lethal condition in critically injured patients eliminated by a simple screening protocol. Injury 2014; 45:245-9. [PMID: 23742861 DOI: 10.1016/j.injury.2013.05.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 04/05/2013] [Accepted: 05/04/2013] [Indexed: 02/02/2023]
Abstract
UNLABELLED Propofol infusion syndrome (PIS) is defined by arrhythmia, rhabdomyolysis, lactic acidosis, and unrecognized leads to death. We sought to determine the incidence of PIS in trauma patients and evaluate the efficacy of a prospective screening protocol in this patient population. MATERIALS AND METHODS In Phase I of the before-and-after study (1st January, 2005-31st December, 2005), trauma patients who received propofol were evaluated. Records were reviewed for demographics, injury severity, propofol time, dose, and rates, laboratory values, and adverse events. Patients were identified with PIS based on two of the following criteria: (1) cardiac arrhythmia/collapse, (2) metabolic acidosis, (3) rhabdomyolysis, and (4) acute kidney injury. Phase II (1st January, 2006-31st December, 2011) consisted of a prospective screening protocol (elevated lactate or creatine phosphokinase (CPK)) to identify patients at risk for PIS. RESULTS 207 patients were identified in Phase I. 6 (2.9%) developed PIS with a 50% mortality. No differences were seen in age, gender, or mechanism. PIS patients were more injured (median ISS 44 vs 26, p=0.04; median head AIS 5 vs 4, p=0.003) and received more propofol (median 50,350 vs 9770 mg, p=0.001) with longer infusion times (413 vs 65 h, p=0.001). Sodium, creatinine, and CPK levels were higher in those that developed PIS (160 vs 145 mmol/L, p=0.001; 4.3 vs 1.1mg/dL, p=0.005; 59,871 vs 520 U/L; p=0.002). Pre-screening PIS incidence was 2.9% (6/207), but after screening (January 2006) the incidence dropped to 0.19% (2/1038, p<0.001). CONCLUSIONS PIS is a morbid and lethal entity associated with sedation of critically injured patients. A simple screening procedure utilizing serum CPK (<5000 U/L) can essentially eliminate the development of PIS.
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Hill DM, Schroeppel TJ, Magnotti LJ, Clement LP, Sharpe JP, Fischer PE, Weinberg JA, Croce MA, Fabian TC. Methicillin-Resistant Staphylococcus aureus in Early Ventilator-Associated Pneumonia: Cause for Concern? Surg Infect (Larchmt) 2013; 14:520-4. [DOI: 10.1089/sur.2012.166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Wood GC, Boucher AB, Johnson JL, Wisniewski JN, Magnotti LJ, Croce MA, Swanson JM, Boucher BA, Fabian TC. Effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock after acute spinal cord injury: a case series. Pharmacotherapy 2013; 34:89-93. [PMID: 23918202 DOI: 10.1002/phar.1335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To evaluate the effectiveness of pseudoephedrine as adjunctive therapy for neurogenic shock in patients with acute spinal cord injury (SCI). DESIGN Case series. SETTING Academic medical center. PATIENTS Thirty-eight patients admitted to the trauma intensive care unit between September 2005 and October 2012 with an acute SCI and who received more than 1 day of pseudoephedrine for one or more of the following: treatment of bradycardia (heart rate ≤ 50 beats/min), treatment of hypotension (systolic blood pressure < 90 mm Hg), or were receiving intravenous vasopressor support. MEASUREMENTS AND MAIN RESULTS The effect of adjunctive pseudoephedrine (PSE) was categorized as a success if vasopressors were discontinued after the initiation of PSE or improvement in the number of episodes of bradycardia was noted after the initiation of PSE as evidenced by decreased use of atropine. The effect of pseudoephedrine was categorized as a failure if it did not meet one of the criteria for success. The effect of pseudoephedrine was categorized as inconclusive if there were confounding factors such as vasopressors being restarted for another indication after initial discontinuation. Pseudoephedrine was successful in 31/38 (82%) patients, failed in 2/38 (5%) patients, and had inconclusive results in 5/38 (13%) patients. The mean ± SD time to successful weaning of intravenous vasopressors was 7 ± 7 days. Daily maximum pseudoephedrine doses ranged from 60-720 mg. Mean ± SD duration of pseudoephedrine therapy was 32 ± 23 days (range 2-135 days), with 64.5% of surviving patients discharged while receiving pseudoephedrine. CONCLUSION These data suggest that pseudoephedrine is an effective adjunctive therapy in facilitating the discontinuation of intravenous vasopressors and/or atropine in patients with acute SCI with neurogenic shock, although patients will typically require long durations of therapy.
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Swanson JM, Connor KA, Magnotti LJ, Croce MA, Johnson J, Wood GC, Fabian TC. Resolution of Clinical and Laboratory Abnormalities after Diagnosis of Ventilator-Associated Pneumonia in Trauma Patients. Surg Infect (Larchmt) 2013; 14:49-55. [DOI: 10.1089/sur.2011.128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sharpe JP, Weinberg JA, Magnotti LJ, Nouer SS, Yoo W, Zarzaur BL, Cullinan DR, Hendrick LE, Fabian TC, Croce MA. Outcomes of operations performed by attending surgeons after overnight trauma shifts. J Am Coll Surg 2013; 216:791-7; discussion 797-9. [PMID: 23313541 DOI: 10.1016/j.jamcollsurg.2012.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 12/07/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND To date, work-hour restrictions have not been imposed on attending surgeons in the United States. The purpose of this study was to investigate the impact of working an overnight trauma shift on outcomes of general surgery operations performed the next day by the post-call attending physician. STUDY DESIGN Consecutive patients over a 3.5-year period undergoing elective general surgical procedures were reviewed. Procedures were limited to hernia repairs (inguinal and ventral), cholecystectomies, and intestinal operations. Any operations that were performed the day after the attending surgeon had taken an overnight trauma shift were considered post-call (PC) cases; all other cases were considered nonpost-call (NP). Outcomes from the PC operations were compared with those from the NP operations. RESULTS There were 869 patients identified; 132 operations were performed PC and 737 were NP. The majority of operations included hernia repairs (46%), followed by cholecystectomies (35%), and intestinal procedures (19%). Overall, the PC operations did not differ from the NP operations with respect to complication rate (13.7% vs 13.5%, p = 0.93) or readmission within 30 days (5% vs 6%, p = 0.84). Additionally, multivariable logistic regression failed to identify an association between PC operations and the development of adverse outcomes. Follow-up was obtained for an average of 3 months. CONCLUSIONS Performance of general surgery operations the day after an overnight in-hospital trauma shift did not affect complication rates or readmission rates. At this time, there is no compelling evidence to mandate work-hour restrictions for attending general surgeons.
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Wells DL, Swanson JM, Wood GC, Magnotti LJ, Boucher BA, Croce MA, Harrison CG, Muhlbauer MS, Fabian TC. Authors' response. Crit Care 2013; 17:401. [PMID: 25215361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
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Wells DL, Swanson JM, Wood GC, Magnotti LJ, Boucher BA, Croce MA, Harrison CG, Muhlbauer MS, Fabian TC. The relationship between serum sodium and intracranial pressure when using hypertonic saline to target mild hypernatremia in patients with head trauma. Crit Care 2012; 16:R193. [PMID: 23068293 PMCID: PMC3682295 DOI: 10.1186/cc11678] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 08/20/2012] [Accepted: 09/25/2012] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Limited data suggest mild hypernatremia may be related to lower intracranial pressure (ICP) in patients with traumatic brain injury (TBI). The practice at the study center has been to use hypertonic saline (HTS) to generate a targeted serum sodium of 145 to 155 mEq/l in patients with TBI. The purpose of this study was to determine the relationship between serum sodium values and ICP, and to evaluate the acute effect of HTS on ICP. METHODS A retrospective review of patients who were admitted to the trauma ICU for TBI, had an ICP monitor placed, and received at least one dose of HTS between January 2006 and March 2011 was performed. Data were collected for up to 120 hours after ICP monitor placement. The primary outcome was the relationship between serum sodium and maximum ICP. Secondary outcomes were the relationship between serum sodium and the mean number of daily interventions for ICP control, and the acute effect of HTS on ICP during the 6 hours after each dose. Linear regression was used to analyze the primary outcome. Analysis of variance on ranks and repeated measures analysis of variance were used to evaluate the number of interventions and the acute effect of HTS on ICP, respectively. RESULTS Eighty-one patients were enrolled with mean ± standard deviation age of 36 ± 15 years and median Glasgow Coma Scale score of 7 (interquartile range, 4 to 7). A total of 1,230 serum sodium values (range, 118 to 174 mEq/l) and 7,483 ICP values (range, 0 to 159 mmHg) were collected. There was no correlation between serum sodium and maximum ICP (R(2) = 0.0052). The overall mean ± standard deviation number of interventions for elevated ICP per day was 4.2 ± 2.9, 2.9 ± 2.0, and 2.6 ± 2.3 for patients with a mean serum sodium of < 145, 145 to 155, and > 155 mEq/l, respectively (P < 0.001). Regarding the acute effect of HTS on ICP, there was no statistical difference in mean ICP compared with baseline during hours 1 through 6 following HTS doses (baseline, 13.7 ± 8.4 mmHg; hour 1, 13.6 ± 8.3 mmHg; hour 2, 13.5 ± 8.8 mmHg; hour 3, 13.3 ± 8.7 mmHg; hour 4, 13.4 ± 8.7 mmHg; hour 5, 13.4 ± 8.3 mmHg; hour 6, 13.5 ± 8.3 mmHg; P = 0.84). CONCLUSIONS Serum sodium concentrations did not correlate with ICP values. These results warrant further evaluation and possible reassessment of sodium goals for ICP management in patients with TBI.
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Sharpe JP, Magnotti LJ, Weinberg JA, Parks NA, Maish GO, Shahan CP, Fabian TC, Croce MA. A Suggested Amendment to the Simplified Management Algorithm for Penetrating Colon Injuries. J Am Coll Surg 2012. [DOI: 10.1016/j.jamcollsurg.2012.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Czosnowski QA, Wood GC, Magnotti LJ, Croce MA, Swanson JM, Boucher BA, Fabian TC. Clinical and microbiologic outcomes in trauma patients treated for Stenotrophomonas maltophilia ventilator-associated pneumonia. Pharmacotherapy 2011; 31:338-45. [PMID: 21449623 DOI: 10.1592/phco.31.4.338] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVES To determine clinical and microbiologic plus clinical success rates in critically ill trauma patients who received treatment for Stenotrophomonas maltophilia ventilator-associated pneumonia (VAP). DESIGN Retrospective medical record review. SETTING Level I trauma intensive care unit of a large academic medical center. PATIENTS A total of 101 patients who developed S. maltophilia VAP between January 1997 and December 2007. MEASUREMENTS AND MAIN RESULTS Patients' baseline demographic and clinical characteristics, as well as characteristics of their VAP, were documented. The primary study outcome was the rate of clinical success in patients with S. maltophilia VAP; a secondary outcome was microbiologic plus clinical success rate in these patients. Standard definitions were employed to determine these outcomes related to VAP treatment. The study population had higher injury severity scores and a higher rate of traumatic brain injury than is typically observed in the study's intensive care unit. The median time to diagnosis of S. maltophilia VAP was 15 days (interquartile range 11-24 days). Stenotrophomonas maltophilia was the sole organism isolated in 34% of patients; the other patients had polymicrobial VAP. Despite inadequate empiric antibiotic therapy being administered to 97% of the patients, the overall clinical success rate was 87%. The microbiologic plus clinical success rate was 82%. The most common treatments for S. maltophilia VAP were trimethoprim-sulfamethoxazole (77 patients received monotherapy, 9 received combination therapy) and ciprofloxacin (6 patients received monotherapy, 8 received combination therapy); all-cause and VAP-related mortality rates were 13% and 7%, respectively. CONCLUSION Critically ill trauma patients with S. maltophilia VAP responded well to therapy despite high rates of inadequate empiric antibiotic administration. Trimethoprim-sulfamethoxazole was the most common therapy, but clinical success rates did not differ significantly based on antibiotic selection. This study adds significantly to the available S. maltophilia VAP outcomes data.
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Magnotti LJ, Croce MA, Zarzaur BL, Swanson JM, Wood GC, Weinberg JA, Fabian TC. Causative Pathogen Dictates Optimal Duration of Antimicrobial Therapy for Ventilator-Associated Pneumonia in Trauma Patients. J Am Coll Surg 2011; 212:476-84; discussion 484-6. [DOI: 10.1016/j.jamcollsurg.2010.12.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 11/24/2022]
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Abstract
Since the advent of minimally invasive surgery, the use of laparoscopy for both diagnostic as well as therapeutic interventions has continued to expand in all of the surgical disciplines. In fact, this modality provides a viable alternative for the diagnosis of occult intra-abdominal injury following both penetrating and blunt trauma. The increased use of laparoscopy coupled with defined management algorithms has decreased the rate of negative and/or nontherapeutic laparotomy. This is particularly important in those patients where the potential for peritoneal violation exists without other clear indications for laparotomy. As technology and instrumentation continue to advance, future directions will include more attempts at therapeutic and ‘awake’ laparoscopy to embrace the advantages of minimally invasive surgery including decreased pain, expedited discharge and reduction of unnecessary laparotomy in suitable patients.
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Magnotti LJ, Bradburn EH, Webb DL, Berry SD, Fischer PE, Zarzaur BL, Schroeppel TJ, Fabian TC, Croce MA. Admission ionized calcium levels predict the need for multiple transfusions: a prospective study of 591 critically ill trauma patients. ACTA ACUST UNITED AC 2011; 70:391-5; discussion 395-7. [PMID: 21307739 DOI: 10.1097/ta.0b013e31820b5d98] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Deaths from uncontrolled exsanguinating hemorrhage occur rapidly postinjury. Any successful resuscitation strategy must also occur early, underscoring the importance of rapid identification of patients at risk for multiple transfusions. Previous studies have shown low ionized calcium (iCa) levels to be associated with hypotension and function as a predictor of mortality. We hypothesized that admission iCa levels could potentially predict the need for multiple transfusions in critically ill trauma patients. METHODS Admission iCa was collected prospectively on all trauma activations during a 9-month period. Youden's index was used to determine the appropriate cutpoint for iCa. Outcomes (mortality, multiple transfusions [≥5 units packed red blood cells in 24 hours] and massive transfusion [≥10 units packed red blood cells in 24 hours]) were compared using Wilcoxon rank-sum and χ tests where appropriate. Multivariable logistic regression was performed to determine whether iCa was an independent predictor of multiple transfusions. RESULTS A total of 591 patients were identified: 461 (78%) men and 130 (22%) women. Cutpoint was identified as 1.00. iCa was <1.00 (lo-Cal) in 332 patients and≥1.00 (hi-Cal) in 259 patients. Mortality was significantly increased in the lo-Cal group (15.5% vs. 8.7%, p=0.036). In addition, both multiple transfusions (17.1% vs. 7.1%, p=0.005) and massive transfusion (8.2% vs. 2.2%, p=0.017) were significantly increased in the lo-Cal group. Multivariable logistic regression analysis identified iCa<1 as an independent predictor of the need for multiple transfusions after adjusting for age and injury severity (odds ratio=2.294, 95% confidence interval=1.053-4.996). CONCLUSIONS Low iCa levels at admission were associated with increased mortality as well as an increased need for both multiple transfusions and massive transfusion. In fact, multivariable logistic regression analysis identified low iCa levels as an independent predictor of multiple transfusions. Admission iCa levels may facilitate the rapid identification of patients requiring massive transfusion, allowing for earlier preparation and administration of appropriate blood products.
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Amin PB, Magnotti LJ, Fischer PE, Fabian TC, Croce MA. Prophylactic antibiotic days as a predictor of sensitivity patterns in Acinetobacter pneumonia. Surg Infect (Larchmt) 2010; 12:33-8. [PMID: 21186957 DOI: 10.1089/sur.2010.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) secondary to Acinetobacter spp. in critically ill trauma patients has increased. More importantly, the incidence of multi-drug-resistant (MDR) Acinetobacter VAP has increased. The risk factors for this increase in resistance have yet to be elucidated. The purpose of this study was to evaluate the change in Acinetobacter sensitivity over time and determine which risk factors predict resistance in trauma patients. METHODS Patients surviving >5 days post-injury who had Acinetobacter VAP (≥10(5) colony-forming units/mL in bronchoalveolar lavage fluid) who were seen over five years were divided according to pathogen sensitivity (sensitive [SEN] vs. MDR) and stratified by age, severity of shock (base excess, number of blood transfusions), injury severity (Injury Severity Score [ISS], admission Glasgow Coma Scale [GCS] score, chest and extremity Abbreviated Injury Scale score [AIS]), and year. Prophylactic (Pro), empiric (Emp), Pro + Emp, and total antibiotic days, ventilator days, and mortality rate were compared. Multivariable logistic regression (MLR) was performed to determine which risk factors were independent predictors of resistance. RESULTS Ninety-six patients (81% male) were identified: 62 SEN and 34 MDR. The groups were clinically similar in terms of age, extent of shock, and injury severity with the exception of extremity AIS. Antibiotic exposure was greater in the MDR group. Over the period of the study, the incidence of MDR Acinetobacter VAP increased from zero to 66% (p < 0.0001). Multiple logistic regression identified Pro antibiotic days as an independent predictor of MDR after adjusting for age and chest AIS (p < 0.0001). CONCLUSIONS The incidence of MDR Acinetobacter VAP has increased over time. More severe extremity injuries, as measured by the AIS, may contribute to prolonged antibiotic exposure in those patients with MDR Acinetobacter VAP. Multiple logistic regression identified Pro antibiotic days as an independent risk factor for MDR Acinetobacter VAP in trauma patients.
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Zarzaur BL, Croce MA, Fabian TC, Fischer P, Magnotti LJ. A population-based analysis of neighborhood socioeconomic status and injury admission rates and in-hospital mortality. J Am Coll Surg 2010; 211:216-23. [PMID: 20670859 DOI: 10.1016/j.jamcollsurg.2010.03.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 03/22/2010] [Accepted: 03/24/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Research indicates that neighborhood socioeconomic status (N-SES) is inversely related to injury and injury-related mortality. We hypothesized that injury-related hospitalization rates would vary by N-SES and that N-SES would be related to in-hospital mortality. STUDY DESIGN Adults (age 18 to 84 years) living in Shelby County, TN, were eligible for the study. Addresses of adults admitted to the only Level I trauma center in the county from 1996 to 2005 were geocoded and matched to 1 of 214 census tract groups. Census tract groups were divided into quintiles based on percent of the population living below the poverty level (lowest to highest income N-SES). Crude injury admission rate ratios (CIRR) and 95% confidence intervals (CI) were calculated. Multivariable logistic regression was used to determine if N-SES was associated with in-hospital mortality. RESULTS Compared with the highest N-SES, those in the lowest N-SES suffered significantly higher rates of blunt (CIRR 5.74; 95% CI 5.35, 6.15) and penetrating injuries (CIRR 20.98; 95% CI 18.03, 24.42). On multivariable logistic regression analysis, compared with the highest N-SES, decreasing N-SES was not associated with in-hospital mortality for blunt (high-middle [0.90; 95% CI 0.57, 1.44]; middle [1.22; 95% CI 0.78, 1.87]; low-middle [0.89; 95% CI 0.58, 1.39]; lowest [0.67; 95% CI 0.42, 1.08]); or penetrating injury (high-middle [1.35; 95% CI 0.48, 3.81]; middle [2.77; 95% CI 0.99, 7.25]; low-middle [1.44; 95% CI 0.55, 3.74]; and lowest [1.03; 95% CI 0.39, 2.73]). CONCLUSIONS N-SES was inversely related to crude injury rates for all mechanisms. However, in-hospital mortality was not associated with N-SES level.
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DiCocco JM, Magnotti LJ, Emmett KP, Zarzaur BL, Croce MA, Sharpe JP, Shahan CP, Jiao H, Goldberg SP, Fabian TC. Long-Term Follow-Up of Abdominal Wall Reconstruction after Planned Ventral Hernia: A 15-Year Experience. J Am Coll Surg 2010; 210:686-95, 695-8. [PMID: 20421031 DOI: 10.1016/j.jamcollsurg.2009.12.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/23/2009] [Indexed: 10/19/2022]
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Swanson JM, Mueller EW, Croce MA, Wood GC, Boucher BA, Magnotti LJ, Fabian TC. Changes in Pulmonary Cytokines during Antibiotic Therapy for Ventilator-Associated Pneumonia. Surg Infect (Larchmt) 2010; 11:161-7. [DOI: 10.1089/sur.2008.067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Hargraves MB, Magnotti LJ, Fischer PE, Schroeppel TJ, Zarzaur BL, Fabian TC, Croce MA. Injury location dictates utility of digital rectal examination and rigid sigmoidoscopy in the evaluation of penetrating rectal trauma. Am Surg 2009; 75:1069-72. [PMID: 19927507 DOI: 10.1177/000313480907501108] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Penetrating pelvic injuries (specifically rectal) pose a difficult diagnostic challenge. Although management of these injuries, once recognized, can be straightforward, the consequences of a missed injury can be devastating. The purpose of this study was to evaluate the utility of digital rectal examination (DRE) and rigid sigmoidoscopy (RS) as screening tests for penetrating rectal injuries. Patients with full-thickness penetrating rectal injury over a 10-year period were identified. All underwent DRE and RS before exploration. Injury location was classified as intraperitoneal (IP) or extraperitoneal (EP). Overall sensitivities for DRE and RS were calculated as well as sensitivities for RS in the identification of IP versus EP injuries. Seventy-seven patients were identified. Overall sensitivity for DRE and RS was 51 per cent (95% CI: 37-65%) and 78 per cent (95% CI: 65-92%), respectively. Sensitivity of RS for identification of rectal injury based on anatomic distinction was 58 per cent (95% CI: 30-86%) for IP and 88 per cent (95% CI: 75-100%) for EP injuries. Anatomic location determines the value of preoperative screening tests for identification of penetrating rectal injuries. RS proved better than DRE for diagnosis. The greatest benefit was observed with EP injuries. The possibility of a missed IP injury associated with a negative screen should prompt exploration if clinical suspicion is high.
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Czosnowski QA, Wood GC, Magnotti LJ, Croce MA, Swanson JM, Boucher BA, Fabian TC. Adjunctive aerosolized antibiotics for treatment of ventilator-associated pneumonia. Pharmacotherapy 2009; 29:1054-60. [PMID: 19698010 DOI: 10.1592/phco.29.9.1054] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine clinical and microbiologic success in patients receiving adjunctive aerosolized antibiotics for the treatment of ventilator-associated pneumonia (VAP). DESIGN Retrospective medical record review. SETTING Level I trauma intensive care unit of a large academic medical center. PATIENTS Forty-nine patients (mean +/- SD age 42 +/- 19 yrs) who received aerosolized antibiotics for the treatment of a total of 60 episodes of VAP caused by Pseudomonas aeruginosa and/or Acinetobacter baumannii between January 2001 and July 2007. MEASUREMENTS AND MAIN RESULTS Patients were identified by using an existing database of patients with documented VAP at the study center. To receive a diagnosis of VAP, patients had to have bacterial growth of 10(5) or more colony-forming units/ml from a bronchoscopic bronchoalveolar lavage and new or changing infiltrate on chest radiograph, plus at least two of the following: abnormal body temperature (> 38 degrees C or < 36 degrees C), abnormal white blood cell count (> 10 or < 4 x 10(3)/mm(3), or > 10% immature bands), or macroscopically purulent sputum. By reviewing patient data, we evaluated clinical and microbiologic success using standard definitions. The median (interquartile range) Injury Severity Score and admission Acute Physiology and Chronic Health Evaluation II score were 40 (29-45) and 17 (9-21), respectively. Pseudomonas aeruginosa, A. baumannii, or both were isolated in 45, 14, and 1 episode(s), respectively. Eighteen VAP episodes included additional bacteria. Aerosolized tobramycin, amikacin, and colistimethate were used in 44, 9, and 9 episodes, respectively. Systemic antibiotics were used in 59 (98%) of the 60 episodes. Clinical success was achieved in 36 (73%) of the 49 first episodes of VAP, 8 (73%) of 11 subsequent episodes, 17 (85%) of 20 episodes that were failing intravenous monotherapy, and 30 (79%) of 38 episodes with multidrug-resistant P. aeruginosa or A. baumannii. Microbiologic success was achieved in 29 (71%) of 41 evaluable episodes. Six patients died from VAP. CONCLUSION Treatment with adjunctive aerosolized antibiotics was associated with a good response rate in critically ill trauma patients with VAP due to nonfermenting gram-negative bacilli. It is noteworthy that episodes of VAP that followed intravenous therapy failure and/or that were due to multidrug-resistant organisms responded well.
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