Cirrhosis Increases the Rate of Failure of Nonoperative Management in Blunt Liver Injuries

Pre-existing cirrhosis is associated with increased mortality in blunt liver injury. Despite widespread use of nonoperative management (NOM) for blunt liver injury, there is a relative paucity of data regarding how pre-existing cirrhosis impacts the success of NOM. Herein, we perform a retrospective cohort study using ACS TQIP 2017-2020 data to assess the relationship between cirrhosis and failure of NOM for adult patients with blunt liver injury. 37,176 patients were included (342 cirrhosis and 36,834 without cirrhosis). After propensity-score matching, patients with pre-existing cirrhosis had higher rates of failure of NOM (32.2 vs 14.1%, p < 0.01) and in-hospital mortality (36.3 vs 10.8%, p < 0.01) than patients without cirrhosis. Hesitancy to operate on patients with pre-existing cirrhosis and trauma, as well as significant underlying coagulopathy, may explain these findings.

Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis

INTRODUCTION

There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy.

METHODS

We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed.

RESULTS

Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044).

CONCLUSIONS

On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

The COST of liver disease: The Cirrhosis Outcomes Score in Trauma Study

BACKGROUND

Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST).

METHODS

Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality.

RESULTS

A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813.

CONCLUSION

Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

Uncontrolled bleeding is the leading cause of preventable death following injury. Trauma-induced coagulopathy can manifest as diverse phenotypes ranging from hypocoagulability to hypercoagulability, which can change quickly during the acute phase of trauma care. The major advances in understanding coagulation over the past 25 years have resulted from the cell-based concept, emphasizing the key role of platelets and their interaction with the damaged endothelium. Consequently, conventional plasma-based coagulation testing is not accurate in predicting bleeding and does not provide an assessment of which blood products are indicated. Viscoelastic hemostatic assays (VHA), conducted in whole blood, have emerged as a superior method to guide goal-directed transfusion. The major change in resuscitation has been the shift from unbridled crystalloid loading to judicious balanced blood product administration. Furthermore, the recognition of the rapid changes from hypocoagulability to hypercoagulability has underscored the importance of ongoing surveillance beyond emergent surgery. While the benefits of VHA testing are maximized when used as early as possible, current technology limits use in the pre-hospital setting and the time to results compromises its utility in the emergency department. Thus, most of the reported experience with VHA in trauma is in the operating room and intensive care unit, where there is compelling data to support its value. This overview will address the current and potential role of VHA in the seriously injured patient, throughout the continuum of trauma management.

Predicting Outcomes in Trauma Patients With Cirrhosis Using Model for End-Stage Liver Disease Score: A Retrospective Study

BACKGROUND

Liver cirrhosis is associated with increased mortality in trauma victims. We stratified the impact of cirrhosis on trauma mortality by Model for End-stage Liver Disease (MELD) score.

METHODS

Trauma center database was accessed for patients with established diagnosis of cirrhosis presenting 2014 - 2018, matched to control patients without cirrhosis in a 2:1 ratio by age, sex, and TRISS. Primary outcome was mortality, secondary outcomes were length of stay, intensive care unit days, and ventilator dependent days.

RESULTS

Cirrhosis was present in 182 (1.5%) trauma patients. Mortality difference between 12 (7%) deaths in cirrhosis cohort versus 14 (4%) in control was not statistically significant (p = 0.38). No difference was found in secondary outcomes. Categorization of cirrhosis severity by MELD score range (MELD 6-7, 8-10, 11-14, 15-20, 21-30) showed a 1.9 fold increase in the odds of mortality for every increase in MELD score category (OR = 1.91, p = 0.03, 95% CI = 1.08 - 3.37).

CONCLUSION

Mortality effects of cirrhosis in trauma patients can be estimated using MELD score.

Damage Control Laparotomy in the Cirrhotic Trauma Patient is Highly Lethal: A Matched Cohort Study

INTRODUCTION

Damage control laparotomy (DCL) has revolutionized trauma care and is considered the standard of care for severely injured patients requiring laparotomy. The role of DCL in cirrhotic patients has not been investigated.

METHODS

A matched cohort study using American College of Surgeons Trauma Quality Improvement Program database including patients undergoing DCL within 24 hours of admission. A 1:2 cohort matching of cirrhotic vs. non-cirrhotic patients was matched for the following criteria: age (>55, ≤55 years), gender, mechanism of injury (blunt and penetrating), injury severity score (ISS) (≤25, >25), head/face/neck Abbreviated Injury Scale (AIS) (<3, ≥3), chest AIS (<3, ≥3), abdominal AIS (<3, ≥3), and overall comorbidities. Outcomes between the 2 cohorts were subsequently compared with univariable analysis.

RESULTS

Overall, 1151 patients with DCL within 24 hours were identified, 29 (2.5%) with liver cirrhosis. Six cirrhotic patients were excluded because there were no suitable matching controls. The remaining 23 cirrhotic patients were matched with 46 non-cirrhotic patients. Overall mortality in the cirrhotic group was 65% vs. 26% in the non-cirrhotic group (P = .002). The higher mortality rate in cirrhotic vs. non-cirrhotic patients was accentuated in the group with ISS >25 (83% vs. 33%; P = .005). 40% of the deaths in cirrhotic patients occurred after 10 days of admission, compared to only 8% in non-cirrhotic patients (P = .091). The total blood product use within 24 hours was significantly higher in cirrhotic than non-cirrhotic patients [33 (14-46) units vs. 19.9 (4-32) units; P = .044].

CONCLUSION

Cirrhotic trauma patients undergoing DCL have a very high mortality. A significant number of deaths occur late and alternative methods of physiological support should be considered.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions

BACKGROUND AND AIMS

Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures.

METHODS

We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review.

RESULTS

Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate.

CONCLUSIONS

Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.

The effect of cirrhosis on trauma outcomes: A systematic review and meta-analysis

BACKGROUND

The negative effect of cirrhosis on mortality following traumatic injury has been quantified in multiple observational studies. However, to our knowledge, the information contained in these studies has never been synthesized. The aims of this study were: (1) to determine the magnitude of the effect of liver cirrhosis on mortality, morbidity, and hospital course among trauma patients and (2) to analyze sources of study heterogeneity that may lead to differing estimates in the observed mortality rate among patients with cirrhosis.

METHODS

A systematic search of EMBASE and PubMed was conducted. Data were extracted from eligible studies and analyzed using a random-effects model to compare trauma outcomes in cirrhotic and noncirrhotic patients (PROSPERO Registration CRD42018088464). Mortality was the primary outcome. Secondary outcomes included complication rate, length of hospital stay, length of intensive care unit stay, and mechanical ventilation days.

RESULTS

Title and abstract review of 15,958 articles led to the identification of 31 relevant articles. Ultimately, 18 observational studies were included in this meta-analysis. The pooled effect sizes for mortality (odds ratio [OR], 4.52; 95% confidence interval [CI], 3.13-6.54) and complication rate (OR, 1.92; 95% CI, 1.30-2.85) were higher in the cirrhotic group than the noncirrhotic group. Trauma patients with cirrhosis also incurred longer hospital stays (mean difference, 3.81 days; 95% CI, 1.22-6.41) and longer ICU stays (mean difference, 2.40 days; 95% CI, 0.65-4.15). There was no difference in days spent on mechanical ventilation.

CONCLUSION

Preexisting liver cirrhosis is associated with increased mortality rate, complication rate, and length of hospitalization among trauma patients, even after adjusting for confounding factors and potential sources of between-study heterogeneity. Trauma patients with cirrhosis would benefit from heightened surveillance and injury prevention interventions.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Modern Management of Bleeding, Clotting, and Coagulopathy in Trauma Patients: What Is the Role of Viscoelastic Assays?

Purpose of Review

The purpose of this review is to briefly outline the current state of hemorrhage control and resuscitation in trauma patients with a specific focus on the role viscoelastic assays have in this complex management, to include indications for use across all phases of care in the injured patient.

Recent Findings

Viscoelastic assay use to guide blood-product resuscitation in bleeding trauma patients can reduce mortality by up to 50%. Viscoelastic assays also reduce total blood products transfused, reduce ICU length of stay, and reduce costs. There are a large number of observational and retrospective studies evaluating viscoelastic assay use in the initial trauma resuscitation, but only one randomized control trial. There is a paucity of data evaluating use of viscoelastic assays in the operating room, post-operatively, and during ICU management in trauma patients, rendering their use in these settings extrapolative/speculative based on theory and data from other surgical disciplines and settings.

Summary

Both hypocoagulable and hypercoagulable states exist in trauma patients, and better indicate what therapy may be most appropriate. Further study is needed, particularly in the operating room and post-operative/ICU settings in trauma patients.

Outcomes of chronic subdural hematoma in patients with liver cirrhosis

OBJECTIVE: Burr hole craniostomy is an effective and simple procedure for treating chronic subdural hematoma (CSDH). However, the surgical outcomes and recurrence of CSDH in patients with liver cirrhosis (LC) remain unknown. METHODS: A nationwide population-based cohort study was retrospectively conducted using data from the Taiwan National Health Insurance Research Database. The study included 29,163 patients who underwent first-time craniostomy for CSDH removal between January 1, 2001, and December 31, 2013. In total, 1223 patients with LC and 2446 matched non-LC control patients were eligible for analysis. All-cause mortality, surgical complications, repeat craniostomy, extended craniotomy, and long-term medical costs were analyzed. RESULTS: The in-hospital mortality rate (8.7% vs 3.1% for patients with LC and non-LC patients, respectively), frequency of hospital admission, length of ICU stay, number of blood transfusions, and medical expenditures of patients with LC who underwent craniostomy for CSDH were considerably higher than those of non-LC control patients. Patients with LC tended to require an extended craniotomy to remove subdural hematomas in the hospital or during long-term follow-up. The surgical outcome worsened with an increase in the severity of LC. CONCLUSIONS: Even for simple procedures following minor head trauma, LC remains a serious comorbidity with a poor prognosis.

Correction of Severe Coagulopathy and Hyperfibrinolysis by Tranexamic Acid and Recombinant Factor VIIa in a Cirrhotic Patient After Trauma: A Case Report

Coagulopathy induced by trauma or cirrhosis is a well-recognized entity. Viscoelastic testing has been used in either condition for goal-directed transfusion and detection of fibrinolysis since conventional coagulation tests do not correlate with clinical risk of bleeding. Hemostatic resuscitation may not be adequate for a trauma patient with liver disease due to complex alterations in coagulation systems and occasionally require adjuvant therapy. We report a case of trauma-induced coagulopathy presenting as severe hyperfibrinolysis in a cirrhotic patient who was refractory to hemostatic resuscitation but was rapidly corrected by the administration of tranexamic acid and recombinant Factor VIIa.

How motorcycle helmets affect trauma mortality: Clinical and policy implications

BACKGROUND

Motorcycles are the most popular vehicles in Taiwan, where more than 14.8 million motorcycles (1 motorcycle per 1.6 people) are in service. Despite the mandatory helmet law passed in 1997, less than 80% of motorcyclists in Taiwan wear helmets.

OBJECTIVE

The objective of this study was to analyze the effect of using motorcycle helmets on fatality rates.

METHODS

A clinical data set including 2,868 trauma patients was analyzed; the cross-sectional registration database was administered by a university medical center in Central Taiwan. A path analysis framework and multiple logistic regressions were used to estimate the marginal effect of helmet use on mortality.

RESULTS

Using a helmet did not directly reduce the mortality rate but rather indirectly reduced the mortality rate through intervening variables such as the severity of head injuries, number of craniotomies, and complications during therapeutic processes. Wearing a helmet can reduce the fatality rate by 1.3%, the rate of severe head injury by 34.5%, the craniotomy rate by 7.8%, and the rate of complications during therapeutic processes by 1.5%. These rates comprise 33.3% of the mortality rate for people who do not wear helmets, 67.3% of the severe head injury rate, 60.0% of the craniotomy rate, and 12.2% of the rate of complications during therapeutic processes.

DISCUSSION

Wearing a helmet and trauma system designation are crucial factors that reduce the fatality rate.

Emergent laparotomy and temporary abdominal closure for the cirrhotic patient

BACKGROUND

Temporary abdominal closure (TAC) may be performed for cirrhotic patients undergoing emergent laparotomy. The effects of cirrhosis on physiologic parameters, resuscitation requirements, and outcomes following TAC are unknown. We hypothesized that cirrhotic TAC patients would have different resuscitation requirements and worse outcomes than noncirrhotic patients.

METHODS

We performed a 3-year retrospective cohort analysis of 231 patients managed with TAC following emergent laparotomy for sepsis, trauma, or abdominal compartment syndrome. All patients were initially managed with negative pressure wound therapy (NPWT) TAC with intention for planned relaparotomy and sequential abdominal closure attempts at 24- to 48-h intervals.

RESULTS

At presentation, cirrhotic patients had higher incidence of acidosis (33% versus 17%) and coagulopathy (87% versus 54%) than noncirrhotic patients. Forty-eight hours after presentation, cirrhotic patients had a persistently higher incidence of coagulopathy (77% versus 44%) despite receiving more fresh frozen plasma (10.8 units versus 4.4 units). Cirrhotic patients had higher NPWT output (4427 mL versus 2375 mL) and developed higher vasopressor infusion rates (57% versus 29%). Cirrhotic patients had fewer intensive care unit-free days (2.3 versus 7.6 days) and higher rates of multiple organ failure (64% versus 34%), in-hospital mortality (67% versus 21%), and long-term mortality (80% versus 34%) than noncirrhotic patients.

CONCLUSIONS

Cirrhotic patients managed with TAC are susceptible to early acidosis, persistent coagulopathy, large NPWT fluid losses, prolonged vasopressor requirements, multiple organ failure, and early mortality. Future research should seek to determine whether TAC provides an advantage over primary fascial closure for cirrhotic patients undergoing emergency laparotomy.

Isolated traumatic brain injury in patients with cirrhosis: do different treatment paradigms result in increased mortality?

BACKGROUND

Cirrhosis is associated with increased mortality in trauma, yet its effects on outcomes after traumatic brain injury (TBI) are unclear. We hypothesized that cirrhosis adversely effects mortality and increases complications after TBI.

METHODS

Cirrhotic patients with isolated TBI were matched with noncirrhotic TBI patients in a 3:1 ratio based on age, sex, injury mechanism, and injury severity score at our academic, level 1 trauma center.

RESULTS

Of the 8,748 patients with isolated TBI, 65 patients had concurrent cirrhosis. Cirrhotic patients had increased mortality compared with matched controls (31% vs 17%, P = .03) and were less likely to undergo emergent neurosurgical operation (12% vs 25%, P = .03). There was no difference in admission Glasgow Coma Score, type of intracranial hemorrhage, length of stay, or complications between the groups.

CONCLUSIONS

Cirrhotic patients have increased mortality after TBI and were less likely to undergo operative intervention. New treatment paradigms may be needed to improve outcomes for cirrhotic patients suffering TBI.

One-Year Mortality after Traumatic Brain Injury in Liver Cirrhosis Patients--A Ten-Year Population-Based Study

This study investigated the 1-year mortality of patients who underwent brain surgery following traumatic brain injury (TBI) who also had alcoholic and/or nonalcoholic liver cirrhosis (LC) using a nationwide database in Taiwan. A longitudinal cohort study matched by propensity score with age, gender, length of ICU stay, HTN, DM, MI, stroke, HF, renal diseases, and year of TBI diagnosis in TBI patients with alcoholic and/or nonalcoholic LC and TBI patients without LC was conducted using the National Health Insurance Research Database in Taiwan between January 1997 and December 2007. The main outcome studied was 1-year mortality. In total, 7296 subjects (2432 TBI patients with LC and 4864 TBI patients without LC) were enrolled in this study. The main findings were (1) TBI patients with LC had a higher 1-year mortality (52.18% vs 30.61%) and a 1.75-fold increased risk of mortality (95% CI 1.61-1.90) compared with non-LC TBI patients, (2) renal diseases and HF are risk factors, but hypertension could be a protective factor in cirrhotic TBI patients, and (3) TBI patients with non-alcoholic LC and the coexistence of alcoholic and nonalcoholic LC had higher 1-year mortality compared with TBI patients with alcoholic cirrhosis. This study showed that patients with LC who have undergone brain surgery might have higher risk of 1-year mortality than those without LC. In addition, nonalcoholic and the coexistence of alcoholic and nonalcoholic LC show higher 1-year mortality risk than alcoholic in TBI patients with LC, especially in those with comorbidities of hypertension, diabetes mellitus, and stroke.

The effect of cirrhosis on the risk for failure of nonoperative management of blunt liver injuries

BACKGROUND

The purpose of this study was to delineate the association between cirrhosis and failure of nonoperative management (F-NOM) after blunt liver trauma.

METHODS

We carried out a review of the National Trauma Databank from 2007 to 2011 including patients ≥ 16 years old admitted after a blunt injury. Propensity score was used to match each cirrhotic to 3 noncirrhotic patients. Primary outcome was F-NOM (liver procedure >2 hours after admission and/or operative intervention directed at the liver after angiography).

RESULTS

A total of 57 cirrhotic patients who met inclusion criteria were matched with 171 noncirrhotic patients. Splenic injury was present in 41% (35% vs 43%; P = .31) and 28% had a high-grade liver injury III/VI/V (26% vs 29%; P = .73). The majority of patients in both groups were selected for a trial of NOM (77% vs 85%; P = .15). There was no difference in the rate of F-NOM between the 2 groups (14% vs 14%; P = 1.00), even for high-grade injuries (13% vs 20%; P = .72). Cirrhotic patients had a greater overall mortality (28% vs 7%; P < .01), especially if they required a laparotomy (58% vs 17%; P < .01) or if they failed NOM (50% vs 4%; P < .01).

CONCLUSION

Cirrhosis has no effect on the selection of patients with blunt liver injuries for a trial of nonoperative management and does not seem to be associated with a greater risk for failure of nonoperative management within the constraints of our study. Nonoperative management in this population is highly successful and failure is rarely related directly to the liver injury itself. Failure of non-operative management increases the already high mortality risk in this population.

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

BACKGROUND

The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank.

METHODS

The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified.

RESULTS

Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality.

CONCLUSION

LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, level III.

Surgery in patients with portal hypertension: a preoperative checklist and strategies for attenuating risk

Patients with liver disease and portal hypertension are at increased risk of complications from surgery. Recent advances have allowed better optimization of patients with cirrhosis before surgery and a reduction in postoperative complications. Despite this progress, the estimation of surgical risk in a patient with cirrhosis is challenging. The MELD score has shown promise in predicting postoperative mortality compared with the Child-Turcotte-Pugh score. This article addresses current concepts in the perioperative evaluation of patients with liver disease and portal tension, including a preoperative liver assessment (POLA) checklist that may be useful towards mitigating perioperative complications.

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

BACKGROUND

The adverse effects of liver cirrhosis on outcomes following trauma has been established in retrospective series. In this study, however, we set out to evaluate prospectively the in-hospital outcome measures in this subgroup of trauma patients.

METHODS

Prospective observational study of all patients admitted to the surgical intensive care unit of a Level I trauma center from January 2008 to December 2011. Cirrhotic trauma cases were matched with noncirrhotic controls in a 1:2 ratio. Matching criteria included age, sex, injury mechanism, vital signs at admission, Abbreviated Injury Scale (AIS) score for all body regions, and Injury Severity Score (ISS). Outcomes included in-hospital morbidity and mortality.

RESULTS

During the 4-year study period, 92 (0.8%) of the 12,102 trauma admissions had liver cirrhosis. After matching, no differences with regard to demographic and clinical injury characteristics were noted comparing the cases and controls. The overall complication rate in cases and controls was 31.5% and 7.1%, respectively (p < 0.001). In-hospital mortality was significantly higher for cirrhotic patients compared with their noncirrhotic counterparts (20.7 vs. 6.5%, p = 0.001). Within the cirrhotic group, mortality increased significantly from 8.0% in Child-Pugh Class A to 32.3% in Class B and 45.5% in Class C (p = 0.003). Likewise, mortality was significantly higher for patients with a Model for End-Stage Liver Disease (MELD) score of 10 or greater versus less than 10 (30.0% vs. 9.5%; odds ratio, 4.07; 95% confidence interval, 1.23-13.45; p = 0.016).

CONCLUSION

In this prospective investigation, liver cirrhosis is associated with adverse outcomes following trauma. Both stepwise increasing Child-Pugh and MELD scores predicted adjusted adverse outcomes. Injured patients with cirrhosis warrant aggressive monitoring and instant treatment after injury.

LEVEL OF EVIDENCE

Prognostic study, level III.

Trauma center level impacts survival for cirrhotic trauma patients

BACKGROUND

Cirrhosis is known to be a significant risk factor for morbidity and mortality following trauma such that its presence is a requirement for trauma center transfer. The impact of trauma center level on post-injury survival in cirrhotic patients has not been well studied.

METHODS

The National Trauma Databank (version 7) was used to identify patients admitted with cirrhosis as a preexisting comorbidity. Patients who were dead on arrival, died in the emergency department, or had missing trauma center information were excluded. Our primary outcome measure was overall mortality stratified by admission trauma center level. Logistic regression analysis was used to derive adjusted mortality results.

RESULTS

A total of 3,395 patients met inclusion criteria (0.16% of all National Trauma Databank patients). Patients admitted to a Level I center were more likely to be younger and minorities, experience penetrating injuries, and require immediate operative intervention despite similar Injury Severity Scores (ISS). Overall mortality was lower at Level I centers compared with other centers (10.3% vs. 14.0%, p = 0.001). After logistic regression, Level I centers were associated with significantly lower mortality compared with non-Level I centers (adjusted odds ratio, 0.70; 95% confidence interval, 0.53-0.89; p = 0.004).

CONCLUSION

The mortality for cirrhotic patients admitted to a Level I trauma center was significantly less compared with those admitted to non-Level I centers. The etiology of this improved outcome needs to be identified and transmitted to non-Level I centers.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Management of cirrhotic patients with blunt abdominal trauma: analysis of risk factor of postoperative death with the Model for End-Stage Liver Disease score

INTRODUCTION

The aim of this retrospective study is to analyse the risk factors of mortality in cirrhotic patients with blunt abdominal trauma (BAT) underwent laparotomy and the value of the Model for End-Stage Liver Disease (MELD) score to predict postoperative death is determined.

MATERIALS AND METHODS

From July 1993 to June 2005, 34 cirrhotic patients with BAT were reviewed. Data are presented as mean ± standard deviation (SD), frequency (percentage), or Pearson correlation coefficient. Predictors were compared by uni- and multiple logistic regression analysis and results were considered statistically significant if P<0.05. The prognostic value of the MELD score in predicting postoperative death was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

Of the 34 patients (27 men, 7 women; mean age, 49 years), the Injury Severity Score (ISS) ranged from 4 to 43 (mean: 14). Of the 34 patients, 12 were treated with nonoperative management (NOM) initially and 4 succeeded and 30 patients (88.2%) eventually required laparotomy. Of the 30 operative patients, 7 died of haemorrhagic shock and the other 6 died of multiple organ failure with a 43.3% mortality rate. Of the 17 survivors after laparotomy, 4 developed intra-abdominal complication, and 3 developed extra-abdominal complication with a 41.2% morbidity rate. On univariate analysis, the significant predictors of surgical mortality were shock at emergency department, damage control laparotomy, ISS and MELD score. On multiple logistic regression analysis, the significant predictors of operative mortality were shock at ED (P=0.021) and MELD score (P=0.012). Analysis by ROC curve identified cirrhotic patients with a MELD score equal to or above 17 as the best cut-off value for predicting postoperative death.

CONCLUSIONS

Liver cirrhosis with BAT has a high operative rate, low salvage rate of NOM, high surgical mortality and morbidity rate. The MELD score can accurately predict postoperative death and a MELD score equal to or above 17 of our data is at high risk of postoperative death.

Brain surgery in patients with liver cirrhosis

OBJECT

Liver cirrhosis was identified as an independent predictor of poor outcomes in patients suffering trauma and in those undergoing major surgeries. The aim of this study was to report the authors' experiences treating patients with cirrhosis who undergo brain surgeries.

METHODS

Between 2004 and 2009, 121 consecutive patients with cirrhosis underwent 144 brain procedures. Patients were categorized as Child-Turcotte-Pugh (referred to as "Child") Class A, B, or C. The patient profiles, including the severity of cirrhosis, reason for surgery, complications, and prognosis factors, were analyzed.

RESULTS

In this retrospective study, the overall surgical complication rate for patients with cirrhosis was 52.1% and the mortality rate was 24.3%. For patients with acute traumatic brain injury (TBI), the complication, rebleeding, and mortality rates reached 84.4%, 68.8%, and 37.5%, respectively. Surgery for TBI was a significant risk factor for postoperative complications (p = 0.0002) and postoperative hemorrhage (p < 0.0001). Otherwise, according to the Child classification, the complication rate increased in a stepwise fashion from 38.7% to 60% to 84.2%, the rebleeding rate from 29.3% to 48.0% to 63.2%, and the mortality rate from 5.3% to 38% to 63.2% for Child A, B, and C, respectively. The Child classification was associated with higher risk of complications-Child B vs A OR 2.84 (95% CI 1.28-6.29), Child C vs A OR 5.39 (95% CI 1.32-22.02). It was also associated with risk of death-Child C vs A OR 30.43 (95% CI 7.71-120.02), Child B vs A OR 10.88 (95% CI 3.42-34.63).

CONCLUSIONS

Liver cirrhosis is a poor comorbidity factor for brain surgery. The authors' results suggest that the Child classification used independently is a poor prognostic factor; in addition, grave outcomes were observed in patients with TBI.

Liver Cirrhosis and Traumatic Brain Injury: A Fatal Combination Based on National Trauma Databank Analysis

The purpose of this study was to evaluate the impact of liver cirrhosis on in-hospital outcomes in victims of isolated traumatic brain injury (TBI). This was a National Trauma Databank study over a 5-year period, including patients with isolated TBI. Propensity scores were calculated to match cirrhotic with noncirrhotic TBI patients in a 1:2 ratio. Primary outcomes included mortality, hospital and surgical intensive care unit length of stay, and ventilator days. Of the 35,005 patients with isolated TBI, 47 (0.13%) had documented liver cirrhosis. After matching with 94 noncirrhotic, isolated TBI patients, no differences with regards to demographic and clinical injury characteristics were observed comparing the two groups. The mean SICU length of stay for cirrhotic and noncirrhotic patients was 5.4 ± 8.8 days and 3.7 ± 7.0 days, respectively ( P = 0.079). Cirrhotic patients experienced significantly more ventilator days compared with their noncirrhotic counterparts (2.9 ± 6.4 days vs 2.0 ± 6.4 days; P = 0.001). Overall mortality in the study population was 23.4 per cent with significantly higher in-hospital mortality among cirrhotic versus noncirrhotic TBI patients [34.0% vs 18.1%; odds ratio (95% confidence interval): 2.34 (1.05-5.20); P = 0.035]. Traumatic brain injury in conjunction with liver cirrhosis is associated with two-fold increased mortality and significantly prolonged ventilator requirements when compared with their noncirrhotic counterparts of isolated TBI.

Do chronic liver disease scoring systems predict outcomes in trauma patients with liver disease? A comparison of MELD and CTP

BACKGROUND

Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma.

METHODS

A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant.

RESULTS

The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70).

CONCLUSION

Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.

Anesthetic concerns in trauma victims requiring operative intervention: the patient too sick to anesthetize

Trauma is the third leading cause of death in the U.S. Timely acute care anesthetic management of patients following traumatic injury may improve outcome. Recognition of highly-mortal injuries to the brain, heart, lungs, liver, and pelvis should guide trauma-specific management strategies. Rapid intraoperative treatment of life-threatening conditions following injury includes the use of 'controlled-under resuscitation' of fluid administration until surgical hemorrhage control, early factor replacement in addition to transfusion of packed red blood cells, and use of adjuvant therapies such as recombinant factor VIIa. These treatment strategies, other recent developments in acute trauma resuscitation, and a review of associated co-existing medical conditions that may impact mortality, are presented.

Cirrhosis and trauma are a lethal combination

BACKGROUND

The objective of this study was to evaluate the risk of mortality and complications associated with cirrhosis in trauma patients.

METHODS

This is an IRB-approved retrospective trauma registry study of patients admitted to an academic level 1 trauma center from 1997 to 2006. The following parameters were abstracted for analysis: age, gender, mechanism of injury, Abbreviated Injury Score, Injury Severity Score, Glasgow Coma Scale, mortality, and complications (ARDS, acute renal failure, pneumonia, intra-abdominal abscess, trauma-associated coagulopathy). Multivariable analysis was utilized to compare the mortality and complication rates between cirrhotic and noncirrhotic trauma patients. The subgroup of patients who underwent laparotomy was also analyzed.

RESULTS

During the 10-year study period there were 36,038 trauma registry patients, of which 468 (1.3%) had a diagnosis of cirrhosis. The mortality in the cirrhotic group was 12% vs. 6% in the noncirrhotic group [adjusted odds ratio = 5.65 (95% CI = 3.72 - 8.41, p < 0.0001)]. ARDS, trauma-associated coagulopathy, and septic complications were significantly more common in the cirrhotic group. The overall severe complication rate in the two groups was 10 and 4%, respectively [adjusted odds ratio = 2.05 (95% CI = 1.45 - 2.84, p < 0.0001)]. For the subgroup of patients who underwent emergent abdominal exploration, the mortality rate increased to 40% compared with that of noncirrhotics at 15% [adjusted odds ratio = 4.35 (95% CI = 2.00 - 9.18, p = 0.0002)].

CONCLUSION

Cirrhosis is an independent risk factor for increased mortality and higher complication rate following trauma. Injured patients who undergo laparotomy are significantly more likely to die than noncirrhotic patients. Injured patients with cirrhosis warrant aggressive monitoring and treatment.

Association of preexisting medical conditions with in-hospital mortality in multiple-trauma patients

BACKGROUND

Mortality after trauma has been shown to be influenced by host factors, such as age and preexisting medical conditions (PMCs). The independent predictive value of specific PMCs for in-hospital mortality after adjustment for injury severity, injury pattern, age, and presence of other PMCs has not been fully elucidated.

STUDY DESIGN

Records of 11,142 trauma patients (18 years of age or older, Injury Severity Score > or = 16, years 2002 to 2007) documented in the Trauma Registry of the German Society for Trauma Surgery were analyzed to assess the association of PMCs with in-hospital mortality. Multiple logistic regression models were used for this analysis.

RESULTS

PMCs were affirmed for 3,836 of the 11,142 patients studied (34.4%). An independent statistical association with increased in-hospital mortality was found for 6 of 14 analyzed PMCs after adjustment for age and the Revised Injury Severity Classification score, respectively, ie, heart disease, obesity, hepatitis/liver cirrhosis, malignancies, coagulation disorder, and peripheral arterial occlusive disease stage IV. The association with mortality varied with different injury patterns.

CONCLUSION

Specific PMCs were associated with increased mortality after trauma independent from injury severity and age. Knowledge of the identified relevant PMCs could help the medical team to be able to assess the mortality risk profile of trauma patients in a more detailed and quantifiable way.

[Significance of liver trauma for the incidence of sepsis, multiple organ failure and lethality of severely injured patients. An organ-specific evaluation of 24,771 patients from the trauma register of the DGU]

BACKGROUND

The prognosis of multiple injured patients is mainly limited by initial severe hemorrhage causing hemorrhagic shock, subsequent sepsis and multiple organ failure (MOF). Although mechanisms of altered microcirculation, cytokine release etc. have been intensively investigated, little is known about the relevance of severe liver trauma as an independent predictive outcome factor in these patients. This study aimed to clarify the impact of severe liver trauma in one of the largest trauma databases.

PATIENTS AND METHODS

The study was based on data from the German trauma register within the German Society for Trauma Surgery (DGU) and 24,711 patients from 113 hospitals were collected for retrospective analysis between 1993 and 2005. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to the injury pattern into I liver group (severe damage of the liver, AIS>3 and AIS abdomen <3), II Abdomen group (severe abdominal trauma AIS>3, AIS liver <3) and III Control group (liver and/or abdominal trauma AIS<3, other trauma AIS>3).

RESULTS

Out of 24,771 multiple injured patients from 113 trauma centers, 321 individuals were identified which matched the criteria of the liver group. Another 574 patients were allocated to the abdomen group while the majority of patients formed the trauma group (9574). Severe injury of the liver is associated with excessive demands for volume resuscitation and induces a significantly increased risk for sepsis and MOF compared to both other groups (sepsis 19.9% vs 11%; MOF 32.7% vs 16.6%). Furthermore, deleterious outcome is more frequent associated with patients with severe liver trauma (lethality 34.9%) compared to severe abdominal trauma (12%) and the control group (19.5%).

CONCLUSIONS

Severe liver trauma is an independent predictor for severe hemorrhage with a substantial increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with severe liver trauma but no hemorrhage is effective, patients with hemodynamic instability seem to form a subgroup where contemporary treatment modalities are not yet sufficient.

Deleterious effect of cirrhosis on outcomes after motor vehicle crashes using the nationwide inpatient sample

OBJECTIVES

Alcohol abuse and minimal hepatic encephalopathy may predispose cirrhotics to a higher motor vehicle crash (MVC) rate. Cirrhotics have poor post-trauma outcomes on small-scale studies. The aim was to examine the effect of cirrhosis on mortality, charges, and length of stay (LOS) after MVCs using the Nationwide Inpatient Sample (NIS) 2004.

METHODS

NIS 2004 was queried for cirrhotics with MVC (C-MVC), cirrhotics only, and MVC only for demographics, comorbidities, hospital characteristics, and the Injury Severity Score (ISS). C-MVC patients were compared with the other groups. Weighted uni/multivariate regression was performed for all MVCs (with/without cirrhosis).

RESULTS

There were 560,080 discharges for cirrhosis only, 262,244 for MVC only, and 1,565 for C-MVC. C-MVC patients were significantly younger (49.8 yr vs 58.6 yr, P < 0.0005) and had less comorbidities than cirrhosis only, but had similar mortality (C-MVC 10.8% vs cirrhosis only 9.9%, P= 0.23). C-MVC patients (49.8 yr) were older than MVC only patients (43.7 yr, P < 0.0005). C-MVC patients also had significantly higher mortality (10.8%) compared with MVC only (3.1%, P < 0.0005) despite similar ISS. C-MVC patients had significantly greater LOS (9.6 days) and charges ($67,119) compared with both MVC only (6.2 days, $43,314) and cirrhosis only (7.4 days, $35,522). Cirrhosis (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.5-5.5) and age >65 yr (OR 5.2, 95% CI 4.4-6.0) were most commonly associated with mortality. Male sex, high ISS, self-pay, teaching, and large and urban hospitals were also significantly associated with mortality. On multivariate regression, cirrhosis was associated with greater charges and LOS.

CONCLUSION

Cirrhosis is associated with greater mortality, LOS, and charges after MVC despite controlling for injury severity, comorbidities, and age in NIS 2004.

Outcomes of Tube Thoracostomies Performed by Advanced Practice Providers vs Trauma Surgeons

Background The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians’ capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians.

Objectives To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure.

Methods Retrospective blinded reviews of patients’ charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers.

Results Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good.

Conclusions Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers.

The influence of hemorrhagic shock on rat liver regeneration after partial hepatectomy: serum aminotranspherases, mitochondrial function, and hepatocellular replication studies

This study was designed to evaluate the influence of hemorrhagic shock on hepatic regeneration in rats submitted to partial hepatectomy. The experimental protocol included 26 male Wistar rats, randomly assigned to 4 groups: GI: simulated operation; GII: 30% hepatectomy without hemorrhagic shock; GIII: only hemorrhagic shock; GIV: 30% hepatectomy associated with hemorrhagic shock. The methodologies used were: determination of aminotranspherases plasma levels; analysis of mitochondrial respiration, membrane potential and osmotic swelling; and markers of hepatocellular replication. Aminotranspherases increased only in GIV. There were no differences in mitochondrial respiration. Mitochondrial membrane potential decreased only in the GIV. There were no differences in mitochondrial swelling among the groups; cellular replication markers increased significantly in the Groups II and IV but without difference between these two groups. Despite the conditions imposed on the organism by hemorrhagic shock, the hepatic regenerative capacity is preserved in animals submitted to partial hepatectomy.

Increased age, male gender, and cirrhosis, but not steatosis or a positive viral serology, negatively impact the life expectancy of patients who undergo liver biopsy

Most survival studies of chronic liver disease avoid including more than one condition, often present in patients with liver disease; survival analysis of patients with liver disease in general was undertaken. Over a 9-year period, the survival experience of 365 patients who underwent liver biopsy, with a median follow-up of 3 years, was assessed. Log rank tests and Cox regression were used to evaluate risk factors. The Flemington-Harrington G(rho) family of tests compared the number of deaths expected in the U.S. population in general, adjusted for age, sex, and year of biopsy, to the observed number of deaths in the patients with cirrhosis and to the observed number of deaths in patients without cirrhosis. Twenty-two (6%) patients died. Cirrhosis (HR = 2.9; 95% c.i.: 1.2-6.7), male sex (HR = 2.7; 95% c.i.: 1.1-6.6), and an additional 20 years of age at biopsy (HR = 2.9; 95% c.i:. 1.4-6.2) each negatively impacted survival. Patients with cirrhosis experienced 4.58 times the number of expected deaths (p < 0.00001). Patients without cirrhosis experienced 1.66 times the number of expected deaths (p = 0.15). Steatosis and a positive viral serology did not increase the risk of death. Male gender, increased age, and cirrhosis increased the risk of death; increased steatosis and positive viral serologic studies did not.

Preoperative evaluation of patients with liver disease

Patients with end-stage liver disease often undergo surgery for indications other than liver transplantation. These patients have an increased risk of morbidity and mortality that is related to their underlying liver disease. Assessments of surgical risk provide a basis for discussion of risks and benefits, treatment decision making, and for optimal management of patients for whom surgery is planned. The most useful indicators of surgical risk are indices that predict advanced disease, such as the Child-Turcotte-Pugh score, or those that predict prognosis, such as the Model for End-stage Liver Disease score. Careful preoperative risk assessment, patient selection, and management of various manifestations of advanced disease might decrease morbidity and mortality from nontransplant surgery in patients with liver disease.