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Lagazzi E, Rafaqat W, Kalva SP, Ly TV, Velmahos GC. The life-over-limb imperative: Damage control angioembolization in pelvic trauma. J Trauma Acute Care Surg 2024; 96:e41-e42. [PMID: 38321604 DOI: 10.1097/ta.0000000000004275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Luckhurst CM, Parks JJ, Albutt KH, Hwabejire JO, DeWane MP. Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures. Surgery 2024; 175:1312-1320. [PMID: 38418297 DOI: 10.1016/j.surg.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/26/2023] [Accepted: 01/12/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamzah Jehanzeb
- Department of Surgery, Medical College, Aga Khan University, Karachi, Pakistan
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine H Albutt
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Rafaqat W, Lagazzi E, McChesney S, Smith MC, UrRahman M, Lee H, DeWane MP, Khan A. To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus. J Surg Res 2024; 297:101-108. [PMID: 38484451 DOI: 10.1016/j.jss.2023.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/29/2023] [Accepted: 12/24/2023] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon McChesney
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Smith
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mujeeb UrRahman
- Department of Surgery, District Headquarters Hospital, Buner, Pakistan
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aimal Khan
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
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Rafaqat W, Abiad M, Lagazzi E, Argandykov D, Proaño-Zamudio JA, Velmahos GC, Hwabejire JO, Parks JJ, Luckhurst CM, DeWane MP. Analyzing the Impact of Concomitant COVID-19 Infection on Outcomes in Trauma Patients. Am Surg 2024:31348241246176. [PMID: 38613452 DOI: 10.1177/00031348241246176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2024]
Abstract
BACKGROUND The impact of COVID-19 infection at the time of traumatic injury remains understudied. Previous studies demonstrate that the rate of COVID-19 vaccination among trauma patients remains lower than in the general population. This study aims to understand the impact of concomitant COVID-19 infection on outcomes in trauma patients. METHODS We conducted a retrospective cohort study of patients ≥18 years old admitted to a level I trauma center from March 2020 to December 2022. Patients tested for COVID-19 infection using a rapid antigen/PCR test were included. We matched patients using 2:1 propensity accounting for age, gender, race, comorbidities, vaccination status, injury severity score (ISS), type and mechanism of injury, and GCS at arrival. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, 30-day readmission, and major complications. RESULTS Of the 4448 patients included, 168 (3.8%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in age, sex, BMI, ISS, type of injury, and regional AIS. The proportion of White and non-Hispanic patients was higher in COV- patients. Following matching, 154 COV+ and 308 COV- patients were identified. COVID-19-positive patients had a higher rate of mortality (7.8% vs 2.6%; P = .010), major complications (15.6% vs 8.4%; P = .020), and thrombotic complications (3.9% vs .6%; P = .012). Patients also had a longer hospital LOS (median, 9 vs 5 days; P < .001) and ICU LOS (median, 5 vs 3 days; P = .025). CONCLUSIONS Trauma patients with concomitant COVID-19 infection have higher mortality and morbidity in the matched population. Focused interventions aimed at recognizing this high-risk group and preventing COVID-19 infection within it should be undertaken.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - May Abiad
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Dias Argandykov
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Rafaqat W, Abiad M, Lagazzi E, Argandykov D, Velmahos GC, Hwabejire JO, Parks JJ, Luckhurst CM, Kaafarani HMA, DeWane MP. From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients. Surgery 2024; 175:1212-1216. [PMID: 38114393 DOI: 10.1016/j.surg.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/27/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. METHODS We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. RESULTS The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. CONCLUSION Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA. https://twitter.com/RafaqatWardah
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA. https://twitter.com/AbiadMay
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA
| | - Dias Argandykov
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA. https://twitter.com/argandykov
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA. https://twitter.com/hayfarani
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Massachusetts General Hospital, Cambridge, MA.
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Dorken-Gallastegi A, Naar L, Argandykov D, Lagazzi E, Dowling M, Montero P, Wallace B, Pallotta JB, Beagle J, Breen K, Velmahos GC, Duggan MJ, King DR. Safety of the injectable expanding biopolymer foam for non-compressible truncal bleeding in swine. Surgery 2024; 175:1189-1197. [PMID: 38092635 DOI: 10.1016/j.surg.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/15/2023] [Accepted: 11/07/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND A novel hydrophobically modified chitosan (hm-chitosan) polymer has been previously shown to improve survival in a non-compressible intra-abdominal bleeding model in swine. We performed a 28-day survival study to evaluate the safety of the hm-chitosan polymer in swine. METHODS Female Yorkshire swine (40-50 kg) were used. A mild, non-compressible, closed-cavity bleeding model was created with splenic transection. The hm-chitosan polymer was applied intra-abdominally through an umbilical nozzle in the same composition and dose previously shown to improve survival. Animals were monitored intraoperatively and followed 28 days postoperatively for survival, signs of pain, and end-organ function. Gross pathological and microscopic evaluations were performed at the conclusion of the experiment. RESULTS A total of 10 animals were included (hm-chitosan = 8; control = 2). The 2 control animals survived through 28 days, and 7 of the 8 animals from the hm-chitosan group survived without any adverse events. One animal from the hm-chitosan group required early termination of the study for signs of pain, and superficial colonic ulcers were found on autopsy. Laboratory tests showed no signs of end-organ dysfunction after exposure to hm-chitosan after 28 days. On gross pathological examination, small (<0.5 cm) peritoneal nodules were noticed in the hm-chitosan group, which were consistent with giant-cell foreign body reaction in microscopy, presumably related to polymer remnants. Microscopically, no signs of systemic polymer embolization or thrombosis were noticed. CONCLUSION Prolonged intraperitoneal exposure to the hm-chitosan polymer was tolerated without any adverse event in the majority of animals. In the single animal that required early termination, the material did not appear to be associated with end-organ dysfunction in swine. Superficial colonic ulcers that would require surgical repair were identified in 1 out of 8 animals exposed to hm-chitosan.
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Affiliation(s)
- Ander Dorken-Gallastegi
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/AnderDorken
| | - Leon Naar
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/lnaar
| | - Dias Argandykov
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA. https://twitter.com/argandykov
| | - Emanuele Lagazzi
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Surgery, Humanitas Research Hospital, Rozzano, Italy. https://twitter.com/EmanueleLagazzi
| | | | | | | | - Jessica B Pallotta
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - John Beagle
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kerry Breen
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - George C Velmahos
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael J Duggan
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David R King
- Trauma, Emergency Surgery, Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Romijn ASC, Proaño-Zamudio JA, Rastogi V, Yadavalli SD, Lagazzi E, Giannakopoulos GF, Schermerhorn ML, Saillant NN. Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury. Eur J Trauma Emerg Surg 2024; 50:551-559. [PMID: 38224357 DOI: 10.1007/s00068-023-02432-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/28/2023] [Indexed: 01/16/2024]
Abstract
PURPOSE Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI. METHODS Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD). RESULTS We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001). CONCLUSION We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.
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Affiliation(s)
- Anne-Sophie C Romijn
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA.
- Division of Trauma & Emergency Surgery, Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Jefferson A Proaño-Zamudio
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Division of Vascular Surgery, Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Emanuele Lagazzi
- Division of Trauma & Emergency Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St., White Building, Suite 506, Boston, MA, 02114, USA
| | - Georgios F Giannakopoulos
- Division of Trauma & Emergency Surgery, Department of Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Noelle N Saillant
- Division of Acute Care and Trauma Surgery, Department of Surgery, Boston Medical Center, Boston, MA, USA
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Rafaqat W, Lagazzi E, Abiad M, Velmahos GC. Diagnostic peritoneal lavage is dead: Long live diagnostic peritoneal aspiration. J Trauma Acute Care Surg 2024; 96:e24. [PMID: 37972941 DOI: 10.1097/ta.0000000000004211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Hwabejire JO, Parks JJ, Kaafarani HM, DeWane MP. Which Volume Matters More? Systematic Review and Meta-Analysis of Hospital vs Surgeon Volume in Intra-Abdominal Emergency Surgery. J Am Coll Surg 2024; 238:332-346. [PMID: 37991251 DOI: 10.1097/xcs.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Wardah Rafaqat
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Emanuele Lagazzi
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Hamzah Jehanzeb
- Medical College, Aga Khan University, Karachi, Pakistan (Jehanzeb)
| | - May Abiad
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - John O Hwabejire
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Jonathan J Parks
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Haytham M Kaafarani
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Michael P DeWane
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
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Argandykov D, Lagazzi E, Proaño-Zamudio JA, Rafaqat W, Abiad M, DeWane M, Paranjape CN, Kaafarani HMA, Velmahos GC, Hwabejire JO. Traumatic lower extremity amputation as a risk factor for venous thromboembolism. Am J Surg 2024:S0002-9610(24)00013-8. [PMID: 38368239 DOI: 10.1016/j.amjsurg.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/07/2024] [Accepted: 01/09/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p < 0.001) and DVT (6.5% vs. 3.4%, p < 0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p = 0.015) and DVT (4.7% vs. 2.6%, p < 0.001). CONCLUSIONS In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.
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Affiliation(s)
- Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/argandykov
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/EmanueleLagazzi
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/eljefe_md
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael DeWane
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/michaeldewane
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/CharuParanjape
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. https://twitter.com/hayfarani
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Lagazzi E, Rafaqat W, Argandykov D, de Roulet A, Abiad M, Proaño-Zamudio JA, Velmahos GC, Hwabejire JO, Paranjape C, Albutt KH. Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion. Surgery 2024; 175:529-535. [PMID: 38167568 DOI: 10.1016/j.surg.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/09/2023] [Accepted: 09/05/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy. https://twitter.com/EmanueleLagazzi
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Amory de Roulet
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charudutt Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Katherine H Albutt
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Rafaqat W, Proaño Zamudio JA, Abiad M, Lagazzi E, Argandykov D, Luckhurst CM, Velmahos GC, DeWane MP, Kaafarani HMA, Hwabejire JO. Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study. Am J Surg 2024; 228:287-294. [PMID: 37981515 DOI: 10.1016/j.amjsurg.2023.10.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/29/2023] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. METHODS We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. RESULTS We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 % vs. 11.9 %; p = 0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 % vs. 4.4 %; p = 0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. CONCLUSION The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jefferson A Proaño Zamudio
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dias Argandykov
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Yadavalli SD, Summers SP, Rastogi V, Romijn ASC, Marcaccio CL, Lagazzi E, Zettervall SL, Starnes BW, Verhagen HJM, Schermerhorn ML. The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury. J Vasc Surg 2024; 79:229-239.e3. [PMID: 38148614 DOI: 10.1016/j.jvs.2023.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Current societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. METHODS Patients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. RESULTS Of 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. CONCLUSIONS Patients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.
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Affiliation(s)
- Sai Divya Yadavalli
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Steven P Summers
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Vinamr Rastogi
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anne-Sophie C Romijn
- Department of Surgery, Division of Trauma & Emergency Surgery, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Christina L Marcaccio
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emanuele Lagazzi
- Department of Surgery, Division of Trauma & Emergency Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sara L Zettervall
- Department of Surgery, Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Benjamin W Starnes
- Department of Surgery, Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Hence J M Verhagen
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Marc L Schermerhorn
- Department of Surgery, Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Rafaqat W, Abiad M, Lagazzi E, Argandykov D, Proaño-Zamudio JA, Van Ee EPX, Velmahos GC, Hwabejire JO, Kaafarani HMA, DeWane MP. The association of disability conditions with access to minimally invasive general surgery. Disabil Health J 2024:101586. [PMID: 38423914 DOI: 10.1016/j.dhjo.2024.101586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/19/2023] [Accepted: 01/21/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dias Argandykov
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elaine P X Van Ee
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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15
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Arnold SC, Rafaqat W, Abiad M, Lagazzi E, Hoekman AH, Panossian VS, Nzenwa IC, Paranjape CN, Velmahos GC, Kaafarani HMA, Hwabejire JO. Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus. Am J Surg 2024:S0002-9610(24)00009-6. [PMID: 38278705 DOI: 10.1016/j.amjsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS 842 patients were included, of which 409 (48.6 %) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 % vs 0.0 %, p = 0.045), reduced ostomy rate (38.3 % vs 29.4 %, p = 0.013), an increased overall length of stay (12 days vs 8 days, p < 0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p < 0.001). CONCLUSION In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.
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Affiliation(s)
- Suzanne C Arnold
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States; Division of Trauma Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Anne H Hoekman
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Vahe S Panossian
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Ikemsinachi C Nzenwa
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
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Lagazzi E, Teodorescu DL, Argandykov D, Samotowka MA, King DR. Moving toward point-of-care surgery in Ukraine: testing an ultra-portable operating room in an active war zone. Eur J Trauma Emerg Surg 2024:10.1007/s00068-023-02410-w. [PMID: 38175279 DOI: 10.1007/s00068-023-02410-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/19/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE In conflict zones, providers may have to decide between delaying time-sensitive surgeries or performing operative interventions in the field, potentially subjecting patients to significant infection risks. We conducted a single-arm crossover study to assess the feasibility of using an ultraportable operating room (U-OR) for surgical procedures on a porcine cadaver abdominal traumatic injury model in an active war zone. METHODS We enrolled participants from an ASSET-type course designed to train Ukrainian surgeons before deployment to active conflict zones. They performed three standardized consecutive abdominal surgical procedures (liver, kidney, and small bowel injury repair) with and without the U-OR. Primary outcomes included surgical procedure completion rate, procedure time, and airborne particle count at the start of surgery. Secondary survey-based outcomes assessed surgery task load index (SURG-TLX) and perceived operative factors. RESULTS Fourteen surgeons performed 76 surgical procedures (38 with the U-OR, 38 without the U-OR). The completion rate for each surgical procedure was 100% in both groups. While the procedure time for the liver injury repair did not differ significantly between the two groups, the use of the U-OR was associated with a longer time for kidney (155 vs. 56 s, p = 0.002), and small bowel (220 vs. 103 s, p = 0.004) injury repair. The average airborne particle count within the U-OR was substantially lower compared to outside the U-OR (6,753,852 vs. 232,282 n/m3, p < 0.001). There was no statistically significant difference in SURG-TLX for procedures performed with and without the U-OR. CONCLUSION The use of the U-OR did not affect the procedure completion rate or SURG-TLX. However, there was a marked difference in airborne particle counts between inside and outside the U-OR during surgery. These preliminary findings indicate the potential feasibility of using a U-OR to perform abdominal damage-control surgical procedures in austere settings.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
- Department of Surgery, Humanitas Research Hospital, Rozzano, MI, Italy
| | - Debbie Lin Teodorescu
- SurgiBox Inc., Cambridge, MA, USA
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | | | - David Richard King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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Lagazzi E, Proaño-Zamudio JA, Argandykov D, Rafaqat W, Abiad M, Romijn AS, van Ee EPX, Velmahos GC, Kaafarani HMA, Hwabejire JO. Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery. Surg Infect (Larchmt) 2023; 24:869-878. [PMID: 38011709 DOI: 10.1089/sur.2023.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.
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Affiliation(s)
- Emanuele Lagazzi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Humanitas Research Hospital, Rozzano, Italy
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Dias Argandykov
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - May Abiad
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anne-Sophie Romijn
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Division of Trauma and Emergency Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Elaine P X van Ee
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Leiden University Medical Center, Leiden, The Netherlands
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Lagazzi E, Argandykov D, de Roulet A, Proaño-Zamudio JA, Romijn ASC, Abiad M, Rafaqat W, Velmahos GC, Hwabejire JO, Paranjape CN. Evaluating the impact of timing to rib fixation in patients with traumatic brain injury: A nationwide analysis. J Trauma Acute Care Surg 2023; 95:846-854. [PMID: 37822127 DOI: 10.1097/ta.0000000000004100] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Early surgical stabilization of rib fractures (SSRF) is associated with improved inpatient outcomes in patients with multiple rib fractures. However, there is still a paucity of data examining the optimal timing of SSRF in patients with concomitant traumatic brain injury (TBI). This study aimed to assess whether earlier SSRF was associated with improved outcomes in patients with multiple rib fractures and TBI. METHODS We performed a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program 2017-2020, including adult patients with TBI and multiple rib fractures who had undergone SSRF. The outcomes were post-procedural length of stay (LOS), hospital LOS, intensive care unit (ICU) LOS, in-hospital mortality, ventilator days, and tracheostomy rate. Multilevel mixed-effects regression analyses accounting for patient, injury, and hospital characteristics as well as institutional SSRF volume were used to assess the association between timing to SSRF and the outcomes of interest. As a sensitivity analysis, propensity-score matching was performed to compare patients who underwent early (<72 hours) versus late SSRF (≥72 hours). RESULTS Of 1,041 patients included in this analysis, 430 (41.3%) underwent SSRF within the first 72 hours from admission. Delay to SSRF was associated with an increase in post-procedural LOS (partial regression coefficient (β) = 0.011; p = 0.036; 95% confidence interval [CI], 0.001-0.023), longer hospital LOS (β = 0.053; p < 0.001; 95% CI, 0.042-0.064), prolonged ICU LOS (β = 0.032; p < 0.001; 95% CI, 0.025-0.038), and more ventilator days (β = 0.026, p < 0.001; 95% CI, 0.020-0.032). CONCLUSION In patients with concurrent multiple rib fractures and TBI, a delay in SSRF is associated with an increase in postprocedural LOS, hospital LOS, ICU LOS, and ventilator days. These findings suggest that the early patient selection and implementation of SSRF may play a beneficial role in patients presenting with concomitant TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Emanuele Lagazzi
- From the Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery (E.L., D.A., A.d.R., J.A.P.-Z., M.A., W.R., G.C.V., J.O.H., C.N.P.), Massachusetts General Hospital, Boston, MA; Department of Surgery (E.L.), Humanitas Research Hospital, Rozzano MI, Italy; and Division of Trauma & Emergency Surgery, Department of Surgery (A.-S.C.R.), Amsterdam University Medical Center, Amsterdam, the Netherlands
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19
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Rafaqat W, Lagazzi E, Proaño-Zamudio JA, Argandykov D, Abiad M, Renne A, Romijn ASC, Van Ee EPX, Hwabejire JO, Velmahos GC, Parks JJ, Kaafarani HMA, Luckhurst CM, DeWane MP. Missing Narrative: Examining the Impact of Disability on Post-Operative Infectious Complications. Surg Infect (Larchmt) 2023; 24:835-842. [PMID: 38015646 DOI: 10.1089/sur.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Background: More than 20% of the population in the United States suffers from a disability, yet the impact of disability on post-operative outcomes remains understudied. This analysis aims to characterize post-operative infectious complications in patients with disability. Patients and Methods: This was a retrospective review of the National Readmission Database (2019) among patients undergoing common general surgery procedures. As per the U.S. Centers for Disease Control and Prevention (CDC), disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. A propensity-matched analysis comparing patients with and without a disability was performed to compare outcomes, including post-operative septic shock, sepsis, bacteremia, pneumonia, catheter-associated urinary tract infection (CAUTI), urinary tract infection (UTI), catheter-associated blood stream infection, Clostridioides Difficile infection, and superficial, deep, and organ/space surgical site infections during index hospitalization. Patients were matched using age, gender, comorbidities, illness severity, income, neighborhood, insurance, elective procedure, and the hospital's bed size and type. Results: A total of 710,548 patients were analysed, of whom 9,451(1.3%) had at least one disability. Motor disability was the most common (3,762; 40.5%), followed by visual, intellectual, and hearing impairment. Patients with disability were older (64 vs. 57 years; p < 0.001), more often insured under Medicare (65.2% vs. 37.3% p < 0.001) and had more medical comorbidities (Elixhauser comorbidity score ≥3; 69.2% vs. 41.9%; p < 0.001). After matching, 9,292 pairs were formed. Patients with a disability had a higher incidence of pneumonia (10.1% vs. 6.5%; p < 0.001), aspiration pneumonia (5.2% vs. 1.4%; p < 0.001), CAUTI (1.0% vs. 0.4%; p < 0.001), UTI (10.4% vs. 6.2%; p < 0.001), and overall infectious complications (21.8% vs. 14.5%; p < 0.001). Conclusions: Severe intellectual, hearing, visual, or motor impairments were associated with a higher incidence of infectious complications. Further investigation is needed to develop interventions to reduce disparities among this high-risk population.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dias Argandykov
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - May Abiad
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Angela Renne
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Anne-Sophie C Romijn
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elaine P X Van Ee
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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Argandykov D, Proaño-Zamudio JA, Lagazzi E, Rafaqat W, Abiad M, Renne AM, Paranjape CN, Kaafarani HMA, Velmahos GC, Hwabejire JO. Low-molecular-weight heparin is superior to unfractionated heparin in lowering the risk of venous thromboembolism after traumatic lower extremity amputation. Surgery 2023; 174:1026-1033. [PMID: 37507306 DOI: 10.1016/j.surg.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/30/2023] [Accepted: 06/18/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Patients undergoing lower extremity amputation after trauma are at high risk of venous thromboembolism. Practice variations persist regarding the optimal pharmacologic agent for venous thromboembolism prophylaxis in this patient population. We aimed to compare the efficacy of unfractionated heparin versus low-molecular-weight heparin in preventing venous thromboembolism. METHODS Using the 2013 to 2019 American College of Surgeons Pediatric Trauma Quality Improvement Program database, all trauma patients (≥18) who underwent lower limb amputation and received venous thromboembolism thromboprophylaxis in the form of unfractionated heparin or low-molecular-weight heparin were included. We excluded patients who died within 24 hours of admission or those who received no thromboprophylaxis. The primary outcome was the rate of venous thromboembolism. Multivariable logistic regression was used to evaluate the independent relationship between the type of pharmacologic prophylaxis and the risk of venous thromboembolism. RESULTS A total of 4,103 patients who underwent lower extremity amputation were identified. Patients were primarily young (median age 43 years) with blunt injuries (83%). The overall rate of venous thromboembolism was 8.6%. Most (77%) patients received low-molecular-weight heparin-based prophylaxis. Compared with patients without venous thromboembolism, the venous thromboembolism cohort had a greater injury severity score (19 vs 13, P < .001), had more patients undergoing above-the-knee amputation (48% vs 36%, P < .001), and less frequently received low-molecular-weight heparin (64% vs 78%, P < .001). Multivariable analysis showed that low-molecular-weight heparin was associated with a significantly lower venous thromboembolism rate than unfractionated heparin (odds ratio: 0.65 [0.51-0.83], P < .001). CONCLUSION Thromboprophylaxis with low-molecular-weight heparin was found to be superior to unfractionated heparin in lowering the risk of venous thromboembolism among traumatic amputees and should be the preferred pharmacologic agent in this patient population prone to venous thromboembolism.
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Affiliation(s)
- Dias Argandykov
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jefferson A Proaño-Zamudio
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Emanuele Lagazzi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Wardah Rafaqat
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - May Abiad
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Angela M Renne
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Charudutt N Paranjape
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - John O Hwabejire
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Lagazzi E, Ballardini G, Drogo A, Viola L, Marrone E, Valente V, Bonetti M, Lee J, King DR, Ricci S. The Certification Matters: A Comparative Performance Analysis of Combat Application Tourniquets versus Non-Certified CAT Look-Alike Tourniquets. Prehosp Disaster Med 2023; 38:450-455. [PMID: 37605860 DOI: 10.1017/s1049023x23006076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
INTRODUCTION The Stop the Bleed campaign provided civilians with tourniquet application training and increased the demand for tourniquets among the general population, which led to the development of new commercially available devices. However, most widely available tourniquets have not undergone testing by regulatory bodies and their efficacy remains unknown. STUDY OBJECTIVE This study aimed to compare the efficacy and performance of Combat Application Tourniquets (CAT) versus uncertified tourniquets. METHODS This study compared 25 CAT with 50 commercially available "look-alike" tourniquets (LA-TQ) resembling the CAT. The CAT and the LA-TQ were compared for cost, size, and tested during one-hour and six-hour applications on a manikin's leg. The outcomes were force applied, force variation during the application, and tourniquet rupture rate. RESULTS The LA-TQ were cheaper (US$6.07 versus US$27.19), shorter, and had higher inter-device variability than the CAT (90.1 [SE = 0.5] cm versus 94.5 [SE = 0.1] cm; P <.001). The CAT applied a significantly greater force during the initial application when compared to the LA-TQ (65 [SE = 3] N versus 14 [SE = 1] N; P <.001). While the initial application force was maintained for up to six hours in both groups, the CAT group applied an increased force during one-hour applications (group effect: F [1,73] = 105.65; P <.001) and during six-hour applications (group effect: F [1,12] = 9.79; P = .009). The rupture rate differed between the CAT and the LA-TQ (0% versus 4%). CONCLUSION The LA-TQ applied a significantly lower force and had a higher rupture rate compared to the CAT, potentially affecting tourniquet performance in the context of public bleeding control. These findings warrant increased layperson education within the framework of the Stop the Bleed campaign and further investigations on the effectiveness of uncertified devices in real-world applications.
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Affiliation(s)
- Emanuele Lagazzi
- Department of Surgery, Humanitas Research Hospital, Rozzano, Lombardia, Italy
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MassachusettsUSA
- Italian Trauma League ODV, Genova, Italy
| | - Giulia Ballardini
- Department of Informatics, Bioengineering, Robotics, and Systems Engineering, University of Genova, Genova, Italy
- Max Planck Institute for Intelligent Systems, Stuttgart, Germany
| | - Alberto Drogo
- Italian Trauma League ODV, Genova, Italy
- School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Ludovica Viola
- Department of Informatics, Bioengineering, Robotics, and Systems Engineering, University of Genova, Genova, Italy
| | - Eva Marrone
- Italian Trauma League ODV, Genova, Italy
- School of Medical and Pharmaceutical Sciences, University of Genova, Genova, Italy
| | - Valerio Valente
- Italian Trauma League ODV, Genova, Italy
- Department of Anesthesia and Intensive Care Unit, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Michele Bonetti
- Italian Trauma League ODV, Genova, Italy
- Schwarzwald-Baar Klinikum, University Hospital of the University of Freiburg - Division of Anesthesia and Intensive - Emergency and Pain Medicine Villingen-Schwenningen, Freiburg, Baden-Württemberg, Germany
| | - Jarone Lee
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MassachusettsUSA
| | - David R King
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MassachusettsUSA
| | - Serena Ricci
- Department of Informatics, Bioengineering, Robotics, and Systems Engineering, University of Genova, Genova, Italy
- Simulation and Advanced Education Center, University of Genova, Genova, Liguria, Italy
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Lagazzi E, de Roulet A, Proaño-Zamudio JA, Argandykov D, Romijn AS, Abiad M, Rafaqat W, Hwabejire JO, Velmahos GC, Paranjape C. Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis. J Trauma Acute Care Surg 2023; 94:823-830. [PMID: 37079864 DOI: 10.1097/ta.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Viola L, Lagazzi E, Ballardini G, Drogo A, Bonetti M, Marrone E, Chirico M, Ricci S. Design of a system to detect the force applied by tourniquets in a manikin's limb. Annu Int Conf IEEE Eng Med Biol Soc 2021; 2021:5019-5022. [PMID: 34892334 DOI: 10.1109/embc46164.2021.9631020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Massive hemorrhage remains the number one cause of preventable death in trauma worldwide. However, immediate intervention by a bystander can significantly improve the survival of the injured person. In this context, the tourniquets represent the most quick and effective devices for stopping arterial and venous blood flow. The aim of this study was to implement a system to detect the force applied by a tourniquet on a simulated limb, without blood flow. The system we designed is characterized by four low-cost force sensing resistors placed on each lower limb of a manikin, below the groin. Tests on 21 tourniquets, revealed that our system is able to detect the force applied for 60 minutes, also discriminating between turns. Hence, this system can be used to compare the performance of different types of devices, but also to assess proper tourniquet placement in trainees and trauma care providers, thus making it a versatile low-cost device.
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Valsecchi D, Sassi G, Tiraboschi L, Bonetti M, Lagazzi E, Michelon AM, Nicolussi T, Stevan A, Bonasera-Vincenti NM, Guelfi-Pulvano R, Tripodi R. The Rise of the Stop the Bleed Campaign in Italy. J Spec Oper Med 2019; 19:95-99. [PMID: 31910480 DOI: 10.55460/rxgj-k1s5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The B-Con Basic 1.0 protocol is a medical training designed to teach how to control massive external haemorrhages in emergency conditions. Spread throughout the United States since 2013, thanks to the Stop the Bleed campaign, it has seen a progressive international spread during 2016-2018. We report here data from the first 18 months of our training in Italy. METHODS Since January 2017, military Operators enlisted to the Volunteer Military Corps of the Italian Red Cross and registered to the ACS B-Con instructor database have provided B-Con courses. These instructors have provided extensive training, involving learners among military and civilian populations, especially health professionals and students. Further, they have obtained a formal adhesion to the National Stop the Bleed Day 2018. RESULTS Through August 2018, we trained 1186 learners in Italy on the B-Con protocol. The learners were mainly military personnel and law enforcement agents (620 [52%]) but also students and civilian health personnel (566 [48%]). CONCLUSION The B-Con protocol has been very well received in Italy by military and police personnel. Good results have been assessed among civilian health professionals and medical students, especially by those operators involved in the field of emergency medicine.
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