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Lammers D, Uhlich R, Rokayak O, Manley N, Betzold RD, Hu P. Comparison of military and civilian surgeon outcomes with emergent trauma laparotomy in a mature military-civilian partnership. Trauma Surg Acute Care Open 2024; 9:e001332. [PMID: 38440096 PMCID: PMC10910416 DOI: 10.1136/tsaco-2023-001332] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction Medical readiness is of paramount concern for active-duty military providers. Low volumes of complex trauma in military treatment facilities has driven the armed forces to embed surgeons in high-volume civilian centers to maintain clinical readiness. It is unclear what impact this strategy may have on patient outcomes in these centers. We sought to compare emergent trauma laparotomy (ETL) outcomes between active-duty Air Force Special Operations Surgical Team (SOST) general surgeons and civilian faculty at an American College of Surgeons verified level 1 trauma center with a well-established military-civilian partnership. Methods Retrospective review of a prospectively maintained, single-center database of ETL from 2019 to 2022 was performed. ETL was defined as laparotomy from trauma bay within 90 min of patient arrival. The primary outcome was to assess for all-cause mortality differences at multiple time points. Results 514 ETL were performed during the study period. 22% (113 of 514) of patients were hypotensive (systolic blood pressure ≤90 mm Hg) on arrival. Six SOST surgeons performed 43 ETL compared with 471 ETL by civilian faculty. There were no differences in median ED length of stay (27 min vs 22 min; p=0.21), but operative duration was significantly longer for SOST surgeons (129 min vs 110 min; p=0.01). There were no differences in intraoperative (5% vs 2%; p=0.30), 6-hour (3% vs 5%; p=0.64), 24-hour (5% vs 5%; p=1.0), or in-hospital mortality rates (5% vs 8%; p=0.56) between SOST and civilian surgeons. SOST surgeons did not significantly impact the odds of 24-hour mortality on multivariable analysis (OR 0.78; 95% CI 0.10, 6.09). Conclusion Trauma-related mortality for patients undergoing ETL was not impacted by SOST surgeons when compared with their civilian counterparts. Military surgeons may benefit from the valuable clinical experience and mentorship of experienced civilian trauma surgeons at high volume trauma centers without creating a deficit in the quality of care provided. Level of evidence Level IV, therapeutic/care management.
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Affiliation(s)
- Daniel Lammers
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Omar Rokayak
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nathan Manley
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Richard D Betzold
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Lammers D, Rokayak O, Uhlich R, Sensing T, Baird E, Richman J, Holcomb JB, Jansen J. Balanced resuscitation and earlier mortality end points: bayesian post hoc analysis of the PROPPR trial. Trauma Surg Acute Care Open 2023; 8:e001091. [PMID: 37575614 PMCID: PMC10414081 DOI: 10.1136/tsaco-2023-001091] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/23/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial failed to demonstrate a mortality difference for hemorrhaging patients receiving a balanced (1:1:1) vs a 1:1:2 resuscitation at 24 hours and 30 days. Recent guidelines recommend earlier mortality end points for hemorrhage-control trials, and the use of contemporary statistical methods. The aim of this post hoc analysis of the PROPPR trial was to evaluate the impact of a balanced resuscitation strategy at early resuscitation time points using a Bayesian analytical framework. Methods Bayesian hierarchical models were created to assess mortality differences at the 1, 3, 6, 12, 18, and 24 hours time points between study cohorts. Posterior probabilities and Bayes factors were calculated for each time point. Results A 1:1:1 resuscitation displayed a 96%, 99%, 94%, 92%, 96%, and 94% probability for mortality benefit at 1, 3, 6, 12, 18, and 24 hours, respectively, when compared with a 1:1:2 approach. Associated Bayes factors for each respective time period were 21.2, 142, 14.9, 11.4, 26.4, and 15.5, indicating 'strong' to 'decisive' supporting evidence in favor of balanced transfusions. Conclusion This analysis provides evidence in support that a 1:1:1 resuscitation has a high probability of mortality benefit when compared with a 1:1:2 strategy, especially at the newly defined more proximate time points during the resuscitative period. Researchers should consider using Bayesian approaches, along with more proximate end points when assessing hemorrhage-related mortality, for the analysis of future clinical trials. Level of evidence Level III/Therapeutic.
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Affiliation(s)
- Daniel Lammers
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Omar Rokayak
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Thomas Sensing
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Emily Baird
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
| | - Jan Jansen
- Division of Trauma and Acute Care Surgery, The University of Alabama at Birmingham Hospital, Birmingham, Alabama, USA
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Uhlich R, Hu P, Yazer M, Jansen JO, Patrician P, Marques MB, Reynolds L, Fifolt M, Stephens SW, Gelbard RB, Kerby J, Holcomb JB. The females have spoken: A patient-centered national survey on the administration of emergent transfusions with the potential for future fetal harm. J Trauma Acute Care Surg 2023; 94:791-797. [PMID: 36808128 DOI: 10.1097/ta.0000000000003914] [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] [Indexed: 02/22/2023]
Abstract
BACKGROUND Traumatic hemorrhage is the leading cause of preventable death. Early in the resuscitation, only RhD-positive red blood cells are likely to be available, which poses a small risk of causing harm to a future fetus if transfused to an RhD-negative females of childbearing age (CBA), that is, 15 to 49 years old. We sought to characterize how the population, in particular females of CBA, felt about emergency blood administration vis-a-vis potential future fetal harm. METHODS A national survey was performed using Facebook advertisements in three waves from January 2021 to January 2022. The advertisements directed users to the survey site with seven demographic questions and four questions on accepting transfusion with differing probabilities for future fetal harm (none/any/1:100/1:10,000). Acceptance of transfusion questions were scored on 3-point Likert scale (likely/neutral/unlikely). Only completed responses by females were analyzed. RESULTS Advertisements were viewed 16,600,430 times by 2,169,805 people with 15,396 advertisement clicks and 2,873 surveys initiated. Most (2,256 of 2,873 [79%]) were fully completed. Majority (2,049 of 2,256 [90%]) of respondents were female. Eighty percent of females (1,645 of 2,049) were of CBA. Most females responded "likely" or "neutral" when asked whether they would accept a lifesaving transfusion if the following risk of fetal harm were present: no risk (99%), any risk (83%), 1:100 risk (85%), and 1:10,000 risk (92%). There were no differences between females of CBA versus non-CBA with respect to the likelihood of accepting lifesaving transfusion with any potential for future fetal harm ( p = 0.24). CONCLUSION This national survey suggests that most females would accept lifesaving transfusion even with the potential low risk of future fetal harm. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Rindi Uhlich
- From the Center for Injury Science and Division of Trauma and Acute Care Surgery, Department of Surgery (R.U., P.H., J.O.J., S.W.S., R.B.G., J.K., J.B.H.), University of Alabama at Birmingham, Birmingham, Alabama; Department of Pathology (M.Y.), University of Pittsburgh, Pittsburgh, Pennsylvania; and School of Nursing (P.P.), Department of Pathology (M.B.M.), and School of Public Health (L.R., M.F.), University of Alabama at Birmingham, Birmingham, Alabama
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Hu P, Uhlich R, Pierce V, Cox T, Kerby J, Bosarge P. Intra-abdominal packing does not increase infection risk or mandate longer presumptive antibiotic therapy. ULUS TRAVMA ACIL CER 2023; 29:618-626. [PMID: 37145040 DOI: 10.14744/tjtes.2022.64438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Damage control laparotomy allows for resuscitation and reversal of coagulopathy with improved mortality. In-tra-abdominal packing is often used to limit hemorrhage. Temporary abdominal closure is associated with increased rates of subse-quent intra-abdominal infection. The effect of increased duration of antibiotics is unknown on these infection rates. We sought to determine the role of antibiotics in damage control surgery. METHODS A retrospective analysis of all trauma patients requiring damage control laparotomy on admission to an ACS verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was intra-abdominal abscess formation following damage control laparotomy. RESULTS Two-hundred and thirty-nine patients underwent DCS during the study period. A majority were packed (141/239, 59.0%). No differences existed in demographics or injury severity between groups, and infection rates were similar (30.5% vs. 38.8%, P=0.18). Patients with infection were more likely to have suffered gastric injury (23.3% vs. 6.1%, P=0.003) than those without complication. There was no significant association between gram negative and anaerobic (Odds Radio [OR] 0.96, 95% confidence interval [CI] 0.87-1.05) or antifungal therapy (OR 0.98, 95% CI 0.74-1.31) and infection rate, regardless of duration on multivariate regression CONCLUSION: Our study offers the first review of the effect of antibiotic duration on intra-abdominal complications following DCS. Gastric injury was more commonly identified in patients who developed intra-abdominal infection. Duration of antimicrobial therapy does not affect infection rate in patients who are packed following DCS.
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Affiliation(s)
- Parker Hu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Virginia Pierce
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Thomas Cox
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Jeffrey Kerby
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Patrick Bosarge
- Department of Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States of America
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Lammers D, Rokayak O, Uhlich R, Hu P, Baird E, Rakestraw S, Betzold R, McClellan J, Eckert M. Early Use of Extracorporeal Membrane Oxygenation for Traumatically Injured Patients: A National Trauma Database Analysis. Am Surg 2023:31348231161082. [PMID: 36876475 DOI: 10.1177/00031348231161082] [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: 03/07/2023]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) in acute trauma patients is a poorly characterized event. While ECMO most commonly has been deployed for advanced cardiopulmonary or respiratory failure following initial resuscitation, growing levels of evidence for out of hospital cardiac arrest support early ECMO cannulation as part of resuscitative efforts. We sought to perform a descriptive analysis evaluating traumatically injured patients, who were placed on ECMO, during their initial resuscitation period. METHODS We performed a retrospective analysis of the Trauma Quality Improvement Program Database from 2017 to 2019. All traumatically injured patients who received ECMO within the first 24 hours of their hospitalization were assessed. Descriptive statistics were used to define patient characteristics and injury patterns associated with the need for ECMO, while mortality represented the primary outcome evaluated. RESULTS A total of 696 trauma patients received ECMO during their hospitalization, of which 221 were placed on ECMO within the first 24 hours. Early ECMO patients were on average 32.5 years old, 86% male, and sustained a penetrating injury 9% of the time. The average ISS was 30.7, and the overall mortality rate was 41.2%. Prehospital cardiac arrest was noted in 18.2% of the patient population resulting in a 46.8% mortality. Of those who underwent resuscitative thoracotomy, a 53.3% mortality rate was present. CONCLUSION Early cannulation for ECMO in severely injured patients may provide an opportunity for rescue therapy following severe injury patterns. Further evaluation regarding the safety profile, cannulation strategies, and optimal injury patterns for these techniques should be evaluated.
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Affiliation(s)
- Daniel Lammers
- Center for Injury Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Omar Rokayak
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Rindi Uhlich
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Parker Hu
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Emily Baird
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Stephanie Rakestraw
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - Richard Betzold
- Center for Injury Science, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL, USA
| | - John McClellan
- Department of General Surgery, 19933Madigan Army Medical Center, Tacoma, WA, USA
| | - Matthew Eckert
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Chapel Hill, NC, USA
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Gelbard RB, Griffin RL, Reynolds L, Abraham P, Warner J, Hu P, Kerby JD, Uhlich R, Marques MB, Jansen JO, Holcomb JB. Over-transfusion with blood for suspected hemorrhagic shock is not associated with worse clinical outcomes. Transfusion 2022; 62 Suppl 1:S177-S184. [PMID: 35753037 DOI: 10.1111/trf.16978] [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: 02/01/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND We evaluated patient outcomes after early, small volume red blood cell (RBC) transfusion in the setting of presumed hemorrhagic shock. We hypothesized that transfusion with even small amounts of blood would be associated with more complications. STUDY DESIGN AND METHODS Retrospective review of trauma patients admitted to a Level 1 trauma center between 2016-2021. Patients predicted to require massive transfusion who survived ≥72 h were categorized according to units of RBCs transfused in the first 24 h. A Cox regression model stratified by dichotomized ISS and adjusted for SBP <90 mm Hg and pulse >120 bpm on arrival was used to estimate hazard ratios (HRs) for outcomes of interest. RESULTS A total of 3121 (24%) received RBC transfusion within the first 24 h. Massive transfusion protocol (MTP) was activated in 38% (1188/3121): 17% received no RBCs, 27.4% 1-3 units, 32.4% 4-9 units, and 22.7% ≥10 units. Mean ISS increased with each category of RBC transfusion. There was no difference in the risk of acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), infection, cardiac arrest, venous thromboembolism or stroke for patients receiving 1-3 units compared to the non-transfused group or 4-9 units group (p > 0.05). Compared to those receiving ≥10 units, the 1-3 units group had a significantly lower risk of AKI, ARDS, and cardiac arrest. DISCUSSION Early empiric RBC transfusion for presumed hemorrhagic shock may subject patients to potential over-transfusion and end-organ damage. Among patients meeting clinical triggers for MTP, 1-3 units of allogeneic RBCs is not associated with worse outcomes.
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Affiliation(s)
- Rondi B Gelbard
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Russell L Griffin
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lindy Reynolds
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter Abraham
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey Warner
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Kerby
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan O Jansen
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Department of Trauma and Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Hu P, Jansen JO, Uhlich R, Hashmi ZG, Gelbard RB, Kerby J, Cox D, Holcomb JB. It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy. J Trauma Acute Care Surg 2022; 92:769-780. [PMID: 35045057 DOI: 10.1097/ta.0000000000003540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/26/2022]
Abstract
BACKGROUND Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL. METHODS A retrospective cohort study of patients undergoing ETL directly from the trauma bay by trauma faculty from December 2019 to February 2021 was conducted. Patients were excluded from mortality analysis if they required resuscitative thoracotomy for arrest before ETL. Surgeons were compared by rates of damage control and mortality at multiple time points. RESULTS There were 242 ETL (7-32 ETLs per surgeon) performed by 14 faculties. Resuscitative thoracotomy was performed in 7.0% (n = 17) before ETL. Six patients without resuscitative thoracotomy died intraoperatively and damage-control laparotomy was performed on 31.9% (n = 72 of 226 patients). Mortality was 4.0% (n = 9) at 24 hours and 7.1% (n = 16) overall. Median Injury Severity Score (p = 0.21), new injury severity score (p = 0.21), and time in emergency department were similar overall among surgeons (p = 0.15), while operative time varied significantly (40-469 minutes; p = 0.005). There were significant differences between rates of individual surgeon's mortality (range [hospital mortality], 0-25%) and damage-control laparotomy (range, 14-63%) in ETL. CONCLUSION Significant differences exist in outcomes by surgeon after ETL. Benchmarking surgeon level performance is a necessary natural progression of quality assurance programs for individual trauma centers. Additional data from multiple centers will be vital to allow for development of more granular quality metrics to foster introspective case review and quality improvement. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Parker Hu
- From the Division of Acute Care Surgery (P.H., J.O.J., Z.G.H., R.B.G., J.K., D.C., J.B.H.), Department of Surgery and Department of Surgery (R.U.), University of Alabama at Birmingham, Birmingham, Alabama
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Uhlich R, Hu P, Yazer M, Jansen JO, Patrician P, Reynolds L, Marques MB, Stephens SW, Gelbard RB, Kerby J, Holcomb JB. Perception of risk in massive transfusion as it relates to fetal outcomes: A survey of surgeons and nurses at one American trauma center. Transfusion 2021; 61 Suppl 1:S159-S166. [PMID: 34269430 DOI: 10.1111/trf.16492] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The use of blood products early in the resuscitation of bleeding trauma patients is widely accepted, but made difficult by limited supplies of D- red blood cell (RBC)-containing products. Use of D+ RBC-containing products would alleviate this issue, but could lead to alloimmunization. Risk associated with transfusing D+ RBC in emergency bleeding situations is being reconsidered. The level of concern surrounding emergency transfusion as it relates to future fetal harm was surveyed among surgeons and nurses. METHODS Faculty and staff in the Departments of Surgery and Nursing were surveyed on the risks of receiving an emergency RBC transfusion and the subsequent potential for fetal harm. Answers were grouped as likely to accept (likely/very likely) or refuse transfusion (unlikely/very unlikely). Participants were compared by sex, and women by child-bearing age, ([15-50 years] vs. [>50 years]). RESULTS Ninety surveys were initiated with 76 fully completed. Male (n = 39) and female (n = 37) respondents were comparable. Most female respondents (30/37, 81%) were of childbearing age. Overall, both males (38/39, 95%) and females (33/37, 89%; p = .19) were likely to accept a transfusion in an emergency. There was no difference in transfusion acceptance if the risk of fetal harm was presented as 1% (p = .73) or 0.1% (p = .51). Most females (34/37, 92%) were not opposed to transfusion even if there was an unspecified risk of future fetal harm. CONCLUSION Most of the surgeons and nurses who responded would accept a transfusion in an emergency situation even if it might lead to harming a future fetus.
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Affiliation(s)
- Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Mark Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan O Jansen
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Patricia Patrician
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lindy Reynolds
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Shannon W Stephens
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rondi B Gelbard
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey Kerby
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science and Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Hu P, Uhlich R, Black J, Jansen JO, Kerby J, Holcomb JB. A new definition for massive transfusion in the modern era of whole blood resuscitation. Transfusion 2021; 61 Suppl 1:S252-S263. [PMID: 34269434 DOI: 10.1111/trf.16453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/24/2021] [Accepted: 01/26/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Multiple thresholds are defined to identify patients at risk of death from hemorrhage, including massive transfusion (MT), critical administration threshold (CAT), and resuscitation intensity (RI). All fail to account for the use of whole blood (WB). We hypothesized that a definition including WB transfusion would better predict early mortality following trauma. METHODS This is a retrospective review of all trauma patients with activation of the MT protocol from December 2018 to February 2020. Combinations of WB, RBCs, and fresh frozen plasma (FFP) units transfused during the initial hour of resuscitation were compared using receiver operating characteristic and area under the receiver curve (AUC) for 3- and 6-h mortality. WB massive transfusion (WB MT) score was defined as the sum of each unit RBC plus three times each unit of WB transfused within the first hour of resuscitation. RESULTS There were 235 patients eligible for analysis with 60 resuscitated using ≥1 unit of WB. Overall, 27 and 29 patients died in the first 3 and 6 h, respectively. WB MT ≥7 had the greatest 3-h and 6-h mortality AUC values (0.78 and 0.79, respectively) when compared to MT, CAT, RI4+, and other attempted definitions using units of WB, RBC, and FFP. Compared to WB MT-, WB MT+ patients died at significantly higher rates at 3 h (28.9% vs. 3.1%, p < .001), 24 h (35.5% vs. 5.7%, p < .001), and 28 days (42.1% vs. 11.9%, p < .001). CONCLUSION WB MT is the first measure of massive resuscitation to incorporate WB and better identifies early mortality than other definitions.
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Affiliation(s)
- Parker Hu
- Center for Injury Science & Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jonathan Black
- Center for Injury Science & Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan O Jansen
- Center for Injury Science & Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey Kerby
- Center for Injury Science & Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science & Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Uhlich R, Kerby JD, Bosarge P, Hu P. Use of continuous intercostal nerve blockade is associated with improved outcomes in patients with multiple rib fractures. Trauma Surg Acute Care Open 2021; 6:e000600. [PMID: 33981859 PMCID: PMC8076940 DOI: 10.1136/tsaco-2020-000600] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/04/2020] [Accepted: 04/05/2021] [Indexed: 11/03/2022] Open
Abstract
Background Rib fractures are common among trauma patients and may result in significant morbidity and mortality. There are numerous treatment options, but ideal management is unclear. Delivery of local anesthetic via an analgesia catheter for continuous intercostal nerve blockade offers an attractive potential option for management of patients with rib fractures. Methods We performed a single-center, retrospective case-control analysis of trauma patients with multiple rib fractures from 2016 to 2018, comparing patients managed with continuous intercostal nerve blockade with standard care. Matching was performed in a 2:1 ratio by Injury Severity Score, age, and gender. Respiratory morbidity potentially secondary to rib fractures, including unplanned intubation, failure of extubation, need for tracheostomy, pneumonia, or mortality, were all identified and included. Potential complications due to catheter insertion were identified to be recorded. The primary outcome of interest was 30-day hospital-free days. Results Nine hundred and thirty-three patients were eligible for analysis, with 48 managed using intercostal blockade compared with 96 matching controls. No complications of intercostal blockade were identified during the study period. Controls demonstrated fewer rib fractures (6.60±4.11 vs. 9.3±3.73, p=0.001) and fewer flail segments (0.8±1.76 vs. 2.0±2.94, p=0.02). Those managed with intercostal blockade demonstrated significantly more 30-day hospital-free days (15.9±6.43 vs. 13.2±9.94, p=0.048), less incidence of pneumonia (4.2% vs. 16.7%, p=0.03), and lower hospital mortality (2.1% vs. 13.5%, p=0.03). When adjusting for number of rib fractures and number of flail segments, use of continuous intercostal nerve blockade was significantly associated with lower hospital mortality (OR 0.10; 95% CI 0.01 to 0.91), pneumonia (OR 0.15; 95% CI 0.03 to 0.76), or need for tracheostomy (OR 0.23; 95% CI 0.06 to 0.83). Discussion The addition of continuous intercostal nerve blockade may help to improve outcomes in patients with multiple rib fractures compared with standard care alone. Level of evidence Therapeutic/care management; level IV.
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Affiliation(s)
- Rindi Uhlich
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Patrick Bosarge
- Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
| | - Parker Hu
- Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Uhlich R, Pierce V, Kerby J, Bosarge P, Hu P. Splenectomy does not affect the development of pneumonia following severe traumatic brain injury. Brain Behav Immun Health 2020; 1:100007. [PMID: 38377417 PMCID: PMC8474628 DOI: 10.1016/j.bbih.2019.100007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 01/01/2023] Open
Abstract
The cholinergic anti-inflammatory pathway offers a proposed mechanism to describe the increased risk of pneumonia following severe traumatic brain injury (sTBI). Vagal activity transmitted to the spleen results in decreased inflammatory cytokine production and immunosuppression. However, no clinical evidence exists. We sought to compare pneumonia rates among patients with TBI and splenectomy using a retrospective analysis of all trauma patients with splenic injury requiring splenectomy or TBI admitted to an ACS verified level one trauma center from 2011 to 2016. Admission Glasgow Coma Score (GCS) ≤ 8 was used to identify sTBI. Pneumonia was defined by respiratory culture obtained by bronchoalveolar lavage. Analysis included χ2 and one-way analysis of variance followed by multivariate logistic regression to determine the association of sTBI and splenectomy of development of pneumonia. Four hundred and twenty-seven patients were included for primary analysis, 247 with sTBI, 180 with splenectomy, and 14 with both sTBI and splenectomy. Rates of pneumonia were increased, although not significant among patients with sTBI and splenectomy and both sTBI alone (71.4 vs. 49.4%, p = 0.11). On multivariate regression, the risk of pneumonia was increased with both splenectomy and sTBI (OR 3.18; 95% CI, 0.75-13.45) and sTBI alone, although significant in the latter only (OR 3.56; 95% CI, 2.12-5.97). Based on these results, splenectomy does not appear to influence the development of pulmonary immunosuppression and pneumonia following sTBI.
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Affiliation(s)
- Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, LHRB 112, Birmingham, AL, 35294, USA
| | - Virginia Pierce
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, LHRB 112, Birmingham, AL, 35294, USA
| | - Jeffrey Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL, 35294, USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, LHRB 112, Birmingham, AL, 35294, USA
| | - Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, LHRB 112, Birmingham, AL, 35294, USA
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Robinson LA, Turco LM, Robinson B, Corsa JG, Mount M, Hamrick AV, Berne J, Mederos DR, McNickle AG, Chestovich PJ, Weinberger J, Grigorian A, Nahmias J, Lee JK, Chow KL, Olson EJ, Pascual JL, Solomon R, Pigneri DA, Ladhani HA, Fraifogl J, Claridge J, Curry T, Costantini TW, Kongwibulwut M, Kaafarani H, San Roman J, Schreiber C, Goldenberg-Sandau A, Hu P, Bosarge P, Uhlich R, Lunardi N, Usmani F, Sakran JV, Babcock JM, Quispe JC, Lottenberg L, Cabral D, Chang G, Gulmatico J, Parks JJ, Rattan R, Massetti J, Gurney O, Bruns B, Smith AA, Guidry C, Kutcher ME, Logan MS, Kincaid MY, Spalding C, Noorbaksh M, Philp FH, Cragun B, Winfield RD. Outcomes in patients with gunshot wounds to the brain. Trauma Surg Acute Care Open 2019; 4:e000351. [PMID: 31799416 PMCID: PMC6861103 DOI: 10.1136/tsaco-2019-000351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/16/2019] [Accepted: 10/24/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence Level II.
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Affiliation(s)
- Leigh Anna Robinson
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Lauren M Turco
- Emergency Medicine, Spectrum Health Butterworth Hospital, Grand Rapids, Michigan, USA
| | - Bryce Robinson
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Joshua G Corsa
- Department of Surgery, Harborview Medical Center, Seattle, Washington, USA
| | - Michael Mount
- Division of Surgery, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
| | - Amy V Hamrick
- Division of Surgery, Spartanburg Regional Healthcare System, Spartanburg, South Carolina, USA
| | - John Berne
- Division of Trauma and Critical Care, Broward Health, Fort Lauderdale, Florida, USA
| | - Dalier R Mederos
- Division of Trauma and Critical Care, Broward Health, Fort Lauderdale, Florida, USA
| | | | - Paul J Chestovich
- Department of Surgery, UNLV School of Medicine, Las Vegas, Nevada, USA
| | | | - Areg Grigorian
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California Irvine School of Medicine, Irvine, California, USA
| | - Jane K Lee
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kevin L Chow
- Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Erik J Olson
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Jose L Pascual
- Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | | | - Husayn A Ladhani
- Department of Surgery, Case Western Reserve University Hospital, Cleveland, Ohio, USA
| | - Joanne Fraifogl
- Department of Surgery, Case Western Reserve University Hospital, Cleveland, Ohio, USA
| | - Jeffrey Claridge
- Department of Surgery, Case Western Reserve University Hospital, Cleveland, Ohio, USA
| | - Terry Curry
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, UC San Diego Health, San Diego, California, USA
| | | | - Haytham Kaafarani
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Janika San Roman
- Division of Trauma, Surgical Critical Care & Acute Care Surgery, Cooper University Hospital, Camden, New Jersey, USA
| | - Craig Schreiber
- Division of Trauma, Surgical Critical Care & Acute Care Surgery, Cooper University Hospital, Camden, New Jersey, USA
| | - Anna Goldenberg-Sandau
- Division of Trauma, Surgical Critical Care & Acute Care Surgery, Cooper University Hospital, Camden, New Jersey, USA
| | - Parker Hu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Patrick Bosarge
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nicole Lunardi
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Farooq Usmani
- Department of Surgery, The Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Jessica M Babcock
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
| | - Juan Carlos Quispe
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
| | | | - Donna Cabral
- St. Mary's Medical Center, Boca Raton, Florida, USA
| | - Grace Chang
- Department of Surgery, Mount Sinai Hospital, Chicago, Illinois, USA
| | | | - Jonathan J Parks
- Department of Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Rishi Rattan
- Department of Surgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Jennifer Massetti
- Department of Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Onaona Gurney
- Department of Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Brandon Bruns
- Department of Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Alison A Smith
- Department of Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Chrissy Guidry
- Department of Surgery, Tulane Medical Center, New Orleans, Louisiana, USA
| | - Matthew E Kutcher
- Department of Surgery, University of Mississippi, University Park, Mississippi, USA
| | - Melissa S Logan
- Department of Surgery, University of Mississippi, University Park, Mississippi, USA
| | - Michelle Y Kincaid
- Trauma and Acute Care Surgery, Grant Medical Center, Columbus, Ohio, USA
| | - Chance Spalding
- Trauma and Acute Care Surgery, Grant Medical Center, Columbus, Ohio, USA
| | | | | | | | - Robert D Winfield
- Department of Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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Uhlich R, Jansen J, Bosarge P, Kerby JD, Hu PJ. Resuscitative Endovascular Balloon Occlusion of the Aorta is Cost-Effective in the Management of the Unstable Trauma Patient. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bukoski A, Uhlich R, Bowling F, Shapiro M, Kerby JD, Llerena L, Armstrong JH, Strayhorn C, Barnes SL. Perceptions of Simulator- and Live Tissue-Based Combat Casualty Care Training of Senior Special Operations Medics. Mil Med 2019; 183:78-85. [PMID: 29635549 DOI: 10.1093/milmed/usx136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 01/02/2018] [Indexed: 01/20/2023] Open
Abstract
The relative effectiveness of live tissue (LT)- and inanimate simulation (SIM)-based training of combat medics is the subject of intense debate. A structured interview was utilized to determine the training modality preferences and the perceived value of LT- and SIM-based combat casualty care training of 25 senior special operations medics. Participant demographics and training experience, Likert scale-based assessment of training modality value, selection of preferred training modality for 11 combat casualty care procedures, and 12 open-ended questions probing opinions of the limitations and benefits of LT- and SIM-based training were collected from this convenience sample. All participants indicated significant combat medic experience and training. Of the 11 procedures questioned, LT was identified as superior for seven with mixed responses for the remaining four. LT was consistently identified as an essential training modality with tactile sensation and the physiologic responses of animal models to injury and therapy as primary benefits. Across procedures, 100% of participants felt that LT should be used in combat casualty care training and 96% felt that SIM should also be utilized. Repeatability and accuracy of size/weight were identified as key benefits of SIM training. Respondents reported that capability, self-confidence, success, and resilience of the combat medic all benefitted from LT training. The overriding theme was the general superiority of LT with recognition of the unique and complementary benefits of SIM.
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Affiliation(s)
- Alex Bukoski
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, 900 East Campus Drive, Columbia, MO 65211
| | - Rindi Uhlich
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
| | - F Bowling
- United States Special Operations Command, 7701 Tampa Point Blvd, MacDill AFB, FL 33621
| | - Mark Shapiro
- Department of Surgery, Division of Trauma and Surgical Critical Care, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710
| | - Jeffrey D Kerby
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
| | - Luis Llerena
- University of South Florida Health, Center for Advanced Medical Learning and Simulation (CAMLS), 124 South Franklin Street, Tampa, FL 33602
| | - John H Armstrong
- University of South Florida Health, Center for Advanced Medical Learning and Simulation (CAMLS), 124 South Franklin Street, Tampa, FL 33602
| | - Catherine Strayhorn
- Information Visualization and Innovative Research (IVIR), 1626 Barber Road, Suite A, Sarasota, FL 34240
| | - Stephen L Barnes
- Department of Surgery, Division of Acute Care Surgery, School of Medicine, University of Missouri, 1 Hospital Drive, Columbia, MO 65212
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Uhlich R, Kerby JD, Bosarge P, Hu P. Diagnosis of diaphragm injuries using modern 256-slice CT scanners: too early to abandon operative exploration. Trauma Surg Acute Care Open 2018; 3:e000251. [PMID: 30539157 PMCID: PMC6267309 DOI: 10.1136/tsaco-2018-000251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/26/2018] [Indexed: 11/30/2022] Open
Abstract
Background Missed injury of the diaphragm may result in hernia formation, enteric strangulation, and death. Compounding the problem, diaphragmatic injuries are rare and difficult to diagnose with standard imaging. As such, for patients with high suspicion of injury, operative exploration remains the gold standard for diagnosis. As no current data currently exist, we sought to perform a pragmatic evaluation of the diagnostic ability of 256-slice multidetector CT scanners for diagnosing diaphragmatic injuries after trauma. Methods A retrospective review of trauma patients from 2011 to 2018 was performed at an American College of Surgeons-verified level 1 trauma center to identify the diagnostic accuracy of CT scan for acute diaphragm injury. All patients undergoing abdominal operation were eligible for inclusion. Two separate levels of CT scan technology, 64-slice and 256-slice, were used during this time period. The prospective imaging reports were reviewed for the diagnosis of diaphragm injury and the results confirmed with the operative record. Injuries were graded using operative description per the American Association for the Surgery of Trauma guidelines. Results One thousand and sixty-eight patients underwent operation after preoperative CT scan. Acute diaphragm injury was identified intraoperatively in 14.7%. Most with diaphragmatic injury underwent 64-slice CT (134 of 157, 85.4%). Comparing patients receiving 64-slice or 256-slice CT scan, there was no difference in the side of injury (left side 57.5% vs. 69.6%, p=0.43) or median injury grade (3 (3, 3) vs. 3 (2, 3), p=0.65). Overall sensitivity, specificity, and diagnostic accuracy of the 256-slice CT were similar to the 64-slice CT (56.5% vs. 45.5%, 93.7% vs. 98.1%, and 89.0% vs. 90.2%). Discussion The new 256-slice multidetector CT scanner fails to sufficiently improve diagnostic accuracy over the previous technology. Patients with suspicion of diaphragm injury should undergo operative intervention. Level of evidence I, diagnostic test or criteria.
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Affiliation(s)
- Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey David Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Hu P, Uhlich R, White J, Kerby J, Bosarge P. Sarcopenia Measured Using Masseter Area Predicts Early Mortality following Severe Traumatic Brain Injury. J Neurotrauma 2018; 35:2400-2406. [DOI: 10.1089/neu.2017.5422] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rindi Uhlich
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jared White
- Division of Transplant Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Hu PJ, Uhlich R, Kerby JD, Bosarge PL. Gastric or Colonic Injury Increases Risk of Empyema Development after Traumatic Injury of the Diaphragm. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Uhlich R, Hu PJ, Kerby JD, Bosarge PL. Intra-Abdominal Packing Does Not Increase Infection Risk or Mandate Longer Presumptive Antibiotic Therapy. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hu P, Uhlich R, Gleason F, Kerby J, Bosarge P. Impact of initial temporary abdominal closure in damage control surgery: a retrospective analysis. World J Emerg Surg 2018; 13:43. [PMID: 30237824 PMCID: PMC6139137 DOI: 10.1186/s13017-018-0204-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
Abstract
Background Damage control surgery has revolutionized trauma surgery. Use of damage control surgery allows for resuscitation and reversal of coagulopathy at the risk of loss of abdominal domain and intra-abdominal complications. Temporary abdominal closure is possible with multiple techniques, the choice of which may affect ability to achieve primary fascial closure and further complication. Methods A retrospective analysis of all trauma patients requiring damage control laparotomy upon admission to an ACS-verified level one trauma center from 2011 to 2016 was performed. Demographic and clinical data including ability and time to attain primary fascial closure, as well as complication rates, were recorded. The primary outcome measure was ability to achieve primary fascial closure during initial hospitalization. Results Two hundred and thirty-nine patients met criteria for inclusion. Primary skin closure (57.7%), ABThera™ VAC system (ABT) (15.1%), Bogota bag (BB) (25.1%), or a modified Barker's vacuum-packing (BVP) (2.1%) were used in the initial laparotomy. Patients receiving skin-only closure had significantly higher rates of primary fascial closure and lower hospital mortality, but also significantly lower mean lactate, base deficit, and requirement for massive transfusion. Between ABT or BB, use of ABT was associated with increased rates of fascial closure. Multivariate regression revealed primary skin closure to be significantly associated with primary fascial closure while BB was associated with failure to achieve fascial closure. Conclusions Primary skin closure is a viable option in the initial management of the open abdomen, although these patients demonstrated less injury burden in our study. Use of vacuum-assisted dressings continues to be the preferred method for temporary abdominal closure in damage control surgery for trauma.
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Affiliation(s)
- Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 701 19th Street South, 112 Lyons-Harrison Research Building, Birmingham, AL 35294 USA
| | - Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Frank Gleason
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Jeffrey Kerby
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL USA
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Affiliation(s)
- Rindi Uhlich
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Parker Hu
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Hu PJ, Bosarge PL, Kerby JD, Uhlich R. Female Sex Is Not Protective after Severe Traumatic Brain Injury. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hu PJ, Uhlich R, Kerby J, Wagener BM, Pittet JF, Bosarge PL. Splenectomy Does Not Affect the Development of Ventilator Associated Pneumonia Following Severe Traumatic Brain Injury. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bukoski A, Uhlich R, Tucker J, Cooper C, Barnes S. Recognition and Treatment of Nerve Agent Casualties: Evidence of Reduced Learner Engagement During Video-based Training. Mil Med 2016; 181:169-76. [DOI: 10.7205/milmed-d-15-00145] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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