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Kwon E, Krause C, Luo-Owen X, McArthur K, Cochran-Yu M, Swentek L, Burruss S, Turay D, Krasnoff C, Grigorian A, Nahmias J, Butt A, Gutierrez A, LaRiccia A, Kincaid M, Fiorentino M, Glass N, Toscano S, Ley EJ, Lombardo S, Guillamondegui O, Bardes JM, DeLa'O C, Wydo S, Leneweaver K, Duletzke N, Nunez J, Moradian S, Posluszny J, Naar L, Kaafarani H, Kemmer H, Lieser M, Hanson I, Chang G, Bilaniuk JW, Nemeth Z, Mukherjee K. Time is domain: factors affecting primary fascial closure after trauma and non-trauma damage control laparotomy (data from the EAST SLEEP-TIME multicenter registry). Eur J Trauma Emerg Surg 2021; 48:2107-2116. [PMID: 34845499 DOI: 10.1007/s00068-021-01814-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 07/15/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Damage control laparotomy (DCL) is used for both traumatic and non-traumatic indications. Failure to achieve primary fascial closure (PFC) in a timely fashion has been associated with complications including sepsis, fistula, and mortality. We sought to identify factors associated with time to PFC in a multicenter retrospective cohort. METHODS We reviewed retrospective data from 15 centers in the EAST SLEEP-TIME registry, including age, comorbidities (Charlson Comorbidity Index [CCI]), small and large bowel resection, bowel discontinuity, vascular procedures, retained packs, number of re-laparotomies, net fluid balance after 24 h, trauma, and time to first takeback in 12-h increments to identify key factors associated with time to PFC. RESULTS In total, 368 patients (71.2% trauma, of which 50.6% were penetrating, median ISS 25 [16, 34], with median Apache II score 15 [11, 22] in non-trauma) were in the cohort. Of these, 92.9% of patients achieved PFC at 60.8 ± 72.0 h after 1.6 ± 1.2 re-laparotomies. Each additional re-laparotomy reduced the odds of PFC by 91.5% (95%CI 88.2-93.9%, p < 0.001). Time to first re-laparotomy was highly significant (p < 0.001) in terms of odds of achieving PFC, with no difference between 12 and 24 h to first re-laparotomy (ref), and decreases in odds of PFC of 78.4% (65.8-86.4%, p < 0.001) for first re-laparotomy after 24.1-36 h, 90.8% (84.7-94.4%, p < 0.001) for 36.1-48 h, and 98.1% (96.4-99.0%, p < 0.001) for > 48 h. Trauma patients had increased likelihood of PFC in two separate analyses (p = 0.022 and 0.002). CONCLUSION Time to re-laparotomy ≤ 24 h and minimizing number of re-laparotomies are highly predictive of rapid achievement of PFC in patients after trauma- and non-trauma DCL. LEVEL OF EVIDENCE 2B.
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Affiliation(s)
- Eugenia Kwon
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Cassandra Krause
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Xian Luo-Owen
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | | | - Meghan Cochran-Yu
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - Lourdes Swentek
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Sigrid Burruss
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA
| | - David Turay
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Chloe Krasnoff
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Jeffrey Nahmias
- Trauma, Critical Care, Acute Care and Burn Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Ahsan Butt
- USC-Keck School of Medicine, Los Angeles, CA, USA
| | - Adam Gutierrez
- General Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Aimee LaRiccia
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michelle Kincaid
- General Surgery, Ohio Health Grant Medical Center, Columbus, OH, USA
| | - Michele Fiorentino
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Nina Glass
- Trauma and Surgical Critical Care, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Samantha Toscano
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric Jude Ley
- General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sarah Lombardo
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oscar Guillamondegui
- Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James Migliaccio Bardes
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Connie DeLa'O
- Trauma, Acute Care Surgery and Surgical Critical Care, West Virginia University, Morgantown, WV, USA
| | - Salina Wydo
- Trauma, Cooper University Health System, Camden, NJ, USA
| | | | - Nicholas Duletzke
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Jade Nunez
- General Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Simon Moradian
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Joseph Posluszny
- Trauma and Critical Care, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Leon Naar
- Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Heidi Kemmer
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Mark Lieser
- Surgery, Research Medical Center-Kansas City Hospital, Kansas City, MO, USA
| | - Isaac Hanson
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | - Grace Chang
- Trauma and Critical Care Surgery, Mount Sinai Hospital-Chicago, Chicago, IL, USA
| | | | - Zoltan Nemeth
- Surgery, Morristown Medical Center, Morristown, NJ, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, 11175 Campus Street CP 21111, Loma Linda, CA, 92350, USA.
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Carlson KA, Dhillon NK, Patel KA, Huang R, Ng P, Margulies DR, Ley EJ, Barmparas G. Utilization of tracheostomy among geriatric trauma patients and association with mortality. Eur J Trauma Emerg Surg 2019; 46:1375-1383. [PMID: 31396650 DOI: 10.1007/s00068-019-01199-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/25/2018] [Accepted: 07/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients. METHODS Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias. RESULTS Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01). CONCLUSION In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified. STUDY TYPE Prognostic/epidemiological. LEVEL OF EVIDENCE III or IV.
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Affiliation(s)
- Kjirsten Ayn Carlson
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Navpreet Kaur Dhillon
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Kavita Anil Patel
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Raymond Huang
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Phillip Ng
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Reed Margulies
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Eric Jude Ley
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA.
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Barmparas G, Navsaria PH, Serna-Gallegos D, Nicol AJ, Edu S, Sayari AA, Margulies DR, Ley EJ. Blunt Pharyngoesophageal Injuries: Current Management Strategies. Scand J Surg 2018; 107:336-344. [PMID: 29628012 DOI: 10.1177/1457496918766692] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. METHODS: The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. RESULTS: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03). CONCLUSION: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.
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Affiliation(s)
- G Barmparas
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - P H Navsaria
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D Serna-Gallegos
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A J Nicol
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - S Edu
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - A A Sayari
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D R Margulies
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - E J Ley
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Liou DZ, Singer MB, Barmparas G, Harada MY, Mirocha J, Bukur M, Salim A, Ley EJ. Insulin-dependent diabetes and serious trauma. Eur J Trauma Emerg Surg 2015; 42:491-496. [PMID: 26253885 DOI: 10.1007/s00068-015-0561-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 05/13/2015] [Accepted: 07/31/2015] [Indexed: 01/04/2023]
Abstract
PURPOSE Trauma patients with diabetes mellitus (DM) represent a unique population as the acute injury and the underlying disease may both cause hyperglycemia that leads to poor outcomes. We investigated how insulin-dependent DM (IDDM) and noninsulin-dependent DM (NIDDM) impact mortality after serious trauma without brain injury. METHODS The National Trauma Data Bank (NTDB) version 7.0 was queried for all patients with moderate to severe traumatic injury [injury severity score (ISS) >9]. Patients were excluded if missing data, age <10 years, severe brain injury [head abbreviated injury scale (AIS) >3], dead on arrival or any AIS = 6. Logistic regression modeled the association between DM and mortality as well as IDDM, NIDDM and mortality. RESULTS Overall 166,103 trauma patients without brain injury were analyzed. Mortality was 7.6 and 4.4 % in patients with and without DM, respectively (p < 0.01). Mortality was 9.9 % for patients with IDDM and 6.7 % for NIDDM (p < 0.01). The increased mortality associated with DM was only significantly higher for DM patients in their forties (5.6 vs. 3.3 %, p < 0.01). Regression analyses demonstrated that DM (AOR 1.14, p = 0.04) and IDDM (AOR 1.46, p < 0.01) were predictors of mortality compared to no DM, but NIDDM was not (AOR 1.02, p = 0.83). CONCLUSIONS While DM was a predictor for higher mortality after serious trauma, this increase was only observed in IDDM and not NIDDM. Our findings suggest IDDM patients who present after serious trauma are unique and attention to their hyperglycemia and related insulin therapy may play a critical role in recovery.
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Affiliation(s)
- D Z Liou
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M B Singer
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - G Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - M Y Harada
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - J Mirocha
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - M Bukur
- Department of Trauma and Critical Care, Delray Medical Center, Delray Beach, FL, USA.,Broward General Medical Center, Fort Lauderdale, FL, USA
| | - A Salim
- Division of Trauma, Burn, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - E J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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