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van Wijck SF, Kongkaewpaisan N, Han K, Kokoroskos N, Kongwibulwut M, King DR, van der Wilden GM, Krijnen P, Schipper IB, Velmahos GC. Association between alcohol intoxication and mortality in severe traumatic brain injury in the emergency department: a retrospective cohort. Eur J Emerg Med 2021; 28:97-103. [PMID: 32941201 PMCID: PMC7919698 DOI: 10.1097/mej.0000000000000754] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 08/08/2020] [Indexed: 10/31/2022]
Abstract
BACKGROUND Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI). METHODS This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication. RESULTS Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09). CONCLUSION In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.
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Affiliation(s)
- Suzanne F van Wijck
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
| | - Kelsey Han
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
| | - Manasnun Kongwibulwut
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
| | - Gwendolyn M van der Wilden
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Inger B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA 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, 165 Cambridge Street, Boston, MA 02114, Massachusetts, USA
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Dijkink S, van der Wilden GM, Krijnen P, Dol L, Rhemrev S, King DR, DeMoya MA, Velmahos GC, Schipper IB. Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care. Injury 2018; 49:104-109. [PMID: 29033079 DOI: 10.1016/j.injury.2017.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/29/2017] [Accepted: 10/09/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Modern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC). METHODS For this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed. RESULTS The USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17-29] vs. 21 [17-26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61-1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2-11] vs. 2 [2-7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3-13] vs. 8 [4-16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01). CONCLUSION Although several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | | | - Pieta Krijnen
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Lisa Dol
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Steven Rhemrev
- Department of Surgery, Haaglanden Medical Center, The Netherlands
| | - David R King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - Marc A DeMoya
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, United States
| | - Inger B Schipper
- Department of Surgery, Leiden University Medical Center, The Netherlands
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van der Wilden GM, Velmahos GC, Chang Y, Bajwa E, O'Donnell WJ, Finn K, Harris NS, Yeh DD, King DR, de Moya MA, Fagenholz PJ. Effects of a New Hospital-Wide Surgical Consultation Protocol in Patients with Clostridium difficile Colitis. Surg Infect (Larchmt) 2017; 18:563-569. [PMID: 28557651 DOI: 10.1089/sur.2016.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Fulminant Clostridium difficile colitis (fCDC) occurs in 2%-8% of patients with CDC and carries a high death rate. Prompt operation may reduce death. Our aim was to determine whether a standardized hospital-wide protocol for surgical referral in CDC would result in earlier surgical consultation, earlier identification of patients who could benefit from surgical therapy, and reduced deaths from fCDC. METHODS A multidisciplinary team developed consensus criteria for surgical consultation. Compliance was evaluated by prospective review of all inpatient CDC cases. Outcomes of the prospective cohort (POST) were compared to an historic control group (PRE). RESULTS From November 1, 2010 to October 31, 2012, we identified 1,106 inpatients with CDC; 339 patients matched the consultation criteria, of whom 213 received a surgical consultation, resulting in an overall compliance rate of 62.8%. All those with fCDC received a surgical consultation, with a median time to surgical referral of three hours. Of 46 patients with fCDC, 11 (23.9%) died, compared with 34.8% in the historical control group (p = 0.15). The death rate was 14.7% in the POST group, when excluding patients with limitations of care and those transferred to our institution in a fulminant state. There was a shorter interval between admission and surgical intervention for those who required operation in the POST group-three (1-11) days versus 1.5 (0-3) days, respectively, in the PRE and POST groups (p = 0.018), and a shorter adjusted median hospital length of stay (adjusted difference 9.0, 95% CI 2.2-12.3, p = 0.007) Conclusions: A hospital-wide protocol with established criteria for surgical consultation resulted in faster intervention and a shorter adjusted median hospital length of stay. The overall death rate for fCDC patients without limitations of life-sustaining treatment who presented to our emergency department or in whom fCDC developed while they were admitted to our hospital was 14.7%.
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Affiliation(s)
- Gwendolyn M van der Wilden
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.,4 Department of Trauma Surgery, Leiden University Medical Center and Leiden University , The Netherlands
| | - George C Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Yuchiao Chang
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Ed Bajwa
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Walter J O'Donnell
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Kathleen Finn
- 2 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - N Stuart Harris
- 3 Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - D Dante Yeh
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - David R King
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Marc A de Moya
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Peter J Fagenholz
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
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van der Wilden GM, Subramanian MP, Chang Y, Lottenberg L, Sawyer R, Davies SW, Ferrada P, Han J, Beekley A, Velmahos GC, de Moya MA. Antibiotic Regimen after a Total Abdominal Colectomy with Ileostomy for Fulminant Clostridium difficile Colitis: A Multi-Institutional Study. Surg Infect (Larchmt) 2015; 16:455-60. [PMID: 26069992 DOI: 10.1089/sur.2013.153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Fulminant Clostridium difficile colitis (fCDC) is a highly lethal disease with mortality rates ranging between 12% and 80%. Although often these patients require a total abdominal colectomy (TAC) with ileostomy, there is no established management protocol for post-operative antibiotics. In this study we aim to make some recommendations for post-operative antibiotic usage, while describing the practice across different institutions. METHODS Multi-institutional retrospective case series including fCDC patients who underwent a TAC between January 1, 2007, and June 30, 2012. We first analyzed the complete cohort and consecutively performed a survivor analysis, comparing different antibiotic regimens. Additionally we stratified by time interval (antibiotics for ≤7 d, or ≥8 d). Primary outcome was in-hospital mortality. Additional secondary outcomes included hospital length of stay (HLOS), ICU LOS, number of ventilator-free days, and occurrence of intra-abdominal complications (proctitis, abscess, sepsis, etc.). RESULTS A total of 100 fCDC patients that underwent a TAC were included across five institutions. Four different antibiotic regimens were compared; A (metronidazole IV+vancomycin PO), B (metronidazole IV), C (metronidazole IV+vanco PO and PR), and D (metronidazole IV+vancomycin PR). The combination of IV metronidazole with or without PO vancomycin showed superior outcomes in terms of a shorter ICU length of stay and more ventilator-free days. However, when comparing metronidazole alone vs. metronidazole and any combination of vancomycin, no significant differences were found. Neither the addition of vancomycin enema, nor the time interval changed outcomes. CONCLUSION Patients, after a TAC for fCDC, may be placed on either IV metronidazole or PO vancomycin depending upon local antibiograms, and proctitis may be treated with the addition of a vancomycin enema (PR). There was no data to support routine treatment of more than 7 d.
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Affiliation(s)
- Gwendolyn M van der Wilden
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts.,2 Department of Trauma Surgery, Leiden University Medical Center and Leiden University , Leiden, the Netherlands
| | - Melanie P Subramanian
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Yuchiao Chang
- 3 Department of Medicine, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Lawrence Lottenberg
- 4 Department of Surgery, UF Health Science Center and University of Florida College of Medicine , Gainesville, Florida
| | - Robert Sawyer
- 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia
| | - Stephen W Davies
- 5 Department of Surgery, University of Virginia Health System and University of Virginia School of Medicine , Charlottesville, Virginia
| | - Paula Ferrada
- 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia
| | - Jinfeng Han
- 6 Department of Surgery, VCU Medical Center and Virginia Commonwealth University School of Medicine , Richmond, Virginia
| | - Alec Beekley
- 7 Department of Surgery, Thomas Jefferson University Hospital and Thomas Jefferson University , Philadelphia, Pennsylvania
| | - George C Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
| | - Marc A de Moya
- 1 Department of Surgery, Division of Trauma, Emergency Surgery & Critical Care, Massachusetts General Hospital and Harvard Medical School , Boston, Massachusetts
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van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg 2014; 38:335-40. [PMID: 24121363 DOI: 10.1007/s00268-013-2257-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT. METHODS Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008–2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort. RESULTS The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01–1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01–1.12). The operative technique did not influence any of the outcomes. CONCLUSIONS Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.
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van der Wilden GM, Fagenholz PJ, Velmahos GC, Quraishi SA, Schipper IB, Camargo CA. Vitamin D status and severity of Clostridium difficile infections: a prospective cohort study in hospitalized adults. JPEN J Parenter Enteral Nutr 2014; 39:465-70. [PMID: 24408036 DOI: 10.1177/0148607113519129] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [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: 10/30/2013] [Accepted: 12/11/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clostridium difficile is the most common cause of nosocomial diarrhea, affecting up to 10% of hospitalized patients. Preliminary studies suggest an association between vitamin D status and C difficile infections (CDIs). Our goal was to investigate whether serum 25-hydroxyvitamin D (25(OH)D) levels are associated with CDI severity. METHODS We prospectively enrolled patients diagnosed with CDI and divided them into 2 severity groups: group A (positive toxin A/B enzyme immunoassay only) and group B (positive toxin A/B enzyme immunoassay with abdominal computed tomography scan findings consistent with colitis). Serum 25(OH)D levels (25(OH)D3, 25(OH)D2, and total 25(OH)D) were measured on all patients after diagnosis of CDI. We performed multivariable logistic regression analyses to investigate the association between 25(OH)D levels and CDI severity, while adjusting for age, Deyo-Charlson Comorbidity Index, recent hospitalization, and vitamin D supplementation. RESULTS One hundred patients were enrolled between July 2011 and February 2013. The mean (standard deviation) cohort age and Deyo-Charlson Comorbidity Index were 62 (19) years and 4 (3), respectively; 54% of patients were male. Mean serum total 25(OH)D level was 22 (10) ng/mL. Mean 25(OH)D3 level was significantly higher in group A (n = 71) than in group B (n = 29): 21 (1) vs 15 (2) ng/mL, respectively (P = .005). There was no observed difference in mean 25(OH)D2 levels and total 25(OH)D levels between the 2 groups. Multivariable logistic regression analysis demonstrated an association between 25(OH)D3 levels and CDI severity (adjusted odds ratio, 0.92; 95% confidence interval, 0.87-0.98). CONCLUSIONS We found a significant inverse association between 25(OH)D3 levels and CDI severity. Further studies are needed to determine whether vitamin D supplementation can improve outcomes in patients with CDI.
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Affiliation(s)
- Gwendolyn M van der Wilden
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston Department of Surgery and Trauma Surgery, Leiden University Medical Center and Leiden University, Leiden, the Netherlands
| | - Peter J Fagenholz
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Inger B Schipper
- Department of Surgery and Trauma Surgery, Leiden University Medical Center and Leiden University, Leiden, the Netherlands
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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van der Wilden GM, Velmahos GC, Joseph DK, Jacobs L, Debusk MG, Adams CA, Gross R, Burkott B, Agarwal S, Maung AA, Johnson DC, Gates J, Kelly E, Michaud Y, Charash WE, Winchell RJ, Desjardins SE, Rosenblatt MS, Gupta S, Gaeta M, Chang Y, de Moya MA. Successful nonoperative management of the most severe blunt renal injuries: a multicenter study of the research consortium of New England Centers for Trauma. JAMA Surg 2013; 148:924-31. [PMID: 23945834 DOI: 10.1001/jamasurg.2013.2747] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for the treating clinicians. The need for an operative vs a nonoperative approach is debated. OBJECTIVE To determine the rate, causes, predictors, and consequences of failure of nonoperative management (NOM) in grade IV and grade V blunt renal injuries (BRIs). DESIGN Retrospective case series. SETTING Twelve level I and II trauma centers in New England. PARTICIPANTS A total of 206 adult patients with a grade IV or V BRI who were admitted between January 1, 2000, and December 31, 2011. MAIN OUTCOMES AND MEASURES Failure of NOM, defined as the need for a delayed operation or death due to renal-related complications during NOM. RESULTS Of 206 patients, 52 (25.2%) were operated on immediately, and 154 (74.8%) were managed nonoperatively (with the assistance of angiographic embolization for 25 patients). Nonoperative management failed for 12 of the 154 patients (7.8%) and was related to kidney injury in 10 (6.5%). None of these 10 patients had complications because of the delay in BRI management. The mean (SD) time from admission to failure was 17.6 (27.4) hours (median time, 7.5 hours; range, 4.5-102 hours), and the cause was hemodynamic instability in 10 of the 12 patients (83.3%). Multivariate analysis identified 2 independent predictors of NOM failure: older than 55 years of age and a road traffic crash as the mechanism of injury. When both risk factors were present, NOM failure occurred for 27.3% of the patients; when both were absent, there were no NOM failures. Of the 142 patients successfully managed nonoperatively, 46 (32.4%) developed renal-related complications, including hematuria (24 patients), urinoma (15 patients), urinary tract infection (8 patients), renal failure (7 patients), and abscess (2 patients). These patients were managed successfully with no loss of renal units (ie, kidneys). The renal salvage rate was 76.2% for the entire population and 90.3% among patients selected for NOM. CONCLUSIONS AND RELEVANCE Hemodynamically stable patients with a grade IV or V BRI were safely managed nonoperatively. Nonoperative management failed for only 6.5% of patients owing to renal-related injuries, and three-fourths of the entire population retained their kidneys.
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Affiliation(s)
- Gwendolyn M van der Wilden
- Department of Surgery, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
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van der Wilden GM, Janjua S, Wedel SK, Agarwal S, Shapiro ML, Andersen ND, Odom SR, Gates JD, Frakes MA, Chang Y, Velmahos GC, Alam HB, King DR, De Moya MA. Multi-institutional comparison of helicopter transfers directly to the operating room versus the pit stop in the emergency department. Am Surg 2013; 79:939-943. [PMID: 24069995] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwabejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. Development of a rugged handheld device for real-time analysis of heart rate: entropy in critically ill patients. J Spec Oper Med 2013; 13:29-33. [PMID: 23526319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. METHODS After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student?s t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. RESULTS Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (p < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. CONCLUSIONS This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.
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van der Wilden GM, Velmahos GC, Emhoff T, Brancato S, Adams C, Georgakis G, Jacobs L, Gross R, Agarwal S, Burke P, Maung AA, Johnson DC, Winchell R, Gates J, Cholewczynski W, Rosenblatt M, Chang Y. Successful nonoperative management of the most severe blunt liver injuries: a multicenter study of the research consortium of new England centers for trauma. ACTA ACUST UNITED AC 2012; 147:423-8. [PMID: 22785635 DOI: 10.1001/archsurg.2012.147] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Grade 4 and grade 5 blunt liver injuries can be safely treated by nonoperative management (NOM). DESIGN Retrospective case series. SETTING Eleven level I and level II trauma centers in New England. PATIENTS Three hundred ninety-three adult patients with grade 4 or grade 5 blunt liver injury who were admitted between January 1, 2000, and January 31, 2010. MAIN OUTCOME MEASURE Failure of NOM (f-NOM), defined as the need for a delayed operation. RESULTS One hundred thirty-one patients (33.3%) were operated on immediately, typically because of hemodynamic instability. Among 262 patients (66.7%) who were offered a trial of NOM, treatment failed in 23 patients (8.8%) (attributed to the liver in 17, with recurrent liver bleeding in 7 patients and biliary peritonitis in 10 patients). Multivariate analysis identified the following 2 independent predictors of f-NOM: systolic blood pressure on admission of 100 mm Hg or less and the presence of other abdominal organ injury. Failure of NOM was observed in 23% of patients with both independent predictors and in 4% of those with neither of the 2 independent predictors. No patients in the f-NOM group experienced life-threatening events because of f-NOM, and mortality was similar between patients with successful NOM (5.4%) and patients with f-NOM (8.7%) (P = .52). Among patients with successful NOM, liver-specific complications developed in 10.0% and were managed definitively without major sequelae. CONCLUSIONS Nonoperative management was offered safely in two-thirds of grade 4 and grade 5 blunt liver injuries, with a 91.3% success rate. Only 6.5% of patients with NOM required a delayed operation because of liver-specific issues, and none experienced life-threatening complications because of the delay.
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Affiliation(s)
- Gwendolyn M van der Wilden
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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King DR, van der Wilden GM, Kragh JF, Blackbourne LH. Forward assessment of 79 prehospital battlefield tourniquets used in the current war. J Spec Oper Med 2012; 12:33-38. [PMID: 23536455 DOI: 10.55460/bv5c-t9ig] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2012] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance. METHODS War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics. RESULTS Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied. DISCUSSION Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow ? convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.
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