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1.
Injury ; 54(5): 1374-1378, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-36774265

RESUMO

BACKGROUND: Cirrhosis in trauma patients is an indicator of poor prognosis, but current trauma injury grading systems do not take into account liver dysfunction as a risk factor. Our objective was to construct a simple clinical mortality prediction model in cirrhotic trauma patients: Cirrhosis Outcomes Score in Trauma (COST). METHODS: Trauma patients with pre-existing cirrhosis or liver dysfunction who were admitted to our ACS Level I trauma center between 2013 and 2021 were reviewed. Patients with significant acute liver trauma (AAST Grade ≥ 3) or those that developed acute liver dysfunction while admitted were excluded. Demographics as well as ISS, MELD, complications, and mortality were evaluated. COST was defined as the sum of age, ISS, and MELD. Univariate and multivariable analysis was used to determine independent predictors of mortality. The area under the receiver operating curve (AUROC) was calculated to assess the ability of COST to predict mortality. RESULTS: A total of 318 patients were analyzed of which the majority were males 214 (67.3%) who suffered blunt trauma 305 (95.9%). Mortality at 30-days, 60-days, and 90-days was 20.4%, 23.6%, and 25.5%, respectively. COST was associated with inpatient, 30-day, and 90-day mortality on regression analyses and the AUROC for COST predicting mortality at these respective time points was 0.810, 0.801, and 0.813. CONCLUSION: Current trauma injury grading systems do not take into account liver dysfunction as a risk factor. COST is highly predictive of mortality in cirrhotic trauma patients. The simplicity of the score makes it useful in guiding clinical care and in optimizing goals of care discussions. Future studies to validate this prediction model are required prior to clinical use.


Assuntos
Cirrose Hepática , Hepatopatias , Masculino , Humanos , Feminino , Cirrose Hepática/complicações , Índice de Gravidade de Doença , Prognóstico , Estudos Retrospectivos , Curva ROC
2.
J Surg Res ; 286: 57-64, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-36753950

RESUMO

INTRODUCTION: Variation in surgical management exists nationally. We hypothesize that geographic variation exists in adhesive small bowel obstruction (aSBO) management. MATERIALS AND METHODS: A retrospective analysis of a national commercial insurance claims database (MarketScan) sample (2017-2019) was performed in adults with hospital admission due to aSBO. Geographic variation in rates of surgical intervention for aSBO was evaluated by state and compared to a risk-adjusted national baseline using a Bayesian spatial rates Poisson regression model. For individual-level analysis, patients were identified in 2018, with 365-d look back and follow-up periods. Logistic regression was performed for individual-level predictors of operative intervention for aSBO. RESULTS: Two thousand one hundred forty-five patients were included. State-level analysis revealed rates of operative intervention for aSBO were significantly higher in Missouri and lower in Florida. On individual-level analysis, age (P < 0.01) and male sex (P < 0.03) but not comorbidity profile or prior aSBO, were negatively associated with undergoing operative management for aSBO. Patients presenting in 2018 with a history of admission for aSBO the year prior experienced a five-fold increase in odds of representation (odds ratio: 5.4, 95% confidence interval: 3.1-9.6) in 2019. Patients who received an operation for aSBO in 2018 reduced the odds of readmission in the next year by 77% (odds ratio: 0.23, 95% confidence interval: 0.1-0.5). The volume of operations performed within a state did not influence readmission. CONCLUSIONS: Surgical management of aSBO varies across the continental USA. Operative intervention is associated with decreased rates of representation in the following year. These data highlight a critical need for standardized guidelines for emergency general surgery patients.


Assuntos
Obstrução Intestinal , Adulto , Humanos , Masculino , Aderências Teciduais/cirurgia , Aderências Teciduais/complicações , Estudos Retrospectivos , Teorema de Bayes , Obstrução Intestinal/cirurgia , Obstrução Intestinal/complicações , Hospitalização , Resultado do Tratamento
3.
Am Surg ; : 31348221146973, 2022 Dec 20.
Artigo em Inglês | MEDLINE | ID: mdl-36537729

RESUMO

BACKGROUND: In adhesive small bowel obstructions (ASBOs), literature has shown that passage of a water-soluble contrast challenge at either 8 hours or 24 hours is predictive of successful non-operative management (NOM) for an ASBO, but the long-term outcomes between these two groups are unknown. We hypothesized that patients who require longer transit times to the colon have a higher one-year recidivism of ASBO. METHODS: This was a 4-year review of patients with presumed ASBO undergoing successful NOM. Those requiring operation or those with an SBO due to something other than adhesions were excluded. Patients were divided into two groups (8 hour and 24 hour) based on when contrast reached their right colon. Patients were followed for one year to determine ASBO recurrence. RESULTS: 137 patients underwent NOM; 112 in the 8-hour group and 25 in the 24-hour group. One-year recurrence rate was 21.4% in the 8-hour group and 40% in the 24-hour group (P = 0.05). The median time to recurrence was 113 days in the 8-hour group and 13 days in the 24-hour group (P = 0.02). Of those who recurred in the 24-hour group, 60% recurred within 30 days (P = 0.01). On univariable analysis, first-time ASBO and 24-hour transit time were risk factors for recurrence. CONCLUSIONS: Adhesive small bowel obstruction patients undergoing NOM in the 24-hour group had a recurrence rate nearly twice that of patients in the 8-hour group and may benefit from an operative exploration during the index hospitalization at the 8-hour mark of a water-soluble contrast challenge, especially if experiencing a first-time ASBO.

4.
Am Surg ; 88(5): 959-963, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35199571

RESUMO

OBJECTIVES: Improved screening has decreased but not eliminated the need for emergent surgery for colon cancer (CC), many of which are performed by acute care surgery (ACS) surgeons. This retrospective review compares outcomes for CC resections on the ACS service to the surgical oncology and colorectal services (SO/CRS). METHODS: Retrospective review was performed for CC operations between 2014 and 2019. Data for margin status, cancer stage, number of lymph nodes dissected, time to medical oncology follow-up, and time to initiation of chemotherapy were collected. Patients with curative resection, who chose comfort care, presented on alternative services or with non-CC indications as well as those were lost to follow-up were excluded. RESULTS: 36 ACS patients and 269 SO/CRS patients underwent CC resections. Most ACS patients presented emergently compared to the SO/CC group (83.3% vs 1%, P < .05) as well as with more advanced tumor stage. There were no statistically significant differences for presence of metastatic disease, number of lymph nodes obtained, or time to post-surgical care (in days) and chemotherapy initiation (in days). 3 (8%) EGS patients had positive margins compared to 6 (2%) CRS/SO patients due to the presence of perforated tumors in the ACS group (p < .05). There were no statistically significant differences in 30- day or 1-year mortality despite the emergent presentation of the ACS patients. DISCUSSION: These findings suggest that despite emergent presentation and advanced disease burden, ACS surgeons provide quality care to CC patients, both in the operating room and in coordination of care.


Assuntos
Neoplasias do Colo , Cirurgia Colorretal , Cirurgiões , Neoplasias do Colo/cirurgia , Cuidados Críticos , Humanos , Estudos Retrospectivos , Especialização
7.
J Surg Educ ; 76(4): 1116-1121, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30711425

RESUMO

OBJECTIVE: Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency. METHODS: Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network. RESULTS: Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p < 0.05, and reduction from 14 to 6 minutes for secondary survey, p < 0.05). Time to primary survey completion did not change (5 minutes). CONCLUSIONS: Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.


Assuntos
Reanimação Cardiopulmonar/educação , Competência Clínica , Equipe de Assistência ao Paciente/organização & administração , Treinamento por Simulação , Centros de Traumatologia , Resultado do Tratamento , Feminino , Mortalidade Hospitalar , Humanos , Comunicação Interdisciplinar , Masculino , Simulação de Paciente , Melhoria de Qualidade , Fatores de Tempo , Tempo para o Tratamento , Índices de Gravidade do Trauma
8.
Trauma Surg Acute Care Open ; 3(1): e000160, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29766138

RESUMO

The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication. The ideal tool would combine individualized assessment with relative ease of use. Trauma Scoring Systems, Critical Care Scoring Systems, Surgical Scoring Systems and Track and Trigger Models are reviewed here, with the conclusion that Emergency Surgery Acuity Score and the American College of Surgeons National Surgical Quality Improvement Programme Universal Surgical Risk Calculator are the most applicable and appropriate for EGS.

9.
Surg Clin North Am ; 97(6): 1381-1397, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29132514

RESUMO

The management of the ventilator in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS) has a dramatic effect on the overall outcome. The incidence of COPD is increasing as the US population grows older. The most effective means to deal with pulmonary complications is to avoid them, but both COPD and ARDS have evidence-based interventions that have been shown to improve outcomes. Pulmonary complications affect up to 40% of patients, and their occurrence is associated with an increased duration of hospital stay, and an increased mortality.


Assuntos
Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Corticosteroides/uso terapêutico , Hélio/uso terapêutico , Humanos , Oxigênio/uso terapêutico , Respiração por Pressão Positiva Intrínseca/diagnóstico , Respiração por Pressão Positiva Intrínseca/terapia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Troca Gasosa Pulmonar/fisiologia , Síndrome do Desconforto Respiratório/fisiopatologia , Músculos Respiratórios/fisiologia , Fatores de Risco , Resultado do Tratamento , Desmame do Respirador/métodos
11.
J Trauma Acute Care Surg ; 83(2): 316-327, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28452889

RESUMO

BACKGROUND: Pancreatic or peripancreatic tissue necrosis confers substantial morbidity and mortality. New modalities have created a wide variation in approaches and timing of interventions for necrotizing pancreatitis. As acute care surgery evolves, its practitioners are increasingly being called upon to manage these complex patients. METHODS: A systematic review of the MEDLINE database using PubMed was performed. English language articles regarding pancreatic necrosis from 1980 to 2014 were included. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included operative timing, the use of adjuvant therapy and the type of operative repair. Grading of Recommendations, Assessment, Development and Evaluations methodology was applied to question development, outcome prioritization, evidence quality assessments, and recommendation creation. RESULTS: Eighty-eight studies were included and underwent full review. Increasing the time to surgical intervention had an improved outcome in each of the periods evaluated (72 hours, 12-14 days, 30 days) with a significant improvement in outcomes if surgery was delayed 30 days. The use of percutaneous and endoscopic procedures was shown to postpone surgery and potentially be definitive. The use of minimally invasive surgery for debridement and drainage has been shown to be safe and associated with reduced morbidity and mortality. CONCLUSION: Acute Care Surgeons are uniquely trained to care for those with pancreatic necrosis due their training in critical care and complex surgery with ongoing shock. In adult patients with pancreatic necrosis, we recommend that pancreatic necrosectomy be delayed until at least day 12. During the first 30 days of symptoms with infected necrotic collections, we conditionally recommend surgical debridement only if the patients fail to improve after radiologic or endoscopic drainage. Finally, even with documented infected necrosis, we recommend that patients undergo a step-up approach to surgical intervention as the preferred surgical approach. LEVEL OF EVIDENCE: Systematic review/guideline, level III.


Assuntos
Desbridamento/métodos , Endoscopia/métodos , Pâncreas/patologia , Pancreatectomia/métodos , Pancreatite Necrosante Aguda/cirurgia , Administração da Prática Médica , Adulto , Terapia Combinada , Drenagem/métodos , Intervenção Médica Precoce , Seguimentos , Humanos , Necrose , Avaliação de Resultados em Cuidados de Saúde , Pancreatite Necrosante Aguda/mortalidade , Complicações Pós-Operatórias/mortalidade , Análise de Sobrevida , Fatores de Tempo
12.
J Trauma Acute Care Surg ; 82(3): 435-443, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28030492

RESUMO

BACKGROUND: Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. METHODS: The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. RESULTS: Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. CONCLUSION: EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. LEVEL OF EVIDENCE: Therapeutic study, level II.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Emergências , Cirurgia Geral/métodos , Grampeamento Cirúrgico , Técnicas de Sutura , Idoso , Anastomose Cirúrgica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento
14.
J Trauma Acute Care Surg ; 80(3): 405-10; discussion 410-1, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26670116

RESUMO

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a new grading system for uniform description of anatomic severity of emergency general surgery (EGS) diseases, ranging from Grade I (mild) to Grade V (severe). The purpose of this study was to determine the relationship of AAST grades for acute colonic diverticulitis with patient outcomes. A secondary purpose was to propose an EGS quality improvement program using risk-adjusted center outcomes, similar to National Surgical Quality Improvement Program and Trauma Quality Improvement Program methodologies. METHODS: This was a retrospective study of 1,105 patients (one death) from 13 centers. At each center, two reviewers (blinded to each other's assignments) assigned AAST grades. Interrater reliability was measured using κ coefficient. Relationship between AAST grade and clinical events (complications, intensive care unit use, surgical intervention, and 30-day readmission) as well as length of stay was measured using regression analyses to control for age, comorbidities, and physiologic status at the time of admission. Final model was also used to calculate observed-to-expected (O-E) ratios for adverse outcomes (death, complications, readmissions) for each center. RESULTS: Median age was 54 years, 52% were males, 43% were minorities, and 22% required a surgical intervention. Almost two thirds had Grade I or II disease. There was a high level of agreement for grades between reviewers (κ = 0.81). Adverse events increased from 13% for Grade I, to 18% for Grade II, 28% for Grade III, 44% for Grade IV, and 50% for Grade V. Regression analysis showed that higher disease grades were independently associated with all clinical events and length of stay, after adjusting for age, comorbidities, and physiology. O-E ratios showed statistically insignificant variations in risk of death, complications, or readmissions. CONCLUSION: AAST grades for acute colonic diverticulitis are independently associated with clinical outcomes and resource use. EGS quality improvement program methodology that incorporates AAST grade, age, comorbidities, and physiologic status may be used for measuring quality of EGS care. High-quality EGS registries are essential for developing meaningful quality metrics. LEVEL OF EVIDENCE: Prognostic study, level V.


Assuntos
Doença Diverticular do Colo/diagnóstico , Serviço Hospitalar de Emergência/normas , Melhoria de Qualidade , Sociedades Médicas , Procedimentos Cirúrgicos Operatórios/normas , Traumatologia , Doença Aguda , Adulto , Doença Diverticular do Colo/classificação , Doença Diverticular do Colo/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos
15.
J Trauma Acute Care Surg ; 78(5): 1059-65, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25909431

RESUMO

The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.


Assuntos
Codificação Clínica/métodos , Emergências , Cirurgia Geral/estatística & dados numéricos , Guias como Assunto/normas , Índice de Gravidade de Doença , Sociedades Médicas , Humanos , Estados Unidos
16.
J Am Coll Surg ; 218(4): 644-8, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24655852

RESUMO

BACKGROUND: Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population. STUDY DESIGN: This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference. RESULTS: From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04). CONCLUSIONS: Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.


Assuntos
Embolização Terapêutica/métodos , Radiografia Intervencionista , Baço/lesões , Artéria Esplênica/diagnóstico por imagem , Ferimentos não Penetrantes/terapia , Adulto , Angiografia , Protocolos Clínicos , Feminino , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Baço/irrigação sanguínea , Baço/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Centros de Traumatologia , Falha de Tratamento , Resultado do Tratamento , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/mortalidade
17.
J Trauma Acute Care Surg ; 76(3): 884-7, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24553565

RESUMO

BACKGROUND: Currently, there is no established system for assessing disease severity in emergency general surgery (EGS) patients. The purpose of this project was to develop a uniform grading system for measuring anatomic severity of disease in this patient population. METHODS: The Committee on Patient Assessment and Outcomes of the American Association for the Surgery of Trauma developed a proposal by consensus of experts for grading severity of EGS diseases. It was then reviewed and approved by the Board of Managers of the American Association for the Surgery of Trauma. RESULTS: A uniform grading system for measuring anatomic severity of disease in EGS is described, with specific grades for eight commonly encountered gastrointestinal conditions. These grades range from Grade I through Grade V, reflecting an escalating clinical progression from mild disease limited within the organ itself to severe disease that is widespread. CONCLUSION: This article provides a unified grading system for measuring anatomic severity of disease that is essential to advance the science of EGS. Once validated, a description of disease grade should be included in the emerging EGS registries and in research studies involving EGS patients.


Assuntos
Tratamento de Emergência/métodos , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/métodos , Humanos , Sociedades Médicas , Traumatologia/métodos
18.
J Trauma Acute Care Surg ; 74(5): 1187-92; discussion 1192-4, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23609266

RESUMO

BACKGROUND: Recent studies have identified unique clinical and physiologic characteristics of emergency general surgery (EGS) patients and called for outcomes data in this population. There are no data in the US literature analyzing the impact of technique on anastomotic failure rates in EGS patients. The purpose of the current study was to compare outcomes of hand-sewn (HS) versus stapled (ST) bowel anastomoses in EGS patients. METHODS: A retrospective chart review of all patients admitted by our EGS service undergoing bowel resection for emergent indications from January 2007 to July 2011 was performed. Time from surgery to diagnosis of anastomotic failure was recorded as were the diagnostic modality and treatment of each anastomotic failure. Specific data on damage-control techniques, if used, were also collected. RESULTS: There were 100 HS (43%), and 133 ST (57%) anastomoses in 231 patients. Operative times were shorter in ST anastomosis technique (205 minutes for HS vs. 193 minutes for ST, p = 0.02). Anastomotic failures were identified in 26 patients (11%) and were significantly higher in the ST group than the HS group (15.0% vs. 6.1%, p = 0.003). A multivariate logistic regression analysis, controlling for age and preoperative nutritional status, revealed ST technique to be an independent risk factor for anastomotic failure (odds ratio, 2.65; 95% confidence interval, 1.08-6.50; p = 0.034). CONCLUSION: Anastomotic failures are more than twice as likely with ST than HS anastomoses in the EGS population. This is true even when controlling for markers of preoperative nutrition and demographics. These data suggest that the HS anastomosis should be the preferred method of reconstruction after bowel resection in EGS patients.


Assuntos
Anastomose Cirúrgica , Grampeamento Cirúrgico , Técnicas de Sutura , Emergências , Feminino , Humanos , Intestinos/cirurgia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento
19.
J Trauma Acute Care Surg ; 73(5): 1229-35, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22914080

RESUMO

BACKGROUND: Pulmonary contusion (PC) is a common injury associated with blunt chest trauma. Complications such as pneumonia and adult respiratory distress syndrome (ARDS) occur in up to 50% of patients with PC. The ability to predict which PC patients are at increased risk of developing complications would be of tremendous clinical utility. In this study, we test the hypothesis that a novel method that objectively measures percent PC can be used to identify patients at risk to develop ARDS after injury. METHODS: Patients with unilateral or bilateral PC with an admission chest computed tomographic angiogram were identified from the trauma registry. Demographic, infectious, and outcome data were collected. Percent PC was determined on admission chest computed tomography using our novel semiautomated, attenuation-defined computer-based algorithm, in which the lung was segmented with minimal manual editing. Factors contributing to the development of ARDS were identified by both univariate and multivariable logistic regression analyses. ARDS was defined as PaO2/FiO2 ratio of less than 200 with diffuse bilateral infiltrates on chest radiograph with no evidence of congestive heart failure. RESULTS: Quantifying percent PC from our objective computer-based approach proved successful. We found that a contusion size of 24% of total lung volume or greater was most significant at predicting ARDS, which occurred in 78% of these patients. Such patients also had a significantly higher incidence of pneumonia when compared with those with contusions less than 24%. The specificity of contusion size of 24% or greater was 94%, although sensitivity was 37%; positive predictive value was 78%, and negative predictive value was 72%. CONCLUSION: We developed and describe a software-based methodology to accurately measure the size of lung contusion in patients of blunt trauma. In our analyses, contusions of 24% or greater most significantly predict the development of ARDS. Such an objective approach can identify patients with PC who are at increased risk for developing respiratory complications before they happen. Further research is needed to use this novel methodology as a means to prevent posttraumatic lung injury in patients with blunt trauma. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; diagnostic study, level IV.


Assuntos
Algoritmos , Diagnóstico por Computador , Lesão Pulmonar/complicações , Síndrome do Desconforto Respiratório/diagnóstico , Síndrome do Desconforto Respiratório/etiologia , Ferimentos não Penetrantes/complicações , Adulto , Feminino , Humanos , Modelos Logísticos , Lesão Pulmonar/diagnóstico por imagem , Lesão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Risco , Tomografia Computadorizada por Raios X , Índices de Gravidade do Trauma , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/fisiopatologia , Adulto Jovem
20.
World J Surg ; 36(2): 270-7, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22113844

RESUMO

BACKGROUND: Hypoglycemia has emerged as a barrier to the practice of intensive insulin therapy. Current literature suggests that hypoglycemia occurs at variable rates and has different effects on outcomes in surgical and medical populations. We sought to determine the incidence, independent predictors, and effect on outcome of severe hypoglycemia (≤ 40 mg/dl) in a surgical population. METHODS: A retrospective analysis was performed on all critically ill surgical patients treated with IIT from October 2004 to February 2007. Euglycemia (goal 80-110 mg/dl) was maintained using automated computerized titration of an insulin infusion. The primary outcome of interest was any episode of severe hypoglycemia (≤ 40 mg/dl). Multivariate logistic regression was used to determine the independent predictors of developing severe hypoglycemia. RESULTS: A total of 60,298 data entries (1,118 patients) for glucose were analyzed. There were 64 severe hypoglycemic episodes in 52 patients (4.6% of the patients). There was a significant increase in deaths among patients who experienced at least one episode of hypoglycemia when compared with those who did not (26.9% vs. 15.3%, P = 0.03). Logistic regression revealed that the time spent on the protocol was the best predictor of developing a hypoglycemic event when controlling for other known risk factors of hypoglycemia. CONCLUSIONS: Intensive insulin therapy can be implemented with a low percentage of patients (4.6%) experiencing severe hypoglycemia. Mortality rate was higher for patients experiencing hypoglycemia. The duration of the time spent on the protocol was the best predictor of hypoglycemia, suggesting that hypoglycemia is a mathematic probability of prolonged illness, not a reflection of illness severity or demographic features.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Hiperglicemia/tratamento farmacológico , Hipoglicemia/induzido quimicamente , Hipoglicemiantes/efeitos adversos , Insulina/efeitos adversos , Adulto , Idoso , Estado Terminal/mortalidade , Esquema de Medicação , Feminino , Mortalidade Hospitalar , Humanos , Hipoglicemia/mortalidade , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios , Fatores de Tempo
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