Trauma Laparotomy for the Cirrhotic Patient: An Outcome-Based Analysis.

INTRODUCTION: There is a lack of large-scale data on outcomes of cirrhotic patients undergoing trauma laparotomy. We aimed to compare outcomes of cirrhotic versus noncirrhotic trauma patients undergoing laparotomy. METHODS: We analyzed 2018 American College of Surgeons Trauma Quality Improvement Program. We included blunt trauma patients (≥18 y) who underwent a laparotomy. Patients who were transferred, dead on arrival, or had penetrating injuries were excluded. Patients were matched in a 1:2 ratio (cirrhotic and noncirrhotic). Outcomes included mortality, complications, failure to rescue, transfusion requirements, and hospital and intensive care unit (ICU) lengths of stay. Multivariable backward stepwise regression analysis was performed. RESULTS: Four hundred and seventy-one patients (cirrhotic, 157; noncirrhotic, 314) were matched. Mean age was 57 ± 15 y, 78% were male, and median injury severity score was 24. Cirrhotic patients had higher rates of mortality (60% versus 30%, P value <0.001), complications (49% versus 37%; P value = 0.01), failure to rescue (66% versus 36%, P value<0.001), and pRBC (units, median, 11 [7-18] versus 7 [4-11], P value <0.001) transfusion requirements. There were no significant differences in hospital and intensive care unit (ICU) lengths of stay (P value ≥0.05). On multivariate analysis, increasing age (adjusted odds ratio [aOR] 1.02, P value <0.001), Glasgow Coma Scale score ≤8 at presentation (aOR 3.3, P value <0.001), and total splenectomy (aOR 5.7, P value <0.001) were associated with higher odds of mortality. Platelet transfusion was associated with lower odds of mortality (aOR 0.84, P value = 0.044). CONCLUSIONS: On a national scale, mortality following trauma laparotomy is twice as high for cirrhotic patients compared to noncirrhotic patients with higher rates of major complications and failure to rescue. Our finding of a protective effect of platelet transfusion may be explained by the platelet dysfunction associated with cirrhosis. Liver cirrhosis among trauma patients warrants heightened surveillance.

Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen.

INTRODUCTION: Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen. METHODS: In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS. RESULTS: 128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS. CONCLUSIONS: Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.

Should We Keep or Transfer Our Severely Injured Geriatric Patients to Higher Levels of Care?

INTRODUCTION: Interfacility transfer to higher levels of care is becoming increasingly common. This study aims to evaluate the association between transfer to higher levels of care and prolonged transfer times with outcomes of severely injured geriatric trauma patients compared to those who are managed definitively at lower-level trauma centers. METHODS: Severely injured (Injury Severity Score >15) geriatric (≥60 y) trauma patients in the 2017-2018 American College of Surgeons Trauma Quality Improvement Program database managing at an American College of Surgeons/State Level III trauma center or transferring to a level I or II trauma center were included. Outcome measures were 24-h and in-hospital mortality and major complications. RESULTS: Forty thousand seven hundred nineteen patients were identified. Mean age was 75 ± 8 y, 54% were male, 98% had a blunt mechanism of injury, and the median Injury Severity Score was 17 [16-21]. Median transfer time was 112 [79-154] min, and the most common transport mode was ground ambulance (82.3%). Transfer to higher levels of care within 90 min was associated with lower 24-h mortality (adjusted odds ratio [aOR]: 0.493, P < 0.001) and similar odds of in-hospital mortality as those managed at level III centers. However, every 30-min delay in transfer time beyond 90 min was progressively associated with increased odds of 24-h (aOR: 1.058, P < 0.001) and in-hospital (aOR: 1.114, P < 0.001) mortality and major complications (aOR: 1.127, P < 0.001). CONCLUSIONS: Every 30-min delay in interfacility transfer time beyond 90 min is associated with 6% and 11% higher risk-adjusted odds of 24-h and in-hospital mortality, respectively. Estimated interfacility transfer time should be considered while deciding about transferring severely injured geriatric trauma patients to a higher level of care.

Pediatric Acute Compartment Syndrome in Long Bone Fractures: Who is at Risk?

INTRODUCTION: There is a paucity of large-scale data on the factors that suggest an impending or underlying extremity pediatric acute compartment syndrome (ACS). In addition, literature regarding the timing of operative fixation and the risk of ACS is mixed. We aimed to describe the factors associated with pediatric ACS. METHODS: Analysis of 2017-2019 Trauma Quality Improvement Program. We included patients aged <18 y diagnosed with upper extremity (UE) and lower extremity (LE) fractures. Burns and insect bites/stings were excluded. Multivariable regression analyses were performed to identify the predictors of ACS. RESULTS: 61,537 had LE fractures, of which 0.5% developed ACS. 76,216 had UE fractures, of which 0.16% developed ACS. Multivariable regression analyses identified increasing age, male gender, motorcycle collision, and pedestrian struck mechanisms of injury, comminuted and open fractures, tibial and concurrent tibial and fibular fractures, forearm fractures, and operative fixation as predictors of ACS (P value <0.05). Among LE fractures, 34% underwent open reduction internal fixation (time to operation = 14 [8-20] hours), and 2.1% underwent ExFix (time to operation = 9 [4-17] hours). Among UE fractures, 54% underwent open reduction internal fixation (time to operation = 11 [6-16] hours), and 1.9% underwent ExFix (time to operation = 9 [4-14] hours). Every hour delay in operative fixation of UE and LE fractures was associated with a 0.4% increase in the adjusted odds of ACS (P value <0.05). CONCLUSIONS: Our results may aid clinicians in recognizing children who are "at risk" for ACS. Future studies are warranted to explore the optimal timing for the operative fixation of long bone fractures to minimize the risk of pediatric ACS.

Rare but There: Ceftriaxone-Induced Neutropenia in a Patient With a Brain Abscess.

This case report details the case of a 70-year-old man with Marfan syndrome and hypertension who developed neutropenia after an eight-week course of ceftriaxone, used to treat a brain abscess. Initially presenting with tonic-clonic seizures and headaches, his condition was managed with ceftriaxone and metronidazole. The subsequent drop in neutrophil counts from 7.54 × 10^9/L to 0.87 × 10^9/L leads to the discontinuation of ceftriaxone and the administration of granulocyte-colony stimulating factor (G-CSF), which effectively restored the neutrophil levels. This case highlights that clinicians should be aware of ceftriaxone-induced neutropenia as a potential complication, especially in patients undergoing prolonged therapy. Regular monitoring and timely management are essential for patient safety and favorable outcomes.

Scale and Safety: Analyzing the Association Between Intraoperative Difficulty and Achieving the Critical View of Safety in Laparoscopic Cholecystectomy.

BACKGROUND:  Laparoscopic cholecystectomy (LC) is the preferred method for gallstone removal, but bile duct injuries remain a concern. Achieving the critical view of safety (CVS) is pivotal in preventing such injuries. The aim of this study was to compare the rates of difficult LC in those with CVS achieved compared to those with CVS not achieved. METHODS: We performed a single-center prospective study on all patients with ultrasound-confirmed symptomatic gallstones. Patients were excluded if they refused to consent or if they underwent LC for indications other than gallstone disease. Patients were stratified into two groups as CVS not achieved and CVS achieved groups and compared for outcomes. Our primary outcome was the rate of intraoperative difficulty on the modified Nassar scale (MNS). Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY). RESULTS: We included 70 patients who underwent LC for gallstones (CVS not achieved = 24 and CVS achieved = 46). The mean (SD) age was 42.2 (12.3) years, and 73.5% were females. The mean (SD) weight in our study cohort was 74.1 (10.9) kg, and there was no difference between the two groups in terms of the baseline demographic characteristics, disease characteristics, and comorbid conditions (p > 0.05). On univariate analyses, achieving CVS was associated with lower rates of higher-grade operative difficulty on the MNS and lower rates of length of stay of more than one day. CONCLUSION: Achieving CVS is associated with easy LC based on significantly lower Nassar scores. These findings highlight the role of the MNS in the successful identification of the operative difficulty of LC and its correlation with achieving CVS.

Validating an Ultrasonographical Assessment Tool for Predicting Difficult Laparoscopic Cholecystectomy in a Tertiary Care Hospital.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the preferred treatment option in non-complicated symptomatic cholelithiasis. In some cases, the surgery might be complicated by different factors resulting in difficult LC. Ultrasound remains the first-line modality for diagnosing symptomatic cholelithiasis; however, its role in predicting difficult LC remains unclear. The aim of this study was to validate an ultrasonographic scoring system in predicting difficult LC. METHODS: We prospectively enrolled patients undergoing LC in a tertiary care unit over six months. All adult (≥18 years) patients undergoing LC for symptomatic cholelithiasis were included. Patients were excluded if they refused to consent, and those who underwent cholecystectomy for indications other than cholelithiasis. Patients were stratified into two groups based on intra-operative difficulty (easy LC and difficult LC) and were compared. Our primary outcome was radiologic difficulty among these groups. Univariate analysis and kappa statistics were performed. RESULTS: We identified 68 patients with an overall mean (SD) age of 42.2 (12.3) years, a mean (SD) weight of 74.1 (10.9) kg, and 73.5% were female. Of the study cohort, 52 patients had easy LC and 16 patients experienced difficult LC. Amongst the total, 14.7% suffered from diabetes mellitus, 29.4% had hypertension, 7.4% had a known ischemic heart disease, and 63% had a body mass index (BMI) ≥30 kg/m2 with no statistically significant difference between the two groups. On the Chi-square test, there was no statistical difference between the two groups in terms of ultrasonographic difficulty (p>0.05). However, we found a Kappa value of -0.127 (p=0.275) corresponding to a strong disagreement between the intraoperative and ultrasonographic difficulty. CONCLUSION: Despite its role in diagnosing cholelithiasis, an ultrasonographic assessment did not have a role in predicting difficult LC according to the present study. Further studies are required to develop a scoring system for predicting difficult LC based on clinical, laboratory, and ultrasonographic assessment.