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1.
Artículo en Inglés | MEDLINE | ID: mdl-39327646

RESUMEN

BACKGROUND: One third of organ donors suffer catastrophic brain injury (CBI). There are no standard guidelines for the management of traumatic CBI prior to brain death, and not all trauma centers have institutional CBI guidelines. In addition, there is high variability in management between institutions with guidelines. Catastrophic brain injury guidelines vary and may include various combinations of hormone therapy, vasopressors, fluid resuscitation, and other practices. We hypothesized that centers with CBI guidelines have higher organ donation rates than those without. METHODS: This prospective, observational EAST-sponsored multicenter trial included adult (18+ years old) traumatic-mechanism CBI patients at 33 level I and II trauma centers from January 2022 to May 2023. Catastrophic brain injury was defined as a brain injury causing loss of function above the brain stem and subsequent death. Cluster analysis with linear mixed-effects model including UNOS regions and hospital size by bed count was used to determine whether CBI guidelines are associated with organ donation. RESULTS: A total of 790 CBI patients were included in this analysis. In unadjusted comparison, CBI guideline centers had higher rates of organ donation and use of steroids, whole blood, and hormone therapy. In a linear mixed-effects model, CBI guidelines were not associated with organ donation. Registered organ donor status, steroid hormones, and vasopressin were associated with increased relative risk of donation. CONCLUSION: There is high variability in management of CBI, even at centers with CBI guidelines in place. While the use of institutional CBI guidelines was not associated with increased organ donation, guidelines in this study were not identical. Hormone replacement with steroids and vasopressin was associated with increased donation. Hormone resuscitation is a common feature of CBI guidelines. Further analysis of individual practices that increase organ donation after CBI may allow for more effective guidelines and an overall increase in donation to decrease the long waiting periods for organ transplant recipients. LEVEL OF EVIDENCE: Prognostic; Level III.

2.
J Surg Res ; 185(1): 294-9, 2013 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-23816247

RESUMEN

BACKGROUND: High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR. METHODS: A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3-6 L crystalloid, and >6 L crystalloid. RESULTS: There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12-19), P = 0.135; median units of FFP: 12 (IQR 7-18) versus 12 (IQR 10-18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65-42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029). CONCLUSIONS: During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.


Asunto(s)
Coloides/uso terapéutico , Soluciones Isotónicas/uso terapéutico , Resucitación/mortalidad , Resucitación/métodos , Heridas y Lesiones/mortalidad , Heridas y Lesiones/terapia , Adulto , Estudios de Casos y Controles , Soluciones Cristaloides , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Centros Traumatológicos , Heridas y Lesiones/cirugía , Adulto Joven
3.
Am Surg ; 77(2): 201-6, 2011 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-21337881

RESUMEN

Damage control surgery emphasizes limited operations with control of bleeding and contamination. Traditional management centered upon correction of acidosis and hypotension with crystalloids. Damage control resuscitation (DCR) is permissive hypotension and early hemostatic resuscitation combined identified and corrects coagulopathy with fresh-frozen plasma (FFP), restricting use of crystalloids. We hypothesize a survival advantage in patients managed with DCR when compared with a historical cohort of patients. During the 2-year retrospective review, a 1-year period after institution of DCR was compared with a historical control. Resuscitation strategies were analyzed and stratified into emergency department (ED) resuscitation and intraoperative resuscitation. Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. Fifty-seven and 61 patients were managed during the NonDCR and DCR periods respectively. Baseline demographic patient characteristics and physiologic variables were similar between groups. ED DCR patients received less crystalloids: 1.1 versus 4.7 liters (P = 0.0001), more FFP: 1.8 versus 0.5 (P = 0.001). NonDCR had a lower initial systolic pressure in the operating room when compared with DCR: 81 mm Hg versus 95 mm Hg (P = 0.03). DCR patients received less intraoperative crystalloids: 5.7 versus 15.8 liters (P = 0.0001) and more FFP: 15.1 versus 6.2 (P = 0.0001). DCR conveyed a survival benefit (Odds Ratio; 95% confidence interval: 0.40 (0.18-0.90), P = 0.024). NonDCR group had 13.2 days longer hospital length of stay. Damage control resuscitation, beginning in the ED, used more packed red blood cells and FFP minimizing crystalloids. DCR was associated with a survival advantage and shorter length of stay in patients with severe hemorrhage.


Asunto(s)
Hemostasis Quirúrgica/métodos , Resucitación/métodos , Choque Hemorrágico/terapia , Heridas y Lesiones/cirugía , Soluciones Cristaloides , Servicio de Urgencia en Hospital , Humanos , Periodo Intraoperatorio , Soluciones Isotónicas/uso terapéutico , Tiempo de Internación , Modelos Lineales , Modelos Logísticos , Quirófanos , Estudios Retrospectivos
4.
Am J Surg ; 222(5): 1017-1022, 2021 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-34272063

RESUMEN

INTRODUCTION: The purpose of this study was to determine the impact of presumptive antibiotics, used in chest traumas requiring thoracostomies, in preventing infections such as empyema and pneumonia. METHODS: According to PRISMA guidelines, a systematic search of PubMed, Embase and Cochrane Library databases was conducted by two independent reviewers. Studies evaluating the role of antibiotics were included. RESULTS: Antibiotic administration was associated with a lower incidence of overall infectious complications (OR:0.6, 95%CI: 0.43 to 0.84, p = 0.003). Subgroup analysis revealing that the best protective effect against empyema (OR:0.35, 95%CI to 0.65, p = 0.001). When stratified by trauma type, antibiotic use was protective in penetrating injuries, against empyema (OR:0.14, 95%CI: 0.04 to 0.47, p = 0.001) and pneumonia (OR:0.24, 95%CI:, 0.12 to 0.53, p = 0.001) while there was no protective effect in blunt trauma against empyema (OR:0.25 95%CI: 0.03 to 1.73, p = 0.16) or pneumonia (OR:1.22, 95%CI: 0.38 3.90, p = 0.72). CONCLUSION: Presumptive antibiotic use in thoracostomies has a clear role in preventing infectious complications in trauma patients. This role is primarily attributed to their protective effect on penetrating trauma patients.


Asunto(s)
Profilaxis Antibiótica , Tubos Torácicos , Infección de la Herida Quirúrgica/prevención & control , Traumatismos Torácicos/cirugía , Toracostomía , Antibacterianos/uso terapéutico , Profilaxis Antibiótica/métodos , Tubos Torácicos/efectos adversos , Humanos , Toracostomía/efectos adversos , Toracostomía/métodos , Resultado del Tratamiento
5.
Am Surg ; 87(5): 784-789, 2021 May.
Artículo en Inglés | MEDLINE | ID: mdl-33190520

RESUMEN

INTRODUCTION: Preventable deaths following trauma are high and unchanged over the last two decades. The objective of this study was to describe the location of death in patients with penetrating trauma, stratified by anatomic location of injury, in order to better tailor our approach to reducing preventable deaths from trauma. METHODS: This retrospective analysis of a prospectively maintained trauma registry included consecutive adult trauma activations with penetrating trauma at a level 1 trauma center between 07/2012 and 03/2018. Injuries were categorized as extremity, junctional, and torso. Head and neck injuries were excluded. Patients injured in >1 defined location were categorized as "multiple." Location of death was defined as on-scene, emergency department (ED), or hospital. Two-sided χ2 tests were used to compare groups. Multivariate analysis was performed using logistic regression. RESULTS: A total of 1024 patients were included with an overall case fatality rate (CFR) of 7.8%. The CFR following extremity injury (3.0%) was significantly lower than all other injury sites (P = .02).There were no significant differences in CFR for junctional (10.4%), torso (8.3%), or multiple injuries (9.6%). Forty percent of fatalities following junctional injury occurred on-scene and an additional 20% occurred in the ED. DISCUSSION: To our knowledge, this is the first study to describe location of death stratified by anatomic location of injury. There was no difference in the CFRs of junctional and torso injuries, and a large proportion of deaths occurred prior to reaching the hospital or in the trauma bay. These findings support reevaluating the classical algorithms and care pathways for patients with proximal penetrating trauma.


Asunto(s)
Servicios Médicos de Urgencia/estadística & datos numéricos , Mortalidad Hospitalaria , Heridas Penetrantes/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Modelos Logísticos , Louisiana/epidemiología , Masculino , Persona de Mediana Edad , Sistema de Registros , Estudios Retrospectivos , Centros Traumatológicos/estadística & datos numéricos
6.
Am J Disaster Med ; 16(1): 25-34, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33954972

RESUMEN

The coronavirus disease 2019 (COVID-19) pandemic is a slow-moving global disaster with unique challenges for maintaining trauma center operations. University Medical Center New Orleans is the only level 1 trauma center in New Orleans, LA, which became an early hotspot for COVID-19. Intensive care unit surge capacity, addressing components including space, staff, stuff, and structure, is important in maintaining trauma center operability during a high resource-strain event like a pandemic. We report management of the trauma center's surge capacity to maintain trauma center operations while assisting in the care of critically ill COVID-19 patients. Lessons learned and recommendations are provided to assist trauma centers in planning for the influx of COVID-19 patients at their centers.


Asunto(s)
COVID-19 , Centros Traumatológicos , Cuidados Críticos , Humanos , Pandemias/prevención & control , SARS-CoV-2
7.
Am Surg ; 76(3): 312-6, 2010 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-20349663

RESUMEN

Polytrauma patients needing aggressive resuscitation can develop intra-abdominal hypertension (IAH) with subsequent secondary abdominal compartment syndrome (SACS). After patients fail medical therapy, decompressive laparotomy is the surgical last resort. In patients with severe pancreatitis SACS, the use of linea alba fasciotomy (LAF) is an effective intervention to lower IAH without the morbidity of laparotomy. A pilot study of LAF was designed to evaluate its benefit in patients with SACS polytrauma. We conducted an observational study of blunt injury polytrauma patients undergoing LAF. Variables measured before and after LAF included intra-abdominal pressure (IAP, mmHg), abdominal perfusion pressure (APP, mmHg), right ventricular end diastolic volume index (RVEDVI, mL/m2), and ejection fraction. Of the five trauma patients with SACS, the mean age was 36 +/- 17, four (80%) male with an Injury Severity Score of 27 +/- 9. Pre- and post-LAF, IAP was 20.6 +/- 4.7 and 10.6 +/- 2.7 (P < 0.0001), APP 55.2 +/- 5.5 and 77.6 +/- 7.1 (P < 0.0001), RVEDVI 86.4 +/- 9.3 and 123.6 +/- 11.9 (P < 0.0001), and EF 27.6 +/- 4.2 and 40.8 +/- 5 (P < 0.0001), respectively. One patient needed full decompression for bile ascites from unrecognized liver injury. Linea alba fasciotomy, as a first-line intervention before committing to full abdominal decompression in patients with SACS trauma, improved physiological variables without mortality. Consideration for LAF as a bridge before full abdominal decompression needs further evaluation in patients with polytrauma SACS.


Asunto(s)
Síndromes Compartimentales/cirugía , Fasciotomía , Traumatismo Múltiple/complicaciones , Heridas no Penetrantes/complicaciones , Adulto , Síndromes Compartimentales/etiología , Síndromes Compartimentales/fisiopatología , Descompresión Quirúrgica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/fisiopatología , Pancreatitis/complicaciones , Proyectos Piloto , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular Derecha , Adulto Joven
8.
J Trauma ; 69(1): 46-52, 2010 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-20622577

RESUMEN

BACKGROUND: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS: This study is a 4-year retrospective study of all DCL patients who required >or=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student's t test followed by multiple logistic regression. RESULTS: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.


Asunto(s)
Hemorragia/cirugía , Laparotomía/mortalidad , Resucitación/mortalidad , Heridas y Lesiones/cirugía , Heridas no Penetrantes/cirugía , Adulto , Transfusión Sanguínea , Femenino , Hemorragia/mortalidad , Humanos , Puntaje de Gravedad del Traumatismo , Laparotomía/métodos , Masculino , Análisis Multivariante , Análisis de Regresión , Soluciones para Rehidratación/uso terapéutico , Resucitación/métodos , Estudios Retrospectivos , Análisis de Supervivencia , Heridas y Lesiones/mortalidad , Heridas no Penetrantes/mortalidad , Heridas Penetrantes/mortalidad , Heridas Penetrantes/cirugía
9.
J Am Coll Surg ; 230(4): 596-602, 2020 04.
Artículo en Inglés | MEDLINE | ID: mdl-32220451

RESUMEN

BACKGROUND: Recent reports suggest that component plasma products contain significant quantities of cellular contamination. We hypothesized that leukoreduction of whole blood before preparation of derived plasma is an effective method to prevent cellular contamination of stored plasma. STUDY DESIGN: Samples of never-frozen liquid plasma prepared by standard methods (n = 25) were obtained from 3 regional blood centers that supply 3 major trauma centers. Samples were analyzed for leukocyte and platelet contamination by flow cytometry. To determine if leukoreduction of whole blood before centrifugation and expression of plasma prevents cellular contamination of liquid plasma, 1 site generated 6 additional units of liquid plasma from leukoreduced whole blood, which were then compared with units of liquid plasma derived by standard processing. RESULTS: Across all centers, each unit of never-frozen liquid plasma contained a mean of 12.8 ± 3.0 million leukocytes and a mean of 4.6 ± 2 billion platelets. Introduction of whole blood leukoreduction (LR) before centrifugation and plasma extraction essentially eliminated all contaminating leukocytes (Non-LR: 12.3 ± 2.9 million vs LR: 0.05 ± 0.05 million leukocytes) and platelets (Non-LR: 4.2 ± 0.3 billion platelets vs LR: 0.00 ± 0.00 billion platelets). CONCLUSIONS: Despite widespread belief that stored plasma is functionally acellular, testing of liquid plasma from 3 regional blood banks revealed a significant amount of previously unrecognized cellular contamination. Introduction of a leukoreduction step before whole blood centrifugation essentially eliminated detectable leukocyte and platelet contaminants from plasma. Therefore, our study highlights a straightforward and cost-effective method to eliminate cellular contamination of stored plasma.


Asunto(s)
Plaquetas , Procedimientos de Reducción del Leucocitos/métodos , Leucocitos , Plasma/citología , Humanos , Masculino
10.
Am Surg ; 75(12): 1193-8, 2009 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-19999911

RESUMEN

Intra-abdominal hypertension (IAH) after damage control laparotomy (DCL) is not unusual and because of this, patients are treated with open-abdomen techniques to prevent abdominal compartment syndrome (ACS). The occurrence of recurrent ACS (R-ACS) after abdominal wall closure under tension in patients managed with DCL can be a trigger factor for second hit syndrome. Outcomes in this subset have not been previously described. In this 1-year retrospective study of severely injured patients in a Level I trauma center managed with DCL and sequential abdominal wall closure, 26 patients were identified. After attempted abdominal wall closure, 13 (50%) patients had R-ACS and 13 (50%) non-R-ACS. R-ACS patients had a statistically significant higher incidence of multisystem organ failure, acute respiratory distress syndrome, and sepsis as well as requiring longer ventilator support and longer hospital length of stay. We concluded that failure to recognize and treat IAH with development of R-ACS after tension abdominal wall closure in patients with DCL will trigger the second hit syndrome with increased risk of morbidity. Institution of a management algorithm with intra-abdominal pressure/abdominal perfusion pressure surveillance at the time of abdominal wall closure can potentially ameliorate complications.


Asunto(s)
Abdomen , Traumatismos Abdominales/cirugía , Pared Abdominal/cirugía , Síndromes Compartimentales/epidemiología , Laparotomía/métodos , Adulto , Femenino , Humanos , Persona de Mediana Edad , Insuficiencia Multiorgánica/epidemiología , Presión , Recurrencia , Estudios Retrospectivos , Factores de Tiempo , Adulto Joven
11.
Am Surg ; 75(12): 1227-33, 2009 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-19999917

RESUMEN

Open-book pelvic fractures (OBPF) with concomitant intra-abdominal injuries carry a high morbidity and mortality; the significance of associated perineal open wound (OBPF-POW) has not been defined. We hypothesize that the presence of perineal open wounds increases morbidity, mortality, and concomitant use of hospital resources. Patients diagnosed with OBPF over a 5-year period at a Level I trauma center were identified by trauma registry review, and were retrospectively reviewed under an Institutional Review Board-approved protocol. Patients with OBPF without a perineal open wound were compared with those with OBPF-POW. Data collected included patient demographics, injury details, management, and outcomes. A total of 1,635 patients with blunt pelvic fractures were identified, of which 177 (10.8%) had OBPF. OBPF-POW (36/177) significantly increased the use of angioembolization, occurrence of sepsis, pelvic sepsis, ARDS, and multi-organ system failure. Patients with OBPF-POW had an increase of 13 days in length of hospitalization compared with the OBPF group (P < 0.001), with cost of $120,647.30 and $62,952.72 respectively (P < 0.001). Perineal open wounds complicate open-book pelvic fractures with significant increase in hospital resource utilization. Aggressive multidisciplinary evaluation and management is appropriate to detect and prevent complications.


Asunto(s)
Fracturas Óseas/epidemiología , Traumatismo Múltiple/terapia , Huesos Pélvicos/lesiones , Perineo/lesiones , Traumatismos Abdominales/epidemiología , Adulto , Femenino , Fracturas Óseas/economía , Costos de Hospital , Humanos , Tiempo de Internación , Louisiana , Masculino , Persona de Mediana Edad , Pronóstico , Respiración Artificial/estadística & datos numéricos , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Adulto Joven
12.
Am Surg ; 75(4): 284-6, 2009 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-19385285

RESUMEN

Charity Hospital (CH) was devastated by Hurricane Katrina and remains closed. Design and staffing of a new, temporary dedicated trauma hospital relied on data from prior experience at CH, updated census information, and a changed trauma demographic. The study objective was to analyze the new trauma program and evaluate changes in demographics, injury patterns, and outcomes between pre- (PK) and post-Katrina (POK) trauma populations. A retrospective review of trauma patients' demographics, anatomical variables, and physiological variables 6 months PK and POK was performed under an approved Institutional Review Board protocol. Trauma activation triage criteria between study periods were also analyzed. Continuous data comparisons between the two time periods were made with Student's t test. Dichotomous data were analyzed using chi2 test. The demographic of trauma patients is different in the POK interval, reflecting changes in the New Orleans population. Modification of triage criteria by the exclusion of mechanism as an activation criterion resulted in an increase of patients with higher acuity and Injury Severity Score, lower initial Glasgow Coma Score, and a higher proportion of penetrating mechanism. Outcome measures reflect longer length of stay (4.4 vs. 6.8 days, P < 0.0001) without a significant difference in mortality (6.0 vs 7.5, P = 0.227). Hospital data demonstrates that the POK trauma system was stressed by the increased acuity, penetrating injury, and number of procedures per patient (1.7 vs. 3.4). Resources should be directed toward patients requiring multidisciplinary care by increasing intensive care unit beds and operating room capacity. Future resource planning in the recovery phases of large-scale natural disasters should take into account these observations.


Asunto(s)
Tormentas Ciclónicas , Atención a la Salud/tendencias , Desastres , Etnicidad , Traumatismos Faciales/etnología , Admisión del Paciente/tendencias , Adulto , Atención a la Salud/métodos , Traumatismos Faciales/diagnóstico , Traumatismos Faciales/terapia , Humanos , Louisiana/epidemiología , Estudios Retrospectivos , Índices de Gravedad del Trauma
13.
J Trauma ; 67(1): 108-12; discussion 112-4, 2009 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-19590318

RESUMEN

BACKGROUND: Obesity is an independent predictor of increased morbidity and mortality in critically injured trauma patients. We hypothesized that obese patients in need of damage control laparotomy (DCL) will encounter an increase incidence of postsurgical complications with a concomitant increase mortality when compared with a cohort of nonobese patients. METHODS: All adult trauma patients who underwent DCL during a 4-year period at a Level I Trauma Center were retrospectively reviewed. Patients were categorized into nonobese (body mass index [BMI] < or = 29 kg/m), obese (BMI 30-39 kg/m), and severely obese (BMI > or = 40 kg/m) groups. Outcome measures included the occurrence of postoperative infectious complications, failure of primary abdominal wall fascial closure, acute respiratory distress syndrome, acute renal insufficiency, multiple system organ failure, days of ventilator support, hospital length of stay, and death. RESULTS: During a 4-year period, 12,759 adult trauma patients were admitted to our Level I Trauma Center of which 1,812 (14.2%) underwent emergent laparotomy. Of these, 104 (5.7%) were treated with DCL: nonobese, n = 51 (49%); obese, n = 38 (37%); and severely obese, n = 15 (14%). In a multivariate adjusted model, multiple system organ failure was 1.82 times more likely in severely obese (95% CI: 1.14-2.90) and 1.74 times more likely in the obese patients (95% CI: 1.14-2.66) when compared with patients with normal BMI after DCL (p < 0.01). In the severely obese patients undergoing DCL, significantly elevated prevalence ratios (PR) for development of postoperative infectious complications, acute renal insufficiency, and failure of primary abdominal wall fascial closure were 1.75, 3.07, and 2.62, respectively. Days of ventilator support, length of stay, and mortality rates were significantly higher in severely obese patients (24 days, 27 days, and 60%) compared with obese (14 days, 14 days, and 21%) and nonobese (9.8 days, 14 days, and 28%) patients. CONCLUSION: Severe obesity was significantly associated with adverse outcomes and increased resource utilization in trauma patients treated with DCL. Measures to improve outcomes in this vulnerable patient population must be directed at multiple levels of health care.


Asunto(s)
Traumatismos Abdominales/cirugía , Laparotomía , Obesidad/complicaciones , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/mortalidad , Adulto , Índice de Masa Corporal , Femenino , Estudios de Seguimiento , Humanos , Tiempo de Internación , Masculino , Morbilidad , Obesidad/epidemiología , Complicaciones Posoperatorias/epidemiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Población Rural , Tasa de Supervivencia , Centros Traumatológicos , Estados Unidos/epidemiología
14.
J Trauma ; 67(1): 33-7; discussion 37-9, 2009 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-19590305

RESUMEN

BACKGROUND: Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS: A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS: Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION: TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.


Asunto(s)
Transfusión de Componentes Sanguíneos/métodos , Coagulación Intravascular Diseminada/terapia , Hemostasis/fisiología , Técnicas Hemostáticas , Cuidados Intraoperatorios/métodos , Resucitación/métodos , Heridas y Lesiones/complicaciones , Adulto , Coagulación Intravascular Diseminada/etiología , Coagulación Intravascular Diseminada/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Estados Unidos/epidemiología , Heridas y Lesiones/mortalidad , Heridas y Lesiones/cirugía
15.
J Trauma ; 66(3): 641-6; discussion 646-7, 2009 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-19276732

RESUMEN

BACKGROUND: Efforts to determine the suitability of low-grade pancreatic injuries for nonoperative management have been hindered by the inaccuracy of older computed tomography (CT) technology for detecting pancreatic injury (PI). This retrospective, multicenter American Association for the Surgery of Trauma-sponsored trial examined the sensitivity of newer 16- and 64-multidetector CT (MDCT) for detecting PI, and sensitivity/specificity for the identification of pancreatic ductal injury (PDI). METHODS: Patients who received a preoperative 16- or 64-MDCT followed by laparotomy with a documented PI were enrolled. Preoperative MDCT scans were classified as indicating the presence (+) or absence (-) of PI and PDI. Operative notes were reviewed and all patients were confirmed as PI (+), and then classified as PDI (+) or (-). As all patients had PI, an analysis of PI specificity was not possible. PI patients formed the pool for further PDI analysis. As sensitivity and specificity data were available for PDI, multivariate logistic regression was performed for PDI patients using the presence or absence of agreement between CT and operative note findings as an independent variable. Covariates were age, gender, Injury Severity Score, mechanism of injury, presence of oral contrast, presence of other abdominal injuries, performance of the scan as part of a dedicated pancreas protocol, and image thickness < or =3 mm or > or =5 mm. RESULTS: Twenty centers enrolled 206 PI patients, including 71 PDI (+) patients. Intravenous contrast was used in 203 studies; 69 studies used presence of oral contrast. Eight-nine percent were blunt mechanisms, and 96% were able to have their duct status operatively classified as PDI (+) or (-). The sensitivity of 16-MDCT for all PI was 60.1%, whereas 64-MDCT was 47.2%. For PDI, the sensitivities of 16- and 64-MDCT were 54.0% and 52.4%, respectively, with specificities of 94.8% for 16-MDCT scanners and 90.3% for 64-MDCT scanners. Logistic regression showed that no covariates were associated with an increased likelihood of detecting PDI for either 16- or 64-MDCT scanners. The area under the curve was 0.66 for the 16-MDCT PDI analysis and 0.77 for the 64-MDCT PDI analysis. CONCLUSION: Sixteen and 64-MDCT have low sensitivity for detecting PI and PDI, while exhibiting a high specificity for PDI. Their use as decision-making tools for the nonoperative management of PI are, therefore, limited.


Asunto(s)
Páncreas/lesiones , Tomografía Computarizada Espiral/instrumentación , Heridas no Penetrantes/diagnóstico por imagen , Heridas Penetrantes/diagnóstico por imagen , Administración Oral , Adolescente , Adulto , Medios de Contraste/administración & dosificación , Femenino , Humanos , Infusiones Intravenosas , Puntaje de Gravedad del Traumatismo , Laparotomía , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Conductos Pancreáticos/diagnóstico por imagen , Conductos Pancreáticos/lesiones , Conductos Pancreáticos/cirugía , Estudios Retrospectivos , Sensibilidad y Especificidad , Estados Unidos , Heridas no Penetrantes/cirugía , Heridas Penetrantes/cirugía , Adulto Joven
16.
J Trauma Acute Care Surg ; 87(5): 1070-1076, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31658237

RESUMEN

BACKGROUND: Ischemia/reperfusion injury (IRI) has been shown to cause endothelial glycocalyx (EG) damage.Whether the hypoxic/ischemic insult or the oxidative and inflammatory stress of reperfusion plays a greater part in glycocalyx damage is not known. Furthermore, the mechanisms by which IRI causes EG damage have not been fully elucidated. The aims of this study were to determine if hypoxia alone or hypoxia/reoxygenation (H/R) caused greater damage to the glycocalyx, and if this damage was mediated by reactive oxygen species (ROS) and Ca signaling. METHODS: Human umbilical vein endothelial cells were cultured to confluence and exposed to either normoxia (30 minutes), hypoxia (2% O2 for 30 minutes), or H/R (30 minutes hypoxia followed by 30 minutes normoxia). Some cells were pretreated with ROS scavengers TEMPOL, MitoTEMPOL, Febuxostat, or Apocynin, or with the Ca chelator BAPTA or Ca channel blockers 2-aminoethoxydiphenyl borate, A967079, Pyr3, or ML204. Intracellular ROS was quantified for all groups. Endothelial glycocalyx was measured using fluorescently tagged wheat germ agglutinin and imaged with fluorescence microscopy. RESULTS: Glycocalyx thickness was decreased in both hypoxia and H/R groups, with the decrease being greater in the H/R group. TEMPOL, MitoTEMPOL, BAPTA, and 2-aminoethoxydiphenyl borate prevented loss of glycocalyx in H/R. The ROS levels were likewise elevated compared with normoxia in both groups, but were increased in the H/R group compared with hypoxia alone. BAPTA did not prevent ROS production in either group. CONCLUSION: In our cellular model for shock, we demonstrate that although hypoxia alone is sufficient to produce glycocalyx loss, H/R causes a greater decrease in glycocalyx thickness. Under both conditions damage is dependent on ROS and Ca signaling. Notably, we found that ROS are generated upstream of Ca, but that ROS-mediated damage to the glycocalyx is dependent on Ca.


Asunto(s)
Señalización del Calcio/fisiología , Endotelio/patología , Glicocálix/patología , Daño por Reperfusión/fisiopatología , Choque/fisiopatología , Calcio/metabolismo , Bloqueadores de los Canales de Calcio/farmacología , Canales de Calcio/metabolismo , Señalización del Calcio/efectos de los fármacos , Hipoxia de la Célula/fisiología , Línea Celular , Quelantes/farmacología , Endotelio/citología , Depuradores de Radicales Libres/farmacología , Células Endoteliales de la Vena Umbilical Humana , Humanos , Especies Reactivas de Oxígeno/antagonistas & inhibidores , Especies Reactivas de Oxígeno/metabolismo , Daño por Reperfusión/patología , Choque/patología
17.
J Am Coll Surg ; 229(3): 252-258, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31029763

RESUMEN

BACKGROUND: Stored plasma products are widely regarded as being functionally acellular, obviating the need for leukoreduction. We tested the hypothesis that donor plasma is contaminated by leukocytes and platelets, which, after frozen storage, would release cellular debris in quantities sufficient to elicit significant pro-inflammatory responses. STUDY DESIGN: Samples of never-frozen liquid plasma from 2 regional Level I trauma centers were analyzed for leukocyte and platelet contamination. To determine if the cellular contamination and associated debris found in liquid plasma were at levels sufficient to evoke an innate immune response, known quantities of leukocytes were subjected to a freeze-thaw cycle, added to whole blood, and the magnitude of the inflammatory response was determined by induction of interleukin-6. RESULTS: Units of never-frozen plasma from 2 regional Level I trauma centers located in Alabama and Louisiana contained significant amounts of leukocyte contamination (Louisiana, n = 22; 17.3 ± 4.5 million vs Alabama, n = 22; 11.3 ± 2.2 million) and platelet contamination (Louisiana, n = 21; 0.86 ± 0.20 billion vs Alabama, n = 22; 1.0 ± 0.3 billion). Cellular debris from as few as 1 million leukocytes induced significant increases in interleukin-6 levels (R2 = 0.74; p < 0.0001). CONCLUSIONS: Stored plasma units from trauma center blood banks were highly contaminated with leukocytes and platelets, at levels more than 15-fold higher than sufficient to elicit ex vivo inflammatory responses. In light of paradigm shifts toward the use of more empiric plasma for treatment of hypovolemia, this study suggests that new manufacturing and quality-control processes are needed to eliminate previously unrecognized cellular contamination present in stored plasma products.


Asunto(s)
Conservación de la Sangre/métodos , Plasma/citología , Alabama , Transfusión de Componentes Sanguíneos , Plaquetas/citología , Humanos , Leucocitos/citología , Louisiana , Control de Calidad , Centros Traumatológicos
18.
Am Surg ; 74(12): 1159-65, 2008 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-19097529

RESUMEN

Recombinant factor VII (rFVIIa) has arisen as an option for the control of life-threatening traumatic bleeding unresponsive to other means. The timing of administration, dosage, mortality, units of blood transfusion saved, risk of thrombotic events, and risk/benefits ratio are presently poorly defined. A Medline search from 1995 through March 2008 was conducted. All English language articles containing the terms "trauma" and "factor VII" or its variants were retrieved. Letters to the editor, animal studies, and general reviews were excluded. A total of 19 articles met inclusion criteria. These articles were then reviewed and stratified into three classes of evidence according to the quality assessment instrument developed by the Brain and Trauma Foundation. Levels of recommendation were developed. A total of 118 articles were identified. Only one Class I study was identified. This study demonstrated that three doses of rFVIIa given in blunt traumatic hemorrhage yielded a significant reduction of 2.6 of red blood cells used. These findings were not statistically significant for penetrating trauma patients. There was no reduction in mortality and no increase in thromboembolic events. Four Class II studies were identified; three showed a significant decrease of blood product usage and one demonstrated significant reductions in 24-hour and 30 day death from hemorrhage in patients receiving rFVIIa. The remaining 14 studies were Class III reviews of databases, registries, case series, and case reports. No identified study specifically addressed the cost/benefit analysis of rFVIIa usage in trauma hemorrhage. Utility of rFVIIa in trauma-associated hemorrhage remains controversial. There is Level I supporting the use of rFVIIa for blunt trauma patients only. There is no Class I evidence supporting decreased mortality or differences in thromboembolic events. Minimal effective dosing regimens and cost/benefit analyses have not yet been examined.


Asunto(s)
Coagulantes/uso terapéutico , Factor VIIa/uso terapéutico , Hemorragia/tratamiento farmacológico , Guías de Práctica Clínica como Asunto , Heridas y Lesiones/complicaciones , Medicina Basada en la Evidencia , Hemorragia/etiología , Humanos , Proteínas Recombinantes/uso terapéutico , Índices de Gravedad del Trauma
19.
J Trauma ; 65(1): 49-53, 2008 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-18580509

RESUMEN

BACKGROUND: Nonoperative management (NOM) of low-grade blunt pancreatic injuries (LGBPI) diagnosed by computed tomographic (CT) abnormalities of the pancreas in the adult hemodynamically stable (HDS) patient has not been previously defined. We report our experience of patients with LGBPI at a single Level I Trauma Center. METHODS: Adult HDS patients during a 5-year period with blunt pancreatic injuries with an abbreviated injury score of

Asunto(s)
Páncreas/lesiones , Heridas no Penetrantes/terapia , Adulto , Algoritmos , Presión Sanguínea , Estudios de Cohortes , Árboles de Decisión , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Índices de Gravedad del Trauma , Resultado del Tratamiento , Heridas no Penetrantes/diagnóstico por imagen , Heridas no Penetrantes/fisiopatología
20.
J Trauma ; 65(2): 327-30, 2008 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-18695466

RESUMEN

BACKGROUND: The predictors of amputation for patients with lower extremity vascular trauma are well described in the literature, but the predictors of amputation in the upper extremity are not so well defined. We hypothesize that the predictors of amputation in the lower extremity are much different when compared with the upper extremity. METHODS: Retrospective chart review of all brachial artery traumatic injuries presenting to a rural-state university trauma center. RESULTS: In a 6-year period, 41 patients presented with brachial artery injuries. Operative management was performed in 38 (93%) patients which included 23 reversed saphenous vein grafts, 13 primary repairs, and 2 synthetic grafts. There were four deaths (9.8%) and four (9.8%) amputations. Comparing the amputation and limb salvage groups, the Injury Severity Score (ISS) was 32 versus 12, whereas the Mangled Extremity Severity Score (MESS) was 7 versus 4.3. Five patients had a MESS score greater than 7; four of whom had an amputation or died. Amputation was performed in only 4 of 23 patients with neurologic deficits. Limb salvage was successful in 24 of 28 patients without a palpable pulse on arrival. CONCLUSIONS: Predictors of amputation in brachial artery injuries differ from lower extremity vascular injuries. Delayed presentation greater than 6 hours, MESS, open fracture, nerve deficits, and diminished capillary refill were not predictive of amputation for patients with brachial artery injuries. These data suggest that the vast majority of upper extremity injuries should have attempted salvage regardless of the severity scoring systems.


Asunto(s)
Brazo/cirugía , Arteria Braquial/lesiones , Recuperación del Miembro , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Áreas de Influencia de Salud , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Recuperación del Miembro/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Mississippi , Reperfusión , Estudios Retrospectivos , Servicios de Salud Rural , Factores de Tiempo , Centros Traumatológicos
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