High-grade liver injuries with contrast extravasation managed initially with interventional radiology versus observation: A secondary analysis of a WTA multicenter study.

BACKGROUND: High-grade liver injuries with extravasation (HGLI â€‹+ â€‹Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI â€‹+ â€‹Extrav. Therefore, we evaluated the management of HGLI â€‹+ â€‹Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. METHODS: HGLI â€‹+ â€‹Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. RESULTS: From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p â€‹= â€‹0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p â€‹> â€‹0.05). CONCLUSION: Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI â€‹+ â€‹Extrav patients.

An observation-first strategy for liver injuries with "blush" on computed tomography is safe and effective.

INTRODUCTION: The management of liver injuries in hemodynamically stable patients is variable and includes primary treatment strategies of observation (OBS), angiography (interventional radiology [IR]) with angioembolization (AE), or operative intervention (OR). We aimed to evaluate the management of patients with liver injuries with active extravasation on computed tomography (CT) imaging, hypothesizing that AE will have more complications without improving outcomes compared with OBS. METHODS: This is a prospective, multicenter, observational study. Patients who underwent CT within 2 hours after arrival with extravasation (e.g., blush) on imaging were included. Exclusion criteria included cirrhosis, nontraumatic hemorrhage, transfers from outside facilities, and pregnancy. No hemodynamic exclusion criteria were used. The primary outcome was liver-specific complications. Secondary outcomes include length of stay and mortality. Angioembolization patients were compared with patients treated without AE. Propensity score matching was used to match based on penetrating mechanism, liver injury severity, arrival vital signs, and early transfusion. RESULTS: Twenty-three centers enrolled 192 patients. Forty percent of patients (n = 77) were initially OBS. Eleven OBS patients (14%) failed nonoperative management and went to IR or OR. Sixty-one patients (32%) were managed with IR, and 42 (69%) of these had AE as an initial intervention. Fifty-four patients (28%) went to OR+/- IR. After propensity score matching (n = 34 per group), there was no difference in baseline characteristics between AE and OBS. The AE group experienced more complications with a higher rate of IR-placed drains for abscess or biloma (22% vs. 0%, p = 0.01) and an increased overall length of stay ( p = 0.01). No difference was noted in transfusions or mortality. CONCLUSION: Observation is highly effective with few requiring additional interventions. Angioembolization was associated with higher rate of secondary drain placement for abscesses or biloma. Given this, a trial of OBS and avoidance of empiric AE may be warranted in hemodynamically stable, liver-injured patient with extravasation on CT. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Infection after penetrating brain injury-An Eastern Association for the Surgery of Trauma multicenter study oral presentation at the 32nd annual meeting of the Eastern Association for the Surgery of Trauma, January 15-19, 2019, in Austin, Texas.

BACKGROUND: Fatality rates following penetrating traumatic brain injury (pTBI) are extremely high and survivors are often left with significant disability. Infection following pTBI is associated with worse morbidity. The modern rates of central nervous system infections (INF) in civilian survivors are unknown. This study sought to determine the rate of and risk factors for INF following pTBI and to determine the impact of antibiotic prophylaxis. METHODS: Seventeen institutions submitted adult patients with pTBI and survival of more than 72 hours from 2006 to 2016. Patients were stratified by the presence or absence of infection and the use or omission of prophylactic antibiotics. Study was powered at 85% to detect a difference in infection rate of 5%. Primary endpoint was the impact of prophylactic antibiotics on INF. Mantel-Haenszel χ and Wilcoxon's rank-sum tests were used to compare categorical and nonparametric variables. Significance greater than p = 0.2 was included in a logistic regression adjusted for center. RESULTS: Seven hundred sixty-three patients with pTBI were identified over 11 years. 7% (n = 51) of patients developed an INF. Sixty-six percent of INF patients received prophylactic antibiotics. Sixty-two percent of all patients received one dose or greater of prophylactic antibiotics and 50% of patients received extended antibiotics. Degree of dural penetration did not appear to impact the incidence of INF (p = 0.8) nor did trajectory through the oropharynx (p = 0.18). Controlling for other variables, there was no statistically significant difference in INF with the use of prophylactic antibiotics (p = 0.5). Infection was higher in patients with intracerebral pressure monitors (4% vs. 12%; p = <0.001) and in patients with surgical intervention (10% vs. 3%; p < 0.001). CONCLUSION: There is no reduction in INF with prophylactic antibiotics in pTBI. Surgical intervention and invasive intracerebral pressure monitoring appear to be risk factors for INF regardless of prophylactic use. LEVEL OF EVIDENCE: Therapeutic, level IV.

Computed tomography to operating room in less than 3 hours minimizes complications from appendicitis.

BACKGROUND: The aim of our study is to select patients with nonperforated appendicitis verified by computed tomography (CT) scan and to determine if there is a temporal component to perforation. METHODS: A retrospective cohort study of patients with CT scan evidence of nonperforated appendicitis from 2007 to 2012. RESULTS: 411 patients, aged 39.7 ± 16.25 years (47.5% male) were included in the study. 330 patients (80.3%) were nonperforated at surgery. Analysis of 3-hour intervals from CT scan to operating room (OR) revealed an absolute reduction in the rate of perforation from 27% at the 6- to 9-hour interval, to 17% and 10% at the 3- to 6-hour and 0- to 3-hour intervals, respectively, (P < .04). All organ space infections occurred in patients who were delayed to the OR greater than 3 hours. Mean length of hospitalization was .93 days and 2.81 days, respectively, in nonperforated and perforated appendicitis patients (P < .001). CONCLUSIONS: Delays to the OR were associated with increased risk of perforation. Patients with uncomplicated appendicitis had shorter hospitalization and fewer postoperative wound infections.

Effect of inpatient electroencephalography on clinical decision making.

CONTEXT: Routine inpatient electroencephalography (EEG) is commonly used as a diagnostic and therapeutic decision-making tool in the care of patients with a wide spectrum of conditions. Previous investigations on EEG use have focused on current guidelines or specific clinical presentations. OBJECTIVE: To assess the effect of EEGs on clinical diagnosis and management of disease in adult inpatients in a community hospital. METHODS: Medical records of adult patients who underwent EEG between October 2008 and June 2009 in a single general community hospital were retrospectively reviewed. Data were collected for comorbidities, diagnoses, and management. Findings from EEGs were classified as normal, abnormal, or uninterpretable and according to whether they resulted in a change in diagnosis or management, supported clinical decision making and resulted in no change in diagnosis or management, or did not contribute to diagnosis or management. RESULTS: A total of 200 medical records were reviewed; 110 (55%) were for male patients and 90 (45%) were for female patients, with a mean (range) age of 60 (18-96) years. The most common pre-EEG diagnoses were altered mental status (52 [26%]) and seizure (48 [24%]). Of all EEGs, 115 (57.5%) had findings that were normal, 83 (41.5%) had findings that were abnormal, and 2 (1%) had findings that were uninterpretable. No EEGs had findings that resulted in a change in diagnosis or management, 8 EEGs (4%) had findings that supported clinical decision making and resulted in no change in diagnosis or management, and 192 EEGs (96%) had findings that did not contribute to diagnosis or management. CONCLUSION: In this study, inpatient EEGs rarely contributed to clinical decision making and in no case resulted in a change in diagnosis or management. These findings warrant future research on the effectiveness of inpatient EEGs for a wide breadth of clinical inpatient diagnoses.