Outcomes With Overlapping Surgery at a Large Academic Medical Center.

OBJECTIVE: The aim of the study was to evaluate the efficiency and safety of overlapping surgery (OS) at a training institution by comparing it with nonoverlapping surgery (NO) with respect to operative time, mortality, readmissions, and complications. BACKGROUND: OS is the practice of an attending physician providing supervision to 2 surgeries that are scheduled at overlapping times. Recent media and government attention have raised concerns about this practice and the need for informed patient consent. METHODS: A population-based, retrospective, cohort study was conducted using data on operative procedures from January 1, 2014 to December 31, 2015 at a large tertiary academic center. Patients who had undergone surgery by attending surgeons who performed ≥10% of their cases overlapping were selected. Thirty-day mortality, readmission within 30 days, and 7 patient safety indicators (PSIs) were recorded. RESULTS: A total of 26,260 cases met our criteria for analysis for surgical time and 15,106 cases for outcomes. OS patients had an average case length of 2.18 hours compared with 1.64 hours among NO patients (P < 0.0001), a decreased risk of mortality [relative risk (RR) 0.42, 95% confidence interval (CI), 0.34-0.52, P < 0.0001), a decreased risk of readmission (RR 0.92, 95% CI, 0.86-0.98, P = 0.0148), and a decreased risk of experiencing any PSI (RR 0.67, 95% CI, 0.55-0.83, P = 0.0002). CONCLUSIONS: The present study confirms prior reports and addresses gaps in the literature regarding OS, such as the effect of resident involvement and the individual effect of OS in 13 different surgical specialties. The findings highlight the need for additional investigation and suggest that the practice of OS does not expose patients to increased risk of negative outcomes.

A Role for the Early Warning Score in Early Identification of Critical Postoperative Complications.

OBJECTIVE: We examined whether an early warning score (EWS) could predict inpatient complications in surgical patients. BACKGROUND: Abnormal vitals often precede in-hospital mortality. The EWS calculated using vital signs has been developed to identify patients at risk for mortality. METHODS: Inpatient general surgery procedures with National Surgical Quality Improvement Project data from 2013 to 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of major complications, unplanned intensive care unit transfer, and medical emergency team activation were classified using the Clavien-Dindo system as grade I to V. Relationship with EWS and timing of complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation. RESULTS: Among 552 patients admitted to the ward postsurgery, 68 (12.3%) developed at least one grade I to III complication and 37 (6.7%) developed a grade IV/V complication. The mean maximum EWS was significantly higher preceding grade IV/V complications (10.1) compared with grade I to III complications (6.4) or across the hospital stay in patients without complications (5.4; P < 0.01). EWS significantly increased in the 3 days preceding grade IV/V complications (P < 0.001) and declined in patients without complications in the 3 days before discharge (P < 0.001). A threshold EWS of 8 predicted occurrence of grade IV/V complications with 81% sensitivity and 84% specificity. CONCLUSIONS: Critical postoperative complications can be preceded by rising EWS. Interventional studies are needed to evaluate whether EWS can reduce the severity of postoperative complications and mortality for surgical patients through early identification and intervention.

Use of a Bundle Checklist Combined With Physician Confirmation Reduces Risk of Nosocomial Complications and Death in Trauma Patients Compared to Documented Checklist Use Alone.

BACKGROUND: Bundle checklists are increasingly utilized in patient care, but data are inconsistent regarding their efficacy in reducing nosocomial complication rates. We examined whether checklist usage was associated with nosocomial complications; when documented, elements were verified by provider bedside rounds. METHODS: We performed a retrospective cohort study of trauma patients admitted to our hospital during a three-phase implementation of a quality improvement project. For this analysis, patients were categorized under predocumentation (PD), documentation only (DO), or documentation with provider review (PR) cohort based on temporal designations. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between documentation cohorts and nosocomial complications. RESULTS: No difference was observed in mean hospital stay, intensive care unit (ICU) days, or ventilator days. The DO cohort showed no significant differences in the risk of complications. Among ICU patients, when compared with the PD cohort, the PR cohort demonstrated a decreased risk of all complications OR 0.72 (95% CI 0.55-0.93), pulmonary embolus OR 0.29 (95% CI 0.11-0.73), pneumonia OR 0.66 (95% CI 0.50-0.88), and death OR 0.50 (95% CI 0.31-0.79). CONCLUSIONS: Bedside confirmation of bundle checklists during physician extender rounds reduces the risk of pulmonary embolus, pneumonia, and death when compared to chart documentation alone. This study underscores the importance of the team approach to the bundle checklist and it's ability to reduce morbidity and mortality.

A 100% departmental mortality review improves observed-to-expected mortality ratios and University HealthSystem Consortium rankings.

BACKGROUND: Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics. STUDY DESIGN: From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression. RESULTS: Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013. CONCLUSIONS: A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.

The deleterious effect of red blood cell storage on microvascular response to transfusion.

BACKGROUND: The transfusion of relatively older red blood cells (RBCs) has been associated with both morbidity and mortality in trauma patients in observational studies. Although the mechanisms responsible for this phenomenon remain unclear, alterations in the microcirculation as a result of the transfusion of relatively older blood may be a causative factor. To assess this hypothesis, we evaluated microvascular perfusion in trauma patients during RBC transfusion. METHODS: Anemic but otherwise stable trauma intensive care unit patients with orders for transfusion were identified. Thenar muscle tissue oxygen saturation (StO(2)) was measured continuously by near-infrared spectroscopy during the course of transfusion of one RBC unit. Sublingual microcirculation was observed by sidestream dark-field illumination microscopy before and after transfusion of one RBC unit. Thenar muscle StO(2) was recorded during the course of transfusion. Pretransfusion and posttransfusion perfused capillary vascular density (PCD) was determined by semiquantitative image analysis. Changes in StO(2) and PCD relative to age of RBC unit were evaluated using mixed models that adjusted for baseline StO(2) and Spearman correlation, respectively. RESULTS: Overall, 93 patients were recruited for study participation, 69% were male, and average Injury Severity Score (ISS) was 26.4. The average pretransfusion hemoglobin was 7.5 mg/dL, and the average age of RBC unit transfused was 29.4 days. The average peritransfusion StO(2) was negatively associated with increasing RBC age (slope, -0.11; p = 0.0014). Change in PCD from pretransfusion to posttransfusion period was found to correlate negatively with RBC storage age (Spearman correlation, -0.27; p = 0.037). CONCLUSION: The transfusion of relatively older RBC units was associated with a decline in both StO(2) and PCD. Collectively, these observations demonstrate that transfusions of older RBC units are associated with the inhibition of regional microvascular perfusion. In patients requiring multiple units of RBCs, alteration of the microcirculation by relatively older units could potentially contribute to adverse outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

Stress-induced hyperglycemia, not diabetic hyperglycemia, is associated with higher mortality in trauma.

OBJECTIVES: To identify all trauma patients with diabetes and compare diabetic hyperglycemia (DH) patients with those with stress-induced hyperglycemia (SIH). BACKGROUND: SIH has been shown to result in worse outcomes after trauma. The presence of diabetes mellitus (DM) or occult DM within the cohort confounded previous studies. We identified 2 distinct populations of trauma patients with SIH or DH to determine the impact of hyperglycemia on these 2 groups. METHODS: Admission glycosylated hemoglobin (HbA1c), glucose levels, and comorbidity data were collected over a 2-year period. DM was determined by patient history or admission HbA1c 6.5% or more. SIH was determined by absence of DM and admission glucose 200 mg/dL or more. Cox proportional hazards models [adjusted for age, sex, injury mechanism, and injury severity score] were used to calculate risk ratios (RRs) and associated 95% confidence intervals (CIs) for outcomes of interest. RESULTS: During the study period, 6852 trauma patients were evaluated, and 5117 had available glucose, HbA1c, and comorbidity data. Patients with SIH had an over twofold increase in mortality risk (RR 2.41, 95% CI 1.81-3.23), and patients with DH had a nonsignificant, near-50% increase in mortality risk (RR 1.47, 95% CI 0.92-2.36). Risk of pneumonia was similarly higher for both the DH (RR 1.49, 95% CI 1.03-2.17) and the SIH (RR 1.44, 95% CI 1.08-1.93). CONCLUSIONS: DM is common in patients with hyperglycemia after trauma. As opposed to DH, SIH is associated with higher mortality after trauma. Further research is warranted to identify mechanisms causing hyperglycemia and subsequent worse outcomes after trauma.

Pediatric obesity and traumatic lower-extremity long-bone fracture outcomes.

BACKGROUND: Pediatric obesity is associated with lower-extremity injuries and poor outcomes after blunt trauma. Our aim was to determine if obese pediatric patients with femur and tibia fractures have more severe injury patterns and worse outcomes compared with those of nonobese patients. METHODS: We performed a retrospective cohort study of obese and nonobese pediatric patients with femur or tibia fractures treated at two Level I trauma centers from 2004 to 2010. Patients weighing 95th percentile or greater for age and sex were classified as obese. Patients were compared regarding demographics, Injury Severity Score (ISS), as well as intra-abdominal and orthopedic injuries. Outcomes included fracture treatment, orthopedic complications, intensive care unit and hospital length of stay, ventilator days, and mortality. RESULTS: Of the 356 patients included in the study, 78 (21.9%) were obese and 278 (78.1%) were nonobese. Obese patients were older (mean [SD], 9.9 [3.7] years vs. 8.8 [3.9] years; p = 0.0162), had a higher ISS (20.8 [13.4] vs. 14.5 [10.8]; p = 0.0002), and sustained more intra-abdominal solid organ (24.4% vs.13.5%; p = 0.0200) and hollow viscus (3.9% vs. 0.0%; p = 0.0105) injuries. They had more pelvic fractures (15.4% vs. 6.9%; p = 0.0196), bilateral tibia fractures (8.0% vs. 0.0%; p = 0.0332), and operatively treated femur fractures (89.9% vs. 79.1%; p = 0.0484). Adjusting for age, obese patients were more likely to be admitted to the intensive care unit (relative risk, 1.68; 95% confidence interval, 1.10-2.55) and die in the hospital (relative risk, 3.45; 95% confidence interval, 1.14-10.41). Adjusting for ISS, these associations were nonsignificant. CONCLUSION: Obese patients with femur and tibia fractures have more severe injuries, which may predispose them to greater inpatient morbidity and mortality than do nonobese patients. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Microvascular response to red blood cell transfusion in trauma patients.

Trauma patients are often transfused allogeneic red blood cells (RBCs) in an effort to augment tissue oxygen delivery. However, the effect of RBC transfusion on microvascular perfusion in this patient population is not well understood. To this end, we investigated the effect of RBC transfusion on sublingual microvascular perfusion in trauma patients. Sublingual microcirculation was imaged at bedside with a sidestream dark-field illumination microscope before and after transfusion of one RBC unit in hemodynamically stable, anemic trauma patients. The perfused proportion of capillaries (PPC) before and after transfusion was determined, and the percent change in capillary perfusion following transfusion (ΔPPC) calculated. Sublingual microcirculation was observed in 30 patients. Mean age was 47 (SD, 21) years, mean Injury Severity Score was 29 (SD, 16), and mean pretransfusion hemoglobin was 7.5 (SD, 0.9) g/dL. No patients had a mean arterial pressure of less than 65 mmHg (mean, 89 [SD, 17] mmHg) or lactate of greater than 2.5 mmol/L (mean, 1.1 [SD, 0.3] mmol/L). Following transfusion, ΔPPC ranged from +68% to -36% and was found to inversely correlate significantly with pretransfusion PPC (Spearman r = -0.63, P = 0.0002). Pretransfusion PPC may be selectively deranged in otherwise stable trauma patients. Patients with relatively altered baseline PPC tend to demonstrate improvement in perfusion following transfusion, whereas those with relatively normal perfusion at baseline tend to demonstrate either no change or, in fact, a decline in PPC. Bedside sublingual imaging may have the potential to detect subtle perfusion defects and ultimately inform clinical decision making with respect to transfusion.

Intubation patterns and outcomes in patients with computed tomography-verified traumatic brain injury.

BACKGROUND: Studies evaluating traumatic brain injury (TBI) patients have shown an association between prehospital (PH) intubation and worse outcomes. However, previous studies have used surrogates, e.g., Glasgow Coma Scale (GCS) score ≤8 and Abbreviated Injury Severity Scale (AIS) score ≥3, which may overestimate the true presence of TBI. This study evaluated the impact of PH intubation in patients with PH GCS score ≤8 and radiographically proven TBI. METHODS: Trauma patients routed to a Level I trauma center over a 3-year period with blunt injury and PH GCS score ≤8 were included. PH and in-hospital records were linked and head computed tomography scans were assigned a Marshall Score (MS). Patients with TBI (MS >1) were categorized into groups based on intubation status (PH, emergency department [ED], and no intubation). Comparisons were made using analysis of variance and χ statistics. Mortality differences, crude and adjusted risk ratios (RRs), and 95% confidence intervals (CIs) were calculated using proportions hazards modeling. RESULTS: Of 334 patients with PH GCS score ≤8, 149 (50%) had TBI by MS. Among the TBI patients, 42.7% of patients were PH intubated, 47.7% were ED intubated, and 9.4% were not intubated during the initial resuscitation. Intubated patients had lower ED GCS score (PH: 4.1 and ED: 5.9 vs. 14.0; p < 0.0001) compared with patients not intubated. Also PH intubated patients had higher mean Injury Severity Score (38.0 vs. 33.7 vs. 23.5, p < 0.001) when compared with ED intubated and nonintubated patients. None of the nonintubated patients had a MS >2. Mortality for TBI patients who required PH intubation was 46.9% and 41.4% among ED-intubated patients. The crude RR of mortality for PH compared with ED intubation was 1.13 (95% CI, 0.68-1.89), and remained nonsignificant (RR, 0.68; 95% CI, 0.36-1.19) when adjusted for key markers of injury severity. CONCLUSIONS: Patients with PH GCS score ≤8 and proven TBI had a high overall rate of intubation (>90%). PH intubation seems to be a marker for more severe injury and conveyed no increased risk for mortality over ED intubation.

Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index.

BACKGROUND: In the prehospital environment, the failure of medical providers to recognize latent physiologic derangement in patients with compensated shock may risk undertriage. We hypothesized that the shock index (SI; heart rate divided by systolic blood pressure [SBP]), when used in the prehospital setting, could facilitate the identification of such patients. The objective of this study was to assess the association between the prehospital SI and the risk of massive transfusion (MT) in relatively normotensive blunt trauma patients. METHODS: Admissions to a Level I trauma center between January 2000 and October 2008 with blunt mechanism of injury and prehospital SBP>90 mm Hg were identified. Patients were categorized by SI, calculated for each patient from prehospital vital signs. Risk ratios (RRs) and 95% confidence intervals (CI) for requiring MT (>10 red blood cell units within 24 hours of admission) were calculated using SI>0.5 to 0.7 (normal range) as the referent for all comparisons. RESULTS: A total of 8,111 patients were identified, of whom 276 (3.4%) received MT. Compared with patients with normal SI, there was no significant increased risk for MT for patients with a SI of ≤0.5 (RR, 1.41; 95% CI, 0.90-2.21) or>0.7 to 0.9 (RR, 1.06; 95% CI, 0.77-1.45). However, a significantly increased risk for MT was observed for patients with SI>0.9. Specifically, patients with SI>0.9 to 1.1 were observed to have a 1.5-fold increased risk for MT (RR, 1.61; 95% CI, 1.13-2.31). Further increases in SI were associated with incrementally higher risks for MT, with an more than fivefold increase in patients with SI>1.1 to 1.3 (RR, 5.57; 95% CI, 3.74-8.30) and an eightfold risk in patients with SI>1.3 (RR, 8.13; 95% CI, 4.60-14.36). CONCLUSION: Prehospital SI>0.9 identifies patients at risk for MT who would otherwise be considered relatively normotensive under current prehospital triage protocols. The risk for MT rises substantially with elevation of SI above this level. Further evaluation of SI in the context of trauma system triage protocols is warranted to analyze whether it triage precision might be augmented among blunt trauma patients with SBP>90 mm Hg.

Prospective identification of patients at risk for massive transfusion: an imprecise endeavor.

Most retrospective studies evaluating fresh-frozen plasma:packed red blood cell ratios in trauma patients requiring massive transfusion (MT) are limited by survival bias. As prospective resource-intensive studies are being designed to better evaluate resuscitation strategies, it is imperative that patients with a high likelihood of MT are identified early. The objective of this study was to develop a predictive model for MT in civilian trauma patients. Patients admitted to the University of Alabama at Birmingham Trauma Center from January 2005 to December 2007 were selected. Admission clinical measurements, including blood lactate 5 mMol/L or greater, heart rate greater than 105 beats/min, international normalized ratio greater than 1.5, hemoglobin 11 g/dL or less, and systolic blood pressure less than 110 mmHg, were used to create a predictive model. Sensitivity (Sens), specificity (Spec), positive predictive value (PPV), and negative predictive value (NPV) were calculated for all possible combinations of clinical measurements as well as each measure individually. A total of 6638 patients were identified, of whom 158 (2.4%) received MT. The best-fit predictive model included three or more positive clinical measures (Sens: 53%, Spec: 98%, PPV: 33%, NPV: 99%). There was increased PPV when all clinical measurements were positive (Sens: 9%, Spec: 100%, PPV: 86%, NPV: 98%). All combinations or clinical measures alone yielded lower predictive probability. Using these emergency department clinical measures, a predictive model to successfully identify civilian trauma patients at risk for MT was not able to be constructed. Given prospective identification of patients at risk for MT remains an imprecise undertaking, appropriate resources to support these efforts will need to be allocated for the completion of these studies.

Duration of red cell storage influences mortality after trauma.

BACKGROUND: Although previous studies have identified an association between the transfusion of relatively older red blood cells (RBCs) (storage ≥ 14 days) and adverse outcomes, they are difficult to interpret because the majority of patients received a combination of old and fresh RBC units. To overcome this limitation, we compared in-hospital mortality among patients who received exclusively old versus fresh RBC units during the first 24 hours of hospitalization. METHODS: Patients admitted to a Level I trauma center between January 2000 and May 2009 who received ≥ 1 unit of exclusively old (≥ 14 days) vs. fresh (< 14 days) RBCs during the first 24 hours of hospitalization were identified. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for the association between mortality and RBC age, adjusted for patient age, Injury Severity Score, gender, receipt of fresh frozen plasma or platelets, RBC volume, brain injury, and injury mechanism (blunt or penetrating). RESULTS: One thousand six hundred forty-seven patients met the study inclusion criteria. Among patients who were transfused 1 or 2 RBC units, no difference in mortality with respect to RBC age was identified (adjusted RR, 0.97; 95% CI, 0.72-1.32). Among patients who were transfused 3 or more RBC units, receipt of old versus fresh RBCs was associated with a significantly increased risk of mortality, with an adjusted RR of 1.57 (95% CI, 1.14-2.15). No difference was observed concerning the mean number of old versus fresh units transfused to patients who received 3 or more units (6.05 vs. 5.47, respectively; p = 0.11). CONCLUSION: In trauma patients undergoing transfusion of 3 or more RBC units within 24 hour of hospital arrival, receipt of relatively older blood was associated with a significantly increased mortality risk. Reservation of relatively fresh RBC units for the acutely injured may be advisable.

Computed tomography identification of latent pseudoaneurysm after blunt splenic injury: pathology or technology?

BACKGROUND: Serial computed tomography (CT) imaging of blunt splenic injury can identify the latent formation of splenic artery pseudoaneurysms (PSAs), potentially contributing to improved success in nonoperative management. However, it remains unclear whether the delayed appearance of such PSAs is truly pathophysiologic or attributable to imaging quality and timing. The objective of this study was to evaluate the influence of recent advancements in imaging technology on the incidence of the latent PSA. METHODS: Consecutive patients with blunt splenic injury over 4.5 years were identified from our trauma registry. Follow-up CT was performed for all but low-grade injuries 24 hours to 48 hours after initial CT. Incidences of both early and latent PSA formation were reviewed and compared with respect to imaging technology (4-slice vs. >or=16-slice). RESULTS: A total of 411 patients were selected for nonoperative management of blunt splenic injury. Of these, 135 had imaging performed with 4-slice CT, and 276 had imaging performed with CTs of >=16-slice. Mean follow-up was 75 days (range, 1-1178 days) and 362 patients (88%) had follow-up beyond 7 days. Comparing 4-slice CT with >or=16-slice CT, there were no significant differences in the incidence of early PSA (3.7% vs. 4.7%; p = 0.91) or latent PSA (2.2% vs. 2.9%; p = 0.90). In both groups, latent PSAs accounted for approximately 38% of all PSAs observed. Splenic injury grade on initial CT was not associated with latent PSA (p = 0.54). Overall, the failure rate of nonoperative management was 7.3%. Overall mortality was 4.6%. No mortalities were related to splenic or other intra-abdominal injury. CONCLUSIONS: The incidences of both early and latent PSA have remained remarkably stable despite advances in CT technology. This suggests that latent PSA is not a result of imaging technique but perhaps a true pathophysiologic phenomenon. Injury grade is unhelpful concerning the prediction of latent PSA formation.

Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage?

BACKGROUND: Standard hemodynamic evaluation of patients in shock may underestimate severity of hemorrhage given physiologic compensation. Blood lactate (BL) is an important adjunct in characterizing shock, and point-of-care devices are currently available for use in the prehospital (PH) setting. The objective of this study was to determine if BL levels have better predictive value when compared with systolic blood pressure (SBP) for identifying patients with an elevated risk of significant transfusion and mortality in a hemodynamically indeterminant cohort. STUDY DESIGN: We selected trauma patients admitted to a level I trauma center over a 9-year period with SBP between 90 and 110 mmHg. The predictive capability of initial emergency department (ED) BL for needing > or =6 units packed RBCs within 24 hours postinjury and mortality was compared with PH-SBP and ED-SBP by comparing estimated area under the receiver operator curve (AUC). RESULTS: We identified 2,413 patients with ED-SBP and 787 patients with PH-SBP and ED-BL. ED-BL was statistically better than PH-SBP (p = 0.0025) and ED-SBP (p < 0.0001) in predicting patients who will need > or = 6 U packed RBCs within 24 hours postinjury (AUC: ED-BL, 0.72 vs PH-SBP, 0.61; ED-BL, 0.76 vs ED-SBP, 0.60). ED-BL was also a better predictor than both PH-SBP (p = 0.0235) and ED-SBP (p < 0.0001) for mortality (AUC: ED-BL, 0.74 vs PH-SBP, 0.60; ED-BL, 0.76 vs ED-SBP, 0.61). CONCLUSIONS: ED-BL is a better predictor than SBP in identifying patients requiring significant transfusion and mortality in this cohort with indeterminant SBP. These findings suggest that point-of-care BL measurements could improve trauma triage and better identify patients for enrollment in interventional trials. Further studies using BL measurement in the PH environment are warranted.

Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients.

BACKGROUND: Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population. METHODS: Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months. RESULTS: As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths. CONCLUSIONS: Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.

A comparison of wakeboard-, water skiing-, and tubing-related injuries in the United States, 2000-2007.

The purpose of the study was to compare tubing-related injuries to wakeboarding- and water skiing-related injuries. Data was collected from the 2000-2007 National Electronic Injury Surveillance Survey for 1,761 individuals seeking care at an emergency department due to a tubing-, wakeboarding, or water skiing-related injury. Data included patient age and sex, as well as injury characteristics including body region injured (i.e., head and neck, trunk, shoulder and upper extremity, and hip and lower extremity) and diagnosis of injury (e.g., contusion, laceration, or fracture). Case narratives were reviewed to ensure that a tubing-, wakeboarding-, or water skiing-related injury occurred while the individual was being towed behind a boat. Severe injury (defined as an injury resulting in the individual being hospitalized, transferred, held for observation) was compared among the groups using logistic regression. Wakeboard- and tubing-related injuries more commonly involved the head and neck, while water skiing- related injuries were likely to involve the hip and lower extremity. Tubing-related injuries, compared to water skiing-related injuries, were more likely to be severe (OR 2.31, 95% CI 1.23-4. 33). Like wakeboarding and water skiing, tubing has inherent risks that must be understood by the participant. While tubing is generally considered a safer alternative to wakeboarding and water skiing, the results of the current study suggest otherwise. Both the number and severity of tubing- related injuries could be prevented through means such as advocating the use of protective wear such as helmets while riding a tube or having recommended safe towing speeds prominently placed on inner tubes. Key pointsIncrease annual injury rate trend in wakeboard injuries.Wakeboard- and tubing-related injuries more often to head and neck, waterskiing-related injuries more often to hip and lower extremity.Tubing-related injuries over 2-times as likely to be severe compared to waterskiing-related injuries.

Epidemiology of tree stand-related injuries in the United States from 2000 to 2007.

BACKGROUND: : Tree stands have remained popular among hunters because of the increased vantage point for the hunter. Although stand styles vary, the typical stand is very minimalistic in design, comprising a seat and an area for the hunter to place his feet. Although there have been studies using state trauma registry data, to date, there has not been a study on the epidemiology of tree stand-related injuries in the national population. METHODS: : The 2000 to 2007 National Electronic Surveillance System provided information among individuals aged 16 years and older regarding tree stand-related injuries that required emergency room attention in the United States. Hunter population estimates from the U.S. Fish and Wildlife Services were used to estimates injury rates by sex, age, race, month, and year. RESULTS: : The rate of tree stand-related injuries remained relatively stable from 2000 to 2007. Rates were higher for men compared with women (48.0 vs. 24.7 per 100,000 hunters, respectively) and highest among those 15 to 24 (55.7 per 100,000) and 25 to 34 (61.0 per 100,000). CONCLUSIONS: : Although a majority of hunters are older, the highest rates occurred among the younger ones. Hunters using and manufacturers of tree stands must be aware of the safety precautions during use of the stands. Improvements in the safety design of the stands as well as knowledge to the proper use of stands can help to minimize the burden of injury in the hunter population related to tree stands.

Management of colon wounds in the setting of damage control laparotomy: a cautionary tale.

BACKGROUND: Although colon wounds are commonly treated in the setting of damage control laparotomy (DCL), a paucity of data exist to guide management. The purpose of this study was to evaluate our experience with the management of colonic wounds in the context of DCL, using colonic wound outcomes after routine, single laparotomy (SL) as a benchmark. METHODS: Consecutive patients during a 7-year period with full-thickness or devitalizing colon injury were identified. Early deaths (<48 hour) were excluded. Colon-related complications (abscess, suture or staple leak, and stomal ischemia) were compared between those managed in the setting of DCL versus those managed by SL, both overall and as stratified by procedure (primary repair, resection and anastomosis, and resection and colostomy). RESULTS: One hundred fifty-seven patients met study criteria: 101 had undergone SL and 56 had undergone DCL. Comparison of DCL patients with SL patients was notable for a significant difference in colon-related complications (30% vs. 12%, p < 0.005) and suture/staple leak in particular (12% vs. 3%, p < 0.05). Stratification by procedure revealed a significant difference in colon-related complications among those that underwent resection and anastomosis (DCL: 39% vs. SL: 18%, p < 0.05), whereas no differences were observed in those who underwent primary repair or resection and colostomy. CONCLUSIONS: Management of colonic wounds in the setting of DCL is associated with a relatively high incidence of complications. The excessive incidence of leak overall and morbidity particular to resection and anastomosis, however, give us pause. Although stoma construction is not without its own complications in the setting of DCL, it may be the safer alternative.

Blood utilization at a level I trauma center: is this as good as it gets?

Recognition of the adverse effects of allogeneic blood resulted in the decreased use of red blood cell (RBC) transfusion in surgical practice in the 1990s. Our objective was to evaluate patterns of RBC transfusion utilization among trauma patients during the current decade. Blunt trauma patients admitted to a regional trauma center between 2000 and 2007 were identified (n = 16,011). Annual trends in RBC utilization were estimated (negative binomial regression for continuous dependent variables and logistic regression for dichotomous variables). Models were stratified by Injury Severity Score to adjust for injury severity. Although the proportion of patients receiving a blood transfusion within 48 hours of hospitalization significantly increased (P < 0.0001), there was no significant change in the rate of units transfused (P = 0.5152) among transfused patients. After stratification by Injury Severity Score, a significantly decreasing trend in the proportion of severely injured patients transfused was observed (P = 0.0243). Annual variation in the relatively less injured groups was not significant. In the current decade, transfusion utilization at a Level I trauma center has demonstrated minimal variation on a year-to-year basis. Among the severely injured, the temporal decrease in relatively early utilization of RBC transfusion may reflect increasing inclination to accept a greater degree of anemia in higher acuity patients.