Early surgical intervention and its impact on patients presenting with necrotizing soft tissue infections: A single academic center experience.

OBJECTIVES: Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. We aimed to study the effect of early surgery on patients' outcomes and, in particular, on hospital length of stay (LOS) and Intensive Care Unit (ICU) LOS. MATERIALS AND METHODS: Over a 6-year period (January 2003 through December 2008), we analyzed the records of patients with NSTIs. We divided patients into two groups based on the time of surgery (i.e., the interval from being diagnosed and surgical intervention): Early (<6 h) and late (≥6 h) intervention groups. For these two groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student's t-test and Pearson Chi-square (χ(2)) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis. RESULTS: In the study population (n = 87; 62% males and 38% females), age, gender, wound locations, and comorbidities were comparable in the two groups. Except for higher proportion of crepitus, the clinical presentations showed no significant differences between the two groups. There were significantly shorter hospital LOS and ICU LOS in the early than late intervention group. The overall mortality rate in our study patients with NSTIs was 12.5%, but early intervention group had a mortality of 7.5%, but this did not reach statistical significance. CONCLUSIONS: Our findings show that early surgery, within the first 6 h after being diagnosed, improves in-hospital outcomes in patients with NSTIs.

Repeat head computed tomography in anticoagulated traumatic brain injury patients: still warranted.

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neurosurgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ(2) and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older (P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission (P < 0.001), were more likely to present with an abnormal neurologic examination (P = 0.004), and had higher hospital and intensive care unit lengths of stay (P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

Modified Veress needle decompression of tension pneumothorax: a randomized crossover animal study.

BACKGROUND: The current prehospital standard of care using a large bore intravenous catheter for tension pneumothorax (tPTX) decompression is associated with a high failure rate. We developed a modified Veress needle (mVN) for this condition. The purpose of this study was to evaluate the effectiveness and safety of the mVN as compared with a 14-gauge needle thoracostomy (NT) in a swine tPTX model. METHODS: tPTX was created in 16 adult swine via thoracic CO2 insufflation to 15 mm Hg. After tension physiology was achieved, defined as a 50% reduction of cardiac output, the swine were randomized to undergo either mVN or NT decompression. Failure to restore 80% baseline systolic blood pressure within 5 minutes resulted in crossover to the alternate device. The success rate of each device, death, and need for crossover were analyzed using χ. RESULTS: Forty-three tension events were created in 16 swine (24 mVN, 19 NT) at 15 mm Hg of intrathoracic pressure with a mean CO2 volume of 3.8 L. tPTX resulted in a 48% decline of systolic blood pressure from baseline and 73% decline of cardiac output, and 42% had equalization of central venous pressure with pulmonary capillary wedge pressure. All tension events randomized to mVN were successfully rescued within a mean (SD) of 70 (86) seconds. NT resulted in four successful decompressions (21%) within a mean (SD) of 157 (96) seconds. Four swine (21%) died within 5 minutes of NT decompression. The persistent tension events where the swine survived past 5 minutes (11 of 19 NTs) underwent crossover mVN decompression, yielding 100% rescue. Neither the mVN nor the NT was associated with inadvertent injuries to the viscera. CONCLUSION: Thoracic insufflation produced a reliable and highly reproducible model of tPTX. The mVN is vastly superior to NT for effective and safe tPTX decompression and physiologic recovery. Further research should be invested in the mVN for device refinement and replacement of NT in the field.

Contemporary acute care surgery percutaneous endoscopic gastrostomy tube placement: an extreme bumper height and complications.

BACKGROUND: As the role of acute care surgery (ACS) becomes more prevalent, clinicians in this specialty will be placing more percutaneous endoscopic gastrostomy (PEG) tubes. In this contemporary series of ACS PEG procedures, we hypothesized that technical aspects of PEG tube placement may play an important role. METHODS: For our retrospective study, we queried our tertiary Level I trauma center's prospectively maintained ACS database for PEG tube placement. Our study period was from July 1, 2010, through June 30, 2012. We excluded patients who underwent "push" PEG placement, an outpatient PEG tube placement, or an open or laparoscopic gastrostomy tube operation. We conducted a multivariate logistic regression analysis of factors contributing to complications. RESULTS: During our 24-month study period, of 184 patients, 133 underwent "pull" PEG tube placement with sufficient data for analysis. The mean (SD) age was 56 (22) years; 66% were male. Overall, 33 (25%) experienced complications: 13 (10%) were major and 20 (15%) were minor complications. In our multivariate logistic regression analysis, we found that an extreme bumper height (<2 or >5 cm) (odds ratio, 1.57; 95% confidence interval, 1.14-2.16) and upper aerodigestive tract malignancy as the operative indication (odds ratio, 1.54; 95% confidence interval, 1.06-2.26) were significantly associated with complications. CONCLUSION: Although pull PEG tube placement is typically a straightforward procedure, morbidity can be significant. Bumper height is an easily modifiable variable; obtaining the proper height for each patient could decrease complications after PEG tube placement. LEVEL OF EVIDENCE: Therapeutic study, level IV.

14 French pigtail catheters placed by surgeons to drain blood on trauma patients: is 14-Fr too small?

BACKGROUND: Small 14F pigtail catheters (PCs) have been shown to drain air quite well in patients with traumatic pneumothorax (PTX). But their effectiveness in draining blood in patients with traumatic hemothorax (HTX) or hemopneumothorax (HPTX) is unknown. We hypothesized that 14F PCs can drain blood as well as large-bore 32F to 40F chest tubes. We herein report our early case series experience with PCs in the management of traumatic HTX and HPTX. METHODS: We prospectively collected data on all bedside-inserted PCs in patients with traumatic HTX or HPTX during a 30-month period (July 2009 through December 2011) at our Level I trauma center. We then compared our PC prospective data with our trauma registry-derived retrospective chest tube data (January 2008 through December 2010) at our center. Our primary outcome of interest was the initial drainage output. Our secondary outcomes were tube duration, insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t-test, χ test, and Wilcoxon rank-sum test; we defined significance by a value of p < 0.05. RESULTS: A total of 36 patients received PCs, and 191 received chest tubes. Our PC group had a higher rate of blunt mechanism injuries than our chest tube group did (83 vs. 62%; p = 0.01). The mean initial output was similar between our PC group (560 ± 81 mL) and our chest tube group (426 ± 37 mL) (p = 0.13). In the PC group, the tube was inserted later (median, Day 1; interquartile range, Days 0-3) than the tube inserted in our chest tube group (median, Day 0; interquartile range, Days 0-0) (p < 0.001). Tube duration, rate of insertion-related complications, and failure rate were all similar. CONCLUSION: In our early experience, 14F PCs seemed to drain blood as well as large-bore chest tubes based on initial drainage output and other outcomes studied. In this early phase, we were being selective in inserting PCs in only stable blunt trauma patients, and PCs were inserted at a later day from the time of the initial evaluation. In the future, we will need a larger sample size and possibly a well-designed prospective study. LEVEL OF EVIDENCE: Therapeutic study, level V.

A prospective cohort study of 200 acute care gallbladder surgeries: the same disease but a different approach.

BACKGROUND: For patients who present to the emergency department (ED) with symptomatic cholelithiasis, surgery is indicated only if they are diagnosed of acute cholecystitis (AC). We hypothesized that, because preoperative signs and diagnostic tests are not sensitive enough to diagnose AC, coupled with the potential health care burden of non-AC gallbladder, surgery may be offered sooner. METHODS: We prospectively evaluated 200 patients who presented to ED with clinical suspicion of gallbladder disease, including a right upper quadrant/epigastric abdominal pain and cholelithiasis, and who underwent laparoscopic cholecystectomy. We correlated the preoperative clinical findings, including ultrasonography results, with the surgeon's intraoperative assessment (OR-GB) and with the pathology report (PA-GB). A multiple logistic regression model was performed. RESULTS: Of the gallbladders, 116 were declared AC by OR-GB but only 54 by PA-GB, (r = 0.31, p < 0.001). The median time to surgery was 17 hours; 75% of the patients underwent surgery within 24 hours. The sensitivity of ultrasonography for AC according to PA-GB was 38%, and 16% when combined all preoperative findings. Both figures dropped to 27% and 11% when correlated to OR-GB. Our regression identified persistent abdominal pain, positive ultrasonography result, and a body mass index of greater than 40 to be significant predictors of AC according to PA-GB; however, only the persistent abdominal pain remained significant according to OR-GB. CONCLUSION: The study confirmed the lack of sensitivity of signs and diagnostic tools to diagnose AC. Because of the acute care surgery model, we believe that the approach to the patients who present to the ED with suspected gallbladder disease is to offer them surgery as soon as feasible, with or without AC. This approach will avoid an unnecessary delay as well as quickly relieve patient's pain and suffering; the health care system will benefit from a cost-effective reduction in number of outpatient referrals and repeated ED visits. LEVEL OF EVIDENCE: Diagnostic study, level II.

Sleep disruptions and nocturnal nursing interactions in the intensive care unit.

BACKGROUND: Sleep deprivation, common in intensive care unit (ICU) patients, may be associated with increased morbidity and/or mortality. We previously demonstrated that significant numbers of nocturnal nursing interactions (NNIs) occur during the routine care of surgical ICU patients. For this study, we assessed the quantity and type of NNIs in different ICU types: medical, surgical, cardiothoracic, pediatric, and neonatal. We hypothesized that the number and type of NNIs vary among different ICU types. MATERIAL AND METHODS: We performed a prospective observational cohort study at our academic medical center examining potential sleep disruption in ICU patients secondary to NNIs from the hours 2200-0600 nightly. From May through November 2011, bedside nursing staff in five different ICUs collected data on NNIs, including the frequency and nature of each event (patient care activity, nursing intervention, nursing assessment, or patient-initiated contact) as well as the length of time of each event and whether the bedside care provider thought that the event could have been safely omitted without negatively affecting patient care. Additional data collected included patient demographics, the need for mechanical ventilation, and sedative/narcotic use. RESULTS: Two hundred ICU patients were enrolled over 51 separate nocturnal time periods (3.9 patients/nocturnal time period). Of those 200 patients, 53 (26.5%) were mechanically ventilated; 12.5% underwent sedative infusion; and 23.0% underwent narcotic infusion. There were a total of 1831 NNIs; most (67%) were due to nursing assessment or patient care activity. The surgical ICU had the most frequent NNIs (11.8 ± 9.0), although they were the shortest (6.66 ± 6.06 min), as well as the highest proportion of NNIs that could have been safely omitted (20.9%). Nursing staff estimated that, of all NNIs in all ICU types, 13.9% could have been safely omitted. CONCLUSIONS: NNIs occur frequently and vary across different ICU types. Many NNIs are due to nursing assessment and patient care activities, much of which could be safely omitted or clustered. A protocol for nocturnal sleep promotion is warranted in order to standardize ICU NNIs and minimize nighttime sleep disruptions.

Pediatric all-terrain vehicle trauma: the epidemic continues unabated.

OBJECTIVES: The popularity of all-terrain vehicles (ATVs) continues to increase, but this form of recreation is not as well regulated and can impact children disproportionately. This study examines the epidemiology of ATV injuries in Arizona with emphasis on pediatric injuries and compares ATV injuries to those associated with motorcycle (MCC) and motor vehicle crashes (MVC). METHODS: The trauma registry of a level 1 trauma center was used to identify all ATV crashes during a 5-year period (2004-2008) in patients younger than 16 years. Registration data of ATV were obtained from the state DMV. All-terrain vehicle-related injuries were compared with both MVC and MCC. RESULTS: A total of 250 pediatric ATV crashes were observed during the 5-year period, rising from 29 in 2004 to 53 in 2008. The median age of patients with ATV-related injuries was 13 years, which is higher than that of patients with MVC-related injuries (9 years). Only 34% of the patients with ATV-related injuries were helmeted, compared with 55% of patients with MCC-related injuries. All-terrain vehicle-related crashes were at least 30 times more likely than MVCs and almost 20 times more likely than MCCs. Statewide pediatric ATV deaths rose during the study period. CONCLUSIONS: All-terrain vehicle-related crashes have increased during this study period and have become a significant source of injuries. Public education and awareness of the dangers associated with ATV use need to be targeted toward both parents and children likely to use ATVs.

Treatment of severe hemolytic anemia caused by Clostridium perfringens sepsis in a liver transplant recipient.

BACKGROUND: Clostridium perfringens bacteremia accompanied by extensive intravascular hemolysis is an almost inescapably fatal infection. METHODS: Case report and literature review. RESULTS: A 52-year-old man with a recent history of liver transplantation developed sepsis and severe hemolytic anemia. The patient had multiple organ dysfunction syndrome and required aggressive transfusion, antibiotics, and continuous hemodialysis. Blood cultures grew C. perfringens. With appropriate resuscitation and antibiotic treatment, the patient had a complete, although complicated recovery. CONCLUSION: This is the first reported case of a liver transplant patient developing fulminant C. perfringens sepsis with hemolysis. This infection usually kills patients within hours of presentation. Early recognition and aggressive treatment is necessary to avoid this outcome.

Incidence and pattern of cervical spine injury in blunt assault: it is not how they are hit, but how they fall.

BACKGROUND: The injury mechanism of blunt cervical spine injury (CSI) involves two forces: (1) an acceleration-deceleration force or change in velocity (delta v) that causes significant head and neck movement, resulting in flexion-extension injury pattern and (2) a direct force to the head or face against an immovable object with force transmitted down the cervical spine. Combining those two forces creates what bioengineers call imparted energy (IE). In blunt assault to the head or face, IE is low; hence, the reported incidence of CSI is low. The goal of our study was to identify the incidence, pattern, and outcome of CSI in blunt assaulted patients. METHOD: We queried the trauma registry at our Level I trauma center for patients admitted with the diagnosis of blunt assault over a 5-year period (2005-2009). Patients with CSI were identified by International Classification Diagnosis (Ninth Revision) codes of 805, 806, 839, or 952. We only included the patients who received the blow to the head and face. For eligible patients, we extracted data from trauma registry and inpatient chart review, including radiographic reports. A single author (N.K.) reviewed computed tomography (CT) scan of all individuals with CSI. We performed summary and Spearman rank correlation statistical analysis with p value <0.05 considered significant. RESULTS: During the study period, 1,335 patients met our study inclusion criteria. All underwent CT of the head, cervical spine, and/or face. CSI was suspected in 78 patients; however, 65 had normal CT results and were diagnosed instead with a cervical sprain. Of the remaining 13 patients, two had a herniated disc, two had spinal stenosis, and nine had a fracture or dislocation, yielding a CSI incidence of 0.7%. We found no correlation between an increased incidence of CSI and either severe head trauma (low Glasgow Coma Scale [GCS] score) (r = -0.02, p = 0.58) or severe facial trauma (high face Abbreviated Injury Scale score [f-AIS]) (r = 0.02, p = 0.59). Three patients had significant subluxation; only two had associated spinal cord injury (SCI). All three required surgical fusion, and all three reported a fall after assault without significant head or face trauma. CONCLUSION: The incidence of CSI after blunt assault is very low, and the pattern of injury and severity is related to a fall occurring after the assault. Our results should encourage clinicians to find out if patient falls after the assault.

Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture--update and systematic review.

BACKGROUND: Hemorrhage from pelvic fracture is common in victims of blunt traumatic injury. In 2001, the Eastern Association for the Surgery of Trauma (EAST) published practice management guidelines for the management of hemorrhage in pelvic trauma. Since that time there have been new practice patterns and larger experiences with older techniques. The Practice Guidelines Committee of EAST decided to replace the 2001 guidelines with an updated guideline and systematic review reflecting current practice. METHODS: Building on the previous systematic literature review in the 2001 EAST guidelines, a systematic literature review was performed to include references from 1999 to 2010. Prospective and retrospective studies were included. Reviews and case reports were excluded. Of the 1,432 articles identified, 50 were selected as meeting criteria. Nine Trauma Surgeons, an Interventional Radiologist, and an Orthopedic Surgeon reviewed the articles. The EAST primer was used to grade the evidence. RESULTS: Six questions regarding hemorrhage from pelvic fracture were addressed: (1) Which patients with hemodynamically unstable pelvic fractures warrant early external mechanical stabilization? (2) Which patients require emergent angiography? (3) What is the best test to exclude extrapelvic bleeding? (4) Are there radiologic findings which predict hemorrhage? (5) What is the role of noninvasive temporary external fixation devices? and (6) Which patients warrant preperitoneal packing? CONCLUSIONS: Hemorrhage due to pelvic fracture remains a major cause of morbidity and mortality in the trauma patient. Strong recommendations were made regarding questions 1 to 4. Further study is needed to answer questions 5 and 6.

Two-year experience of using pigtail catheters to treat traumatic pneumothorax: a changing trend.

BACKGROUND: The traditional treatment of patients with traumatic hemopneumothorax has been an insertion of a chest tube (CT). But CT, because of its large caliber and significant trauma during an insertion, can cause pain, prevent full lung expansion, and worsen pulmonary outcome. Pigtail catheters (PCs) are smaller and less invasive; they have worked well in patients with nontraumatic pneumothorax (PTX). The purpose of this study was to review our early experience of PC use in trauma patients. METHODS: We retrospectively reviewed the charts of trauma patients who required CT or PC placement over a 2-year period (January 2008 through December 2009) at a Level I trauma center. The PCs were 14-French (14-F) Cook catheters placed by the trauma team, using a Seldinger technique. We compared outcome for the subgroups that had CT or PC placed for a PTX. For our statistical analysis, we used the unpaired Student t-test, χ(2) test, and Wilcoxon rank-sum test; we considered a p value < 0.05 as significant. RESULTS: Of 9,624 trauma patients evaluated, 94 were treated with PC and 386 with CT. Of the PC patients, 89% was inserted for PTX. When comparing patients with PC and CT inserted for PTX, demographics, tube days, need for mechanical ventilation, and insertion-related complications were similar. The tube failure rate, defined by a requirement for an additional tube or by recurrence that needed intervention, was higher in PC (11%) than in CT (4%) (p = 0.06), but the difference was not statistically significant. We observed a trend of increased PC use over time. CONCLUSION: PC is safe and can be performed at the bedside. It has a comparable efficacy to CT in patients with PTX. A prospective study is needed to determine the precise role of PC placement, including its indication, the associated tube-site pain, and any significant clinical advantages.

Nutrition in Trauma and Critically Ill Patients.

Despite significant improvements in the practice of metabolic support of critically ill patients in recent years, malnutrition continues to be common among surgical patients, adding significantly to complications, infections, length of stay, costs, and increased mortality. Furthermore, hypercatabolism is the major metabolic response after major trauma and emergency surgery, making this patient population a unique subgroup of critically ill patients vulnerable to further decline in nutritional status. Many questions have already been answered, such as whether critically ill patients should be fed, when they should be fed, and how nutrients should be delivered. What is not entirely clear is what we should feed critically ill patients at different phases of specific diseases and disorders, as well as whether or not we should enhance and/or modulate patients' immunity.

Initial experiences and outcomes of telepresence in the management of trauma and emergency surgical patients.

BACKGROUND: Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas. METHODS: A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center. RESULTS: A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of $19,698 per air transport or $2,055 per ground transport. CONCLUSIONS: The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care.

The effect of ACGME duty hour restrictions on operative continuity of care.

Resident work restrictions limit participation in operations that address problems created by a prior operation, because complications occur at any time. We compared resident and attending surgeon staffing of operative complications. We reviewed all complications that required a second operation reported at our Morbidity and Mortality Conference over 1 year, noting surgeons present, their postgraduate year level, and call shift. Comparisons were done using chi2. Of 142 cases, 39 involved a second operation. The same attending surgeon was present for both in 79 per cent of cases, whereas the same resident was present in only 44 per cent (P = 0.002). Postgraduate year 4 to 5 were less likely to be present for second operations than attendings (48% vs 87%, P = 0.011). Resident shift (day, night float, and weekend) was known in 32 cases. When the first operation occurred during day hours, attendings and residents were equally likely to be present at the second (55% and 45%, P = 0.16). When original operations took place during night float or weekend shifts, residents were less likely to be present (33%) than attendings (83%) at second operations (P = 0.036). Duty hour restrictions interfere with operative continuity of care. Reoperations should be exempted from duty hour restrictions.

Impedance cardiography: a potential monitor for hemodialysis.

BACKGROUND: Impedance cardiography (ICG) technology has improved dramatically, and at least one device now can give a measurement of fluid status by using thoracic fluid content (TFC), along with cardiac output (CO) and cardiac index (CI). With a built-in sphygmomanometer cuff, it can also provide blood pressure (BP) and systemic vascular resistance index (SVRI). A currently available small portable ICG that provides reliable measures of fluid status could be an ideal noninvasive monitor for hemodialysis (HD), with the potential of helping avoid significant hemodynamic instability during HD. METHODS: A case series of patients with chronic renal failure was studied while undergoing HD using ICG (BioZ, CardioDynamics, Int. Corp., San Diego, CA). Parameters recorded at 15-min intervals included TFC, CI, BP (systolic, diastolic, and mean arterial), SVRI, and heart rate. Using the Pearson method, the percentage changes in each of the parameters during the HD session were correlated to the amount of fluid removed (FR), normalized to body weight. RESULTS: Forty-one patients were enrolled, but six patients were excluded due to incomplete data; therefore, 35 patients (13 men and 22 women) formed the basis of the analysis. The age range was 28 to 87 (mean 55.1 +/- 16.1) years. The amount of FR was 2.88 +/- 1.13 L (37.3 +/- 14.6 ml/kg). TFC decreased in all patients during the HD session (average reduction 12.7 +/- 8 kohms(-1)); whereas all other hemodynamic parameters showed both increases and decreases. The correlation of change in TFC with FR was moderate (r = 0.579, P = 0.0003); other hemodynamic parameters showed a poor correlation with FR. Neither the standard hemodynamic parameters nor the ICG device's special parameters were able to identify the five patients in this series who experienced significant hemodynamic instability or intradialytic hypotension. CONCLUSION: TFC, measured easily and noninvasively using ICG, correlates with the amount of fluid removed during HD. In comparison with the other hemodynamic parameters measured, TFC changed most consistently with fluid removal. Whether or not serial TFC measurements in a given patient at different HD sessions can guide the extent of FR will require additional study. This compact, easily operated, and nonobtrusive ICG device with the capability for continuously providing the standard hemodynamic parameters plus CO, TFC, and standard limb lead electrocardiography could replace current monitoring systems.