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OBJECTIVE: To determine the relationship between race/ethnicity and case volume among graduating surgical residents. BACKGROUND: Racial/ethnic minority individuals face barriers to entry and advancement in surgery; however, no large-scale investigations of the operative experience of racial/ethnic minority residents have been performed. METHODS: A multi-institutional retrospective analysis of the Accreditation Council for Graduate Medical Education case logs of categorical general surgery residents at 20 programs in the US Resident OPerative Experience Consortium database was performed. All residents graduating between 2010 and 2020 were included. The total, surgeon chief, surgeon junior, and teaching assistant case volumes were compared between racial/ethnic groups. RESULTS: The cohort included 1343 residents. There were 211 (15.7%) Asian, 65 (4.8%) Black, 73 (5.4%) Hispanic, 71 (5.3%) "Other" (Native American or Multiple Race), and 923 (68.7%) White residents. On adjusted analysis, Black residents performed 76 fewer total cases (95% CI, -109 to -43, P <0.001) and 69 fewer surgeon junior cases (-98 to -40, P <0.001) than White residents. Comparing adjusted total case volume by graduation year, both Black residents and White residents performed more cases over time; however, there was no difference in the rates of annual increase (10 versus 12 cases per year increase, respectively, P =0.769). Thus, differences in total case volume persisted over the study period. CONCLUSIONS: In this multi-institutional study, Black residents graduated with lower case volume than non-minority residents throughout the previous decade. Reduced operative learning opportunities may negatively impact professional advancement. Systemic interventions are needed to promote equitable operative experience and positive culture change.
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Cirurgia Geral , Internato e Residência , Humanos , Estudos Retrospectivos , Etnicidade , Competência Clínica , Grupos Minoritários , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educaçãoRESUMO
OBJECTIVE: To examine differences in resident operative experience between male and female general surgery residents. BACKGROUND: Despite increasing female representation in surgery, sex and gender disparities in residency experience continue to exist. The operative volume of male and female general surgery residents has not been compared on a multi-institutional level. METHODS: Demographic characteristics and case logs were obtained for categorical general surgery graduates between 2010 and 2020 from the US Resident OPerative Experience Consortium database. Univariable, multivariable, and linear regression analyses were performed to compare differences in operative experience between male and female residents. RESULTS: There were 1343 graduates from 20 Accreditation Council for Graduate Medical Education-accredited programs, and 476 (35%) were females. There were no differences in age, race/ethnicity, or proportion pursuing fellowship between groups. Female graduates were less likely to be high-volume residents (27% vs 36%, P < 0.01). On univariable analysis, female graduates performed fewer total cases than male graduates (1140 vs 1177, P < 0.01), largely due to a diminished surgeon junior experience (829 vs 863, P < 0.01). On adjusted multivariable analysis, female sex was negatively associated with being a high-volume resident (OR = 0.74, 95% CI: 0.56 to 0.98, P = 0.03). Over the 11-year study period, the annual total number of cases increased significantly for both groups, but female graduates (+16 cases/year) outpaced male graduates (+13 cases/year, P = 0.02). CONCLUSIONS: Female general surgery graduates performed significantly fewer cases than male graduates. Reassuringly, this gap in operative experience may be narrowing. Further interventions are warranted to promote equitable training opportunities that support and engage female residents.
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Cirurgia Geral , Internato e Residência , Cirurgiões , Humanos , Masculino , Feminino , Competência Clínica , Educação de Pós-Graduação em Medicina , Etnicidade , Cirurgia Geral/educaçãoRESUMO
INTRODUCTION: Utilizing a physician-reported survey, we assessed general surgeons (GS) comfort level in the management of bladder trauma, from a GS and urologist's perspective. MATERIALS AND METHODS: Online questionnaires were distributed electronically to physicians of the American College of Surgeons and American Urological Association. This survey queried demographic data, clinical factors that may influence urology consultations, and bladder injury scenarios of varying severities. Two questions were presented for each scenario, the first querying GS comfort level in bladder trauma management, the second assessing the likelihood of obtaining urology consultations in such scenarios. Responses were graded on a Likert scale. RESULTS: Overall, 108 (51%) GS and 104 (49%) urologists responded. When compared to managing Grade I injuries, the comfort level of GS decreased as the severity of bladder trauma increased, while the likelihood of obtaining a urology consultation increased. While the perceived comfort of GS by urologists decreased from 84% to 5% for Grade I to Grade V injuries, GS reported a significantly higher comfort level (Grade I: 92%, p = 0.09; Grade V: 31%, p < 0.001). Majority of GS indicated that preoperative diagnosis on imaging (56%), intraoperative diagnosis (62%), and timing of patient presentation (76%), did not affect their decision to consult urology for assistance in bladder trauma (p < 0.001). CONCLUSIONS: GS-reported comfort levels for bladder trauma management remains higher than urology-perceived comfort levels. Contrary to urologists' perception, most peri-injury factors did not affect GS decision to consult urology for bladder trauma. We hope this study can foster discussion and improve interdisciplinary collaboration in bladder trauma management.
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Cirurgiões , Urologia , Humanos , Padrões de Prática Médica , Encaminhamento e Consulta , Inquéritos e Questionários , Bexiga Urinária/lesões , Bexiga Urinária/cirurgia , Urologistas , Urologia/métodosRESUMO
Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients.
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Unidades de Terapia Intensiva , Cuidados Paliativos , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados Paliativos/métodos , Cuidados Paliativos/estatística & dados numéricos , Inquéritos e Questionários , Equipe de Assistência ao Paciente/estatística & dados numéricos , Equipe de Assistência ao Paciente/tendências , Equipe de Assistência ao Paciente/normas , Masculino , FemininoRESUMO
BACKGROUND: Prior analyses of general surgery resident case logs have indicated a decline in the number of endocrine procedures performed during residency. This study aimed to identify factors contributing to the endocrine operative experience of general surgery residents and compare those who matched in endocrine surgery fellowship with those who did not. METHODS: We analyzed the case log data of graduates from 18 general surgery residency programs in the US Resident Operative Experience Consortium over an 11-year period. RESULTS: Of the 1,240 residents we included, 17 (1%) matched into endocrine surgery fellowships. Those who matched treated more total endocrine cases, including more thyroid, parathyroid, and adrenal cases, than those who did not (81 vs 37, respectively, P < .01). Program-level factors associated with increased endocrine volume included endocrine-specific rotations (+10, confidence interval 8-12, P < .01), endocrine-trained faculty (+8, confidence interval 7-10, P < .01), and program co-location with otolaryngology residency (+5, confidence interval 2 -8, P < .01) or endocrine surgery fellowship (+4, confidence interval 2-6, P < .01). Factors associated with decreased endocrine volume included bottom 50th percentile in National Institute of Health funding (-10, confidence interval -12 to -8, P < .01) and endocrine-focused otolaryngologists (-3, confidence interval -4 to -1, P < .01). CONCLUSION: Several characteristics are associated with a robust endocrine experience and pursuit of an endocrine surgery fellowship. Modifiable factors include optimizing the recruitment of dedicated endocrine surgeons and the inclusion of endocrine surgery rotations in general surgery residency.
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Procedimentos Cirúrgicos Endócrinos , Cirurgia Geral , Internato e Residência , Cirurgiões , Humanos , Bolsas de Estudo , Cirurgia Geral/educação , Educação de Pós-Graduação em Medicina/métodos , Competência ClínicaRESUMO
Although palliative care focuses on supporting patients and families through serious illness, it is underutilized in the surgical intensive care unit (SICU). In 2020, patients in the SICU represented only 2.75% of our palliative team's consults. We hypothesize that utilization of palliative care triggers in the SICU will increase collaboration between SICU and palliative care teams and improve patient/family experiences. After reviewing our team's consultation records and the published literature, a consult trigger program was implemented for patients with a SICU length of stay >10 days, unplanned SICU readmission, or new diagnosis of metastatic cancer. A pre-intervention survey assessed SICU providers' perceptions of palliative care. Retrospective analysis evaluated qualitative and quantitative measures. 97% of SICU providers felt increased palliative care would be helpful. During the 6-month project, January 1, 2021 - June 30, 2021, our palliative team performed 27 triggered consults, representing 3.3% of the total 818 consults performed during this period and thus a 20% increase in SICU palliative consults. Triggered consults represented many primary surgical services and the most common consult reason was length-of-stay. All consults included discussions about goals of care and 16 of the 27 patients/families expressed restorative goals. Numerous notes documented family appreciation.
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Unidades de Terapia Intensiva , Cuidados Paliativos , Humanos , Estudos Retrospectivos , Estudos de Viabilidade , Cuidados CríticosRESUMO
OBJECTIVE: The objective of this study was to identify out-of-hospital cardiac arrest characteristics for patients treated by collegiate-based emergency medical services (CBEMS) organizations. PARTICIPANTS: CBEMS organizations provided data via the National Collegiate EMS Foundation Cardiac Arrest Data Registry. METHODS: CBEMS organization details, patient demographics, cardiac arrest characteristics and treatments, and prehospital outcomes for cases spanning October 2007 to May 2020 were analyzed with descriptive statistics. RESULTS: There were 65 OHCA entries. The majority were for male patients (82%) and a notable number of cases occurred in patients 45 years of age or younger (41%). Cases were frequently witnessed (71%) with high rates of bystander cardiopulmonary resuscitation (57%) and defibrillation (29%) prior to EMS arrival. Almost half of the patients (48%) had achieved return of spontaneous circulation until care was transferred to a provider of equal/higher level. CONCLUSIONS: CBEMS organizations may be well situated to respond rapidly to on-campus OHCAs.
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BACKGROUND: Direct to operating room resuscitation (DOR) is used by some trauma centers for severely injured trauma patients as an approach to minimize time to hemorrhage control. It is unknown whether this strategy results in favorable outcomes. We hypothesized that utilization of an emergency department operating room (EDOR) for resuscitation of patients with abdominal trauma at an urban Level I trauma center would be associated with decreased time to laparotomy and improved outcomes. METHODS: We included patients 15 years or older with abdominal trauma who underwent emergent laparotomy within 120 minutes of arrival both at our institution and within a National Trauma Data Bank sample between 2007 to 2019 and 2013 to 2016, respectively. Our institutional sample was matched 1:1 to an American College of Surgeons National Trauma Databank sample using propensity score matching based on age, sex, mechanism of injury, and abdominal Abbreviated Injury Scale score. The primary outcome was time to laparotomy incision. Secondary outcomes included blood transfusion requirement, intensive care unit (ICU) length of stay (LOS), ventilator days, hospital LOS, and in-hospital mortality. RESULTS: Two hundred forty patients were included (120 institutional, 120 national). Both samples were well balanced, and 83.3% sustained penetrating trauma. There were 84.2% young adults between the ages of 15 and 47, 91.7% were male, 47.5% Black/African American, with a median Injury Severity Score of 14 (interquartile range [IQR], 8-29), Glasgow Coma Scale score of 15 (IQR, 13-15), 71.7% had an systolic blood pressure of >90 mm Hg, and had a shock index of 0.9 (IQR, 0.7-1.1) which did not differ between groups (p > 0.05). Treatment in the EDOR was associated with decreased time to incision (25.5 minutes vs. 40 minutes; p ≤ 0.001), ICU LOS (1 vs. 3.1 days; p < 0.001), transfusion requirement within 24 hours (3 units vs. 5.8 units packed red blood cells; p = 0.025), hospital LOS (5 days vs. 8.5 days, p = 0.014), and ventilator days (1 day vs. 2 days; p ≤ 0.001). There were no significant differences in in-hospital mortality (22.5% vs. 15.0%; p = 0.14) or outcome-free days (4.9 days vs. 4.5 days, p = 0.55). CONCLUSION: The use of an EDOR is associated with decreased time to hemorrhage control as evidenced by the decreased time to incision, blood transfusion requirement, ICU LOS, hospital LOS, and ventilator days. These findings support DOR for patients sustaining operative abdominal trauma. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III.
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Traumatismos Abdominais , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/cirurgia , Adolescente , Feminino , Humanos , Escala de Gravidade do Ferimento , Laparotomia , Tempo de Internação , Masculino , Centros de Traumatologia , Adulto JovemRESUMO
BACKGROUND: There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship. METHODS: Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed. RESULTS: There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P < .01) and graduate from a high-volume program (49.2% vs 33.0%, P < .01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P < .01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P < .01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P < .01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P < .01). CONCLUSION: This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.
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Internato e Residência , Acreditação , Escolha da Profissão , Educação de Pós-Graduação em Medicina , Bolsas de Estudo , Humanos , Estados UnidosRESUMO
BACKGROUND: Resuscitation of hemorrhagic shock with isotonic crystalloids has been shown to activate polymorphonuclear neutrophils (PMNs). Although hypertonic saline (HTS) can reduce PMN activation and interactions with endothelial cells (EC) in systemic microvascular beds, no data exist demonstrating that the same occurs in the unique blood-brain barrier microcirculation. We hypothesized that resuscitation of hemorrhagic shock with HTS would blunt brain in vivo PMN-EC interactions. METHODS: Wistar rats (250-350 g) underwent craniotomy and placement of a window for live intravital viewing of pial vessels. Twenty animals were bled to a mean arterial pressure of 30 mm Hg to 35 mm Hg for 1 hour and resuscitated with shed blood and either 5% HTS (6 mL/kg) or Ringer's lactate (RL) (2× shed blood volume). Circulating rhodamine-6G-labeled PMN in pial venules were captured by videomicroscopy at baseline (preshock), end of the shock period, after resuscitation, and every 15 minutes to 30 minutes for 2 hours. Hemodynamics and arterial gases were monitored. Off-line footage analysis allowed comparisons of PMN-EC interactions between groups. RESULTS: Animals in both groups developed significant metabolic acidosis (p < 0.01) after hemorrhage, but postresuscitation blood pressures were similar at all time points. Crystalloid resuscitation volumes were 10× greater in RL than HTS animals (p < 0.001). For all time points, we did not observe the expected reduction in PMN rolling and adhesion in HTS animals, instead noted trends of consistently lower interactions in RL counterparts. CONCLUSIONS: In contradistinction to studies evaluating the systemic microcirculation, HTS may activate PMN-EC crosstalk in the blood-brain microcirculation. Further studies are needed to analyze whether this effect is due to the unique nature of the blood-brain interface.
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Barreira Hematoencefálica/fisiologia , Células Endoteliais/fisiologia , Endotélio Vascular/fisiologia , Neutrófilos/fisiologia , Solução Salina Hipertônica/uso terapêutico , Choque Hemorrágico/terapia , Animais , Modelos Animais de Doenças , Endotélio Vascular/citologia , Soluções Isotônicas , Masculino , Microcirculação/fisiologia , Ratos , Lactato de RingerRESUMO
BACKGROUND: Acute cervical spinal cord injury (cSCI) is associated with significant morbidity and mortality. Vertebral level and American Spinal Injury Association (ASIA) score influence both hospital course and ultimate outcome. While controlling for these variables, we describe the effect of age on cSCI-related pneumonia and mortality. METHODS: All patients treated at our regional spinal cord injury center with an acute cSCI during a 5-year period (2005-2009) were reviewed retrospectively. Patient demographics, injury level, ASIA score, length of stay (LOS), radiologic, laboratory, and microbiology data were reviewed. Pneumonia was defined as an infiltrate on chest X-ray along with two of the following: leukocytosis, fever greater than 101°F, or positive bronchial alveolar lavage cultures; all occurring within the same 24-hour period. RESULTS: There were 244 cSCI during the study period. In-hospital mortality was significantly higher for those older than 75 years (40.5% vs. 4.0%, p < 0.0001). Pneumonia rates were not significantly different between age groups. In all age groups, high ASIA scores (A and B) were associated with increased pneumonia (61.9% vs. 17.4%, p < 0.0001) and mortality (16.7% vs. 3.5%, p = 0.002). Similarly, patients with higher cervical injury levels (C4 and above) had a higher incidence of pneumonia (39.5% vs. 25.9%, p < 0.05) and a trend toward higher mortality. CONCLUSIONS: Age was associated with an increase in mortality among patients with an acute cSCI. Injury level and ASIA score contributed significantly to overall pneumonia rate and mortality at all ages; however, pneumonia did not correlate directly with mortality in this population. Other factors play a role in the mortality associated with geriatric spinal cord-injured patients, including end-of-life decision making; these need to be investigated further in future studies.
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Pneumonia/epidemiologia , Traumatismos da Medula Espinal/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais , Comorbidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos da Medula Espinal/complicações , Traumatismos da Medula Espinal/mortalidade , Adulto JovemRESUMO
BACKGROUND: The Surgeon General oversees the Commissioned Corps of the U.S. Public Health Service (USPHS) and is viewed as the "Nation's Doctor," responsible for providing the public with information on living healthier and safer lives. The Surgeon General's influence is seen through public health initiatives such as warning labels on tobacco and alcohol products. The objectives of this paper are to describe the tradition of the Office of the Surgeon General as created by Dr John M. Woodworth and to describe the careers of Dr C. Everett Koop and Dr Richard H. Carmona-the only 2 surgeons by training to hold the role. METHODS: This is a historical literature review using a combination of primary and secondary sources. RESULTS: Dr Woodworth set the priorities and responsibilities of the Surgeon General's Office: education, public service, sanitation, and public health. Dr Koop is widely regarded as the most influential Surgeon General of all time. He was both a pioneer in pediatric surgery and a highly influential public figure, issuing landmark reports on smoking, violence, and AIDS. Dr Carmona is a trauma surgeon by training and focused on the dangers of second-hand smoke as Surgeon General. Dr Carmona served in a more political role as Surgeon General, eventually running for Senate at the end of his term. CONCLUSION: This brief review of the history of the Surgeon General's Office highlights the contributions of the first Surgeon General and the only 2 surgeons who have held the position.
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Cirurgiões/história , United States Public Health Service/organização & administração , História do Século XIX , História do Século XX , História do Século XXI , Humanos , Masculino , Estados Unidos , United States Public Health Service/históriaRESUMO
Importance: The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective: To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants: This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures: The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results: Of 35â¯666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21â¯014 [58.9%]), White (21â¯584 [60.5%]), and admitted for nonpenetrating trauma (28â¯909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance: Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.
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Hérnia Incisional/epidemiologia , Laparotomia , Complicações Pós-Operatórias/epidemiologia , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Custos de Cuidados de Saúde , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estados Unidos/epidemiologiaRESUMO
CONTEXT: Malignant melanoma commonly metastasizes to the small intestine where it can cause pain, bleeding, and obstruction. However, jaundice from metastatic melanoma is relatively uncommon. CASE REPORT: A case of known malignant melanoma presenting as new onset obstructive jaundice as a result of a rarely reported metastasis to the ampulla of Vater. CONCLUSION: Multidisciplinary management of patients with metastatic melanoma is essential.
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Ampola Hepatopancreática/patologia , Neoplasias do Ducto Colédoco/diagnóstico , Neoplasias do Ducto Colédoco/secundário , Icterícia Obstrutiva/diagnóstico , Melanoma/diagnóstico , Melanoma/patologia , Idoso , Diagnóstico Diferencial , Feminino , Antebraço , Humanos , Icterícia Obstrutiva/etiologia , Neoplasias Cutâneas/diagnóstico , Neoplasias Cutâneas/patologiaRESUMO
Deep vein thrombosis (DVT) is linked to reimbursements and publicly reported metrics. Some hospitals discourage venous duplex ultrasound (VDUS) screening in asymptomatic trauma patients because they often find higher rates of DVT. We aim to evaluate the association between lower extremity (LE) VDUS screening and pulmonary embolism (PE) in trauma patients. Trauma patients admitted to an urban Level-1 trauma center between 2010 and 2015 were retrospectively analyzed. We characterized the association of asymptomatic LE VDUSs with PE, upper extremity DVT, proximal LE DVT, and distal LE DVT by univariate and multivariable logistic regression controlling for confounders. Of the 3959 trauma patients included in our study-after adjusting for covariates related to patient demographics, injury, and procedures-there was a significantly lower likelihood of PE in screened patients (odds ratio (OR) = 0.02, P < 0.001) and a higher rate of distal LE DVT (OR 11.1, P = 0.004). Screening was not associated with higher rates of proximal LE DVT after adjustment for covariates (OR = 1.8, P = 0.193). PE was associated with patient transfer status, pelvis fracture, and spinal procedures in unscreened patients. After adjusting for covariates, we have shown that LE VDUS asymptomatic screening is associated with lower rates of PE in trauma patients and not associated with higher rates of proximal LE DVT. Our detailed institutional review of a large cohort of trauma patients over five years provides support for ongoing asymptomatic screening and better characterizes venous thromboembolism outcomes than similarly sized purely administrative data reviews. As a retrospective cohort study with a large sample size, no loss to follow-up, and a population with low heterogeneity, this study should be considered as level III evidence for care management.
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Doenças Assintomáticas , Embolia Pulmonar/diagnóstico por imagem , Tromboembolia Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico por imagem , Ferimentos e Lesões/complicações , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Extremidade Inferior/irrigação sanguínea , Extremidade Inferior/diagnóstico por imagem , Masculino , Razão de Chances , Embolia Pulmonar/complicações , Embolia Pulmonar/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Ultrassonografia Doppler Dupla/estatística & dados numéricos , Tromboembolia Venosa/complicações , Trombose Venosa/complicaçõesRESUMO
BACKGROUND: Our institution amended its trauma activation criteria to require a Level II activation for patients ≥65 years old on antithrombotic medication presenting with suspected head trauma. METHODS: Our institutional trauma registry was queried for geriatric patients on antithrombotic medication in the year before and after this criteria change. Demographics, presentation metrics, level of activation, and outcomes were compared between groups. RESULTS: After policy change, a greater proportion of patients received a trauma activation (19.9 vs. 74.9%, Pâ¯<â¯0.001) and a greater proportion of these patients were discharged directly home without injury (4.3 vs. 44%, Pâ¯<â¯0.001). However, a smaller proportion of patients with a critical Emergency Department disposition or traumatic intracranial hemorrhage failed to receive a trauma activation (65.1 vs. 23.5%, Pâ¯<â¯0.001; 70.7% vs. 27.3%, Pâ¯<â¯0.001). There was no change in mortality (4.3 vs. 2.0%, Pâ¯=â¯0.21). CONCLUSIONS: Implementing new criteria increased overtriage, decreased undertriage, and had little effect on mortality.
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Fibrinolíticos/uso terapêutico , Avaliação Geriátrica , Triagem/estatística & dados numéricos , Triagem/normas , Ferimentos e Lesões , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Cervical spine injuries (CSIs) can have major effects on the respiratory system and carry a high incidence of pulmonary complications. Respiratory failure can be due to spinal cord injuries, concomitant facial fractures or chest injury, airway obstruction, or cognitive impairments. Early tracheostomy (ET) is often indicated in patients with CSI. However, in patients with anterior cervical fusion (ACF), concerns about cross-contamination often delay tracheostomy placement. This study aimed to demonstrate the safety of ET within 4 days of ACF. METHODS: Retrospective chart review was performed for all trauma patients admitted to our institution between 2001 and 2015 with diagnosis of CSI who required both ACF and tracheostomy, with or without posterior cervical fusion, during the same hospitalization. Thirty-nine study patients with ET (within 4 days of ACF) were compared with 59 control patients with late tracheostomy (5-21 days after ACF). Univariate and logistic regression analyses were performed to compare risk of wound infection, length of intensive care unit and hospital stay, and mortality between both groups during initial hospitalization. RESULTS: There was no difference in age, sex, preexisting pulmonary or cardiac conditions, Glasgow Coma Scale score, Injury Severity Score, Chest Abbreviated Injury Scale score, American Spinal Injury Association score, cervical spinal cord injury levels, and tracheostomy technique between both groups. There was no statistically significant difference in surgical site infection between both groups. There were no cases of cervical fusion wound infection in the ET group (0%), but there were five cases (8.47%) in the late tracheostomy group (p = 0.15). Four involved the posterior cervical fusion wound, and one involved the ACF wound. There was no statistically significant difference in intensive care unit stay (p = 0.09), hospital stay (p = 0.09), or mortality (p = 0.06) between groups. CONCLUSION: Early tracheostomy within 4 days of ACF is safe without increased risk of infection compared with late tracheostomy. LEVEL OF EVIDENCE: Evidence, level III.
Assuntos
Traumatismos da Medula Espinal/cirurgia , Fusão Vertebral/efeitos adversos , Infecção da Ferida Cirúrgica/etiologia , Traqueostomia/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Vértebras Cervicais , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: The indications and outcomes associated with temporary intravascular shunting (TIVS) for vascular trauma in the civilian sector are poorly understood. The objective of this study was to perform a contemporary multicenter review of TIVS use and outcomes. METHODS: Patients sustaining vascular trauma, requiring TIVS insertion (January 2005 to December 2013), were retrospectively identified at seven Level I trauma centers. Clinical demographics, operative details, and outcomes were abstracted. RESULTS: A total of 213 injuries (2.7%; 94.8% arterial) requiring TIVS were identified in 7,385 patients with vascular injuries. Median age was 27.0 years (range, 4-89 years), 91.0% were male, Glasgow Coma Scale (GCS) score was 15.0 (interquartile range, 4.0), Injury Severity Score (ISS) was 16.0 (interquartile range, 15.0), 26.0% had an ISS of 25 or greater, and 71.1% had penetrating injuries. The most common mechanism was gunshot wound (62.7%), followed by auto versus pedestrian (11.4%) and motor vehicle collision (6.5%). Shunts were placed for damage control in 63.4%, staged repair for combined orthopedic and vascular injuries in 36.1%, and for insufficient surgeon skill set in 0.5%. The most common vessel shunted was the superficial femoral artery (23.9%), followed by popliteal artery (18.8%) and brachial artery (13.2%). An argyle shunt (81.2%) was the most common conduit, followed by Pruitt-Inahara (9.4%). Dwell time was less than 6 hours in 61.4%, 24 hours in 86.5%, 48 hours in 95.9%, with only 4.1% remaining in place for more than 48 hours. Of the patients, 81.6% survived to definitive repair, and 79.6% survived overall. Complications included shunt thrombosis (5.6%) and dislodgment (1.4%). There was no association between dwell time and shunt thrombosis. The use of a noncommercial shunt (chest tube/feeding tube) did not impact shunt thrombosis but was an independent risk factor for subsequent graft failure. The limb salvage rate was 96.3%. No deaths could be attributed to a shunt complication. CONCLUSION: In the largest civilian TIVS experience insertion to date, both damage control and staged orthopedic vascular injuries were common indications for shunting. With an acceptable complication burden and no associated mortality attributed to this technique, shunting should be considered a viable treatment option. LEVEL OF EVIDENCE: Therapeutic study, level V.