Ischemia-induced lower extremity neurologic impairment after fenestrated endovascular aneurysm repair.

OBJECTIVE: Placement of large sheaths in the iliac system during fenestrated endovascular aneurysm repair (FEVAR) leads to lower extremity (LE) ischemia that can be associated with serious neurologic complications. We sought to determine the effect of LE ischemic time on neurologic impairment after FEVAR. METHODS: Consecutive patients who underwent FEVAR at a single institution were analyzed. LE ischemic time was calculated from the time of large sheath (≥18F) insertion to the time of sheath removal from the iliac arteries that led to continuous LE ischemia. The primary outcome was neurologic impairment defined as any new sensory or motor deficit in either LE. Outcomes were analyzed using descriptive statistics and modeled with logistic regression with interaction terms. Each individual LE was used as a unit of analysis. RESULTS: We examined 101 patients (202 lower extremities) who underwent FEVAR over a 5-year period. The median LE ischemic time was 2.75 hours (range, 0.8-5.2 hours). Neurologic impairment developed in 18 extremities (9%). Of those, 12 (67%) developed mild sensory loss, 6 (33%) complete sensory loss, 4 (22%) loss of proprioception, and 2 (11%) motor dysfunction. Sensory deficit was permanent in four limbs (2%) and motor dysfunction in one limb (0.5%). In all other cases, the neurologic examination returned to baseline by postoperative day 15. Duration of LE ischemic time (odds ratio, 6.3; 95% confidence interval, 3.1-12.4; P < .001) and common iliac artery (CIA) stenosis to a lumen of 8 mm or less (odds ratio, 2.7; 95% confidence interval, 1.5-7.3; P = .002) were independent predictors for the development of neurologic impairment. An interaction term between LE ischemic time and CIA stenosis was statistically significant (P = .042), indicating that the presence of CIA stenosis modifies the effect of LE ischemic time. In those with CIA stenosis to a lumen of 8 mm or less, the risk of neurologic impairment increased rapidly after 2.5 hours of LE ischemia, and became nearly certain after 4 hours of ischemic time. By contrast, patients without CIA stenosis tolerated longer ischemic times and demonstrated a less steep increase in the risk for LE neurologic impairment. CONCLUSIONS: LE neurologic impairment after FEVAR is strongly associated with LE ischemic time and CIA occlusive disease to a lumen of 8 mm or less. Our data indicate that, when the LE ischemic time is expected to exceed 2.5 hours (in patients with CIA stenosis) or 3 hours (in patients without CIA stenosis), measures to ensure LE perfusion should be given consideration.

Outcome Comparison between Open and Endovascular Management of TASC II D Aortoiliac Occlusive Disease.

BACKGROUND: Endovascular management of complex aortoiliac occlusive disease (AIOD) has been described as a viable alternative to open surgical reconstruction. To date, few studies have directly compared the 2 techniques. We therefore, evaluated short and mid- term outcomes of open and endovascular therapy in TASC II D AIOD patients. METHODS: TASC II D patients undergoing treatment between January 2009 and December 2016 were retrospectively reviewed. Patient demographics, clinical data, and outcomes (complications [technical and systemic] and graft patency) were collected. The primary outcome of this study was primary graft patency. Patients were compared according to treatment group (open versus endovascular). Kaplan-Meier curves were used to analyze follow up results. RESULTS: A total of 75 consecutive patients (open: 30; endovascular: 45) were included in this analysis. In the endovascular group, 25 (55.6%) patients were managed using a hybrid approach with 100% technical success. Critical limb ischemia was the indication for intervention in 16.0% of this cohort (open, 13.3% vs. endovascular, 17.8%, P = 0.397). Overall, there were no significant differences in gender (male: open, 50.0% vs. endovascular, 55.6%, P = 0.637) or age (54.5 ± 5.9 years vs. 57.0 ± 8.7 years, P = 0.171). No in hospital deaths occurred in this cohort. The overall complication rate was significantly higher in the open group (43.3% vs. 17.8%, OR 3.5, 95% CI [1.2-10.1], P = 0.016) with peri-operative systemic complications being more likely in the open cohort (40.0% vs. 6.7%, OR 9.3, 95% CI [2.3-37.3], P < 0.001) while technical complications did not differ between the 2 groups (6.7% vs. 11.1%, OR 0.6, 95% CI [0.1-3.1], P = 0.517). Follow up data was available for 68 patients (90.7%), for a mean of 21.3 ± 17.1 months (range: 1-72 months). Re-intervention rates were significantly higher in the endovascular group (3.3% vs. 20.0%, OR 7.2, 95% CI [1.1-14.3], P = 0.038). The overall primary patency at 2 years was significantly higher in the open group (96.7% vs. 80.0%, OR 7.2, 95% CI [1.2-60.5], P = 0.038). Cox regression analysis revealed separation of the primary outcome for open therapy relative to endovascular repair (log rank, P = 0.320). CONCLUSIONS: In this comparison of open and endovascular therapy for complex AIOD, endovascular therapy was associated with high initial technical success and fewer in-hospital systemic complications but also high re-intervention rates when compared to open repair. Further prospective studies aimed at reduction of complications, optimization of patency, and patient selection for such procedures is warranted.

Distal vein patch use and limb events after infragenicular prosthetic bypasses.

OBJECTIVE: In the absence of suitable autologous vein, the use of prosthetic grafts for infragenicular bypasses in peripheral arterial disease has become standard practice. The purpose of this study was to investigate whether creating a vein patch at the distal anastomosis would further improve patency and freedom from major adverse limb events (MALEs). Furthermore, we sought to investigate whether the use of a distal vein patch (DVP) was associated with lower rates of acute limb ischemia (ALI) for those presenting with occluded prosthetic bypass graft. METHODS: The cases of all patients undergoing infragenicular prosthetic bypass grafts between January 2009 and July 2016 were retrospectively reviewed. Demographics of the patients, clinical data, and outcomes (graft patency and MALEs) were collected. Patients were compared according to treatment group (DVP vs no DVP). A Cox regression analysis was used to analyze follow-up results. RESULTS: During the study period, a total of 373 patients underwent infragenicular bypass at our institution; of those, 93 (24.9%) had prosthetic grafts (DVP, 39; no DVP, 54). Overall, 92 (98.9%) patients were male; the mean age was 63.3 ± 6.6 years and did not differ between the two groups. Patients undergoing prosthetic bypass with DVP were more likely to have chronic obstructive pulmonary disease (38.5% vs 14.8%; P = .009) and less likely to have chronic kidney disease (2.6% vs 20.4%; P = .011). Follow-up data were available for all patients for a median of 7.8 months (range, 1-89 months). After adjustment for differences in demographics and clinical data between the two groups, when outcomes were analyzed, MALEs were significantly lower in the DVP group (35.9% vs 57.4%; odds ratio [OR], 0.4; 95% confidence interval [CI], 0.2-0.9; P = .041). Similarly, reintervention rates were significantly lower in the DVP group (30.8% vs 50.0%; OR, 0.4; 95% CI, 0.2-0.9; P = .044). There was a trend toward higher primary patency in the DVP group (46.2% vs 35.2%; OR, 1.5; 95% CI, 0.7-3.5; P = .206) and lower rates of ALI after bypass occlusion (30.0% vs 42.9%; OR, 0.6; 95% CI, 0.2-1.8; P = .345). A Cox regression time-to-event analysis revealed late separation of freedom from MALEs for DVP relative to no DVP (log rank, P = .269). CONCLUSIONS: In this evaluation of infragenicular prosthetic bypass grafts, the creation of a vein patch at the distal anastomosis was associated with lower reintervention rates and a trend toward improved primary patency and MALEs. Furthermore, for those presenting with occluded prosthetic bypass graft, the use of a DVP was associated with a trend toward lower rates of ALI.

Survival trends after inferior vena cava and aortic injuries in the United States.

OBJECTIVE: Recent studies have demonstrated an increase in trauma mortality relative to mortality from cancer and heart diseases in the United States. Major vascular injuries such as to the inferior vena cava (IVC) and aortic injuries remain responsible for a significant proportion of early trauma deaths in modern trauma care. The purpose of this study was to explore patterns in epidemiology and mortality after IVC and aortic injuries in the United States. METHODS: A 13-year analysis of the National Trauma Databank (2002-2014) was performed to extract all patients who sustained IVC, abdominal aortic, or thoracic aortic injuries. Demographics, clinical data, and outcomes were extracted. Patients were analyzed according to injury mechanism. RESULTS: A total of 25,428 patients were included in this analysis. Overall, the mean age was 39.8 ± 19.1 years, 70.3% were male, and 14.1% sustained a penetrating trauma. Although the incidence of all three injuries remained constant throughout the study period, for blunt trauma, mortality decreased over the study period (from 48.8% in 2002 to 28.7% in 2014; P < .001), in particular for thoracic aortic injuries (from 46.1% in 2002 to 23.7% in 2014; P < .001) and abdominal aortic injuries (from 58.3% in 2002 to 26.2% in 2014; P < .001). This decrease in mortality after blunt trauma was accompanied by an increase in endovascular procedures over the study period (from 1.0% in 2002 to 30.4% in 2014; P < .001), in particular for blunt thoracic aortic injuries (from 0.7% in 2002 to 41.4% in 2014; P < .001). When penetrating trauma patients were analyzed, overall there was an increase in mortality (from 43.8% in 2002 to 50.6% in 2014; P < .001), in particular after abdominal aortic injury (from 30.4% in 2002 to 66.0% in 2014; P < .001). Similar trends were observed for IVC injuries. No increase in endovascular use in penetrating trauma was identified (from 0.1% in 2002 to 3.4% in 2014; P < .001). CONCLUSIONS: The present study demonstrates an overall decrease in mortality after blunt aortic injuries in the United States. This decrease was accompanied by an increase in the use of endovascular procedures. After penetrating trauma, however, despite contemporary advances in trauma care, mortality has increased over the study period, in particular after abdominal aortic injury. No increase in endovascular use in penetrating trauma was demonstrated.

Endovascular management of inferior vena cava filter thrombotic occlusion.

Objective Inferior vena cava occlusion is a potentially life-threatening complication related to caval filters. We present our experience with filter-induced inferior vena cava occlusion in order to assess the feasibility, safety, and effectiveness of endovascular management. Methods A retrospective review of all patients undergoing inferior vena cava filter placement over a 60-month study period was performed. From this cohort, a total of 10 cases of inferior vena cava occlusion after filter placement were identified. Demographics, clinical data, procedures, and outcomes were extracted. Patients were followed to the last clinic visit or until they died. Results One-hundred eighty filters were placed by our group practice during the study period. Of those, a total of 10 patients were identified. Overall, there were 7 males; the mean age was 57.1 years (25-78 years). The median time between inferior vena cava filter placement and filter occlusion was 105 days (range 5-4745 days). All patients were clinically symptomatic at the time of their presentation. Nine out of 10 patients were successfully managed endovascularly. Trellis™-8 thrombectomy was the most common endovascular strategy performed ( n = 9). Four patients had balloon angioplasty, two of those with stent placement for chronically occluded inferior vena cava/iliac veins. No thromboembolic complications developed during a median follow-up period of 233 days (range 4-1083 days). Conclusions Endovascular management of inferior vena cava occlusion is feasible, safe, and effective in decreasing thrombus burden in the presence of an inferior vena cava filter. Further studies evaluating long-term inferior vena cava patency and optimal surveillance regimen after endovascular management of filter-related inferior vena cava occlusion are warranted.

Increasing use of endovascular therapy in pediatric arterial trauma.

BACKGROUND: Endovascular therapy has been increasingly used for critically injured adults. However, little is known about the epidemiology and outcomes of endovascularly managed arterial injuries in children. We therefore aimed to evaluate recent trends in the endovascular management of pediatric arterial injuries and its association with early survival. METHODS: An 8-year analysis of the National Trauma Databank (2007-2014) was performed to extract all pediatric trauma patients (aged ≤16 years) with arterial injuries. Demographics, clinical data, interventions (endovascular vs open), and outcomes (in-hospital mortality and length of stay) were extracted. Patients undergoing endovascular or open procedures were compared for differences in clinical characteristics using bivariate analysis. Multivariable logistic regression analysis quantified the association between endovascular therapy and survival in the context of other variables predictive of survival on univariate analysis, with α ≤ .05. RESULTS: There were 35,771 pediatric patients available for analysis. Overall, there was a significant increase in the use of endovascular procedures (from 7.8% in 2007 to 12.9% in 2014; P < .001), particularly among blunt trauma patients (5.8% in 2007 to 15.7% in 2014; P < .001). Conversely, a significant decrease was noted for open procedures (P < .001). There was a stepwise increase in the proportion of patients managed endovascularly as the Injury Severity Score (ISS) increased (highest in the ISS spectrum of 31-50). Angioembolization of internal iliac injury and thoracic aortic endograft placement were the two most common endovascular procedures (n = 88 [33.4%] and n = 60 [22.9%], respectively). There were 331 decedents (9.1% vascular injured children), 242 (73.1%) of whom were dead on arrival. After controlling for differences in demographics and clinical data, when outcomes were compared between patients who underwent endovascular and open procedures, there were no significant differences regarding in-hospital mortality (3.0% vs 3.6%; odds ratio, 0.7; 95% confidence interval, 0.1-6.1; P = .778). A logistic regression model identified Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure <90 mm Hg on admission as independent risk factors for death. CONCLUSIONS: The use of endovascular therapy in pediatric vascular arterial trauma has significantly increased, especially among severely injured blunt trauma patients. Despite this successful integration into care, there was no in-hospital survival advantage conferred by endovascular therapy compared with traditional open therapy. Approximately 10% of children with arterial injuries died during initial trauma assessment before therapy could be offered. Glasgow Coma Scale score ≤8, ISS ≥16, positive result of ethanol or drug screen, and systolic blood pressure <90 mm Hg on admission were identified as independent risk factors for death. As children are a population of vulnerable patients, long-term, multicenter studies are required to determine the most appropriate use of and indications for endovascular therapy in pediatric arterial trauma.

Outcome comparison between open and endovascular management of axillosubclavian arterial injuries.

BACKGROUND: Endovascular repair (ER) of axillosubclavian arterial injuries is a minimally invasive alternative to open repair (OR). The purpose of this study was to compare the outcomes of ER vs OR. METHODS: A retrospective study was performed of patients who sustained axillosubclavian arterial injuries admitted to two high-volume academic trauma centers between 2003 and 2013. Patients undergoing ER and OR were matched according to 25 different demographic and clinical variables in a 1:3 ratio using propensity scores. The primary outcome was in-hospital mortality. Secondary outcomes were complications and length of stay. RESULTS: Among 153 patients (79.7% male; mean age, 32.7 ± 15.9 years) who sustained axillosubclavian arterial injuries, 18 (11.8%) underwent ER and 135 (88.2%) had OR. Matched cases (ER, n = 18) and controls (OR, n = 54) had similar demographic and clinical data, such as age, gender, admission systolic blood pressure and Glasgow Coma Scale score, body Abbreviated Injury Scale scores, Injury Severity Score, and transfusion requirements. Patients undergoing ER had significantly lower in-hospital mortality compared with patients undergoing OR (5.6% vs 27.8%; P = .040; odds ratio, 0.7; 95% confidence interval, 0.6-0.9). Similarly, patients undergoing ER had substantially lower rates of surgical site infections and a trend toward lower rates of sepsis. Outpatient follow-up was available in 88.2% (n = 15) of the patients at a median time of 8 months (1-30 months). Two ER patients required open reintervention for stent-related complications (one for a type Ia endoleak and another for stent thrombosis). CONCLUSIONS: In our experience with axillosubclavian arterial injuries, ER was associated with improved mortality and lower complication rates. Patient follow-up demonstrates an acceptable reintervention rate after ER. Further multicenter prospective evaluation is warranted to determine long-term outcomes.

The Society for Vascular Surgery lower extremity threatened limb classification system based on Wound, Ischemia, and foot Infection (WIfI) correlates with risk of major amputation and time to wound healing.

OBJECTIVE: The purpose of this study was to evaluate whether the new Society for Vascular Surgery (SVS) Wound, Ischemia, and foot Infection (WIfI) classification system correlates with important clinical outcomes for limb salvage and wound healing. METHODS: A total of 201 consecutive patients with threatened limbs treated from 2010 to 2011 in an academic medical center were analyzed. These patients were stratified into clinical stages 1 to 4 on the basis of the SVS WIfI classification. The SVS objective performance goals of major amputation, 1-year amputation-free survival (AFS) rate, and wound healing time (WHT) according to WIfI clinical stages were compared. RESULTS: The mean age was 58 years (79% male, 93% with diabetes). Forty-two patients required major amputation (21%); 159 (78%) had limb salvage. The amputation group had a significantly higher prevalence of advanced stage 4 patients (P < .001), whereas the limb salvage group presented predominantly as stages 1 to 3. Patients in clinical stages 3 and 4 had a significantly higher incidence of amputation (P < .001), decreased AFS (P < .001), and delayed WHT (P < .002) compared with those in stages 1 and 2. Among patients presenting with stage 3, primarily as a result of wound and ischemia grades, revascularization resulted in accelerated WHT (P = .008). CONCLUSIONS: These data support the underlying concept of the SVS WIfI, that an appropriate classification system correlates with important clinical outcomes for limb salvage and wound healing. As the clinical stage progresses, the risk of major amputation increases, 1-year AFS declines, and WHT is prolonged. We further demonstrated benefit of revascularization to improve WHT in selected patients, especially those in stage 3. Future efforts are warranted to incorporate the SVS WIfI classification into clinical decision-making algorithms in conjunction with a comorbidity index and anatomic classification.

The influence of do-not-resuscitate status on the outcomes of patients undergoing emergency vascular operations.

BACKGROUND: Do-not-resuscitate (DNR) orders allow patients to communicate their wishes regarding cardiopulmonary resuscitation. Although DNR status may influence physician decision making regarding resuscitation, the effect of DNR status on outcomes of patients undergoing emergency vascular operation remains unknown. The aim of this study was to analyze the effect of DNR status on the outcomes of emergency vascular surgery. METHODS: The National Surgical Quality Improvement Program database was queried to identify all patients requiring emergency vascular surgical interventions between 2005 and 2010. Demographics, clinical data, and outcomes were extracted. Patients were compared according to DNR status. The primary outcome measure was 30-day mortality. RESULTS: During the study period, 16,678 patients underwent emergency vascular operations (10.8% of the total vascular surgery population). Of those, 548 patients (3.3%) had a DNR status. The differences in rates of open or endovascular repair or of intraoperative blood requirement between the two groups were not significant. After adjusting for differences in demographics and clinical data, DNR patients were more likely to have higher rates of graft failure (8.7% vs 2.4%; adjusted P < .01) and failure to wean from mechanical ventilation (14.9 % vs 9.9%; adjusted P < .001). DNR status was associated with a 2.5-fold rise in 30-day mortality (35.0% vs 14.0%; 95% confidence interval, 1.7-2.9; adjusted P < .001). CONCLUSIONS: The presence of a DNR order was independently associated with mortality. Patient and family counseling on surgical expectations before emergency vascular operations is warranted because the risks of perioperative events are significantly elevated when a DNR order exists.

Pharmacomechanical thrombolysis in the management of acute inferior vena cava filter occlusion using the Trellis-8 device.

PURPOSE: To evaluate the performance and safety of the Trellis-8 system, a pharmacomechanical thrombolysis infusion catheter, and adjunctive therapies in the treatment of symptomatic inferior vena cava (IVC) filter-related acute thrombotic occlusion. METHODS: Eight consecutive patients (6 men; mean age 57.4 years, range 34-78 years) with acute thrombotic occlusion of the IVC in the presence of an IVC filter underwent percutaneous venous thrombectomy using the Trellis-8 thrombectomy system and adjunctive techniques between January 2009 and November 2013. Demographics, clinical data, procedures, and outcomes were retrospectively reviewed. All patients had clinical signs of lower extremity venous hypertension on presentation. The median time between IVC filter placement and occlusion was 25 months. Patients were followed for the development of thromboembolic complications to the last clinic visit or until they died. RESULTS: The procedure was technically successful in 6 patients, whereas it could not be performed in 2 due to failure to cross the occlusion. The median follow-up period was 7.8 months, at which time all patients undergoing successful Trellis-8 thrombectomy had relief of symptoms without thromboembolic or bleeding complications. CONCLUSION: In this limited performance and safety evaluation, the Trellis-8 thrombectomy system combined with adjunctive therapies, such as mechanical thrombectomy and balloon angioplasty, was effective in 75% of patients with IVC filter-related acute caval occlusion.

Trends and outcomes of endovascular therapy in the management of civilian vascular injuries.

OBJECTIVE: The rapid evolution of endovascular surgery has greatly expanded management options for a wide variety of vascular diseases. Endovascular therapy provides a less invasive alternative to open surgery for critically ill patients who have sustained arterial injuries. The purpose of this study was to evaluate recent trends in the management of arterial injuries in the United States with specific reference to the use of endovascular strategies and to examine the outcomes of endovascular vs open therapy for the treatment of civilian arterial traumatic injuries. METHODS: A 9-year analysis of the National Trauma Data Bank was performed to identify all patients who sustained arterial injuries. Demographics, clinical data, interventions, and outcomes were extracted. Propensity scores were used to match endovascular patients to those undergoing open operation. Patient outcomes were compared according to treatment approach. RESULTS: A total of 23,105 patients were available for analysis. Overall, there was a significant increase in the use of endovascular procedures during 9 years (from 0.3% in 2002 to 9.0% in 2010; P < .001), particularly among blunt trauma patients (from 0.4% in 2002 to 13.2% in 2010; P < .001). This increase was noteworthy and dramatic for injuries of the internal iliac artery (from 8.0% in 2002 to 40.3% in 2010; P < .001), thoracic aorta (from 0.5% in 2002 to 21.9% in 2010; P < .001), and common/external iliac arteries (from 0.4% in 2002 to 20.4% in 2010; P < .001). A significant decrease was noted for open procedures (49.1% in 2002 to 45.6%; P < .001), especially for blunt trauma (42.9% in 2002 to 35.8% in 2010; P < .001). There was a stepwise increase in the proportion of patients managed by endovascular therapy as the Injury Severity Score increased (highest in the spectrum Injury Severity Score 31-50). When outcomes were compared between matched patients who underwent endovascular and open procedures, patients who underwent endovascular procedures had significantly lower in-hospital mortality (12.9% vs 22.4%; odds ratio, 0.5; 95% confidence interval, 0.4-0.6; P < .001). Endovascular patients also had decreased rates of sepsis (7.5% vs 5.4%; odds ratio, 0.7; 95% confidence interval, 0.5-0.9; P = .025). CONCLUSIONS: The use of endovascular therapy in the United States has increased dramatically during the last decade, in particular among severely injured blunt trauma patients. Endovascular therapy was associated with improved in-hospital mortality and lower rates of sepsis.

Discrepancies between capillary glucose measurements and traditional laboratory assessments in both shock and non-shock states after trauma.

INTRODUCTION: The purpose of this study was to analyze the accuracy of capillary blood glucose (CBG) against laboratory blood glucose (LBG) in critically ill trauma patients during the shock state. METHODS: All critically ill trauma patients admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center requiring blood glucose monitoring from January 2007 to December 2008 were included. Accuracy of CBG was compared against LBG during shock and non-shock states. Shock was defined as either systolic blood pressure <90 mm Hg or mean arterial pressure <70 mm Hg and the need for vasopressor therapy. The Bland-Altman method was used to determine the agreement between CBG and LBG during shock and non-shock states. CBG values were considered to disagree significantly with LBG values when the difference exceeded 15%. RESULTS: During the 2-y study period, a total of 1215 patients were admitted to the Surgical Intensive Care Unit. Overall, the mean age was 38.4 ± 20.9 y, 79.6% (967) were male, and 75.0% (911) sustained blunt trauma. A total of 1935 paired samples of CBG and LBG were included in this analysis (367 during shock and 1568 during non-shock). During shock, the mean difference between CBG and LBG levels was 13.4 mg/dL (95% CI, -15.4 to 42.2 mg/dL), and the limits of agreement were -27.1 and 53.9 mg/dL. A total of 136 CBG values (37.1%) differed from the LBG values by more than 15%. During non-shock, the mean difference between CBG and LBG levels was 12.6 mg/dL (95% CI, -19.9 to 32.5 mg/dL), and the limits of agreement were -20.6 and 45.8 mg/dL. A total of 639 CGB values (40.8%) differed from the LBG values by more than 15%. Agreement was lowest among hypoglycemic readings in both shock and non-shock states. CONCLUSION: There is poor correlation between the capillary and laboratory glucose values in both shock and non-shock states.

Biochemical profile and outcomes in trauma patients subjected to open cardiopulmonary resuscitation: a prospective observational pilot study.

BACKGROUND: The predictive factors to regain a heartbeat following emergency department resuscitative thoracotomy (EDT) for trauma are poorly understood. The objective of the present study was to prospectively assess the electrolyte profile, coagulation parameters, and acid-base status from intracardiac blood samples in trauma patients subjected to open cardiopulmonary resuscitation (CPR) in the presence of established cardiac arrest. METHODS: All patients who underwent EDT following trauma were considered for inclusion. Prior to the injection of any resuscitative medications, a sample of intracardiac blood from the right ventricle was obtained for analysis. RESULTS: During the study period, a total of 22 patients had intracardiac blood samples obtained and were eligible for analysis. Twelve patients never regained cardiac activity, and 10 patients transiently regained a heartbeat for a mean of 51 ± 69 min, but ultimately died. Some 91 % (20/22) of patients presented with severe acidosis (pH < 7.20). The pCO(2) was <45 mmHg in 68 % (15/22) of patients, and the pO(2) level was >75 mmHg in 77 % (17/22) of patients. Patients who never regained cardiac activity had a significantly higher lactate level than those with a return of cardiac rhythm (17.1 ± 2.6 vs. 10.6 ± 4.9 mmol/L, p = 0.018). The sodium and potassium levels were higher for those who never regained a rhythm than for those who did regain a pulse (sodium: 155 ± 14 vs. 147 ± 9 mmol/L, p = 0.094; potassium: 6.0 ± 1.1 vs. 4.6 ± 1.0 mmol/L, p = 0.014). Severe hyperkalemia (potassium > 5.5 mmol/L) occurred significantly more often in patients who did not regain a heart beat (p = 0.030). Coagulopathy (INR > 1.2 and/or prothrombin time >15 s and/or platelet count <100,000/µL) was noted in 96 % of patients. CONCLUSIONS: Most patients undergoing open CPR have normal blood gas levels. Severe lactic acidosis, hyperkalemia, and hypernatremia are associated with decreased probability for return of cardiac function. Calcium and magnesium levels were not significantly different between the two groups, making the therapeutic role of these electrolytes very questionable.

A new survivable damage control model including hypothermia, hemodilution, and liver injury.

BACKGROUND: The purpose of this article is to describe a new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model that incorporates damage control principles and allows for survival. MATERIALS AND METHODS: Twenty swine underwent a standardized 35% blood volume hemorrhage followed by resuscitation. Ten animals sustained nonsurgical and 10 a surgical high-grade liver injury. In the surgical liver injury, damage control gauze packing was performed. No operative treatment was provided for the nonsurgical liver injury, which was designed to test the efficacy of systemic hemostatic agents. After a 15 min treatment phase, the abdominal cavity was closed, with the packing in place for the surgical injury, and all animals were resuscitated. Necropsy was performed at 48 h post-injury. RESULTS: At the time of liver injury, the animals were hemodiluted and hypothermic. Both injuries caused a 20% drop in the mean arterial pressure from baseline (P<0.001). Comparing baseline thromboelastography results with the results after hemodilution, hypothermia, and liver injury, a hypercoagulopathic state was observed. Mortality was 30% for both types of liver injury. The mean volume of intra-abdominal blood present at autopsy was similar for both types of liver injuries (202 ± 161 mL and 214 ± 203 mL, respectively). CONCLUSION: A new model of traumatic intra-cavitary hemorrhage in a hypothermic, hemodiluted liver injury model with damage control that allows for survival has been described. The mortality rate of 30% allows for the comparison of therapeutic interventions that may lead to improved survival.

Donor conversion and procurement failure: the fate of our potential organ donors.

BACKGROUND: Donor availability remains the primary limiting factor for organ transplantation today. The purpose of this study was to examine the causes of procurement failure amongst potential organ donors. METHODS: After Institutional Review Board approval, all surgical intensive care unit (SICU) patients admitted to the LAC+USC Medical Center from 01/2006 to 12/2008 who became potential organ donors were identified. Demographics, clinical data, and procurement data were abstracted. In non-donors, the causes of procurement failure were documented. RESULTS: During the 3-year study period, a total of 254 patients were evaluated for organ donation. Mean age was 44.8±18.7 years; 191 (75.2%) were male, 136 (53.5%) were Hispanic, and 148 (58.3%) were trauma patients. Of the 254 patients, 116 (45.7%) were not eligible for donation: 34 had multi-system organ failure, 24 did not progress to brain death and had support withdrawn, 18 had uncontrolled sepsis, 15 had malignancy, 6 had human immunodeficiency virus or hepatitis B or C, and 19 patients had other contraindications to organ donation. Of the remaining 138 eligible patients, 83 (60.2%) did not donate: 56 because the family denied consent, 9 by their own choice. In six, next of kin could not be located, five died because of hemodynamic instability before organ procurement was possible, four had organs that could not be placed, and three had their organs declined by the organ procurement organization. The overall consent rate was 57.5% (n=67). From the 55 donors, 255 organs were procured (yield 4.6 organs/donor). CONCLUSIONS: Of all patients screened for organ donation, only a fifth actually donated. Denial of consent was the major potentially preventable cause of procurement failure, whereas hemodynamic instability accounted for only a small percentage of donor losses. With such low conversion rates, the preventable causes of procurement failure warrant further study.

Unstable cervical spine fracture after penetrating neck injury: a rare entity in an analysis of 1,069 patients.

BACKGROUND: The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients. METHODS: This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified. RESULTS: A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score ≤8 on admission (R = 0.16). CONCLUSION: The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in <1% of patients. After cervical SW, however, no spinal instability was noted precluding the need for spinal precautions in these instances.

Incidence and clinical predictors for tracheostomy after cervical spinal cord injury: a National Trauma Databank review.

BACKGROUND: The purpose of this study was to determine the incidence and identify clinical predictors for the need for tracheostomy after cervical spinal cord injury (CSCI). METHODS: The National Trauma Databank version 7.0 (2002-2006) was used to identify all patients who sustained a CSCI. Patients with severe traumatic brain injury (TBI) were excluded. Demographics, clinical data, and outcomes were abstracted. Patients requiring tracheostomy were compared with those who did not require tracheostomy. Logistic regression analysis was used to identify independent predictors for the need of tracheostomy. RESULTS: There were 5,265 eligible patients. Of these, 1,082 (20.6%) required tracheostomy and 4,174 (79.4%) did not. The majority patients were men and blunt trauma predominated. Patients requiring tracheostomy had a higher Injury Severity Score (ISS) (33.5±17.7 vs. 24.4±16.2, p<0.001) and required intubation more frequently on scene and Emergency Department (ED) (4.2 vs. 1.4%, p<0.001 and 31.1 vs. 7.9%, p<0.001, respectively). Patients requiring tracheostomy had higher rates of complete CSCI at C1-C4 (18.2 vs. 8.4%, p<0.001) and C5-C7 levels (37.8 vs. 16.9%, p<0.001). Patients requiring tracheostomy had more ventilation days, longer intensive care unit and hospital lengths of stay, but lower mortality. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS≥16, facial fracture, and thoracic trauma were identified as independent predictors for the need of tracheostomy. CONCLUSION: After CSCI, a fifth of patients will require tracheostomy. Intubation on scene or ED, complete CSCI at C1-C4 or C5-C7 levels, ISS≥16, facial fracture, and thoracic trauma were independently associated with the need for tracheostomy.

In-hospital small bowel obstruction after exploratory laparotomy for trauma.

BACKGROUND: The purpose of this study was to examine the incidence and risk factors of in-hospital small bowel obstruction (SBO) after exploratory laparotomy for trauma. METHODS: A retrospective review of patients surviving over 72 hours after an exploratory laparotomy for trauma. Patients with intestinal obstructive symptoms were reviewed by a consensus panel, which evaluated the clinical, laboratory, and radiologic findings to validate the diagnosis of SBO. RESULTS: A total of 571 patients met inclusion criteria. The incidence of early SBO was 3.9%, with 22.7% of these patients requiring surgical intervention. Patients with gastrointestinal (GI) perforation had a significantly higher incidence of SBO, compared with those with no GI perforation (5.7% vs. 1.3%, p = 0.007). A forward logistic regression identified the presence of a GI perforation as the only factor independently associated with early SBO (adjusted odds ratio: 4.39; 95% confidence interval: 1.28-15.15; p = 0.019). The overall hospital stay was significantly longer for SBO patients (27.0 days ± 26.7 days vs. 16.0 days ± 22.8 days; adjusted mean difference: 11.5; 95% confidence interval: 1.6-21.3; p = 0.022). Development of SBO increased the cost by 59.7%. CONCLUSION: The incidence of in-hospital SBO after laparotomy for trauma is significant at 3.9%. The presence of a GI perforation is independently associated with the development of this complication. Over a fifth of patients with early SBO will require a surgical intervention. The use of preventive strategies may be justified in selected, high-risk patients to reduce the burden associated with early SBO.

The increasing burden of radiation exposure in the management of trauma patients.

BACKGROUND: As trauma care evolves, there has been increased reliance on imaging. The purpose of this study was to examine changes in trauma imaging and radiation exposure over time. Our hypothesis was that there has been an increased usage of imaging in the management of trauma patients without measurable improvements in outcomes. METHODS: A continuous series of injured patients admitted to a Level I trauma center during a 2-month period in 2002 was compared with the same period in 2007. All computed tomography (CT)s and plain radiographs performed for each patient were tabulated. Effective radiation dose estimates for each patient were then calculated. The outcome measures were length of stay, mortality, and missed injuries. RESULTS: The 495 patients in 2007 and 497 patients in 2002 demonstrated no significant differences in demographics, clinical data, or outcomes between groups. However, from 2002 to 2007, for blunt trauma, the mean CTs per patient increased significantly (2.1 ± 1.6 vs. 3.2 ± 2.0, p < 0.001), as did plain radiographs (8.8 ± 12.9 vs. 14.9 ± 17.0, p < 0.001). For penetrating trauma, roentgenogram usage increased significantly (4.2 ± 5.3 vs. 9.1 ± 14.4, p = 0.01) with a trend toward increased CTs (0.7 ± 1.1 vs.1.0 ± 1.6, p = 0.11). Total radiation dose estimates demonstrated significantly increased radiation exposure in 2007; blunt (11.5 ± 11.3 mSv vs. 20.7 ± 14.9 mSv, p < 0.05) and penetrating (2.9 ± 4.9 mSv vs. 5.4 ± 7.9 mSv, p < 0.05). CONCLUSION: From 2002 to 2007, there was a significant increase in the use of CT and plain radiographs in the management of trauma patients, leading to significantly higher radiation exposure with no demonstrable improvements in the diagnosis of missed injuries, mortality, or length of stay.

Optimal positioning for emergent needle thoracostomy: a cadaver-based study.

BACKGROUND: Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate. METHODS: Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position. RESULTS: A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p < 0.001); right chest: 100% versus 60.0% (p = 0.003) and left chest: 100% versus 55.0% (p = 0.001). Overall, the thickness of the chest wall was 3.5 cm ± 0.9 cm at the fifth intercostal space and 4.5 cm ± 1.1 cm at the second intercostal space (p < 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm ± 1.0 cm vs. 4.5 cm ± 1.1 cm, p = 0.007; left, 3.5 ± 0.9 cm vs. 4.4 cm ± 1.1 cm, p = 0.008). CONCLUSIONS: In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.