Non-operative management of cirrhotic patients with acute calculous cholecystitis: How effective is it?

INTRODUCTION: Nonoperative management (NOM) of acute calculous cholecystitis (ACC) in patients with cirrhosis was proposed. We examined the outcomes of cirrhotic patients with ACC treated with cholecystectomy compared to NOM. METHODS: We analyzed the 2017-Nationwide Readmissions Database including cirrhotic patients with ACC. Patients were stratified: cholecystectomy, percutaneous cholecystostomy (PCT), and antibiotics only. PRIMARY OUTCOMES: complications, failure of NOM. SECONDARY OUTCOMES: mortality, length of stay (LOS), and charges. RESULTS: 3454 patients were identified. 1832 underwent cholecystectomy, 360 PCT, and 1262 were treated with antibiotics. PCT patients had higher mortality 16.9% vs. the antibiotics group 10.9% vs. cholecystectomy group 4.2%. PCT patients had longer LOS, but lower charges compared to the operative group. Failure of NOM was 28.2%. On regression, PCT was associated with mortality. CONCLUSION: ACC remains a morbid disease in cirrhosis patients. One in three failed NOM, had longer LOS, and higher mortality. Further studies are warranted to identify predictors of NOM failure. LEVEL OF EVIDENCE: Level III, prognostic.

Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care.

OBJECTIVE: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. BACKGROUND: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. METHODS: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. CONCLUSION: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE: Level III Prognostic. STUDY TYPE: Prognostic.

Improving blunt cerebrovascular injury screening in motor vehicle collision patients: Does airbag deployment matter?

BACKGROUND: Motor vehicle collisions (MVCs) can cause blunt cerebrovascular injury (BCVI). Exploring MVC characteristics that increase BCVI may reduce missed injuries. This study aims to evaluate the association between airbag deployment and BCVI. METHODS: We analyzed the 2016-Trauma Quality Improvement Database including adult MVC drivers. Patients were stratified: airbag deployment(A+) and no-airbag deployment(A-). Outcomes were BCVI, and cervical spine injuries (CSI). RESULTS: A total of 122,973 patients were identified: A+: 106,492, and A-: 16,481. The incidence of BCVI was 1907 (1.6%): and CSI was 20,711 (16.8%). A+ patients had a higher rate of BCVI (1.6% vs. 1.1%; p < 0.001), but a lower rate of CSI (16.2% vs. 21.4%; p < 0.001). On regression analysis, A+ was associated with BCVI (1.419[1.184-1.701]; p < 0.001) but was protective for CSI (0.767[0.672-0.878]; p < 0.001). CONCLUSION: A+ may be an unrecognized risk factor for BCVI even for patients without a CSI. Expanding BCVI screening criteria to include A+ may reduce missed injuries. LEVEL OF EVIDENCE: Level III, prognostic.

Venous thromboembolism as the first sign of malignancy.

BACKGROUND: Venous thromboembolism (VTE) is commonly associated with hypercoagulability in patients with cancer; however, there have been few investigations of VTE as the first sign of malignancy and even fewer performed in the United States. The aim of our study was to evaluate the incidence and predictors of unrecognized malignancy in patients presenting with VTE. METHODS: We performed a 1-year retrospective analysis of the Nationwide Readmission Database, including patients aged 18 years or older, presenting with a primary diagnosis of deep vein thrombosis (DVT) or a pulmonary embolism (PE). Patients known to have preexisting malignant diseases were excluded. Outcomes included the rate of newly diagnosed malignancy within 6 months from the discovery of VTE and demographic or associated illness predictors for the diagnosis of malignancy. A regression analysis was performed, based on which a VTE malignancy score was developed. RESULTS: A total of 116,048 patients were identified with VTE (49.8% DVT, 41.7% PE, 8.6% DVT and PE), 16% (n = 18,294) with malignancy. Of the remaining 97,754 patients, 31% were readmitted within 6 months. The incidence of newly diagnosed malignancy within 6 months was 2.4% (n = 2354). The most common malignancies were gastrointestinal in origin (29.2%). Demographic and diagnostic predictors for malignancy included age 65 years or older, female sex, inferior vena cava (IVC) thrombus, upper extremity thrombus, and a Charlson Comorbidity Index score of 5 or more. Receiver operating characteristic curve analysis found a cutoff VTE Malignancy score of 3 (sensitivity, 86%; specificity, 89%) to be predictive of an increased risk of a newly discovered malignancy within 6 months. CONCLUSIONS: VTE can be a risk indicator of underlying malignancy. Validation of a patient risk stratification score using multiple demographic or comorbid predictors for VTE on index admission may offer an opportunity for earlier diagnosis of occult malignancy.

Hospitalization Costs and Outcomes of Open, Laparoscopic, and Robotic Liver Resections.

INTRODUCTION: Most liver resections performed in the United States are open. With the ever-increasing role of robotic surgery, our study's role is to assess national outcomes based on the surgical approach. METHODS: We performed a retrospective analysis of the 2015 National Readmission Database (NRD). We selected patients undergoing open, laparoscopic, and robotic hepatectomy. Propensity score matching was performed to match the three groups in terms of demographics, hospital characteristics, and resection type. Our primary outcome was 6-month readmission rates and associated costs. RESULTS: 3,872 patients were included in the analysis (open = 3,420, laparoscopic = 343, and robotic = 109). Robotic liver resection has lower 6-month readmission rates (18.3%) than the laparoscopic (26.7%) and open (30%) counterparts. The robotic approach was more cost-effective ($127,716.56 ± 12,567.31) than the open ($157,880.82 ± 18,560.2) and laparoscopic approach ($152,060.78 ± 8,890.13) in terms of the total cost which includes cost per readmission. CONCLUSIONS: There is a financial benefit of using robotics in terms of cost, hospital length of stay, and readmission rates in patients undergoing liver resection, cost.

Hepatectomy for Breast Cancer Metastasis and Sarcoma are more likely to have Adverse Outcomes than Hepatectomy for Primary Hepatocellular Cancer or for Colorectal Metastasis.

INTRODUCTION: Outcomes for hepatectomy for breast cancer metastasis and sarcomatous disease processes are not well defined in literature. We sought to use a national database to identify outcomes in these patients compared to subset of patients more well studied in literature - primary Hepatocellular cancer patients and patients with colorectal metastasis. METHODS: We identified patients undergoing major hepatectomy (≥ 3 segments) for primary hepatocellular cancer (HCC), sarcoma metastasis, breast cancer metastasis, and colorectal metastasis using NSQIP database. The Primary outcome measure was 30-day mortality. Secondary outcome measures were 30-day readmission and complication rates. RESULTS: A total of 5580 patients underwent major hepatectomy during the study period. Patients who underwent hepatectomy for breast cancer metastasis had higher incidence of in-hospital complications (37%) compared to sarcoma (29%), colon (26%), and HCC patients (24%) and 30-days readmission rate (37% vs. 29% - sarcoma vs. 26% - colon vs. 25% HCC). There was no difference in 30-days mortality among the groups. CONCLUSION: Patients undergoing major hepatectomies for breast cancer metastasis and sarcoma are more likely to have adverse outcomes than compared to their counterparts. This difference highlights the lack of experience in managing breast cancer and sarcoma with metastatic disease to the liver. This also highlights the difference in tumor biology among all the lesions we studied. An extensive discussion should take place when dealing with breast and sarcoma lesions in the liver because of these outcomes.

Angioembolization in intra-abdominal solid organ injury: Does delay in angioembolization affect outcomes?

INTRODUCTION: Angioembolization (AE) is an integral component in multidisciplinary algorithms for achieving hemostasis in patients with trauma. The American College of Surgeons Committee on Trauma recommends that interventional radiologists be available within 30 minutes to perform emergent AE. However, the impact of the timing of AE on patient outcomes is still not well known. We hypothesized that a delay in AE would be associated with increased mortality and higher blood transfusion requirements in patients with blunt intra-abdominal solid organ injury. METHODS: A 4-year (2013-2016) retrospective review of the ACS Trauma Quality Improvement Program database was performed. We included adult patients (age, ≥18 years) with blunt intra-abdominal solid organ injury who underwent AE within 4 hours of hospital admission. Patients who underwent operative intervention before AE were excluded. The primary outcome was 24-hour mortality. The secondary outcome was blood product transfusions. Patients were grouped into four 1-hour intervals according to their time from admission to AE. Multivariate regression analysis was performed to accommodate patient differences. RESULTS: We analyzed 1,009,922 trauma patients, of which 924 (1 hour, 76; 1-2 hours, 224; 2-3 hours, 350; 3-4 hours, 274) were deemed eligible. The mean ± SD age was 44 ± 19 years, and 66% were male. The mean ± SD time to AE was 144 ± 54 minutes, and 92% of patients underwent AE more than 1 hour after admission. Overall 24-hour mortality was 5.2%. On univariate analysis, patients receiving earlier AE had decreased 24-hour mortality (p = 0.016), but no decrease in blood products transfused. On regression analysis, every hour delay in AE was significantly associated with increased 24-hour mortality (p < 0.05). CONCLUSION: Delayed AE for hemorrhagic control in blunt trauma patients with an intra-abdominal solid organ injury is associated with increased 24-hour mortality. Trauma centers should ensure timeliness of interventional radiologist availability to prevent a delay in vital AE, and it should be a focus of quality improvement projects. LEVEL OF EVIDENCE: Prognostic, level III.

Nationwide analysis of whole blood hemostatic resuscitation in civilian trauma.

INTRODUCTION: Renewed interest in whole blood (WB) resuscitation in civilians has emerged following its military use. There is a paucity of data on its role in civilians where balanced component therapy (CT) resuscitation is the standard of care. The aim of this study was to assess nationwide outcomes of using WB as an adjunct to CT versus CT alone in resuscitating civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program. We included adult (age, ≥18 years) trauma patients presenting with hemorrhagic shock and requiring at least 1 U of packed red blood cells (pRBCs) within 4 hours. Patients were stratified into WB-CT versus CT only. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were hospital length of stay and major complications. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 8,494 patients were identified, of which 280 received WB-CT (WB, 1 [1-1]; pRBC, 16 [10-23]; FFP, 9 [6-16]; platelets, 3 [2-5]) and 8,214 received CT only (pRBC, 15 [10-24]; FFP, 10 [6-16]; platelets, 2 [1-4]). Mean ± SD age was 34 ± 16 years, 79% were male, Injury Severity Score was 33 (24-43), and 63% had penetrating injuries. Patients who received WB-CT had a lower 24-hour mortality (17% vs. 25%; p = 0.002), in-hospital mortality (29% vs. 40%; p < 0.001), major complications (29% vs. 41%; p < 0.001), and a shorter length of stay (9 [7-12] vs. 15 [10-21]; p = 0.011). On regression analysis, WB was independently associated with reduced 24-hour mortality (odds ratio [OR], 0.78 [0.59-0.89]; p = 0.006), in-hospital mortality (OR, 0.88 [0.81-0.90]; p = 0.011), and major complications (OR, 0.92 [0.87-0.96]; p = 0.013). CONCLUSION: The use of WB as an adjunct to CT is associated with improved outcomes in resuscitation of severely injured civilian trauma patients. Further studies are required to evaluate the role of adding WB to massive transfusion protocols. LEVEL OF EVIDENCE: Therapeutic, level IV.

Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury.

BACKGROUND: The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI. METHODS: We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed. RESULTS: A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality. CONCLUSION: Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle. LEVEL OF EVIDENCE: Therapeutic, level IV.

Nationwide analysis of cryopreserved packed red blood cell transfusion in civilian trauma.

BACKGROUND: Liquid packed red blood cells (LPRBCs) have a limited shelf life and worsening quality with age. Cryopreserved packed red blood cells (CPRBCs) can be stored up to 10 years with no quality deterioration. The effect of CPRBCs on outcomes in civilian trauma is less explored. This study aims to evaluate the safety and efficacy of CPRBCs in civilian trauma patients. METHODS: We analyzed the (2015-2016) Trauma Quality Improvement Program, including adult (age, ≥18 years) patients who received a RBC transfusion within 4 hours of admission. Patients were stratified, those who received LPRBC and those who received CPRBC. Primary outcomes were 24-hour and in-hospital mortality. Secondary outcomes were major complications. Propensity matching was performed adjusting for demographics, vitals, blood components, injury parameters, comorbidities, and center parameters. RESULTS: A total of 39,975 patients were identified, and a matched cohort of 483 was obtained. A total of 161 received CPRBC (CPRBC, 2 [2-4]; plasma, 2 [0-5]; platelets, 1 [0-2]) and 322 received LPRBC (LPRBC, 3 [2-6]; plasma, 3 [0-6]; platelets, 1 [0-2]). The mean age was 43 ± 22 years, 62% were men, Injury Severity Score was 18 (12-27), and 65% had a blunt injury. Patients who received CPRBC had similar 24-hour mortality (1.8% vs. 2.3%; p = 0.82) and in-hospital mortality (4.9% vs. 5.2%; p = 0.88). No difference was found in terms of complications (15.3% vs. 17.2%; p = 0.21) between the two groups. CONCLUSION: Transfusion of CPRBCs may be as safe and effective as transfusion of LPRBCs in moderately injured trauma patients. Cryopreservation has the potential to expand our transfusion armamentarium in diverse settings, such as periods of increased usage, disaster scenarios, and rural areas. LEVEL OF EVIDENCE: Therapeutic study, level III.

The role of cryoprecipitate in massively transfused patients: Results from the Trauma Quality Improvement Program database may change your mind.

BACKGROUND: Cryoprecipitate was developed for the treatment of inherited and acquired coagulopathies. The role of cryoprecipitate in hemorrhaging trauma patients is still speculative. The aim of our study was to assess the role of cryoprecipitate as an adjunct to transfusion in trauma patients. METHODS: We performed a 2-year (2015-2016) analysis of the American College of Surgeons-Trauma Quality Improvement Program data set and included all adult trauma patients who received 4 or greater packed red blood cells (pRBCs)/4 hours. Patients were stratified based on receipt of cryoprecipitate within the first 24 hours (cryoprecipitate vs. no-cryoprecipitate). Outcomes were blood products transfused, in-hospital complications, and mortality. Regression analyses were performed. RESULTS: A total of 19,643 (cryoprecipitate, 4,945; no-cryoprecipitate, 14,698) were included. Mean age was 40 ± 22 years, median Injury Severity Score was 27 [18-40], and Glasgow Coma Scale score was 9 [3-14]. The overall complication rate was 45%, mortality was 47%, and 29% of the patients died in the first 24 hours. Patients in the cryoprecipitate group received a lower volume of plasma (p < 0.01), and pRBCs (p < 0.01). Additionally, patients who received cryoprecipitate had lower rates of 24-hour mortality (p < 0.01) and in-hospital mortality (p < 0.01). However, there was no difference between the two groups regarding complications (p = 0.36) or volume of platelet transfused (p = 0.22). On multivariate logistic regression, the use of cryoprecipitate was associated with decreased (odds ratio [OR], 0.78 [0.63-0.84]; p = 0.02), in-hospital mortality (OR, 0.79 [0.77-0.87]; p = 0.01), but had no association with in-hospital complications (OR, 1.48 [0.71-1.99]; p = 0.31). On linear regression analysis, the use of cryoprecipitate was not associated with 24-hour pRBCs (ß = -0.12 [-0.28 to 0.27], p = 0.47), 24-hour plasma (ß = -0.06 [-0.21 to 0.43], p = 0.29), and 24-hour platelets (ß = -0.24 [-0.09 to 0.33], p = 0.17) transfusion requirements. CONCLUSION: The adjunctive use of cryoprecipitate in hemorrhaging trauma patients may reduce mortality without affecting in-hospital complications and transfusion requirements. Further studies are needed to better understand its potentially beneficial effects. LEVEL OF EVIDENCE: Therapeutic, level IV.

Treatment of blunt cerebrovascular injuries: Anticoagulants or antiplatelet agents?

BACKGROUND: Blunt cerebrovascular injury (BCVI) is associated with cerebrovascular accidents (CVA). Early therapy with antiplatelet agents or anticoagulants is recommended. There are limited data comparing the effectiveness of these treatments. The aim of our study was to compare outcomes between BCVI patients who received anticoagulants versus those who received antiplatelet agents. METHODS: We performed an (2011-2015) analysis of the Nationwide Readmission Database and included all adult trauma patients 18 years or older who had an isolated BCVI (other body regions Abbreviated Injury Scale [AIS] < 3). Head injury patients or those who developed a CVA during the index admission were excluded. Patients were stratified into anticoagulants and antiplatelet agents. Propensity score matching was performed (1:1 ratio) to control for demographics, comorbidities, BCVI grade, distribution, and severity of injuries. Outcomes were readmission with CVA and mortality within 6 months. RESULTS: A total of 725 BCVI patients were identified. A matched cohort of 370 patients (antiplatelet agents, 185; anticoagulants, 185) was obtained. Mean age was 50 ± 15 years, neck AIS was 3 (3,4), and Injury Severity Score was 12 (9-17). The majority of the patients (69%) had high-grade BCVI (AIS ≥ 3). Overall, 3.7% were readmitted with CVA and 3% died within 6 months. Patients who received anticoagulants had a lower rate of readmission with CVA (1.8% vs. 5.72%; p = 0.03), and a lower rate of 6-month mortality (1.3% vs. 4.9%; p = 0.03). There was no significant difference between the two groups reading the median time to stroke (9 days vs. 6 days; p = 0.12). CONCLUSION: The BCVI patients on CVA prophylaxis for BCVI have a 3.7% rate of stroke after discharge. Compared with antiplatelet agents, anticoagulants are associated with lower rates of CVA in the first 6-month postdischarge. Further studies are required to identify the optimal agent to prevent CVA in this high-risk subset of trauma patients. LEVEL OF EVIDENCE: Therapeutic, level IV.

Barriers to improving health care value in emergency general surgery: A nationwide analysis.

INTRODUCTION: There is a growing need to improve the quality of care while decreasing health care costs in emergency general surgery (EGS). Health care value includes costs and quality and is a targeted metric by improvement programs. The aim of our study was to evaluate the trend of health care value in EGS over time and to identify barriers to high-value surgical care. METHODS: The (2012-2015) National Readmission Database was queried for patients 18 years or older who underwent an EGS procedure (according to the American Association for the Surgery of Trauma definition). Health care value (V = quality metrics/cost) was calculated from the rates of freedom from readmission, major complications, reoperation, and failure to rescue (FTR) indexed over inflation-adjusted hospital costs. Outcomes were the trends in the quality metrics: 6-month readmission, major complications, reoperation, FTR, hospital costs, and health care value over the study period. Multivariable linear regression was performed to determine the predictors of lower health care value. RESULTS: We identified 887,013 patients who underwent EGS. Mean ± SD age was 51 ± 20 years, and 53% were male. The rates of 6-month readmission, major complications, reoperation, and FTR increased significantly over the study period. The median hospital costs also increased over the study period (2012, US $9,600 to 2015, US $13,000; p < 0.01). However, the health care value has decreased over the study period (2012, 0.35; 2013, 0.30; 2014, 0.28; 2015, 0.25; p < 0.01). Predictors of decreased health care value in EGS are age 65 years or older (ß = -0.568 [-0.689 to -0.418], more than three comorbidities (ß = -0.292 [-0.359 to -0.21]), readmission to a different hospital (ß = -0.755 [-0.914 to -0.558]), admission to low volume centers (ß = -0.927 [-1.126 to -0.682]), lack of rehabilitation (ß = -0.004 [-0.005 to -0.003]), and admission on a weekend (ß = -0.318 [-0.366 to -0.254]). CONCLUSION: Health care value in EGS appears to be declining over time. Some of the factors leading to decreased health care value in EGS are potentially modifiable. Health care value could potentially be improved by reducing fragmentation of care and promoting regionalization. LEVEL OF EVIDENCE: Economic, level IV.

Prospective evaluation of preoperative cognitive impairment and postoperative morbidity in geriatric patients undergoing emergency general surgery.

BACKGROUND: Cognitive impairment (CI) is common in geriatric patients. We aimed to evaluate the prevalence and impact of CI on outcomes in geriatric patients undergoing emergency general surgery (EGS). METHODS: We performed a (2017-2018) prospective analysis of patients (age ≥65y) who underwent EGS. Cognition was assessed using the Montreal Cognitive Assessment (MoCA). Patients were stratified into: CI (MoCA score<26) and no-CI (MoCA≥26). Outcomes were the prevalence of CI, in-hospital complications, discharged to rehab/skilled nursing facility (SNF), and mortality. RESULTS: A total of 142 patients were enrolled. Overall prevalence of CI was 20%. Patients with CI had higher rates of complications (OR 1.6 [1.4-1.9]; p = 0.01), and discharge to rehab/SNF (OR 2.2 [2.0-2.5]; p = 0.03). There was no difference in mortality (OR 1.1 [0.6-1.8]; p = 0.24) between the 2 groups. CONCLUSION: One in five geriatric EGS patients has CI. It is associated with higher complications and adverse discharge. Cognitive assessment should be included in preoperative risk stratification.

Beta-Blocker Therapy in Severe Traumatic Brain Injury: A Prospective Randomized Controlled Trial.

BACKGROUND: Observational studies have demonstrated improved outcomes in TBI patients receiving in-hospital beta-blockers. The aim of this study is to conduct a randomized controlled trial examining the effect of beta-blockers on outcomes in TBI patients. METHODS: Adult patients with severe TBI (intracranial AIS ≥ 3) were included in the study. Hemodynamically stable patients at 24 h after injury were randomized to receive either 20 mg propranolol orally every 12 h up to 10 days or until discharge (BB+) or no propranolol (BB-). Outcomes of interest were in-hospital mortality and Glasgow Outcome Scale-Extended (GOS-E) score on discharge and at 6-month follow-up. Subgroup analysis including only isolated severe TBI (intracranial AIS ≥ 3 with extracranial AIS ≤ 2) was carried out. Poisson regression models were used. RESULTS: Two hundred nineteen randomized patients of whom 45% received BB were analyzed. There were no significant demographic or clinical differences between BB+ and BB- cohorts. No significant difference in in-hospital mortality (adj. IRR 0.6 [95% CI 0.3-1.4], p = 0.2) or long-term functional outcome was measured between the cohorts (p = 0.3). One hundred fifty-four patients suffered isolated severe TBI of whom 44% received BB. The BB+ group had significantly lower mortality relative to the BB- group (18.6% vs. 4.4%, p = 0.012). On regression analysis, propranolol had a significant protective effect on in-hospital mortality (adj. IRR 0.32, p = 0.04) and functional outcome at 6-month follow-up (GOS-E ≥ 5 adj. IRR 1.2, p = 0.02). CONCLUSION: Propranolol decreases in-hospital mortality and improves long-term functional outcome in isolated severe TBI. This randomized trial speaks in favor of routine administration of beta-blocker therapy as part of a standardized neurointensive care protocol. LEVEL OF EVIDENCE: Level II; therapeutic. STUDY TYPE: Therapeutic study.

Multicenter Validation of the Revised Assessment of Bleeding and Transfusion (RABT) Score for Predicting Massive Transfusion.

BACKGROUND: Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients. METHODS: We performed a (2015-2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score's predictive power compared to the Assessment of Blood Consumption (ABC) score. RESULTS: We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22-36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score. CONCLUSION: The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.

Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery.

BACKGROUND: The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients. STUDY DESIGN: We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery. RESULTS: A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01). CONCLUSIONS: The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.

Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury.

BACKGROUND: Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI. METHODS: We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed. RESULTS: We analyzed 292 patients. Mean age was 11 ±â€¯6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01). CONCLUSION: NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes. LEVEL OF EVIDENCE: III Prognostic.