Moving the needle on time to resuscitation: An EAST prospective multicenter study of vascular access in hypotensive injured patients using trauma video review.

BACKGROUND: Vascular access in hypotensive trauma patients is challenging. Little evidence exists on the time required and success rates of vascular access types. We hypothesized that intraosseous (IO) access would be faster and more successful than peripheral intravenous (PIV) and central venous catheter (CVC) access in hypotensive patients. METHODS: An EAST prospective multicenter trial was performed; 19 centers provided data. Trauma video review was used to evaluate the resuscitations of hypotensive (systolic blood pressure ≤90 mm Hg) trauma patients. Highly granular data from video recordings were abstracted. Data collected included vascular access attempt type, location, success rate, and procedural time. Demographic and injury-specific variables were obtained from the medical record. Success rates, procedural durations, and time to resuscitation were compared among access strategies (IO vs. PIV vs. CVC). RESULTS: There were 1,410 access attempts that occurred in 581 patients with a median age of 40 years (27-59 years) and an Injury Severity Score of 22 [10-34]. Nine hundred thirty-two PIV, 204 IO, and 249 CVC were attempted. Seventy percent of access attempts were successful but were significantly less likely to be successful in females (64% vs. 71%, p = 0.01). Median time to any access was 5.0 minutes (3.2-8.0 minutes). Intraosseous had higher success rates than PIV or CVC (93% vs. 67% vs. 59%, p < 0.001) and remained higher after subsequent failures (second attempt, 85% vs. 59% vs. 69%, p = 0.08; third attempt, 100% vs. 33% vs. 67%, p = 0.002). Duration varied by access type (IO, 36 [23-60] seconds; PIV, 44 [31-61] seconds; CVC 171 [105-298]seconds) and was significantly different between IO versus CVC ( p < 0.001) and PIV versus CVC ( p < 0.001) but not PIV versus IO. Time to resuscitation initiation was shorter in patients whose initial access attempt was IO, 5.8 minutes versus 6.7 minutes ( p = 0.015). This was more pronounced in patients arriving to the hospital with no established access (5.7 minutes vs. 7.5 minutes, p = 0.001). CONCLUSION: Intraosseous is as fast as PIV and more likely to be successful compared with other access strategies in hypotensive trauma patients. Patients whose initial access attempt was IO were resuscitated more expeditiously. Intraosseous access should be considered a first line therapy in hypotensive trauma patients. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Quality of Life Is Improved 1 Year After Cardiac Surgery.

BACKGROUND: Quality of life (QoL) is increasingly important in the era of patient-centered outcomes and value-based reimbursement. However most follow-up is limited to 30 days, and long-term data on QoL improvement associated with symptom relief are lacking. Therefore we sought to analyze QoL after cardiac surgery in a nonemergent, all-comers population. METHODS: Four hundred two patients undergoing routine cardiac surgery at 2 large urban hospitals in the Dallas, Texas area were enrolled. Follow-up was complete for 364 patients. Data were collected from August 2013 to January 2017. The Kansas City Cardiomyopathy Questionnaire was administered at baseline, 1 month, and 1 year after surgery. Repeated-measures analysis was used for each domain of the questionnaire for all procedures and stratified by procedure. If time was found to be a significant factor, pairwise analysis was performed with P values adjusted using the Tukey-Kramer method. RESULTS: There was a significant increase across all domains of Kansas City Cardiomyopathy Questionnaire scores for all procedures and for most domains when stratifying by procedure. This increase in QoL was most marked after 1 month. All domain scores increased through 1 year except symptom stability, which peaked at 1 month postsurgery and then regressed at 1 year, suggesting an overall improvement and stabilization of symptoms. The occurrence of complications did not alter this trajectory. CONCLUSIONS: QoL and other patient-centered outcomes are improved at 1 month and continue to improve throughout the year. Knowledge of these data is important for patient selection, fully informed consent, and shared decision-making.

Open Surgical Approach for Type II Endoleak in Subclavian Artery Pseudoaneurysm Presented With Neurological Symptoms After Endovascular Repair.

We present a rare case of a 10-cm right subclavian artery pseudoaneurysm, with slow growth over 4 years after a traumatic fracture of the right clavicle. The patient had multiple prior endovascular attempts of embolization and stenting at other hospitals; despite this the pseudoaneurysm continued to grow and caused mass effect and neurologic symptoms. We present our open approach for the repair and a review of literature.

Albumin Is Predictive of 1-Year Mortality After Transcatheter Aortic Valve Replacement.

BACKGROUND: A validated model for predicting 1-year outcomes after transcatheter aortic valve replacement (TAVR) does not exist. TAVR-specific risk models may benefit from frailty markers, and sarcopenia may represent an objective frailty marker. This study assessed the predictive ability of sarcopenia and frailty markers on 1-year mortality after TAVR. METHODS: We evaluated 470 patients undergoing TAVR at a single center. Frailty was assessed using four markers: gait speed, hand grip strength, serum albumin, and Katz activities of daily living. Sarcopenia was measured as the cross-sectional psoas muscle area on pre-TAVR computed tomography. Performance of four models incorporating The Society of Thoracic Surgeons Predicted Risk of Mortality, frailty, or sarcopenia metrics, or both, for predicting 1-year mortality was assessed with area under the curve, Hosmer-Lemeshow statistics, and calibration plots. RESULTS: A total of 63 deaths (13.4%) deaths occurred by 1 year. The Society of Thoracic Surgeons Predicted Risk of Mortality alone was poorly predictive of 1-year mortality (area under the curve, 0.52; 95% confidence interval, 0.42 to 0.68). Only the model including sarcopenia and all frailty markers (area under the curve, 0.61; 95% confidence interval, 0.53 to 0.68) significantly improved predictive ability compared with The Society of Thoracic Surgeons Predicted Risk of Mortality alone (p = 0.05). Albumin was the only frailty marker significantly associated with increased risk for 1-year mortality (p = 0.03). Psoas muscle area, as a surrogate for sarcopenia, was not significantly associated with increased risk for 1-year mortality. CONCLUSIONS: Most of the commonly used pre-TAVR risk assessments are poorly predictive of 1-year mortality. Albumin was the only frailty marker that was associated with higher mortality. Future studies should investigate whether optimization of nutritional status can improve outcomes after TAVR.

Impingement of Single-Tilting Disc Mitral Prosthesis During Transcatheter Aortic Valve Replacement.

An 80-year-old woman with a medical history of mitral valve replacement with single-tilting disc prosthesis underwent transcatheter aortic valve replacement (TAVR). The tilting disc was noted to have abnormal motion after re-ballooning of the TAVR valve. Cardiopulmonary bypass was initiated, and the procedure was converted to surgical aortic valve replacement. After removal of the TAVR valve, the tilting disc moved freely. Although TAVR in patients with mitral prostheses is technically feasible, particular caution is necessary, and postdeployment dilation should be avoided.

David-V Procedure in a Patient with Aortic Dilation and Competent Quadricuspid Aortic Valve: Are Genetics to Blame?

Quadricuspid aortic valves (QAVs) are extremely rare. In this case study, we report a David-V valve-sparing aortic root replacement with reimplantation of a native QAV in a patient with aortic dilation, normal valve function, and a family history of aortic dissection. Microscopic pathological examination of the excised section of the aorta revealed scattered small foci of cystic medical degeneration throughout. A genetic predisposition for aortic dilation may be present in patients with QAV, even in the setting of a competent valve. Regular screening for aortic dilation in patients with known QAV should therefore be considered.