Venous Thromboembolism Chemoprophylaxis Compliance in the Surgical Intensive Care Unit.

INTRODUCTION: Early initiation of venous thromboembolism chemoprophylaxis (VTEp) decreases VTE risk in trauma patients in the Surgical Intensive Care Unit (SICU). The frequency and variation of VTEp interruption by different surgical subspecialties in the SICU is incompletely described in the literature. The objective of this study was to examine VTEp compliance in the SICU in terms of uninterrupted VTEp following initiation, both by surgical service and time of year, to identify opportunities for improvement. METHODS: This single-center quality improvement (QI) study examined all SICU patients, which are almost exclusively trauma patients, at our institution (1/2021-04/2022). Exclusions were therapeutic anticoagulation. Type of VTEp, calendar month of SICU stay, perceived indications for interruption, and primary service were collected. RESULTS: Of 5 434 patient days (PD), VTEp was not administered in 1879 (35%). Common reasons for VTEp interruption were ongoing bleeding (n = 964 PD, 51%) and periprocedural status (n = 651 PD, 35%). Periprocedural interruption was highest in July. Acute Care Surgery (ACS) (n = 208 PD, 32%) and Orthopedics (n = 188 PD, 29%) interrupted VTEp most often. ACS most commonly withheld VTEp for second look laparotomies while Orthopedics withheld VTEp for intramedullary nailing or external fixator application. CONCLUSION: Missed VTEp doses occurred most frequently at the beginning of the residency year, with a high percentage held for periprocedural status. Because the necessity of periprocedural VTEp holds is unclear, the appropriateness of these holds and any impact on VTE rates will be assessed as the next steps. In the interim, our findings provide targets for multidisciplinary QI endeavors.

Pseudoaneurysm after High-Grade Penetrating Solid Organ Injury and Utility of Delayed CT Angiography.

BACKGROUND: Leaving an injured solid organ in situ allows preservation of structure function but invites complications from the damaged parenchyma, including pseudoaneurysms (PSAs). Empiric PSA screening after solid organ injury is not yet established, particularly following penetrating trauma. The study objective was definition of delayed CT angiography (dCTA) yield in triggering intervention for PSA after penetrating solid organ injury. METHODS: Penetrating trauma patients at our American College of Surgeons-verified level 1 center with American Association for the Surgery of Trauma grade ≥3 abdominal solid organ injury (liver, spleen, kidney) were retrospectively screened (January 2017 to October 2021). Exclusions were age <18 y, transfers, death within <48 h, and nephrectomy/splenectomy within <4 h. Primary outcome was intervention triggered by dCTA. Statistical testing with ANOVA/chi-square compared outcomes between screened vs unscreened patients. RESULTS: A total of 136 penetrating trauma patients met study criteria: 57 patients (42%) screened for PSA with dCTA and 79 (58%) unscreened. Liver injuries were most common (n = 41, 64% vs n = 55, 66%), followed by kidney (n = 21, 33% vs n = 23, 27%) and spleen (n = 2, 3% vs n = 6, 7%) (p = 0.48). Median American Association for the Surgery of Trauma grade of solid organ injury was 3 (3 to 4) across groups (p = 0.75). dCTA diagnosed 10 PSAs (18%) at a median of hospital day 5 (3 to 9). Among screened patients, dCTA triggered intervention in 17% of liver patients, 29% of kidney patients, and 0% of spleen-injured patients, for an overall yield of 23%. CONCLUSIONS: Half of eligible penetrating high-grade solid organ injuries were screened for PSA with dCTA. dCTA identified a significant number of PSAs and triggered intervention in 23% of screened patients. dCTA did not diagnose any PSAs after splenic injury, although sample size hinders interpretation. To avoid missing PSAs and incurring their risk of rupture, universal screening of high-grade penetrating solid organ injuries may be prudent.

Pseudoaneurysms after high-grade blunt solid organ injury and the utility of delayed computed tomography angiography.

PURPOSE: Pseudoaneurysms (PSA) can occur following high-grade solid organ injury. PSA natural history is unclear but risk for spontaneous rupture and exsanguination exist. The yield of delayed CT Angiography (dCTA) for PSA diagnosis is not well delineated and optimal timing is undefined. The study objective was definition of dCTA utility in diagnosing and triggering intervention for PSA after high-grade blunt solid organ injury. METHODS: All blunt trauma patients arriving to our ACS-verified Level 1 trauma center with AAST grade ≥ III liver, spleen, and/or kidney injury were included in this retrospective observational study (01/2017-10/2021). Exclusions were age < 18 year, transfers in, death < 48 h, and immediate nephrectomy/splenectomy. dCTA performance was not protocolized and pursued at attending surgeon discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was dCTA-triggered intervention. Statistical testing with ANOVA/Chi squared compared outcomes by type of solid organ. RESULTS: 349 blunt trauma patients with 395 high-grade solid organ injuries met study criteria. Median AAST grade of solid organ injury was 3 [3-4]. dCTA for PSA screening was pursued in 175 patients (44%), typically on hospital day 4 [3-7]. dCTA identified vascular lesions in 16 spleen, 10 liver, and 6 kidney injuries. dCTA triggered intervention in 24% of spleen, 13% of kidney, and 9% of liver injured patients who were screened, for an overall yield of 14%. Intervention was typically AE (n = 23, 92%), although two splenic PSA necessitated splenectomy. CONCLUSION: Delayed CTA for PSA screening after high-grade blunt solid organ injury was performed in half of eligible patients. dCTA identified numerous vascular lesions requiring endovascular or surgical intervention, with highest yield for splenic injuries. We recommend consideration of universal screening of high-grade blunt solid organ injuries with delayed abdominal CTA to avoid missing PSA.

Asymptomatic Covid-19 Trauma Patients Have Worse Outcomes and Resource Utilization: A Matched Cohort Study.

OBJECTIVE: To evaluate the impact of COVID-19 positivity on outcomes and resource utilization in the trauma population. INTRODUCTION: COVID-19 infection worsens outcomes of trauma patients, but it is not known if asymptomatic COVID-19 trauma patients have different outcomes from COVID-19-negative patients. METHODS: All trauma patients admitted to an urban level 1 trauma center between March 2020 and October 2021 were collected and reviewed for COVID-19 status. COVID-19-positive patients with symptoms or initial chest radiographs consistent with infections were excluded. Propensity score model 1:3 matched asymptomatic COVID-19-positive to COVID-19-negative trauma patients for their age, body mass index, MOA, injury severity score, SBP<90, GCS<9, and comorbidities. Outcomes included mortality, complications, and resource utilization. RESULTS: A total of 185 asymptomatic COVID-19-positive patients were matched with 554 COVID-19-negative patients. Asymptomatic COVID-19 -positive patients had higher rates of myocardial infarction and cardiac arrest (3.2% vs. 0.9%, P =0.023), higher ventilator days (3.33 vs. 1.49 days, P <0.001), ICU-length of stay [LOS (4.92 vs. 3.41 d, P =0.034)], overall LOS (11.41 vs. 7.24 d, P <0.001), and hospital charges ($ 176.505.80 vs. 107.591.93, P =0.002). CONCLUSION: Asymptomatic COVID-19 trauma patients have significantly higher rates of cardiac events, longer LOS, and higher hospital charges when compared with similar trauma patients who are COVID-19-negative.

REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been used as a damage control procedure in trauma patients. We hypothesized that REBOA increases risk of venous thromboembolic (VTE) complications. METHODS: This was an American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database study. Excluded were transfers, deaths within 24 h, and severe head injuries. Included were trauma patients receiving REBOA within 4 h from arrival. Outcomes in the two groups were compared after using propensity score matching (PSM) for demographic and clinical characteristics, body area abbreviated injury scale, injury severity score, pelvis and lower extremity fractures, angiographic intervention, preperitoneal pelvic packing, pharmacological VTE prophylaxis, laparotomy, laparotomy and specific orthopedic procedures. RESULTS: After PSM, 339 REBOA patients were matched with 663 patients with No REBOA. REBOA patients were significantly more likely to develop pulmonary embolism (PE) (5.3% vs. 2.7%, p = .037) and VTE (14.7% vs. 10.0%, p = .025). CONCLUSION: REBOA is associated with an increased risk of PE and VTE complications. Patients managed with REBOA should receive adequate thromboprophylaxis and be monitored closely for VTE complications.

Pseudoaneurysm Screening after Pediatric High Grade Solid Organ Injury.

BACKGROUND: High grade solid organ injuries carry risk of complications, including pseudoaneurysms (PSA). The optimal approach to PSA screening among pediatric patients is unknown and may include delayed Computed Tomography Angiography (dCTA) and/or contrast-enhanced ultrasound (CEUS). This study endeavored to define dCTA/CEUS yield in PSA diagnosis after pediatric high grade solid organ injury. METHODS: Patients <18y presenting to our ACS-verified Level 1 trauma center with ≥1 AAST grade ≥3 abdominal solid organ injury (kidney, liver, and spleen) were included (01/2017-10/2021). Transfers in, death <48h, and immediate nephrectomy/splenectomy were exclusions. PSA screening was pursued selectively based on attending discretion. Demographics, clinical/injury data, and outcomes were collected. Primary outcome was performance of dCTA or CEUS. RESULTS: Forty-two patients satisfied criteria, with median age 12.5y and ISS 22. Liver injuries were most frequent (48%), followed by spleen (33%) and kidney (19%). Initial management strategy was most commonly nonoperative (liver 60%, spleen 64%, kidney 75%). Overall, 26% underwent PSA screening at a median of hospital day 4, with dCTA (21%) or CEUS (5%). CEUS was only used among liver injuries (10%), with no PSA identified. One PSA was diagnosed on dCTA after splenic injury and was managed with observation. CONCLUSION: PSA screening occurs infrequently after pediatric high grade solid organ injury, potentially due to concerns about radiation exposure from dCTA which would be mitigated with CEUS. Further delineation of PSA incidence and yield of screening investigations are needed to avoid missing this important diagnosis and to determine the diagnostic accuracy of dCTA and CEUS.

Nanoparticle-mediated miR200-b delivery for the treatment of diabetic retinopathy.

We recently reported that the Ins2(Akita) mouse is a good model for late-onset diabetic retinopathy. Here, we investigated the effect of miR200-b, a potential anti-angiogenic factor, on VEGF receptor 2 (VEGFR-2) expression and to determine the underlying angiogenic response in mouse endothelial cells, and in retinas from aged Ins2(Akita) mice. MiR200-b and its native flanking sequences were amplified and cloned into a pCAG-eGFP vector directed by the ubiquitous CAG promoter (namely pCAG-miR200-b-IRES-eGFP). The plasmid was compacted by CK30PEG10K into DNA nanoparticles (NPs) for in vivo delivery. Murine endothelial cell line, SVEC4-10, was first transfected with the plasmid. The mRNA levels of VEGF and VEGFR-2 were quantified by qRT-PCR and showed significant reduction in message expression compared with lipofectamine-transfected cells. Transfection of miR200-b suppressed the migration of SVEC4-10 cells. There was a significant inverse correlation between the level of expression of miR200-b and VEGFR-2. Intravitreal injection of miR200-b DNA NPs significantly reduced protein levels of VEGFR-2 as revealed by western blot and markedly suppressed angiogenesis as evaluated by fundus imaging in aged Ins2(Akita) mice even after 3months of post-injection. These findings suggest that NP-mediated miR200-b delivery has negatively regulated VEGFR-2 expression in vivo.