Optimal timing and outcomes among COVID-19 patients undergoing tracheostomy.

BACKGROUND: Patients who require mechanical ventilation secondary to severe COVID-19 infection have poor survival. It is unknown if the benefit of tracheostomy extends to COVID-19 patients. If so, what is the optimal timing? METHODS: Retrospective cohort study within a large hospital system in the United States. The population included patients with COVID-19 from January 1, 2020 to September 30, 2020. In total, 93,918 cases were identified. They were excluded if no intubation or tracheostomy, underwent tracheostomy before intubation, <18 years old, hospice patients before admission, and bacterial pneumonia. In total, 5,911 patients met the criteria. Outcomes between patients who underwent endotracheal intubation only versus tracheostomy were compared. The primary outcome was inpatient mortality. All patients who underwent tracheostomy versus intubation only were compared. Three cohort analysis compared early (<10 days) versus late (>10 days) tracheostomy versus control. Eight cohort analysis compared days 0-2, days 3-6, days 7-10, days 11-14, days 15-18, days 19-22, and days 23+ to tracheostomy versus control. RESULTS: There was an overall inpatient mortality rate of 37.5% in the tracheostomy cohort compared to 54.4% in the control group (P < .0001). There was an early tracheostomy group inpatient mortality rate of 44.7% (adjusted odds ratio 0.73, 95% confidence interval 0.52-1.01) compared to 33.1% (adjusted odds ratio 0.44, 95% confidence interval 0.34-0.58) in the late tracheostomy group. CONCLUSION: COVID-19 patients with tracheostomy had a significantly lower mortality rate compared to intubated only. Optimal timing for tracheostomy placement for COVID-19 patients is 11 days or later. Future studies should focus on early tracheostomy patients.

Practice Patterns of Transesophageal Echocardiography Use Among Trauma Patients: A Multi-Institutional Retrospective Study.

Transesophageal echocardiography (TEE) can be utilized for hemodynamic monitoring and resuscitation. In order to study the pattern of TEE use in trauma patients, a multi-institutional retrospective cohort study was performed comparing adult trauma patients who underwent TEE or those who underwent traditional invasive hemodynamic monitoring (TIHM). TIHM was defined as the use of arterial line, central venous line, or pulmonary artery catheter without TEE. Mortality rates were obtained and multivariable logistic regression was used to risk adjust for age, gender, race, insurance status, Glasgow coma scale (GCS), ICD Injury severity score (ICISS). Compared to TIHM group, more patients in TEE group had a history of congestive heart failure (CHF) or chronic pulmonary disease (CPD). Mortality rate was lower in the TEE group 7 versus 23% (P-value < .0001). After adjusting for GCS and ICISS in multivariable analysis, inpatient mortality was significantly lower in the TEE cohort.

Statewide Seasonal Variations of Infections Within the Intensive Care Unit Among the Trauma Population.

BACKGROUND: Infections within intensive care unit (ICU) are a persistent problem among the critically ill. Viral pneumonias have already been established as having a season variations. We attempt to evaluate the seasonal variations of pneumonia among the traumatically injured and the critically ill. MATERIALS AND METHODS: A retrospective cohort study among traumatized patients admitted from 1997 to 2017 to an ICU within the state of Florida was performed who were diagnosed with pneumonia. A multivariate regression analysis was performed to adjust for confounders. Time periods were divided into seasons: summer, winter, spring, and fall. A subset analysis of geriatric patients (>65 years) was also performed. RESULTS: A total of 869 553 patients were identified. The most common viral infection was influenza with adenovirus the least. The most common bacterial pneumonia was Staphylococcus aureus with Bordetella pertussis the least. Pneumonias had a seasonal variation. Compared to summer, winter had a higher likelihood of pneumonia overall (Adjusted Odds Ratio (AOR)1.13). This was seen in the spring (AOR 1.04) but not in fall (AOR 1.00). Viral infections were more pronounced (AOR 3.79) in all other seasons, while bacterial showed increased likelihood during winter (AOR 1.05). In geriatrics, pneumonia was again more likely in the winter (AOR 1.22) with both viral and bacterial infections being more pronounced during winter (AOR 4.79, AOR 1.09). DISCUSSION: Pneumonias are seen more frequently within the ICU during the winter for the traumatized patient. This held true with the critically ill geriatric population as well. This effect was observed in both viral and bacterial pneumonias.

Using a relational database to improve mortality and length of stay for a department of surgery: a comparative review of 5200 patients.

The emphasis on high-quality care has spawned the development of quality programs, most of which focus on broad outcome measures across a diverse group of providers. Our aim was to investigate the clinical outcomes for a department of surgery with multiple service lines of patient care using a relational database. Mortality, length of stay (LOS), patient safety indicators (PSIs), and hospital-acquired conditions were examined for each service line. Expected values for mortality and LOS were derived from University HealthSystem Consortium regression models, whereas expected values for PSIs were derived from Agency for Healthcare Research and Quality regression models. Overall, 5200 patients were evaluated from the months of January through May of both 2011 (n = 2550) and 2012 (n = 2650). The overall observed-to-expected (O/E) ratio of mortality improved from 1.03 to 0.92. The overall O/E ratio for LOS improved from 0.92 to 0.89. PSIs that predicted mortality included postoperative sepsis (O/E:1.89), postoperative respiratory failure (O/E:1.83), postoperative metabolic derangement (O/E:1.81), and postoperative deep vein thrombosis or pulmonary embolus (O/E:1.8). Mortality and LOS can be improved by using a relational database with outcomes reported to specific service lines. Service line quality can be influenced by distribution of frequent reports, group meetings, and service line-directed interventions.

Candida albicans necrotizing soft tissue infection: a case report and literature review of fungal necrotizing soft tissue infections.

BACKGROUND: Necrotizing fasciitis (NF) most often is caused by bacterial infection while a fungal source has been reported in immunosuppressed patients. Early wide surgical resection remains the mainstay of treatment. Split thickness skin grafts are both versatile and easy to harvest, thus making them a long-established option for soft tissue reconstruction. CASE REPORT: A 55-year-old man was admitted for gunshot wounds. Purulence was noted at the central catheter site. Cultures grew Candida albicans. Antifungal therapy was initiated and debridement for NF of the neck and upper chest was performed. The patient underwent reconstruction using a split thickness skin graft obtained from the anterolateral thigh. CONCLUSIONS: Necrotizing fasciitis secondary to Candida species infection is exceedingly rare. We report an unusual case of candidal NF in a patient with no past medical history of immunocompromise. Patients with this type of infection can be successfully treated with aggressive surgical debridement and intravenous anidulafungin.

Predicting resource utilization of elderly burn patients in the baby boomer era.

BACKGROUND: Census predictions for Florida suggest a 3-fold increase in the 65 and older population within 20 years. We predict resource utilization for burn patients in this age group. METHODS: Using the Florida Agency for Healthcare Administration admission dataset, we evaluated the effect of age on length of stay, hospital charges, and discharge disposition while adjusting for clinical and demographic factors. Using US Census Bureau data and burn incidence rates from this dataset, we estimated future resource use. RESULTS: Elderly patients were discharged to home less often and were discharged to short-term general hospitals, intermediate-care facilities, and skilled nursing facilities more often than the other age groups (P < .05). They also required home health care and intravenous medications significantly more often (P < .05). Their length of stay was longer, and total hospital charges were greater (P < .05) after adjusting for sex, race, Charleson comorbidity index, payer, total body surface area burned, and burn center treatment. CONCLUSIONS: Our data show an age-dependent increase in the use of posthospitalization resources, the length of stay, and the total charges for elderly burn patients.

A genomic analysis of Clostridium difficile infections in blunt trauma patients.

BACKGROUND: Evidence demonstrates that susceptibility to Clostridium difficile infection is related to host risk factors as much as bacterial potency. Using blood leukocyte genome-wide expression patterns of severe blunt trauma patients obtained by the National Institute of General Medical Sciences-sponsored Glue Grant Inflammation and the Host Response to Injury, we examined leukocyte genomic profiles of patients with C. difficile infection to determine preinfection and postinfection gene expression changes. METHODS: The genomic responses of 21 severe trauma patients were analyzed (5 C. difficile, 16 controls matched for age and severity of injury). After elimination of probe sets whose expression was below baseline or were unchanged, remaining probe sets underwent hierarchical clustering and principal component analysis. Molecular pathways were generated through Ingenuity Pathways Analysis. RESULTS: Supervised analysis demonstrated 118 genes whose expression in patients with C. difficile infection varied before and after their infection. Supervised analysis comparing patients with C. difficile infection with matched non-C. difficile patients before infection suggested that the expression of 501 genes were different in the two groups with up to 87% class prediction (p < 0.05). Many of these genes are related to cell-mediated immune responses, signaling, and interaction. CONCLUSION: Genomic analysis of severe blunt trauma patients reveals a distinct leukocyte expression profile of C. difficile both before and after infection. We conclude that an association may exist between a severe trauma patient's leukocyte genomic expression profile and subsequent susceptibility to C. difficile infection. Further prospective expression analysis of this C. difficile population may reveal potential therapeutic interventions and allow early identification of C. difficile-susceptible patients. LEVEL OF EVIDENCE: Prognostic/diagnostic study, level III.

Utilization of minimally invasive breast biopsy for the evaluation of suspicious breast lesions.

BACKGROUND: Percutaneous needle biopsy, also known as minimally invasive breast biopsy (MIBB), has become the gold standard for the initial assessment of suspicious breast lesions. The purpose of this study is to determine modern rates of MIBB and open breast biopsy. METHODS: The Florida Agency for Health Care Administration outpatient surgery and procedure database was queried for patients undergoing open surgical biopsy and MIBB between 2003 and 2008. RESULTS: Although there was an increase in the use of MIBB, the overall rate of open surgical biopsy remained high (∼30%). A reduction in the open biopsy rate from 30% to 10% could be associated with a charge reduction of >$37.2 million per year. CONCLUSIONS: The current rate of open surgical breast biopsy remains high. Interventions and quality initiatives are warranted, which could lead to a reduction in unnecessary operations for women, improved patient care, and a reduction in breast health care costs.

Complication rates among trauma centers.

BACKGROUND: The goal of this study was to examine the association between patient complications and admission to Level I trauma centers (TC) compared with nontrauma centers (NTC). STUDY DESIGN: This was a retrospective cohort study of data derived from the National Study on the Costs and Outcomes of Trauma (NSCOT). Patients were recruited from 18 Level I TCs and 51 NTCs in 15 regions encompassing 14 states. Trained study nurses, using standardized forms, abstracted the medical records of the patients. The overall number of complications per patient was identified, as was the presence or absence of 13 specific complications. RESULTS: Patients treated in TCs were more likely to have any complication compared with patients in NTCs, with an adjusted relative risk (RR) of 1.34 (95% CI, 1.03, 1.74). For individual complications, only the urinary tract infection RR of 1.94 (95% CI, 1.07, 3.17) was significantly higher in TCs. TC patients were more likely to have 3 or more complications (RR, 1.83; 95% CI, 1.16, 2.90). Treatment variables that are surrogates for markers of injury severity, such as use of pulmonary artery catheters, multiple operations, massive transfusions (> 2,500 mL packed red blood cells), and invasive brain catheters, occurred significantly more often in TCs. CONCLUSIONS: Trauma centers have a slightly higher incidence rate of complications, even after adjusting for patient case mix. Aggressive treatment may account for a significant portion of TC-associated complications. Pulmonary artery catheter use and intubation had the most influence on overall TC complication rates. Additional study is needed to provide accurate benchmark measures of complication rates and to determine their causes.

A case of dual thoracoabdominal impalement in vehicular trauma.

Impalement injuries are relatively uncommon during vehicular trauma. We present a dual case report of patients sustaining simultaneous impalement injuries during a high-speed motor vehicle collision in a rural (austere) environment. After Institutional Review Board approval, we performed a review of the patients' medical records. Two young men were traveling in an automobile at high speed when the driver lost control of the vehicle, causing it to strike a wooden fence. Portions of the fence were dislodged, penetrated the windshield, and impaled both the driver and passenger. Both patients were extricated rapidly and transported to our trauma center. Multidisciplinary teams consisting of trauma, thoracic, plastic, and hepatobiliary surgeons addressed the injuries of both patients. Both survived their injuries and have since returned to their homes. This case of dual impalements highlights three key points: first, the principles of management of thoracoabdominal impalement injuries; second, the importance of rapid action of first responders in complex traumas; and finally, the value of using a multidisciplinary surgical team in complicated trauma cases.

The use of Seprafilm in pediatric surgical patients.

Hyaluronate carboxymethylcellulose (Seprafilm; Genzyme Corp., Cambridge, MA) has been demonstrated to be safe and efficacious for the prevention of abdominal and pelvic adhesions; however, information is scarce regarding its use in children and adolescents. We wanted to characterize our experience with Seprafilm in a pediatric surgical population. After Institutional Review Board approval, we searched our hospital and pediatric surgery database for cases in which Seprafilm was used and retrospectively reviewed medical records for demographic and clinical information. Between July 2000 and October 2005, 18 patients had Seprafilm placed. Patients ranged in age from 0.25 to 18 years. Seven patients had not undergone any previous operations. Of patients having undergone prior surgery, the most common preceding intervention was a Ladd's procedure. Seprafilm was applied in a variety of scenarios, the most frequently being adhesiolysis for bowel obstruction. No patient required reoperation for obstruction. Two patients underwent subsequent operations for unrelated reasons; one was noted to have no significant adhesions, but the other had extensive adhesions. No patient demonstrated signs or symptoms of small bowel obstruction, intraperitoneal abscess, or localized inflammatory reaction to Seprafilm. Seprafilm was successfully used in our pediatric surgical population without complications.