A comprehensive analysis of undertriage in a mature trauma system using geospatial mapping.

INTRODUCTION: The correct triage of trauma patients to trauma centers (TCs) is essential. We sought to determine the percentage of patients who were undertriaged within the Pennsylvania (PA) trauma system and spatially analyze areas of undertriage (UTR) in PA for all age groups: pediatric, adult, and geriatric. We hypothesized that there would be certain areas that had high UTR for all age groups. METHODS: From 2003 to 2015, all admissions from the Pennsylvania Trauma Systems Foundation registry and those meeting trauma criteria (International Classification of Diseases, Ninth Diseases: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Admissions were divided into age groups: pediatric (<15 years), adult (15-64 years), and geriatric (≥65 years). All pediatric trauma cases were included from the Pennsylvania Trauma Systems Foundation and PHC4 registry, while only cases with Injury Severity Score of >9 were included in adult and geriatric age groups. Undertriage was defined as patients not admitted to level I/II adult TCs (n = 24), pediatric (n = 3), or adult and pediatric combined facility (n = 3) divided by the total number of patients from the PHC4 database. ArcGIS Desktop (version 10.7; ESRI, Redlands, CA) and GeoDa (version 1.14.0; CSDS, Chicago, IL) open source license were used for geospatial mapping of UTR with a spatial empirical Bayesian smoothed UTR by zip code tabulation area (ZCTA) and Stata (version 16.1; Stata Corp., College Station, TX) for statistical analyses. RESULTS: There were significant percentages of UTR for all age groups. One area of high UTR for all age groups had TCs and large nontrauma centers in close proximity. There were high rates of UTR for all ages in rural areas, specifically in the upper central regions of PA, with limited access to TCs. CONCLUSION: It appears there are two patterns leading to UTR. The first is in areas where TCs are in close proximity to large competing nontrauma centers, which may lead to inappropriate triage. The second has to do with lack of access to TCs. Geospatial mapping is a valuable tool that can be used to ascertain where trauma systems should focus scarce resources to decrease UTR. LEVEL OF EVIDENCE: Epidemiological, level III; Care management, level III.

The Effects of Fasting Status on the Relative Risk of Pulmonary Aspiration in Acute Care Surgery Patients.

BACKGROUND: Acute care surgery patients are often unfasted at the time of surgery, presenting a unique opportunity to study the effects of fasting on the risk of pulmonary aspiration. We aimed to determine the relative risk of aspiration in patients who were fasted at the time of surgery according to guidelines versus those in an unfasted state. METHODS: A retrospective chart review of 100 patients who underwent appendectomy (n = 76) or exploratory laparotomy (n = 24) was conducted at a single institution in 2016-2017. Using the American Society of Anesthesiologists (ASA) Practice Guidelines for Preoperative Fasting, patients were stratified into study and control groups according to whether they were unfasted (nothing by mouth for <8 hours prior to surgery) or fasted (nothing by mouth for >8 hours prior to surgery). Data controlled for patients' age, sex, body mass index (BMI), most recent hemoglobin A1c, presence of gastroesophageal reflux disease (GERD), and presence of hiatal hernia. RESULTS: Of the 76 patients who underwent appendectomy, 15% were unfasted with a total of 0 aspiration events (P < .001). Of the 24 patients who underwent exploratory laparotomy, 42% were unfasted with a total of 0 aspiration events (P < .001). This yields a relative risk of pulmonary aspiration of 1.0 (absolute risk of 0) in both the study and control groups. DISCUSSION: In an acute care surgery population including patients who were not fasted according to guidelines, there was no increase in the risk of pulmonary aspiration. LEVEL OF EVIDENCE: Epidemiological study; Level III.

Contemporary management of civilian penetrating cervicothoracic arterial injuries.

BACKGROUND: The management of arterial injury at the thoracic outlet has long hinged on the fundamental principles of extensile exposure and vascular anastomosis. Nonetheless, treatment options for such injuries have evolved to include both endovascular stent placement and temporary vascular shunts. The purpose of this study was to evaluate our recent experience with penetrating cervicothoracic arterial injuries in light of these developments in trauma care. METHODS: Patients with penetrating injuries to the innominate, carotid, subclavian, or axillary arteries managed at a single civilian trauma center between 2000 and 2013 were categorized as the modern era (ME) cohort. The management strategies and outcomes pertaining to the ME group were compared to those of previously reported experience (PE) concerning injuries to the innominate, carotid, subclavian, or axillary arteries at the same institution from 1974 to 1988. RESULTS: Over the two eras, there were 202 patients: 110 in the ME group and 92 in the PE group. Most of the injuries in both groups were managed with primary repair (45% vs. 46%; p = 0.89). A similar proportion of injuries in each group was managed with anticoagulation alone (14% vs. 10%; p = 0.40). In the ME group, two cases were managed with temporary shunt placement, and endovascular stent placement was performed in 12 patients. Outcomes were similar between the groups (bivariate comparison): mortality (ME, 15% vs. PE, 14%; p = 0.76), amputation following subclavian or axillary artery injury (ME, 5% vs. PE, 4%; p = 0.58), and posttreatment stroke following carotid injury (ME, 2% vs. PE, 6%; p = 0.57). CONCLUSIONS: Experience with penetrating arterial cervicothoracic injuries at a high-volume urban trauma center remained remarkably similar with respect to both anatomic distribution of injury and treatment. Conventional operative exposure and repair remain the cornerstone of treatment for most civilian cervicothoracic arterial injuries. LEVEL OF EVIDENCE: Therapeutic study, level V.

A reappraisal of nitrogen requirements for patients with critical illness and trauma.

BACKGROUND: Studies regarding protein requirements for patients with critical illness are inconclusive owing to small sample size and population heterogeneity. The primary objectives of this study were to determine the amount of protein required to achieve nitrogen equilibrium or a positive nitrogen balance (NB, -4 g/d or better) and ascertain whether patients with traumatic brain injury (TBI) exhibit greater protein catabolism than those without TBI. METHODS: Adult patients admitted to the trauma center, given specialized nutrition support, and had an NB determination within 5 days to 14 days after injury were evaluated. Patients with obesity, incomplete urine collection, kidney disease, corticosteroid or pentobarbital therapy, or an oral diet were excluded. RESULTS: A total of 300 NB determinations from 249 patients were evaluated. Increasing the protein dosage generally resulted in improved NB; however, the data were highly variable. Of the patients who received a protein intake of 2 g/kg per day or greater, 54% achieved nitrogen equilibrium or positive NB (-4 g/d or better) in contrast to 38% and 29% of patients who received 1.5 g/kg per day to 1.99 g/kg per day and 1 g/kg per day to 1.49 g/kg per day, respectively (p < 0.001). There was no significant difference in NB between patients with and without TBI at similar protein intakes. CONCLUSION: A higher protein intake was generally associated with an improved NB; yet, many patients remained having a negative NB. A protein dosage of 2 g/kg per day or greater was more successful in achieving nitrogen equilibrium than were lower-dosage intakes. Patients with TBI do not exhibit significantly greater protein catabolism than do patients without TBI. LEVEL OF EVIDENCE: Prognostic study, level III.

Efficacy of monotherapy in the treatment of Pseudomonas ventilator-associated pneumonia in patients with trauma.

BACKGROUND: Controversy persists regarding the optimal treatment regimen for Pseudomonas ventilator-associated pneumonia (VAP). Combination antibiotic therapy is used to broaden the spectrum of activity of empiric treatment and provide synergistic bacteriocidal activity. The relevance of such "synergy" is commonly supposed but poorly supported. The purpose of this study was to evaluate the efficacy of monotherapy in the treatment of Pseudomonas VAP as measured by microbiological resolution. METHODS: Patients admitted to the trauma intensive care unit during a 36-month period with gram-negative VAP diagnosed on initial bronchoalveolar lavage (BAL) (> or = 10(5) colony forming units [CFU]/mL) were evaluated. All patients received empiric antibiotic monotherapy based on the duration of intensive care unit stay. Patients with Pseudomonas VAP were identified and appropriate monotherapy was selected. Repeat BAL was performed on day 4 of appropriate antibiotic therapy to determine efficacy. Microbiological resolution was defined as < or = 10(3) CFU/mL. Combination therapy with an aminoglycoside was reserved for patients with either persistent positive or increasing colony counts on repeat BAL. Recurrence was defined as > or = 10(5) CFU/mL on subsequent BAL after 2 weeks of appropriate therapy. RESULTS: One hundred ninety-six patients were identified with late gram-negative VAP. There were 84 patients with Pseudomonas VAP. Monotherapy achieved microbiological resolution in 79 patients (94.1%) with zero recurrence. Thirty-six isolates were completely eradicated at repeat BAL. Five patients (5.9%) required combination therapy to achieve resolution. CONCLUSIONS: Monotherapy in the treatment of Pseudomonas VAP has an excellent success rate in patients with trauma. Empiric monotherapy therapy should be modified once susceptibility of the microorganism is documented (all isolates were sensitive to cefepime) and antibiotic choice should be based on local patterns of susceptibilities. The routine use of combination therapy for synergy is unnecessary. Combination therapy should be reserved for patients with persistent microbiological evidence of Pseudomonas VAP despite adequate therapy.

The evolution of blunt splenic injury: resolution and progression.

BACKGROUND: Nonoperative management of blunt splenic injury (BSI) has become the standard of care for hemodynamically stable patients. Successful nonoperative management raises two related questions: (1) what is the time course for splenic healing and (2) when may patients safely return to usual activities? There is little evidence to guide surgeon recommendations regarding return to full activities. Our hypothesis was that time to healing is related to severity of BSI. METHODS: The trauma registry at a level I trauma center was queried for patients diagnosed with a BSI managed nonoperatively between 2002 and 2007. Follow-up abdominal computed tomography scans were reviewed with attention to progression to healing of BSI. Kaplan-Meier curves were compared for mild (American Association for the Surgery of Trauma grades I-II) and severe (grades III-V) BSI. RESULTS: Six hundred thirty-seven patients (63.9% mild spleen injury and 36.1% severe injury) with a BSI were eligible for analysis. Fifty-one patients had documented healing as inpatients. Ninety-seven patients discharged with BSI had outpatient computed tomography scans. Nine had worsening of BSI as outpatients and two (1 mild and 1 severe) required intervention (2 splenectomies). Thirty-three outpatients were followed to complete healing. Mild injuries had faster mean time to healing compared with severe (12.5 vs. 37.2 days, p < 0.001). Most healing occurred within 2 months but approximately 20% of each group had not healed after 3 months. CONCLUSION: Although mild BSIs heal faster than severe BSIs, nearly 10% of all the BSIs followed as outpatients worsened. Close observation of patients with BSI should continue until healing can be confirmed.

Routine follow-up imaging is unnecessary in the management of blunt hepatic injury.

BACKGROUND: Nonoperative management of hemodynamically stable patients with blunt hepatic injuries has become the standard of care over the past decade. However, controversy regarding the role of in-hospital follow-up computed tomographic (CT) scans as a part of this nonoperative management scheme is ongoing. Although many institutions, including our own, have advocated routine in-hospital follow-up scans, others have suggested a more selective policy. Over time, we have perceived a low yield from follow-up studies. The hypothesis for this study is that routine follow-up imaging of asymptomatic patients is unnecessary. METHODS: All patients selected for nonoperative management of blunt hepatic injury were evaluated for utility of follow-up CT scans over a 4-year period. RESULTS: There were 530 stable patients with hepatic injury on admission CT scans in which follow-up scans were obtained within a week of admission. All injuries were classified according to the revised American Association for the Surgery of Trauma Organ Injury Scale: 102 (19.2%) grade I, 181 (34.1%) grade II, 158 (29.8%) grade III, 74 (13.9%) grade IV, and 15 (2.8%) grade V. Follow-up scans showed that most injuries were either unchanged (51%) or improved (34.7%). Only three patients underwent intervention based on their follow-up scans: two patients had arteriography (one with therapeutic embolization) and one had percutaneous drainage. Each of those patients had clinical signs or symptoms that were indicative of ongoing hepatic abnormality. CONCLUSION: These data demonstrate that, regardless of injury grade, routine in-hospital follow-up scans are not indicated as part of the nonoperative management of blunt liver injuries. Follow-up scans are indicated for patients who develop signs or symptoms suggestive of hepatic abnormality.

The open preperitoneal approach to recurrent inguinal hernias in high-risk patients.

BACKGROUND: Whether it is an open anterior, laparoscopic, or open preperitoneal approach, we have no general consensus on the preferred approach to recurrent inguinal hernia repairs. Recent reevaluations of the previously described open preperitoneal approach have shown promising results. We critically evaluate our experience with this procedure in our high-risk patient population and compare the results to other useful techniques. METHODS: We present a retrospective study of 48 consecutive patients with 49 recurrent inguinal hernias. All patients underwent an open preperitoneal approach using a Bard Kugel Patch supervised by the senior author. Complications and recurrences were evaluated with all patients returning to the clinic postoperatively. RESULTS: Among the 49 (6%) hernia repairs, there were three recurrences. The overall complication rate was 8%, including postoperative hematoma requiring drainage (1), pain leading to the patch being removed (1), and postoperative urinary retention (2). CONCLUSION: The open preperitoneal approach using the Bard Kugel Patch for recurrent inguinal hernias results in a low recurrence rate and an acceptable complication rate. It is the preferred approach at our institution.