Open versus percutaneous tube thoracostomy with and without thoracic lavage for traumatic hemothorax: a novel randomized controlled simulation trial.

Objective: To quantify and assess the relative performance parameters of thoracic lavage and percutaneous thoracostomy (PT) using a novel, basic science 2×2 randomized controlled simulation trial. Summary background data: Treatment of traumatic hemothorax (HTX) with open tube thoracostomy (TT) is painful and retained HTX is common. PT is potentially less painful whereas thoracic lavage may reduce retained HTX. Yet, procedural time and the feasibility of combining PT with lavage remain undefined. Methods: A simulated partially clotted HTX (2%-gelatin-saline mixture) was loaded into a TT trainer and then evacuated after randomization to one of four protocols: TT+/-lavage or PT+/-lavage. Standardized inserts with fixed 28-Fr TT or 14-Fr PT positioning were used to minimize tube positioning variability. Lavage consisted of two 500 mL aliquots of warm saline after initial HTX evacuation. The primary outcome was HTX volume evacuated. The secondary outcome was additional procedural time required for the addition of the lavage. Results: A total of 40 simulated HTX trials were randomized. TT alone evacuated a median of 1236 mL (IQR 1168, 1294) leaving a residual volume of 265 mL (IQR 206, 333). PT alone resulted in a significantly greater median residual volume of 588 mL (IQR 497, 646) (p=0.002). Adding lavage resulted in similar residual volumes for TT compared with TT alone but significantly less for PT compared with PT alone (p=0.002). Lavage increased procedural time for TT by a median of 7.0 min (IQR 6.5, 8.0) vs 11.7 min (IQR 10.2, 12.0) for PT (p<0.001). Conclusion: This simulation trial characterized HTX evacuation in a standardized fashion. Adding lavage to thoracostomy placement may improve evacuation, particularly for small-diameter tubes, with little added procedural time. Further prospective clinical study is warranted. Level of evidence: NA.

Effect of an intervention standardization system on pediatric dosing and equipment size determination: a crossover trial involving simulated resuscitation events.

BACKGROUND: Pediatric medication dosing has been recognized as a high-error activity with the potential to cause serious harm. Few studies assess systems approaches to error reduction in pediatrics. OBJECTIVE: To estimate the decrease in deviation from recommended medication doses associated with use of a pediatric intervention standardization system in the acute setting. DESIGN: Two-period, 2-treatment crossover trial with data collected between December 1, 1999, and February 29, 2000. SETTING: Tertiary, academic medical center. PARTICIPANTS: Convenience sample of 28 resident physicians, representing 69% of pediatrics and 50% of medicine-pediatrics residents. INTERVENTION: Each resident participated in 4 simulated pediatric resuscitations. The Broselow Pediatric Emergency Tape and color-coded materials were available in either the first or second 2 scenarios. Traditional dosing references were available in all scenarios. MAIN OUTCOME MEASURE: Median difference between deviation from recommended dose range (DRDR) in scenarios where color coding was used (intervention) and DRDR in scenarios where color coding was not available (control). RESULTS: Median DRDR in intervention scenarios was 25.4% lower than in control scenarios (95% confidence interval [CI], 19.1%-32.5%; P<.001). In 4 medication prescriptions in intervention scenarios and in 54 prescriptions in control scenarios, DRDRs exceeded 100%. Median deviation from recommended equipment sizes in intervention scenarios was 0.12 size lower than in control scenarios (95% CI, 0.03-0.22 size; P<.001). Deviations in equipment size of 2 or more sizes were noted in 1 size determination in intervention scenarios and in 21 size determinations in control scenarios. CONCLUSIONS: Color coding was associated with a significant reduction in deviation from recommended doses in simulated pediatric emergencies. Numerous potentially clinically significant deviations from recommended doses and equipment sizes were avoided. Future studies should measure impact in the real clinical setting.

Comorbid illness affects hospital costs related to hip arthroplasty: quantification of health status and implications for fair reimbursement and surgeon comparisons.

Optimized resource allocation, reimbursement negotiations, and provider comparisons hinge on an understanding of the drivers of healthcare costs. Indices of comorbid illness may be useful for stratifying patients based on cost. Total hospital cost was analyzed for 1 surgeon's hip arthroplasty patients (June 1998-March 2001). Three scales of health status were selected as independent predictors. One thousand ninety-two hip arthroplasty inpatient stays were evaluated. The median total hospital cost was 14,011 dollars. An increasing burden of comorbid illness as measured by the All Patient Refined Diagnosis Related Group Severity of Illness scale and the modified Charlson Comorbidity Index was significantly associated with increasing hospital cost. Comorbid illness is associated with cost; scales may be used to stratify patients based on risk of high cost care.

Patterns of tumor spread and risk of fracture and epidural impingement in metastatic vertebrae.

Among patients with vertebral metastases, the identification of candidates for surgical stabilization has a limited basis in evidence. We retrospectively studied patterns of tumor spread (n = 756 vertebrae) and predictors of fracture and epidural impingement (n = 113 vertebrae) in infiltrated vertebrae with varying tumor histologies using sequential magnetic resonance images. Vertebral bodies were divided into 16 cells to map lesions. Fractured vertebrae were classified based on histology, level, fracture pattern, prefracture infiltration, and epidural impingement. Lesions were most often located within upper lumbar levels and the medial vertebral body. Fracture risk was greatest for upper lumbar (RR = 1.95; 95% CI: 1.12, 3.38) and undifferentiated tumors (RR = 7.36; 95% CI: 2.69, 20.12). A fourfold increase in fracture risk was noted in vertebrae with >80% body infiltration (HR = 4.5966; 95% CI: 1.66, 12.71). Symmetric fractures with fragments had the greatest risk of epidural impingement (p = 0.002). These findings have implications for management of patients with vertebral metastases.