Short Courses of Antibiotics Are Safe in Necrotizing Soft Tissue Infections.

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) carry high morbidity and mortality. While early aggressive surgical debridement is well-accepted treatment for NSTIs, the optimum duration of adjunct antibiotic therapy is unclear. An increasing focus on safety and evidence-based antimicrobial stewardship suggests a value in addressing this knowledge gap. OBJECTIVE: To determine whether shorter antibiotic courses have similar outcomes compared to longer courses in patients with NSTI following adequate source control. POPULATION: 142 consecutive patients with surgically managed NSTI were identified on retrospective chart review between December 2014 and December 2018 at two academic medical centers. RESULTS: Patients were predominately male (74%) with a median age of 52 and similar baseline characteristics. The median number of debridements to definitive source control was 2 (IQR 1-3) with the short course group undergoing a greater number of debridements control 2.57 ± 1.8 vs 1.9 ± 1.2, (P = .01). Of 142 patients, 34.5% received a short course and the remaining 65.5% received a longer course of antibiotics. There was no significant difference in the incidence of bacteremia or wound culture positivity between groups. There was also no significant difference in in-hospital mortality, 8% vs 6% (P = .74), incidence of C. difficile infection, median length of stay, or 30-day readmission. CONCLUSION: Provided adequate surgical debridement, similar outcomes in morbidity and mortality suggest antibiotic courses of 7 days or less are equally safe compared to longer courses.

Recovery of Pediatric Patients After Firearm Injury: Can Health Systems Do More?

BACKGROUND: Firearm injuries are the second leading cause of death among youth in the United States. Nonfatal firearm injuries far outnumber fatalities, yet data detailing the recovery and post-injury needs of pediatric patients after hospital discharge are limited. This study evaluated health system support of pediatric patients after firearm injury, from acute hospitalization to outpatient follow-up. METHODS: We conducted a retrospective chart review of patients <18 years who presented to an urban level 1 trauma center between 2014 and 2019. Cases were categorized as accidental or intentional (stratified as assault-related or "crossfire" injuries). Outcomes included biopsychosocial assessment (BA) utilization, trauma psychology service consultation, and linkage to outpatient services. RESULTS: Among 115 patients, 94% were victims of community violence. Black (50%) and Latinx (44%) patients were disproportionately affected, as were males aged 15-16 years (71%). Overall mortality was 8%. Biopsychosocial assessment and trauma psychology consultations occurred in 43% and 20% of cases, respectively. Of eligible patients, 71% received referral to post-hospitalization support services. The most commonly identified needs were counseling, gang intervention, and help with the carceral system. CONCLUSION: Health systems should support long-term recovery of pediatric patients after firearm injury, particularly addressing social and structural determinants of health. Inpatient-to-outpatient linkages should be strengthened, and prospective follow-up is needed.

Current Burden of Gunshot Wound Injuries at Two Los Angeles County Level I Trauma Centers.

BACKGROUND: Gunshot wound (GSW) injuries present a unique surgical challenge. This study explored the financial and clinical burdens of GSW patients across 2 Los Angeles County Level I trauma centers over the last 12 years, and compared them with other forms of interpersonal injury (OIPI). STUDY DESIGN: This was a retrospective study of patients presenting as those with GSW and OIPI (defined as combined stab wound or blunt assault), between January 1, 2006 and March 30, 2018, at LAC+USC Medical Center (LAC+USC) and Harbor UCLA Medical Center (HUCLA). Demographic and clinical variables were assessed for GSW patients and compared with victims of OIPI. RESULTS: There were 17,871 patients who met inclusion criteria. There was a significant difference in mortality for patients with GSW vs OIPI (11% vs 2%, p < 0.001). The odds ratio for GSW patients requiring operation was twice as high as those suffering OIPI (odds ratio [OR] 2.0, 95% CI 1.8 to 2.2). The odds ratio for GSW patients requiring ICU admission was 20% higher than that for OIPI patients (OR 1.23, 95% CI 1.11 to 1.36). Gunshot wound patients experienced a longer median length of stay vs OIPI patients (3 days vs 2 days, p < 0.001). The median hospital charge per admission for GSW was twice that of OIPI (GSW $12,612 vs OIPI $6,195; p < 0.001). CONCLUSIONS: When compared with OIPI, GSW patients arrived more severely injured and required more operations, more ICU admissions, and longer hospital stays. Patients with GSW incurred significantly higher hospital charges and had a significantly higher mortality rate. Gunshot wound injury is a unique public health concern requiring comprehensive, nation-wide, contemporary study.

Admission Variables Associated with a Favorable Outcome after Mild Traumatic Brain Injury.

Consensus is lacking for ideal management of mild traumatic brain injury (mTBI) with intracranial hemorrhage (ICH). Patients are often monitored in the intensive care unit (ICU) without additional interventions. We sought to identify admission variables associated with a favorable outcome (ICU admission for 24 hours, no neurosurgical interventions, no complications or mortality) to divert these patients to a non-ICU setting in the future. We reviewed all patients with mTBI [Glasgow Coma Scale (GCS) = 13-15] and concomitant ICH between July 1, 2012, and June 30, 2015. Variables collected included demographics, vital signs, neurologic examination, imaging results, ICU course, mortality, and disposition. Of 201 patients, 78 (39%) had a favorable outcome. On univariate analysis, these patients were younger, more often had an isolated subarachnoid hemorrhage, and were more likely to have a GCS of 15 at admission. On multivariate regression analysis, after controlling for admission blood pressure, time to CT scan, and Marshall Score, age <55, GCS of 15 on arrival to the ICU, and isolated subarachnoid hemorrhage remained independent predictors of a favorable outcome. Patients meeting these criteria after mTBI with ICH likely do not require ICU-level care.

Clinical predictors of early acute respiratory distress syndrome in trauma patients.

BACKGROUND: The objectives of this study were to examine the incidence and severity of early acute respiratory distress syndrome (ARDS) according to the Berlin Definition and to identify risk factors associated with the development of early post-traumatic ARDS. METHODS: A 2.5-year retrospective database of adult trauma patients who required mechanical ventilation for greater than 48 hours at a level 1 trauma center was analyzed for variables predictive of early (<48 hours after injury), mild, moderate, and severe ARDS and in-hospital mortality. RESULTS: Of 305 patients, 59 (19.3%) developed early ARDS: mild, 27 (45.8%); moderate, 26 (44.1%); and severe, 6 (10.1%). Performance of an emergent thoracotomy, blunt mechanism, and fresh frozen plasma administration were independently associated with the development of early ARDS. ARDS was not predictive of mortality. CONCLUSIONS: Trauma patients with blunt mechanism, who receive fresh frozen plasma, or undergo thoracotomy, are at risk of developing early ARDS.

Predictors of mortality in necrotizing soft tissue infection.

Necrotizing soft tissue infections (NSTIs) are a major source of morbidity and mortality, yet predictors of mortality for these critically ill patients remain poorly characterized. The aim of this study was to identify risk factors for mortality in patients with NSTI. We performed a retrospective review of all patients presenting with an NSTI to our county-funded, academic medical center between 2008 and 2013. Admission characteristics, comorbidities, laboratory values, time to operation, and perioperative cultures were assessed to identify predictors of mortality. During the 5-year study period, 138 patients were admitted with a NSTI; 20 (14.5%) of the patients died. Univariate predictors of mortality included bandemia, elevated creatinine, low bicarbonate, elevated lactate, a lower admission temperature, and shorter duration of presenting symptoms. Using Classification And Regression Tree analysis and subsequent logistic regression, bands greater than 25 per cent (odds ratio [OR], 8.0; 95% confidence interval [CI], 2.7 to 24.1; P = 0.0002), duration of symptoms less than 3.5 days (OR, 4.0; 95% CI, 1.2 to 13.9; P = 0.03), and temperature 37°C or less (OR, 3.6; 95% CI, 1.1 to 11.8; P = 0.03) were found to be independent predictors of mortality. Awareness of these predictors should prompt aggressive management of this at-risk population.

Open appendectomy: no longer an intern case.

Laparoscopy and work-hour restrictions are altering surgical training. We hypothesized interns were no longer gaining experience in open appendectomy, historically an intern index case. We retrospectively reviewed Accreditation Council for Graduate Medical Education (ACGME) case logs of postgraduate Year (PGY) 1 general surgery trainees from our academic teaching program for the last 9 years. Number of appendectomies performed (Current Procedural Terminology codes 44950, 44960, and 44970) were recorded and analyzed. The national ACGME database was similarly evaluated for resident experience during junior (PGY-1 to 4) years. Data were available for 47 residents completing internship at our institution between 2003 and 2011. Mean number of appendectomies performed per intern steadily decreased throughout the study period from 22 in 2003 to 5 in 2011 (P=0.0367). Mean percentage of cases done open decreased from 79.5 to 2.4 per cent (P=0.0001). National data found residents graduating in the year 2000 performed an average of 26.6 open appendectomies during junior years, whereas those graduating in 2011 had done only 13.7. Surgical trainees are performing fewer open appendectomies than just several years ago. Open appendectomy traditionally served as an introduction to open surgery. Because outcome differences are small between open and laparoscopic appendectomy, we propose teaching institutions consider performing open appendectomies in select patients to preserve an important educational experience.

Mortality risk stratification in elderly trauma patients based on initial arterial lactate and base deficit levels.

Elderly trauma patients have worse outcomes than their younger counterparts. Early risk stratification remains difficult, particularly because traditional vital signs are less reliable. We hypothesized that arrival lactate and base deficit (BD) could be used to predict mortality in elderly trauma patients with a normal admission blood pressure. We retrospectively evaluated the prospectively collected trauma registry at our urban Level I trauma center between 2003 and 2009. Patients sustaining blunt trauma, age 55 years or older, with a systolic blood pressure 90 mmHg or higher, and who had arterial lactate and/or BD measured within 4 hours of arrival comprised the study group. Primary outcomes were in-hospital and 24-hour mortality. There were 364 patients with a lactate and 324 with a BD drawn. Patients with a lactate 2.5 mmol or greater were 3.7 times more likely to die than those with a lactate less than 2.5 mmol (95% CI, 1.6 to 8.2; P = 0.0018). The OR for mortality was 5.2 (95% CI, 2.5 to 11.2; P < 0.0001) in patients with a BD -4 or less. Elevated lactate and BD were even stronger predictors of early mortality (within first 24 hours). After increasing the hypotension threshold to a systolic blood pressure 110 mmHg or greater, lactate and BD remained highly predictive of in-hospital and 24-hour mortality.

The use of drotrecogin alpha for necrotizing soft tissue infections.

The use of Drotrecogin alfa (DAA) (Xigris) in select patients with sepsis has had demonstrable improvement in survival, though its benefit in necrotizing soft tissue infections (NSTI) is unclear. A retrospective review of NSTI patients receiving DAA at our institution from 2006 to 2009 was performed. Our previously derived mortality prediction model, based on classification and regression tree analysis, was applied to patients and the predicted mortality was compared with the actual mortality rate. Ten patients with severe NSTI received DAA. The median admission values were: white blood cell count of 27,000/mm3, serum lactate of 4.0 mmol/L, and serum sodium of 128 mEq/L. Four (40%) patients had systemic complications, five (50%) patients required amputation, and one died (10%). Median time to DAA administration was 12 hours after debridement. There were no bleeding complications attributed to DAA use. Mortality in this series of severe NSTI was only 10 per cent, which compares favorably with the predicted mortality of 18 per cent based on classification and regression tree analysis (P = 0.2). A prospective, randomized study is warranted to determine if the use of DAA should be part of the standard therapy for NSTI patients with a predicted high mortality.

Hilar control in penetrating chest trauma: a simplified approach to an underutilized maneuver.

BACKGROUND: In both urban and military settings, penetrating thoracic injuries remain a significant source of trauma-related mortality, and many patients require resuscitative thoracotomy. Existing literature emphasizes relief of pericardial tamponade and aortic clamp application as the key therapeutic maneuvers. The purpose of this report is to revisit pulmonary hilar clamping and highlight its application for hemorrhage control, air embolism prevention, and other benefits in the setting of massive hemothorax. METHODS: Records from an urban, American College of Surgeons verified level I trauma center were evaluated over a six-month period. Patients who underwent early pulmonary hilar clamping were identified. RESULTS: Twenty-four patients with trauma presented during the study period required thoracotomy. Of these, three (13%) underwent early pulmonary hilar clamping for massive hemothorax. Trauma mechanism was penetrating in each instance. Injuries included pulmonary lobe destruction, subclavian artery disruption, and internal thoracic artery transection. These cases illustrate the utility of early pulmonary hilar clamping for hemorrhage control, prevention of air embolization, and improved exposure. CONCLUSION: To decrease morbidity and mortality at our institution, a method of pulmonary hilar control has evolved using an organized, "hand-over-hand" approach that controls hemorrhage, prevents fatal air embolism, protects against blood spillage into contralateral airways, and facilitates pulmonary surgery. Several features distinguish our approach from those previously reported.

Impact on patient outcomes after closure of an adjacent trauma center.

In 2005, a major Level I trauma center closed in Los Angeles County, leading to media speculation that the sudden expansion of our catchment area would adversely affect outcome. We sought to determine whether the closure led to longer transport times and increased trauma morbidity and mortality at our Level I trauma center. Annual patient volume, paramedic transport times, injury severity score (ISS), mechanism of injury, complication rate, and mortality were retrospectively compared between two time periods, Period 1 (1997-2005, before closure) and Period 2 (March 1, 2005 to March 1, 2006, after closure), using multivariable logistic regression models. Median monthly patient volume rose from 123 patients to 190 patients in Period 2 (P < 0.01). Median transport time increased from 12 to 13 minutes (P = 0.004) and median ISS increased from four to five (P < 0.01) in Period 2. The proportion of patients with ISS > 15 increased from 17 to 24 per cent as well (P < 0.01). After accounting injury severity, the adjusted mortality rate decreased in Period 2 (odds ratio 0.69, P = 0.03) and the adjusted complication rate was unchanged (odds ratio 1.16, P = 0.2). In conclusion, the closure of a Level I trauma center resulted in a significant increase in trauma patient volume and injury severity, as well as a slight increase in paramedic transport times. However, the adjusted complication rate was unchanged, and the adjusted mortality rate actually improved.

Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay.

BACKGROUND: The timing of cholecystectomy in gallstone pancreatitis remains controversial. We hypothesized that in patients with mild to moderate gallstone pancreatitis (three or fewer Ranson's criteria), performing early cholecystectomy before resolution of laboratory or physical examination abnormalities would result in shorter hospitalization, without adversely affecting outcomes. STUDY DESIGN: An observational study consisting of a retrospective and a prospective group was conducted. For the prospective group, a deliberate policy of early cholecystectomy (less than 48 hours from admission) was used. The primary end point was total length of hospital stay. Secondary endpoints were time from admission to definitive operation, need for endoscopic retrograde cholangiography, and major complications (organ failure and death). RESULTS: Group I consisted of 177 patients retrospectively reviewed, and Group II was composed of 43 patients prospectively followed. There were no differences between the two groups with respect to demographics. With respect to admission laboratory values, there was a significant difference in median serum amylase, but there were no differences in median serum levels of lipase, total bilirubin, albumin, white blood cell count, or Ranson's score. The median length of hospital stay was 7 days in Group I versus 4 days in Group II (p=or< 0.001). Median time from admission to cholecystectomy was 5 days in Group I versus 2 days in Group II (p=or< 0.0001). Complication rates were similar and there were no deaths in either group. CONCLUSIONS: In patients with mild to moderate gallstone pancreatitis, a policy of early cholecystectomy resulted in a significantly reduced length of hospital stay with no increase in complications or mortality.

The 80-hour resident workweek does not adversely affect patient outcomes or resident education.

PURPOSE: To determine whether the 80-hour resident workweek adversely affects patient outcomes or resident education. METHODS: To assess patient outcomes, the authors reviewed trauma patient morbidity and mortality at the second busiest level I trauma center in Los Angeles County before (July 1998-June 2003, Period 1) and after (July 2003-June 2005, Period 2) implementation of the duty hour limitation via a retrospective review of a prospective database. All patients were operated and managed by residents under faculty supervision. Patient characteristics included the injury severity score (ISS), mechanism of injury, complications, and death. To assess resident education, the authors compared ABSITE percentile scores, first-time pass rates on the American Board of Surgery Qualifying and Certifying Examinations, and total and chief resident operative case volumes. In addition, they estimated institutional costs incurred to comply with the new duty hour rules. RESULTS: Patient outcomes. Over the entire 7-year study period, 11,518 trauma patients were transported to Harbor-UCLA Medical Center. Compared with Period 1, Period 2 experienced an increase in average yearly patient volume from 1510 to 1981 (p 0.01). The average ISS also increased, from 7.9 to 9.6 (p < 0.0001), as did the proportion of penetrating trauma from 14.8% to 17.6% (p < 0.0001). Morbidity and mortality rates remained unchanged. Resident education. Mean ABSITE scores and first-time Qualifying and Certifying Exam pass rates were unchanged. Mean resident total major case volumes increased significantly in Period 2 from 831 to 1156 (p < 0.0001), whereas chief resident year case volumes were unchanged. The estimated cost incurred by this institution to conform to the new work hour standards was approximately 359,000 dollars per year. CONCLUSIONS: Despite concerns that the 80-hour workweek might threaten patient care and resident education, the morbidity and mortality rates at a busy level I trauma center remained unchanged. The quality of surgical resident education, as measured by operative volumes, ABSITE scores, and written and oral board examination pass rates were likewise unchanged. The reorganization of the authors' general surgery residency program to comply with the duty hour restrictions was achieved within reasonable cost.