Quetiapine therapy in critically injured trauma patients is associated with an increased risk of pulmonary complications.

BACKGROUND: The aim of this study was to evaluate quetiapine-associated pulmonary complications (PC) in critically injured trauma patients. METHODS: Injured adults admitted during 2016 to the ICU at a Level I trauma center were analyzed. Outcomes were evaluated by competing risks survival analysis. RESULTS: Of 254 admissions, 40 (15.7%) had PC and 214 (84.3%) were non-events. PC patients were more severely injured, had longer hospital stays and were more likely to die. Patients administered quetiapine were more likely to develop PC and acquire PC earlier than those without quetiapine. Quetiapine was a positive risk factor for PC (sHR 2.24, p = 0.013). Stratification by ventilator use revealed non-ventilated patients administered quetiapine had the highest risk for PC (sHR 4.66, p = 0.099). CONCLUSIONS: Quetiapine exposure in critically injured trauma patients was associated with increased risk of PC. Guidelines for treatment of delirium with quetiapine in critically injured trauma patients should account for this risk.

Association of complicated gallstone disease in pregnancy and adverse birth outcomes.

BACKGROUND: Complicated gallstone disease (CGD) is a common condition requiring intervention during pregnancy to avert adverse birth outcomes (ABO). METHODS: Cohort study using the California OSHPD 2007-2014 database. Records of pregnant patients were analyzed for gallbladder calculus within four months of delivery. Biliary system interventions were evaluated as the primary exposure. RESULTS: Of 7,597 patients, those with CGD had a greater likelihood of biliary system procedures than those with uncomplicated gallstone disease (36.6% vs. 2.5%, p < 0.001). Patients with CGD also had increased odds of ABO (OR 2.02, 95% CI, 1.48-2.76). Compared to patients without biliary system procedures, those with interventions for gallstones had an OR of 3.46 (95% CI, 2.48-4.82) for ABO. After adjustment, biliary system intervention for CGD had an even greater risk of ABO (OR 4.26, 95% CI, 2.86-6.35). CONCLUSIONS: The risk of ABO is significantly increased in women with CGD and intervention for gallstones.

Association of Operative Repair Type and Trauma Center Designation With Outcomes in Ruptured Abdominal Aortic Aneurysm Repair.

OBJECTIVE: Open repair of ruptured abdominal aortic aneurysm (rAAA) has shown improved outcomes at trauma centers. Whether the benefit of trauma center designation extends to endovascular repair of rAAA is unknown. METHODS: Retrospective cohort study using the California Office of Statewide Health Planning and Development 2007 to 2014 discharge database to identify patients with rAAA. Data included demographic and admission factors, discharge disposition, International Classification of Diseases, Ninth Revision, Clinical Modification codes, and hospital characteristics. Hospitals were categorized by trauma center designation and teaching hospital status. The effect of repair type and trauma center designation (level I, level II, or other-other trauma centers and nondesignated hospitals) was evaluated to determine rates and risks of 9 postoperative complications, in-hospital mortality, and 30-day postdischarge mortality. RESULTS: Of 1941 rAAA repair patients, 61.2% had open and 37.8% had endovascular; 1.0% had both. Endovascular repair increased over the study interval. Hospitals were 12.0% level I, 25.0% level II, and 63.0% other. A total of 48.7% of hospitals were teaching hospitals (level I, 100%; level II, 42.2%; and other, 41.8%). Endovascular repair was significantly more common at teaching hospitals (41.5% vs 34.3%, P < .001) and was the primary repair method at level I trauma centers (P < .001). Compared with open repair, endovascular repair was protective for most complications and in-hospital mortality. The risk for in-hospital mortality was highest among endovascular patients at level II trauma centers (hazard ratio 1.67, 95% confidence interval [CI]: 0.95-2.92) and other hospitals (hazard ratio 1.66, 95% CI: 1.01-2.72). CONCLUSIONS: Endovascular repair overall was associated with a lower risk of adverse outcomes. Endovascular repair at level I trauma centers had a lower risk of in-hospital mortality which may be a result of their teaching hospital status, organizational structure, and other factors. The weight of the contributions of such factors warrants further study.

Outcomes in adhesive small bowel obstruction from a large statewide database: What to expect after nonoperative management.

BACKGROUND: Although adhesive small-bowel obstruction (ASBO) is frequently managed nonoperatively, little is known regarding outcomes on readmission following this approach. Using a large population-based dataset, we evaluated risk factors for operative intervention and mortality at readmission in patients with ASBO who were initially managed nonoperatively. METHODS: The ASBO patients were identified in the California Office of Statewide Health Planning and Development 2007 to 2014 patient discharge database. Patients who were managed operatively at index admission or had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for nonadhesive obstructive small bowel disease were excluded. Associations between risk factors and both operative intervention and death following readmission were evaluated using survival analysis. RESULTS: Among 15,963 ASBO patients, 3,103 (19.4%) had at least one readmission. The 1,069 (34.5%) who received an operation during their first readmission presented sooner (175 days vs. 316 days, p < 0.001) and were more likely to die during that readmission (5.2% vs. 0.7%, p < 0.001). Operative management at first readmission was associated with younger age, fewer comorbidities, and shorter times to readmission. Patients operatively managed at first readmission had longer times to second readmission compared with nonoperative patients. Stratified analyses using nonoperative patients as the reference over the study period revealed that patients who underwent lysis of adhesions and bowel resection were 5.04 times (95% confidence interval [CI], 2.82-9.00) as likely to die while those who underwent lysis only were 2.09 times (95% CI, 1.14-3.85) as likely to die. Patients with bowel resection only were at an increased risk for subsequent interventions beyond the first readmission (hazard ratio, 1.79; 95% CI, 1.11-2.87). CONCLUSION: In a large cohort readmitted for ASBO and initially managed nonoperatively, subsequent operative intervention conferred a greater risk of death and a longer time to readmission among survivors. Prospective research is needed to further delineate outcomes associated with initial nonoperative management of ASBO. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Outcomes for popliteal artery injury repair after discharge: A large-scale population-based analysis.

BACKGROUND: Although short-term outcomes for popliteal artery injury after endovascular versus open repair appear similar, studies on outcomes after discharge are limited. We evaluated popliteal artery injury repair in a population-based data set. We hypothesized that postdischarge outcomes for open repair are superior to endovascular repair. METHODS: Patients with popliteal artery injury were identified in the California Office of Statewide Health Planning and Development 2007-2014 discharge database. Popliteal artery injury and other lower-extremity injuries were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Procedure codes were evaluated to identify open repair, endovascular repair, fasciotomy, and amputation. Primary outcomes were mortality or amputation. The association between repair method and each outcome was evaluated with logistic regression. Postdischarge amputation and all-cause mortality were evaluated using survival analysis. RESULTS: Among 769 patients with popliteal artery injury, open repair occurred in 456 (59.3%), endovascular repair in 37 (4.3%), combined endovascular and open in 18 (2.3%), and nonoperative management in 258 (33.6%). Fasciotomy was performed more frequently in open than endovascular repair (p = 0.001) during index admission. Amputation rate was also increased in open repair, but this was not significant (p = 0.196). Arterial thromboembolus during index admission was more likely after endovascular or combined endovascular and open compared with open (24.3%, 55.6%, 16.7%, respectively, p < 0.001). Patients requiring both endovascular and open were more likely to undergo amputation postdischarge (hazard ratio, 4.11; 95% confidence interval, 1.16-14.53). Patients undergoing endovascular repair were more likely to die postdischarge (hazard ratio, 4.43; 95% confidence interval, 1.06-18.56) compared with patients who had open repair (median, 98.5 days postdischarge). CONCLUSIONS: In a large cohort with popliteal artery injury, open repair was associated with lower rates of index admission arterial thromboembolus as well as postdischarge amputation and all-cause mortality. We recommend conducting a prospective multicenter study to examine the appropriate use of endovascular repair for this injury. LEVEL OF EVIDENCE: Therapeutic, level IV.

Outcomes after single-look trauma laparotomy: A large population-based study.

BACKGROUND: Outcomes following damage control laparotomy for trauma have been studied in detail. However, outcomes following a single operation, or "single-look trauma laparotomy" (SLTL), have not. We evaluated the association between SLTL and both short-term and long-term outcomes in a large population-based data set. METHODS: The California Office of Statewide Health Planning and Development patient discharge database was evaluated for calendar years 2007 through 2014. Injured patients with SLTL during their index admission were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. Diagnosis and procedure codes were used to identify specific abdominal organ injuries, surgical interventions, and perioperative complications. Subsequent acute care admissions were examined for postoperative complications and related surgical interventions. Clinical characteristics, injuries, surgical interventions, and outcomes were analyzed by mechanism of injury. RESULTS: There were 2113 patients with SLTL during their index admission; 712 (33.7%) had at least one readmission to an acute care facility. Median time to first readmission was 110 days. Penetrating mechanism was more common than blunt (60.6% vs. 39.4%). Compared to patients with penetrating injury, blunt-injured patients had a significantly higher median Injury Severity Score (9 vs. 18, p < 0.0001) and a significantly higher mortality rate during the index admission (4.1% vs. 27.0%, p < 0.0001). More than 30% of SLTL patients requiring readmission had a surgery-related complication. The most common primary reasons for readmission were bowel obstruction (17.7%), incisional hernia (11.8%), and infection (9.1%). There was no significant association between mechanism of injury and development of surgery-related complications requiring readmission. CONCLUSIONS: Patients with SLTL had postinjury morbidity and mortality, and more than 30% required readmission. Complication rates for SLTL were comparable to those reported for emergency general surgery procedures. Patients should be educated on signs and symptoms of the most common complications before discharge following SLTL. Further investigation should focus on the factors associated with the development of these complications. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.