Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: Occult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined. METHODS: A pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed. RESULTS: Fifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy. CONCLUSION: No pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.

Risk factors associated with early reintubation in trauma patients: a prospective observational study.

BACKGROUND: After mechanical ventilation, extubation failure is associated with poor outcomes and prolonged hospital and intensive care unit (ICU) stays. We hypothesize that specific and unique risk factors exist for failed extubation in trauma patients. The purpose of this study was to identify the risk factors in trauma patients. METHODS: We performed an 18-month (January 2008-June 2009) prospective, cohort study of all adult (8 years or older) trauma patients admitted to the ICU who required mechanical ventilation. Failure of extubation was defined as reintubation within 24 hours of extubation. Patients who failed extubation (failed group) were compared with those who were successfully extubated (successful group) to identify independent risk factors for failed extubation. RESULTS: A total of 276 patients were 38 years old, 76% male, 84% sustained blunt trauma, with an mean Injury Severity Score = 21, Glasgow Coma Scale (GCS) score = 7, and systolic blood pressure = 125 mm Hg. Indications for initial intubation included airway (4%), breathing (13%), circulation (2%), and neurologic disability (81%). A total of 17 patients (6%) failed extubation and failures occurred a mean of 15 hours after extubation. Independent risk factors to fail extubation included spine fracture, airway intubation, GCS at extubation, and delirium tremens. Patients who failed extubation spent more days in the ICU (11 vs. 6, p = 0.006) and hospital (19 vs. 11, p = 0.002). Mortality was 6% (n = 1) in the failed group and 0.4% (n = 1) in the successful extubation group. CONCLUSIONS: Independent risk factors for trauma patients to fail extubation include spine fracture, initial intubation for airway, GCS at extubation, and delirium tremens. Trauma patients with these four risk factors should be observed for 24 hours after extubation, because the mean time to failure was 15 hours. In addition, increased complications, extended need for mechanical ventilation, and prolonged ICU and hospital stays should be expected for trauma patients who fail extubation.

Intraoperative assessment of breast cancer specimens decreases cost and number of reoperations.

It is the aim of our study to determine if the assessment of intraoperative breast cancer margins leads to decreased incidence of repeat operations and decreased cost. We collected data prospectively from two hospitals in Austin, TX, University Medical Center at Brackenridge (UMCB) and Seton Northwest Hospital (SNW), over a 2-year period. Comparison was made to see if intraoperative margin assessment affected total surgical costs and need for reoperation. One hundred and seven cases met criteria for inclusion in the study (UMCB = 45, SNW = 62). Intraoperative margin assessment was used in zero cases at SNW (0%) and in 17 at UMCB (38%). Intraoperative assessment was used in 16 per cent of total cases. Sixty per cent of cases at SNW required subsequent return to the operating room. Twenty-four per cent of cases at UMCB required subsequent reoperation (P < 0.05). The average number of surgical interventions required was 1 ± 0.3 with intraoperative assessment, 2 ± 0.6 without, (P < 0.05). Total surgical costs were $15,341 ± $4,328 with intraoperative assessment and $22,013 ± $13,821 without (P < 0.05). Use of intraoperative margin assessment for breast cancer operations leads to both a decrease in reoperations as well as a decrease in total operative costs.

Autologous blood transfusion during emergency trauma operations.

HYPOTHESIS: Intraoperative cell salvage (CS) of shed blood during emergency surgical procedures provides an effective and cost-efficient resuscitation alternative to allogeneic blood transfusion, which is associated with increased morbidity and mortality in trauma patients. DESIGN: Retrospective matched cohort study. SETTING: Level I trauma center. PATIENTS: All adult trauma patients who underwent an emergency operation and received CS as part of their intraoperative resuscitation. The CS group was matched to a no-CS group for age, sex, Injury Severity Score, mechanism of injury, and operation performed. MAIN OUTCOME MEASURES: Amount and cost of allogeneic transfusion of packed red blood cells and plasma. RESULTS: The 47 patients in the CS group were similar to the 47 in the no-CS group for all matched variables. Patients in the CS group received an average of 819 mL of autologous CS blood. The CS group received fewer intraoperative (2 vs 4 U; P = .002) and total (4 vs 8 U; P < .001) units of allogeneic packed red blood cells. The CS group also received fewer total units of plasma (3 vs 5 U; P = .03). The cost of blood product transfusion (including the total cost of CS) was less in the CS group ($1616 vs $2584 per patient; P = .004). CONCLUSION: Intraoperative CS provides an effective and cost-efficient resuscitation strategy as an alternative to allogeneic blood transfusion in trauma patients undergoing emergency operative procedures.

Computed tomography versus magnetic resonance imaging for evaluation of the cervical spine: how many slices do you need?

Controversy exists regarding the correlation between CT and MRI for evaluation of the cervical spine. We hypothesize that newer-generation CT scanners will improve diagnostic accuracy and may obviate the need for MRI in patients with a normal CT. We compared the missed injury rate of four-slice CT and 64-slice CT performed to evaluate the cervical spine. We conducted a retrospective study from January 2004 to June 2008 of all blunt trauma patients who underwent both a CT and MRI to evaluate the cervical spine. One hundred six blunt trauma patients underwent both CT and MRI, including 43 with four-slice and 63 with 64-slice CT. CT missed three injuries (3%), all of which were clinically significant ligamentous injuries seen only on MRI. The 64-slice CT missed no injuries (0%), whereas the four-slice CT missed all three (7%) of the ligamentous injuries (P = 0.03). Older-generation CT scanners miss clinically significant injuries in blunt trauma patients and should not be independently relied on to evaluate the cervical spine. The newer 64-slice CT scan does not appear to miss clinically significant cervical spine injuries and may allow clearance of the cervical spine in blunt trauma patients without the addition of an MRI.

Trauma surgeon personality and job satisfaction: results from a national survey.

Personality is correlated with job satisfaction, whereas job satisfaction is linked to performance. This study examines personality of practicing trauma surgeons in relation to their job satisfaction. The dominant theory in personality research is the five-factor model, which includes: extraversion, agreeableness, conscientiousness, emotional stability, and openness. The sample was identified from American Association for Surgery of Trauma, Eastern Association for Surgery of Trauma, and Western Trauma Association membership. A web-based survey of demographics and empirically supported measures was created. Four hundred and twelve trauma surgeons (49 +/- 14-years-old, 85% male) completed the survey. When comparing satisfied to unsatisfied trauma surgeons on personality variables, extraversion (5.0 +/- 1.6 vs 4.4 +/- 1.6, P = 0.014) and emotional stability (5.8 +/- 1.1 vs 5.4 +/- 1.2, P = 0.007) were significantly higher in satisfied surgeons. Moderate correlations were found for job satisfaction with emotional stability (r = 0.20, P < 0.01) and extraversion (r = 0.20, P < 0.01). Logistic regression of personality variables highlighted the significance of emotional stability and extraversion in prediction of job satisfaction. Extraversion and emotional stability are the most significant personality factors to job satisfaction of trauma surgeons. These findings may have important implications for surgical resident recruitment, job performance, and retention.

Recombinant factor VIIa for the correction of coagulopathy before emergent craniotomy in blunt trauma patients.

BACKGROUND: Recombinant activated factor VII (rFVIIa) has been associated with decreased blood transfusion requirements in trauma patients. Clinical use has recently been extended to the treatment of coagulopathic patients with traumatic brain injury, and results have been encouraging. However, the cost and possible thromboembolic complications of rFVIIa have been considered barriers to its widespread use. We hypothesize that rFVIIa would provide an effective and cost efficient means of correcting coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy. METHODS: We performed a 2-year (2005-2006) retrospective study of adult blunt trauma patients with traumatic brain injury who presented coagulopathic (international normalized ratio [INR] >1.3) and required emergent craniotomy. We compared patients who did (rFVIIa group) and did not (no-rFVIIa group) receive rFVIIa to correct coagulopathy before craniotomy. RESULTS: There were 14 rFVIIa patients and 14 no-rFVIIa patients. The rFVIIa patients were older (59 years vs. 41 years, p = 0.04), but there was no difference in male gender (79% vs. 79%, p = 0.68), injury severity score (29 vs. 29, p = 1.0), or Glasgow Coma Scale score (10 vs. 7, p = 0.67). Although there was no difference in admission INR (2.6 vs. 1.9, p = 0.10), the rFVIIa group was more often taking preinjury coumadin (57% vs. 14%, p = 0.05). The rFVIIa group had a preoperative INR (1.2 +/- 0.4 vs. 1.4 +/- 0.2, p = 0.05), but there was no difference in the time from admission to craniotomy (135 minutes vs. 182 minutes, p = 0.51). The rFVIIa group received fewer units of packed red blood cells (PRBCs) and plasma during the perioperative period. In addition, the rVIIa group consumed fewer costs of PRBC ($756 per patient vs. $2,916 per patient, p < 0.001) and plasma ($369 per patient vs. $927 per patient, p = 0.001). The rFVIIa group still consumed fewer total costs of transfused blood products when cost of rFVIIa was included ($2,557 per patient vs. $4,110 per patient, p = 0.04). There were no thromboembolic complications in either group. CONCLUSIONS: rFVIIa provides a cost-efficient option to effectively correct coagulopathy in patients with traumatic brain injury undergoing emergent craniotomy. In addition, the use of rFVIIa is associated with decreased transfusion of PRBC and plasma and decreased transfusion-related hospital costs in this population.

Barriers to obtaining family consent for potential organ donors.

BACKGROUND: Our country suffers from a chronic shortage of organ donors, and the list of individuals in desperate need of life-saving organ transplants is growing every year. Family consent represents an important limiting factor for successful donation. We hypothesize that specific barriers to obtaining family consent can be identified and improved upon to increase organ donation consent rates. The purpose of this study was to compare families who declined organ donation to those who granted consent, specifically to identify barriers to family consent for successful organ donation. METHODS: We performed a 4-year (2004-2007) retrospective study of potential organ donors covered by our regional organ procurement organization (OPO). Variables collected included age, gender, race, cause of brain death (trauma vs. medical) of the potential organ donor, and elapsed time from declaration of brain death to family approach by OPO. Potential organ donors whose family declined organ donation (DECLINE group) were compared with potential organ donors whose family consented to organ donation (CONSENT group). Groups were compared using univariate and multivariate analysis. RESULTS: There were a total of 827 potential organ donors during the 4-year period within our OPO region. Overall, 471 families (57%) consented to organ donation, whereas 356 families (43%) declined. Although there was no difference in male gender between the DECLINE and CONSENT groups (59% vs. 53%, p = 0.12), the DECLINE group had more medical brain deaths (73% vs. 58%, p < 0.001), more potential donors aged 50 years or older (43% vs. 34%, p < 0.001), as well as more potential organ donors of Hispanic (67% vs. 43%, p < 0.001) and African American (10% vs. 4%, p < 0.001) descent. In addition, time from declaration of brain death to family approach by OPO was longer for the DECLINE group (350 minutes vs. 112 minutes, p = 0.001). Logistic regression identified race, older age, and death from a medical cause as independent risk factors for failure of obtaining consent. CONCLUSION: Several barriers exist to family consent for successful organ donation. Family members of minority populations, medical brain deaths, and older potential donors more often decline consent for organ donation. Family education and resource utilization toward these specific populations of potential organ donors may help to improve organ donation consent rates. In addition, delayed family approach by OPO seems to be associated with decreased consent rates. System improvements to expedite family approach by OPO may likewise lead to improved consent rates.