Comparison of outcomes between observation and tube thoracostomy for small traumatic pneumothoraces.

BACKGROUND: Traumatic pneumothorax management has evolved to include the use of smaller caliber tube thoracostomy and even observation alone. Data is limited comparing tube thoracostomy to observation for small traumatic pneumothoraces. We aimed to investigate whether observing patients with a small traumatic pneumothorax on initial chest radiograph (CXR) is associated with improved outcomes compared to tube thoracostomy. METHODS: We retrospectively reviewed trauma patients at our level 1 trauma center from January 1, 2016 through December 31, 2020. We included those with a pneumothorax size <30 mm as measured from apex to cupola on initial CXR. We excluded patients with injury severity score ≥ 25, operative requirements, hemothorax, bilateral pneumothoraces, and intensive care unit admission. Patients were grouped by management strategy (observation vs tube thoracostomy). Our primary outcome was length of stay with secondary outcomes of pulmonary infection, failed trial of observation, readmission, and mortality. Results are listed as mean ± standard error of the mean. RESULTS: Of patients who met criteria, 39 were in the observation group, and 34 were in the tube thoracostomy group. Baseline characteristics were similar between the groups. Average pneumothorax size on CXR was 18 ± 1.0 mm in the observation group and 18 ± 0.84 mm in the tube thoracostomy group (p > 0.99). Average pneumothorax sizes on computed tomography were 25 ± 2.1 and 37 ± 3.9 mm in the observation and tube thoracostomy groups, respectively (p = 0.01). Length of stay in the observation group was significantly shorter than the tube thoracostomy group (3.6 ± 0.33 vs 5.8 ± 0.81 days, p < 0.01). While pneumothorax size on computed tomography was associated with tube thoracostomy, only tube thoracostomy correlated with length of stay on multivariable analysis; pneumothorax size on CXR and computed tomography did not. There were no deaths or readmissions in either cohort. One patient in the observation group required tube thoracostomy after 18 h for worsening subcutaneous emphysema, and one patient in the tube thoracostomy group developed an empyema. CONCLUSIONS: Select patients with small traumatic pneumothoraces on initial chest radiograph who were treated with observation experienced an average length of stay over two days shorter than those treated with tube thoracostomy. Outcomes were otherwise similar between the two groups suggesting that an observation-first strategy may be a superior treatment approach for these patients.

Racial Disparities Among Trauma Patients During the COVID-19 Pandemic.

INTRODUCTION: Given the disparate effects of the COVID-19 pandemic on people of color, we hypothesized that patients of color experienced a disproportionate increase in trauma during the COVID-19 pandemic. MATERIALS AND METHODS: We compared trauma patients arriving in the 3 y before our statewide stay-at-home mandate on March 20, 2020 (PRE) to those arriving in the year afterward (POST). In addition to race/ethnicity, we assessed patient demographics and other clinical variables. Chi-squared, Fisher's exact, and Mann-Whitney U tests were used for univariate analyses. A multivariable logistic regression was performed to assess for associations with mortality. RESULTS: During the study period, 8583 patients were included in the PRE group and 2883 were included in the POST group. There were increases in penetrating trauma (PRE 14.7%, POST 23.1%; P < 0.001) and mortality rates (PRE 3.20%, POST 4.60%; P < 0.001). From PRE to POST, the percentage of Black patients increased from 35.0% to 38.3% (P = 0.01) and the percentage of Hispanic patients increased from 19.2% to 23.0% (P < 0.001). After a multivariable analysis, Asian patients experienced an independent increase in mortality from PRE to POST (odds ratio 2.00, 95% confidence interval 1.13-3.54, P = 0.02). CONCLUSIONS: Penetrating trauma and mortality rates increased during the pandemic. There was a simultaneous increase in the percentage of Black and Hispanic trauma patients. Asian patient mortality increased significantly after the start of the pandemic independent of other variables. Identifying racial/ethnic disparities is the first step in finding ways to improve dissimilar outcomes.

A step-up approach to management of complex bronchopleural fistula.

Bronchopleural fistula (BPF) is a sinus tract between a mainstem, lobar or segmental bronchus and the pleural space. We present a 68-year-old male with a 13 mm spiculated left lower lobe nodule who underwent video-assisted thoracoscopic surgery left lower lobe wedge resection followed by persistent BPF requiring open window thoracostomy. We present a step-up approach to management of persistent BPF with discussion of conservative, operative and reconstructive techniques for closure.

An Epidemic Within the Pandemic: The Rising Tide of Trauma During COVID-19.

BACKGROUND: In the age of COVID-19 and enforced social distancing, changes in patterns of trauma were observed but poorly understood. Our aim was to characterize traumatic injury mechanisms and acuities in 2020 and compare them with previous years at our level I trauma center. MATERIAL AND METHODS: Patients with trauma triaged in 2016 through 2020 from January to May were reviewed. Patient demographics, level of activation (1 versus 2), injury severity score, and mechanism of injury were collected. Data from 2016 through 2019 were combined, averaged by month, and compared with data from 2020 using chi-squared analysis. RESULTS: During the months of interest, 992 patients with trauma were triaged in 2020 and 4311 in 2016-2019. The numbers of penetrating and level I trauma activations in January-March of 2020 were similar to average numbers for the same months during 2016 through 2019. In April 2020, there was a significant increase in the incidence of penetrating trauma compared with the prior 4-year average (27% versus 16%, P < 0.002). Level I trauma activations in April 2020 also increased, rising from 17% in 2016 through 2019 to 32% in 2020 (P < 0.003). These findings persisted through May 2020 with similarly significant increases in penetrating and high-level trauma. CONCLUSIONS: In the months after the initial spread of COVID-19, there was a perceptible shift in patterns of trauma. The significant increase in penetrating and high-acuity trauma may implicate a change in population dynamics, demanding a need for thoughtful resource allocation at trauma centers nationwide in the context of a global pandemic.

Early Monocyte Chemoattractant Protein-1 Elevation Predicts Surgical Site Infections after Blunt Trauma.

Background: Dysregulation of the inflammatory and immune response to injury may increase susceptibility to secondary infections after trauma. It is unknown whether cytokines involved in this response could function as plasma biomarkers for surgical site infection (SSI). We hypothesized that the early cytokine response differs between patients who develop SSI and those who do not and that critical cytokine threshold values could be used to predict risk of SSI. Patients and Methods: Using the Glue Grant database, we performed an analysis of severely injured blunt trauma patients who underwent a major procedure and had available cytokine data. Patients were divided into SSI and no SSI groups. Receiver operating curve analysis was used to determine acceptable early cytokine predictors of SSI and critical threshold values. Multivariable regression analysis was then performed to determine the odds of developing SSI using threshold values, adjusting for key patient or injury factors. Cytokine levels were compared between SSI and no SSI groups at three time points. Results: The study cohort consisted of 70 patients and 11 patients developed SSI. Monocyte chemoattractant protein-1 (MCP-1) was the only acceptable early predictor of SSI with an area under the curve (AUC) of 0.71 (p = 0.03) and a critical threshold value of 490 pg/mL. Monocyte chemoattractant protein-1 levels above this threshold within 24 hours of injury were associated with SSI (adjusted odds ratio [AOR] 8.1; p = 0.01). Monocyte chemoattractant protein-1 levels within 24 hours of injury were higher in those who developed SSI (994 vs. 259 pg/mL; p < 0.01) and remained higher in the SSI group at 33 hours from injury (338 vs. 144 pg/mL; p = 0.01), but were similar by 106 hours (155 vs. 97 pg/mL; p = 0.19). Conclusion: Among cytokines involved in the early response to trauma, only early elevation of MCP-1 predicted SSI after blunt trauma. Monocyte chemoattractant protein-1 may act as a specific and early marker for SSI after blunt trauma, allowing for preventative measures to mitigate risks.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis.

BACKGROUND: Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS: A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS: In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS: ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Do Ventriculoperitoneal Shunts Increase Complications After Laparoscopic Gastrostomy in Children?

BACKGROUND: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement and determine their incidence of complications. MATERIALS AND METHODS: Children 18 y old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between January 2014 and October 2016 were reviewed. Data collected included demographics, management, and outcomes. Patients were compared based on their presence of a VP shunt before laparoscopic gastrostomy. Statistical analysis was performed using chi square, Fisher's exact, and Wilcoxon rank-sum tests. RESULTS: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt with those without a VP shunt, there was no significant difference in median age (4 versus 3 y, P = 0.92), gender (48% versus 51% males, P = 0.80), body mass index (15 versus 16, P = 0.69), preoperative diet (48% versus 47% nasogastric tube dependent, P = 0.60), or procedure time (43 versus 42 min, P = 0.37). The postoperative management of these children was similar: day of initiation of postoperative feeds (84% versus 73% on postoperative day #1, P = 0.70), method of initiation of feeds (60% versus 55% continuous, P = 0.25), and type of initial feeds (83% versus 71% Pedialyte, P = 0.24). Similarly, there was no difference in hospital length of stay, return to the emergency department, or postoperative complications within 90 d (P > 0.05). CONCLUSIONS: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement and may be managed similar to other children in the postoperative period.

Postoperative Feeding Regimens After Laparoscopic Gastrostomy Placement.

PURPOSE: The objective of this study was to evaluate postoperative feeding regimens after laparoscopic gastrostomy placement and their effect on outcomes. METHODS: Children 18 years of age or younger, who underwent laparoscopic gastrostomy placement at a tertiary-care academic children's hospital between January 2014 and October 2016, were reviewed. Data collected included patient characteristics, postoperative feeding regimen, and clinical outcomes. Statistical analysis was performed using Chi-square, Fisher's exact, and Wilcoxon Rank-Sum tests. RESULTS: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. The median age was 2.7 (interquartile range [IQR], 0.7-9.6) years, and 50% (n = 136) were male. The median body mass index was 15.5 (IQR, 14.0-17.5). Complications within 90 days included: granulation tissue (34%), leakage (17%), dislodgement (14%), and skin and soft-tissue infection (9%). Two patients returned to the operating room, 1 for a dislodged tube, and another for a volvulus within 10 days of gastrostomy tube placement. A subset analysis of outpatients that underwent elective laparoscopic gastrostomy placement showed variation in the day of initial feeds (0-2 postoperative days [POD]), method of initial feeds (continuous versus bolus) and choice of initial feeds (Pedialyte versus formula/breast milk). There was a significant difference in median hospital length of stay for early versus late initiation of feeds (POD 0: 2.1 days versus POD ≥1: 3.1 days, P < .01) without a difference in postoperative complications. CONCLUSION: There is substantial variation in the postoperative feeding regimen after laparoscopic gastrostomy. Initiation of early postoperative feeds may result in decreased length of stay without increasing complications.