Elective paraesophageal hernia repair in elderly patients: an analysis of ACS-NSQIP database for contemporary morbidity and mortality.

BACKGROUND: Elective paraesophageal hernia (PEH) repair in asymptomatic or minimally symptomatic patients ≥ 65 years of age remains controversial. The widely cited Markov Monte Carlo decision analytic model recommends watchful waiting in this group, unless the mortality rate for elective repair was to reach ≤ 0.5%; at which point, surgery would become the optimal treatment. We hypothesized that with advances in minimally invasive surgery, perioperative care, and practice specialization, that mortality threshold has been reached in the contemporary era. However, the safety net would decrease as age increases, particularly in octogenarians. METHODS: We identified 12,422 patients from the 2015-2017 ACS-NSQIP database, who underwent elective minimally invasive PEH repair, of whom 5476 (44.1%) were with age ≥ 65. Primary outcome was 30-day mortality. Secondary outcomes were length of stay (LOS), operative time, pneumonia, pulmonary embolism, unplanned intubation, sepsis, bleeding requiring transfusion, readmission, and return to OR. RESULTS: Patients age ≥ 65 had a higher 30-day mortality (0.5% vs 0.2%; p < 0.001). Subset analysis of patients age 65-80 and > 80 showed a 30-day mortality of 0.4% vs. 1.8%, respectively (p < 0.001). Independent predictors of mortality in patients ≥ 65 years were age > 80 (OR 5.23, p < 0.001) and COPD (OR 2.59, p = 0.04). Patients ≥ 65 had a slightly higher incidence of pneumonia (2% vs 1.2%; p < 0.001), unplanned intubation (0.8% vs 0.5%; p < 0.05), pulmonary embolism (0.7% vs 0.3%; p = 0.001), bleeding requiring transfusion (1% vs 0.5%; p < 0.05), and LOS (2.38 vs 1.86 days, p < 0.001) with no difference in sepsis, return to OR or readmission. CONCLUSION: This is the largest series evaluating elective PEH repair in the recent era. While morbidity and mortality do increase with age, the mortality remains below 0.5% until age 80. Our results support consideration for a paradigm shift in the management of patients < 80 years toward elective repair of PEH.

The Use of Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome in Severe Burns Without Inhalation Injury.

Burn injury results in a severe systemic inflammatory response which is associated with the development of acute respiratory distress syndrome (ARDS), even without associated inhalation injury. Venous-venous extracorporeal membrane oxygenation (VV-ECMO) has been implemented in various cases of ARDS to provide support and allow for protective lung ventilation strategies. We report the case of a 27-year-old man presenting with a 60% total body surface area partial thickness burn who developed refractory ARDS with Murray Score of 3.75. ECMO was initiated on hospital day 9 for a total of 10 days with concurrent lung-protective ventilation. He subsequently recovered and was discharged on hospital day 48. ECMO should be considered as an adjunctive strategy in burn patients without inhalation injury to minimize ventilator-induced lung injury when high levels of support are needed to achieve adequate ventilation in patients with ARDS.

Hybrid Revascularization Combining Iliofemoral Endarterectomy and Iliac Stent Grafting for TransAtlantic Inter-Society Consensus C and D Aortoiliac Occlusive Disease.

BACKGROUND: This study examines the outcome of hybrid revascularization combining iliofemoral endarterectomy and iliac artery stenting using covered stents in TransAtlantic Inter-Society Consensus (TASC) C and D aortoiliac occlusive disease (AIOD) involving the common femoral artery (CFA). METHODS: A retrospective review was conducted in patients with TASC C and D AIOD involving the CFA and undergoing hybrid revascularization. Covered stents were used primarily. Demographics, indications for surgery, lesion classification, hospital length of stay (LOS), 30-day morbidity/mortality, hemodynamic and clinical success, and patency were assessed. RESULTS: Thirty-six male patients (41 limbs), mean age 63.9 ± 6 years, were identified (TASC C = 39%, D = 61%). Indications for surgery were claudication (27%), rest pain (44%), and tissue loss (29%). A simultaneous adjunctive procedure (5 infrainguinal bypass, 3 superficial femoral artery stents) was performed in 22%. Thirty-day outcomes included 1 mortality (2.7%) and 2 reoperation (5.5%), 1 for femoral artery pseudoaneurysm and 1 for bilateral groin seroma. LOS was 4 days (interquartile range 3-6). All patients with available data experienced 30-day clinical and hemodynamic success. Mean follow-up was 23 months (range 1-79 months) with a primary patency of 85.4%. Cumulative primary assisted and secondary patency was 92.6%. The femoral patch repair was the most frequent site of reintervention (3/3). Mortality was 34% during the study period, and it was significantly higher in patients with tissue loss (57.1% vs. 14.8%, P = 0.01). CONCLUSIONS: The hybrid approach has low morbidity, mortality, and fast recovery. The use of covered stents/stent grafts provides good mid-term patency. Close follow-up with noninvasive imaging is paramount to avoid repair failure, in particular at the femoral patch repair site.

Increased risk of fibrinolysis shutdown among severely injured trauma patients receiving tranexamic acid.

BACKGROUND: The association between tranexamic acid (TXA) and fibrinolysis shutdown is unknown. We hypothesize that TXA is associated with fibrinolysis shutdown in critically injured trauma patients. METHODS: Two hundred eighteen critically injured adults admitted to the intensive care unit at an urban Level I trauma center from August 2011 to January 2015 who had thromboelastography performed upon intensive care unit admission were reviewed. Groups were stratified based on fibrinolysis shutdown, which was defined as LY30 of 0.8% or less. Continuous variables were expressed as mean ± standard deviation or median (interquartile range). Poisson regression analysis was used to determine predictors of shutdown. RESULTS: Patients were age 46 ± 18 years, 81% male, 75% blunt trauma, Injury Severity Score of 28 ± 13, 16% received TXA, 64% developed fibrinolysis shutdown, and mortality was 15%. In the first 24 hours, 4 (2-9) units packed red blood cells and 2 (0-6) units fresh frozen plasma were administered. Those with shutdown had worse initial systolic blood pressure (114 ± 38 mm Hg vs. 129 ± 43 mm Hg, p = 0.006) and base deficit (-5 ± 6 mEq/L vs -3 ± 5 mEq/L, p = 0.013); received more packed red blood cells [6 (2-11) vs. 2 (1-5) units, p < 0.0001], and fresh frozen plasma [3 (0-8) vs. 0 (0-4) units, p < 0.0001]; and more often received TXA (23% vs. 4%, p <0.0001). After controlling for confounders, TXA (relative risk, 1.35; 95% confidence interval, 1.10-1.64; p = 0.004) and cryoprecipitate transfusion (relative risk, 1.29; 95% confidence interval, 1.07-1.56; p = 0.007) were independently associated with fibrinolysis shutdown. CONCLUSION: Patients who received TXA were at increased risk of fibrinolysis shutdown compared with patients who did not receive TXA. We recommend that administration of TXA be limited to severely injured patients with evidence of hyperfibrinolysis and recommend caution in those with evidence of fibrinolysis shutdown. LEVEL OF EVIDENCE: Therapeutic, level III.

Incidence and Operative Factors Associated With Discretional Postoperative Mechanical Ventilation After General Surgery.

BACKGROUND: Mechanical ventilation after general surgery is associated with worse outcomes, prolonged hospital stay, and increased health care cost. Postoperatively, patients admitted to the intensive care unit (ICU) may be categorized into 1 of 3 groups: extubated patients (EXT), patients with objective medical indications to remain ventilated (MED), and patients not meeting these criteria, called "discretional postoperative mechanical ventilation" (DPMV). The objectives of this study were to determine the incidence of DPMV in general surgery patients and identify the associated operative factors. METHODS: At a large, tertiary medical center, we reviewed all surgical cases performed under general anesthesia from April 1, 2008 to February 28, 2015 and admitted to the ICU postoperatively. Patients were categorized into 1 of 3 cohorts: EXT, MED, or DPMV. Operative factors related to the American Society of Anesthesiologists Physical Status (ASA PS), duration of surgery, surgery end time, difficult airway management, intraoperative blood and fluid administration, vasopressor infusions, intraoperative arterial blood gasses, and ventilation data were collected. Additionally, anesthesia records were reviewed for notes indicating a reason or rationale for postoperative ventilation. Categorical variables were compared by χ test, and continuous variables by analysis of variance or Kruskal-Wallis H test. Categorical variables are presented as n (%), and continuous variables as mean ± standard deviation or median (interquartile range) as appropriate. Significance level was set at P≤ .05. RESULTS: Sixteen percent of the 3555 patients were categorized as DPMV and 12.2% as MED. Compared to EXT patients, those classified as DPMV had received significantly less fluid (2757 ± 2728 mL vs 3868 ± 1885 mL; P < .001), lost less blood during surgery (150 [20-625] mL vs 300 [150-600] mL; P< .001), underwent a shorter surgery (199 ± 215 minutes vs 276 ± 143 minutes; P< .001), but received more blood products, 900 (600-1800) mL vs 600 (300-900) mL. The DPMV group had more patients with high ASA PS (ASA III-V) than the EXT group: 508 (90.4%) vs 1934 (75.6%); P< .001. Emergency surgery (ASA E modifier) was more common in the DPMV group than the EXT group: 145 (25.8%) vs 306 (12%), P< .001, respectively. Surgery end after regular working hours was not significantly higher with DPMV status compared to EXT. DPMV cohort had fewer cases with difficult airway when compared to EXT or MED. When compared to MED patients, those classified as DPMV received less fluid (2757 ± 2728 mL vs 4499 ± 2830 mL; P< .001), lost less blood (150 [20-625] mL vs 500 [200-1350] mL; P < .001), but did not differ in blood products transfused or duration of surgery. CONCLUSIONS: In our tertiary medical center, patients often admitted to the ICU on mechanical ventilation without an objective medical indication. When compared to patients admitted to the ICU extubated, those mechanically ventilated but without an objective indication had a higher ASA PS class and were more likely to have an ASA E modifier. A surgery end time after regular working hours or difficult airway management was not associated with higher incidence of DPMV.

Low End-Tidal Carbon Dioxide at the Onset of Emergent Trauma Surgery Is Associated With Nonsurvival: A Case Series.

BACKGROUND: End-tidal carbon dioxide (EtCO2) is a valuable marker of the return of adequate circulation after cardiac arrest due to medical causes. Previously, the prognostic value of capnography in trauma has been studied among limited populations in prehospital and emergency department settings. We aimed to investigate the relationship between early intraoperative EtCO2 and nonsurvival of patients undergoing emergency surgery at a level 1 academic trauma center as a case series. If there is a threshold below which survival was extremely unlikely, it might be useful in guiding decision-making in the early termination of futile resuscitative efforts. METHODS: After institutional review board approval, a data set was created to investigate the relationship between EtCO2 values at the onset of emergent trauma surgery and nonsurvival. Patients who were admitted and transferred to the operating room (OR) directly from a resuscitation bay were identified using the Ryder Center trauma registry (October 1, 2013, to June 30, 2016). Electronic records from the hospital's anesthesia information management system were queried to identify the matching anesthesia records. The maximum EtCO2 values within 5 and 10 minutes of the onset of mechanical ventilation in the OR were determined for patients undergoing general anesthesia with mechanical ventilation. Patients were divided into 2 groups: those who were discharged from the hospital alive (survivors) and those who died in the hospital before discharge (nonsurvivors). The threshold EtCO2 giving a positive predictive value of 100% for in-hospital mortality was determined from a graphical analysis of the data. Association of determined threshold and mortality was analyzed using the 2-tailed Fisher exact test. RESULTS: There were 1135 patients who met the inclusion criteria. Within the first 5 minutes of the onset of mechanical ventilation in the OR, if the maximum EtCO2 value was ≤20 mm Hg, hospital mortality was 100% (21/21, 95% binomial confidence interval, 83.2%-100%). CONCLUSIONS: A maximum EtCO2 ≤20 mm Hg within 5 minutes of the onset of mechanical ventilation in the OR may be useful in decision-making related to the termination of resuscitative efforts during emergent trauma surgery. However, a large-scale study is needed to establish the statistical reliability of this finding before potential adoption.

Shake It Off: A Randomized Pilot Study of the Effect of Whole Body Vibration on Pain in Healing Burn Wounds.

Whole body vibration (WBV) has been shown to improve strength in extremities with healed burn wounds. We hypothesize that WBV reduces pain during rehabilitation compared to standard therapy alone. Patients with ≥1% TBSA burn to one or more extremities from October 2014 to December 2015 were randomized to vibration (VIBE) or control. Each burned extremity was tested separately within the assigned group. Patients underwent one to three therapy sessions (S1, S2, S3) consisting of five upper and/or lower extremity exercises with or without WBV. Pain was assessed pre-, mid-, and postsession on a scale of 1 to 10. Mean pain scores at S1 to S3 were compared between groups with paired samples t-tests. An independent t-test was used to compare differences in pain scores between groups. Continuous variables were compared using a t-test or Mann-Whitney U test, and categorical variables were compared using a χ or Fisher's exact test, as appropriate. Forty-eight randomized test extremities (VIBE = 26, control = 22) were analyzed from a total of 31 subjects. There were no significant differences between groups in age, gender, overall TBSA, TBSA in the test extremity, pain medication use before therapy session, or skin grafting before therapy session. At S1, S2, and S3, there was a statistically significant decrease in mid- and postsession pain compared to presession pain in VIBE vs controls. Exposure to WBV decreased pain during and after physical therapy. This modality may be applicable to a variety of soft tissue injuries and warrants additional investigation.

Mechanism of Injury May Influence Infection Risk from Early Blood Transfusion.

BACKGROUND: Blood transfusion is a known risk factor for infection in trauma patients. Differences based on mechanism of injury have not been well described. We hypothesize that infection risk in trauma patients with early blood transfusion is different based on blunt or penetrating mechanism of injury. PATIENTS AND METHODS: Adults admitted to the trauma intensive care unit from January 2010 through January 2015 were reviewed retrospectively. Those receiving transfusion after 24 h were excluded. Infections were defined as positive bronchoalveolar lavage, blood, urine, wound, or abdominal cultures. Logistic regression identified independent predictors of infection. Significance was considered at p ≤ 0.05. RESULTS: With blunt trauma (n = 625), the transfusion rate was 36% (n = 223), with 30% (n = 186) infections. Those with an infection were more severely injured, had a higher operation rate, lower Glasgow Coma Score (GCS), longer hospital stay, and higher transfusion rate (all p < 0.001). With penetrating trauma (n = 292), the transfusion rate was 54% (n = 159), with 26% (n = 77) infections. Those with an infection were older, more severely injured, had a higher operation rate, lower GCS, longer length of stay, and higher transfusion rate (all p < 0.01). Controlling for age, injury severity score (ISS), revised trauma score (RTS), GCS, and hospital stay, transfusion was an independent predictor of infection in patients with blunt (odds ratio: 2.1, 95% confidence intervals: 1.272-3.393, p = 0.003) but not penetrating trauma. CONCLUSIONS: Early blood transfusion increases infection risk in blunt but not penetrating trauma.

Admission Hyperglycemia Predicts Infectious Complications After Burns.

Inflammation and hypermetabolism post burn predisposes to hyperglycemia and insulin resistance. The authors hypothesize that admission hyperglycemia predicts infectious outcomes. A retrospective review of all patients greater than 20 years of age admitted for initial burn management from January 2008 to December 2013 was conducted. Nonthermal injuries, transfers, and those without admission glucose or histories were excluded. Hyperglycemia was defined as admission glucose ≥150 mg/dl. Patients were grouped as follows: euglycemic without diabetes (control), euglycemic with diabetes (-H+D), hyperglycemic without diabetes (+H-D), and hyperglycemic with diabetes (+H+D). Outcomes included infection, mortality, length of stay, and disposition. Comparisons were made using Fisher's exact test and multiple logistic regression. A total of 411 patients were analyzed. No significant differences between any of the groups and controls were noted in race, inhalation injury, or obesity. All three groups had higher mortality compared with controls. Longer hospital stays were noted only in +H-D. +H-D and +H+D were less likely to be discharged home than controls. +H-D had higher rates of bacteremia, +H-D and +H+D had higher rates of pneumonia, and -H+D and +H-D had higher rates of urinary tract infection. Regression for infection and mortality outcomes with TBSA, age, diabetes, hyperglycemia, obesity, race, gender, and inhalation injury as covariates was performed. Hyperglycemia was the only independent predictor of bacteremia (area under curve [AUC] = 0.736). Hyperglycemia was also a predictor of pneumonia and urinary tract infection (AUC = 0.766 and 0.802, respectively). The only independent predictors of mortality were age, TBSA, and inhalation injury (AUC = 0.892). Acute glucose dysregulation may be more important than diabetes in predicting infectious outcomes after burns. Therefore, admission glucose may have prognostic value.

Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients.

BACKGROUND: Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. STUDY DESIGN: Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). RESULTS: Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022). CONCLUSIONS: Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.

Association of Mechanism of Injury With Risk for Venous Thromboembolism After Trauma.

Importance: To date, no study has assessed whether the risk of venous thromboembolism (VTE) varies with blunt or penetrating trauma. Objective: To test whether the mechanism of injury alters risk of VTE after trauma. Design, Setting, and Participants: A retrospective database review was conducted of adults admitted to the intensive care unit of an American College of Surgeons-verified level I trauma center between August 1, 2011, and January 1, 2015, with blunt or penetrating injuries. Univariate and multivariable analyses identified independent predictors of VTE. Main Outcomes and Measures: Differences in risk factors for VTE with blunt vs penetrating trauma. Results: In 813 patients with blunt trauma (mean [SD] age, 47 [19] years) and 324 patients with penetrating trauma (mean [SD] age, 35 [15] years), the rate of VTE was 9.1% overall (104 of 1137) and similar between groups (blunt trauma, 9% [n = 73] vs penetrating trauma, 9.6% [n = 31]; P = .76). In the blunt trauma group, more patients with VTE than without VTE had abnormal coagulation results (49.3% vs 35.7%; P = .02), femoral catheters (9.6% vs 3.9%; P = .03), repair and/or ligation of vascular injury (15.1% vs 5.4%; P = .001), complex leg fractures (34.2% vs 18.5%; P = .001), Glasgow Coma Scale score less than 8 (31.5% vs 10.7%; P < .001), 4 or more transfusions (51.4% vs 17.6%; P < .001), operation time longer than 2 hours (35.6% vs 16.4%; P < .001), and pelvic fractures (43.8% vs 21.4%; P < .001); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Profile scores (13 [6] vs 8 [4]; P ≤ .001). However, with multivariable analysis, only receiving 4 or more transfusions (odds ratio [OR], 3.47; 95% CI, 2.04-5.91), Glasgow Coma Scale score less than 8 (OR, 2.75; 95% CI, 1.53-4.94), and pelvic fracture (OR, 2.09; 95% CI, 1.23-3.55) predicted VTE, with an area under the receiver operator curve of 0.730. In the penetrating trauma group, more patients with VTE than without VTE had abnormal coagulation results (64.5% vs 44.4%; P = .03), femoral catheters (16.1% vs 5.5%; P = .02), repair and/or ligation of vascular injury (54.8% vs 25.3%; P < .001), 4 or more transfusions (74.2% vs 39.6%; P < .001), operation time longer than 2 hours (74.2% vs 50.5%; P = .01), Abbreviated Injury Score for the abdomen greater than 2 (64.5% vs 42.3%; P = .02), and were aged 40 to 59 years (41.9% vs 23.2%; P = .02); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Profile scores (12 [4] vs 7 [4]; P < .001). However, with multivariable analysis, only repair and/or ligation of vascular injury (OR, 3.32; 95% CI, 1.37-8.03), Abbreviated Injury Score for the abdomen greater than 2 (OR, 2.77; 95% CI, 1.19-6.45), and age 40 to 59 years (OR, 2.69; 95% CI, 1.19-6.08) predicted VTE, with an area under the receiver operator curve of 0.760. Conclusions and Relevance: Although rates of VTE are the same in patients who experienced blunt and penetrating trauma, the independent risk factors for VTE are different based on mechanism of injury. This finding should be a consideration when contemplating prophylactic treatment protocols.

A simplified stratification system for venous thromboembolism risk in severely injured trauma patients.

BACKGROUND: The objective of this study was to re-evaluate and simplify the Greenfield risk assessment profile (RAP) for venous thromboembolism (VTE) in trauma using information readily available at the bedside. METHODS: Retrospective review of 1233 consecutive admissions to the trauma intensive care unit from August 2011-January 2015. Univariate analyses were performed to determine which RAP risk factors were significant contributors to VTE. Multivariable logistic regression was used to develop models for risk stratification. All results were considered statistically significant at P ≤ 0.05. RESULTS: The study population was as follows: age 44 ± 19, 75% male, 72% blunt, injury severity score 21 ± 13, RAP score 9 ± 5, and 8% mortality. Groups were separated into +VTE (n = 104) and -VTE (n = 1129). They were similar in age, gender, mechanism, and mortality, but injury severity and RAP scores were higher in the +VTE group (all P < 0.0001). The +VTE group had more transfusions and longer time to prophylaxis (all P < 0.05). Receiving four or more transfusions in the first 24 h (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.64-4.13), Glasgow coma score <8 for >4 h (OR, 2.13; 95% CI, 1.28-3.54), pelvic fracture (OR, 2.26; 95% CI, 1.44-3.57), age 40-59 y (OR, 1.70; 95% CI, 1.10-2.63), and >2-h operation (OR, 1.80; 95% CI, 1.14-2.85) predicted VTE with an area under the receiver operator curve of 0.729, which was comparable with 0.740 for the RAP score alone. CONCLUSIONS: VTE risk in trauma can be easily assessed using only five risk factors, which are all readily available at the bedside (transfusion, Glasgow coma scale, pelvic fracture, prolonged operation, and age). This simplified model provides similar predictive ability to the more complicated RAP score. Prospective validation of a simplified risk assessment score is warranted.

Admission hyperglycemia is associated with different outcomes after blunt versus penetrating trauma.

BACKGROUND: Stress-induced hyperglycemia is associated with worse outcomes after trauma; however, the effect of mechanism of injury has not been studied. To fill this gap, we tested the hypothesis that blunt and penetrating trauma evoke different glycemic responses which are associated with different outcomes. MATERIALS AND METHODS: A retrospective cohort study comparing adults with blunt (n = 835) or penetrating trauma (n = 858) and admission glucose levels ≥ 106 mg/dL, ≥150 mg/dL, and ≥200 mg/dL at a level 1 trauma center from 02, 2011 to 08, 2013. Primary outcomes were mortality and infectious complications. RESULTS: For all patients, mean Injury Severity Score was 14 ± 12, with 10% (n = 162) infections and 6% (n = 102) mortality. Median admission glucose was 122 mg/dL (102-154 mg/dL). Hyperglycemia was associated with infections, length of stay, and mortality (all P < 0.01). Ten percent had an admission glucose ≥200 mg/dL, which was associated with infections after blunt trauma (odds ratio [OR], 2.28; 95% CI, 1.16-4.47; P = 0.017) but not penetrating trauma. Hyperglycemia was not an independent predictor of mortality in blunt trauma. In contrast, glucose ≥150 mg/dL (OR, 2.58; 95% CI, 1.13-5.89; P = 0.025) and ≥200 mg/dL (OR, 2.98; 95% CI, 1.27-6.98; P = 0.012) both predicted mortality in penetrating trauma patients. CONCLUSIONS: This is the first study to show that hyperglycemia is associated with fundamentally different outcomes after blunt versus penetrating trauma. Patients who died were 4-8 times more likely to have hyperglycemia and penetrating, not blunt, trauma. Incorporation of hyperglycemia in injury scoring systems might improve outcome predictions after trauma.

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes.

INTRODUCTION: Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05. RESULTS: The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. CONCLUSIONS: Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Is Hydroxyethyl Starch Safe in Penetrating Trauma Patients?

OBJECTIVES: For logistic reasons, a bolus of 6% hydroxyethyl starch (HES 450/0.7 in lactated electrolyte injection) is recommended for battlefield resuscitation even though it has risks of mortality and acute kidney injury (AKI) in certain patient populations. The purpose of this study was to test the hypothesis that victims of penetrating trauma have no increased risks of AKI and/or death when receiving a single bolus of HES during initial fluid resuscitation. METHODS: 816 consecutive admissions with penetrating trauma were reviewed. Patients who died within 24 hours were excluded. Propensity scores and a 1:1 fixed ratio nearest neighbor matching were used to compare those who received HES to those who did not. Data were expressed as mean ± SD and significance was assessed at p < 0.05. RESULTS: The cohort was 88% male, age 35 ± 14 years, injury severity score of 10 ± 10, with a 3.8% rate of AKI, and 3.2% rate of mortality. HES was administered to 121 (14.8%) patients. In HES and no HES propensity matched groups, the rate of AKI was 3.8% vs. 4.8% (p = 0.749) and the 90-day mortality rate was 3.8% vs. 4.8% (p = 0.749). CONCLUSION: An increased risk of mortality or AKI was not observed in penetrating trauma patients who were resuscitated with low volume HES.

Evaluation of Miniature Wireless Vital Signs Monitor in a Trauma Intensive Care Unit.

A previous study demonstrated basic proof of principle of the value of a miniature wireless vital signs monitor (MWVSM, MiniMedic, Athena GTX, Des Moines, Iowa) for battlefield triage However, there were unanswered questions related to sensor reliability and uncontrolled conditions in the prehospital environment. This study determined whether MWVSM sensors track vital signs and allow for appropriate triage compared to a gold standard bedside monitor in trauma patients. This was a prospective study in 59 trauma intensive care unit patients. Systolic blood pressure, temperature, heart rate (HR), skin temperature, and pulse oximetry (SpO2) were displayed on a bedside monitor for 60 minutes. Shock index (SI) was calculated. A separate MWVSM monitor was attached to the forehead and finger of each patient. Data from each included pulse wave transit time (PWTT), temperature, HR, SpO2, and a summary status termed "Murphy Factor" (MF), which ranges from 0 to 5. Patients are classified as "routine" if MF = 0 to 1 or SI = 0 to 0.7, "priority" if MF = 2 to 3 or SI = 0.7 to 0.9, and "critical" if MF = 4 to 5 or SI ≥ 0.9. Forehead and finger MWVSM HRs both differed from the monitor (both p < 0.001), but the few beats per minute differences were clinically insignificant. Differences in MWVSM SpO2 (1-7%) and temperature (6-13°F) from the monitor were site specific (all p < 0.001). Forehead PWTT (271 ± 50 ms) was less (p < 0.001) than finger PWTT (315 ± 42 ms); both were dissociated from systolic blood pressure (r(2) < 0.05). The SI distributed patients about equally as "routine," "priority," and "critical," whereas MF overtriaged to "routine" and undertriaged to "critical" for both sensors (all p < 0.001). Our findings suggest that MF does not accurately predict the most critical patients, likely because erroneous PWTT values confound MF calculations. MF and the MWVSM are promising, but require fine-tuning before deployment.

Coagulation Changes following Combined Ablative and Reconstructive Breast Surgery.

BACKGROUND: This study assessed hemostatic function in cancer patients at high risk for venous thromboembolism. METHODS: Thirty-eight female patients (age, 53 ± 9 years) undergoing immediate postmastectomy reconstruction were prospectively studied with informed consent. Blood was sampled preoperatively, on postoperative day 1, and at 1 week follow-up. Rotational thromboelastography clotting time, α-angle (clot kinetics), clot formation time, and maximum clot firmness were studied with three different activating agents: intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D. Thromboprophylaxis was unfractionated heparin plus sequential compression devices if not contraindicated. Hypercoagulability was defined by one or more parameters outside the reference range. RESULTS: Preoperatively, 29 percent of patients were hypercoagulable, increasing to 67 percent by week 1 (p = 0.017). Clotting time, clot formation time, and α-angle remained relatively constant over time, but maximum clot formation increased in intrinsically activated test using ellagic acid, extrinsically activated test with tissue factor, and fibrin-based extrinsically activated test with tissue factor and the platelet inhibitor cytochalasin D (all p < 0.05). Body mass index was 28 ± 5 kg/m, 23 percent received preoperative chemotherapy, and 15 percent had a history of tobacco use, but there was no association between these risk factors and hypercoagulability. CONCLUSIONS: Despite perioperative thromboprophylaxis, two-thirds of patients undergoing combined tumor resection and reconstructive surgery for breast cancer were hypercoagulable 1 week after surgery. Hypercoagulability was associated with increased clot strength mediated by changes in platelet and fibrin function. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Potentially preventable prehospital deaths from motor vehicle collisions.

BACKGROUND: In 2011, about 30,000 people died in motor vehicle collisions (MVCs) in the United States. We sought to evaluate the causes of prehospital deaths related to MVCs and to assess whether these deaths were potentially preventable. METHODS: Miami-Dade Medical Examiner records for 2011 were reviewed for all prehospital deaths of occupants of 4-wheeled motor vehicle collisions. Injuries were categorized by affected organ and anatomic location of the body. Cases were reviewed by a panel of 2 trauma surgeons to determine cause of death and whether the death was potentially preventable. Time to death and hospital arrival times were determined using the Fatality Analysis Reporting System (FARS) data from 2002 to 2012, which allowed comparison of our local data to national prevalence estimates. RESULTS: Local data revealed that 39% of the 98 deaths reviewed were potentially preventable (PPD). Significantly more patients with PPD had neurotrauma as a cause of death compared to those with a nonpreventable death (NPD) (44.7% vs. 25.0%, P =.049). NPDs were significantly more likely to have combined neurotrauma and hemorrhage as cause of death compared to PPDs (45.0% vs. 10.5%, P <.001). NPDs were significantly more likely to have injuries to the chest, pelvis, or spine. NPDs also had significantly more injuries to the following organ systems: lung, cardiac, and vascular chest (all P <.05). In the nationally representative FARS data from 2002 to 2012, 30% of deaths occurred on scene and another 32% occurred within 1 h of injury. When comparing the 2011 FARS data for Miami-Dade to the remainder of the United States in that year, percentage of deaths when reported on scene (25 vs. 23%, respectively) and within 1 h of injury (35 vs. 32%, respectively) were similar. CONCLUSIONS: Nationally, FARS data demonstrated that two thirds of all MVC deaths occurred within 1 h of injury. Over a third of prehospital MVC deaths were potentially preventable in our local sample. By examining injury patterns in PPDs, targeted intervention may be initiated.

Risk factors for venous thromboembolism after pediatric trauma.

BACKGROUND/PURPOSE: The purposes of this study were to identify independent predictors of venous thromboembolism (VTE), to evaluate the relative impact of adult VTE risk factors, and to identify a pediatric population at high-risk for VTE after trauma. METHODS: 1934 consecutive pediatric admissions (≤ 17 years) from 01/2000 to 12/2012 at a level 1 trauma center were reviewed. Logistic regression was used to identify predictors of VTE. RESULTS: Twenty-two patients (1.2%) developed a VTE, including 5% of those requiring orthopedic surgery, 14% of those with major vascular injury (MVI), and 36% of those with both. Most (84%) were diagnosed at the primary site of injury. 86% of those who developed a VTE were receiving thromboprophylaxis at the time of diagnosis. Independent predictors were age (odds ratio (OR): 1.59, 95% confidence interval (CI): 1.11-2.25), orthopedic surgery (OR: 8.10, CI: 3.10-21.39), transfusion (OR: 3.37, CI: 1.26-8.99), and MVI (OR: 15.43, CI: 5.70-41.76). When known risk factors for VTE in adults were adjusted, significant factors were age ≥ 13 years (OR: 9.16, CI: 1.08-77.89), indwelling central venous catheter (OR: 4.41, CI: 1.31-14.82), orthopedic surgery (OR: 6.80, CI: 2.47-18.74), and MVI (OR: 14.41, CI: 4.60-45.13). CONCLUSION: MVI and orthopedic surgery are synergistic predictors of pediatric VTE. Most children who developed a VTE were receiving thromboprophylaxis at the time of diagnosis.