Determinants of reoperation after decompressive craniectomy in patients with traumatic brain injury: A comparative study.

OBJECTIVES: Reoperation after decompressive craniectomy (DC) in patients with traumatic brain injury (TBI) remains a dilemma and the risk factors are to be identified. The aim of the current study was to determine the determinants and risk factors of reoperation after DC in patients with TBI. PATIENTS AND METHODS: This retrospective case-controlled study was conducted during a 4-year period from September 2013 to October 2017 in a level I trauma center affiliated with Shiraz University of Medical Sciences in southern Iran. We included all the adult (≥18 years) patients with TBI who underwent primary or secondary DC in our center during the study period. Those who underwent reoperation were compared to those who underwent DC only regarding the demographic findings, clinical features and neuroimaging findings. A univariate and multivariate logistic regression analysis was performed to determine the determining factors of reoperation. RESULTS: Overall we included 371 patients with mean age of 36.45 ± 14.18 years. Among the patients there were 325 (87.6%) men and 46 (12.4%) women. The reoperation in patients undergoing DC due to TBI was associated with primary DC (p = 0.039) and higher Marshall grade (p = 0.027). Those who underwent reoperation after DC for TBI had significantly higher ICU (p = 0.007) and hospital LOS (p = 0.001) and lower 6-month GOSE (p = 0.010). Age (p < 0.001), GCS (p < 0.001) and pupils (p = 0.027) were predictors of outcome in reoperation group. Reoperation in primary DC group was associated with pupil reactivity (p = 0.002) and number of episodes with INR above 1.5 (p = 0.037) Conclusion: Reoperation after DC for TBI is associated with primary DC, and Marshall grade. The reoperation after DC is associated with worse outcome and longer ICU and hospital stay. The age, GCS and pupil reactivity are the main predictors of outcome in those with reoperation after DC for TBI.

Effect of Implementation of Standard Clinical Practice Guideline on Management of Gastrointestinal Bleeding Patients in Emergency Department; a Cross-Sectional Study.

INTRODUCTION: A clinical practice guideline (CPG) is developed with the aim of improving the quality of health care and reducing unnecessary interventions, hospitalization time, and related costs. OBJECTIVE: This study attempted to design a standard protocol for gastrointestinal bleeding (GIB) patients. METHODS: This was a cross-sectional study conducted during 2013 and 2014 in an educational medical center in Isfahan, Iran. A checklist containing questions about waiting time for the services, hospitalization time, and costs was completed for the GIB patients. After this primary data gathering, a CPG was designed, codified, underwent several revisions, and finally implemented. Thereafter, the checklist was completed by GIB patients and compared with the previous ones. RESULTS: Fifty patients in each of the two phases were included. The mean age and sex of the studied patients were not different.The time from emergency departments (ED) arrival until the first visit (14 ± 9.8 Vs. 19.4 ± 13.4 minutes; p = 0.03), hospitalization (73.7 ± 49.2 Vs. 116.2 ± 7.2 hours; p=0.003) and costs (1.3 ± 0.81 Vs. 3.68 ± 3.51 million rials; p < 0.001) were significantly reduced following the CPG implementation. The time from admission until conducting endoscopy was not different in the two study periods (16.5 ± 7.8 Vs. 23.9 ± 24.5 hours, p = 0.89). CONCLUSION: The implementation of the CPG for the management of GIB patients in the ED resulted in a reduction in the waiting time for the services and, further, reduction of hospitalization time and related costs.

Effects of Intravenous Fluid Therapy on Clinical and Biochemical Parameters of Trauma Patients.

INTRODUCTION: The administration of crystalloid fluids is considered as the first line treatment in management of trauma patients. Infusion of intravenous fluids leads to various changes in hemodynamic, metabolic and coagulation profiles of these patients. The present study attempted to survey some of these changes in patients with mild severity trauma following normal saline infusion. METHODS: This study comprised 84 trauma patients with injury of mild severity in Shahid Rajaei Hospital, Shiraz, Iran, during 2010-2011. The coagulation and metabolic values of each patient were measured before and one and six hours after infusion of one liter normal saline. Then, the values of mentioned parameters on one and six hours after infusion were compared with baseline measures using repeated measures analysis of variance. RESULTS: Eighty four patients included in the present study (76% male). Hemoglobin (Hb) (df: 2; F=32.7; p<0.001), hematocrit (Hct) (df: 2; F=30.7; p<0.001), white blood cells (WBC) (df: 2; F=10.6; p<0.001), and platelet count (df: 2; F=4.5; p=0.01) showed the decreasing pattern following infusion of one liter of normal saline. Coagulation markers were not affected during the time of study (p>0.05). The values of blood urea nitrogen (BUN) showed statistically significant decreasing pattern (df: 2; F=5.6; p=0.007). Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following hydration therapy. CONCLUSION: It seems that, the infusion of one liter normal saline during one hour will cause a statistically significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and PCO2 in trauma patients with mild severity of injury and stable condition. The changes in, coagulation profiles, pH, PvO2, and electrolytes were not statistically remarkable.