Risk factors for bleeding hepatocellular adenoma in a United States cohort.

BACKGROUND & AIMS: Known risk factors for hepatocellular adenoma (HCA) bleeding are size >5 cm, growth rate, visible vascularity, exophytic lesions, ß-catenin and Sonic Hedgehog activated HCAs. Most studies are based on European cohorts. The objective of this study is to identify additional risk factors for HCA bleeding in a US cohort. METHODS: Retrospective chart review was performed on patients diagnosed with HCA on magnetic resonance imaging (n = 184) at an academic tertiary institution. Clinical, pathological, and imaging data were collected. Primary outcomes measured were HCA bleeding and malignancy. Statistical analysis was performed with SAS 9.4 using Chi-Square, Fisher's exact test, sample t test, non-parametric Wilcoxon test, and logistic regression. RESULTS: After excluding patients whose pathology showed focal nodular hyperplasia and non-adenoma lesions, follow-up data were available for 167 patients. 16% experienced microscopic or macroscopic bleeding and 1.2% had malignancy. HCA size predicted bleeding (P < .0001) and no patients with lesion size <1.8 cm bled. In unadjusted analysis, hepatic adenomatosis (≥10 lesions) trended towards 2.8-fold increased risk of bleeding. Of patients with a single lesion that bled, 77% bled from a lesion >5 cm. In patients with multiple HCAs that bled, 50% bled from lesions <5 cm. In patients with multiple adenomas, size (P = .001) independently predicted bleeding and hepatic steatosis trended towards increased risk of bleeding (P = .05). CONCLUSIONS: In a large US cohort, size predicted increased risk of HCA bleeding while hepatic adenomatosis trended towards increased risk of bleeding. In patients with multiple HCAs, size predicted bleeding and hepatic steatosis trended toward increased risk of bleeding.

Code Critical Airway: A Collaborative Solution to a Catastrophic Problem.

BACKGROUND: In 2006, a multi-disciplinary "Code Critical Airway" (CCA) Team was created at our institution. The objective of this study is to examine the demographics and outcomes of the patients for whom a CCA is activated. METHODS: A retrospective review was conducted of patients for whom a CCA was activated from 2008-2020. Data from 2006-2008 was not available due to timing of the implementation of the hospital's electronic medical record system. The early period of the experience with CCAs (2008-2014) was compared to the later period (2015-2020) CCA activations. RESULTS: There were 953 CCA activations. Over time, there was a statistically significantly increase in the number of CCA activations. CCAs occurred in the emergency department in 274 (29.0%), intensive care unit in 255 (27.0%), step-down unit in 60 (6.4%), wards in 294 (31.1%), and elsewhere in 61 (6.5%) cases. CCAs were managed with direct laryngoscopy in 97 patients (10.2%), video laryngoscope in 160 patients (16.8%), fiberoptic bronchoscopy in 179 patients (18.8%), bougie in 7 patient (0.7%), replacement of a prior tracheostomy in 262 patients (27.5%), and creation of a new surgical airway in 95 patients (10.0%). The definitive management of the CCA was not recorded in 76 patients (8.0%). Seven patients required removal of a foreign body (0.7%). There was no intervention in 70 patients (7.3%). There was an increase in successful first attempts at obtaining an airway comparing our experience in the early period (2008-2014) compared to the later period (2015-2020) (P < 0 .001). There was also a decrease in number of CCAs requiring a surgical airway (P = .030). CONCLUSION: Inculcation of aggressive early escalation of airway emergencies through implementation of a CCA Team has resulted in significant improvement in first attempt airway stabilization and a decrease in surgical airways.