Angioembolization is necessary with any volume of contrast extravasation in blunt trauma.

INTRODUCTION: Reduction of nonessential angiogram and embolization for patients sustaining blunt abdominal and pelvic trauma would allow improved utilization and decreased morbidity related to nontherapeutic embolization. We hypothesized that the nature of intravenous contrast extravasation (IVCE) on computed tomography (CT) would be directly related to the finding of extravasation on angiogram and need for embolization. METHODS: A 5-year retrospective evaluation of trauma patients with IVCE on CT. Demographics, hemodynamics, and IVCE location and maximal dimension/volume were examined for relationship to IVCE on angiography and need for embolization. Primary complications were defined as nephropathy and acute respiratory distress syndrome. RESULTS: A total of 128 patients were identified with IVCE on CT. Ninety-seven (75.8%) also had IVCE identified on angiography requiring some form of embolization. The size of IVCE on CT was not related to IVCE on angiogram (P = 0.69). Location of IVCE was related to need for embolization, with spleen embolization (85.4%) being much more frequent than liver (51.5%, P = 0.006). Complication rate was 8.7% in all patients, and was not different between patients undergoing embolization and those who did not (P = 0.40). CONCLUSION: IVCE volume was not predictive of continued bleeding and need for embolization. However, splenic injuries with IVCE required embolization more frequently. In contrast, liver injuries were found to have infrequent on-going IVCE on angiography. Complications associated with angiogram with or without embolization are infrequent, and CT findings may not be predictive of ongoing bleeding. We do not recommend selective exclusion of patients from angiographic evaluation when a blush is present.

Mortality and readmission of outcomes after discharge from the surgical intensive care unit to long-term, acute-care hospitals.

BACKGROUND: Patients with prolonged hospitalizations in the surgical intensive care unit often have ongoing medical needs that require further care at long-term, acute-care hospitals upon discharge. Setting expectations for patients and families after protracted operative intensive care unit hospitalization is challenging, and there are limited data to guide these conversations. The purpose of this study was to determine patient survival and readmission rates after discharge from the surgical intensive care unit directly to a long-term, acute-care hospital. METHODS: All patients who were admitted to the surgical intensive care unit at an academic, tertiary care medical center from 2009-2014 and discharged directly to long-term, acute-care hospitals were retrospectively reviewed. Patients represented all surgical subspecialties excluding cardiac and vascular surgery patients. Primary outcomes included 30-day readmission, and 1- and 3-year mortality rates following discharge. RESULTS: In total, 296 patients were discharged directly from the surgical intensive care unit to a long-term, acute-care hospital during the study period. There were 190 men (64%) and mean age was 61 ± 16 years. Mean duration of stay in the surgical intensive care unit was 27 ± 17 days. The most frequent complication was prolonged mechanical ventilation (277, 94%) followed by pneumonia (139, 47%), sepsis (78, 26%), and acute renal failure (32, 11%); 93% of patients required tracheostomy and enteral feeding access prior to discharge, and 19 patients (6%) were newly dependent on hemodialysis. The readmission rate was 20%. There were 86 deaths within 1 year from discharge (29%) with an overall 3-year mortality of 32%. In a multiple logistic regression analysis, a history of end-stage renal disease had a greater odds of readmission (odds ratio 6.07, P = .028). Patients with history of cancer had greater odds of 1- and 3-year mortality (odds ratio = 2.99, P = .028 and odds ratio 2.56, P = .053, respectively), and patients with a neurologic diagnosis had greater odds of 3-year mortality (odds ratio 4.69, P = .031). Readmission significantly increased the odds of 1- and 3-year mortality (odds ratio 3.12, P = .020 and odds ratio 2.90, P = .027, respectively). Patients who had both private insurance and Medicare had greater odds of 1- and 3-year mortality (odds ratio 10.39, P = .005 and odds ratio 10.65, P = .004, respectively). CONCLUSION: Patients who are discharged to long-term, acute-care hospitals have prolonged hospitalizations with high complication rates. These patients have high readmission and 1-year mortality rates. Patients and families should be counseled regarding these outcomes related to post-intensive care unit recovery after discharge to a long-term, acute-care hospital to allow for realistic expectations of survival after prolonged intensive care unit hospitalization.

Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial.

BACKGROUND: Following blunt splenic injury, there is conflicting evidence regarding the natural history and appropriate management of patients with vascular injuries of the spleen such as pseudoaneurysms or blushes. The purpose of this study was to describe the current management and outcomes of patients with pseudoaneurysm or blush. METHODS: Data were collected on adult (aged ≥18 years) patients with blunt splenic injury and a splenic vascular injury from 17 trauma centers. Demographic, physiologic, radiographic, and injury characteristics were gathered. Management and outcomes were collected. Univariate and multivariable analyses were used to determine factors associated with splenectomy. RESULTS: Two hundred patients with a vascular abnormality on computed tomography scan were enrolled. Of those, 14.5% were managed with early splenectomy. Of the remaining patients, 59% underwent angiography and embolization (ANGIO), and 26.5% were observed. Of those who underwent ANGIO, 5.9% had a repeat ANGIO, and 6.8% had splenectomy. Of those observed, 9.4% had a delayed ANGIO, and 7.6% underwent splenectomy. There were no statistically significant differences between those observed and those who underwent ANGIO. There were 111 computed tomography scans with splenic vascular injuries available for review by an expert trauma radiologist. The concordance between the original classification of the type of vascular abnormality and the expert radiologist's interpretation was 56.3%. Based on expert review, the presence of an actively bleeding vascular injury was associated with a 40.9% risk of splenectomy. This was significantly higher than those with a nonbleeding vascular injury. CONCLUSIONS: In this series, the vast majority of patients are managed with ANGIO and usually embolization, whereas splenectomy remains a rare event. However, patients with a bleeding vascular injury of the spleen are at high risk of nonoperative failure, no matter the strategy used for management. This group may warrant closer observation or an alternative management strategy. LEVEL OF EVIDENCE: Prognostic study, level III.

Implementation of a shared-savings program for surgical supplies decreases inventory cost.

BACKGROUND: Management of operating room inventory has substantial cost-saving opportunities if surgeons agree to standardize supplies used to perform procedures; however, there is no incentive for surgeons to participate in these decisions, because the cost-savings are realized only by the hospital, not the practitioner. In an attempt to engage surgeons with the management of the operating room supply chain, a shared-savings programs was instituted that returned 50% of money saved to the surgery divisions. METHODS: Opportunities for savings in the use of biologic mesh, cranial plating systems, and neurostimulators was identified. Each item was assigned a physician champion responsible for ensuring that there was clinical equipoise between the products being used. Any cost-savings realized during the fiscal year were shared 50-50 between the hospital and the surgery divisions. RESULTS: The total cost-savings was $893,865 with $446,932 being shared across 15 surgery divisions. Standardization of cranial plating systems ($374,805) generated the greatest amounts of savings followed by neurostimulators ($278,404) and biologic mesh ($240,655). CONCLUSION: Aligning hospital and surgeon incentives led to dramatic cost-savings and standardization of the operative inventory used. Quality of care is not compromised by this approach, and no conflicts of interest are created.