Video-assisted thoracoscopic surgery in the management of penetrating and blunt thoracic trauma

BACKGROUND:

The role of video-assisted Thoracoscopic Surgery (VATS) is still being defined in the management of thoracic trauma. We report our trauma cases managed by VATS and review the role of VATS in the management of thoracic trauma.

MATERIALS AND METHODS:

All the trauma patients who underwent VATS from 2000 to 2007 at Cedars-Sinai Medical Center were retrospectively studied.

RESULTS:

Twenty-three trauma patients underwent 25 cases of VATS. The most common indication for VATS was retained haemothorax. Thoracotomy was avoided in 21 patients. VATS failed in two cases. On an average VATS was performed on trauma day seven (range 1-26) and the length of hospital stay was 20 days (range 3-58). There was no mortality. VATS was performed in an emergency (day 1-2), or in the early (day 2-7) or late (after day 7) phases of trauma.

CONCLUSION:

VATS can be performed safely for the management of thoracic traumas. VATS can be performed before or after thoracotomy and at any stage of trauma. The use of VATS in trauma has a trimodal distribution (emergent, early, late), each with different indications.

Attitudes and behaviors on alcohol use and impaired driving in adolescents

BACKGROUND

Underage drinking and driving is a national safety issue. We hypothesized students would have lenient thoughts and behaviors about drinking and driving. The aim of our study was to assess current adolescent behavior and attitudes on alcohol use and driving.

METHODS

A survey of 40 multiple choice questions was administered to 11th and 12th grade students at an urban, public high school in Los Angeles, California.

RESULTS

Of the 1282 upper class students, 302 completed the survey (127 eleventh graders and 175 twelfth graders; 31% response rate). Overall, 64.2% reported having used alcohol. Significantly more 12th graders than 11th graders had consumed alcohol (71.4% versus 54.3%; P = 0.002); irrespective of gender. Binge drinking was reported by 8.6% of students (11.4% 12th graders vs. 4.7% 11th graders; P = 0.06). Nearly one-half (49.7%) of students indicated they disapproved of binge drinking. Students were more willing to discuss alcohol issues with peers (63.2%) than parents (44.0%) or teachers/counselors (19.5%; P = < 0.001). Most students (88.1%) indicated they would not drive when they had consumed one to two drinks.

CONCLUSIONS

Greater than 60% of respondents reported having used alcohol. Students expressed strong concern about alcohol-impaired driving. Binge drinking appears prevalent in high school-aged individuals and increases with age. The lack of communication between students and adults on the topic of alcohol offers opportunity for improvement. Since the number of young drivers injured in alcohol-related crashes remains unacceptably high, more effective prevention strategies are necessary.

Do pregnant women have improved outcomes after traumatic brain injury?

BACKGROUND

Pregnant women, who have significantly elevated levels of estrogen and progesterone, might benefit from the neuroprotective effect of steroid hormones.

METHODS

Pregnant patients were identified and compared with their nonpregnant counterparts with respect to demographics and outcome.

RESULTS

Of the 18,800 female, moderate to severe TBI patients, 71 were pregnant. Similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 9.3%, P = .84). Adjusting for confounding variables, pregnant TBI patients had a trend toward increased mortality (adjusted odds ratio [AOR] = 2.2; 95% confidence interval [CI], .9-5.1; P = .07). In patients aged 15 to 47 years (n = 8,854), similar mortalities were noted in pregnant and nonpregnant TBI patients (9.9% vs 6.8%, P = .34). After adjusting for risk factors, again there was a trend toward increased mortality in the pregnant TBI group (AOR = 2.0; 95% CI, .8-4.6; P = .12).

CONCLUSIONS

Pregnant patients with moderate to severe TBI show no statistically significant difference in mortality compared with their nonpregnant counterparts.

Pre-hospital intubation is associated with increased mortality after traumatic brain injury

BACKGROUND

Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI.

METHODS

The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality.

RESULTS

A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004).

CONCLUSIONS

Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.

Does Health Care Insurance Affect Outcomes after Traumatic Brain Injury? Analysis of the National Trauma Databank

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 ± 22.4 vs 37.3 ± 16.3 years, P < 0.0001), more severely injured (ISS > 16: 78.4% vs 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 ± 9.4 vs 5.1 ± 7.6, P < 0.0001) and had higher mortality (9.3% vs 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.

Defining Hypotension in Moderate to Severely Injured Trauma Patients: Raising the Bar for the Elderly

Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. The Los Angeles County Trauma Database was queried for all moderate to severely injured patients without major head injuries admitted between 1998 and 2005. Several fit statistic analyses were performed for each systolic blood pressure from 50 to 180 mm Hg to identify the model that most accurately defined hypotension for three age groups. The optimal definition of hypotension for each group was determined from the best fit model. A total of 24,438 patients were analyzed. The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg.

Serum Ethanol Levels in Patients with Moderate to Severe Traumatic Brain Injury Influence Outcomes: A Surprising Finding

Animal studies routinely demonstrate an alcohol (ETOH) -mediated increase in survival after experimental traumatic brain injury (TBI). Recent clinical studies also suggest ETOH plays a neuroprotective role in moderate to severe TBI. We sought to investigate the relationship between ETOH and outcomes in patients with moderate to severe TBI using a countywide database. The Los Angeles County Trauma System database was queried for all adult (older than 14 years) patients with isolated moderate to severe TBI trauma (head Abbreviated Injury Score [AIS] 3 or greater, all other AIS 3 or less) who had ETOH levels measured on admission between 1998 and 2005. A total of 7304 patients were evaluated with 3219 (44.1%) patients testing positive for serum ETOH. ETOH-positive patients with TBI had a significantly lower mortality rate compared with ETOH negative patients (8.5 vs 10.5%, P = 0.005). Even after logistic regression analysis, a positive ETOH was associated with reduced mortality (adjusted OR 0.82, 95% CI: 0.69-0.99, P = 0.035). Therefore, a positive serum ETOH level was independently associated with significantly improved survival in patients with isolated moderate to severe TBI. The neuroprotective role ETOH plays in TBI is in contrast to previous findings and deserves further attention as a potential therapeutic.

Does health care insurance affect outcomes after traumatic brain injury? Analysis of the National Trauma Databank

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 +/- 22.4 vs. 37.3 +/- 16.3 years, P < 0.0001), more severely injured (ISS > or =16: 78.4% vs. 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 +/- 9.4 vs. 5.1 +/- 7.6, P < 0.0001) and had higher mortality (9.3% vs. 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.

Serum ethanol levels in patients with moderate to severe traumatic brain injury influence outcomes: a surprising finding

Animal studies routinely demonstrate an alcohol (ETOH) -mediated increase in survival after experimental traumatic brain injury (TBI). Recent clinical studies also suggest ETOH plays a neuroprotective role in moderate to severe TBI. We sought to investigate the relationship between ETOH and outcomes in patients with moderate to severe TBI using a countywide database. The Los Angeles County Trauma System database was queried for all adult (older than 14 years) patients with isolated moderate to severe TBI trauma (head Abbreviated Injury Score [AIS] 3 or greater, all other AIS 3 or less) who had ETOH levels measured on admission between 1998 and 2005. A total of 7304 patients were evaluated with 3219 (44.1%) patients testing positive for serum ETOH. ETOH-positive patients with TBI had a significantly lower mortality rate compared with ETOH negative patients (8.5 vs. 10.5%, P = 0.005). Even after logistic regression analysis, a positive ETOH was associated with reduced mortality (adjusted OR 0.82, 95% CI: 0.69-0.99, P = 0.035). Therefore, a positive serum ETOH level was independently associated with significantly improved survival in patients with isolated moderate to severe TBI. The neuroprotective role ETOH plays in TBI is in contrast to previous findings and deserves further attention as a potential therapeutic.

Defining hypotension in moderate to severely injured trauma patients: raising the bar for the elderly

Hypotension, defined as systolic blood pressure less than 90 mm Hg, is recognized as a sign of hemorrhagic shock and is a validated prognostic indicator. The definition of hypotension, particularly in the elderly population, deserves attention. We hypothesized that the systolic blood pressure associated with increased mortality resulting from hemorrhagic shock increases with increasing age. The Los Angeles County Trauma Database was queried for all moderate to severely injured patients without major head injuries admitted between 1998 and 2005. Several fit statistic analyses were performed for each systolic blood pressure from 50 to 180 mm Hg to identify the model that most accurately defined hypotension for three age groups. The optimal definition of hypotension for each group was determined from the best fit model. A total of 24,438 patients were analyzed. The optimal definition of hypotension was systolic blood pressure of 100 mm Hg for patients 20 to 49 years, 120 mm Hg for patients 50 to 69 years, and 140 mm Hg for patients 70 years and older. The optimal systolic blood pressure for improved mortality in hemorrhagic shock increases significantly with increasing age. Elderly trauma patients without major head injuries should be considered hypotensive for systolic blood pressure less than 140 mm Hg.

Indications for routine pathologic examination of specimens removed during trauma operations

BACKGROUND

Surgical specimens removed during trauma operations are routinely submitted for examination by pathology. This practice has not been systematically evaluated and the incidence of abnormal results from these examinations remains unknown. The objective of this study was to identify the incidence and management implications of abnormal findings at pathology review of trauma specimens.

METHODS

This is a retrospective chart and pathology review of all surgical specimens obtained during laparotomy or thoracotomy for trauma between January 1, 1993 and December 31, 2005. Reports were assessed for significant abnormal findings, including malignancy, infectious processes, and chronic inflammation. Additional clinical and demographic data were obtained. The main outcome measure was any change in management due to the pathology result.

RESULTS

A total of 1686 specimens were obtained from 1307 trauma patients. Ten patients (0.8%) were identified as having clinically significant abnormal findings on pathology. Six findings (0.5%) were evidence of malignancy. The pathology reports did not alter care in any patients. In all instances malignancy was known or highly suspected prior to specimen examination based on other diagnostic modalities or gross examination during surgery. Patients with an abnormal finding were significantly older than the patients with normal pathology reports (70.5 vs. 30.4, P < 0.0001).

CONCLUSIONS

The routine pathology review of specimens obtained during trauma operations did not alter patient care and should not continue. In all instances of abnormal pathology, preoperative imaging or gross intraoperative findings led to increased suspicion of occult disease. The suggestion of abnormalities on imaging or intraoperatively warrants pathologic examination, especially in older patients.

Positive serum ethanol level and mortality in moderate to severe traumatic brain injury

HYPOTHESIS

Ethanol exposure is associated with decreased mortality in patients with moderate to severe traumatic brain injury.

DESIGN

Retrospective database review.

SETTING

Trauma centers contributing to the National Trauma Data Bank (NTDB).

PATIENTS

Version 6.2 of the NTDB (2000-2005) was queried for all patients with moderate to severe traumatic brain injury (head Abbreviated Injury Score > or =3) and ethanol levels measured on admission. Demographics and outcomes were compared between patients with traumatic brain injuries with and without ethanol in their blood. Logistic regression analysis was used to investigate the relationship between mortality and ethanol.

MAIN OUTCOME MEASURES

Mortality and complications.

RESULTS

A total of 38 019 patients with severe traumatic brain injuries were evaluated. Thirty-eight percent tested positive for ethanol. Ethanol-positive patients were younger (mean [SD], 37.7 [15.1] vs 44.1 [22.0] years, P < .001), had a lower Injury Severity Score (22.3 [10.0] vs 23.0 [10.3], P < .001), and a lower Glasgow Coma Scale score (10.0 [5.1] vs 11.0 [4.9], P < .001) compared with their ethanol-negative counterparts. After logistic regression analysis, ethanol was associated with reduced mortality (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.96; P = .005) and higher complications (adjusted odds ratio, 1.24; 95% confidence interval, 1.15-1.33; P < .001).

CONCLUSIONS

Serum ethanol is independently associated with decreased mortality in patients with moderate to severe head injuries. Additional research is warranted to investigate the potential therapeutic implications of this association.

What is the significance of thrombocytosis in patients with trauma?

BACKGROUND

The incidence and risk factors for the development of thrombocytosis after trauma have not been well established. Although it has been suggested that the occurrence of this sequela may be associated with adverse events, there are also limited data regarding outcomes of patients developing posttraumatic thrombocytosis. The objective of this study was to determine the incidence of, risk factors for, and sequela of posttraumatic thrombocytosis.

METHODS

A retrospective review of all trauma intensive care unit (ICU) admissions between July 1998 and December 2005 identified patients with early (< or = 7 days), late, and no thrombocytosis. Bivariate analysis was used to compare the clinical and demographic characteristics with outcomes between the three patient groups.

RESULTS

A total of 3,484 patients were admitted to the ICU during the 7-year study period. After exclusions, the study population consisted of 3,286 patients. The overall incidence of thrombocytosis was 18.7%; early thrombocytosis was found in 72 patients, and late thrombocytosis was identified in 542 patients. All complications examined were significantly higher in patients with thrombocytosis. Overall, the venous thromboembolic rate was 2.4%; for patients with thrombocytosis it was 4.6% compared with 1.9% in patients without thrombocytosis. Overall mortality was 15.4%, but was significantly lower in patients with thrombocytosis (3.8% vs. 18.1%, p < 0.0001). Independent risk factors for the development of thrombocytosis included obesity, laparotomy, blunt injury, Injury Severity Score > 16, mechanical ventilation, Chest Abbreviated Injury Score > 3, and tachycardia.

CONCLUSION

Thrombocytosis is a common finding among patients with trauma admitted to the ICU. The occurrence of both early and late thrombocytosis is associated with significantly higher rates of complications, particularly venous thromboembolism. However, patients developing posttraumatic thrombocytosis may have a significantly lower mortality compared with those without this sequela of injury.

The Impact of Intoxication on the Number of Organs Available for Transplantation after Brain Death

A significant number of head-injured trauma patients are likely to present with a positive toxicology. The purpose of this study is to investigate whether intoxication with substances such as cocaine, amphetamine, alcohol, and opiates on admission has any influence on the number of organs that are recovered after brain death in these patients. We conducted a retrospective review of all organ donor patients admitted to a Level I trauma center over a 4-year period (2002 to 2005). Patients with positive toxicology screens on admission were compared to counterparts with negative screens with regard to the number of organs harvested. There were 90 organ donor patients during the 4-year period. There were 63 (70%) patients to negative toxicology screens. The remaining 27 (30%) were found to be intoxicated with a variety of substances, including alcohol (18%), cocaine (4%), amphetamines (9%), benzodiazepines (4%), opiates (4%), and poly-substances (10%). A comparison of total organs and individual organs donated by both intoxicated and nonintoxicated patients showed no overall statistical difference in the number or type of organs donated between the two groups. Thus, the prospect of organ procurement should not be overlooked in intoxicated patients.

The impact of intoxication on the number of organs available for transplantation after brain death

A significant number of head-injured trauma patients are likely to present with a positive toxicology. The purpose of this study is to investigate whether intoxication with substances such as cocaine, amphetamine, alcohol, and opiates on admission has any influence on the number of organs that are recovered after brain death in these patients. We conducted a retrospective review of all organ donor patients admitted to a Level I trauma center over a 4-year period (2002 to 2005). Patients with positive toxicology screens on admission were compared to counterparts with negative screens with regard to the number of organs harvested. There were 90 organ donor patients during the 4-year period. There were 63 (70%) patients to negative toxicology screens. The remaining 27 (30%) were found to be intoxicated with a variety of substances, including alcohol (18%), cocaine (4%), amphetamines (9%), benzodiazepines (4%), opiates (4%), and polysubstances (10%). A comparison of total organs and individual organs donated by both intoxicated and nonintoxicated patients showed no overall statistical difference in the number or type of organs donated between the two groups. Thus, the prospect of organ procurement should not be overlooked in intoxicated patients.

Does the use of pulmonary artery catheters increase the number of organs available for transplantation?

Aggressive donor management, including the placement of a pulmonary artery catheter (PAC) to monitor hemodynamic status and tissue perfusion, has been associated with a significant increase in the number of organs recovered for transplantation. Nonetheless, there has been growing scrutiny over the use of PACs because of their known complications and lack of therapeutic effect. The purpose of this study is to evaluate the use of PACs in the management of organ donors. The records of all patients who successfully donated organs between January 1, 2002 and December 31, 2005 were reviewed. A total of 96 patients underwent successful organ donation during the four-yr study period. Of these, 49 (51.0%) were managed with a PAC. Compared with donors managed without a PAC, there were significantly more hearts recovered from donors managed with a PAC (71.4% vs. 44.7%; p = 0.0079) with no difference in the daily administration of fluids and vasopressors between the two groups. The management of organ donors with a PAC can help maximize cardiac procurement.

Noninvasive Doppler ultrasonography for assessing cardiac function: can it replace the Swan-Ganz catheter?

BACKGROUND

Cardiac function, including cardiac index (CI), traditionally has been measured by a pulmonary artery catheter (PAC). A noninvasive alternative for measuring cardiac function would offer obvious advantages.

METHODS

A prospective study of trauma and nontrauma patients was performed in a surgical intensive care unit over a 3-month period. CI was determined using both a standard PAC and a continuous-wave Doppler ultrasound (UTS). The study had 2 phases: phase I was nonblinded and phase II was blinded; the correlation between UTS- and PAC-derived CI was assessed.

RESULTS

A total of 120 paired measurements of CI were observed in 31 patients. The UTS-derived CI measurements showed agreement with PAC measurements in both phase I and phase II of the study with a bias of .06 L/min/m(2) +/- .4 L/min/m(2). Paired measurements correlated well in both phase I (r = .97, R2 = .95, P < .0001) and phase II (r = .93, R2 = .86, P < .0001) of the study.

CONCLUSIONS

Doppler UTS correlates well with PAC measurements of CI. This noninvasive modality is an accurate and safe alternative to PAC.

Predictors of positive angiography in pelvic fractures: a prospective study

BACKGROUND

Severe pelvic fractures continue to be a major problem for trauma surgeons. Early identification of patients who would benefit from therapeutic angiographic embolization (AE) of pelvic bleeding would be beneficial. We hope to identify simple risk factors that would pinpoint patients who would benefit from therapeutic AE.

STUDY DESIGN

This is a prospective observational study at an academic Level I trauma center. All blunt trauma patients with a pelvic fracture admitted from December 2003 to February 2007 were included. AE was performed for hemodynamic instability (systolic blood pressure < 100 mmHg), fracture pattern (sacroiliac joint [SIJ] disruption, butterfly, open book), or CT demonstrating a large pelvic hematoma. AE was considered therapeutic if contrast extravasation was noted and addressed with embolization. Main outcomes measures were positive angiography and mortality. Stepwise logistic regression was performed to identify predictors of therapeutic AE. A predictive model was built based on these independent risk factors to estimate the probability of a therapeutic AE.

RESULTS

One hundred thirty-seven (23%) of 603 patients with pelvic fractures had angiography. Therapeutic AE was performed in 85 patients (62%). Indications for angiography included hemodynamic instability (58%), fracture pattern (26%), and CT findings (9%). Nineteen patients (22%) with therapeutic AE had no hypotension or tachycardia. Independent predictors for therapeutic AE were SIJ disruption (odds ratio [OR]: 4.5; 95% CI, 1.6 to 12.6; p = 0.005), female gender (OR: 3.9; 95% CI, 1.5 to 10.0; p = 0.005), and duration (in minutes) of systolic blood pressure < 100 mmHg (OR: 1.4; 95% CI, 1.1 to 1.9; p = 0.007).

CONCLUSIONS

Presence of SIJ disruption, female gender, and duration of hypotension can reliably predict patients who would benefit from AE. This predictive model can help early identification of patients who would benefit from pelvic angiography.

Role of anemia in traumatic brain injury

BACKGROUND

Few studies have investigated the effects of anemia in patients with traumatic brain injury (TBI). The objective of this study was to examine the role of anemia and blood transfusion on outcomes in TBI patients.

STUDY DESIGN

We performed a retrospective review of all blunt trauma patients with TBI admitted to the ICU from July 1998 to December 2005. Admission and daily ICU blood hemoglobin (hemoglobin) levels and blood transfusions during the first week of hospitalization were measured. Anemia was defined as a hemoglobin<9 g/dL occurring on 3 consecutive blood draws. The role of anemia and blood transfusion was investigated using logistic regression adjusting for factors, with p<0.2 from the bivariate analysis.

RESULTS

During the study period, 1,150 TBI patients were admitted to the ICU. When both anemia and blood transfusion were included in the full model, blood transfusion was significantly associated with higher mortality (adjusted odds ratio [AOR], 2.19 [95% CI, 1.27, 3.75]; p=0.0044) and more complications (AOR, 3.67 [95% CI, 2.18, 6.17]; p<0.0001), but anemia was not. But when transfusion was not included in the full model, anemia was a significant risk factor for mortality (AOR, 1.59 (95% CI, 1.13, 2.24); p=0.007) and for complications (AOR, 1.95 [95% CI, 1.42, 2.70]; p<0.0001).

CONCLUSIONS

Blood transfusion is associated with significantly worse outcomes in traumatic brain injured patients. In addition, blood transfusion is a major contributing factor to worse outcomes in TBI patients who are anemic. We caution against the liberal use of blood in TBI patients.

Obesity does not affect mortality after trauma

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] > or = 30), and nonobese patients (NOB; BMI < or = 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.

Obesity Does Not Affect Mortality after Trauma

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] ≥ 30), and nonobese patients (NOB; BMI ≤ 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.

CT angiography in penetrating neck trauma reduces the need for operative neck exploration

The evaluation of penetrating neck injury has evolved dramatically from mandatory operative exploration of Zone II injuries that penetrate the platysma to selective management based on physical examination and adjunctive studies. More recently, CT angiography has emerged as an efficient, noninvasive method of evaluating penetrating neck injury. We retrospectively reviewed our experience over 10 years with the management of penetrating neck injury. One hundred thirty cases were reviewed with 34 undergoing CT angiogram (Group CTA) and 96 with no CT angiogram (Group nCTA). Group CTA had significantly fewer neck explorations, 1 (3%) versus 32 (33%), P < 0.001. Negative explorations were significantly higher in nCTA as well, with a rate of 22 per cent versus 0 in CTA (P < 0.01). The use of angiogram and esophagram was also significantly lower in CTA versus nCTA (P = 0.02 and P = 0.04). Of the 34 patients in CTA, 4 (12%) also underwent angiography and 4 (12%) received a contrast esophagram. Of the 64 patients in nCTA who did not undergo a neck exploration, 19 (29%) underwent angiography, and 17 (26%) received a contrast esophagram. The use of CT angiogram increased over time with a concomitant decrease in the rate of neck explorations.

CT Angiography in Penetrating Neck Trauma Reduces the Need for Operative Neck Exploration

The evaluation of penetrating neck injury has evolved dramatically from mandatory operative exploration of Zone II injuries that penetrate the platysma to selective management based on physical examination and adjunctive studies. More recently, CT angiography has emerged as an efficient, noninvasive method of evaluating penetrating neck injury. We retrospectively reviewed our experience over 10 years with the management of penetrating neck injury. One hundred thirty cases were reviewed with 34 undergoing CT angiogram (Group CTA) and 96 with no CT angiogram (Group nCTA). Group CTA had significantly fewer neck explorations, 1 (3%) versus 32 (33%), P < 0.001. Negative explorations were significantly higher in nCTA as well, with a rate of 22 per cent versus 0 in CTA ( P < 0.01). The use of angiogram and esophagram was also significantly lower in CTA versus nCTA ( P = 0.02 and P = 0.04). Of the 34 patients in CTA, 4 (12%) also underwent angiography and 4 (12%) received a contrast esophagram. Of the 64 patients in nCTA who did not undergo a neck exploration, 19 (29%) underwent angiography, and 17 (26%) received a contrast esophagram. The use of CT angiogram increased over time with a concomitant decrease in the rate of neck explorations.

Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury

Splenosis represents the autotransplantation of splenic tissue after splenic trauma or surgery. Disruption of the splenic capsule causes fragments of splenic tissue to be seeded mainly throughout the peritoneal cavity, where they are characterized by diffusely scattered bluish implants. Extraperitoneal locations are very rare and mainly include the thoracic cavity after thoracoabdominal trauma with simultaneous splenic rupture and diaphragmatic laceration. We retrospectively identified all patients in the pathology registry with the diagnosis of splenosis between December 1974 and July 2003 at our urban teaching hospital. Data collected included presenting signs and symptoms, history, imaging studies, treatment, pathology, and outcome. Five cases of splenosis were identified and described. Location of the splenosis was intraperitoneal in two and intrahepatic, intrathoracic, and subcutaneous in one each. In these cases, there was an average interval of 29 years between splenic injury and diagnosis, and most were found incidentally. One of the cases was managed entirely laparoscopically and another thoracoscopically.

Objective indications for early tracheostomy after blunt head trauma

BACKGROUND

Early tracheostomy has been shown to be beneficial after trauma; however, there are few objective data to identify early in the recovery period which patients will ultimately require tracheostomy after blunt head trauma.

METHODS

The charts of all patients admitted to the surgical intensive care unit intubated at a level 1 urban trauma center, over a 5-year period with a primary admission diagnosis of blunt head trauma were retrospectively reviewed.

RESULTS

Sixty-four patients met inclusion and exclusion criteria and were divided into two groups: those extubated and those that required tracheostomy. By day 3 the Glasgow Coma Scores for the two groups were significantly different and on day 4 the Simplified Acute Physiology (SAPS) Scores were significantly different.

CONCLUSIONS

Calculating objective scores such as GCS and SAPS can aid in identifying those patients who will ultimately require a tracheostomy for prolonged airway protection after blunt head trauma with high positive predictive value.

The value of laparoscopy in management of abdominal trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.

The Value of Laparoscopy in Management of Abdominal Trauma

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOD, indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.

Analysis of causes and prevention of early readmission to surgical intensive care

The purpose of this study was to analyze causes of early readmission to the surgical intensive care unit (SICU), to determine whether readmission can be predicted or prevented, and to compare outcomes of patients readmitted to the SICU with patients not requiring readmission. All patients admitted to the Cedars-Sinai SICU from January 1, 1996, to December 31, 2001, were included. Clinical data was prospectively collected in an on-line computer system. The charts of all early readmission patients were retrospectively reviewed. SICU and hospital outcomes were abstracted from a computerized data warehouse. During the study period, 10,840 patients were admitted to the SICU including 97 (0.89%) early readmissions. SICU admission APACHE II and SAPS I scores, SICU and hospital length of stay, and mortality were significantly higher in readmitted patients compared to patients not requiring readmission. The majority of early SICU readmissions were due to respiratory and neurologic deterioration. Upon review, 62 per cent of all readmissions met appropriate SICU discharge criteria and were not predictable while only 5 per cent of SICU discharge were felt to have been premature. Patient outcomes are adversely affected by early readmission to the SICU. Careful neurologic assessment, meticulous attention to respiratory care transfer orders, and prompt respiratory therapy on floor care may significantly decrease the need for early readmission to the SICU.

Analysis of Causes and Prevention of Early Readmission to Surgical Intensive Care

The purpose of this study was to analyze causes of early readmission to the surgical intensive care unit (SICU), to determine whether readmission can be predicted or prevented, and to compare outcomes of patients readmitted to the SICU with patients not requiring readmission. All patients admitted to the Cedars-Sinai SICU from January 1, 1996, to December 31, 2001, were included. Clinical data was prospectively collected in an on-line computer system. The charts of all early readmission patients were retrospectively reviewed. SICU and hospital outcomes were abstracted from a computerized data warehouse. During the study period, 10,840 patients were admitted to the SICU including 97 (0.89%) early readmissions. SICU admission APACHE II and SAPS I scores, SICU and hospital length of stay, and mortality were significantly higher in readmitted patients compared to patients not requiring readmission. The majority of early SICU readmissions were due to respiratory and neurologic deterioration. Upon review, 62 per cent of all readmissions met appropriate SICU discharge criteria and were not predictable while only 5 per cent of SICU discharge were felt to have been premature. Patient outcomes are adversely affected by early readmission to the SICU. Careful neurologic assessment, meticulous attention to respiratory care transfer orders, and prompt respiratory therapy on floor care may significantly decrease the need for early readmission to the SICU.

Craniofacial and skull base trauma

BACKGROUND

Traumatic craniofacial and skull base injuries require a multidisciplinary team approach. Trauma physicians must evaluate carefully, triage properly, and maintain a high index of suspicion to improve survival and enhance functional recovery. Frequently, craniofacial and skull base injuries are overlooked while treating more life-threatening injuries. Unnoticed complex craniofacial and skull base fractures, cerebrospinal fluid fistulae, and cranial nerve injuries can result in blindness, diplopia, deafness, facial paralysis, or meningitis. Early recognition of specific craniofacial and skull base injury patterns can lead to identification of associated injuries and allow for more rapid and appropriate management.

CONCLUSION

Early detection and treatment of craniofacial and skull base traumatic injuries should lead to decreased morbidity and mortality. This review discusses the most common of these injuries, their possible complications, and treatment.

Decompressive craniectomy in trauma patients with severe brain injury

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.

Intensive care unit outcome of vehicle-related injury in elderly trauma patients

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.

Intensive Care Unit Outcome of Vehicle-Related Injury in Elderly Trauma Patients

Vehicle-related trauma is a common mechanism of injury in elderly (age ≥65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.

Decompressive Craniectomy in Trauma Patients with Severe Brain Injury

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.

Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy

HYPOTHESIS

Elderly patients who have appendicitis have a greater morbidity and mortality rate when compared with younger patients. We hypothesized that recent changes in the diagnosis and management of appendicitis in elderly patients might affect the outcome.

DESIGN

Retrospective review.

SETTING

Large metropolitan teaching hospital.

PATIENTS

All patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991, and December 31, 2000, were divided into groups 1 (those treated from January 1, 1991, through December 31, 1995) and 2 (those treated from January 1, 1996, through December 31, 2000).

MAIN OUTCOME MEASURES

Age, sex, preoperative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. Continuous and categorical variables were analyzed using t and chi(2) tests, respectively.

RESULTS

Ninety-five patients met inclusionary criteria. The mean age (78 years), sex, preoperative suggestion of appendicitis (group 1, 39 [83%] of 47 patients; group 2, 45 [94%] of 48 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 11 patients [23%]; group 2, 9 patients [19%]) were similar in both groups. There was an increasing use of diagnostic computed tomography (group 1, 13 patients [28%]; group 2, 32 patients [67%]; P<.001) and laparoscopy (group 1, 14 patients [30%]; group 2, 23 patients [48%]; P =.02) between the 2 study periods associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time increased in the second period (ie, January 1, 1996, through December 31, 2000).

CONCLUSIONS

Appendicitis in elderly patients continues to be a challenging surgical problem. While computed tomography may represent a useful diagnostic tool and laparoscopic appendectomy may be appropriate therapy for selected patients, neither has affected outcome when measured for morbidity and mortality rates. Overall results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical consultation and operation.

Endoscopically Placed Nasogastrojejunal Feeding Tubes: A Safe Route for Enteral Nutrition in Patients with Hepatic Encephalopathy

Patients with hepatic encephalopathy are at particular risk for aspiration when given oral or gastric feedings. An ideal strategy might combine distal enteral feeding with proximal gastric decompression, which is offered by a nasogastrojejunal (NGJ) feeding tube. One objective was to determine the efficacy and safety of endoscopically placed NGJ feeding tubes in patients with hepatic encephalopathy. Charts of patients who underwent NGJ tube placements between April 1997 and January 2000 were retrospectively reviewed. Two endoscopic techniques (“push” and “pull”) were used. Eighteen patients (nine male and nine female) underwent 32 procedures. Twelve patients had undergone liver transplantation, four had decompensated cirrhosis, and two had fulminant hepatic failure. Twenty procedures used the push technique and 12 required the pull technique. The insertion time was shorter for the push technique compared with the pull technique (21.8 vs 39.6 min, P < 0.05). Enteral feedings were begun at an average of 5.2 hours after tube placement. The tubes remained in place for an average of 13.9 days. Complications related to the NGJ tubes included self-removal in eight, tube clogging in five, proximal migration in four, and intraduodenal migration of the gastric port in one. No aspiration episodes occurred. We conclude that NGJ feeding tubes may be placed endoscopically as a bedside procedure for patients with hepatic encephalopathy and provide a safe, efficacious, and rapid route for enteral nutrition in these patients.

Endoscopically placed nasogastrojejunal feeding tubes: a safe route for enteral nutrition in patients with hepatic encephalopathy

Patients with hepatic encephalopathy are at particular risk for aspiration when given oral or gastric feedings. An ideal strategy might combine distal enteral feeding with proximal gastric decompression, which is offered by a nasogastrojejunal (NGJ) feeding tube. One objective was to determine the efficacy and safety of endoscopically placed NGJ feeding tubes in patients with hepatic encephalopathy. Charts of patients who underwent NGJ tube placements between April 1997 and January 2000 were retrospectively reviewed. Two endoscopic techniques ("push" and "pull") were used. Eighteen patients (nine male and nine female) underwent 32 procedures. Twelve patients had undergone liver transplantation, four had decompensated cirrhosis, and two had fulminant hepatic failure. Twenty procedures used the push technique and 12 required the pull technique. The insertion time was shorter for the push technique compared with the pull technique (21.8 vs 39.6 min, P < 0.05). Enteral feedings were begun at an average of 5.2 hours after tube placement. The tubes remained in place for an average of 13.9 days. Complications related to the NGJ tubes included self-removal in eight, tube clogging in five, proximal migration in four, and intraduodenal migration of the gastric port in one. No aspiration episodes occurred. We conclude that NGJ feeding tubes may be placed endoscopically as a bedside procedure for patients with hepatic encephalopathy and provide a safe, efficacious, and rapid route for enteral nutrition in these patients.

Percutaneous dilatational tracheostomy is as safe as open tracheostomy

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.

Percutaneous Dilatational Tracheostomy is as Safe as Open Tracheostomy

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT ( P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.

Peptic ulcers in the elderly is a surgical disease

BACKGROUND

Operative management for peptic ulcer disease (PUD) has changed significantly over the last 30 years.

METHODS

For a 15-year period, records of patients undergoing operative management for peptic ulcer disease were stratified into age groups and examined with respect to presentation, type of operation, and risk factors.

RESULTS

In all, 154 patients underwent surgery for PUD during the 1990s. Elderly patients were more likely to require an emergent operation (91%, P = 0.005), present with hemodynamic instability (25%, P = 0.025), and have a longer hospital stay (21 days, P = 0.012). Among the elderly in the 1990s as compared with the 1980s, there was increased use of nonsteroidal anti-inflammatory drugs ([NSAIDs] (49%, P = 0.005), decreased tobacco use (22%, P = 0.014), and less likelihood of postoperative renal failure (6%, P = 0.014).

CONCLUSIONS

Elderly patients in the 1990s comprise the majority of cases presenting in a more unstable condition as compared with patients <60 years old, but show similar rates of morbidity and mortality. Elderly patients undergoing surgery for PUD have shown an increase in use of NSAIDs over the last 15 years. The types of procedures have not changed, but operations are more likely to be an emergent basis.

Nosocomial pneumonia is not prevented by protective contact isolation in the surgical intensive care unit

Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard "universal precautions" (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient's room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only "standard precautions" including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients (P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) (P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

Early postoperative enteral feeding increases anastomotic strength in a peritonitis model

BACKGROUND

Tumor necrosis factor alpha (TNF-alpha) has been shown to decrease collagen synthesis and increase collagenase activity leading to impaired wound healing. Our hypothesis was that immediate postoperative feeding would decrease TNF-alpha, therefore increasing anastomotic healing in a peritonitis model.

METHODS

Twelve Sprague-Dawley rats underwent cecal ligation and puncture to induce peritonitis. Six hours after induction of peritonitis an ileocecectomy and ileocolostomy was performed. Group 1 animals (n = 6) had immediate access to food and water, whereas group 2 (n = 6) had free access to water only. At 48 hours, weight loss, nitrogen loss, anastamotic bursting strength (ABS), TNF-alpha, interleukin-6 (IL-6), and IL-10 were measured.

RESULTS

Weight loss was similar in the two groups. Group 1 rats had a significantly lower mean TNF-alpha level (17.3 +/- 10 versus 17.3 +/- 10 mcg/Dl, P = 0.05). ABS was also significantly higher in group 1 rats when compared with group 2 rats (81 +/- 34 versus 39 +/- 13 mm HG, P = 0.03).

CONCLUSIONS

These data suggest that immediate postoperative feeding results in a beneficial change in the cytokine profile.

Nosocomial Pneumonia is Not Prevented by Protective Contact Isolation in the Surgical Intensive Care Unit

Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard “universal precautions” (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient's room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only “standard precautions” including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients ( P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) ( P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

A dedicated craniofacial trauma team improves efficiency and reduces cost

BACKGROUND

In this era of limited medical resources there is ever increasing pressure to lower costs, while preserving high-quality patient care. A dedicated craniofacial and skull base trauma team (SBT) was established at our Level I trauma center in July 1998. Previously, a rotating call panel of multiple private surgical subspecialists consulted on trauma patients with craniofacial or skull base injuries (Pre-SBT). This study was designed to assess the impact a dedicated craniofacial and skull base trauma team has on the cost and quality of patient care.

MATERIALS AND METHODS

A retrospective review of the trauma registry and charts was performed including all craniofacial and skull base trauma cases in the 18 months Pre-SBT and 18 months following the establishment of a SBT.

RESULTS

During the Pre-SBT period there were 29 craniofacial and skull base operations, whereas 28 such cases were performed by the SBT. The age, sex, injury severity score (ISS), mechanism of injury, and type of craniofacial/skull base injuries were comparable between groups. The SBT group demonstrated a reduction in the number of patients transferred to other institutions for definitive care (7 vs 1, P = 0.05) and statistically significant reduction in the number of subspecialty consultations (2.4 vs 1.3), time to operation (7.5 vs 3.0 days), and length of hospitalization (11.8 vs 6.8, all with P <or= 0.001). Additionally, hospital charges were markedly reduced in the SBT group (106,424 dollars vs 58,136 dollars, P < 0.01).

CONCLUSIONS

The addition of a dedicated craniofacial trauma team to a Level I trauma center provides more comprehensive care, improves efficiency, and reduces cost.

Patient volume per surgeon does not predict survival in adult level I trauma centers

BACKGROUND

The 1999 American College of Surgeons resources for optimal care document added the requirement that Level I trauma centers admit over 240 patients with Injury Severity Score (ISS) > 15 per year or that trauma surgeons care for at least 35 patients per year. The purpose of this study was to test the hypothesis that high volume of patients with ISS > 15 per individual trauma surgeon is associated with improved outcome.

METHODS

Data were obtained from the trauma registry of the five American College of Surgeons-verified adult Level I trauma centers in our mature trauma system between January 1, 1998, and March 31, 1999. Data abstracted included age, sex, Glasgow Coma Scale (GCS) score, intensive care unit length of stay, hospital length of stay, probability of survival (Ps), mechanism of injury, number of patients per each trauma surgeon and institution, and mortality. Multiple logistic regression was performed to select independent variables for modeling of survival.

RESULTS

From the five Level I centers there were 11,932 trauma patients in this time interval; of these, 1,754 patients (14.7%) with ISS > 15 were identified and used for analysis. Patients with ISS > 15 varied from 173 to 625 per institution; trauma surgeons varied from 8 to 25 per institution; per-surgeon patient volume varied from 0.8 to 96 per year. Logistic regression analysis revealed that the best independent predictors of survival were Ps, GCS score, age, mechanism of injury, and institutional volume (p < 0.01). Age and institutional volume correlated negatively with survival. Analysis of per-surgeon patient caseload added no additional predictive value (p = 0.44).

CONCLUSION

The significant independent predictors of survival in severely injured trauma patients are Ps, GCS score, age, mechanism of injury, and institutional volume. We found no statistically meaningful contribution to the prediction of survival on the basis of per-surgeon patient volume. Since this volume criterion for surgeon enpanelment and trauma center designation would not be expected to improve outcome, such a requirement should be justified by other measures or abandoned.

Splenectomy for Splenic Metastases: A Changing Clinical Spectrum

Splenic metastases from solid tumors are unusual with only scattered case reports of patients treated with splenectomy before 1987. We conducted a retrospective chart review at our large tertiary-care private teaching hospital between January 1990 and September 1999 and found splenic metastases in 31 patients. In eight patients (26%), the spleen was the only site of metastatic disease. Of the 31 splenectomies for metastases, 23 were performed for ovarian neoplasms, five during primary operative procedures, and 18 during secondary cytoreductive procedures or explorations for late recurrences at an average of 3.9 years after the original operation. Nearly half of the metastases (15 of 31) appeared entirely within the splenic parenchyma, representing probable hematogenous spread, whereas seven involved both the splenic parenchyma and capsule and nine involved the capsule only. Between 1990 and 1999 we identified a statistically significant increase in use of splenectomy for treatment of metastatic tumor with a Spearman rank correlation value of 0.86 ( P < 0.05). Most of this increase was attributable to ovarian cancer cases and may be due to expansion of treatment options or improved imaging methods. We report the largest series of splenectomy for splenic metastases and the ninth case report in the world literature of splenectomy for isolated splenic metastasis due to colorectal cancer.