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Grant AA, Badiye A, Vianna RM, Patel A, Namias N, Loebe M, Ghodsizad A. Extracorporeal membrane oxygenation: Establishing a robust, tertiary extracorporeal membrane oxygenation referral center in South Florida. Int J Artif Organs 2018; 41:185-189. [PMID: 29637831 DOI: 10.1177/0391398817753341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Allen CJ, Baldor DJ, Hanna MM, Namias N, Bullock MR, Jagid JR, Proctor KG. Early Craniectomy Improves Intracranial and Cerebral Perfusion Pressure after Severe Traumatic Brain Injury. Am Surg 2018. [DOI: 10.1177/000313481808400332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After traumatic brain injury, decompressive craniectomy (DC) is a second-tier, late therapy for refractory intracranial hypertension. We hypothesize that early DC, based on CT evidence of intracranial hypertension, improves intracranial pressure (ICP) and cerebral perfusion pressure (CPP). From September 2008 to January 2015, 286 traumatic brain injury patients requiring invasive ICP monitoring at a single Level I trauma center were reviewed. DC and non-DC patients were propensity score matched 1:1, based on demographics, hemodynamics, injury severity score (ISS), Glasgow Coma Scale (GCS), transfusion requirements, and need for vasopressor therapy. Data are presented as M ± SD or median (IQR) and compared at P ≤ 0.05. The study population was 42 ± 17 years, 84 per cent male, ISS = 29 ± 11, GCS = 6 (5), length of stay (LOS) = 32(40) days, and 28 per cent mortality. There were 116/286 (41%) DC, of which 105/116 (91%) were performed at the time of ICP placement. For 50 DC propensity matched to 50 non-DC patients, the midline shift was 7(11) versus 0(5) mm ( P < 0.001), abnormal ICP (hours > 20 mm Hg) was 1(10) versus 8(16) ( P = 0.017), abnormal CPP (hours < 60 mm Hg) was 0(6) versus 4(9) ( P = 0.008), daily minimum CPP (mm Hg) was 67(13) versus 62(17) ( P = 0.010), and daily maximum ICP (mm Hg) was 18(9) versus 22(11) ( P < 0.001). However, LOS [33(37) versus 25(34) days], mortality (24 versus 30%), and Glasgow Outcome Score Extended [3.0(3.0) versus 3.0(4.0)] did not improve significantly. Early DC for CT evidence of intracranial hypertension decreased abnormal ICP and CPP time and improved ICP and CPP thresholds, but had no obvious effect on the outcome.
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Allen CJ, Baldor DJ, Hanna MM, Namias N, Bullock MR, Jagid JR, Proctor KG. Early Craniectomy Improves Intracranial and Cerebral Perfusion Pressure after Severe Traumatic Brain Injury. Am Surg 2018; 84:443-450. [PMID: 29559063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
After traumatic brain injury, decompressive craniectomy (DC) is a second-tier, late therapy for refractory intracranial hypertension. We hypothesize that early DC, based on CT evidence of intracranial hypertension, improves intracranial pressure (ICP) and cerebral perfusion pressure (CPP). From September 2008 to January 2015, 286 traumatic brain injury patients requiring invasive ICP monitoring at a single Level I trauma center were reviewed. DC and non-DC patients were propensity score matched 1:1, based on demographics, hemodynamics, injury severity score (ISS), Glasgow Coma Scale (GCS), transfusion requirements, and need for vasopressor therapy. Data are presented as M ± SD or median (IQR) and compared at P ≤ 0.05. The study population was 42 ± 17 years, 84 per cent male, ISS = 29 ± 11, GCS = 6(5), length of stay (LOS) = 32(40) days, and 28 per cent mortality. There were 116/286 (41%) DC, of which 105/116 (91%) were performed at the time of ICP placement. For 50 DC propensity matched to 50 non-DC patients, the midline shift was 7(11) versus 0(5) mm (P < 0.001), abnormal ICP (hours > 20 mm Hg) was 1(10) versus 8(16) (P = 0.017), abnormal CPP (hours < 60 mm Hg) was 0(6) versus 4(9) (P = 0.008), daily minimum CPP (mm Hg) was 67(13) versus 62(17) (P = 0.010), and daily maximum ICP (mm Hg) was 18(9) versus 22(11) (P < 0.001). However, LOS [33(37) versus 25(34) days], mortality (24 versus 30%), and Glasgow Outcome Score Extended [3.0(3.0) versus 3.0(4.0)] did not improve significantly. Early DC for CT evidence of intracranial hypertension decreased abnormal ICP and CPP time and improved ICP and CPP thresholds, but had no obvious effect on the outcome.
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Allen CJ, Ruiz XD, Meizoso JP, Ray JJ, Livingstone AS, Schulman CI, Namias N, Proctor KG. Is Hydroxyethyl Starch Safe in Penetrating Trauma Patients? Mil Med 2018; 181:152-5. [PMID: 27168566 DOI: 10.7205/milmed-d-15-00132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Meizoso JP, Allen CJ, Ray JJ, Van Haren RM, Teisch LF, Baez XR, Livingstone AS, Namias N, Schulman CI, Proctor KG. Evaluation of Miniature Wireless Vital Signs Monitor in a Trauma Intensive Care Unit. Mil Med 2018; 181:199-204. [PMID: 27168573 DOI: 10.7205/milmed-d-15-00162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
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.
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Sanders JM, Tessier JM, Sawyer R, Dellinger E, Miller PR, Namias N, West MA, Cook CH, O'Neill P, Napolitano L, Rattan R, Cuschieri J, Claridge JA, Guidry CA, Askari R, Banton K, Rotstein O, Moore BJ, Duane TM. Does Isolation ofEnterococcusAffect Outcomes in Intra-Abdominal Infections? Surg Infect (Larchmt) 2017; 18:879-885. [DOI: 10.1089/sur.2017.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Rattan R, Parreco J, Zakrison TL, Yeh DD, Lieberman HM, Namias N. Same-Hospital Re-Admission Rate Is Not Reliable for Measuring Post-Operative Infection-Related Re-Admission. Surg Infect (Larchmt) 2017; 18:904-909. [PMID: 29027888 DOI: 10.1089/sur.2017.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Post-operative infections cause morbidity, consume resources, and are an important quality measure in assessing and comparing hospitals. Commonly used metrics do not account for re-admission to a different hospital. The Nationwide Readmissions Database (NRD) tracks re-admissions across United States (US) hospitals. Infection-related re-admission across US hospitals has not been studied previously. PATIENTS AND METHODS The 2013 NRD was queried for admissions with a primary International Classification of Diseases and Related Health Problems, 9th revision, Clinical Modification code for the most frequently performed operations. Non-elective all-cause, infection-related, and different hospital 30-day re-admission rates were calculated, using All Patient Refined Diagnosis Related Groups codes. Multi-variable logistic regression identified risk factors for re-admission. RESULTS Of 826,836 surviving to discharge, 39,281 (4.8%) had an unplanned re-admission within 30 days, occurring at a different hospital 20.5% of the time. The most common reason for re-admission was infection (25.1%). Orthopedic and spinal procedures were at highest risk for all-cause and infection-related different hospital re-admission. Infection-related different hospital re-admission risk factors included: Length of stay >30 days (odds ratio [OR] 2.28 [1.62-3.21], p < 0.01), age ≥65 years (OR 1.56 [1.38-1.76], p < 0.01), and Charlson Comorbidity Index >1 (OR 1.14 [1.01-1.28], p < 0.01) and differed from predictors of same-hospital infectious re-admission. Non-elective surgical procedure (OR 0.79 [0.72-0.87], p < 0.01) and initial hospitalization at a large hospital (OR 0.66 [0.59-0.74], p < 0.01) were protective. CONCLUSION A substantial proportion of post-operative re-admissions are missed by same-hospital re-admission data. All-cause and infection-related post-operative re-admissions to a different hospital are affected by unique patient and institution-specific factors. Re-admission reduction programs, quality metrics, and policy based on same hospital re-admission data should be updated to incorporate different hospital re-admission.
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Zakrison TL, Ruiz X, Namias N, Crandall M. A 20-year review of pediatric pregnant trauma from a Level I trauma center. Am J Surg 2017; 214:596-598. [PMID: 28724500 DOI: 10.1016/j.amjsurg.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/06/2017] [Accepted: 07/09/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Trauma in pregnancy remains an important but understudied public health issue. We aimed to determine the prevalence of interpersonal violence in our pregnant trauma population (including pediatric) over the last 20 years, from our Level I trauma center. METHODS We conducted a descriptive, retrospective chart review to identify all pregnant trauma patients between Jan 1993 and Sept 2013. Pediatric was ≤18 years of age. We evaluated demographics, mechanism of injury, injury location, disposition, and outcome data. RESULTS We treated 438 pregnant patients at our center over 20 years. 378 (86%) were adult and 60 (14%) were pediatric. Intentional injuries occurred in 89 (20%) patients. The pediatric pregnant patients experienced a significantly higher proportion of intentional, interpersonal violence (33% vs. 18%, p = 0.007) compared to adults. Patients presenting after intentional, interpersonal violence had a higher mortality compared to non-intentional 5% vs 1% (p = 0.019). CONCLUSIONS Pediatric pregnant trauma patients remain at risk of interpersonal violence, especially firearm-related injury. Screening should be instituted by obstetricians and pediatricians for primary prevention.
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan D, Ruiz XD, Schulman CI, Namias N, Proctor KG. Association of Mechanism of Injury With Risk for Venous Thromboembolism After Trauma. JAMA Surg 2017; 152:35-40. [PMID: 27682749 DOI: 10.1001/jamasurg.2016.3116] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Hassinger TE, Guidry CA, Rotstein OD, Duane TM, Evans HL, Cook CH, O'Neill PJ, Mazuski JE, Askari R, Napolitano LM, Namias N, Miller PR, Dellinger EP, Coimbra R, Cocanour CS, Banton KL, Cuschieri J, Popovsky K, Sawyer RG. Longer-Duration Antimicrobial Therapy Does Not Prevent Treatment Failure in High-Risk Patients with Complicated Intra-Abdominal Infections. Surg Infect (Larchmt) 2017. [PMID: 28650745 DOI: 10.1089/sur.2017.084] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent studies have suggested the length of treatment of intra-abdominal infections (IAIs) can be shortened without detrimental effects on patient outcomes. However, data from high-risk patient populations are lacking. We hypothesized that patients at high risk for treatment failure will benefit from a longer course of antimicrobial therapy. METHODS Patients enrolled in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated retrospectively to identify risk factors associated with treatment failure, which was defined as the composite outcome of recurrent IAI, surgical site infection, or death. Variables were considered risk factors if there was a positive statistical association with treatment failure. Patients were then stratified according to the presence and number of these risk factors. Univariable analyses were performed using the Kruskal-Wallis, χ2, and Fisher exact tests. Logistic regression controlling for risk factors and original randomization group, either a fixed four-day antimicrobial regimen (experimental) or a longer course based on clinical response (control), also was performed. RESULTS We identified corticosteroid use, Acute Physiology and Chronic Health Evaluation II score ≥5, hospital-acquired infection, or a colonic source of IAI as risk factors associated with treatment failure. Of the 517 patients enrolled, 263 (50.9%) had one or two risk factors and 16 (3.1%) had three or four risk factors. The rate of treatment failure rose as the number of risk factors increased. When controlling for randomization group, the presence and number of risk factors were independently associated with treatment failure, but the duration of antimicrobial therapy was not. CONCLUSIONS We were able to identify patients at high risk for treatment failure in the STOP-IT trial. Such patients did not benefit from a longer course of antibiotic administration. Further study is needed to determine the optimum duration of antimicrobial therapy in high-risk patients.
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Allen CJ, Baldor DJ, Schulman CI, Pizano LR, Livingstone AS, Namias N. Assessing Field Triage Decisions and the International Classification Injury Severity Score (ICISS) at Predicting Outcomes of Trauma Patients. Am Surg 2017. [DOI: 10.1177/000313481708300632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Florida considers the International Classification Injury Severity Score (ICISS) from hospital discharges within a geographic region in the apportionment of trauma centers (TCs). Patients with an ICISS <0.85 are considered to require triage to a TC, yet many are triaged to an emergency department (ED). We assess outcomes of those with an ICISS <0.85 by the actual triage decision of emergency medical services (EMS). From October 2011 to October 2013, 39,021 consecutive admissions with injury ICD-9 codes were analyzed. ICISS was calculated from the product of the survival risk ratios for a patient's three worst injuries. Outcomes were compared between patients with ICISS <0.85 either triaged to the ED or its separate, neighboring, free-standing TC at a large urban hospital. A total of 32,191 (83%) patients were triaged to the ED by EMS and 6,827 (17%) were triaged to the TC. Of these, 2544 had an ICISS <0.85, with 2145 (84%) being triaged to the TC and 399 (16%) to the ED. In these patients, those taken to the TC more often required admission, and those taken to the ED had better outcomes. When the confounders influencing triage to an ED or a TC are eliminated, those triaged by EMS to the ED rather than the TC had better overall outcomes. EMS providers better identified patients at risk for mortality than did the retrospective application of ICISS. ICISS <0.85 does not identify the absolute need for TC as EMS providers were able to appropriately triage a large portion of this population to the ED.
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan DB, Ruiz XD, Schulman CI, Namias N, Proctor KG. Mechanism of Injury May Influence Infection Risk from Early Blood Transfusion. Surg Infect (Larchmt) 2017; 18:83-88. [DOI: 10.1089/sur.2016.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Meizoso JP, Karcutskie CA, Ray JJ, Namias N, Schulman CI, Proctor KG. Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients. J Am Coll Surg 2016; 224:575-582. [PMID: 28017804 DOI: 10.1016/j.jamcollsurg.2016.12.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 11/18/2022]
Abstract
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.
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Meizoso JP, Ray JJ, Karcutskie CA, Teisch LF, Allen CJ, Namias N, Schulman CI, Proctor KG. Admission hyperglycemia is associated with different outcomes after blunt versus penetrating trauma. J Surg Res 2016; 206:83-89. [DOI: 10.1016/j.jss.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/24/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan DB, Ruiz X, Livingstone AS, Schulman CI, Ginzburg E, Namias N, Proctor KG. Transfusion of Packed Red Blood Cells and Fresh Frozen Plasma are Synergistic Risk Factors for Venous Thromboembolism in Trauma Patients. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rattan R, Allen CJ, Sawyer RG, Mazuski J, Duane TM, Askari R, Banton KL, Claridge JA, Coimbra R, Cuschieri J, Dellinger EP, Evans HL, Guidry CA, Miller PR, O'Neill PJ, Rotstein OD, West MA, Popovsky K, Namias N. Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection. Am Surg 2016; 82:860-866. [PMID: 27670577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intra-abdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.
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Rattan R, Allen CJ, Sawyer RG, Mazuski J, Duane TM, Askari R, Banton KL, Claridge JA, Coimbra R, Cuschieri J, Dellinger EP, Evans HL, Guidry CA, Miller PR, O'Neill PJ, Rotstein OD, West MA, Popovsky K, Namias N. Patients with Risk Factors for Complications Do Not Require Longer Antimicrobial Therapy for Complicated Intra-Abdominal Infection. Am Surg 2016. [DOI: 10.1177/000313481608200951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A prospective, multicenter, randomized controlled trial found that four days of antibiotics for source-controlled complicated intra-abdominal infection resulted in similar outcomes when compared with a longer duration. We hypothesized that patients with specific risk factors for complications also had similar outcomes. Short-course patients with obesity, diabetes, or Acute Physiology and Chronic Health Evaluation II ≥15 from the STOP-IT trial were compared with longer duration patients. Outcomes included incidence of and days to infectious complications, mortality, and length of stay. Obese and diabetic patients had similar incidences of and days to surgical site infection, recurrent intra-abdominal infection, extra-abdominal infection, and Clostridium difficile infection. Short- and long-course patients had similar incidences of complications among patients with Acute Physiology and Chronic Health Evaluation II ≥15. However, there were fewer days to the diagnosis of surgical site infection (9.5 ± 3.4 vs 21.6 ± 6.2, P = 0.010) and extra-abdominal infection (12.4 ± 6.9 vs 21.8 ± 6.1, P = 0.029) in the short-course group. Mortality and length of stay was similar for all groups. A short course of antibiotics in complicated intraabdominal infection with source control seems to have similar outcomes to a longer course in patients with diabetes, obesity, or increased severity of illness.
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Sanders JM, Tessier JM, Sawyer RG, Lipsett PA, Miller PR, Namias N, O'Neill PJ, Dellinger EP, Coimbra R, Guidry CA, Cuschieri J, Banton KL, Cook CH, Moore BJ, Duane TM. Inclusion of Vancomycin as Part of Broad-Spectrum Coverage Does Not Improve Outcomes in Patients with Intra-Abdominal Infections: A Post Hoc Analysis. Surg Infect (Larchmt) 2016; 17:694-699. [PMID: 27483362 DOI: 10.1089/sur.2016.095] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Management of complicated intra-abdominal infections (cIAIs) includes broad-spectrum antimicrobial coverage and commonly includes vancomycin for the empiric coverage of methicillin-resistant Staphylococcus aureus (MRSA). Ideally, culture-guided de-escalation follows to promote robust antimicrobial stewardship. This study assessed the impact and necessity of vancomycin in cIAI treatment regimens. PATIENTS AND METHODS A post hoc analysis of the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial was performed. Patients receiving piperacillin-tazobactam (P/T) and/or a carbapenem were included with categorization based on use of vancomycin. Univariate and multivariable analyses evaluated effects of including vancomycin on individual and the composite of undesirable outcomes (recurrent IAI, surgical site infection [SSI], or death). RESULTS The study cohort included 344 patients with 110 (32%) patients receiving vancomycin. Isolation of MRSA occurred in only eight (2.3%) patients. Vancomycin use was associated with a similar composite outcome, 29.1%, vs. no vancomycin, 22.2% (p = 0.17). Patients receiving vancomycin had (mean [standard deviation]) higher Acute Physiology and Chronic Health Evaluation II scores (13.1 [6.6] vs. 9.4 [5.7], p < 0.0001), extended length of stay (12.6 [10.2] vs. 8.6 [8.0] d, p < 0.001), and prolonged antibiotic courses (9.1 [8.0] vs. 7.1 [4.9] d, p = 0.02). After risk adjustment in a multivariate model, no significant difference existed for the measured outcomes. CONCLUSIONS This post hoc analysis reveals that addition of vancomycin occurred in nearly one third of patients and more often in sicker patients. Despite this selection bias, no appreciable differences in undesired outcomes were demonstrated, suggesting limited utility for adding vancomycin to cIAI treatment regimens.
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95
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Rattan R, Namias N, Sawyer RG. Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy. J Am Coll Surg 2016; 223:206-7. [DOI: 10.1016/j.jamcollsurg.2016.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
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96
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Ray JJ, Sznol JA, Teisch LF, Meizoso JP, Allen CJ, Namias N, Pizano LR, Sleeman D, Spector SA, Schulman CI. Association Between American Board of Surgery In-Training Examination Scores and Resident Performance. JAMA Surg 2016; 151:26-31. [PMID: 26536059 DOI: 10.1001/jamasurg.2015.3088] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. OBJECTIVE To determine whether favorable evaluations are associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. EXPOSURES Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. MAIN OUTCOMES AND MEASURES Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. RESULTS The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile (r(2) = 0.014; P = .15), percentage correct unadjusted for PGY level (r(2) = 0.019; P = .09), or percentage correct adjusted for PGY level (r(2) = 0.429; P = .91). CONCLUSIONS AND RELEVANCE Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.
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97
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Rosa R, Arheart KL, Depascale D, Cleary T, Kett DH, Namias N, Pizano L, Fajardo-Aquino Y, Munoz-Price LS. Environmental Exposure to Carbapenem-Resistant Acinetobacter baumannii as a Risk Factor for Patient Acquisition of A. baumannii. Infect Control Hosp Epidemiol 2016; 35:430-3. [DOI: 10.1086/675601] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We aimed to determine the association between environmental exposure to carbapenem-resistant Acinetobacter baumannii and the subsequent risk of acquiring this organism. Patients exposed to a contaminated hospital environment had 2.77 times the risk of acquiring carbapenem-resistant A. baumannii than did unexposed patients (relative risk, 2.77 [95% confidence interval, 1.50–5.13]; P = .002).
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98
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Rattan R, Allen CJ, Sawyer RG, Askari R, Banton KL, Claridge JA, Cocanour CS, Coimbra R, Cook CH, Cuschieri J, Dellinger EP, Duane TM, Evans HL, Lipsett PA, Mazuski JE, Miller PR, O’Neill PJ, Rotstein OD, Namias N. Patients with Complicated Intra-Abdominal Infection Presenting with Sepsis Do Not Require Longer Duration of Antimicrobial Therapy. J Am Coll Surg 2016; 222:440-6. [DOI: 10.1016/j.jamcollsurg.2015.12.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
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99
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Dietch ZC, Duane TM, Cook CH, O'Neill PJ, Askari R, Napolitano LM, Namias N, Watson CM, Dent DL, Edwards BL, Shah PM, Guidry CA, Davies SW, Willis RN, Sawyer RG. Obesity Is Not Associated with Antimicrobial Treatment Failure for Intra-Abdominal Infection. Surg Infect (Larchmt) 2016; 17:412-21. [PMID: 27027416 DOI: 10.1089/sur.2015.213] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Obesity and commonly associated comorbidities are known risk factors for the development of infections. However, the intensity and duration of antimicrobial treatment are rarely conditioned on body mass index (BMI). In particular, the influence of obesity on failure of antimicrobial treatment for intra-abdominal infection (IAI) remains unknown. We hypothesized that obesity is associated with recurrent infectious complications in patients treated for IAI. METHODS Five hundred eighteen patients randomized to treatment in the Surgical Infection Society Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial were evaluated. Patients were stratified by obese (BMI ≥30) versus non-obese (BMI≥30) status. Descriptive comparisons were performed using Chi-square test, Fisher exact test, or Wilcoxon rank-sum tests as appropriate. Multivariable logistic regression using a priori selected variables was performed to assess the independent association between obesity and treatment failure in patients with IAI. RESULTS Overall, 198 (38.3%) of patients were obese (BMI ≥30) versus 319 (61.7%) who were non-obese. Mean antibiotic d and total hospital d were similar between both groups. Unadjusted outcomes of surgical site infection (9.1% vs. 6.9%, p = 0.36), recurrent intra-abdominal infection (16.2% vs. 13.8, p = 0.46), death (1.0% vs. 0.9%, p = 1.0), and a composite of all complications (25.3% vs. 19.8%, p = 0.14) were also similar between both groups. After controlling for appropriate demographics, comorbidities, severity of illness, treatment group, and duration of antimicrobial therapy, obesity was not independently associated with treatment failure (c-statistic: 0.64). CONCLUSIONS Obesity is not associated with antimicrobial treatment failure among patients with IAI. These results suggest that obesity may not independently influence the need for longer duration of antimicrobial therapy in treatment of IAI versus non-obese patients.
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Allen CJ, Meizoso JP, Ray JJ, Teisch LF, Schulman CI, Namias N, Proctor KG. Does Isolated Hemoperitoneum Cause Peritonitis? A Review of 400 Trauma Laparotomies. Am Surg 2016; 82:184-186. [PMID: 26874145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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