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Kozar RA, Arbabi S, Stein DM, Shackford SR, Barraco RD, Biffl WL, Brasel KJ, Cooper Z, Fakhry SM, Livingston D, Moore F, Luchette F. Injury in the aged: Geriatric trauma care at the crossroads. J Trauma Acute Care Surg 2015; 78:1197-209. [PMID: 26151523 PMCID: PMC4976060 DOI: 10.1097/ta.0000000000000656] [Citation(s) in RCA: 158] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Biffl WL. International Association of Trauma and Surgical Intensive Care Symposium: Penetrating Trauma. Update on Penetrating Trauma. World J Surg 2015; 39:1341-2. [PMID: 25840821 DOI: 10.1007/s00268-015-3059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Biffl WL, Gallagher AW, Pieracci FM, Berumen C. Suboptimal compliance with surgical safety checklists in Colorado: A prospective observational study reveals differences between surgical specialties. Patient Saf Surg 2015; 9:5. [PMID: 25642287 PMCID: PMC4312457 DOI: 10.1186/s13037-014-0056-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/29/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Surgical safety checklists (SSCs) are designed to improve team communication and consistency in care, ultimately avoiding complications. In Colorado, hospitals reported that use of SSCs was standard practice, but a statewide survey indicated that SSC use was inconsistent. The purpose of this project was to directly observe the compliance with the SSC in Colorado hospitals, through direct observation of the perioperative checklist process. METHODS Ten hospitals participated in a quality improvement initiative. Trained team members recorded compliance with each of the components of the SSC. Data analysis was performed using a chi-squared test or ANOVA, depending on the number of categorical variables, with p < 0.05 determining statistical significance. RESULTS Ten hospitals representing statewide diversity submitted 854 observations (median 98, range 24-106). 83% of cases were elective, 13% urgent, and 4% emergent/trauma. There was significant variation across hospitals in: team introductions, cessation of activity, affirming correct procedure, assessing hypothermia risk, need for beta blocker, or VTE prophylaxis. Uniformly poor compliance was observed with respect to assessment of case duration, blood loss, anesthesiologists' concerns, or display of essential imaging. Only 71% of observers reported active participation by physicians; 9% reported that "the majority did not pay attention" and 4% reported that the team was "just going through the motions". There were significant differences among surgical specialty groups in the majority of the elements. CONCLUSION SSCs have been implemented by the vast majority of hospitals in our state; however, compliance with SSC completion in the operating room has wide variation and is generally suboptimal. Although this study was not designed to correlate SSC compliance with outcomes, there are concerns about the risk of a sentinel event or unanticipated complication resulting from poor preparation.
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Sartelli M, Abu-Zidan FM, Ansaloni L, Bala M, Beltrán MA, Biffl WL, Catena F, Chiara O, Coccolini F, Coimbra R, Demetrashvili Z, Demetriades D, Diaz JJ, Di Saverio S, Fraga GP, Ghnnam W, Griffiths EA, Gupta S, Hecker A, Karamarkovic A, Kong VY, Kafka-Ritsch R, Kluger Y, Latifi R, Leppaniemi A, Lee JG, McFarlane M, Marwah S, Moore FA, Ordonez CA, Pereira GA, Plaudis H, Shelat VG, Ulrych J, Zachariah SK, Zielinski MD, Garcia MP, Moore EE. The role of the open abdomen procedure in managing severe abdominal sepsis: WSES position paper. World J Emerg Surg 2015; 10:35. [PMID: 26269709 PMCID: PMC4534034 DOI: 10.1186/s13017-015-0032-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 08/03/2015] [Indexed: 02/07/2023] Open
Abstract
The open abdomen (OA) procedure is a significant surgical advance, as part of damage control techniques in severe abdominal trauma. Its application can be adapted to the advantage of patients with severe abdominal sepsis, however its precise role in these patients is still not clear. In severe abdominal sepsis the OA may allow early identification and draining of any residual infection, control any persistent source of infection, and remove more effectively infected or cytokine-loaded peritoneal fluid, preventing abdominal compartment syndrome and deferring definitive intervention and anastomosis until the patient is appropriately resuscitated and hemodynamically stable and thus better able to heal. However, the OA may require multiple returns to the operating room and may be associated with significant complications, including enteroatmospheric fistulas, loss of abdominal wall domain and large hernias. Surgeons should be aware of the pathophysiology of severe intra-abdominal sepsis and always keep in mind the option of using open abdomen to be able to use it in the right patient at the right time.
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Monti PM, Colby SM, Mastroleo NR, Barnett NP, Gwaltney CJ, Apodaca TR, Rohsenow DJ, Magill M, Gogineni A, Mello MJ, Biffl WL, Cioffi WG. Individual versus significant-other-enhanced brief motivational intervention for alcohol in emergency care. J Consult Clin Psychol 2014; 82:936-48. [PMID: 25111430 DOI: 10.1037/a0037658] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Effects of brief motivational interventions (BMIs) for heavy drinkers identified by alcohol-related emergency department (ED) visits are mixed. The successes of including significant others (SOs) in behavioral treatment suggest that involving SOs in ED-delivered BMI might prove beneficial. This study investigated the relative efficacy of an SO-enhanced motivational intervention (SOMI) compared with an individual motivational intervention (IMI) to address heavy drinking in emergency care settings. METHOD ED (n = 317) or trauma unit (n = 89) patients were randomly assigned to receive either an IMI or an SOMI and were reassessed at 6 and 12 months for alcohol consumption, alcohol-related consequences, and perceived alcohol-specific SO support. RESULTS Generalized estimating equation analyses showed consistent reductions over time for both alcohol consumption and consequences. At 1-year follow-up, the average reduction in total drinks consumed per week was greater for patients in the SOMI condition than the IMI condition. In SOMI, 9.4% more patients moved to within the national guidelines for weekly drinking than did IMI patients. Frequency of heavy drinking and negative alcohol consequences showed no differential effects of intervention. CONCLUSIONS Emergence of a modest treatment effect at 12 months suggests that SO involvement in the SOMI condition may have led to more sustained positive influence on patient drinking than in the IMI condition. Implications and limitations regarding SO involvement in brief treatment are discussed.
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Burlew CC, Biffl WL, Moore EE, Pieracci FM, Beauchamp KM, Stovall R, Wagenaar AE, Jurkovich GJ. Endovascular stenting is rarely necessary for the management of blunt cerebrovascular injuries. J Am Coll Surg 2014; 218:1012-7. [PMID: 24661857 DOI: 10.1016/j.jamcollsurg.2014.01.042] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND The role of stenting for blunt cerebrovascular injuries (BCVI) continues to be debated, with a trend toward more endovascular stenting. With the recent intracranial stenting trial halted in favor of medical therapy, however, management of BCVI warrants reassessment. The study purpose was to determine if antithrombotic therapy, rather than stenting, was effective in post-injury patients with high-grade vascular dissections and pseudoaneurysms. STUDY DESIGN In 1996, we began screening for BCVI. After the 2005 report on the risks of carotid stenting for BCVI, a virtual moratorium was placed on stenting at our institution; our primary therapy for BCVI has been antithrombotics. Patients with grade II (luminal narrowing >25%) and grade III (pseudoaneurysms) injuries were included in the analysis. RESULTS Grade II or III BCVIs were diagnosed in 195 patients. Before 2005, 25% (21 of 86) of patients underwent stent placement, with 2 patients suffering stroke. Of patients treated with antithrombotics, 1 had a stroke. After 2005, only 2% (2 of 109) of patients with high-grade injuries had stents placed. After 2005, no patient treated with antithrombotics suffered a stroke and there was no rupture of a pseudoaneurysm. CONCLUSIONS Antithrombotic treatment for BCVI is effective for stroke prevention. Routine stenting entails increased costs and potential risk for stroke, and does not appear to provide additional benefit. Intravascular stents should be reserved for the rare patient with symptomatology or a markedly enlarging pseudoaneurysm.
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Biffl WL, Biffl SE. Surgical Quality Improvement. Patient Saf Surg 2014. [DOI: 10.1007/978-1-4471-4369-7_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, Tugnoli G, Velmahos GC, Sartelli M, Bendinelli C, Fraga GP, Kelly MD, Moore FA, Mandalà V, Mandalà S, Masetti M, Jovine E, Pinna AD, Peitzman AB, Leppaniemi A, Sugarbaker PH, Goor HV, Moore EE, Jeekel J, Catena F. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg 2013; 8:42. [PMID: 24112637 PMCID: PMC4124851 DOI: 10.1186/1749-7922-8-42] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/23/2013] [Indexed: 12/19/2022] Open
Abstract
Background In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery. Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery. Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
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Chapman BC, Moore EE, Barnett C, Stovall RT, Biffl WL, Burlew CC, Bensard DD, Jurkovich GJ, Pieracci FM. Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation. Am J Surg 2013; 206:917-22; discussion 922-3. [PMID: 24112665 DOI: 10.1016/j.amjsurg.2013.07.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 07/27/2013] [Accepted: 07/31/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown. METHODS Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours. RESULTS Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance). CONCLUSIONS Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.
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Kluger Y, Ben-Ishay O, Sartelli M, Ansaloni L, Abbas AE, Agresta F, Biffl WL, Baiocchi L, Bala M, Catena F, Coimbra R, Cui Y, Di Saverio S, Das K, El Zalabany T, Fraga GP, Gomes CA, Gonsaga RAT, Kenig J, Leppäniemi A, Marwah S, Junior GAP, Sakakushev B, Siribumrungwong B, Sato N, Tranà C, Vettoretto N, Moore EE. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg 2013; 8:17. [PMID: 23634784 PMCID: PMC3652724 DOI: 10.1186/1749-7922-8-17] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 04/26/2013] [Indexed: 12/18/2022] Open
Abstract
Timing of surgical intervention is critical for outcomes of patients diagnosed with surgical emergencies. Facing the challenge of multiple patients requiring emergency surgery, or of limited resource availability, the acute care surgeon must triage patients according to their disease process and physiological state. Emergency operations from all surgical disciplines should be scheduled by an agreed time frame that is based on accumulated data of outcomes related to time elapsed from diagnosis to surgery. Although literature exists regarding the optimal timing of various surgical interventions, implementation of protocols for triage of surgical emergencies is lacking. For institutions of a repetitive triage mechanism, further discussion on optimal timing of surgery in diverse surgical emergencies should be encouraged. Standardizing timing of interventions in surgical emergencies will promote clinical investigation as well as a commitment by administrative authorities to proper operating theater provision for acute care surgery.
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Kluger Y, Ben-Ishay O, Sartelli M, Ansaloni L, Abbas AE, Agresta F, Biffl WL, Baiocchi L, Bala M, Catena F, Coimbra R, Cui Y, Di Saverio S, Das K, El Zalabany T, Fraga GP, Gomes CA, Gonsaga RAT, Kenig J, Leppäniemi A, Marwah S, Junior GAP, Sakakushev B, Siribumrungwong B, Sato N, Tranà C, Vettoretto N, Moore EE. World society of emergency surgery study group initiative on Timing of Acute Care Surgery classification (TACS). World J Emerg Surg 2013. [PMID: 23634784 DOI: 10.1186/1749-7922-8-17.pmid:23634784;pmcid:pmc3652724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023] Open
Abstract
Timing of surgical intervention is critical for outcomes of patients diagnosed with surgical emergencies. Facing the challenge of multiple patients requiring emergency surgery, or of limited resource availability, the acute care surgeon must triage patients according to their disease process and physiological state. Emergency operations from all surgical disciplines should be scheduled by an agreed time frame that is based on accumulated data of outcomes related to time elapsed from diagnosis to surgery. Although literature exists regarding the optimal timing of various surgical interventions, implementation of protocols for triage of surgical emergencies is lacking. For institutions of a repetitive triage mechanism, further discussion on optimal timing of surgery in diverse surgical emergencies should be encouraged. Standardizing timing of interventions in surgical emergencies will promote clinical investigation as well as a commitment by administrative authorities to proper operating theater provision for acute care surgery.
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Stovall RT, Haenal JB, Jenkins TC, Jurkovich GJ, Pieracci FM, Biffl WL, Barnett CC, Johnson JL, Bensard DD, Moore EE, Cothren Burlew C. A negative urinalysis rules out catheter-associated urinary tract infection in trauma patients in the intensive care unit. J Am Coll Surg 2013; 217:162-6. [PMID: 23639202 DOI: 10.1016/j.jamcollsurg.2013.02.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) in trauma patients is associated with increased mortality. Whether the urinalysis (UA) is an adequate test for a urinary source of fever in the ICU trauma patient has not been demonstrated. We hypothesized that the UA is a valuable screen for UTI in the febrile, critically ill trauma patient. STUDY DESIGN All trauma ICU patients in our surgical ICU who had a fever (temperature >38.0°C), urinary catheter, UA, and a urine culture between January 1, 2011 and December 13, 2011 were reviewed. A positive UA was defined as positive leukocyte esterase, positive nitrite, WBC > 10/high power field, or presence of bacteria. A positive urine culture was defined as growth of ≥10(5) colony forming units (cfu) of an organism irrespective of the UA result or ≥10(3) cfu in the setting of a positive UA. A UTI was defined as positive urine culture without an alternative cause of the fever. RESULTS There were 232 UAs from 112 patients that met criteria. The majority (75%) of patients were men; the mean age was 40 (±16) years. Of the 232 UAs, 90 (38.7%) were positive. There were 14 UTIs. The sensitivity, specificity, positive predictive value, and negative predictive value of the UA for UTI were 100%, 65.1%, 15.5%, and 100%, respectively. CONCLUSIONS A negative UA reliably excludes a catheter-associated UTI in the febrile, trauma ICU patient with a 100% negative predictive value, and it can rapidly direct the clinician toward more likely sources of fever and reduce unnecessary urine cultures.
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Yu C, Xu L, Chen LF, Guan YJ, Kim M, Biffl WL, Chin YE. PRBC-derived plasma induces non-muscle myosin type IIA-mediated neutrophil migration and morphologic change. Immunopharmacol Immunotoxicol 2012; 35:71-9. [PMID: 23083320 PMCID: PMC3541669 DOI: 10.3109/08923973.2012.677046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Context: Neutrophils are the primary effector cells in the pathogenesis of transfusion-related acute lung injury or multiple organ failure after blood transfusion. Objective: We aimed to investigate the effect of fresh (1 day preparation) and aged (42 day preparation) PRBC-derived plasma on neutrophil morphology, migration and phagocytosis. Materials and methods: We evaluated the production of reactive oxygen species (ROS) and the expression of non-muscle myosin heavy chain IIA (MYH9) in neutrophils treated with PRBC-derived plasma. We used western blots and antibody arrays to evaluate changes in signal transduction pathways in plasma-treated neutrophils. Results: Aged PRBC-derived plasma elicited a stronger oxidative burst in neutrophils when compared with fresh PRBC-derived plasma (p < 0.05). Antibody arrays showed increased phosphorylation of NF-ĸB proteins (p105, p50 and Ikk) in aged PRBC-derived plasma-treated neutrophils. The expression of non-muscle myosin IIA (MYH9), a cytoskeleton protein involved in immune cell migration and morphological change, was also significantly upregulated in neutrophils treated with aged PRBC-derived plasma compared to fresh plasma (p < 0.05). Pretreatment of neutrophils with blebbistatin (a specific type II myosin inhibitor), ascorbic acid (an antioxidant), or staurosporine (a protein tyrosine kinase inhibitor), effectively abrogated the morphological changes, neutrophil migration, and phagocytosis induced by aged PRBC-derived plasma. Conclusion: Upregulation of MYH9 in neutrophils treated with aged PRBC-derived plasma and abrogation of neutrophil migration in blebbistatin-treated neutrophils suggested a functional role of MYH9 in the directional migration of immune cells. Our data help elucidate the cellular and molecular mechanisms of transfusion-related injury.
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Pieracci FM, Witt J, Moore EE, Burlew CC, Johnson J, Biffl WL, Barnett CC, Bensard DD. Early death and late morbidity after blood transfusion of injured children: a pilot study. J Pediatr Surg 2012; 47:1587-91. [PMID: 22901922 DOI: 10.1016/j.jpedsurg.2012.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 02/07/2012] [Accepted: 02/20/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Early postinjury death after packed red blood cell (pRBC) transfusion is attributed to uncontrolled hemorrhage and coagulopathy. The adverse immunomodulatory effects of blood transfusion are implicated in subsequent morbidity. We hypothesized that injured children requiring pRBC transfusion demonstrate patterns in outcome similar to those observed in adults. METHODS Our prospectively collected trauma registry was queried for demographics, treatment, and outcome (2006-2009). Outcomes of children who received pRBC transfusion were compared with those of age- and Injury Severity Score (ISS)-matched children who did not receive pRBC transfusion by both univariate and multivariable analysis. RESULTS Eight percent (43/512) of injured children received a pRBC transfusion: 20 early and 23 late. The likelihood of pRBC transfusion increased with increasing ISS (ISS <15, 2%; ISS 16-25, 17%; ISS >25, 72%). One-half of injured children who received an early pRBC transfusion died; however, most deaths were because of central nervous system injury. Both ventilator and intensive care unit days were increased in children who received pRBC transfusion as compared with those who did not. CONCLUSION Early pRBC transfusion is associated with a high mortality in children. Late blood transfusion is associated with worse outcomes, although this relationship may not be causal. This pilot study provides evidence of an association between pRBC transfusion, morbidity, and mortality among injured children that warrants refinement in larger, prospective investigations.
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Jones TS, Burlew CC, Kornblith LZ, Biffl WL, Partrick DA, Johnson JL, Barnett CC, Bensard DD, Moore EE. Blunt cerebrovascular injuries in the child. Am J Surg 2012; 204:7-10. [DOI: 10.1016/j.amjsurg.2011.07.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Revised: 07/25/2011] [Accepted: 07/25/2011] [Indexed: 10/14/2022]
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Burlew CC, Kornblith LZ, Moore EE, Johnson JL, Biffl WL. Blunt trauma induced splenic blushes are not created equal. World J Emerg Surg 2012; 7:8. [PMID: 22462560 PMCID: PMC3337796 DOI: 10.1186/1749-7922-7-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 03/30/2012] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Currently, evidence of contrast extravasation on computed tomography (CT) scan is regarded as an indication for intervention in splenic injuries. In our experience, patients transferred from other institutions for angioembolization have often resolved the blush upon repeat imaging at our hospital. We hypothesized that not all splenic blushes require intervention. METHODS During a 10-year period, we reviewed all patients transferred with blunt splenic injuries and contrast extravasation on initial postinjury CT scan. RESULTS During the study period, 241 patients were referred for splenic injuries, of whom 16 had a contrast blush on initial CT imaging (88% men, mean age 35 ± 5, mean ISS 26 ± 3). Eight (50%) patients were managed without angioembolization or operation. Comparing patients with and without intervention, there was a significant difference in admission heart rate (106 ± 9 vs 83 ± 6) and decline in hematocrit following transfer (5.3 ± 2.0 vs 1.0 ± 0.3), but not in injury grade (3.9 ± 0.2 vs 3.5 ± 0.3), systolic blood pressure (125 ± 10 vs 115 ± 6), or age (38.5 ± 8.2 vs 30.9 ± 4.7). Of the 8 observed patients, 3 underwent repeat imaging immediately upon arrival with resolution of the blush. In the intervention group, 4 patients had ongoing extravasation on repeat imaging, 2 patients underwent empiric embolization, and 2 patients underwent splenectomy for physiologic indications. CONCLUSIONS For blunt splenic trauma, evidence of contrast extravasation on initial CT imaging is not an absolute indication for intervention. A period of observation with repeat imaging could avoid costly, invasive interventions and their associated sequelae.
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Judkins SE, Moore EE, Witt JE, Barnett CC, Biffl WL, Burlew CC, Johnson JL. Surgeons provide definitive care to patients with gallstone pancreatitis. Am J Surg 2011; 202:673-7; discussion 677-8. [DOI: 10.1016/j.amjsurg.2011.06.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Revised: 06/14/2011] [Accepted: 06/28/2011] [Indexed: 12/25/2022]
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Judkins SE, Moore EE, Witt JE, Barnett CC, Biffl WL, Burlew CC, Johnson JL. Surgeons provide definitive care to patients with gallstone pancreatitis. Am J Surg 2011. [PMID: 22014646 DOI: 10.1016/j.amjsurg.2011.06.031.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The optimal management of patients with gallstone pancreatitis (GP) remains a matter of debate. There are wide variations in the use of diagnostic testing and same-stay cholecystectomy. We hypothesize that a general surgery service (SURG) will deliver more efficient, definitive care for patients with GP. METHODS A retrospective cohort study of consecutive GP patients in an urban hospital from 2006 to 2009. Differences between groups were assessed by the two-tailed Student t test for continuous variables and the Fisher exact test for ordinal data. RESULTS One hundred twenty-four patients with GP were admitted, 79 to medicine (MED) and 45 to surgery (SURG). In the MED group, 21 patients (27%) underwent same-stay cholecystectomy, and 7 patients (9%) returned with recurrent biliary pancreatitis. In the SURG group, 44 patients had definitive surgery, and none returned with recurrent disease (P < .01 and .09, respectively). The SURG group had fewer laboratory tests, antibiotics, and consultations. CONCLUSIONS For patients with GP, admission to surgery results in definitive treatment with same-stay cholecystectomy. This is a more efficient approach with fewer readmissions for the same disease process.
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Kashuk JL, Moore EE, Wohlauer M, Johnson JL, Pezold M, Lawrence J, Biffl WL, Burlew CCC, Barnett C, Sawyer M, Sauaia A. Initial experiences with point-of-care rapid thrombelastography for management of life-threatening postinjury coagulopathy. Transfusion 2011; 52:23-33. [DOI: 10.1111/j.1537-2995.2011.03264.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Burlew CC, Moore EE, Smith WR, Johnson JL, Biffl WL, Barnett CC, Stahel PF. Preperitoneal Pelvic Packing/External Fixation with Secondary Angioembolization: Optimal Care for Life-Threatening Hemorrhage from Unstable Pelvic Fractures. J Am Coll Surg 2011; 212:628-35; discussion 635-7. [DOI: 10.1016/j.jamcollsurg.2010.12.020] [Citation(s) in RCA: 166] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 11/24/2022]
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Jenkins TC, Knepper BC, Sabel AL, Sarcone EE, Long JA, Haukoos JS, Morgan SJ, Biffl WL, Steele AW, Price CS, Mehler PS, Burman WJ. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess. ACTA ACUST UNITED AC 2011; 171:1072-9. [PMID: 21357799 DOI: 10.1001/archinternmed.2011.29] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been adequately studied. We hypothesized that implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess would decrease antibiotic and health care resource utilization. METHODS A retrospective preintervention-postintervention study was performed to compare management before and after implementation of the guideline (January 1, 2007-December 31, 2007, and July 9, 2009-July 8, 2010). RESULTS A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased from 13 days (interquartile range [IQR], 10-15 days) to 10 days (IQR, 9-12 days) (P < .001). Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases (P = .93), respectively. CONCLUSION Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.
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Abstract
Early recognition and differentiation of shock, as well as goal-directed resuscitation, are fundamental principles in the care of the critically ill or injured patient. Substantial progress has been made over the last decade in the understanding of both shock and resuscitation. Specific areas of advancement, particularly pertaining to hemorrhagic shock, include a heightened appreciation of dynamic measurements of preload responsiveness (e.g., respiratory-induced pulse pressure and venous diameter variability), an improved awareness of the detrimental effects of blood product transfusion, and better recognition of the complications of overzealous volume expansion. However, several areas of controversy remain regarding the optimal resuscitation strategy. These include the optimal targets for perfusion pressure and oxygen delivery, endpoints of resuscitation, resuscitative fluid, and transfusion strategies for packed red blood cells and blood products. This article reviews the diagnosis and differentiation of shock, measurements of tissue perfusion, current evidence regarding various resuscitative techniques, and complications of resuscitation.
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Abstract
Originally thought to be a rare occurrence, blunt cerebrovascular injuries (BCVIs) are now diagnosed in approximately 1% of blunt trauma patients. Early imaging of patients has resulted in the diagnosis of BCVIs during the asymptomatic phase, thus allowing prompt treatment. Although the ideal regimen of antithrombotic therapy has yet to be determined, treatment with either antiplatelet agents or anticoagulation has been shown to markedly reduce BCVI-related stroke rate. BCVIs are rare, potentially devastating injuries; appropriate imaging in high-risk patients should be performed and prompt treatment initiated to prevent ischemic neurologic events.
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Catena F, Di Saverio S, Kelly MD, Biffl WL, Ansaloni L, Mandalà V, Velmahos GC, Sartelli M, Tugnoli G, Lupo M, Mandalà S, Pinna AD, Sugarbaker PH, Van Goor H, Moore EE, Jeekel J. Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery. World J Emerg Surg 2011; 6:5. [PMID: 21255429 PMCID: PMC3037327 DOI: 10.1186/1749-7922-6-5] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 01/21/2011] [Indexed: 12/11/2022] Open
Abstract
Background There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications. Methods A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1st International Congress of the World Society of Emergency Surgery and 9th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus. Recommendations In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay. NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended. Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment. Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained. Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.
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