1
|
Som MN, Chao NT, Karwoski A, Pitsenbarger LT, Dunlap E, Nagarsheth KH. Modified Frailty Index Helps Predict Mortality and Ambulation Differences Between Genders and Racial Differences Following Major Lower Extremity Amputation. Am Surg 2024; 90:1030-1036. [PMID: 38063164 DOI: 10.1177/00031348231220570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Major lower extremity amputation (LEA) is associated with significant morbidity and mortality. The modified frailty index (mFI-5) has been used to predict outcomes including ambulation and mortality after LEA. It remains unknown for which patient demographics the mFI-5 is a reliable predictor. METHODS This was a retrospective review of all patients who underwent a first-time major LEA at our institution from 2015 to 2022. Patients were stratified into 2 risk groups based on their mFI-5 score: non-frail (mFI<3) and frail (mFI≥3) and assessed on outcomes. RESULTS Our sample consisted of 687 patients of whom 134 (19.6%) were considered frail and 551 (80.4%) were considered non-frail. A higher mFI-5 is associated with decreased ambulation rates (OR: 0.565, P = .004), increased hospital readmission (OR: 1.657, P = .021), and increased mortality (OR: 2.101, P = .001) following major LEA. In African American patients, frail and non-frail patients differed on readmission at 90 days (P = .008), mortality at 1 year (P = .001), ambulatory status (P < .001), and prosthesis use (P = .023). In male patients, frail and non-frail patients differed on readmission at 90 days (P = .019), death at 1 year (P = .001), and ambulatory status (P = .002). In Caucasian patients and female patients, frail and non-frail patients did not differ significantly on outcomes. DISCUSSION The mFI-5 is a valuable predictor of outcomes following major LEA, specifically in males and African American patients. Moreover, surgeons should consider using frailty status to risk stratify patients and inform treatment plans.
Collapse
Affiliation(s)
- Maria N Som
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Natalie T Chao
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Allison Karwoski
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Luke T Pitsenbarger
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Eleanor Dunlap
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Khanjan H Nagarsheth
- Department of Vascular Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| |
Collapse
|
2
|
Workneh E, Karwoski A, Chao N, Pitsenbarger L, Dunlap N, Fitzpatrick SS, Nagarsheth KH. Delayed Closure of Guillotine Lower Extremity Amputation in Obese Patients is Associated with Increased Mortality. Ann Vasc Surg 2024:S0890-5096(24)00058-X. [PMID: 38395341 DOI: 10.1016/j.avsg.2023.12.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Staged surgery with open guillotine amputation (OGA) prior to a definitive major lower extremity amputation (LEA) has been shown to be effective for sepsis control and improving wound healing. Studies have evaluated postoperative complications including infection, return to the operating room for re-amputation, and amputation failure following OGA. However, the role of timing to close OGA for predictive outcomes remains poorly understood. We aim to assess outcomes of major LEA related to the time of OGA closure. METHODS Data from patients who underwent major LEA from 2015 to 2021 was collected retrospectively. The study included all patients undergoing below-, through-, or above-knee amputations. Next, patients who had OGA prior to a definitive amputation were selected. Patients who died before amputation closure were excluded. Post-amputation outcomes such as surgical site infection (SSI), postoperative sepsis, postoperative ambulation, hospital length of stay (LOS), and 30-day, 1-year, and 5-year mortality were reviewed. The study cohort was stratified by demographics and comorbidities. Receiver operating characteristic (ROC) curve analysis was performed to determine the time of closure (TOC) cut-off value. Univariate and multivariate analysis was performed to assess outcomes. Statistical significance was set at p < 0.05. RESULT Of 688 patients who underwent major LEA, 322 underwent staged amputation with OGA before the formalization procedure and were included. The TOC ranged from 1-47 days with a median of 4 days (interquartile range (IQR) from 3 to 7). The optimal TOC point of 8 days (ranging from 2 - 42 days) in obese patients (199/322) for predicting mortality showed the largest area under the curve (AUC) (0.709) with 64.71% sensitivity and 78.3% specificity. Patients who are obese and grouped in TOC less than 8 days had no 30-day mortality, significantly lower 1-year mortality, better survival, and a lower rate of deep venous thrombosis (DVT) complication. There was no significant difference in LOS, postoperative SSI, sepsis, and ambulation between the two subgroups of obese patients. Multivariable analysis showed that gender, CKD, and postoperative ambulation independently predict overall mortality in obese patients. CONCLUSION TOC cutoff in obese patients showed statistically significant results in predicting mortality. Our findings indicated better survival in obese patients with a lower TOC (less than 8 days). This emphasizes the importance of earlier closure of OGA in obese patients.
Collapse
Affiliation(s)
- Eyerusalem Workneh
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201.
| | - Allison Karwoski
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201
| | - Natalie Chao
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201
| | - Luke Pitsenbarger
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201
| | - Nora Dunlap
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201
| | | | - Khanjan H Nagarsheth
- University of Maryland School of Medicine, 22 S Greene Street, Baltimore, MD, 21201
| |
Collapse
|
3
|
Choudhry S, Er S, Ha M, Brown M, Karwoski A, Ludwig SC, Cavanaugh DL, Sansur CA, Crandall KM, Rasko YM. A 10-Year Retrospective Review on the Use of Prophylactic Spinal Reconstruction in Spinal Surgery Involving High-Risk Patients. Ann Plast Surg 2023:00000637-990000000-00333. [PMID: 37967246 DOI: 10.1097/sap.0000000000003535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND Spinal surgeries are being offered to a broader patient population who are both medically and surgically complex. History of prior spinal surgery, advanced age, and presence of comorbidities, such as obesity, malnutrition, steroid use, and tobacco use, are risk factors for postoperative complications. Prophylactic spinal reconstruction at the time of spinal surgery has been shown to have improved outcomes and decreased wound complications; however, outcomes focusing specifically on complex patients with a history of previous spinal surgery (or surgeries) have not been well described. METHODS This is a retrospective study performed at the University of Maryland Medical Center (Baltimore, MD) of high-risk patients who underwent complex spinal surgery with prophylactic spinal reconstruction from 2011 to 2022. One hundred forty-three consecutive surgeries from 136 patients were included in the study. Patients younger than 17 years or who had an incomplete medical record were excluded. RESULTS Most patients were female (63.6%) versus male (31.5%). The average American Society of Anesthesiologists score was 3. All but 6 patients (11%) had a history of at least 1 spinal surgery, with nearly half of patients having had between 2 and 5 spinal surgeries. Reconstruction was performed with paraspinous flaps in most cases (n = 133 [93%]). The overall complication rate was 10.5%, with surgical site infection being the most common complication. Seventeen patients (12.5%) underwent reoperation within 90 days of initial surgery. Average length of follow-up was 4.18 months (range, 0.03-40.53 months). CONCLUSIONS In appropriately selected patients, prophylactic spinal reconstruction offers improved outcomes with decreased wound complications compared with salvage. For large defects, paraspinous flaps are recommended over other reconstructive options. Prolonged drain placement is felt to be protective against complications.
Collapse
Affiliation(s)
- Salman Choudhry
- From the Anne Arundel Medical Center, Department of General Surgery; 2001 Medical Parkway, Annapolis, MD
| | - Seray Er
- University of Maryland School of Medicine; 655 W Baltimore St S, Baltimore, MD
| | - Michael Ha
- University of Maryland, Division of Plastic Surgery, 620 W Lexington St, Baltimore, MD
| | - Madeline Brown
- University of Maryland School of Medicine; 655 W Baltimore St S, Baltimore, MD
| | - Allison Karwoski
- University of Maryland School of Medicine; 655 W Baltimore St S, Baltimore, MD
| | - Steven C Ludwig
- University of Maryland, Department of Orthopedics; 655 W Baltimore St S, Baltimore, MD
| | - Daniel L Cavanaugh
- University of Maryland, Department of Orthopedics; 655 W Baltimore St S, Baltimore, MD
| | - Charles A Sansur
- University of Maryland, Department of Neurosurgery; 22 South Greene Street, Baltimore, MD
| | - Kenneth M Crandall
- University of Maryland, Department of Neurosurgery; 22 South Greene Street, Baltimore, MD
| | - Yvonne M Rasko
- University of Maryland, Division of Plastic Surgery, 620 W Lexington St, Baltimore, MD
| |
Collapse
|
4
|
Lu J, Karwoski A, Abdulrahman L, Chaparala S, Chaudhary M, Nagarsheth K. Neutrophil-to-Lymphocyte Ratio as a Predictor of Mortality for COVID-19-Related Acute Respiratory Distress Syndrome (ARDS) Patients Requiring Extracorporeal Membrane Oxygenation Therapy. Cureus 2023; 15:e46238. [PMID: 37908950 PMCID: PMC10613713 DOI: 10.7759/cureus.46238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) has been studied as an indicator of systemic inflammation and as a prognostic tool in multiple areas of medicine. Previous research has suggested that higher NLR and rapid increase to peak NLR are associated with poorer outcomes in patients with coronavirus disease 2019 (COVID-19), particularly in those experiencing acute respiratory distress syndrome (ARDS). Within vascular surgery, there is data to suggest a positive correlation between elevated pre-extracorporeal membrane oxygenation (ECMO) NLR and higher rates of mortality following major procedures. This study explores the prognostic value of peri-ECMO NLR in patients requiring veno-venous ECMO (VV-ECMO) therapy for COVID-19-related ARDS. The objective of this study was to explore the utility of pre-ECMO NLR as an easily accessible prognostic factor for patients suffering from COVID-19-associated ARDS that require VV-ECMO. METHODS This was a retrospective cohort study within a tertiary care hospital conducted between April 2020 and January 2021. Patients requiring VV-ECMO therapy for COVID-19-associated ARDS were included. Peri-ECMO NLR values, length of stay (LOS), duration on VV-ECMO, and discharge status were recorded. Receiver operating characteristic (ROC) curve analysis and Youden's J statistics were performed to calculate a cut-off value of 11.005 for pre-ECMO NLR and 17.616 for on-ECMO NLR. Pre-ECMO and on-ECMO Kaplan-Meyer curves were generated for two groups of patients, those above and below NLR cutoff thresholds. Two-sample T-test was performed to test for significant differences in LOS and duration on VV-ECMO. RESULTS Twenty-six patients were included in the study for final analyses. There was an overall mortality of 39% (n = 10). ROC curve analysis and Youden's J statistic revealed an optimal cut-off value of pre-ECMO NLR = 11.005 and on-ECMO NLR = 17.616. Results showed that the patient group placed on VV-ECMO with a pre-ECMO NLR less than 11.005 experienced no mortality (n = 7) and a median LOS of 28 days (IQR = 14.5-64.5 days). The patient group on VV-ECMO with a pre-ECMO NLR greater than 11.005 (n = 19) included all mortality (n = 10) and had a median LOS of 49 days (IQR = 25.5-63.5 days). The patient group with on-ECMO NLR less than 17.616 also conferred a survival advantage. There was no significant difference in LOS or duration on VV-ECMO between the two groups, pre-ECMO or on-ECMO. CONCLUSIONS A pre-ECMO NLR cutoff was identified and offered statistically significant prognostic value in predicting mortality. A lower on-ECMO NLR value also indicated a survival advantage. Future studies should include NLR within multivariate models to better discern the effect of NLR and elucidate how it can be factored into clinical decision-making. Importantly, this data can be expanded to assess the predictive value of NLR pertaining to the COVID-19-induced ARDS population and matched cohorts.
Collapse
Affiliation(s)
- Jeffrey Lu
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Allison Karwoski
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Lena Abdulrahman
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Swati Chaparala
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Mirnal Chaudhary
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Khanjan Nagarsheth
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
5
|
Chao N, Som M, Workneh E, Karwoski A, Dunlap E, Fitzpatrick S, Nagarsheth K. Comparison of Pre-existing Mood Disorders and Chronic Kidney Disease as Predictors of Ambulatory Status After Major Limb Amputation. Cureus 2023; 15:e39215. [PMID: 37337488 PMCID: PMC10276894 DOI: 10.7759/cureus.39215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/21/2023] Open
Abstract
Objective We aim to compare the effects of pre-existing mood disorders and chronic kidney disease (CKD) on ambulation outcomes for patients who have undergone major lower extremity amputation (MLEA) while also stratifying by the presence of social factors. Methods We performed a retrospective chart review of 700 patients admitted from 2014 to 2022 who underwent MLEA. We performed Chi-square tests and binomial logistic regression with p < 0.05 as our significance level. Results Mood disorder patients have higher rates of independent ambulation if they have familial support (p = 0.022), a listed primary care provider (PCP; p = 0.013), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). Patients with a history of mood disorder have significantly decreased odds of prosthesis usage (OR: 0.58, 95% CI: 0.40-0.86) but have higher rates of prosthesis usage if they have familial support (p = 0.002), a PCP listed (p = 0.005), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). CKD patients have significantly decreased odds of eventual independent ambulation (OR: 0.69, 95% CI: 0.49-0.97) but have significantly increased rates of independent ambulation if they have familial support (p =0.041) and six-month (p < 0.001) or one-year follow-up (p < 0.001). CKD patients only have significant changes in prosthesis usage with a six-month (p < 0.001) or one-year follow-up (p < 0.001). Conclusions Pre-existing CKD and mood disorders are associated with decreased odds of independent ambulation and prosthesis usage, respectively. Social factors such as family support, a listed PCP, and timely follow-up are associated with markedly improved ambulatory outcomes for MLEA patients with mood disorders and CKD, with significantly improved prosthesis usage outcomes in only the mood disorder population.
Collapse
Affiliation(s)
- Natalie Chao
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Maria Som
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Eyerusalem Workneh
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Allison Karwoski
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| | - Eleanor Dunlap
- Vascular Surgery, University of Maryland Medical Center, Baltimore, USA
| | | | - Khanjan Nagarsheth
- Vascular Surgery, University of Maryland School of Medicine, Baltimore, USA
| |
Collapse
|
6
|
Tran Q, Gelmann D, Alam Z, Beher R, Engelbrecht-Wiggans E, Fairchild M, Hart E, Hollis G, Karwoski A, Palmer J, Raffman A, Haase D. Discrepancy Between Invasive and Noninvasive Blood Pressure Measurements in Patients with Sepsis by Vasopressor Status. West J Emerg Med 2022; 23:358-367. [PMID: 35679499 PMCID: PMC9183768 DOI: 10.5811/westjem.2022.1.53211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/07/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: Blood pressure (BP) monitoring is an essential component of sepsis management. The Surviving Sepsis Guidelines recommend invasive arterial BP (IABP) monitoring, although the benefits over non-invasive BP (NIBP) monitoring are unclear. This study investigated discrepancies between IABP and NIBP measurement and their clinical significance. We hypothesized that IABP monitoring would be associated with changes in management among patients with sepsis requiring vasopressors.
Methods: We performed a retrospective study of adult patients admitted to the critical care resuscitation unit at a quaternary medical center between January 1–December 31, 2017. We included patients with sepsis conditions AND IABP monitoring. We defined a clinically significant BP discrepancy (BPD) between NIBP and IABP measurement as a difference of > 10 millimeters of mercury (mm Hg) AND change of BP management to maintain mean arterial pressure ≥ 65 mm Hg.
Results: We analyzed 127 patients. Among 57 (45%) requiring vasopressors, 9 (16%) patients had a clinically significant BPD vs 2 patients (3% odds ratio [OR] 6.4; 95% CI: 1.2-30; P = 0.01) without vasopressors. In multivariable logistic regression, higher Sequential Organ Failure Assessment (SOFA) score (OR 1.33; 95% CI: 1.02-1.73; P = 0.03) and serum lactate (OR 1.27; 95% CI: 1.003-1.60, P = 0.04) were associated with increased likelihood of clinically significant BPD. There were no complications (95% CI: 0-0.02) from arterial catheter insertions.
Conclusion: Among our population of septic patients, the use of vasopressors was associated with increased odds of a clinically significant blood pressure discrepancy between IABP and NIBP measurement. Additionally, higher SOFA score and serum lactate were associated with higher likelihood of clinically significant blood pressure discrepancy. Further studies are needed to confirm our observations and investigate the benefits vs the risk of harm of IABP monitoring in patients with sepsis.
Collapse
Affiliation(s)
- Quincy Tran
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Dominique Gelmann
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Zain Alam
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Richa Beher
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Emily Engelbrecht-Wiggans
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Matthew Fairchild
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Emily Hart
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Grace Hollis
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Allison Karwoski
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Jamie Palmer
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Alison Raffman
- University of Maryland School of Medicine, Department of Emergency Medicine, The Research Associate Program in Emergency Medicine and Critical Care, Baltimore, Maryland
| | - Daniel Haase
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| |
Collapse
|