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Shen A, Di Meo B, Perez IA, Hashim Y, Ko A, Margulies DR, Klapper EB, Barmparas G. Reconsidering Fresh Frozen Plasma Availability to Reduce Blood Product Waste During Massive Transfusion Events in Trauma. Am Surg 2024:31348241248811. [PMID: 38658467 DOI: 10.1177/00031348241248811] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Within component therapy of massive transfusion protocol (MTP) in trauma, thawed plasma is particularly susceptible to expiring without use given its short 5-day shelf life. Optimizing the number of thawed products without compromising safety is important for hospital resource management. The goal is to examine thawed plasma utilization rates in trauma MTP events and optimize the MTP cooler content at our Level I trauma center. METHODS Trauma MTP activations from 01/2019 to 12/2022 were retrospectively reviewed. During the study period, blood products were distributed in a 12:12:1 ratio of packed red blood cells (pRBC): plasma: platelets per cooler, with up to 4 additional units of low-titer, group O whole blood (LTOWB) available. The primary measure was percent return of unused, thawed plasma. RESULTS There were 367 trauma MTP activations with a median (IQR) activation call-to-first cooler delivery time of 8 (6-10) minutes. 73.0% of thawed plasma was returned to the blood bank unused. In one third of MTP activations, all dispensed plasma was returned. The majority (74.1%) of patients required 6 or fewer units of plasma. In 81.5% of activations, 10 or fewer units of plasma and 10 or fewer units of pRBC were used. DISCUSSION The majority of trauma MTP requirements may be accommodated with a reduced cooler content of 6 units pRBC, 6 units plasma, and 1 pheresis platelets, buffered by up to 4 units LTOWB (approximates 4 units of pRBC/4 units plasma), in conjunction with a sub-10min cooler delivery time. Follow-up longitudinal studies are needed.
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Affiliation(s)
- Aricia Shen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brent Di Meo
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ingrid A Perez
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ara Ko
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ellen B Klapper
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Shen A, Barmparas G, Melo N, Chung R, Burch M, Bhatti U, Margulies DR, Wang A. Incorporating Robotic Cholecystectomy in an Acute Care Surgery Practice Model is Feasible. Am Surg 2024:31348241248816. [PMID: 38654460 DOI: 10.1177/00031348241248816] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The role of robotic surgery in the nonelective setting remains poorly defined. Accessibility, patient acuity, and high turn-over may limit its applicability and utilization. The goal is to characterize the role of robotic cholecystectomy (CCY) in a busy acute care surgery (ACS) practice at a quaternary medical center, and compare surgical outcomes and resource utilization between robotic and laparoscopic CCY. METHODS Adult patients who underwent robotic (Da Vinci Xi) or laparoscopic CCY between 01/2021-12/2022 by an ACS attending within 1 week of admission were included. Primary outcomes included time from admission to surgery, off hour (weekend and 6p-6a) cases, operation time, and hospital costs, to reflect "feasibility" of robotic compared to laparoscopic CCY. Secondary outcomes encompassed surgery-related outcomes and complications. RESULTS The proportion of robotic CCY increased from 5% to 32% within 2 years. In total 361 laparoscopic and 89 robotic CCY were performed. Demographics and gallbladder disease severity were similar. Feasibility measures-operation time, case start time, time from admission to surgery, proportion of off-hour cases, and cost-were comparable between robotic and laparoscopic CCY. There were no differences in surgical complications, common bile duct injury, readmission, or mortality. Conversion to open surgery occurred more often in laparoscopic cases (5% vs 0%, P = .02, OR = 1.05). DISCUSSION Robotic CCY is associated with fewer open conversions and otherwise similar outcomes compared to laparoscopic CCY in the non-elective setting. Incorporation of robotic CCY in a busy ACS practice model is feasible with available resources.
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Affiliation(s)
- Aricia Shen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nicolas Melo
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rex Chung
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Miguel Burch
- Department of Surgery, Division of Minimally Invasive and Gastrointestinal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Umar Bhatti
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew Wang
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Bhatti UF, Shen AS, Melo N, Barmparas G, Wang AS, Margulies DR, Alban RF. Don't Let the Sun Rise on Small Bowel Obstruction Without Surgical Consultation-Redefining Nonoperative Management Pathways. Am Surg 2024:31348241248797. [PMID: 38644162 DOI: 10.1177/00031348241248797] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Introduction: Small bowel obstruction (SBO) is a common cause of hospital admission leading to resource utilization. The majority of these patients require non-operative management (NOM) which can lead to increased length of stay (LOS), readmissions, resource utilization, and throughput delays. Early surgical consultation (SC) for SBO may improve efficiency and outcomes. Methods: We implemented an institution-wide intervention (INT) to encourage early SC (<1 day of diagnosis) for SBO patients in July 2022. A retrospective analysis was performed on all patients with SBO requiring NOM from January 2021 to June 2023, categorized into pre- and post-INT groups. The primary outcome was the number of SC's and secondary outcomes were early SC (<1 day of diagnosis), utilization of SBFT, LOS, 30-day readmission, and costs of admission. Results: A total of 670 patients were included, 438 in the pre-INT and 232 in the post-INT group. Overall, SBFT utilization was significantly higher in cases with SC (17.2% vs 41.4%, P < .001). Post-INT patients were more likely to receive SC (94.0% vs 83.3%, P < .001) and increased SBFT utilization (47.0% vs 33.6%, P = .001). Additionally, early SC improved significantly in the post-INT group (74.3% vs 65.7%, P = .03). There was no difference in LOS between groups (4.0 vs 3.8 days, P = .48). There was a trend toward decreased readmission rates in the INT group at 30 days (7.3% vs 11.0%, P = .13) and reduced direct costs in the INT group (US$/admission = 8467 vs 8708, P = .1). Conclusion: Hospital-wide interventions to increase early surgical involvement proved effective by improving early SC, increased SBFT utilization, and showed a trend towards decreased readmission rates and direct costs.
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Affiliation(s)
- Umar F Bhatti
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Aricia S Shen
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Nicolas Melo
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew S Wang
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Rodrigo F Alban
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, CA, USA
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Dhanasekara CS, Marschke B, Morris E, Bashrum BS, Shrestha K, Richmond R, Dissanaike S, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner J, Keith SL, Mcnutt MK, Kregel H, Gandhi R, Schroeppel T, Margulies DR, Hashim Y, Herrold J, Goetz M, Simpson L, Xuan-Lan D. Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study. Am J Surg 2023; 226:770-775. [PMID: 37270399 DOI: 10.1016/j.amjsurg.2023.05.032] [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] [Received: 03/24/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.
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Affiliation(s)
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Bryan S Bashrum
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Ara Ko
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lakshika Tennakoon
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Frank C Wood
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Maggie Brandt
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Michelle K Mcnutt
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Sciences Center at Houston, Houston, TX, USA
| | - Rajesh Gandhi
- Department of Surgery, JPS Health Network, Ft. Worth, TX, USA
| | - Thomas Schroeppel
- Department of Surgery, UCHealth, Memorial Hospital, Colorado Springs, CO, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yassar Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - LeRone Simpson
- McAllen Medical Center Trauma Department, McAllen, TX, USA
| | - Doan Xuan-Lan
- McAllen Medical Center Trauma Department, McAllen, TX, USA
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Grossman H, Dhanasekara CS, Shrestha K, Marschke B, Morris E, Richmond R, Ko A, Tennakoon L, Campion EM, Wood FC, Brandt M, Ng G, Regner JL, Keith SL, McNutt MK, Kregel H, Gandhi RR, Schroeppel TJ, Margulies DR, Hashim YM, Herrold J, Goetz M, Simpson L, Doan XL, Dissanaike S. Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study. Trauma Surg Acute Care Open 2023; 8:e001178. [PMID: 38020867 PMCID: PMC10668238 DOI: 10.1136/tsaco-2023-001178] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence III.
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Affiliation(s)
- Holly Grossman
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | | | - Kripa Shrestha
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Brianna Marschke
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Erin Morris
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Robyn Richmond
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Ara Ko
- Department of Surgery, Stanford Medicine, Stanford, California, USA
| | | | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Frank C Wood
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Maggie Brandt
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Grace Ng
- Department of Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Stacey L Keith
- Department of Surgery, Baylor Scott & White Medical Center Temple, Temple, Texas, USA
| | - Michelle K McNutt
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Heather Kregel
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Rajesh R Gandhi
- Department of Surgery, JPS Health Network, Fort Worth, Texas, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Herrold
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Mallory Goetz
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - LeRone Simpson
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Xuan-Lan Doan
- Department of Surgery, McAllen Medical Center, McAllen, Texas, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Horwitz D, Dumas RP, Cunningham K, Palacio CH, Margulies DR, Eme C, Bukur M. How do we PI? Results of an EAST quality, patient safety, and outcomes survey. Trauma Surg Acute Care Open 2023; 8:e001059. [PMID: 37560073 PMCID: PMC10407366 DOI: 10.1136/tsaco-2022-001059] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/16/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Quality improvement is a cornerstone for any verified trauma center. Conducting effective quality and performance improvement, however, remains a challenge. In this study, we sought to better explore the landscape and challenges facing the members of the Eastern Association for the Surgery of Trauma (EAST) through a survey. METHODS A survey was designed by the EAST Quality Patient Safety and Outcomes Committee. It was reviewed by the EAST Research and Scholarship Committee and then distributed to 2511 EAST members. The questions were designed to understand the frequency, content, and perceptions surrounding quality improvement processes. RESULTS There were 151 respondents of the 2511 surveys sent (6.0%). The majority were trauma faculty (55%) or trauma medical directors (TMDs) (37%) at American College of Surgeons level I (62%) or II (17%) trauma centers. We found a wide variety of resources being used across hospitals with the majority of cases being identified by a TMD or attending (81%) for a multidisciplinary peer review (70.2%). There was a statistically significant difference in the perception of the effectiveness of the quality improvement process with TMDs being more likely to describe their process as moderately or very effective compared with their peers (77.5% vs. 57.7%, p=0.026). The 'Just Culture' model appeared to have a positive effect on the process improvement environment, with providers less likely to report a non-conducive environment (10.9% vs. 27.6%, p=0.012) and less feelings of assigning blame (3.1% vs. 13.8%, p=0.026). CONCLUSION Case review remains an essential but challenging process. Our survey reveals a need to continue to advocate for appropriate time and resources to conduct strong quality improvement processes. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Daniel Horwitz
- Department of Surgery, NYU Langone Health, New York, New York, USA
- Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York City, New York, USA
| | - Ryan Peter Dumas
- Department of Surgery, UT Southwestern Medical, Dallas, Texas, USA
| | - Kyle Cunningham
- Department of Surgery, Atrium Health, Charlotte, North Carolina, USA
| | | | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Christine Eme
- Eastern Association for the Surgery of Trauma, Chicago, Illinois, USA
| | - Marko Bukur
- Department of Surgery, NYU Langone Health, New York, New York, USA
- Division of Trauma and Acute Care Surgery, Bellevue Hospital Center, New York City, New York, USA
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7
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Lee JS, Khan AD, Quinn CM, Colborn K, Patel DC, Barmparas G, Margulies DR, Waller CJ, Kallies KJ, Fitzsimmons AJ, Kothari SN, Raines AR, Mahnken H, Dunn J, Zier L, McIntyre RC, Urban S, Coleman JR, Campion EM, Burlew CC, Schroeppel TJ. Patient characteristics and diagnostic tests associated with syncopal falls: A Southwestern surgical congress multicenter study. Am J Surg 2022; 224:1374-1379. [PMID: 35940931 DOI: 10.1016/j.amjsurg.2022.07.018] [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: 03/25/2022] [Revised: 07/01/2022] [Accepted: 07/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients suspected of syncope frequently undergo laboratory and imaging studies to determine the etiology of the syncope. Variability exists in these workups across institutions. The purpose of this study was to evaluate the utilization and diagnostic yield of these workups and the patient characteristics associated with syncopal falls. METHODS A multi-institutional retrospective review was performed on adult patients admitted after a fall between 1/2017-12/2018. Syncopal falls were compared to non-syncopal falls. RESULTS 4478 patients were included. There were 795 (18%) patients with a syncopal fall. Electrocardiogram, troponin, echocardiogram, CT angiography (CTA), and carotid ultrasound were more frequently tested in syncope patients compared to non-syncope patients. Syncope patients had higher rates of positive telemetry/Holter monitoring, CTAs, and electroencephalograms. CONCLUSION Patients who sustain syncopal falls frequently undergo diagnostic testing without a higher yield to determine the etiology of syncope.
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Affiliation(s)
- Janet S Lee
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA; Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Abid D Khan
- Department of Surgery, Division of Trauma and Acute Care Surgery, University of Chicago, Chicago, IL, USA.
| | - Christopher M Quinn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Surgical Outcomes and Applied Research, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Deven C Patel
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | | | - Kara J Kallies
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Alec J Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA.
| | - Shanu N Kothari
- Department of General Surgery, Prisma Health, Greenville, SC, USA.
| | - Alexander R Raines
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Heidi Mahnken
- Department of Surgery, University of Oklahoma Health Science Center, Oklahoma City, OK, USA.
| | - Julie Dunn
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Linda Zier
- Department of Trauma and Acute Care Surgery, UCHealth Medical Center of the Rockies, Loveland, CO, USA.
| | - Robert C McIntyre
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Shane Urban
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Julia R Coleman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Clay C Burlew
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA.
| | - Thomas J Schroeppel
- Department of Trauma and Acute Care Surgery, UCHealth Memorial Hospital, Colorado Springs, CO, USA.
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8
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Barmparas G, Huang R, Lee WG, Hashim YM, Pepkowitz SH, Klapper EB, Margulies DR. Overtransfusion of packed red blood cells during massive transfusion activation: a potential quality metric for trauma resuscitation. Trauma Surg Acute Care Open 2022; 7:e000896. [PMID: 35979038 PMCID: PMC9330347 DOI: 10.1136/tsaco-2022-000896] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 01/28/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023] Open
Abstract
Objectives The goal of this study was to explore the incidence of overtransfusion in trauma patients requiring massive transfusion protocol (MTP) activation and identify modifiable risk factors. We hypothesized that overtransfusion is common after MTP activation. Methods Patients admitted to a level I trauma center from July 2016 to December 2019 and who required MTP activation were selected. The primary outcome was overtransfusion, defined as a hemoglobin (Hg) ≥11 g/dL at 24 hours (±2 hours). A Cox regression model was used to identify independent risk factors for overtransfusion. Results 140 patients met inclusion criteria. The median age was 39.0 years, with the majority (74.3%) being male. The median (IQR) Injury Severity Score (ISS) was 24.0 (58.0) and 38.4% had a penetrating mechanism. The median (IQR) admission Hg was 12.6 (11.7) g/dL. Overall, 71.4% of patients were overtransfused by the conclusion of MTP, 43.6% 24 hours later, and 29.5% at discharge. Overtransfusion did not correlate with the number of units of blood transfused nor with the duration of MTP. Overtransfused patients at 24 hours after the conclusion of MTP were significantly more likely to present with a penetrating injury (52.5% vs. 27.3%, p=0.003) and have a significantly lower ISS (median (IQR) 18.5 (44.0) vs. 26.0 (58.0), p=0.035.) In a Cox regression model, penetrating mechanism (adjusted HR (AHR): 2.93; adjusted p=0.004) and admission base excess (BE) (AHR: 1.15; adjusted p=0.001) were the only variables independently associated with overtransfusion. Conclusions Overtransfusion of trauma patients requiring MTP activation is highly common, leading to overutilization of a limited resource. Penetrating trauma and BE may be modifiable risk factors that can help limit overtransfusion. Overtransfusion should be tracked as a data point by blood banks and trauma centers and be further studied as a potential quality metric for the resuscitation of massively transfused trauma patients. Level of evidence III.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Trauma and Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Raymond Huang
- Department of Surgery, Division of Trauma and Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - William G Lee
- Department of Surgery, Division of Trauma and Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Yassar M Hashim
- Department of Surgery, Division of Trauma and Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samuel H Pepkowitz
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ellen B Klapper
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Acute Care Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Chen SY, Huang R, Kallini J, Wachsman AM, Van Allan RJ, Margulies DR, Phillips EH, Barmparas G. Correction to: Outcomes Following Percutaneous Cholecystostomy Tube Placement for Acalculous Versus Calculous Cholecystitis. World J Surg 2022; 46:2538. [PMID: 35748895 DOI: 10.1007/s00268-022-06632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Stephanie Y Chen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Raymond Huang
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Joseph Kallini
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ashley M Wachsman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard J Van Allan
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Section of Interventional Radiology, Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Edward H Phillips
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA.
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10
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Barmparas G, Huang R, Hayes C, Pepkowitz SH, Abumuhor IA, Thomasian SE, Margulies DR, Klapper EB. Implementation of a low-titer stored whole blood transfusion program for civilian trauma patients: Early experience and logistical challenges. Injury 2022; 53:1576-1580. [PMID: 35123798 DOI: 10.1016/j.injury.2022.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 01/05/2022] [Accepted: 01/26/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Cold-stored low titer group O whole blood (LTOWB) is increasingly utilized in the initial resuscitation of exsanguinating trauma patients. We report on our early experience with LTOWB, focusing on logistics, implementation challenges, and outcomes. METHODS In February, 2019, LTOWB was incorporated into the massive transfusion protocol (MTP) activated for trauma patients in the emergency department (ED.) Up to 4 units of LTOWB were included in the MTP cooler, depending on availability, and were transfused prior to transfusion of any other blood products from the MTP cooler. Demographics, injury characteristics, and outcomes were obtained, and the logistics of LTOWB availability were reviewed. RESULTS Over a 12-month period, MTP was activated for 74 trauma patients. Of those, 38 (51%) MTP included at least one unit of LTOWB, with 19/38 (50%) including 4 LTOWB units. A total of 177 units of LTOWB were purchased during the study period, and of those, 74 (42%) expired before use. Patients who received LTOWB had a similar mortality compared to those who received component therapy (39% vs. 47%; Odds Ratio [95% CI]: 0.7 [0.3, 2.0]; p = 0.72,) however, they were able to achieve a significantly higher plasma:pRBC ratio during the duration of MTP activation (mean [SD] 0.8 [0.2] vs. 0.4 [0.4]; mean difference [95% CI]: 0.4 [0.2, 0.5]; p < 0.01.) CONCLUSIONS: Our early experience with LTOWB transfusion demonstrates feasibility, but also highlights challenges with inventory management. These findings triggered changes to our protocol aiming at minimizing wastage. The use of LTOWB may yield a higher plasma:pRBC ratio early during the resuscitation period. Further investigation is required to explore whether this may yield a survival advantage. LEVEL OF EVIDENCE III (Therapeutic/Care Management).
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Raymond Huang
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Chelsea Hayes
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Samuel H Pepkowitz
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Ihab A Abumuhor
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Sandra E Thomasian
- Department Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA USA.
| | - Ellen B Klapper
- Department of Pathology, Division of Transfusion Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA.
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11
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Dhillon NK, Patel DC, Huang R, Yang AR, Sekhon HK, Margulies DR, Ley EJ, Barmparas G. Impact of Aggressive Treatments in Trauma: Using the Emergent Department Thoracotomy to Death Ratio. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03392-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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12
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Chen SY, Huang R, Kallini J, Wachsman AM, Van Allan RJ, Margulies DR, Phillips EH, Barmparas G. Outcomes Following Percutaneous Cholecystostomy Tube Placement for Acalculous Versus Calculous Cholecystitis. World J Surg 2022; 46:1886-1895. [DOI: 10.1007/s00268-022-06566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
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13
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Huang R, Patel DC, Kallini JR, Wachsman AM, Van Allan RJ, Margulies DR, Phillips EH, Barmparas G. Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis. J Surg Res 2021; 270:405-412. [PMID: 34749121 DOI: 10.1016/j.jss.2021.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 08/21/2021] [Accepted: 09/20/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. METHODS Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. RESULTS Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. CONCLUSIONS Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.
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Affiliation(s)
- Raymond Huang
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Deven C Patel
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph R Kallini
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ashley M Wachsman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Edward H Phillips
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
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14
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Barmparas G, Alhaj Saleh A, Huang R, Eaton BC, Bruns BR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner JL, Frazee R, Campion EM, Bartley M, Mortus JR, Ward J, Margulies DR, Dissanaike S. Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer. Trauma Surg Acute Care Open 2021; 6:e000662. [PMID: 34079912 PMCID: PMC8137227 DOI: 10.1136/tsaco-2020-000662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/24/2021] [Accepted: 04/24/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI). Methods This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts. Results A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53). Conclusion For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary. Study type Original article, case series. Level of evidence III.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
| | - Raymond Huang
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Barbara C Eaton
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Brandon R Bruns
- Department of Surgery, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Alexander Raines
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Cressilee Bryant
- Department of Surgery, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Christopher E Crane
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Elizabeth P Scherer
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Thomas J Schroeppel
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Eliza Moskowitz
- Department of Surgery, University of Colorado, Colorado Springs, Colorado, USA
| | - Justin L Regner
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Richard Frazee
- Department of Surgery, Baylor Scott and White Health, Temple, Texas, USA
| | - Eric M Campion
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Matthew Bartley
- Department of Surgery, Denver Health Medical Center, Denver, Colorado, USA
| | - Jared R Mortus
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremy Ward
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center School of Medicine-Lubbock Campus, Lubbock, Texas, USA
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Bloom MB, Noorzad A, Lin C, Little M, Lee EY, Margulies DR, Torbati SS. Standing electric scooter injuries: Impact on a community. Am J Surg 2021; 221:227-232. [PMID: 32778397 PMCID: PMC7933485 DOI: 10.1016/j.amjsurg.2020.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 07/20/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study investigates the impact of standing electric scooter-related injuries within an entire integrated hospital system. METHODS We performed a retrospective review of patients involved in standing electric scooter incidents presenting throughout an urban hospital network over a 10 month period. Rates of Google searches of scooter-related terms performed locally were used as a surrogate for ride frequency. Injury, mechanism, and cost data were analyzed. RESULTS Data on 248 patients were reviewed. Twenty-three (9%) were under 18 years old. Loss of balance was the most common cause of injury accounting for nearly half, while tripping over a scooter 14 (6%) affected the elderly disproportionately. Eight (3%) riders wore helmets. All TBI and closed head injuries occurred in unhelmeted patients. Most incidents occurred in the street, only one in a bicycle lane. Facilities costs were greater for patients under the influence of alcohol and marijuana. CONCLUSION Policies related to the use of mandated safety equipment, dedicated bicycle lanes, and the proper storage of empty vehicles should be further investigated.
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Affiliation(s)
- Matthew B Bloom
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ali Noorzad
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Carol Lin
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Milton Little
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ernest Y Lee
- UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Sam S Torbati
- Department of Emergency Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Dhillon NK, Huang R, Mason R, Melo N, Margulies DR, Ley EJ, Barmparas G. Vasopressors in traumatic brain injury: Quantifying their effect on mortality. Am J Surg 2020; 220:1498-1502. [DOI: 10.1016/j.amjsurg.2020.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/03/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022]
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17
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Dhillon NK, Barmparas G, Lin TL, Linaval NT, Yang AR, Sekhon HK, Mason R, Margulies DR, Gewertz BL, Ley EJ. A Systems-based Approach to Reduce Deep Venous Thrombosis and Pulmonary Embolism in Trauma Patients. World J Surg 2020; 45:738-745. [PMID: 33169176 DOI: 10.1007/s00268-020-05849-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. STUDY DESIGN A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL. RESULTS There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p < 0.01). The overall VTE rate was lower in POST (6.9% vs. 3.6%, p < 0.01). The adjusted risk of VTE (AOR 0.61, adjusted p = 0.04) was lower in POST and POST was independently protective for VTE (AOR 0.54; p = 0.01). CONCLUSION By implementing system changes to improve enoxaparin dosing after trauma, a significant reduction in VTE rate was observed. Wider application of this strategy should be considered.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Ting Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Nikhil T Linaval
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Harveen K Sekhon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Russell Mason
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Bruce L Gewertz
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, 8635 W. 3rd Street - Suite 650W, Los Angeles, CA, 90048, USA.
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18
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Huang R, Ryu RC, Kim TT, Alban RF, Margulies DR, Ley EJ, Barmparas G. Is magnetic resonance imaging becoming the new computed tomography for cervical spine clearance? Trends in magnetic resonance imaging utilization at a Level I trauma center. J Trauma Acute Care Surg 2020; 89:365-370. [PMID: 32744833 DOI: 10.1097/ta.0000000000002752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center. METHODS All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends. RESULTS There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit. CONCLUSION MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources. LEVEL OF EVIDENCE Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.
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Affiliation(s)
- Raymond Huang
- From the Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery (R.H., R.F.A., D.R.M., E.J.L., G.B.), and Department of Orthopedics (R.C.R., T.T.K.), Cedars-Sinai Medical Center, Los Angeles, California
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Abstract
Surgeons are often unfamiliar with the costs of surgical instrumentation and supplies. We hypothesized that surgeon cost feedback would be associated with a reduction in cost. A multidisciplinary team evaluated surgical supply costs for laparoscopic appendectomies of 7 surgeons (surgeons A-G) at a single-center academic institution. In the intervention, each surgeon was debriefed with their average supply cost per case, their partner's average supply cost per case, the cost of each surgical instrument/supply, and the cost of alternatives. In addition, the laparoscopic appendectomy tray was standardized to remove extraneous instruments. Pre-intervention (March 2017-February 2018) and post-intervention (March 2018-October 2018) costs were compared. Pre-intervention, the surgeons' average supply cost per case ranged from $754-$1189; when ranked from most to least expensive, surgeon A > B > C > D > E > F > G. Post-intervention, the surgeons' average supply cost per case ranged from $676 to $846, and ranked from surgeon G > D > F > C > E > B > A. Overall, the average cost per case was lower in the post-intervention group ($854.35 vs. $731.11, P < .001). This resulted in savings per case of $123.24 (14.4%), to a total annualized savings of $29 151.
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Affiliation(s)
- Joshua Tseng
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harry C Sax
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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20
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Knight MT, Li T, Dhillon NK, Srour M, Huang R, Margulies DR, Ley EJ, Barmparas G. Walking Under the Influence : Association of Time of the Day With the Incidence and Outcomes of Intoxicated Pedestrians Struck by Vehicles. Am Surg 2020; 87:354-363. [PMID: 32988238 DOI: 10.1177/0003134820947365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity. METHODS The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (-) BAC. The primary outcome was mortality. RESULT 35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001). CONCLUSION Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.
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Affiliation(s)
- Margot T Knight
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tong Li
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa Srour
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Raymond Huang
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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21
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Lin TL, Dhillon NK, Conde G, Toscano S, Margulies DR, Barmparas G, Ley EJ. Early positive fluid balance is predictive for venous thromboembolism in critically ill surgical patients. Am J Surg 2020; 222:220-226. [PMID: 32900497 DOI: 10.1016/j.amjsurg.2020.08.032] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Positive fluid balance (FB) in the intensive care unit (ICU) may be a marker for increased venous thromboembolism (VTE) risk. We hypothesized that an early positive fluid balance (FB) would be associated with increased VTE occurrence. METHODS A single-center retrospective review of surgical ICU patients was conducted from May 2011 to December 2014. Patients with a VTE were compared to those who did not develop a VTE (NVTE). RESULTS There were 619 patients analyzed with 77 (12.4%) diagnosed with a VTE; these patients had longer ventilator days (12.3 vs. 5.0 days, p < 0.01) and ICU stays (10.3 vs. 6.4 days, p < 0.01), and were more likely to have a net FB ≥ 4L over the first three days (62% vs. 44%, p < 0.01). A FB ≥ 4L over the first three ICU days was an independent predictor of VTE (AOR 1.74, p = 0.04). CONCLUSION Patients with an early positive FB are more likely to develop a VTE.
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Affiliation(s)
- Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States; Departments of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Geena Conde
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Samantha Toscano
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care Cedars-Sinai Medical Center, Los Angeles, CA, United States.
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Felder SI, Barmparas G, Lynn J, Murrell Z, Margulies DR, Fleshner P. Can the Need for Colectomy after Computed Tomography-guided Percutaneous Drainage for Diverticular Abscess be Predicted? Am Surg 2020. [DOI: 10.1177/000313481307901012] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The primary aim of this study was to define predictors of computed tomography (CT)-guided percutaneous abscess drainage treatment failure in complicated diverticulitis. A 10-year retrospective analysis of inpatients seen in surgical consultation for diverticular abscess management subsequently referred for CT-guided percutaneous drainage (PD) was conducted. The clinical courses of patients undergoing a technically successful PD were categorized into three groups: 1) no colectomy; 2) elective colectomy; and 3) nonelective colectomy. Forty study patients were identified. Thirteen (33%) of the 40 patients required a nonelective colectomy, 20 patients (50%) underwent elective resection, and seven patients (18%) have been managed nonoperatively with no recurrent diverticulitis for a median of 46.8 months (range, 3.2 to 84.3 months). Forward logistic regression identified the presence of immunosuppression or renal insufficiency (creatinine 1.5 mg/dL or greater) as factors independently associated with failure of PD and need for non-elective colectomy. No clinical, laboratory, or radiologic variables were predictive of long-term nonoperative success. Although PD allows for the resolution of intra-abdominal sepsis for most cases of diverticulitis complicated by an abscess, a substantial proportion progress to nonelective colectomy, emphasizing the need for clinical vigilance in follow-up.
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Affiliation(s)
- Seth I. Felder
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Juliane Lynn
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Zuri Murrell
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Phillip Fleshner
- From the Division of Colon and Rectal Surgery of General Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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23
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Wang AS, Dhillon NK, Linaval NT, Rottler N, Yang AR, Margulies DR, Ley EJ, Barmparas G. The Impact of IV Electrolyte Replacement on the Fluid Balance of Critically Ill Surgical Patients. Am Surg 2020. [DOI: 10.1177/000313481908501021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IVelectrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.
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Affiliation(s)
- Andrew S. Wang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K. Dhillon
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil T. Linaval
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicholas Rottler
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Audrey R. Yang
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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24
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Berry C, Ley EJ, Margulies DR, Pruett J, Miller C, Bukur M, Palestrant D, Malinoski D, Salim A. Prospective Evaluation of Posttraumatic Vasospasm: Determining Its Clinical Significance after Traumatic Brain Injury. Am Surg 2020. [DOI: 10.1177/000313481408000330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Cherisse Berry
- Department of Surgery Division of Trauma and Critical Care Cedars-Sinai Medical Center Los Angeles, California
| | - Eric J. Ley
- Department of Surgery Division of Trauma and Critical Care Cedars-Sinai Medical Center Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery Division of Trauma and Critical Care Cedars-Sinai Medical Center Los Angeles, California
| | - Jessica Pruett
- Department of Surgery Division of Trauma and Critical Care Cedars-Sinai Medical Center Los Angeles, California
| | - Chad Miller
- Department of Neurology Division of Cerebrovascular Diseases and Neurocritical Care Wexner Medical Center Columbus, Ohio
| | - Marko Bukur
- Department of Trauma and Critical Care Broward Health and Del Ray Medical Centers Fort Lauderdale, Florida
| | - David Palestrant
- Department of Neurology Division of Neurocritical Care Cedars-Sinai Medical Center Los Angeles, California
| | - Darren Malinoski
- Surgical Critical Care Section Portland Veterans Affairs Medical Center Portland, Oregon
| | - Ali Salim
- Department of Surgery Division of Trauma, Burns, and Surgical Critical Care Brigham and Women's Hospital Boston, Massachusetts
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25
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Akhmerov A, Huang R, Carlson K, Dhillon NK, Ley EJ, Margulies DR, Ramzy D, Barmparas G. Access to extracorporeal life support as a quality metric: Lessons from trauma. J Card Surg 2020; 35:826-830. [PMID: 32092196 DOI: 10.1111/jocs.14474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities. METHODS A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities. RESULTS Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P < .001). The overall mortality was 3.3%. The adjusted OR for mortality associated with admission to an ECMO facility vs a non-ECMO facility was 0.96 (95% confidence interval: 0.95-0.97; adjusted P < .001). CONCLUSIONS The use of ECMO for patients with trauma is expanding. Our study demonstrates a survival benefit associated with admission to a facility with ECMO capabilities. Thus, access to ECMO is a potential quality metric for trauma centers.
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Affiliation(s)
- Akbarshakh Akhmerov
- Department of Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raymond Huang
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kjirsten Carlson
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K Dhillon
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R Margulies
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danny Ramzy
- Department of Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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26
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Manguso N, Barmparas G, Dhillon NK, Ley EJ, Huang R, Melo N, Alban RF, Margulies DR. New cars on the highways: Trends in injuries and outcomes following ejection. Surg Open Sci 2019; 2:22-26. [PMID: 32754704 PMCID: PMC7391881 DOI: 10.1016/j.sopen.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 01/19/2019] [Revised: 07/18/2019] [Accepted: 08/30/2019] [Indexed: 11/28/2022] Open
Abstract
Background Although ejections from motor vehicles are considered a marker of a significant mechanism and a predictor of severe injuries and mortality, scant recent data exist to validate these outcomes. This study investigates whether ejections increase the mortality risk following a motor vehicle crash using data that reflect the introduction of new vehicles to the streets of a large city in the United States. Methods The Trauma and Emergency Medicine Information System of Los Angeles County was queried for patients ≥ 16 years old admitted following a motor vehicle crash between 2002 and 2012. Ejected patients were compared to nonejected. Primary outcome was mortality. A logistic regression model was used to identify predictors of mortality and severe trauma. Results A total of 9,742 (6.8%) met inclusion criteria. Of these, 449 (4.6%) were ejected; 368 (82.0%) were passengers and 81 (18.0%) were drivers. The rate of ejection decreased linearly (6.1% in 2002 to 3.4% in 2012). Compared to nonejected patients, ejected patients were more likely to require intensive care unit admission (43.7% vs 22.1%, P < .01), have critical injuries (Injury Severity Score > 25) (24.2% vs 7.3%, P <.01), require emergent surgery (16.3% vs 8.0%, P <.01), and expire in the emergency department (3.6% vs 1.2%, P <.01). Overall mortality was 3.6%: 9.6% for ejected and 3.3% for nonejected patients (P <.01). In a logistic regression model, ejection and extrication both predicted mortality (adjusted odds ratio: 1.83, P <.01 and 1.87, P <.01, respectively). Ejection also predicted critical injuries (Injury Severity Score > 25) with adjusted odds ratio of 2.48 (P <.01). Conclusion Ejections following motor vehicle crash have decreased throughout the years; however, they remain a marker of critical injuries and predictive of mortality. The rate of ejection during a motor vehicle crash has decreased since 2002. Ejected patients had a significantly higher mortality compared to nonejected. Ejection was a predictor of both critical injuries and mortality.
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Affiliation(s)
| | | | | | | | | | | | | | - Daniel R. Margulies
- Corresponding author at: Division of Acute Care Surgery, Department of Surgery, Cedars-Sinai Medical Center. Tel.: + 1 310 423 4349; fax: + 1 310 423 0139.
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27
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Wang AS, Dhillon NK, Linaval NT, Rottler N, Yang AR, Margulies DR, Ley EJ, Barmparas G. The Impact of IV Electrolyte Replacement on the Fluid Balance of Critically Ill Surgical Patients. Am Surg 2019; 85:1171-1174. [PMID: 31657318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Avoiding excess fluid administration is necessary when managing critically ill surgical patients. The aim of this study was to delineate the current practices of IV electrolyte (IVE) replacement in a surgical ICU and quantify their contribution to the fluid balance (FB) status. Patients admitted to the surgical ICU over a six-month period were reviewed. Patients undergoing dialysis and those with ICU stay <72 hours were excluded. A total of 248 patients were included. The median age was 60 years, and 57 per cent were male. Overall, 1131 patient ICU days were analyzed. The median daily FB was 672 mL. IVEs were administered in 62 per cent of ICU days. In days that IVEs were used, negative FB was significantly less likely to be achieved (62% vs 69%, P = 0.02). The most commonly administered IVE was calcium (32% of ICU days); however, the largest volume of IVE was administered in the form of phosphorus (median 225 mL). Diuretics were administered in 17 per cent of ICU days. Patients who received diuretics were significantly more likely to receive IVE (70% vs 61%, P = 0.02). Administration of IVE may contribute to the daily positive FB of surgical ICU patients. Implementation of practices that can ameliorate this effect is encouraged.
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28
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Alhaj Saleh A, Esquivel EC, Lung JT, Eaton BC, Bruns BR, Barmparas G, Margulies DR, Raines A, Bryant C, Crane CE, Scherer EP, Schroeppel TJ, Moskowitz E, Regner J, Frazee R, Campion EM, Bartley M, Mortus J, Ward J, Almekdash MH, Dissanaike S. Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study. Am J Surg 2019; 218:1060-1064. [PMID: 31537324 DOI: 10.1016/j.amjsurg.2019.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/24/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.
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Affiliation(s)
- Adel Alhaj Saleh
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Esteban C Esquivel
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - John T Lung
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Barbara C Eaton
- Department of Surgery, University of Maryland Medical System, Baltimore, MD, USA
| | - Brandon R Bruns
- Department of Surgery, University of Maryland Medical System, Baltimore, MD, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Alexander Raines
- Department of Surgery, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Cressilee Bryant
- Department of Surgery, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Christopher E Crane
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Elizabeth P Scherer
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Thomas J Schroeppel
- Department of Surgery, UCHealth Memorial Hospital Center, Colorado Springs, CO, USA
| | - Eliza Moskowitz
- Department of Surgery, UCHealth Memorial Hospital Center, Colorado Springs, CO, USA
| | - Justin Regner
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Richard Frazee
- Department of Surgery, Baylor Scott and White Health, Temple, TX, USA
| | - Eric M Campion
- Department of Surgery, Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Matthew Bartley
- Department of Surgery, Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | - Jared Mortus
- Department of Surgery, Baylor College of Medicine, Ben Taub, TX, USA
| | - Jeremy Ward
- Department of Surgery, Baylor College of Medicine, Ben Taub, TX, USA
| | - Mhd Hasan Almekdash
- Clinical Research Institute, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
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29
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Dhillon NK, Barmparas G, Lin TL, Alban RF, Melo N, Yang AR, Margulies DR, Ley EJ. Unexpected complicated appendicitis in the elderly diagnosed with acute appendicitis. Am J Surg 2019; 218:1219-1222. [PMID: 31481154 DOI: 10.1016/j.amjsurg.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 03/15/2019] [Revised: 07/10/2019] [Accepted: 08/16/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis. METHODS Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis. RESULTS The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p < 0.01) and prolonged stays (3.8 vs. 2.3 days; p < 0.01). CONCLUSION Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ting-Lung Lin
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Rodrigo F Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Nicolas Melo
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Audrey R Yang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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30
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Bloom MB, Johnson J, Volod O, Lee EY, White T, Margulies DR. Improved prediction of HIT in the SICU using an improved model of the Warkentin 4-T system: 3-T. Am J Surg 2019; 219:54-57. [PMID: 31400811 DOI: 10.1016/j.amjsurg.2019.07.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/18/2019] [Accepted: 07/27/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The Warkentin 4-T scoring system for determining the pretest probability of heparin-induced thrombocytopenia (HIT) has been shown to be inaccurate in the ICU and does not take into account body mass index (BMI). METHODS Prospectively collected data on patients in the surgical and cardiac ICU between January 2007 and February 2016 who were presumed to have HIT by clinical suspicion were reviewed. Patients were categorized into 3 BMI groups and assigned scores: Normal weight, overweight, and obese. Multivariate analyses were used to identify independent predictors of HIT. RESULTS A total of 523 patients met inclusion criteria. Multivariate analysis showed that only BMI, Timing, and oTher variables were independently associated with HIT. This new 3-T model was better than a five-component model consisting of the entire 4-T scoring system plus BMI (AUC = 0.791). CONCLUSIONS Incorporating patient 'T'hickness into a pretest probability model along with platelet 'T'iming and the exclusion of o'T'her causes of thrombocytopenia yields a simplified "3-T" scoring system that has increased predictive accuracy in the ICU.
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Affiliation(s)
- Matthew B Bloom
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Jeffrey Johnson
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Oksana Volod
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
| | - Ernest Y Lee
- UCLA-Caltech Medical Scientist Training Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, 90095, USA.
| | - Terris White
- United Regional Health Care System, Wichita Falls, TX, USA.
| | - Daniel R Margulies
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA.
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31
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Margulies DR. Surgery, the view from an island. Am J Surg 2019; 217:991-994. [PMID: 31076075 DOI: 10.1016/j.amjsurg.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Daniel R Margulies
- The Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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32
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Abstract
Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18–64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 ( P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.
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Affiliation(s)
- Deven C. Patel
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet K. Dhillon
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil Linaval
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita Patel
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Patel DC, Dhillon NK, Linaval N, Patel K, Margulies DR, Ley EJ, Barmparas G. Data-Driven Opportunity to Reduce Elderly Pedestrian Trauma. Am Surg 2019; 85:466-470. [PMID: 31126357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18-64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤ 8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 (P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.
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Tatum JM, Barmparas G, Dhillon NK, Edu S, Margulies DR, Ley EJ, Nicol AJ, Navsaria PH. Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011. J INVEST SURG 2019; 33:896-903. [PMID: 30897974 DOI: 10.1080/08941939.2019.1576810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.
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Affiliation(s)
- James M Tatum
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Sorin Edu
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Andrew J Nicol
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Pradeep H Navsaria
- Department of Surgery, University of Cape Town Health Sciences Faculty, Trauma Centre, Groote Schuur Hospital, Observatory, Cape Town, South Africa
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Dhillon NK, Dodd BA, Hotz H, Patel KA, Linaval NT, Margulies DR, Ley EJ, Barmparas G. What Happens After a Stop the Bleed Class? The Contrast Between Theory and Practice. J Surg Educ 2019; 76:446-452. [PMID: 30219522 DOI: 10.1016/j.jsurg.2018.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 07/28/2018] [Accepted: 08/15/2018] [Indexed: 05/07/2023]
Abstract
OBJECTIVE The Department of Homeland Security launched the Stop the Bleed initiative, a campaign intended to teach bystanders hemorrhage control strategies. Despite the program's popularity, little is known about actions taken by participants afterwards. We sought to determine how often participants acquired the equipment that is necessary in applying the skills taught. DESIGN A standardized survey instrument was distributed to all American College of Surgeons Bleeding Control Basic (B-Con) class participants from 05/2017 to 01/2018. The instrument queried about the likelihood of applying skills and obtaining materials. A web-based survey was administered one month later inquiring whether materials were obtained and barriers that would prohibit acquisition. SETTING Academic, urban, Level I trauma center. PARTICIPANTS Healthcare and nonhealthcare personnel. RESULTS There were 336 and 183 participants who completed the initial and subsequent web-based survey, respectively. Participants indicated a high likelihood of applying a tourniquet (95.5%), applying pressure (97.9%), and packing a wound (96.4%), if required. Additionally, 74.7% and 76.2% reported a high likelihood of obtaining a tourniquet and packing material, respectively. However, only 21.3% and 50.8% obtained a tourniquet and packing material, respectively, 1 month later. Cost, time, and accessibility of items during a time of need were cited to be common reasons for not obtaining these materials. CONCLUSIONS Despite reporting a high likelihood of utilizing hemorrhage control skills upon completion of the B-Con class, few went on to acquire the materials needed to apply these skills among those who responded. These results may be impacted by loss of follow up and response bias. Developing strategies that allow for easy access to materials is imperative and may lead to both better implementation of the purposes of the program and improved dissemination of its principles within the community.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Brett A Dodd
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Heidi Hotz
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita A Patel
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil T Linaval
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California.
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Barmparas G, Dhillon NK, Tatum JM, Patel K, Thomsen GM, Mason R, Margulies DR, Ley EJ. Extended neuromuscular blockade in acute respiratory distress syndrome does not increase mortality. J Surg Res 2018; 231:434-440. [DOI: 10.1016/j.jss.2018.06.074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 06/04/2018] [Accepted: 06/20/2018] [Indexed: 12/15/2022]
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Dhillon NK, Barmparas G, Thomsen GM, Patel KA, Linaval NT, Gillette E, Margulies DR, Ley EJ. Nonoperative Management of Blunt Splenic Trauma in Patients with Traumatic Brain Injury: Feasibility and Outcomes. World J Surg 2018; 42:2404-2411. [PMID: 29387960 DOI: 10.1007/s00268-018-4494-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM. METHODS Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM. RESULTS Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95). CONCLUSIONS NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.
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Affiliation(s)
- Navpreet K Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA.
| | - Gretchen M Thomsen
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Kavita A Patel
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Nikhil T Linaval
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Emma Gillette
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Daniel R Margulies
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
| | - Eric J Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 West 3rd Street, Suite 650 W, Los Angeles, CA, 90048, USA
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Barmparas G, Kobayashi L, Dhillon NK, Patel KA, Ley EJ, Coimbra R, Margulies DR. The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study. Am J Surg 2018; 217:1051-1054. [PMID: 30336936 DOI: 10.1016/j.amjsurg.2018.10.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of this study was to characterize the risk of a delayed intracranial hemorrhage (ICH) in trauma patients on direct-acting oral anticoagulants (DOACs). METHODS Patients on DOACs admitted to two Level I Trauma Centers between 2014 and 2017 were reviewed. Only patients with a negative admission CT brain were included. The primary outcome was a delayed ICH. RESULTS Overall, 249 patients were included. The median age was 81 years with 82% undergoing a repeat CT. Three patients developed a delayed ICH (1.2%). One developed an ICH after receiving tissue plasminogen activator for a cerebrovascular accident after two negative CTs. Excluding this patient, the incidence dropped to 0.8%. None required neurosurgical intervention. CONCLUSION For patients at risk for a TBI who are on DOACs, repeat cross-sectional imaging of the brain when the initial imaging is negative is not necessary. A period of clinical observation may be warranted.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Leslie Kobayashi
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, CA, USA
| | - Navpreet K Dhillon
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kavita A Patel
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Raul Coimbra
- Department of Surgery, Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, University of California, San Diego, CA, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Dhillon NK, Linaval NT, Patel KA, Colovos C, Ko A, Margulies DR, Ley EJ, Barmparas G. Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized. Am Surg 2018. [DOI: 10.1177/000313481808401019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.
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Affiliation(s)
- Navpreet K. Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nikhil T. Linaval
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kavita A. Patel
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christos Colovos
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Dhillon NK, Linaval NT, Patel KA, Colovos C, Ko A, Margulies DR, Ley EJ, Barmparas G. Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized. Am Surg 2018; 84:1630-1634. [PMID: 30747684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 (P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period (P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.
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Affiliation(s)
- Navpreet K Dhillon
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Tseng J, Nuño M, Lewis AV, Srour M, Margulies DR, Alban RF. Firearm legislation, gun violence, and mortality in children and young adults: A retrospective cohort study of 27,566 children in the USA. Int J Surg 2018; 57:30-34. [PMID: 30071359 DOI: 10.1016/j.ijsu.2018.07.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested. MATERIALS AND METHODS The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race. RESULTS 27,566 children analyzed in the study. Most were adolescents aged 15-19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R2 = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0-4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0-4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p < 0.001), and firearm injury type (p = 0.001) were associated with mortality; Hispanics (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (2.03, 1.30-3.17) and suicide attempts (15.6, 11.6-20.9) had higher odds of in-hospital mortality. CONCLUSIONS Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children.
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Miriam Nuño
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis, Davis, CA, USA.
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Marissa Srour
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, CA, USA.
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Barmparas G, Navsaria PH, Serna-Gallegos D, Nicol AJ, Edu S, Sayari AA, Margulies DR, Ley EJ. Blunt Pharyngoesophageal Injuries: Current Management Strategies. Scand J Surg 2018; 107:336-344. [PMID: 29628012 DOI: 10.1177/1457496918766692] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. METHODS: The National Trauma Databank datasets 2007-2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. RESULTS: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p < 0.01) and need for intensive care unit admission (75% vs 31%, p < 0.01). The overall mortality was 2%: 3.1% for neck explorations versus 1.6% for conservative management (adjusted p = 0.54). Neck exploration patients were more likely to remain longer in the hospital (median 13 vs 10 days, adjusted p = 0.03). CONCLUSION: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.
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Affiliation(s)
- G Barmparas
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - P H Navsaria
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D Serna-Gallegos
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - A J Nicol
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - S Edu
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - A A Sayari
- 2 Department of Surgery, Trauma Centre, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - D R Margulies
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - E J Ley
- 1 Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Barmparas G, Dhillon NK, Smith EJ, Mason R, Melo N, Thomsen GM, Margulies DR, Ley EJ. Patterns of vasopressor utilization during the resuscitation of massively transfused trauma patients. Injury 2018; 49:8-14. [PMID: 28985912 DOI: 10.1016/j.injury.2017.09.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 09/21/2017] [Accepted: 09/22/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality. METHODS Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized. RESULTS Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p <0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time. CONCLUSION In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required.
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Affiliation(s)
- Galinos Barmparas
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States.
| | - Navpreet K Dhillon
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Eric Jt Smith
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Russell Mason
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Nicolas Melo
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Gretchen M Thomsen
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Eric J Ley
- Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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Aquino L, Kang CY, Harada MY, Ko A, Do-Nguyen A, Ley EJ, Margulies DR, Alban RF. Is Routine Continuous EEG for Traumatic Brain Injury Beneficial? Am Surg 2017; 83:1433-1437. [PMID: 29336768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and subclinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of "routine" cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
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Abstract
Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
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Affiliation(s)
- Lia Aquino
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Christopher Y. Kang
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Megan Y. Harada
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Amy Do-nguyen
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rodrigo F. Alban
- Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Tseng J, Loper B, Jain M, Lewis AV, Margulies DR, Alban RF. Predictive factors of mortality after colectomy in ischemic colitis: an ACS-NSQIP database study. Trauma Surg Acute Care Open 2017; 2:e000126. [PMID: 29766117 PMCID: PMC5887781 DOI: 10.1136/tsaco-2017-000126] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/26/2017] [Accepted: 10/03/2017] [Indexed: 01/09/2023] Open
Abstract
Background Surgical intervention for ischemic colitis is associated with significant postoperative morbidity and mortality. Predictive factors of adverse outcomes have been reported in the literature, but are based on small sample populations. We sought to identify risk factors for mortality after emergent colectomy for ischemic colitis using a clinical outcomes database. Methods The American College of Surgeons National Surgical Quality Improvement Project database was queried from 2010 to 2015 to identify emergent colectomies performed for ischemic colitis using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. Univariate and multivariate logistic regression analysis was used to identify independent risk factors associated with increased risk of mortality. Results A total of 4548 patients undergoing emergent colectomies for ischemic colitis were identified. Overall, 30-day postoperative mortality was 25.3%. On univariate analysis, preoperative risk factors associated with a higher rate of mortality include dyspnea, functional status, ventilator dependency, history of chronic obstructive pulmonary disease, ascites, congestive heart failure exacerbation, hypertension, dialysis dependency, cancer, open wounds, chronic steroids, weight loss >10%, transfusions within 72 hours before surgery, septic shock and duration from hospital admission to surgery. Factors that were significant for mortality on logistic regression analysis include elderly age, poor functional status, multiple comorbidities, septic shock, blood transfusion, acute renal failure and the duration of time from hospital admission to surgery. Conclusions Postoperative morbidity and mortality rates for ischemic colitis remain significantly high. Identification of risk factors may help patient selection for surgical interventions, and make informed decisions with patients and family members. Although it is certainly challenging, early diagnosis and prompt surgical intervention for patients with ischemic colitis may improve outcomes. Study type and level of evidence Therapeutic/care management, level II
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Affiliation(s)
- Joshua Tseng
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brandi Loper
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Monica Jain
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Azaria V Lewis
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Daniel R Margulies
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rodrigo F Alban
- Department of Surgery, Division of Acute Care Surgery, Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Tatum JM, Barmparas G, Ko A, Dhillon N, Smith E, Margulies DR, Ley EJ. Analysis of Survival After Initiation of Continuous Renal Replacement Therapy in a Surgical Intensive Care Unit. JAMA Surg 2017; 152:938-943. [PMID: 28636702 PMCID: PMC5710279 DOI: 10.1001/jamasurg.2017.1673] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/01/2017] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Continuous renal replacement therapy (CRRT) benefits patients with renal failure who are too hemodynamically unstable for intermittent hemodialysis. The duration of therapy beyond which continued use is futile, particularly in a population of patients admitted to and primarily cared for by a surgical service (hereinafter referred to as surgical patients), is unclear. OBJECTIVE To analyze proportions of and independent risk factors for survival to discharge after initiation of CRRT among patients in a surgical intensive care unit (SICU). DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included all patients undergoing CRRT from July 1, 2012, through January 31, 2016, in an SICU of an urban tertiary medical center. The population included patients treated before or after general surgery and patients admitted to a surgical service during inpatient evaluation and care before liver transplant. The pretransplant population was censored from further survival analysis on receipt of a transplant. EXPOSURES Continuous renal replacement therapy. MAIN OUTCOMES AND MEASURES Hospital mortality among patients in an SICU after initiation of CRRT. RESULTS Of 108 patients (64 men [59.3%] and 44 women [40.7%]; mean [SD] age, 62.0 [12.7] years) admitted to the SICU, 53 were in the general surgical group and 55 in the pretransplant group. Thirteen of the 22 patients in the pretransplant group who required 7 or more days of CRRT died (in-hospital mortality, 59.1%); among the 12 patients in the general surgery group who required 7 or more days of CRRT, 12 died (in-hospital mortality, 100%). In the general surgical group, each day of CRRT was associated with an increased adjusted odds ratio of death of 1.39 (95% CI, 1.01-1.90; P = .04). CONCLUSIONS AND RELEVANCE Continuous renal replacement therapy is valuable for surgical patients with an acute and correctable indication; however, survival decreases significantly with increasing duration of CRRT. Duration of CRRT does not correlate with survival among patients awaiting liver transplant.
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Affiliation(s)
- James M. Tatum
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Galinos Barmparas
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ara Ko
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Navpreet Dhillon
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric Smith
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Steggerda JA, Bresee C, Malinoski D, Margulies DR, Bloom MB. Predictors of Hepatic Steatosis in Potential Deceased Adult Liver Donors. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Barmparas G, Ko A, Dhillon NK, Tatum JM, Choi M, Ley EJ, Margulies DR. Extreme Interventions for Trauma Patients in Extremis: Variations among Trauma Centers. Am Surg 2017. [DOI: 10.1177/000313481708301004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDTamong ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.
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Affiliation(s)
- Galinos Barmparas
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Ara Ko
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Navpreet K. Dhillon
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - James M. Tatum
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Mark Choi
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Eric J. Ley
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
| | - Daniel R. Margulies
- Cedars-Sinai Medical Center, Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Los Angeles, California
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Steggerda JA, Malinoski D, Margulies DR, Klein AS, Bloom MB. Transplantation of Livers from High Body Mass Index Donors and the Impact of Hepatic Steatosis on Utilization and Outcomes: National and Regional Trends Over the Past Decade. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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