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Collie BL, Lyons NB, O'Neil CF, Ramsey WA, Lineen EB, Schulman CI, Proctor KG, Meizoso JP, Namias N, Ginzburg E. When is it safe to start thromboprophylaxis after splenic angioembolization? Surgery 2024; 175:1418-1423. [PMID: 38418296 DOI: 10.1016/j.surg.2024.01.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Thromboprophylaxis after blunt splenic trauma is complicated by the risk of bleeding, but the risk after angioembolization is unknown. We hypothesized that earlier thromboprophylaxis initiation was associated with increased bleeding complications without mitigating venous thromboembolism events. METHODS All blunt trauma patients who underwent splenic angioembolization within 24 hours of arrival were identified from the American College of Surgeons Trauma Quality Improvement Program datasets from 2017 to 2019. Cases with <24-hour length of stay, other serious injuries, and surgery before angioembolization were excluded. Venous thromboembolism was defined as deep vein thrombosis or pulmonary embolism. Bleeding complications were defined as splenic surgery, additional embolization, or blood transfusion after thromboprophylaxis initiation. Data were compared with χ2 analysis and multivariate logistic regression at P < .05. RESULTS In 1,102 patients, 84% had American Association for the Surgery of Trauma grade III to V splenic injuries, and 73% received thromboprophylaxis. Splenic surgery after angioembolization was more common in those with thromboprophylaxis initiation within the first 24 hours (5.7% vs 1.7%, P = .007), whereas those with the initiation of thromboprophylaxis after 72 hours were more likely to have a pulmonary embolism (2.3% vs 0.2%, P = .001). Overall, venous thromboembolism increased considerably when thromboprophylaxis was initiated after day 3. In multivariate analysis, time to thromboprophylaxis initiation was associated with bleeding (odds ratio 0.74 [95% confidence interval 0.58-0.94]) and venous thromboembolism complications (odds ratio 1.5 [95% confidence interval 1.20-1.81]). CONCLUSION This national study evaluates bleeding and thromboembolic risk to elucidate the specific timing of thromboprophylaxis after splenic angioembolization. Initiation of thromboprophylaxis between 24 and 72 hours achieves the safest balance in minimizing bleeding and venous thromboembolism risk, with 48 hours particularly serving as the ideal time for protocolized administration.
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Affiliation(s)
- Brianna L Collie
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL.
| | - Nicole B Lyons
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Christopher F O'Neil
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Walter A Ramsey
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Edward B Lineen
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Carl I Schulman
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Kenneth G Proctor
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Jonathan P Meizoso
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Nicholas Namias
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
| | - Enrique Ginzburg
- Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, FL
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Collie BL, Emami S, Lyons NB, Ramsey WA, O'Neil CF, Meizoso JP, Ginzburg E, Pizano LR, Schulman CI, Parker BM, Namias N, Proctor KG. Survival of In-Hospital Cardiopulmonary Arrest in Trauma Patients. J Surg Res 2024; 298:379-384. [PMID: 38669784 DOI: 10.1016/j.jss.2024.03.043] [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: 12/11/2023] [Revised: 02/23/2024] [Accepted: 03/22/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Relative to other hospitalized patients, trauma patients are younger with fewer comorbidities, but the incidence and outcomes of in-hospital cardiopulmonary arrest (IHCA) with cardiopulmonary resuscitation (CPR) in this population is unknown. Therefore, we aimed to investigate factors associated with survival in trauma patients after IHCA to test the hypothesis that compared to other hospitalized patients, trauma patients with IHCA have improved survival. METHODS Retrospective review of the Trauma Quality Improvement Program database 2017 to 2019 for patients who had IHCA with CPR. Primary outcome was survival to hospital discharge. Secondary outcomes were in-hospital complications, hospital length of stay, intensive care unit length of stay, and ventilator days. Data were compared with univariate and multivariate analyses at P < 0.05. RESULTS In 22,346,677 admitted trauma patients, 14,056 (0.6%) received CPR. Four thousand three hundred seventy-seven (31.1%) survived to discharge versus 26.4% in a national sample of all hospitalized patients (P < 0.001). In trauma patients, median age was 55 y, the majority were male (72.2%). Mortality was higher for females versus males (70.3% versus 68.3%, P = 0.026). Multivariate regression showed that older age 1.01 (95% confidence interval (CI) 1.01-1.02), Hispanic ethnicity 1.21 (95% CI 1.04-1.40), and penetrating trauma 1.51 (95% CI 1.32-1.72) were risk factors for mortality, while White race was a protective factor 0.36 (95% CI 0.14-0.89). CONCLUSIONS This is the first study to show that the incidence of IHCA with CPR is approximately six in 1000 trauma admissions and 31% survive to hospital discharge, which is higher than other hospitalized patients. Age, gender, racial, and ethnic disparities also influence survival.
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Affiliation(s)
- Brianna L Collie
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida.
| | - Shaheen Emami
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicole B Lyons
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Walter A Ramsey
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Christopher F O'Neil
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Jonathan P Meizoso
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Enrique Ginzburg
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Louis R Pizano
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Carl I Schulman
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Brandon M Parker
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Kenneth G Proctor
- Division of Trauma, Burns, and Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Saberi RA, Parker GB, Mohsin N, Gilna GP, Cioci AC, Urrechaga EM, Buzzelli CMD, Schulman CI, Proctor KG, Garcia LRGD. Advanced Surgical Skills for Exposure in Trauma (ASSET) course improves military surgeon confidence. Am J Disaster Med 2024; 19:45-51. [PMID: 38597646 DOI: 10.5055/ajdm.0469] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Active duty military surgeons often have limited trauma surgery experience prior to deployment. Consequently, military-civilian training programs have been developed at high-volume trauma centers to evaluate and maintain proficiencies. Advanced Surgical Skills for Exposure in Trauma (ASSET) was incorporated into the predeployment curriculum at the Army Trauma Training Detachment in 2011. This is the first study to assess whether military surgeons demonstrated improved knowledge and increased confidence after taking ASSET. DESIGN Retrospective cohort study. SETTING Quaternary care hospital. PATIENTS AND PARTICIPANTS Attending military surgeons who completed ASSET between July 2011 and October 2020. MAIN OUTCOME MEASURE(S) Pre- and post-course self-reported comfort level with procedures was converted from a five-point Likert scale to a percentage and compared using paired t-tests. RESULTS In 188 military surgeons, the median time in practice was 3 (1-8) years, with specialties in general surgery (52 percent), orthopedic surgery (29 percent), trauma (7 percent), and other disciplines (12 percent). The completed self-evaluation response rate was 80 percent (n = 151). The self-reported comfort level for all body regions improved following course completion (p < 0.001): chest (27 percent), neck (23 percent), upper extremity (22 percent), lower extremity (21 percent), and abdomen/pelvis (19 percent). The overall score on the competency test improved after completion of ASSET, with averages increasing from 62 ± 18 percent pretest to 71 ± 13 percent post-test (p < 0.001). CONCLUSIONS After taking the ASSET course, military surgeons demonstrated improved knowledge and increased confidence in the operative skills taught in the course. The ASSET course may provide sustainment of knowledge and confidence if used at regular intervals to maintain trauma skills and deployment readiness.
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Affiliation(s)
- Rebecca A Saberi
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Graham B Parker
- Department of Medicine, Los Angeles General Medical Center, Los Angeles, California. ORCID: https://orcid.org/0000-0002-0446-3446
| | - Noreen Mohsin
- Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Gareth P Gilna
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Alessia C Cioci
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Eva M Urrechaga
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Col Mark D Buzzelli
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Carl I Schulman
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida; Department of Dermatology, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth G Proctor
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care; United States Army Trauma Training Detachment, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
| | - Ltc Ret George D Garcia
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care; United States Army Trauma Training Detachment, University of Miami/Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida
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Ramsey WA, Huerta CT, O'Neil CF, Stottlemyre RL, Saberi RA, Gilna GP, Lyons NB, Collie BL, Parker BM, Perez EA, Sola JE, Proctor KG, Namias N, Thorson CM, Meizoso JP. Admission to a Verified Pediatric Trauma Center is Associated With Improved Outcomes in Severely Injured Children. J Pediatr Surg 2024; 59:488-493. [PMID: 37993397 DOI: 10.1016/j.jpedsurg.2023.10.064] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Previous studies have shown improved survival for severely injured adult patients treated at American College of Surgeons verified level I/II trauma centers compared to level III and undesignated centers. However, this relationship has not been well established in pediatric trauma centers (PTCs). We hypothesize that severely injured children will have lower mortality at verified level I/II PTCs compared to centers without PTC verification. METHODS All patients 1-15 years of age with ISS >15 in the 2017-2019 American College of Surgeons Trauma Quality Programs (ACS TQP) dataset were reviewed. Patients with pre-hospital cardiac arrest, burns, and those transferred out for ongoing inpatient care were excluded. Logistic regression models were used to assess the effects of pediatric trauma center verification on mortality. RESULTS 16,301 patients were identified (64 % male, median ISS 21 [17-27]), and 60 % were admitted to verified PTCs. Overall mortality was 6.0 %. Mortality at centers with PTC verification was 5.1 % versus 7.3 % at centers without PTC verification (p < 0.001). After controlling for injury mechanism, sex, age, pediatric-adjusted shock index (SIPA), ISS, arrival via interhospital transfer, and adult trauma center verification, pediatric level I/II trauma center designation was independently associated with decreased mortality (OR 0.72, 95 % CI 0.61-0.85). CONCLUSIONS Treatment at ACS-verified pediatric trauma centers is associated with improved survival in critically injured children. These findings highlight the importance of PTC verification in optimizing outcomes for severely injured pediatric patients and should influence trauma center apportionment and prehospital triage. LEVEL OF EVIDENCE Level IV - Retrospective review of national database.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | | | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Brianna L Collie
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Brandon M Parker
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA; Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL, USA.
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Lyons NB, Berg A, Collie BL, Meizoso JP, Sola JE, Thorson CM, Proctor KG, Namias N, Pizano LR, Marttos AC, Sciarretta JD. Management of lower extremity vascular injuries in pediatric trauma patients: 20-year experience at a level 1 trauma center. Trauma Surg Acute Care Open 2024; 9:e001263. [PMID: 38347895 PMCID: PMC10860056 DOI: 10.1136/tsaco-2023-001263] [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] [Indexed: 02/15/2024] Open
Abstract
Introduction Pediatric lower extremity vascular injuries (LEVI) are rare but can result in significant morbidity. We aimed to describe our experience with these injuries, including associated injury patterns, diagnostic and therapeutic challenges, and outcomes. Methods This was a retrospective review at a single level 1 trauma center from January 2000 to December 2019. Patients less than 18 years of age with LEVI were included. Demographics, injury patterns, clinical status at presentation, and intensive care unit (ICU) and hospital length of stay (LOS) were collected. Surgical data were extracted from patient charts. Results 4,929 pediatric trauma patients presented during the 20-year period, of which 53 patients (1.1%) sustained LEVI. The mean age of patients was 15 years (range 1-17 years), the majority were Black (68%), male (96%), and most injuries were from a gunshot wound (62%). The median Glasgow Coma Scale score was 15, and the median Injury Severity Score was 12. The most commonly injured arteries were the superficial femoral artery (28%) and popliteal artery (28%). Hard signs of vascular injury were observed in 72% of patients and 87% required operative exploration. There were 36 arterial injuries, 36% of which were repaired with a reverse saphenous vein graft and 36% were repaired with polytetrafluoroethylene graft. One patient required amputation. Median ICU LOS was three days and median hospital LOS was 15 days. There were four mortalities. Conclusion Pediatric LEVIs are rare and can result in significant morbidity. Surgical principles for pediatric vascular injuries are similar to those applied to adults, and this subset of patients can be safely managed in a tertiary specialized center. Level of evidence Level IV, retrospective study.
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Affiliation(s)
- Nicole B Lyons
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Arthur Berg
- NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Brianna L Collie
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan P Meizoso
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Juan E Sola
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Namias
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Louis R Pizano
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Antonio C Marttos
- Division of Trauma, Burns, and Surgical Critical Care, Dewitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jason D Sciarretta
- Trauma/Surgical Critical Care at Grady Memorial Hospital, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Ramsey WA, O'Neil CF, Shatz CD, Lyons NB, Cohen BL, Saberi RA, Gilna GP, Meizoso JP, Pizano LR, Schulman CI, Proctor KG, Namias N. Nationwide Analysis of Firearm Injury Versus Other Penetrating Trauma: It's Not All the Same Caliber. J Surg Res 2024; 294:106-111. [PMID: 37866065 DOI: 10.1016/j.jss.2023.09.067] [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: 05/26/2023] [Revised: 08/25/2023] [Accepted: 09/24/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Ballistic injuries cause both a temporary and permanent cavitation event, making them far more destructive and complex than other penetrating trauma. We hypothesized that global injury scoring and physiologic parameters would fail to capture the lethality of gunshot wounds (GSW) compared to other penetrating mechanisms. METHODS The 2019 American College of Surgeons Trauma Quality Programs participant use file was queried for the mortality rate for GSW and other penetrating mechanisms. A binomial logistic regression model ascertained the effects of sex, age, hypotension, tachycardia, mechanism, Glasgow Coma Scale, ISS, and volume of blood transfusion on the likelihood of mortality. Subgroup analyses examined isolated injuries by body regions. RESULTS Among 95,458 cases (82% male), GSW comprised 46.4% of penetrating traumas. GSW was associated with longer hospital length of stay (4 [2-9] versus 3 [2-5] days), longer intensive care unit length of stay (3 [2-6] versus 2 [2-4] days), and more ventilator days (2 [1-4] versus 2 [1-3]) compared to stab wounds, all P < 0.001. The model determined that GSW was linked to increased odds of mortality compared to stab wounds (odds ratio 4.19, 95% confidence interval 3.55-4.93). GSW was an independent risk factor for acute kidney injury, acute respiratory distress syndrome, venous thromboembolism, sepsis, and surgical site infection. CONCLUSIONS Injury scoring systems based on anatomical or physiological derangements fail to capture the lethality of GSW compared to other mechanisms of penetrating injury. Adjustments in risk stratification and reporting are necessary to reflect the proportion of GSW seen at each trauma center. Improved classification may help providers develop quality processes of care. This information may also help shape public discourse on this highly lethal mechanism.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida.
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Connor D Shatz
- University of Miami Miller School of Medicine, Miami, Florida
| | - Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida; Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida
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Lyons NB, Proctor KG. Are the Outcomes of a Pig Endotoxemia Model Applicable to Human Sepsis? Crit Care Med 2023; 51:1102-1104. [PMID: 37439647 DOI: 10.1097/ccm.0000000000005904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Affiliation(s)
- Nicole B Lyons
- Both authors: Division of Trauma, Burns, and Surgical Critical Care, Daughtry Family, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
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Lyons NB, Cohen BL, O'Neil CF, Ramsey WA, Proctor KG, Namias N, Meizoso JP. Short Versus Long Antibiotic Duration for Necrotizing Soft Tissue Infection: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2023. [PMID: 37222708 DOI: 10.1089/sur.2023.037] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Background: Necrotizing soft tissue infections (NSTIs) are rapidly spreading, life-threatening infections that require emergent surgical intervention with immediate antibiotic initiation. However, there is no consensus regarding duration of antibiotic therapy after source control. We hypothesized that a short course of antibiotic therapy is as effective as a long course of antibiotic therapy after final debridement for NSTI. Methods: A systematic review of the literature was performed using PubMed, Embase, and Cochrane Library from inception to November 2022. Observational studies comparing short (≤7 days) versus long (>7 days) antibiotic duration for NSTI were included. Primary outcome was mortality and secondary outcomes included limb amputation and Clostridium difficile infection (CDI). Cumulative analysis was performed with Fisher exact test. Meta-analysis was performed using a fixed effects model and heterogeneity was assessed using Higgins I2. Results: A total of 622 titles were screened and four observational studies evaluating 532 patients met inclusion criteria. Mean age was 52 years, 67% were male, 61% had Fournier gangrene. There was no difference in mortality when comparing short to long duration antibiotic agents on both cumulative analysis (5.6% vs. 4.0%; p = 0.51) and meta-analysis (relative risk, 0.9; 95% confidence interval, 0.8-1.0; I2 0; p = 0.19). There was no significant difference in rates of limb amputation (11% vs. 8.5%; p = 0.50) or CDI (20.8% vs. 13.3%; p = 0.14). Conclusions: Short duration antibiotic therapy may be as effective as longer duration antibiotic therapy for NSTI after source control. Further high-quality data such as randomized clinical trials are required to create evidence-based guidelines.
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Affiliation(s)
- Nicole B Lyons
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Brianna L Cohen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, and Ryder Trauma Center, Miami, Florida, USA
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Ramsey WA, O'Neil CF, Corona AM, Cohen BL, Lyons NB, Meece MS, Saberi RA, Gilna GP, Satahoo SS, Kaufman JI, Schulman CI, Namias N, Proctor KG, Pizano LR. Burn Excision Within 48 Hours Portends Better Outcomes Than Standard Management: A Nationwide Analysis. J Trauma Acute Care Surg 2023:01586154-990000000-00330. [PMID: 37038260 DOI: 10.1097/ta.0000000000003951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Previous studies have debated the optimal time to perform excision and grafting of second- and third-degree burns. The current consensus is that excision should be performed before the sixth hospital day. We hypothesize that patients who undergo excision within 48 hours have better outcomes. METHODS The ACS Trauma Quality Programs (ACS TQP) dataset was used to identify all patients with at least 10% total body surface area (TBSA) second- and third-degree burns from years 2017-2019. Patients with other serious injuries (any AIS >3), severe inhalational injury, pre-hospital cardiac arrest, and interhospital transfers were excluded. ICD-10 procedure codes were used to ascertain time of first excision. Patients who underwent first excision within 48 hours of admission (early excision) were compared to those who underwent surgery 48-120 hours from admission (standard therapy). Propensity score matching was performed to control for age and TBSA burned. RESULTS 2,270 patients (72% male) were included in the analysis. Median age was 37 (23-55) years. Early excision was associated with shorter hospital length of stay (LOS), and ICU LOS (Table 2). Complications including deep venous thrombosis, pulmonary embolism, ventilator-associated pneumonia, and catheter-associated urinary tract infection were significantly lower with early excision. There was no significant difference in mortality. CONCLUSIONS Performance of excision within 48 hours is associated with shorter hospital LOS and fewer complications than standard therapy. We recommend taking patients for operative debridement and temporary or, when feasible, permanent coverage within 48 hours. Prospective trials should be performed to verify the advantages of this treatment strategy. LEVEL OF EVIDENCE Level III - Retrospective Cohort Study.
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Affiliation(s)
| | | | - Andrew M Corona
- University of Miami Miller School of Medicine, Miami, Florida, USA
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Ramsey WA, O'Neil CF, Ramdev RA, Sleeman EA, Danton GH, Kaufman JI, Pizano LR, Meizoso JP, Proctor KG, Namias N. Illuminating the Use of Trauma Whole-Body CT Scan During the Global Contrast Shortage. J Am Coll Surg 2023; 236:937-942. [PMID: 36728386 DOI: 10.1097/xcs.0000000000000551] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI). STUDY DESIGN All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared. RESULTS The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality. CONCLUSIONS Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.
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Affiliation(s)
- Walter A Ramsey
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Christopher F O'Neil
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Rajan A Ramdev
- University of Miami Miller School of Medicine (Ramdev, Sleeman), Miami, FL
| | - Ella A Sleeman
- University of Miami Miller School of Medicine (Ramdev, Sleeman), Miami, FL
| | - Gary H Danton
- Department of Radiology (Danton), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Joyce I Kaufman
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Louis R Pizano
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Jonathan P Meizoso
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Kenneth G Proctor
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
| | - Nicholas Namias
- From the DeWitt Daughtry Family Department of Surgery (Ramsey, O'Neil, Kaufman, Pizano, Meizoso, Proctor, Namias), Miami, FL
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, FL (Ramsey, O'Neil, Danton, Kaufman, Pizano, Meizoso, Proctor, Namias)
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Ramsey WA, O'Neil CF, Saberi RA, Meece MS, Gilna GP, Kaufman JI, Lieberman HM, Lineen EB, Meizoso JP, Pizano LR, Satahoo SS, Danton GH, Proctor KG, Namias N. Examining the Definition of Ventilator-Associated Pneumonia in the Trauma Setting: A Single-Center Analysis. Surg Infect (Larchmt) 2023; 24:322-326. [PMID: 36944154 DOI: 10.1089/sur.2022.272] [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: 03/23/2023] Open
Abstract
Background: Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP. Patients and Methods: The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence. Results: Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = -0.071; sensitivity, 64.3%; specificity, 28.6%). Conclusions: Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.
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Affiliation(s)
- Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Matthew S Meece
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Joyce I Kaufman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Howard M Lieberman
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Edward B Lineen
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jonathan P Meizoso
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Shevonne S Satahoo
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Gary H Danton
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- Ryder Trauma Center, Jackson Memorial Hospital, Miami, Florida, USA
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Ramsey WA, O'Neil CF, Fils AJ, Botero-Fonnegra C, Saberi RA, Gilna GP, Pizano LR, Parker BM, Proctor KG, Schulman CI, Namias N, Meizoso JP. Improved Survival for Severely Injured Patients Receiving Massive Transfusion at US Teaching Hospitals: A Nationwide Analysis. J Trauma Acute Care Surg 2023; 94:672-677. [PMID: 36749659 DOI: 10.1097/ta.0000000000003895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have shown improved survival for patients treated at American College of Surgeons (ACS) verified level I trauma centers compared to level II, level III, and undesignated centers. This mortality difference is more pronounced in severely injured patients. However, a survival benefit for severely injured trauma patients has not been established at teaching institutions compared to non-teaching centers. As massive transfusion (MT) is associated with high mortality, we hypothesize that patients receiving MT have lower mortality at teaching hospitals than at non-teaching hospitals. METHODS All adult ACS Trauma Quality Improvement Program-eligible patients who underwent MT, defined as >10 units of packed red blood cells in the first 4 hours after arrival, in the 2019 ACS Trauma Quality Programs participant use file were eligible. Patients with severe head injury (AIS Head ≥3), prehospital cardiac arrest, and interhospital transfers were excluded. Logistic regression models were used to assess the effects of trauma center hospital teaching status on the adjusted odds of 3-hour, 6-hour, and 24-hour mortality. RESULTS 1,849 patients received MT [81% male, median ISS 26 (18-35)], 72% were admitted to level I trauma centers, and 28% were admitted to level II centers. Overall hospital mortality was 41%; 17% of patients died in 3 hours, 25% in 6 hours and 33% in 24 hours. Teaching hospitals were associated with decreased 3-hour (OR 0.45, 95% CI 0.27-0.75), 6-hour (OR 0.37, 95% CI 0.24-0.56), 24-hour (OR 0.50, 95% CI 0.34-0.75), and overall mortality (OR 0.66, 95% CI 0.44-0.98), compared to non-teaching hospitals, controlling for sex, age, heart rate, injury severity, injury mechanism, and trauma center verification level. CONCLUSIONS Severely injured patients requiring MT experience significantly lower mortality at teaching hospitals compared to non-teaching hospitals, independently of trauma center verification level. LEVEL OF EVIDENCE Level III: Retrospective comparative study.
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Affiliation(s)
| | | | - Aaron J Fils
- University of Miami Miller School of Medicine, Miami, Florida, USA
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13
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Urrechaga EM, Byerly SE, Lee EE, Cioci AC, Rattan R, Proctor KG, Namias N, Ginzburg E. Traumatic Gluteal Artery Injuries: A Marker of Injury Severity. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.612] [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: 10/20/2022]
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14
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Saberi RA, Parker GB, Mohsin N, Gilna GP, Cioci AC, Urrechaga EM, Buzzelli MD, Proctor KG, Garcia GD. Advanced Surgical Skills for Exposure in Trauma Improves Confidence in Military Surgeons. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.312] [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: 10/20/2022]
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15
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Sussman MS, Ryon EL, Urrechaga EM, Cioci AC, Herrington TJ, Pizano LR, Garcia GD, Namias N, Wetstein PJ, Buzzelli MD, Gross KR, Proctor KG. The Key to Combat Readiness Is a Strong Military-Civilian Partnership. Mil Med 2021; 186:571-576. [PMID: 33394041 DOI: 10.1093/milmed/usaa565] [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] [Received: 11/18/2020] [Accepted: 12/15/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents <0.5% of military hospital admissions and not all team members have daily clinical responsibilities. Military surgeon clinical experience has been described, but no data exist for other members of the FRST. We test the hypothesis that the clinical experience of non-physician FRST members varies between active duty (AD) and Army reservists (AR). METHODS Over a 3-year period, all FRSTs were surveyed at one civilian center. RESULTS Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P < .001). These differences persisted across all specialties, including perioperative nurses, certified registered nurse anesthetists, operating room (OR) techs, critical-care nurses, emergency room (ER) nurses, licensed practical nurse (LPN), and combat medics. CONCLUSIONS This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Tyler J Herrington
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Louis R Pizano
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - George D Garcia
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Paul J Wetstein
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Mark D Buzzelli
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Kirby R Gross
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care & Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Ryder Trauma Center, and US Army Trauma Training Center, Miami, FL 33136, USA
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16
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Mulder MB, Sussman MS, Eidelson SA, Gross KR, Buzzelli MD, Batchinsky AI, Schulman CI, Namias N, Proctor KG. Heart Rate Complexity in US Army Forward Surgical Teams During Pre Deployment Training. Mil Med 2021; 185:e724-e733. [PMID: 32722768 DOI: 10.1093/milmed/usz434] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 06/28/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION For trauma triage, the US Army has developed a portable heart rate complexity (HRC) monitor, which estimates cardiac autonomic input and the activity of the hypothalamic-pituitary-adrenal (HPA) axis. We hypothesize that autonomic/HPA stress associated with predeployment training in U.S. Army Forward Surgical Teams will cause changes in HRC. MATERIALS AND METHODS A prospective observational study was conducted in 80 soldiers and 10 civilians at the U.S. Army Trauma Training Detachment. Heart rate (HR, b/min), cardiac output (CO, L/min), HR variability (HRV, ms), and HRC (Sample Entropy, unitless), were measured using a portable non-invasive hemodynamic monitor during postural changes, a mass casualty (MASCAL) situational training exercise (STX) using live tissue, a mock trauma (MT) STX using moulaged humans, and/or physical exercise. RESULTS Baseline HR, CO, HRV, and HRC averaged 72 ± 11b/min, 5.6 ± 1.2 L/min, 48 ± 24 ms, and 1.9 ± 0.5 (unitless), respectively. Supine to sitting to standing caused minimal changes. Before the MASCAL or MT, HR and CO both increased to ~125% baseline, whereas HRV and HRC both decreased to ~75% baseline. Those values all changed an additional ~5% during the MASCAL, but an additional 10 to 30% during the MT. With physical exercise, HR and CO increased to >200% baseline, while HRV and HRC both decreased to 40 to 60% baseline; these changes were comparable to those caused by the MT. All the changes were P < 0.05. CONCLUSIONS Various forms of HPA stress during Forward Surgical Team STXs can be objectively quantitated continuously in real time with a portable non-invasive monitor. Differences from resting baseline indicate stress anticipating an impending STX whereas differences between average and peak responses indicate the relative stress between STXs. Monitoring HRC could prove useful to field commanders to rapidly and objectively assess the readiness status of troops during STXs or repeated operational missions. In the future, health care systems and regulatory bodies will likely be held accountable for stress in their trainees and/or obliged to develop wellness options and standardize efforts to ameliorate burnout, so HRC metrics might have a role, as well.
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Affiliation(s)
- Michelle B Mulder
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Matthew S Sussman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Sarah A Eidelson
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Kirby R Gross
- U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Mark D Buzzelli
- U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, Battlefield Health & Trauma Center for Human Integrative Physiology, U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, JBSA Fort Sam Houston, TX 78234-6315.,The Geneva Foundation, Tacoma, WA 98402
| | - Carl I Schulman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136.,U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Nicholas Namias
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
| | - Kenneth G Proctor
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136.,U.S. Army Trauma Training Detachment, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, FL 33136
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17
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Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg 2021; 36:1450-1457. [PMID: 33586229 DOI: 10.1111/jocs.15406] [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] [Received: 08/26/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In trauma patients, the recognition of fibrinolysis phenotypes has led to a re-evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis-generating study was to fill that gap. METHODS Seventy-eight cardiac surgery patients were retrospectively reviewed. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (0.8%-3.0%), and hyperfibrinolytic (>3%) based on thromboelastogram. RESULTS The population was 65 ± 10-years old, 74% male, average body mass index of 29 ± 5 kg/m2 . Fibrinolytic phenotypes were distributed as physiologic = 45% (35 of 78), hypo = 32% (25 of 78), and hyper = 23% (18 of 78). There was no obvious effect of age, gender, race, or ethnicity on this distribution; 47% received AF. For AF versus no AF, the time with chest tube was longer (4 [1] vs. 3 [1] days, p = .037), and all-cause morbidity was more prevalent (51% vs. 25%, p = .017). However, when these two groups were further stratified by phenotypes, there were within-group differences in the percentage of patients with congestive heart failure (p = .022), valve disease (p = .024), on-pump surgery (p < .0001), estimated blood loss during surgery (p = .015), transfusion requirement (p = .015), and chest tube output (p = .008), which highlight other factors along with AF that might have affected all-cause morbidity. CONCLUSION This is the first description of the prevalence of three different fibrinolytic phenotypes and their potential influence on cardiac surgery patients. The use of AF was associated with increased morbidity, but because of the small sample size and treatment allocation bias, additional confirmatory studies are necessary. We hope these present findings open the dialog on whether it is safe to administer AFs to cardiac surgery patients who are normo- or hypofibrinolytic.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Rahul S Iyengar
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tyler J Herrington
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - David L Galbut
- Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tomas A Salerno
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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Mulder MB, Gilna GP, Iyengar RS, Quintana OD, Nardiello DC, Kaufman JI, Pizano LR, Namias N, Schulman CI, Proctor KG. Electrical Burns During Fruit Harvesting. J Burn Care Res 2020; 40:427-429. [PMID: 31051035 DOI: 10.1093/jbcr/irz050] [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: 11/14/2022]
Abstract
Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.
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Affiliation(s)
- Michelle B Mulder
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Gareth P Gilna
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Rahul S Iyengar
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Olga D Quintana
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Dawn C Nardiello
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Joyce I Kaufman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Louis R Pizano
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Carl I Schulman
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Kenneth G Proctor
- Dewitt Daughtry Department of Surgery Divisions of Trauma, Burns, & Surgical Critical Care, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
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19
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Sussman MS, Mulder MB, Ryon EL, Urrechaga EM, Lama GA, Bahga A, Eidelson SA, Lieberman HM, Schulman CI, Namias N, Proctor KG. Acute Kidney Injury Risk in Patients Treated with Vancomycin Combined with Meropenem or Cefepime. Surg Infect (Larchmt) 2020; 22:415-420. [PMID: 32783764 DOI: 10.1089/sur.2020.105] [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: 01/04/2023] Open
Abstract
Background: No previous studies have determined the incidence of acute kidney injury (AKI) in trauma patients treated with vancomycin + meropenem (VM) versus vancomycin + cefepime (VC). The purpose of this study was to fill this gap. Methods: A series of 99 patients admitted to an American College of Surgeons-verified level 1 trauma center over a two-year period who received VC or VM for >48 hours were reviewed retrospectively. Exclusion criteria were existing renal dysfunction or on renal replacement therapy. The primary outcome was AKI as defined by a rise in serum creatinine (SCr) to 1.5 times baseline. Multi-variable analysis was performed to control for factors associated with AKI (age, obesity, gender, length of stay [LOS], nephrotoxic agent(s), and baseline SCr), with significance defined as p < 0.05. Results: The study population was 50 ± 19 years old, 76% male, with a median LOS of 21 [range 15-39] days, and baseline SCr of 0.9 ± 0.2 mg/dL. Antibiotics, diabetes mellitus, and Injury Severity Score were independent predictors of AKI (odds ratio [OR] 4.4; 95% confidence interval [CI] 1.4-12; OR 9.3; 95% CI 1-27; OR 1.2; 95% CI 1.023-1.985, respectively). The incidence of AKI was higher with VM than VC (10/26 [38%] versus 14/73 [19.1%]; p = 0.049). Conclusions: The renal toxicity of vancomycin is potentiated by meropenem relative to cefepime in trauma patients. We recommend caution when initiating vancomycin combination therapy, particularly with meropenem.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Michelle B Mulder
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Gabriel A Lama
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Amritpal Bahga
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Sarah A Eidelson
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Howard M Lieberman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Carl I Schulman
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Burns, and Surgical Critical Care and Dewitt Daughtry Family Dept of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida, USA
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Mulder MB, Proctor KG, Valle EJ, Livingstone AS, Nguyen DM, Van Haren RM. Hypercoagulability After Resection of Thoracic Malignancy: A Prospective Evaluation. World J Surg 2020; 43:3232-3238. [PMID: 31407092 DOI: 10.1007/s00268-019-05123-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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
BACKGROUND Rates of venous thromboembolism are increased in thoracic malignancy; however, coagulation patterns are not established. We hypothesize that patients with esophageal and lung malignancy have similar hypercoagulable pre- and postoperative profiles as defined by rotational thromboelastometry (ROTEM). METHODS Prospective study was conducted in 47 patients with esophageal and lung cancer undergoing surgical resection. ROTEM evaluated pre/postoperative coagulation status. RESULTS Patients with thoracic malignancy were hypercoagulable by ROTEM, but not by conventional coagulation tests. Preoperative hypercoagulability was higher in lung versus esophageal cancer (64 vs. 16%, p = 0.001). Lung cancer patients that were hypercoagulable preoperatively demonstrated decreased maximum clot firmness (MCF) (p = 0.044) and increased clot time (p = 0.049) after surgical resection, suggesting reversal of hypercoagulability. Resection of esophageal cancer increased hypercoagulability (16 vs. 56%, p = 0.002) via elevated MCF (reflecting platelet activity). Hypercoagulability remained at follow-up clinic for both lung and esophageal cancer patients. CONCLUSIONS Hypercoagulability in patients with lung malignancies reversed following complete surgical resection, whereas hypercoagulability occurred only postoperatively in those with esophageal malignancies. In both, hypercoagulability was associated with fibrin and platelet function.
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Affiliation(s)
- Michelle B Mulder
- Dewitt-Daughtry Family Department of Surgery, Miller School of Medicine and Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Kenneth G Proctor
- Dewitt-Daughtry Family Department of Surgery, Miller School of Medicine and Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Evan J Valle
- Dewitt-Daughtry Family Department of Surgery, Miller School of Medicine and Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Alan S Livingstone
- Dewitt-Daughtry Family Department of Surgery, Miller School of Medicine and Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Dao M Nguyen
- Dewitt-Daughtry Family Department of Surgery, Miller School of Medicine and Ryder Trauma Center, University of Miami, Miami, FL, USA
| | - Robert M Van Haren
- Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
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Thorson CM, Ryan ML, Van Haren RM, Pereira R, Olloqui J, Otero CA, Schulman CI, Livingstone AS, Proctor KG. Change in Hematocrit during Trauma Assessment Predicts Bleeding Even with Ongoing Fluid Resuscitation. Am Surg 2020. [DOI: 10.1177/000313481307900430] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study tests the hypothesis that a change in hematocrit (ΔHct) during initial trauma work-up is as reliable as conventional vital signs for detecting bleeding, even with ongoing fluid resuscitation. Consecutive trauma patients admitted to a Level I trauma center receiving two Hct measurements during initial resuscitation between January 2010 and January 2011 were stratified based on estimated blood loss greater than 250 mL (bleeding) or nonbleeding. Sensitivity, specificity, and receiver operating characteristic curves were calculated for systolic blood pressure (SBP), heart rate, base deficit, and ΔHct. In 168 (72%) nonbleeding versus 64 (28%) bleeding patients, age and gender were similar. Arrival SBP was highly specific (90 to 99%) but poorly sensitive (13 to 31%) for detecting bleeding. Combinations of vital signs increased specificity, albeit at the expense of sensitivity. For bleeding versus nonbleeding patients (all receiving resuscitation fluid), ΔHct was 9.0 versus 1.8, ΔHct/liter was 4.8 versus 1.5, and ΔHct/liter/hour was 2.8 vs 0.6 (all P < 0.001). Only SBP (area under the curve [AUC] 0.608 to 0.695) and ΔHct (AUC 0.731 to 0.921) were significant for identifying bleeding with ΔHct 6 or greater being the best predictor (sensitivity 89%, specificity 95%, AUC 0.921). During ongoing fluid resuscitation of a trauma victim, ΔHct is the single most reliable indicator of continuing blood loss. A ΔHct 6 or greater during initial resuscitation is highly suspicious for ongoing blood loss, but even lesser changes have predictive value. Altogether, these results support the idea that fluid shifts are rapid after hemorrhage and Hct can be valuable during initial trauma assessment.
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Affiliation(s)
- Chad M. Thorson
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Mark L. Ryan
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Robert M. Van Haren
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Reginald Pereira
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Jeremy Olloqui
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Christian A. Otero
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Carl I. Schulman
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Alan S. Livingstone
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
| | - Kenneth G. Proctor
- From the Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida
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Van Haren RM, Thorson CM, Valle EJ, Guarch GA, Jouria JM, Busko AM, Namias N, Livingstone AS, Proctor KG. Vasopressor Use during Emergency Trauma Surgery. Am Surg 2020. [DOI: 10.1177/000313481408000518] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most evidence suggests early vasopressor use is associated with death after trauma, but no previous study has focused on patients requiring emergency operative intervention (OR). We test the hypothesis that vasopressors are harmful in this population. Records from 746 patients requiring OR from July 2009 to March 2013 were retrospectively reviewed and stratified based on vasopressor use (epinephrine [EPI], phenylephrine, ephedrine, norepinephrine, dobutamine, vasopressin) or no vasopressor use. Vasopressors were administered to 225 patients (30%) during OR; 59 patients (8%) received multiple vasopressors. Patients who received vasopressors were older, more severely injured, had worse vital signs, and increased mortality rate (all P < 0.001). EPI was independently associated with mortality (odds ratio, 6.88; P = 0.001). If patients who received EPI were excluded, there was no difference in mortality between those who received vasopressors alone or in combination and those that did not (5 vs 6%, P = 0.523), although multiple markers of injury severity were worse. We conclude that vasopressor use is relatively common in the most severely injured patients requiring OR and is associated with mortality. EPI is most often used for cardiac arrest, whereas other vasopressors are used for their vasoconstrictive properties. This suggests that, except for EPI, vasopressors during OR are not independently associated with mortality.
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Affiliation(s)
- Robert M. Van Haren
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Chad M. Thorson
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Evan J. Valle
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Gerardo A. Guarch
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Jassin M. Jouria
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Alexander M. Busko
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Nicholas Namias
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Alan S. Livingstone
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
| | - Kenneth G. Proctor
- From the Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, Miami, Florida
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Mulder MB, Quiroz HJ, Yang WJ, Lasko DS, Perez EA, Proctor KG, Sola JE, Thorson CM. The unborn fetus: The unrecognized victim of trauma during pregnancy. J Pediatr Surg 2020; 55:938-943. [PMID: 32061362 DOI: 10.1016/j.jpedsurg.2020.01.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 01/16/2020] [Accepted: 01/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Trauma is the leading cause of non-obstetric death in pregnancy. While maternal management is defined, few studies have examined the effects on the fetus. METHODS Following IRB approval, all pregnant females (2010-2017) at a level-1 trauma center were retrospectively reviewed. Maternal and fetal demographics, interventions, and clinical outcomes were analyzed. RESULTS There were 188 pregnancies in 5654 females. Maternal demographics were 26 ± 7 years old, gestational age at trauma 21 ± 12 weeks, 81% blunt mechanism, and maternal mortality 6%. Forty-one (22%) fetuses were immediately affected by the trauma including 20 (11%) born alive, 12 (7%) fetal demise, and 9 (5%) stillbirths. Of those that initially survived (n = 20), 5 (25%) expired during neonatal hospitalization. Two mothers returned immediately after trauma discharge with stillbirths for an overall infant mortality of 14% (n = 26). There were 84 patients with complete data to delivery including the 41 born at trauma and 43 born on a subsequent hospitalization. Those born at the time of trauma had significantly more delivery/neonatal complications and worse outcomes. Overall trauma burden to the fetus (preterm delivery, stillbirth, delivery/neonatal complication, or long-term disability) was 66% (56/84). CONCLUSIONS Trauma during pregnancy has significant immediate mortality and delayed effects on the unborn fetus. This study has uncovered a previously hidden burden and mortality of trauma during pregnancy. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michelle B Mulder
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Hallie J Quiroz
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Wendy J Yang
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Davis S Lasko
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Eduardo A Perez
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Kenneth G Proctor
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Juan E Sola
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136
| | - Chad M Thorson
- Dewitt-Daughtry Family Department of Surgery, Divisions of Pediatric Surgery and Trauma, Critical Care and Burn Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, 1800 NW 10th Ave. Miami, FL, USA 33136.
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Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-Induced Changes in Compensatory Reserve and Heart Rate Complexity. Aerosp Med Hum Perform 2019; 90:1009-1015. [PMID: 31747997 DOI: 10.3357/amhp.5460.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND: Portable noninvasive Heart Rate Complexity (HRC) and Compensatory Reserve Measurement (CRM) monitors have been developed to triage supine combat casualties. Neither monitor has been tested in upright individuals during physical exercise. This study tests the hypothesis that exercise evokes proportional changes in HRC and CRM.METHODS: Two instruments monitored volunteers (9 civilian and 11 soldiers) from the Army Trauma Training Department (ATTD) before, during, and following physical exercise. One recorded heart rate (HR, bpm), cardiac output (CO, L · min-1), heart rate variability (HRV, root mean square of successive differences, ms), and HRC (Sample Entropy, unitless). The other recorded HR, pulse oximetry (Spo₂, %), and CRM (%).RESULTS: Baseline HR, CO, HRV, HRC, and CRM averaged 72 ± 1 bpm, 5.6 ± 1.2 L · min-1, 48 ± 24 ms, 1.9 ± 0.5, and 85 ± 10% in seated individuals. Exercise evoked peak HR and CO at > 200% of baseline, while HRC and CRM were simultaneously decreased to minimums that were ≤ 50% of baseline (all P < 0.001). HRV changes were variable and unreliable. Spo₂ remained consistently above 95%. During a 60 min recovery, HR and CRM returned to baseline on parallel tracks (t1/2=11 ± 8 and 18 ± 14 min), whereas HRC recovery was slower than either CRM or HR (t1/2=40 ± 18 min, both P < 0.05).DISCUSSION: Exercise evoked qualitatively similar changes in CRM and HRC. CRM recovered incrementally faster than HRC, suggesting that vasodilation, muscle pump, and respiration compensate faster than cardiac autonomic control in young, healthy volunteers. Both HRC and CRM appear to provide reliable, objective, and noninvasive metrics of human performance in upright exercising individuals.Mulder MB, Eidelson SA, Buzzelli MD, Gross KR, Batchinsky AI, Convertino VA, Schulman CI, Namias N, Proctor KG. Exercise-induced changes in compensatory reserve and heart rate complexity. Aerosp Med Hum Perform. 2019; 90(12):1009-1015.
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Sussman M, Mulder MB, Ryon EL, Lama G, Williams CE, Ginzburg E, Namias N, Proctor KG. Endotoxemia in Transplant Patients with Culture Negative Sepsis. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1029] [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: 11/17/2022]
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Mulder MB, Sussman MS, Eidelson SA, Gross KR, Buzzelli MD, Batchinsky AI, Namias N, Schulman CI, Proctor KG. Heart Rate Complexity in US Army Forward Surgical Teams During Pre-Deployment Training. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.414] [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: 11/17/2022]
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Sussman M, Mulder MB, Ryon EL, Brecount H, Wittels SP, Namias N, Galbut D, Salerno T, Proctor KG. Fibrinolysis Phenotypes Differ Amongst Cardiac Surgery Patients: Antifibrinolytic Therapy for All? J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.111] [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: 11/16/2022]
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Karcutskie CA, Dharmaraja A, Patel J, Eidelson SA, Padiadpu AB, Martin AG, Lama G, Lineen EB, Namias N, Schulman CI, Proctor KG. Association of Anti-Factor Xa-Guided Dosing of Enoxaparin With Venous Thromboembolism After Trauma. JAMA Surg 2019; 153:144-149. [PMID: 29071333 DOI: 10.1001/jamasurg.2017.3787] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Importance The efficacy of anti-factor Xa (anti-Xa)-guided dosing of thromboprophylaxis after trauma remains controversial. Objective To assess whether dosing of enoxaparin sodium based on peak anti-Xa levels is associated with the venous thromboembolism (VTE) rate after trauma. Design, Setting, and Participants Retrospective review of 950 consecutive adults admitted to a single level I trauma intensive care unit for more than 48 hours from December 1, 2014, through March 31, 2017. Within 24 hours of admission, these trauma patients were screened with the Greenfield Risk Assessment Profile (RAP) (possible score range, 0-46). Patients younger than 18 years and those with VTE on admission were excluded, resulting in a study population of 792 patients. Exposures The control group received fixed doses of either heparin sodium, 5000 U 3 times a day, or enoxaparin sodium, 30 mg twice a day. The adjustment cohort initially received enoxaparin sodium, 30 mg twice a day. A peak anti-Xa level was drawn 4 hours after the third dose. If the anti-Xa level was 0.2 IU/mL or higher, no adjustment was made. If the anti-Xa level was less than 0.2 IU/mL, each dose was increased by 10 mg. The process was repeated up to a maximum dose of 60 mg twice a day. Main Outcomes and Measures Rates of VTE were measured. Venous duplex ultrasonography and computed tomographic angiography were used for diagnosis. Results The study population comprised 792 patients with a mean (SD) age of 46 (19) years and was composed of 598 men (75.5%). The control group comprised 570 patients, was older, and had a longer time to thromboprophylaxis initiation. The adjustment group consisted of 222 patients, was more severely injured, and had a longer hospital length of stay. The mean (SD) RAP scores were 9 (4) for the control group and 9 (5) for the adjustment group (P = .28). The VTE rates were similar for both groups (34 patients [6.0%] vs 15 [6.8%]; P = .68). Prophylactic anti-Xa levels were reached in 119 patients (53.6%) in the adjustment group. No difference in VTE rates was observed between those who became prophylactic and those who did not (7 patients [5.9%] vs 8 [7.8%]; P = .58). To control for confounders, 132 patients receiving standard fixed-dose enoxaparin were propensity matched to 84 patients receiving dose-adjusted enoxaparin. The VTE rates remained similar between the control and adjustment groups (3 patients [2.3%] vs 3 [3.6%]; P = .57). Conclusions and Relevance Rates of VTE were not reduced with anti-Xa-guided dosing, and almost half of the patients never reached prophylactic anti-Xa levels; achieving those levels did not decrease VTE rates. Thus, other targets, such as platelets, may be necessary to optimize thromboprophylaxis after trauma.
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Affiliation(s)
- Charles A Karcutskie
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Arjuna Dharmaraja
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Jaimin Patel
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Sarah A Eidelson
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Anish B Padiadpu
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Arch G Martin
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Gabriel Lama
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Edward B Lineen
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Carl I Schulman
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Kenneth G Proctor
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
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Eidelson SA, Rattan R, Parreco J, Mulder MB, Proctor KG, Hilton LR. National Analysis of Missed Venous Thromboembolism after Bariatric Surgery: Are We Missing Our Own Complications? J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.029] [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: 11/15/2022]
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Eidelson SA, Parreco J, Mulder MB, Dharmaraja A, Kaufman JI, Proctor KG, Pizano LR, Schulman CI, Namias N, Rattan R. Variation in National Readmission Patterns After Burn Injury. J Burn Care Res 2018; 39:670-675. [DOI: 10.1093/jbcr/iry034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Sarah A Eidelson
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Joshua Parreco
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Michelle B Mulder
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Arjuna Dharmaraja
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Joyce I Kaufman
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Kenneth G Proctor
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Louis R Pizano
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Carl I Schulman
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Nicholas Namias
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
| | - Rishi Rattan
- DeWitt Daughtry Family Department of Surgery, Miller School of Medicine, University of Miami, Florida
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Allen CJ, Baldor DJ, Hanna MM, Namias N, Bullock MR, Jagid JR, Proctor KG. Early Craniectomy Improves Intracranial and Cerebral Perfusion Pressure after Severe Traumatic Brain Injury. Am Surg 2018. [DOI: 10.1177/000313481808400332] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
After traumatic brain injury, decompressive craniectomy (DC) is a second-tier, late therapy for refractory intracranial hypertension. We hypothesize that early DC, based on CT evidence of intracranial hypertension, improves intracranial pressure (ICP) and cerebral perfusion pressure (CPP). From September 2008 to January 2015, 286 traumatic brain injury patients requiring invasive ICP monitoring at a single Level I trauma center were reviewed. DC and non-DC patients were propensity score matched 1:1, based on demographics, hemodynamics, injury severity score (ISS), Glasgow Coma Scale (GCS), transfusion requirements, and need for vasopressor therapy. Data are presented as M ± SD or median (IQR) and compared at P ≤ 0.05. The study population was 42 ± 17 years, 84 per cent male, ISS = 29 ± 11, GCS = 6 (5), length of stay (LOS) = 32(40) days, and 28 per cent mortality. There were 116/286 (41%) DC, of which 105/116 (91%) were performed at the time of ICP placement. For 50 DC propensity matched to 50 non-DC patients, the midline shift was 7(11) versus 0(5) mm ( P < 0.001), abnormal ICP (hours > 20 mm Hg) was 1(10) versus 8(16) ( P = 0.017), abnormal CPP (hours < 60 mm Hg) was 0(6) versus 4(9) ( P = 0.008), daily minimum CPP (mm Hg) was 67(13) versus 62(17) ( P = 0.010), and daily maximum ICP (mm Hg) was 18(9) versus 22(11) ( P < 0.001). However, LOS [33(37) versus 25(34) days], mortality (24 versus 30%), and Glasgow Outcome Score Extended [3.0(3.0) versus 3.0(4.0)] did not improve significantly. Early DC for CT evidence of intracranial hypertension decreased abnormal ICP and CPP time and improved ICP and CPP thresholds, but had no obvious effect on the outcome.
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Affiliation(s)
- Casey J. Allen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care
| | - Daniel J. Baldor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care
| | - Mena M. Hanna
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care
| | - Nicholas Namias
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care
| | - M. Ross Bullock
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Jonathan R. Jagid
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Kenneth G. Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care
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Allen CJ, Baldor DJ, Hanna MM, Namias N, Bullock MR, Jagid JR, Proctor KG. Early Craniectomy Improves Intracranial and Cerebral Perfusion Pressure after Severe Traumatic Brain Injury. Am Surg 2018; 84:443-450. [PMID: 29559063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
After traumatic brain injury, decompressive craniectomy (DC) is a second-tier, late therapy for refractory intracranial hypertension. We hypothesize that early DC, based on CT evidence of intracranial hypertension, improves intracranial pressure (ICP) and cerebral perfusion pressure (CPP). From September 2008 to January 2015, 286 traumatic brain injury patients requiring invasive ICP monitoring at a single Level I trauma center were reviewed. DC and non-DC patients were propensity score matched 1:1, based on demographics, hemodynamics, injury severity score (ISS), Glasgow Coma Scale (GCS), transfusion requirements, and need for vasopressor therapy. Data are presented as M ± SD or median (IQR) and compared at P ≤ 0.05. The study population was 42 ± 17 years, 84 per cent male, ISS = 29 ± 11, GCS = 6(5), length of stay (LOS) = 32(40) days, and 28 per cent mortality. There were 116/286 (41%) DC, of which 105/116 (91%) were performed at the time of ICP placement. For 50 DC propensity matched to 50 non-DC patients, the midline shift was 7(11) versus 0(5) mm (P < 0.001), abnormal ICP (hours > 20 mm Hg) was 1(10) versus 8(16) (P = 0.017), abnormal CPP (hours < 60 mm Hg) was 0(6) versus 4(9) (P = 0.008), daily minimum CPP (mm Hg) was 67(13) versus 62(17) (P = 0.010), and daily maximum ICP (mm Hg) was 18(9) versus 22(11) (P < 0.001). However, LOS [33(37) versus 25(34) days], mortality (24 versus 30%), and Glasgow Outcome Score Extended [3.0(3.0) versus 3.0(4.0)] did not improve significantly. Early DC for CT evidence of intracranial hypertension decreased abnormal ICP and CPP time and improved ICP and CPP thresholds, but had no obvious effect on the outcome.
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Allen CJ, Ruiz XD, Meizoso JP, Ray JJ, Livingstone AS, Schulman CI, Namias N, Proctor KG. Is Hydroxyethyl Starch Safe in Penetrating Trauma Patients? Mil Med 2018; 181:152-5. [PMID: 27168566 DOI: 10.7205/milmed-d-15-00132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES For logistic reasons, a bolus of 6% hydroxyethyl starch (HES 450/0.7 in lactated electrolyte injection) is recommended for battlefield resuscitation even though it has risks of mortality and acute kidney injury (AKI) in certain patient populations. The purpose of this study was to test the hypothesis that victims of penetrating trauma have no increased risks of AKI and/or death when receiving a single bolus of HES during initial fluid resuscitation. METHODS 816 consecutive admissions with penetrating trauma were reviewed. Patients who died within 24 hours were excluded. Propensity scores and a 1:1 fixed ratio nearest neighbor matching were used to compare those who received HES to those who did not. Data were expressed as mean ± SD and significance was assessed at p < 0.05. RESULTS The cohort was 88% male, age 35 ± 14 years, injury severity score of 10 ± 10, with a 3.8% rate of AKI, and 3.2% rate of mortality. HES was administered to 121 (14.8%) patients. In HES and no HES propensity matched groups, the rate of AKI was 3.8% vs. 4.8% (p = 0.749) and the 90-day mortality rate was 3.8% vs. 4.8% (p = 0.749). CONCLUSION An increased risk of mortality or AKI was not observed in penetrating trauma patients who were resuscitated with low volume HES.
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Affiliation(s)
- Casey J Allen
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Xiomara D Ruiz
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Jonathan P Meizoso
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Juliet J Ray
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Alan S Livingstone
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Carl I Schulman
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Nicholas Namias
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
| | - Kenneth G Proctor
- Divisions of Trauma and Surgical Critical Care, DeWitt Daughtry Department of Surgery, Ryder Trauma Center, University of Miami School of Medicine, 1800 Northwest 10th Avenue, Miami, FL 33136
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Meizoso JP, Allen CJ, Ray JJ, Van Haren RM, Teisch LF, Baez XR, Livingstone AS, Namias N, Schulman CI, Proctor KG. Evaluation of Miniature Wireless Vital Signs Monitor in a Trauma Intensive Care Unit. Mil Med 2018; 181:199-204. [PMID: 27168573 DOI: 10.7205/milmed-d-15-00162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
A previous study demonstrated basic proof of principle of the value of a miniature wireless vital signs monitor (MWVSM, MiniMedic, Athena GTX, Des Moines, Iowa) for battlefield triage However, there were unanswered questions related to sensor reliability and uncontrolled conditions in the prehospital environment. This study determined whether MWVSM sensors track vital signs and allow for appropriate triage compared to a gold standard bedside monitor in trauma patients. This was a prospective study in 59 trauma intensive care unit patients. Systolic blood pressure, temperature, heart rate (HR), skin temperature, and pulse oximetry (SpO2) were displayed on a bedside monitor for 60 minutes. Shock index (SI) was calculated. A separate MWVSM monitor was attached to the forehead and finger of each patient. Data from each included pulse wave transit time (PWTT), temperature, HR, SpO2, and a summary status termed "Murphy Factor" (MF), which ranges from 0 to 5. Patients are classified as "routine" if MF = 0 to 1 or SI = 0 to 0.7, "priority" if MF = 2 to 3 or SI = 0.7 to 0.9, and "critical" if MF = 4 to 5 or SI ≥ 0.9. Forehead and finger MWVSM HRs both differed from the monitor (both p < 0.001), but the few beats per minute differences were clinically insignificant. Differences in MWVSM SpO2 (1-7%) and temperature (6-13°F) from the monitor were site specific (all p < 0.001). Forehead PWTT (271 ± 50 ms) was less (p < 0.001) than finger PWTT (315 ± 42 ms); both were dissociated from systolic blood pressure (r(2) < 0.05). The SI distributed patients about equally as "routine," "priority," and "critical," whereas MF overtriaged to "routine" and undertriaged to "critical" for both sensors (all p < 0.001). Our findings suggest that MF does not accurately predict the most critical patients, likely because erroneous PWTT values confound MF calculations. MF and the MWVSM are promising, but require fine-tuning before deployment.
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Affiliation(s)
- Jonathan P Meizoso
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Casey J Allen
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Juliet J Ray
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Robert M Van Haren
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Laura F Teisch
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Xiomara Ruiz Baez
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Alan S Livingstone
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Nicholas Namias
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Carl I Schulman
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
| | - Kenneth G Proctor
- Divisions of Trauma Surgical Critical Care and Burns, DeWitt Daughtry Family Department of Surgery, Ryder Trauma Center, University of Miami Miller School of Medicine, 1800 NW 10th Avenue, Suite T-215 (D-40), Miami, FL 33136
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Allen CJ, Subhawong TK, Hanna MM, Chelala L, Bullock MR, Schulman CI, Proctor KG. Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury? Am Surg 2018. [DOI: 10.1177/000313481808400121] [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: 11/16/2022]
Abstract
Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. Results: To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
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Affiliation(s)
- Casey J. Allen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Ty K. Subhawong
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - Mena M. Hanna
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Lydia Chelala
- Department of Radiology, and, University of Miami Miller School of Medicine, Miami, Florida
| | - M. Ross Bullock
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Carl I. Schulman
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
| | - Kenneth G. Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miami, Florida
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Allen CJ, Subhawong TK, Hanna MM, Chelala L, Bullock MR, Schulman CI, Proctor KG. Does Vasopressin Exacerbate Cerebral Edema in Patients with Severe Traumatic Brain Injury? Am Surg 2018; 84:43-50. [PMID: 29428027] [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: 06/08/2023]
Abstract
UNLABELLED Arginine vasopressin (AVP) is often used as an alternative pressor to catecholamines (CATs). However, unlike CATs, AVP is a powerful antidiuretic that could promote edema. We tested the hypothesis that AVP promoted cerebral edema and/or increased requirements for osmotherapy, relative to those who received CATs, for cerebral perfusion pressure (CPP) management after traumatic brain injury (TBI). This is a retrospective review of 286 consecutive TBI patients with intracranial pressure monitoring at a single institution from September 2008 to January 2015. Cerebral edema was quantitated using CT attenuation in prespecified areas of gray and white matter. RESULTS To maintain CPP >60 mm Hg, 205 patients required no vasopressors, 41 received a single CAT, 12 received AVP, and 28 required both. Those who required no pressors were generally less injured; required less hyperosmolar therapy and less total fluid; and had lower plasma Na, lower intracranial pressure, less edema, and lower mortality (all P < 0.05). Edema; daily mean, minimum, and maximum Na levels; and mortality were similar with AVP versus CATs, but the daily requirement of mannitol and 3 per cent NaCl were reduced by 45 and 35 per cent (both P < 0.05). In patients with TBI who required CPP therapy, AVP reduced the requirements for hyperosmolar therapy and did not delay resolution or increase cerebral edema compared with CATs.
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Meizoso JP, Proctor KG. Persistent Fibrinolysis Shutdown: In reply to Tonglet and colleagues. J Am Coll Surg 2017; 225:832-833. [PMID: 29173340 DOI: 10.1016/j.jamcollsurg.2017.09.007] [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] [Received: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 11/25/2022]
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Allen CJ, Griswold AJ, Schulman CI, Sleeman D, Levi JU, Livingstone AS, Proctor KG. Global Gene Expression Change Induced by Major Thoracoabdominal Surgery. Ann Surg 2017; 266:981-987. [PMID: 27611612 DOI: 10.1097/sla.0000000000001992] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To test the hypothesis that major thoracoabdominal surgery induces gene expression changes associated with adverse outcomes. BACKGROUND Widely different traumatic injuries evoke surprisingly similar gene expression profiles, but there is limited information on whether the iatrogenic injury caused by major surgery is associated with similar patterns. METHODS With informed consent, blood samples were obtained from 50 patients before and after open transhiatal esophagectomy or pancreaticoduodenectomy. Twelve cases with complicated recoveries (death, infection, venous thromboembolism) were matched with 12 cases with uneventful recoveries. Global gene expression was assayed using human microarray chips. A 2-fold change with a corrected P < 0.05 was considered differentially expressed. RESULTS In these 24 patients, 522 genes were differentially expressed after surgery; 248 (48%) were upregulated (innate immunity and inflammation) and 274 (52%) were downregulated [adaptive immunity (antigen presentation, T-cell function)]. Hierarchical clustering of the profile reliably predicted pre- and postoperative status. The within-patient change was 3.08 ± 0.91-fold. There was no measurable association with age, malignancy, procedure, surgery length, operative blood loss, or transfusion requirements, but was positively associated with postoperative infection (3.81 ± 0.97 vs 2.79 ± 0.73; P = 0.009) and hospital length of stay (r = 0.583, P = 0.003). Venous thromboembolism and mortality each occurred in one patient, thus no associations were possible. CONCLUSIONS Major surgery induces a quantifiable pattern of gene expression change that is associated with adverse outcome. This could reflect early impaired adaptive immunity and suggests potential therapeutic targets to improve postoperative recovery.
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Affiliation(s)
- Casey J Allen
- *Division of Trauma and Surgical Critical Care, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL †John P. Hussman Institute for Human Genomics, University of Miami Miller School of Medicine, Miami, FL ‡Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan D, Ruiz XD, Schulman CI, Namias N, Proctor KG. Association of Mechanism of Injury With Risk for Venous Thromboembolism After Trauma. JAMA Surg 2017; 152:35-40. [PMID: 27682749 DOI: 10.1001/jamasurg.2016.3116] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To date, no study has assessed whether the risk of venous thromboembolism (VTE) varies with blunt or penetrating trauma. Objective To test whether the mechanism of injury alters risk of VTE after trauma. Design, Setting, and Participants A retrospective database review was conducted of adults admitted to the intensive care unit of an American College of Surgeons-verified level I trauma center between August 1, 2011, and January 1, 2015, with blunt or penetrating injuries. Univariate and multivariable analyses identified independent predictors of VTE. Main Outcomes and Measures Differences in risk factors for VTE with blunt vs penetrating trauma. Results In 813 patients with blunt trauma (mean [SD] age, 47 [19] years) and 324 patients with penetrating trauma (mean [SD] age, 35 [15] years), the rate of VTE was 9.1% overall (104 of 1137) and similar between groups (blunt trauma, 9% [n = 73] vs penetrating trauma, 9.6% [n = 31]; P = .76). In the blunt trauma group, more patients with VTE than without VTE had abnormal coagulation results (49.3% vs 35.7%; P = .02), femoral catheters (9.6% vs 3.9%; P = .03), repair and/or ligation of vascular injury (15.1% vs 5.4%; P = .001), complex leg fractures (34.2% vs 18.5%; P = .001), Glasgow Coma Scale score less than 8 (31.5% vs 10.7%; P < .001), 4 or more transfusions (51.4% vs 17.6%; P < .001), operation time longer than 2 hours (35.6% vs 16.4%; P < .001), and pelvic fractures (43.8% vs 21.4%; P < .001); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Profile scores (13 [6] vs 8 [4]; P ≤ .001). However, with multivariable analysis, only receiving 4 or more transfusions (odds ratio [OR], 3.47; 95% CI, 2.04-5.91), Glasgow Coma Scale score less than 8 (OR, 2.75; 95% CI, 1.53-4.94), and pelvic fracture (OR, 2.09; 95% CI, 1.23-3.55) predicted VTE, with an area under the receiver operator curve of 0.730. In the penetrating trauma group, more patients with VTE than without VTE had abnormal coagulation results (64.5% vs 44.4%; P = .03), femoral catheters (16.1% vs 5.5%; P = .02), repair and/or ligation of vascular injury (54.8% vs 25.3%; P < .001), 4 or more transfusions (74.2% vs 39.6%; P < .001), operation time longer than 2 hours (74.2% vs 50.5%; P = .01), Abbreviated Injury Score for the abdomen greater than 2 (64.5% vs 42.3%; P = .02), and were aged 40 to 59 years (41.9% vs 23.2%; P = .02); patients with VTE also had higher mean (SD) Greenfield Risk Assessment Profile scores (12 [4] vs 7 [4]; P < .001). However, with multivariable analysis, only repair and/or ligation of vascular injury (OR, 3.32; 95% CI, 1.37-8.03), Abbreviated Injury Score for the abdomen greater than 2 (OR, 2.77; 95% CI, 1.19-6.45), and age 40 to 59 years (OR, 2.69; 95% CI, 1.19-6.08) predicted VTE, with an area under the receiver operator curve of 0.760. Conclusions and Relevance Although rates of VTE are the same in patients who experienced blunt and penetrating trauma, the independent risk factors for VTE are different based on mechanism of injury. This finding should be a consideration when contemplating prophylactic treatment protocols.
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Affiliation(s)
- Charles A Karcutskie
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Jonathan P Meizoso
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Juliet J Ray
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Davis Horkan
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Xiomara D Ruiz
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Carl I Schulman
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Kenneth G Proctor
- Ryder Trauma Center, Division of Trauma and Surgical Critical Care Services, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida2Ryder Trauma Center, Division of Burns, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan DB, Ruiz XD, Schulman CI, Namias N, Proctor KG. Mechanism of Injury May Influence Infection Risk from Early Blood Transfusion. Surg Infect (Larchmt) 2017; 18:83-88. [DOI: 10.1089/sur.2016.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Charles A. Karcutskie
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Jonathan P. Meizoso
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Juliet J. Ray
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Davis B. Horkan
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Xiomara D. Ruiz
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Carl I. Schulman
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Nicholas Namias
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Kenneth G. Proctor
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
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Meizoso JP, Karcutskie CA, Ray JJ, Namias N, Schulman CI, Proctor KG. Persistent Fibrinolysis Shutdown Is Associated with Increased Mortality in Severely Injured Trauma Patients. J Am Coll Surg 2016; 224:575-582. [PMID: 28017804 DOI: 10.1016/j.jamcollsurg.2016.12.018] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Acute fibrinolysis shutdown is associated with early mortality after trauma; however, no previous studies have investigated the incidence of persistent fibrinolysis or its association with mortality. We tested the hypothesis that persistent fibrinolysis shutdown is associated with mortality in critically ill trauma patients. STUDY DESIGN Thromboelastography was performed on ICU admission in 181 adult trauma patients and at 1 week in a subset of 78 patients. Fibrinolysis shutdown was defined as LY30 ≤ 0.8% and was considered transient if resolved by 1 week postinjury or persistent if not. Logistic regression adjusted for age, sex, hemodynamics, and Injury Severity Score (ISS). RESULTS Median age was 52 years, 88% were male, and median ISS was 27, with 56% transient fibrinolysis shutdown, 44% persistent fibrinolysis shutdown and 12% mortality. Median LY30 was 0.23% (interquartile range [IQR] 0% to 1.20%) at admission and 0.10% (IQR 0% to 2.05%) at 1 week. Transient shutdown more often occurred after head injury (p = 0.019); persistent shutdown was more often associated with penetrating injury (29% vs 9%; p = 0.020), lower LY30 at ICU admission (0.10% vs 1.15%; p < 0.0001) and at 1 week (0% vs 1.68%; p < 0.0001), and higher mortality (21% vs 5%; p = 0.036). Persistent fibrinolysis shutdown was associated with admission LY30 (odds ratio [OR] 0.05; 95% CI 0.01 to 0.34; p = 0.002) and transfusion of packed RBCs (OR 0.81; 95% CI 0.68 to 0.97; p = 0.021) and platelets (OR 2.81; 95% CI 1.16 to 6.84; p = 0.022); moreover, it was an independent predictor of mortality (OR 8.48; 95% CI 1.35 to 53.18; p = 0.022). CONCLUSIONS Persistent fibrinolysis shutdown is associated with late mortality after trauma. A high index of suspicion should be maintained, especially in patients with penetrating injury, reduced LY30 on admission, and/or receiving blood product transfusion. Judicious use of tranexamic acid is advised in this cohort.
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Affiliation(s)
- Jonathan P Meizoso
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Charles A Karcutskie
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Juliet J Ray
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Nicholas Namias
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Carl I Schulman
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Kenneth G Proctor
- Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL.
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Meizoso JP, Ray JJ, Karcutskie CA, Teisch LF, Allen CJ, Namias N, Schulman CI, Proctor KG. Admission hyperglycemia is associated with different outcomes after blunt versus penetrating trauma. J Surg Res 2016; 206:83-89. [DOI: 10.1016/j.jss.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/24/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
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Karcutskie CA, Meizoso JP, Ray JJ, Horkan DB, Ruiz X, Livingstone AS, Schulman CI, Ginzburg E, Namias N, Proctor KG. Transfusion of Packed Red Blood Cells and Fresh Frozen Plasma are Synergistic Risk Factors for Venous Thromboembolism in Trauma Patients. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Allen CJ, Straker RJ, Murray CR, Hannay WM, Hanna MM, Meizoso JP, Manning RJ, Schulman CI, Seery JM, Proctor KG. Recent Advances in Forward Surgical Team Training at the U.S. Army Trauma Training Department. Mil Med 2016; 181:553-9. [DOI: 10.7205/milmed-d-15-00084] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Allen CJ, Meizoso JP, Ray JJ, Teisch LF, Schulman CI, Namias N, Proctor KG. Does Isolated Hemoperitoneum Cause Peritonitis? A Review of 400 Trauma Laparotomies. Am Surg 2016; 82:184-186. [PMID: 26874145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Casey J Allen
- Dewitt Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, Miller School of Medicine, University of Miami, Miami, Florida, USA
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Allen CJ, Meizoso JP, Ray JJ, Teisch LF, Schulman CI, Namias N, Proctor KG. Does Isolated Hemoperitoneum Cause Peritonitis? A Review of 400 Trauma Laparotomies. Am Surg 2016. [DOI: 10.1177/000313481608200226] [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: 11/17/2022]
Affiliation(s)
- Casey J. Allen
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Jonathan P. Meizoso
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Juliet J. Ray
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Laura F. Teisch
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Carl I. Schulman
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Nicholas Namias
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
| | - Kenneth G. Proctor
- Dewitt Daughtry Department of Surgery Divisions of Trauma and Surgical Critical Care Miller School of Medicine University of Miami Miami, Florida
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Allen CJ, Murray CR, Meizoso JP, Ray JJ, Neville HL, Schulman CI, Namias N, Sola JE, Proctor KG. Risk factors for venous thromboembolism after pediatric trauma. J Pediatr Surg 2016; 51:168-71. [PMID: 26547285 DOI: 10.1016/j.jpedsurg.2015.10.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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: 10/03/2015] [Accepted: 10/09/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE The purposes of this study were to identify independent predictors of venous thromboembolism (VTE), to evaluate the relative impact of adult VTE risk factors, and to identify a pediatric population at high-risk for VTE after trauma. METHODS 1934 consecutive pediatric admissions (≤ 17 years) from 01/2000 to 12/2012 at a level 1 trauma center were reviewed. Logistic regression was used to identify predictors of VTE. RESULTS Twenty-two patients (1.2%) developed a VTE, including 5% of those requiring orthopedic surgery, 14% of those with major vascular injury (MVI), and 36% of those with both. Most (84%) were diagnosed at the primary site of injury. 86% of those who developed a VTE were receiving thromboprophylaxis at the time of diagnosis. Independent predictors were age (odds ratio (OR): 1.59, 95% confidence interval (CI): 1.11-2.25), orthopedic surgery (OR: 8.10, CI: 3.10-21.39), transfusion (OR: 3.37, CI: 1.26-8.99), and MVI (OR: 15.43, CI: 5.70-41.76). When known risk factors for VTE in adults were adjusted, significant factors were age ≥ 13 years (OR: 9.16, CI: 1.08-77.89), indwelling central venous catheter (OR: 4.41, CI: 1.31-14.82), orthopedic surgery (OR: 6.80, CI: 2.47-18.74), and MVI (OR: 14.41, CI: 4.60-45.13). CONCLUSION MVI and orthopedic surgery are synergistic predictors of pediatric VTE. Most children who developed a VTE were receiving thromboprophylaxis at the time of diagnosis.
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Affiliation(s)
- Casey J Allen
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Clark R Murray
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jonathan P Meizoso
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juliet J Ray
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Holly L Neville
- Division of Pediatric Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Carl I Schulman
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nicholas Namias
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- Division of Pediatric Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Kenneth G Proctor
- Division of Trauma and Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Allen CJ, Murray CR, Meizoso JP, Ginzburg E, Schulman CI, Lineen EB, Namias N, Proctor KG. Surveillance and Early Management of Deep Vein Thrombosis Decreases Rate of Pulmonary Embolism in High-Risk Trauma Patients. J Am Coll Surg 2015; 222:65-72. [PMID: 26616034 DOI: 10.1016/j.jamcollsurg.2015.10.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/12/2015] [Accepted: 10/13/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Venous duplex ultrasound (VDU) is the modality of choice for surveillance of venous thromboembolism (VTE), but there is controversy about its appropriate implementation as a screening method. We hypothesize that VDU surveillance in trauma patients at high risk for VTE decreases the rate of pulmonary embolism (PE). STUDY DESIGN One thousand two hundred and eighty-two trauma ICU admissions were screened with Greenfield's Risk Assessment Profile from August 2011 to September 2014. Four hundred and two patients were identified as high risk for VTE (Risk Assessment Profile ≥10). Those who received weekly VDU to evaluate for deep vein thrombosis (n = 259 [64%]) were compared with those who did not (n = 143 [36%]). Parametric data are reported as mean ± SD and nonparametric data are reported as median (interquartile range). Statistical significance was determined at an α level of 0.05. RESULTS The overall study population was 47 ± 19 years old and 75% were male, 78% of injuries were blunt mechanism, Injury Severity Score was 28 ± 13, Risk Assessment Profile was 14 ± 4, and mortality was 14.3%. Deep vein thrombosis rate was 11.6% (n = 30) in the surveillance group vs 2.1% (n = 3) in the non-surveillance group (p < 0.001). Deep vein thromboses detected in the surveillance group were managed with systemic anticoagulation (43%) or with IVC filter placement (57%). In the surveillance group, the PE rate was 1.9% (n = 5) vs 7.0% (n = 10) in the non-surveillance group (p = 0.014). CONCLUSIONS Trauma patients at high risk for VTE and who received VDU surveillance and early management of deep vein thrombosis have decreased rates of pulmonary embolism.
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Affiliation(s)
- Casey J Allen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Clark R Murray
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Jonathan P Meizoso
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Enrique Ginzburg
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Carl I Schulman
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Edward B Lineen
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Nicholas Namias
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL
| | - Kenneth G Proctor
- Dewitt-Daughtry Department of Surgery, Divisions of Trauma and Surgical Critical Care, University of Miami, Miller School of Medicine, Miami, FL.
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Allen CJ, Meizoso JP, Kaufman J, Teisch LF, Ruiz XD, Van Haren RM, Schulman CI, Lineen EB, Namias N, Proctor KG. Surveillance and Early Management of Deep Vein Thrombosis Decreases the Rate of Pulmonary Embolism in High-Risk Trauma Patients. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.400] [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: 10/23/2022]
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Meizoso JP, Teisch LF, Ray JJ, Allen CJ, Livingstone AS, Namias N, Schulman CI, Proctor KG. Admission hyperglycemia is not just a marker of injury severity after trauma. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.273] [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: 10/22/2022]
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