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Mazzei M, Donohue JK, Schreiber M, Rowell S, Guyette FX, Cotton B, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Brown JB, Neal MD, Sperry JL. Prehospital tranexamic acid is associated with a survival benefit without an increase in complications: results of two harmonized randomized clinical trials. J Trauma Acute Care Surg 2024:01586154-990000000-00670. [PMID: 38523128 DOI: 10.1097/ta.0000000000004315] [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: 03/26/2024]
Abstract
INTRODUCTION Recent randomized clinical trials have demonstrated that prehospital tranexamic acid (TXA) administration following injury is safe and improves survival. However, the effect of prehospital TXA on adverse events, transfusion requirements and any dose response relationships require further elucidation. METHODS A secondary analysis was performed using harmonized data from two large, double-blinded, randomized prehospital TXA trials. Outcomes, including 28-day mortality, pertinent adverse events and 24-hour red cell transfusion requirements were compared between TXA and placebo groups. Regression analyses were utilized to determine the independent associations of TXA after adjusting for study enrollment, injury characteristics and shock severity across a broad spectrum of injured patients. Dose response relationships were similarly characterized based upon grams of prehospital TXA administered. RESULTS A total of 1744 patients had data available for secondary analysis and were included in the current harmonized secondary analysis. The study cohort had an overall mortality of 11.2% and a median injury severity score of 16 (IQR: 5-26). TXA was independently associated with a lower risk of 28-day mortality (HR: 0.72, 95% CI 0.54, 0.96, p = 0.03). Prehospital TXA also demonstrated an independent 22% lower risk of mortality for every gram of prehospital TXA administered (HR: 0.78, 95% CI 0.63, 0.96, p = 0.02). Multivariable linear regression verified that patients who received TXA were independently associated with lower 24-hour red cell transfusion requirements (β: -0.31, 95% CI -0.61, -0.01, p = 0.04) with a dose-response relationship (β: -0.24, 95% CI -0.45, -0.02, p = 0.03). There was no independent association of prehospital TXA administration on VTE, seizure, or stroke. CONCLUSIONS In this secondary analysis of harmonized data from two large randomized interventional trials, prehospital TXA administration across a broad spectrum of injured patients is safe. Prehospital TXA is associated with a significant 28-day survival benefit, lower red cell transfusion requirements at 24 hours and demonstrates a dose-response relationship. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
| | | | - Martin Schreiber
- Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Susan Rowell
- Department of Surgery, University of Chicago, Chicago, IL
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Houston, Houston, TX
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Donohue JK, Iyanna N, Lorence JM, Brown JB, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL. Missingness matters: a secondary analysis of thromboelastography measurements from a recent prehospital randomized tranexamic acid clinical trial. Trauma Surg Acute Care Open 2024; 9:e001346. [PMID: 38375027 PMCID: PMC10875568 DOI: 10.1136/tsaco-2023-001346] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/31/2024] [Indexed: 02/21/2024] Open
Abstract
Background Tranexamic acid (TXA) has been hypothesized to mitigate coagulopathy in patients after traumatic injury. Despite previous prehospital clinical trials demonstrating a TXA survival benefit, none have demonstrated correlated changes in thromboelastography (TEG) parameters. We sought to analyze if missing TEG data contributed to this paucity of findings. Methods We performed a secondary analysis of the Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport Trial. We compared patients that received TEG (YES-TEG) and patients unable to be sampled (NO-TEG) to analyze subgroups in which to investigate TEG differences. TEG parameter differences across TXA intervention arms were assessed within subgroups disproportionately present in the NO-TEG relative to the YES-TEG cohort. Generalized linear models controlling for potential confounders were applied to findings with p<0.10 on univariate analysis. Results NO-TEG patients had lower prehospital systolic blood pressure (SBP) (100 (78, 140) vs 125 (88, 147), p<0.01), lower prehospital Glascow Coma Score (14 (3, 15) vs 15 (12, 15), p<0.01), greater rates of prehospital intubation (39.4% vs 24.4%, p<0.01) and greater mortality at 30 days (36.4% vs 6.8%, p<0.01). NO-TEG patients had a greater international normalized ratio relative to the YES-TEG subgroup (1.2 (1.1, 1.5) vs 1.1 (1.0, 1.2), p=0.04). Within a severe prehospital shock cohort (SBP<70), TXA was associated with a significant decrease in clot lysis at 30 min on multivariate analysis (β=-27.6, 95% CI (-51.3 to -3.9), p=0.02). Conclusions Missing data, due to the logistical challenges of sampling certain severely injured patients, may be associated with a lack of TEG parameter changes on TXA administration in the primary analysis. Previous demonstration of TXA's survival benefit in patients with severe prehospital shock in tandem with the current findings supports the notion that TXA acts at least partially by improving clot integrity. Level of evidence Level II.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Frances X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Terence O'Keeffe
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Donohue JK, Gruen DS, Iyanna N, Lorence JM, Brown JB, Guyette FX, Daley BJ, Eastridge BJ, Miller RS, Nirula R, Harbrecht BG, Claridge JA, Phelan HA, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Billiar TR, Sperry JL. Mechanism matters: mortality and endothelial cell damage marker differences between blunt and penetrating traumatic injuries across three prehospital clinical trials. Sci Rep 2024; 14:2747. [PMID: 38302619 PMCID: PMC10834504 DOI: 10.1038/s41598-024-53398-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/31/2024] [Indexed: 02/03/2024] Open
Abstract
Injury mechanism is an important consideration when conducting clinical trials in trauma. Mechanisms of injury may be associated with differences in mortality risk and immune response to injury, impacting the potential success of the trial. We sought to characterize clinical and endothelial cell damage marker differences across blunt and penetrating injured patients enrolled in three large, prehospital randomized trials which focused on hemorrhagic shock. In this secondary analysis, patients with systolic blood pressure < 70 or systolic blood pressure < 90 and heart rate > 108 were included. In addition, patients with both blunt and penetrating injuries were excluded. The primary outcome was 30-day mortality. Mortality was characterized using Kaplan-Meier and Cox proportional-hazards models. Generalized linear models were used to compare biomarkers. Chi squared tests and Wilcoxon rank-sum were used to compare secondary outcomes. We characterized data of 696 enrolled patients that met all secondary analysis inclusion criteria. Blunt injured patients had significantly greater 24-h (18.6% vs. 10.7%, log rank p = 0.048) and 30-day mortality rates (29.7% vs. 14.0%, log rank p = 0.001) relative to penetrating injured patients with a different time course. After adjusting for confounders, blunt mechanism of injury was independently predictive of mortality at 30-days (HR 1.84, 95% CI 1.06-3.20, p = 0.029), but not 24-h (HR 1.65, 95% CI 0.86-3.18, p = 0.133). Elevated admission levels of endothelial cell damage markers, VEGF, syndecan-1, TM, S100A10, suPAR and HcDNA were associated with blunt mechanism of injury. Although there was no difference in multiple organ failure (MOF) rates across injury mechanism (48.4% vs. 42.98%, p = 0.275), blunt injured patients had higher Denver MOF score (p < 0.01). The significant increase in 30-day mortality and endothelial cell damage markers in blunt injury relative to penetrating injured patients highlights the importance of considering mechanism of injury within the inclusion and exclusion criteria of future clinical trials.
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Affiliation(s)
- Jack K Donohue
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Danielle S Gruen
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nidhi Iyanna
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - John M Lorence
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | - Brian J Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | | | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Department of Surgery, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Timothy R Billiar
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA.
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Matta R, Keihani S, Hebert K, Horns JJ, Nirula R, McCrum M, McCormick BJ, Gross JA, Joyce RP, Rogers DM, Wang SS, Hagedorn JC, Selph JP, Sensenig RL, Moses RA, Dodgion CM, Gupta S, Mukherjee K, Majercik S, Broghammer JA, Schwartz I, Elliott SP, Breyer BN, Baradaran N, Zakaluzny S, Erickson BA, Miller BD, Askari R, Carrick MM, Burks FN, Norwood S, Myers JB. PROPOSED REVISION OF THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA RENAL TRAUMA ORGAN INJURY SCALE: SECONDARY ANALYSIS OF THE MULTI-INSTITUTIONAL GENITOURINARY TRAUMA STUDY. J Trauma Acute Care Surg 2024:01586154-990000000-00628. [PMID: 38319246 DOI: 10.1097/ta.0000000000004232] [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: 02/07/2024]
Abstract
BACKGROUND This study updates the American Association for Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS This was a secondary analysis of a multi-center retrospective study including patients with high grade renal trauma from 7 Level-1 trauma centers from 2013-2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells (PRBCs) transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the receiver-operator curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST organ injury scale. RESULTS based on the 2018 OIS grading system, we included 549 patients with AAST Grade III-V injuries and CT scans (III: 52% (n = 284), IV: 45% (n = 249), and V: 3% (n = 16)). Among these patients, 89% experienced blunt injury (n = 491) and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC = 0.805, revised AUC = 0.883; p = 0.001) and number of units of PRBCs transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSIONS A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Rano Matta
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sorena Keihani
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kevin Hebert
- Department of Surgery, Louisiana State University Health Shreveport, Shreveport, LA, USA
| | - Joshua J Horns
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Marta McCrum
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Joel A Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Ryan P Joyce
- NYU Grossman School of Medicine, New York, NY, USA
| | - Douglas M Rogers
- Department of Radiology, University of Utah Salt Lake City, UT, USA
| | | | - Judith C Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, Washington
| | - J Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rachel L Sensenig
- Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Rachel A Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Shubham Gupta
- Department of Urology, Case Western Reserve University, Cleveland, OH, USA
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Murray, UT, USA
| | | | - Ian Schwartz
- Department of Urology, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN, USA
| | - Benjamin N Breyer
- Department of Urology, University of California - San Francisco, San Francisco, CA, USA
| | - Nima Baradaran
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Scott Zakaluzny
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Brandi D Miller
- Department of Urology, Detroit Medical Center, Detroit, MI, USA
| | - Reza Askari
- Division of Trauma, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Frank N Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Scott Norwood
- Department of Surgery, UT Health Tyler, Tyler, TX, USA
| | - Jeremy B Myers
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
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Albert RK, Jurkovich GJ, Connett J, Helgeson ES, Keniston A, Voelker H, Lindberg S, Proper JL, Bochicchio G, Stein DM, Cain C, Tesoriero R, Brown CVR, Davis J, Napolitano L, Carver T, Cipolle M, Cardenas L, Minei J, Nirula R, Doucet J, Miller PR, Johnson J, Inaba K, Kao L. Sigh Ventilation in Patients With Trauma: The SiVent Randomized Clinical Trial. JAMA 2023; 330:1982-1990. [PMID: 37877609 PMCID: PMC10600720 DOI: 10.1001/jama.2023.21739] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023]
Abstract
Importance Among patients receiving mechanical ventilation, tidal volumes with each breath are often constant or similar. This may lead to ventilator-induced lung injury by altering or depleting surfactant. The role of sigh breaths in reducing ventilator-induced lung injury among trauma patients at risk of poor outcomes is unknown. Objective To determine whether adding sigh breaths improves clinical outcomes. Design, Setting, and Participants A pragmatic, randomized trial of sigh breaths plus usual care conducted from 2016 to 2022 with 28-day follow-up in 15 academic trauma centers in the US. Inclusion criteria were age older than 18 years, mechanical ventilation because of trauma for less than 24 hours, 1 or more of 5 risk factors for developing acute respiratory distress syndrome, expected duration of ventilation longer than 24 hours, and predicted survival longer than 48 hours. Interventions Sigh volumes producing plateau pressures of 35 cm H2O (or 40 cm H2O for inpatients with body mass indexes >35) delivered once every 6 minutes. Usual care was defined as the patient's physician(s) treating the patient as they wished. Main Outcomes and Measures The primary outcome was ventilator-free days. Prespecified secondary outcomes included all-cause 28-day mortality. Results Of 5753 patients screened, 524 were enrolled (mean [SD] age, 43.9 [19.2] years; 394 [75.2%] were male). The median ventilator-free days was 18.4 (IQR, 7.0-25.2) in patients randomized to sighs and 16.1 (IQR, 1.1-24.4) in those receiving usual care alone (P = .08). The unadjusted mean difference in ventilator-free days between groups was 1.9 days (95% CI, 0.1 to 3.6) and the prespecified adjusted mean difference was 1.4 days (95% CI, -0.2 to 3.0). For the prespecified secondary outcome, patients randomized to sighs had 28-day mortality of 11.6% (30/259) vs 17.6% (46/261) in those receiving usual care (P = .05). No differences were observed in nonfatal adverse events comparing patients with sighs (80/259 [30.9%]) vs those without (80/261 [30.7%]). Conclusions and Relevance In a pragmatic, randomized trial among trauma patients receiving mechanical ventilation with risk factors for developing acute respiratory distress syndrome, the addition of sigh breaths did not significantly increase ventilator-free days. Prespecified secondary outcome data suggest that sighs are well-tolerated and may improve clinical outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT02582957.
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Affiliation(s)
| | | | - John Connett
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | | | - Helen Voelker
- Division of Biostatistics, University of Minnesota, Minneapolis
| | - Sarah Lindberg
- Division of Biostatistics, University of Minnesota, Minneapolis
| | | | - Grant Bochicchio
- Department of Surgery, Washington University, St Louis, St Louis, Missouri
| | | | - Christian Cain
- Department of Surgery, University of Maryland, Baltimore
| | - Ron Tesoriero
- Department of Surgery, University of Maryland, Baltimore
| | | | - James Davis
- Department of Surgery, University of California San Francisco, Fresno
| | | | - Thomas Carver
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Mark Cipolle
- Department of Surgery, Lehigh Valley Health Network, Bethlehem, Pennsylvania
| | - Luis Cardenas
- Department of Surgery, Christiana Care Health System, Wilmington, Delaware
| | - Joseph Minei
- Department of Surgery, University of Texas Southwestern, Dallas
| | | | - Jay Doucet
- Department of Surgery, University of California San Diego
| | - Preston R. Miller
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeffrey Johnson
- Department of Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Kenji Inaba
- Department of Surgery, University of Southern California Los Angeles County
| | - Lillian Kao
- Department of Surgery, University of Texas, Houston
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Gruen DS, Brown JB, Guyette FX, Johansson PI, Stensballe J, Li SR, Leeper CM, Eastridge BJ, Nirula R, Vercruysse GA, O’Keeffe T, Joseph B, Neal MD, Sperry JL. Prehospital tranexamic acid is associated with a dose-dependent decrease in syndecan-1 after trauma: A secondary analysis of a prospective randomized trial. J Trauma Acute Care Surg 2023; 95:642-648. [PMID: 37125811 PMCID: PMC10615664 DOI: 10.1097/ta.0000000000003955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/25/2023] [Accepted: 03/02/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND In the Study of Tranexamic Acid During Air and Ground Prehospital Transport (STAAMP) Trial, prehospital tranexamic acid (TXA) was associated with lower mortality in specific patient subgroups. The underlying mechanisms responsible for a TXA benefit remain incompletely characterized. We hypothesized that TXA may mitigate endothelial injury and sought to assess whether TXA was associated with decreased endothelial or tissue damage markers among all patients enrolled in the STAAMP Trial. METHODS We collected blood samples from STAAMP Trial patients and measured markers of endothelial function and tissue damage including syndecan-1, soluble thrombomodulin (sTM), and platelet endothelial cell adhesion molecule-1 at hospital admission (0 hours) and 12 hours, 24 hours, and 72 hours after admission. We compared these marker values for patients in each treatment group during the first 72 hours, and modeled the relationship between TXA and marker concentration using regression analysis to control for potential confounding factors. RESULTS We analyzed samples from 766 patients: 383 placebo, 130 abbreviated dosing, 119 standard dosing, and 130 repeat dosing. Lower levels of syndecan-1, TM, and platelet endothelial cell adhesion molecule measured within the first 72 hours of hospital admission were associated with survival at 30 days ( p < 0.001). At hospital admission, syndecan-1 was lower in the TXA group (28.30 [20.05, 42.75] vs. 33.50 [23.00, 54.00] p = 0.001) even after controlling for patient, injury, and prehospital factors ( p = 0.001). For every 1 g increase in TXA administered over the first 8 hours of prehospital transport and hospital admission, there was a 4-ng/mL decrease in syndecan-1 at 12 hours controlling for patient, injury, and treatment factors ( p = 0.03). CONCLUSION Prehospital TXA was associated with decreased syndecan-1 at hospital admission. Syndecan-1 measured 12 hours after admission was inversely related to the dose of TXA received. Early prehospital and in-hospital TXA may decrease endothelial glycocalyx damage or upregulate vascular repair mechanisms in a dose-dependent fashion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Deeb AP, Guyette FX, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge BJ, Joseph B, Nirula R, Vercruysse GA, Sperry JL, Brown JB. Time to early resuscitative intervention association with mortality in trauma patients at risk for hemorrhage. J Trauma Acute Care Surg 2023; 94:504-512. [PMID: 36728324 PMCID: PMC10038862 DOI: 10.1097/ta.0000000000003820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death after injury. Others have shown that delays in massive transfusion cooler arrival increase mortality, while prehospital blood product resuscitation can reduce mortality. Our objective was to evaluate if time to resuscitation initiation impacts mortality. METHODS We combined data from the Prehospital Air Medical Plasma (PAMPer) trial in which patients received prehospital plasma or standard care and the Study of Tranexamic Acid during Air and ground Medical Prehospital transport (STAAMP) trial in which patients received prehospital tranexamic acid or placebo. We evaluated the time to early resuscitative intervention (TERI) as time from emergency medical services arrival to packed red blood cells, plasma, or tranexamic acid initiation in the field or within 90 minutes of trauma center arrival. For patients not receiving an early resuscitative intervention, the TERI was calculated based on trauma center arrival as earliest opportunity to receive a resuscitative intervention and were propensity matched to those that did to account for selection bias. Mixed-effects logistic regression assessed the association of 30-day and 24-hour mortality with TERI adjusting for confounders. We also evaluated a subgroup of only patients receiving an early resuscitative intervention as defined above. RESULTS Among the 1,504 propensity-matched patients, every 1-minute delay in TERI was associated with 2% increase in the odds of 30-day mortality (adjusted odds ratio [aOR], 1.020; 95% confidence interval [CI], 1.006-1.033; p < 0.01) and 1.5% increase in odds of 24-hour mortality (aOR, 1.015; 95% CI, 1.001-1.029; p = 0.03). Among the 799 patients receiving an early resuscitative intervention, every 1-minute increase in TERI was associated with a 2% increase in the odds of 30-day mortality (aOR, 1.021; 95% CI, 1.005-1.038; p = 0.01) and 24-hour mortality (aOR, 1.023; 95% CI, 1.005-1.042; p = 0.01). CONCLUSION Time to early resuscitative intervention is associated with morality in trauma patients with hemorrhagic shock. Bleeding patients need resuscitation initiated early, whether at the trauma center in systems with short prehospital times or in the field when prehospital time is prolonged. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., J.B.B.), and Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.D.), University of Tennessee Health Science Center, Knoxville, Tennessee; Department of Surgery (R.S.M.), John Peter Smith Health Network, Fort Worth, Texas; Department of Surgery (B.G.H.), University of Louisville, Louisville, Kentucky;Department of Surgery (J.A.C.), MetroHealth Medical Center/Case Western Reserve University, Cleveland, Ohio; Department of Surgery (H.A.P.), Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (B.J., G.A.V.), University of Arizona, Tucson, Arizona; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Trauma and General Surgery, Department of Surgery (J.L.S.), University of Pittsburgh, Pittsburgh, Pennsylvania
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Mukherjee K, Schubl SD, Tominaga G, Cantrell S, Kim B, Haines KL, Kaups KL, Barraco R, Staudenmayer K, Knowlton LM, Shiroff AM, Bauman ZM, Brooks SE, Kaafarani H, Crandall M, Nirula R, Agarwal SK, Como JJ, Haut ER, Kasotakis G. Non-surgical management and analgesia strategies for older adults with multiple rib fractures: A systematic review, meta-analysis, and joint practice management guideline from the Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society. J Trauma Acute Care Surg 2023; 94:398-407. [PMID: 36730672 DOI: 10.1097/ta.0000000000003830] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/04/2023]
Abstract
BACKGROUND Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry (IS), noninvasive positive pressure ventilation (NIPPV), and the use of ketamine, epidural, and other locoregional approaches to analgesia. METHODS Relevant questions regarding older patients with significant chest wall injury with patient population(s), intervention(s), comparison(s), and appropriate selected outcomes were chosen. These focused on intensive care unit (ICU) admission, IS, NIPPV, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review were conducted, our data were analyzed qualitatively and quantitatively, and the quality of evidence was assessed per the Grading of Recommendations Assessment, Development, and Evaluation methodology. No funding was used. RESULTS Our literature review (PROSPERO 2020-CRD42020201241, MEDLINE, EMBASE, Cochrane, Web of Science, January 15, 2020) resulted in 151 studies. Intensive care unit admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor IS performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia ( p < 0.0001) and 81% reduction in odds of mortality ( p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay, or mortality. CONCLUSION We do not recommend for or against routine ICU admission. We recommend use of IS to inform ICU status and conditionally recommend use of NIPPV in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural, or other locoregional analgesia. LEVEL OF EVIDENCE Systematic Review/Meta-analysis; Level IV.
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Affiliation(s)
- Kaushik Mukherjee
- From the Division of Acute Care Surgery, Loma Linda University Medical Center (K.M.), Loma Linda; University of California Irvine Medical Center (S.D.S.), Irvine; Scripps Memorial La Jolla (G.T.), San Diego, California; Division of Trauma and Critical Care Surgery, Department of Surgery (S.C., K.L.H., S.K.A., G.K.), Duke University Medical Center, Durham, North Carolina; The Mayo Clinic (B.K.), Rochester, Minnesota; University of California San Francisco-Fresno (K.L.K.), Fresno, California; Lehigh Valley Health Network (R.B.), Allentown, Pennsylvania; Stanford University Medical Center (K.S., L.M.K.), Palo Alto, California; University of Pennsylvania Medical Center (A.M.S.), Philadelphia, Pennsylvania; University of Nebraska Medical Center (Z.M.B.), Omaha, Nevada; Texas Tech University Health Sciences Center (S.E.B.), Lubbock, Texas; Massachusetts General Hospital (H.K.), Boston, Massachusetts; University of Florida College of Medicine (M.C.), Jacksonville, Florida; University of Utah Medical Center (R.N.), Salt Lake City, Utah; MetroHealth Cleveland Medical Center (J.J.C.), Cleveland, Ohio; Johns Hopkins Medical Center (E.R.H.), Baltimore, Maryland
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9
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Campwala I, Guyette FX, Brown JB, Yazer MH, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Eastridge B, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Zuckerbraun BS, Sperry JL. Evaluation of critical care burden following traumatic injury from two randomized controlled trials. Sci Rep 2023; 13:1106. [PMID: 36670216 PMCID: PMC9860020 DOI: 10.1038/s41598-023-28422-5] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Trauma resuscitation practices have continued to improve with new advances targeting prehospital interventions. The critical care burden associated with severely injured patients at risk of hemorrhage has been poorly characterized. We aim to describe the individual and additive effects of multiorgan failure (MOF) and nosocomial infection (NI) on delayed mortality and resource utilization. A secondary analysis of harmonized data from two large prehospital randomized controlled trials (Prehospital Air Medical Plasma (PAMPer) Trial and Study of Tranexamic Acid during Air and Ground Medical Prehospital Transport (STAAMP) Trial) was conducted. Only those patients who survived beyond the first 24 hours post-injury and spent at least one day in the ICU were included. Patients were stratified by development of MOF only, NI only, both, or neither and diagnosis of early (≤ 3 days) versus late MOF (> 3 days). Risk factors of NI and MOF, time course of these ICU complications, associated mortality, and hospital resource utilization were evaluated. Of the 869 patients who were enrolled in PAMPer and STAAMP and who met study criteria, 27.4% developed MOF only (n = 238), 10.9% developed NI only (n = 95), and 15.3% were diagnosed with both MOF and NI (n = 133). Patients developing NI and/or MOF compared to those who had an uncomplicated ICU course had greater injury severity, lower GCS, and greater shock indexes. Early MOF occurred in isolation, while late MOF more often followed NI. MOF was associated with 65% higher independent risk of 30-day mortality when adjusting for cofounders (OR 1.65; 95% CI 1.04-2.6; p = 0.03), however NI did not significantly affect odds of mortality. NI was individually associated with longer mechanical ventilation, ICU stay, hospital stay, and rehabilitation requirements, and the addition of MOF further increased the burden of inpatient and post-discharge care. MOF and NI remain common complications for those who survive traumatic injury. MOF is a robust independent predictor of mortality following injury in this cohort, and NI is associated with higher resource utilization. Timing of these ICU complications may reveal differences in pathophysiology and offer targets for continued advancements in treatment.
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Affiliation(s)
- Insiyah Campwala
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Mark H Yazer
- The Institute for Transfusion Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brian J Daley
- Department of Surgery, University of Tennessee Health Science Center, Knoxville, TN, USA
| | | | - Brian G Harbrecht
- Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Jeffrey A Claridge
- Department of Surgery, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Herbert A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Brian Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Matthew D Neal
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Brian S Zuckerbraun
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Jason L Sperry
- Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA.
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10
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Place A, McCrum M, Bell T, Nirula R. EGS plus: Predicting futility in LVAD patients with emergency surgical disease. Am J Surg 2022; 224:1421-1425. [PMID: 36319484 DOI: 10.1016/j.amjsurg.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND While emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making. METHODS The Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance. RESULTS There were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70-65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50-8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%. CONCLUSION Older LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.
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Affiliation(s)
- Aubrey Place
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Marta McCrum
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
| | - Teresa Bell
- Department of Surgery, University of Utah School of Medicine, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah School of Medicine, USA; Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
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11
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Deeb AP, Hoteit L, Li S, Guyette FX, Eastridge BJ, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Sperry JL, Brown JB. Prehospital synergy: Tranexamic acid and blood transfusion in patients at risk for hemorrhage. J Trauma Acute Care Surg 2022; 93:52-58. [PMID: 35393385 PMCID: PMC9233003 DOI: 10.1097/ta.0000000000003620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage. METHODS We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders. RESULTS A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45-0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17-0.88; p = 0.02). CONCLUSION For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Andrew-Paul Deeb
- From the Division of Trauma and General Surgery, Department of Surgery (A.-P.D., L.H., S.L., M.D.N., J.L.S., J.B.B.), Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery (B.J.E.), University of Texas Health San Antonio, San Antonio, Texas; Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; and Department of Surgery (G.A.V., T.O.K., B.J.), University of Arizona, Tucson, Arizona
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12
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Li SR, Guyette F, Brown J, Zenati M, Reitz KM, Eastridge B, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Zuckerbraun BS, Sperry JL. Early Prehospital Tranexamic Acid Following Injury Is Associated With a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial. Ann Surg 2021; 274:419-426. [PMID: 34132695 PMCID: PMC8480233 DOI: 10.1097/sla.0000000000005002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND TXA has been shown to be safe in the prehospital setting post-injury. METHODS We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Francis Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Brian Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
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13
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Walker HR, Evans E, Nirula R, Hyngstrom J, Matsen C, Nelson E, Pickron B, Zurbuchen E, Morrow EH. "I need to have a fulfilling job": A qualitative study of surgeon well-being and professional fulfillment. Am J Surg 2021; 223:6-11. [PMID: 34332744 DOI: 10.1016/j.amjsurg.2021.07.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 03/23/2021] [Revised: 05/25/2021] [Accepted: 07/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Burnout, often regarded as an individual failing, rather than a systemic one, negatively impacts quality of care, patient safety and healthcare costs. Focusing on improving well-being can help mitigate burnout. This study examined protective factors that promote well-being and professional fulfillment in surgeons. METHODS Using a purposive sample, 32 semi-structured 30-60-min interviews were conducted with surgeons of varying sub-specialties and rank. Abductive exploratory analysis was used to code and interpret interview transcripts and to build a conceptual model of surgeon well-being. RESULTS Emergent protective factors were placed into one of three levels of implementation: individual, team-level, and institutional (figure). Individual factors for well-being included autonomy and adequate time to pursue non-clinical endeavors. Team-level factors consisted of adaptability, boundaries, and cohesion. Institutional factors related to diversifying performance evaluations and celebrating and recognizing individual value and contributions. CONCLUSIONS The conceptual model developed from the results of this study highlights factors important to surgeons' professional well-being. This model can be used to guide quality improvement efforts.
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Affiliation(s)
| | - Ethan Evans
- University of Utah Health, Resiliency Center, United States.
| | - Raminder Nirula
- University of Utah School of Medicine, Department of Surgery, United States.
| | - John Hyngstrom
- University of Utah School of Medicine, Department of Surgery, United States.
| | - Cindy Matsen
- University of Utah School of Medicine, Department of Surgery, United States.
| | - Edward Nelson
- University of Utah School of Medicine, Department of Surgery, United States.
| | - Bartley Pickron
- University of Utah School of Medicine, Department of Surgery, United States.
| | | | - Ellen H Morrow
- University of Utah Health, Resiliency Center, United States; University of Utah School of Medicine, Department of Surgery, United States.
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14
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McCrum ML, Wan N, Lizotte SL, Han J, Varghese T, Nirula R. Use of the spatial access ratio to measure geospatial access to emergency general surgery services in California. J Trauma Acute Care Surg 2021; 90:853-860. [PMID: 33797498 PMCID: PMC8068585 DOI: 10.1097/ta.0000000000003087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) encompasses a spectrum of time-sensitive and resource-intensive conditions, which require adequate and timely access to surgical care. Developing metrics to accurately quantify spatial access to care is critical for this field. We sought to evaluate the ability of the spatial access ratio (SPAR), which incorporates travel time, hospital capacity, and population demand in its ability to measure spatial access to EGS care and delineate disparities. METHODS We constructed a geographic information science platform for EGS-capable hospitals in California and mapped population location, race, and socioeconomic characteristics. We compared the SPAR to the shortest travel time model in its ability to identify disparities in spatial access overall and for vulnerable populations. Reduced spatial access was defined as >60 minutes travel time or lowest three classes of SPAR. RESULTS A total of 283 EGS-capable hospitals were identified, of which 142 (50%) had advanced resources. Using shortest travel time, only 166,950 persons (0.4% of total population) experienced prolonged (>60 minutes) travel time to any EGS-capable hospital, which increased to 1.05 million (2.7%) for advanced-resource centers. Using SPAR, 11.5 million (29.5%) had reduced spatial access to any EGS hospital, and 13.9 million (35.7%) for advanced-resource centers. Rural residents had significantly decreased access for both overall and advanced EGS services when assessed by SPAR despite travel times within the 60-minute threshold. CONCLUSION While travel time and SPAR showed similar overall geographic patterns of spatial access to EGS hospitals, SPAR identified a greater a greater proportion of the population as having limited access to care. Nearly one third of California residents experience reduced spatial access to EGS hospitals when assessed by SPAR. Metrics that incorporate measures of population demand and hospital capacity in addition to travel time may be useful when assessing spatial access to surgical services. LEVEL OF EVIDENCE Cross-sectional study, level VI.
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Affiliation(s)
- Marta L McCrum
- From the Department of Surgery (M.L.M., T.V., R.N.), and Department of Geography (N.W., S.L.L., J.H.), University of Utah, Salt Lake City, Utah
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15
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Keihani S, Wang SS, Joyce RP, Rogers DM, Gross JA, Nocera AP, Selph JP, Fang E, Hagedorn JC, Voelzke BB, Rezaee ME, Moses RA, Arya CS, Sensenig RL, Glavin K, Broghammer JA, Higgins MM, Gupta S, Becerra CMC, Baradaran N, Zhang C, Presson AP, Nirula R, Myers JB. External validation of a nomogram predicting risk of bleeding control interventions after high-grade renal trauma: The Multi-institutional Genito-Urinary Trauma Study. J Trauma Acute Care Surg 2021; 90:249-256. [PMID: 33075030 PMCID: PMC8717860 DOI: 10.1097/ta.0000000000002987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Renal trauma grading has a limited ability to distinguish patients who will need intervention after high-grade renal trauma (HGRT). A nomogram incorporating both clinical and radiologic factors has been previously developed to predict bleeding control interventions after HGRT. We aimed to externally validate this nomogram using multicenter data from level 1 trauma centers. METHODS We gathered data from seven level 1 trauma centers. Patients with available initial computed tomography (CT) scans were included. Each CT scan was reviewed by two radiologists blinded to the intervention data. Nomogram variables included trauma mechanism, hypotension/shock, concomitant injuries, vascular contrast extravasation (VCE), pararenal hematoma extension, and hematoma rim distance (HRD). Mixed-effect logistic regression was used to assess the associations between the predictors and bleeding intervention. The prediction accuracy of the nomogram was assessed using the area under the receiver operating characteristic curve and its 95% confidence interval (CI). RESULTS Overall, 569 HGRT patients were included for external validation. Injury mechanism was blunt in 89%. Using initial CT scans, 14% had VCE and median HRD was 1.7 (0.9-2.6) cm. Overall, 12% underwent bleeding control interventions including 34 angioembolizations and 24 nephrectomies. In the multivariable analysis, presence of VCE was associated with a threefold increase in the odds of bleeding interventions (odds ratio, 3.06; 95% CI, 1.44-6.50). Every centimeter increase in HRD was associated with 66% increase in odds of bleeding interventions. External validation of the model provided excellent discrimination in predicting bleeding interventions with an area under the curve of 0.88 (95% CI, 0.84-0.92). CONCLUSION Our results reinforce the importance of radiologic findings such as VCE and hematoma characteristics in predicting bleeding control interventions after renal trauma. The prediction accuracy of the proposed nomogram remains high using external data. These variables can help to better risk stratify high-grade renal injuries. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.
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Affiliation(s)
- Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sherry S. Wang
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Ryan P. Joyce
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Douglas M. Rogers
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Joel A. Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Alexander P. Nocera
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J. Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elisa Fang
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Judith C. Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Michael E. Rezaee
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Rachel A. Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Chirag S. Arya
- Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Rachel L. Sensenig
- Division of Trauma, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Katie Glavin
- University of Kansas Medical Center, Kansas City, KS, USA
| | | | | | - Shubham Gupta
- Department of Urology, Case Western Reserve University, Cleveland, OH, USA
| | | | - Nima Baradaran
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Chong Zhang
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P. Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Raminder Nirula
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jeremy B. Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
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16
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Armas-Phan M, Keihani S, Agochukwu-Mmonu N, Cohen AJ, Rogers DM, Wang SS, Gross JA, Joyce RP, Hagedorn JC, Voelzke B, Moses RA, Sensenig RL, Selph JP, Gupta S, Baradaran N, Erickson BA, Schwartz I, Elliott SP, Mukherjee K, Smith BP, Santucci RA, Burks FN, Dodgion CM, Carrick MM, Askari R, Majercik S, Nirula R, Myers JB, Breyer BN. Clinical and Radiographic Factors Associated With Failed Renal Angioembolization: Results From the Multi-institutional Genitourinary Trauma Study (Mi-GUTS). Urology 2020; 148:287-291. [PMID: 33129870 DOI: 10.1016/j.urology.2020.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To find clinical or radiographic factors that are associated with angioembolization failure after high-grade renal trauma. MATERIAL AND METHODS Patients were selected from the Multi-institutional Genito-Urinary Trauma Study. Included were patients who initially received renal angioembolization after high-grade renal trauma (AAST grades III-V). This cohort was dichotomized into successful or failed angioembolization. Angioembolization was considered a failure if angioembolization was followed by repeat angiography and/or an exploratory laparotomy. RESULTS A total of 67 patients underwent management initially with angioembolization, with failure in 18 (27%) patients. Those with failed angioembolization had a larger proportion ofgrade IV (72% vs 53%) and grade V (22% vs 12%) renal injuries. A total of 53 patients underwent renal angioembolization and had initial radiographic data for review, with failure in 13 cases. The failed renal angioembolization group had larger perirenal hematoma sizes on the initial trauma scan. CONCLUSION Angioembolization after high-grade renal trauma failed in 27% of patients. Failed angioembolization was associated with higher injury grade and a larger perirenal hematoma. Likely these characteristics are associated with high-grade renal trauma that may be less amenable to successful treatment after a single renal angioembolization.
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Affiliation(s)
- Manuel Armas-Phan
- School of Medicine, University of California-San Francisco, San Francisco, CA; Department of Urology, Emory University, Atlanta, GA
| | - Sorena Keihani
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | | | - Andrew J Cohen
- Department of Urology, University of California-San Francisco, San Francisco, CA; Department of Urology, James Buchanan Brady Urological Institute, Baltimore, MD
| | | | - Sherry S Wang
- Department of Radiology, University of Utah, Salt Lake City, UT
| | - Joel A Gross
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Ryan P Joyce
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Judith C Hagedorn
- Department of Urology, Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Rachel A Moses
- Department of Surgery, Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Rachel L Sensenig
- Department of Surgery, Division of Trauma, Cooper University Hospital, Camden, NJ
| | - J Patrick Selph
- Department of Urology, University of Alabama at Birmingham, Birmingham, AL
| | - Shubham Gupta
- Department of Urology, Case Western Reserve University, Cleveland, OH
| | - Nima Baradaran
- Department of Urology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Ian Schwartz
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Sean P Elliott
- Department of Urology, University of Minnesota, Minneapolis, MN
| | - Kaushik Mukherjee
- Division of Acute Care Surgery, Loma Linda University Medical Center, Loma Linda, CA
| | - Brian P Smith
- Division of Trauma and Surgical Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Frank N Burks
- Department of Urology, Oakland University William Beaumont School of Medicine, Auburn Hills, MI
| | | | | | - Reza Askari
- Department of Surgery, Division of Trauma, Brigham and Women's Hospital, Boston, MA
| | - Sarah Majercik
- Division of Trauma and Surgical Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA; Department of Biostatistics and Epidemiology, University of California-San Francisco, San Francisco, CA.
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17
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Guyette FX, Brown JB, Zenati MS, Early-Young BJ, Adams PW, Eastridge BJ, Nirula R, Vercruysse GA, O’Keeffe T, Joseph B, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Forsythe RM, Rosengart MR, Billiar TR, Yealy DM, Peitzman AB, Sperry JL. Tranexamic Acid During Prehospital Transport in Patients at Risk for Hemorrhage After Injury: A Double-blind, Placebo-Controlled, Randomized Clinical Trial. JAMA Surg 2020; 156:2771225. [PMID: 33016996 PMCID: PMC7536625 DOI: 10.1001/jamasurg.2020.4350] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/13/2020] [Indexed: 12/14/2022]
Abstract
IMPORTANCE In-hospital administration of tranexamic acid after injury improves outcomes in patients at risk for hemorrhage. Data demonstrating the benefit and safety of the pragmatic use of tranexamic acid in the prehospital phase of care are lacking for these patients. OBJECTIVE To assess the effectiveness and safety of tranexamic acid administered before hospitalization compared with placebo in injured patients at risk for hemorrhage. DESIGN, SETTING, AND PARTICIPANTS This pragmatic, phase 3, multicenter, double-blind, placebo-controlled, superiority randomized clinical trial included injured patients with prehospital hypotension (systolic blood pressure ≤90 mm Hg) or tachycardia (heart rate ≥110/min) before arrival at 1 of 4 US level 1 trauma centers, within an estimated 2 hours of injury, from May 1, 2015, through October 31, 2019. INTERVENTIONS Patients received 1 g of tranexamic acid before hospitalization (447 patients) or placebo (456 patients) infused for 10 minutes in 100 mL of saline. The randomization scheme used prehospital and in-hospital phase assignments, and patients administered tranexamic acid were allocated to abbreviated, standard, and repeat bolus dosing regimens on trauma center arrival. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality. RESULTS In all, 927 patients (mean [SD] age, 42 [18] years; 686 [74.0%] male) were eligible for prehospital enrollment (460 randomized to tranexamic acid intervention; 467 to placebo intervention). After exclusions, the intention-to-treat study cohort comprised 903 patients: 447 in the tranexamic acid arm and 456 in the placebo arm. Mortality at 30 days was 8.1% in patients receiving tranexamic acid compared with 9.9% in patients receiving placebo (difference, -1.8%; 95% CI, -5.6% to 1.9%; P = .17). Results of Cox proportional hazards regression analysis, accounting for site, verified that randomization to tranexamic acid was not associated with a significant reduction in 30-day mortality (hazard ratio, 0.81; 95% CI, 0.59-1.11, P = .18). Prespecified dosing regimens and post-hoc subgroup analyses found that prehospital tranexamic acid were associated with significantly lower 30-day mortality. When comparing tranexamic acid effect stratified by time to treatment and qualifying shock severity in a post hoc comparison, 30-day mortality was lower when tranexamic acid was administered within 1 hour of injury (4.6% vs 7.6%; difference, -3.0%; 95% CI, -5.7% to -0.3%; P < .002). Patients with severe shock (systolic blood pressure ≤70 mm Hg) who received tranexamic acid demonstrated lower 30-day mortality compared with placebo (18.5% vs 35.5%; difference, -17%; 95% CI, -25.8% to -8.1%; P < .003). CONCLUSIONS AND RELEVANCE In injured patients at risk for hemorrhage, tranexamic acid administered before hospitalization did not result in significantly lower 30-day mortality. The prehospital administration of tranexamic acid after injury did not result in a higher incidence of thrombotic complications or adverse events. Tranexamic acid given to injured patients at risk for hemorrhage in the prehospital setting is safe and associated with survival benefit in specific subgroups of patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02086500.
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Affiliation(s)
- Francis X. Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joshua B. Brown
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S. Zenati
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara J. Early-Young
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter W. Adams
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian J. Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio
| | | | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson
| | - Louis H. Alarcon
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Clifton W. Callaway
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D. Neal
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raquel M. Forsythe
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R. Rosengart
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Timothy R. Billiar
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew B. Peitzman
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Division of Trauma and General Surgery, Department of Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
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18
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Brecha FS, Ozanne EM, Esplin J, Stoddard GJ, Nirula R, Huang LC, Cohan JN. Patient Willingness to Accept Antibiotic Side Effects to Reduce Surgical Site Infection After Colorectal Surgery. J Surg Res 2020; 261:417-422. [PMID: 32917390 DOI: 10.1016/j.jss.2020.07.083] [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: 02/28/2020] [Revised: 06/25/2020] [Accepted: 07/11/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Mechanical bowel preparation with antibiotics is associated with decreased surgical site infections (SSI) after colorectal surgery. However, antibiotics have side effects, such as vomiting. It is unknown how patient willingness to take antibiotics is affected by side effect severity. MATERIALS AND METHODS This was a single-center study of 86 patients (37 undergoing colorectal surgery) using a modified standard gamble technique. We presented patients with four hypothetical scenarios, holding SSI reduction constant and varying antibiotic side effect severity. Patients reported willingness to take antibiotics using a scale from 0 to 100. Patients also reported the maximum level of side effects they would accept. We examined the association between side effect severity and willingness to take antibiotics with a multivariable mixed-effects regression model and investigated differences in surgical and nonsurgical patients. RESULTS After adjusting for age, sex, and patient type, willingness scores decreased with increasing side effect severity. No side effects: 92 (CI 86,99), mild: 83 (CI 76,90), moderate: 76 (CI 69,83), and severe: 46 (CI 38,52), P < 0.001. Surgical patients were more willing to take antibiotics at all severity levels compared with nonsurgical patients, P < 0.001. Surgical (57%) and nonsurgical (58%) patients reported that they would accept moderate side effects. Patients with prior SSI (n = 5) would take antibiotics regardless of side effect severity. CONCLUSIONS Increasing antibiotic side effect severity is associated with decreased willingness to take antibiotics during bowel preparation, despite a reduction in SSI. Adherence may be improved with strategies that increase patient education and decrease side effects during bowel preparation.
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Affiliation(s)
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Jordan Esplin
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Gregory J Stoddard
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Lyen C Huang
- Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Jessica N Cohan
- Department of Surgery, University of Utah, Salt Lake City, Utah; Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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19
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Harvin JA, Zarzaur BL, Nirula R, King BT, Malhotra AK. Alternative clinical trial designs. Trauma Surg Acute Care Open 2020; 5:e000420. [PMID: 32154379 PMCID: PMC7046952 DOI: 10.1136/tsaco-2019-000420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/03/2019] [Indexed: 01/19/2023] Open
Abstract
High-quality clinical trials are needed to advance the care of injured patients. Traditional randomized clinical trials in trauma have challenges in generating new knowledge due to many issues, including logistical difficulties performing individual randomization, unclear pretrial estimates of treatment effect leading to often unpowered studies, and difficulty assessing the generalizability of an intervention given the heterogeneity of both patients and trauma centers. In this review, we discuss alternative clinical trial designs that can address some of these difficulties. These include pragmatic trials, cluster randomization, cluster randomized stepped wedge designs, factorial trials, and adaptive designs. Additionally, we discuss how Bayesian methods of inference may provide more knowledge to trauma and acute care surgeons compared with traditional, frequentist methods.
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Affiliation(s)
- John A Harvin
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Ben L Zarzaur
- Surgery, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Raminder Nirula
- Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin T King
- Neurology, University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Ajai K Malhotra
- Surgery, University of Vermont Medical Center, Burlington, Vermont, USA
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20
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Colonna AL, Bellows BK, Enniss TM, Young JB, McCrum M, Nunez JM, Nirula R, Nelson RE. Reducing the pain: A cost-effectiveness analysis of transversus abdominis plane block using liposomal bupivacaine for outpatient laparoscopic ventral hernia repair. Surg Open Sci 2020; 2:75-80. [PMID: 33997752 PMCID: PMC8097728 DOI: 10.1016/j.sopen.2019.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 12/16/2019] [Accepted: 12/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background Transversus abdominis plane block with liposomal bupivacaine has been studied as an effective method of reducing the need for postoperative opioids and increasing same-day discharge rates. However, less is known about the cost-effectiveness of this strategy relative to opioids alone for hernia repair. We performed an economic evaluation of these strategies using a computer simulation model. Methods A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios per quality-adjusted life-year. Base-case costs, quality-adjusted life-year values, and probabilities were derived from published studies and Medicare fee schedules. For input parameters for which we could not find values in the published literature, we used expert opinion. A 1-month time horizon was selected to focus on the immediate postoperative period. Finally, we performed 1-way, 2-way, and probabilistic sensitivity analyses. Results The liposomal bupivacaine transversus abdominis plane block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in quality-adjusted life-years relative to opioids alone. In 1-way sensitivity analysis of cost incremental cost-effectiveness ratio, values were most sensitive to variations in the amount saved by same-day discharge and the cost of bupivacaine. In probabilistic sensitivity analyses, transversus abdominis plane strategy was cost-effective at a willingness-to-pay threshold of $50,000/quality-adjusted life-year in 94.5% of iterations and at a willingness-to-pay threshold of $100,000/quality-adjusted life-year in 97.1% of iterations. Conclusion The use of liposomal bupivacaine transversus abdominis plane block resulted in cost savings and improved quality-adjusted life-years in base-case analyses and was cost-effective at conventional willingness-to-pay thresholds in the majority of iterations in probabilistic sensitivity analyses. A decision tree was constructed to determine cost-effectiveness as measured by incremental cost-effectiveness ratios (ICER) per quality-adjusted life-year (QALY). The liposomal bupivacaine TAP block was a dominant strategy yielding a $456.75 decrease in cost and an 0.1 increase in QALYs relative to opioids alone. In 1-way sensitivity analysis of cost, ICER values were most sensitive to variations in the amount saved by SDD and the cost of bupivacaine. In probabilistic sensitivity analyses, TAP strategy was cost-effective at a willingness-to-pay threshold of $50,000/QALY in 94.5% of iterations and pay threshold of $100,000/QALY in 97.1% of iterations.
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Affiliation(s)
- Alexander L Colonna
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Brandon K Bellows
- University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
| | - Toby M Enniss
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Jason B Young
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Marta McCrum
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Jade M Nunez
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Raminder Nirula
- University of Utah, Department of Surgery, 30 N 1900 E, Salt Lake City, UT 84132
| | - Richard E Nelson
- University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132
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21
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Carlock TC, Barrett JR, Kalvelage JP, Young JB, Nunez JM, Colonna AL, Enniss TM, Nirula R, McCrum ML. Telephone Follow-Up for Emergency General Surgery Procedures: Safety and Implication for Health Resource Use. J Am Coll Surg 2019; 230:228-236. [PMID: 31654733 DOI: 10.1016/j.jamcollsurg.2019.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/01/2019] [Accepted: 10/02/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is unknown whether replacing clinic follow-up visits with telephone follow-up for low-risk core emergency general surgery (cEGS) procedures is safe. We measured the efficacy of telephone follow-up to determine if it could safely reduce the need for routine postoperative clinic visits in this population. STUDY DESIGN Low-risk nonelective laparoscopic appendectomy, laparoscopic cholecystectomy, umbilical hernia, and inguinal hernia repair patients received telephone follow-up for symptoms concerning for surgical complication within 10 days of discharge. Clinic appointments were made if critical thresholds were reached. Outcomes of interest included rates of completed telephone screens, clinic visits avoided, and missed complications at 30 days postoperatively. RESULTS Of 402 patients screened, 62 (15.4%) were scheduled for a clinic visit due to threshold responses and 27 (6.7%) were scheduled per patient request, while 275 (68.4%) patients screened negative and did not attend a clinic visit. One hundred sixty-three (59.3%) of the negative screen cohort were contacted after 30 days. Nine (5.5%) patients in this cohort were diagnosed with low-grade complications; no high-grade (Clavien-Dindo ≥ 3) complications were missed by telephone screening. Twenty surgery-related complications were identified in the full patient population; early telephone screening successfully identified the single high-grade complication. CONCLUSIONS Post-discharge telephone follow-up in cEGS patients reduced the need for clinic follow-up visits by 68%. Missed complications were infrequent and low grade; telephone screening identified the single high-grade complication. Telephone follow-up for low-risk EGS patients is safe and increases efficiency of postoperative resource use.
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Affiliation(s)
- Tanner C Carlock
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - James R Barrett
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - James P Kalvelage
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jason B Young
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Jade M Nunez
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Alexander L Colonna
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Toby M Enniss
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Raminder Nirula
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Marta L McCrum
- Division of General Surgery, Department of Surgery, University of Utah, Salt Lake City, UT.
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22
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Moses RA, Anderson RE, Keihani S, Hotaling JM, Nirula R, Vargo DJ, Myers JB. High grade renal trauma management: a survey of practice patterns and the perceived need for a prospective management trial. Transl Androl Urol 2019; 8:297-306. [PMID: 31555553 DOI: 10.21037/tau.2019.07.04] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background To evaluate the current practice patterns of practitioners managing high grade renal trauma and determine perceived need for a prospective trial on the management of renal trauma. Methods We distributed an electronic survey to members of the American Association for the Surgery of Trauma (AAST) and The Society of Genitourinary Reconstructive Surgeons (GURS). The survey evaluated demographics, interventional radiology (IR) access, and renal trauma management. Descriptive statistics were utilized to analyze participants' responses. Results A total of 253 practitioners responded (age 48.4±10.4 years). The majority were acute care/trauma surgeons (ACS/TS) (63.2%), followed by urologists (34.4%) practicing at level 1 trauma centers (80.6%) in 39 US states. Most participants were in practice >10 years (62.8%); and had completed an ACS/TS (53.8%), or trauma/reconstructive urology (25.7%) fellowship. Ninety-five percent (241/253) found value in renal preservation with 74% utilizing IR embolization in the last year. However, there was wide variation in threshold for angiography, low rates of renal repair (24%) or packing (20%) and half reported performing a nephrectomy within the prior year. More than 80% believed there was value in a prospective trial to evaluate a protocol to decrease nephrectomy rates in renal trauma management. Conclusions The majority of respondents had access to IR, reported comfort in renorrhaphy, and valued renal preservation. There was variation in thresholds for bleeding intervention, and nephrectomy was still a common management strategy. There is great interest among trauma surgeons and urologists for a prospective trial of renal trauma management aimed at decreasing nephrectomy when possible.
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Affiliation(s)
- Rachel A Moses
- Section of Urology, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Ross E Anderson
- Division of Urology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Sorena Keihani
- Division of Urology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - James M Hotaling
- Division of Urology, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Daniel J Vargo
- Department of Surgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Jeremy B Myers
- Division of Urology, University of Utah Medical Center, Salt Lake City, UT, USA
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23
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Jalali A, Nelson R, Nirula R. Abstract 3352: Cost-effectiveness of current and potential serum based colorectal screening strategies: Can a serum based test do better. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-3352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Despite efficacy of colorectal cancer (CRC) screening, recent trends in screening rates have not improved. Furthermore, national society recommendations have not prioritized a single screening modality. Both flexible sigmoidoscopy (Flex-Sig) and guaiac fecal occult blood test (gFOBT)) have been recommended. Studies suggest that noninvasive tests may improve screening rates, however, compliance remains modest for such tests. A recent study found that health system transition from gFOBT to a fecal immunochemical test (FIT) moderately improved test compliance rates. However, FIT is an expensive substitute for gFOBT and sensitivity of fecal based tests for precursor lesions in the colon remain inferior to structural examinations. Serum-based blood tests (SBT) may provide higher compliance rates, but necessary accuracy for such a test to be a dominant or cost-effective screening strategy over current recommendations have not been determined. This study analyzed the cost-effectiveness of multiple CRC screening strategies and estimated minimum test characteristics of a hypothetical SBT to be a preferred screening strategy over current modalities.
Methods: A Markov microsimulation model was developed to analyze the costs and effects, (quality-adjusted life-years, QALYs) of CRC screening following a hypothetical cohort of 10,000 individuals at age 50 until death. Our model considered three strategies: 1) initial colonoscopy followed by Flex-Sig every 5 years, 2) initial colonoscopy with yearly gFOBT, and 3) initial colonoscopy with yearly FIT. An initial colonoscopy with a hypothetical yearly SBT was also examined at a range of test sensitivities. A long-term payer perspective was assumed for professional and facility costs and lifetime costs of cancer treatment. Model probabilities and utility values were obtained from the literature or calculated from National Vital Statistics Reports.
Results: Annual gFOBT was the least costly strategy ($3,242) while annual FIT was eliminated through extended dominance. Flex-Sig was the costliest strategy at $4,667 but had the highest expected QALYs at 19.68. The incremental cost-effectiveness ratio (ICER) of Flex-Sig relative to gFOBT was $35,615. Our secondary analysis demonstrated that a minimum joint sensitivity of 70% and 60% is required for an SBT at 80% and 100% compliance rates, respectively, to achieve extended dominance of both Flex-Sig and FIT by SBT and gFOBT. ICER’s of SBT ranged from $12,984 to $4,779 in these sensitivity ranges compared to gFOBT with expected QALYs as high as 19.96. Total individual costs in the model varied from $365 to $111,535.
Conclusion: With improved sensitivity and high compliance rates, annual screening for CRC via a non-invasive SBT is a cost-effective approach compared to structural examinations and currently recommended gFOBT and FIT.
Citation Format: Ali Jalali, Richard Nelson, Raminder Nirula. Cost-effectiveness of current and potential serum based colorectal screening strategies: Can a serum based test do better [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 3352.
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Affiliation(s)
| | - Richard Nelson
- 2University of Utah School of Medicine, Salt Lake City, UT
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24
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Keihani S, Putbrese BE, Rogers DM, Zhang C, Nirula R, Luo-Owen X, Mukherjee K, Morris BJ, Majercik S, Piotrowski J, Dodgion CM, Schwartz I, Elliott SP, DeSoucy ES, Zakaluzny S, Sherwood BG, Erickson BA, Baradaran N, Breyer BN, Fick CN, Smith BP, Okafor BU, Askari R, Miller B, Santucci RA, Carrick MM, Kocik JF, Hewitt T, Burks FN, Heilbrun ME, Myers JB. The associations between initial radiographic findings and interventions for renal hemorrhage after high-grade renal trauma: Results from the Multi-Institutional Genitourinary Trauma Study. J Trauma Acute Care Surg 2019; 86:974-982. [PMID: 31124895 DOI: 10.1097/ta.0000000000002254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Indications for intervention after high-grade renal trauma (HGRT) remain poorly defined. Certain radiographic findings can be used to guide the management of HGRT. We aimed to assess the associations between initial radiographic findings and interventions for hemorrhage after HGRT and to determine hematoma and laceration sizes predicting interventions. METHODS The Genitourinary Trauma Study is a multicenter study including HGRT patients from 14 Level I trauma centers from 2014 to 2017. Admission computed tomography scans were categorized based on multiple variables, including vascular contrast extravasation (VCE), hematoma rim distance (HRD), and size of the deepest laceration. Renal bleeding interventions included angioembolization, surgical packing, renorrhaphy, partial nephrectomy, and nephrectomy. Mixed-effect Poisson regression was used to assess the associations. Receiver operating characteristic analysis was used to define optimal cutoffs for HRD and laceration size. RESULTS In the 326 patients, injury mechanism was blunt in 81%. Forty-seven (14%) patients underwent 51 bleeding interventions, including 19 renal angioembolizations, 16 nephrectomies, and 16 other procedures. In univariable analysis, presence of VCE was associated with a 5.9-fold increase in risk of interventions, and each centimeter increase in HRD was associated with 30% increase in risk of bleeding interventions. An HRD of 3.5 cm or greater and renal laceration depth of 2.5 cm or greater were most predictive of interventions. In multivariable models, VCE and HRD were significantly associated with bleeding interventions. CONCLUSION Our findings support the importance of certain radiographic findings in prediction of bleeding interventions after HGRT. These factors can be used as adjuncts to renal injury grading to guide clinical decision making. LEVEL OF EVIDENCE Prognostic and Epidemiological Study, Level III and Therapeutic/Care Management, Level IV.
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Affiliation(s)
- Sorena Keihani
- From the Division of Urology, Department of Surgery (S.K., J.B.M.), Department of Radiology (B.E.P., D.M.R.), Division of Epidemiology, Department of Internal Medicine (C.Z.), Department of Surgery (R.N.), University of Utah, Salt Lake City, Utah; Division of Acute Care Surgery (X. L-O, K.M), Loma Linda University Medical Center, Loma Linda, California; Division of Trauma and Surgical Critical Care (B.J.M., S.M), Intermountain Medical Center, Murray, Utah; Department of Urology (J.P.), Department of Surgery (C.M.D.), University of Wisconsin, Milwaukee, Wisconsin; Department of Urology (I.S., S.P.E.), Hennepin County Medical Center, University of Minnesota, Minneapolis, Minnesota; Department of Surgery (E.S.D.); Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery (S.Z.), University of California Davis Medical Center, Sacramento, California; Department of Urology (B.G.S., BA.E), University of Iowa, Iowa City, Iowa; Department of Urology (N.B., B.N.B.), University of California-San Francisco, San Francisco, California; Division of Trauma and Surgical Critical Care (C.N.F., B.P.S), Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Trauma, Department of Surgery (B.U.O., R.A.), Brigham and Women's Hospital, Boston, Massachusetts; Department of Urology (B.M., R.A.S), Detroit Medical Center, Detroit, Michigan; Medical City Plano (M.M.C.), Plano; Department of Surgery (J.F.K.), East Texas Medical Center, Tyler, Texas; Department of Urology (T.H., F.N.B.), Oakland University William Beaumont School of Medicine, Royal Oak, Michigan; Department of Radiology and Imaging Sciences (M.E.H.), Emory University Hospital, Atlanta, Georgia
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Colonna AL, Griffiths TM, Robison DC, Enniss TM, Young JB, McCrum ML, Nunez JM, Nirula R, Hardman RL. Cholecystostomy: Are we using it correctly? Am J Surg 2019; 217:1010-1015. [PMID: 31023549 DOI: 10.1016/j.amjsurg.2019.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/02/2019] [Accepted: 04/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Percutaneous Cholecystostomy Tubes (PCT) have become an accepted and common modality of treating acute cholecystitis in patients that are not appropriate surgical candidates. As percutaneous gallbladder drainage has rapidly increased newer research suggests that the technique may be overused, and patients may be burdened with them for extended periods. We examined our experience with PCT placement to identify independent predictors of interval cholecystectomy versus destination PCT. METHODS All patients with cholecystitis initially treated with PCT from 2014 to 2017 were stratified by whether they underwent subsequent interval cholecystectomy. Demographic data, initial laboratory values, Tokyo Grade, Charlson Comorbidity Index, ASA Class, complications related to PCT, complications related to cholecystectomy, and mortality data were retrospectively collected. Descriptive statistics, univariable, and multivariable Poisson regression were performed. RESULTS 165 patients received an initial cholecystostomy tube to treat cholecystitis. 61 (37%) patients went on to have an interval cholecystectomy. There were 4 complications reported after cholecystectomy. A total of 46 (27.9%) deaths were reported, only one of which was in the cholecystectomy group. Age, Tokyo Grade, liver function tests, ASA Class, and Charlson Comorbidity Index were significantly different between the interval cholecystectomy and no-cholecystectomy groups. Univariable regression was performed and variables with p < 0.2 were included in the multivariable model. Multivariable Poisson regression showed that increasing Tokyo Grade (IRR 0.454, p = 0.042, 95% CI 0.194-0.969); and increasing Charlson Comorbidity Score (IRR 0.890, p = 0.026, 95% CI 0.803-0.986) were associated with no-cholecystectomy. Higher Albumin (IRR 1.580, p = 0.011, 95% CI 1.111-2.244) was associated with having an interval cholecystectomy. CONCLUSION Patients in the no-cholecystectomy group were older, had more comorbidities, higher Tokyo Grade, ASA Class, and initial liver function test values than those that had interval cholecystectomy. Since interval cholecystectomy was performed with a low rate of complications, we may be too conservative in performing cholecystectomy after drainage and condemning many patients to destination tubes.
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Affiliation(s)
- Alexander L Colonna
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Travis M Griffiths
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Douglas C Robison
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Toby M Enniss
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Jason B Young
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Marta L McCrum
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Jade M Nunez
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Raminder Nirula
- University of Utah, Department of Surgery, 30 N 1900 East, Salt Lake City, UT, 84132, USA.
| | - Rulon L Hardman
- University of Utah, Department of Radiology & Imaging Sciences, 30 North 1900 East, Salt Lake City, UT, 84132, USA.
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Kobayashi LM, Brito A, Barmparas G, Bosarge P, Brown CV, Bukur M, Carrick MM, Catalano RD, Holly-Nicolas J, Inaba K, Kaminski S, Klein AL, Kopelman T, Ley EJ, Martinez EM, Moore FO, Murry J, Nirula R, Paul D, Quick J, Rivera O, Schreiber M, Coimbra R. Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT. Trauma Surg Acute Care Open 2018; 3:e000231. [PMID: 30402564 PMCID: PMC6203140 DOI: 10.1136/tsaco-2018-000231] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 09/11/2018] [Accepted: 09/15/2018] [Indexed: 12/22/2022] Open
Abstract
Background Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). Methods This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. Results 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. Discussion Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. Level of evidence Level IV.
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Affiliation(s)
- Leslie M Kobayashi
- Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Alexandra Brito
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Galinos Barmparas
- Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Patrick Bosarge
- Division of Acute Care Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Carlos V Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Marko Bukur
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Surgical Intensive Care Unit Bellevue Hospital Center, New York, USA
| | - Matthew M Carrick
- University of North Texas Health Science Center, Fort Worth, Texas, USA
| | | | - Jan Holly-Nicolas
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Kenji Inaba
- Division of Trauma & Critical Care, University of Southern California, Los Angeles, California, USA
| | - Stephen Kaminski
- Department of General Surgery and Surgical Critical Care, Santa Barbara Cottage Hospital, Santa Barbara, California, USA
| | - Amanda L Klein
- Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Tammy Kopelman
- Division of Burns, Trauma, and Surgical Critical Care, University of Arizona Medical School-Phoenix Campus, Phoenix, Arizona, USA
| | - Eric J Ley
- Department of General Surgery, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Ericca M Martinez
- Chandler Regional Medical Center, Grand Canyon University, Phoenix, Arizona, USA
| | - Forrest O Moore
- Department of General Surgery, Trauma and Surgical Critical Care, Chandler Regional Medical Center, University of Arizona College of Medicine, Chandler, Arizona, USA
| | - Jason Murry
- Department of General Surgery Trauma Services, East Texas Medical Center, Tyler, Texas, USA
| | - Raminder Nirula
- Department of General Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Douglas Paul
- Division of Trauma, Critical Care and Acute Care Surgery, Kettering Medical Center, Kettering, Ohio, USA
| | - Jacob Quick
- Division of Acute Care Surgery, University of Missouri, Columbia, Missouri, USA
| | - Omar Rivera
- Division of Trauma and Critical Care, University of Southern California, Los Angeles, California, USA
| | - Martin Schreiber
- Division of Trauma, Critical Care & Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Raul Coimbra
- Department of General Surgery, Riverside University Health System Medical Center, Loma Linda University School of Medicine, Moreno Valley, California, USA
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Morrow EH, Chen J, Patel R, Bellows B, Nirula R, Glasgow R, Nelson RE. Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis. Am J Surg 2018; 216:760-763. [PMID: 30054004 DOI: 10.1016/j.amjsurg.2018.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/21/2018] [Accepted: 07/14/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALY's. RESULTS ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.
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Affiliation(s)
- Ellen H Morrow
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jennwood Chen
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ravi Patel
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Brandon Bellows
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Robert Glasgow
- Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Richard E Nelson
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Hirschi R, Rommel C, Letsinger J, Nirula R, Hawryluk GWJ. Brain Trauma Foundation Guideline Compliance: Results of a Multidisciplinary, International Survey. World Neurosurg 2018; 116:e399-e405. [PMID: 29751187 DOI: 10.1016/j.wneu.2018.04.215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Brain Trauma Foundation (BTF) guidelines reflect evidence-based best practices in management of traumatic brain injury. The aim of this study was to examine self-reported physician compliance and predictors of compliance related to BTF guidelines. METHODS We conducted an international, multidisciplinary survey examining self-reported adherence to BTF guidelines and multiple factors potentially affecting adherence. We also surveyed intracranial pressure monitoring practices. RESULTS Of 154 physician respondents, 15.9% reported their institutions "always" follow BTF guidelines and 72.2% reported that they follow them "most of the time." Personal volume of traumatic brain injury cases and years in practice were not significantly related to adherence. Reported adherence varied significantly in association with respondent's institutional trauma level (P = 0.0010): 17.3% of practitioners at level I, 13.0% at level II, and 0% at level III trauma centers reported "always" following guidelines. Reported adherence to guidelines also varied significantly in association with provider specialty (P = 0.015) and institutional volume of severe traumatic brain injury cases (P = 0.008). Regarding intracranial pressure monitoring practices, 52% of respondents used external ventricular drains, 21% used intraparenchymal monitors, and 27% had no preference (P < 0.001). Of respondents not routinely using external ventricular drains, 36% claimed to "always" follow guidelines. There was no apparent association between type of intracranial pressure monitoring used and reported guideline adherence. CONCLUSIONS Few respondents reported their institutions "always" follow BTF guidelines. General surgeons and providers at high-volume level I trauma centers were more likely to comply with guidelines. Differences in survey responses based on provider and institutional characteristics may help target educational efforts.
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Affiliation(s)
- Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Casey Rommel
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joshua Letsinger
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Gregory W J Hawryluk
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah, USA.
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Keihani S, Moses R, Xu Y, Putbrese B, Rogers D, Luo-Owen X, Mukherjee K, Morris B, Majercik S, Piotrowski J, Dodgion C, Sherwood B, Erickson B, Schwartz I, Elliott S, DeSoucy E, Zakaluzny S, Baradaran N, Breyer B, Smith B, Miller B, Santucci R, Carrick M, Kocik J, Hewitt T, Burks F, Heilbrun M, Hotaling J, Presson A, Nirula R, Myers J. MP25-18 IMAGING FINDINGS ASSOCIATED WITH RENAL BLEEDING INTERVENTIONS AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITO-URINARY TRAUMA STUDY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.855] [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: 11/30/2022]
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Martin LA, Wiesner E, Zhang C, Presson AP, Burningham Z, Nirula R, Morrow E, Brooke BS, Peche WJ. Challenging the Tokyo Guidelines: Are Cholecystostomy Tubes Beneficial among Patients Undergoing Delayed Cholecystectomy? J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.746] [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: 11/28/2022]
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Letsinger J, Rommel C, Hirschi R, Nirula R, Hawryluk GWJ. The aggressiveness of neurotrauma practitioners and the influence of the IMPACT prognostic calculator. PLoS One 2017; 12:e0183552. [PMID: 28832674 PMCID: PMC5568296 DOI: 10.1371/journal.pone.0183552] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 08/07/2017] [Indexed: 11/24/2022] Open
Abstract
Published guidelines have helped to standardize the care of patients with traumatic brain injury; however, there remains substantial variation in the decision to pursue or withhold aggressive care. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic calculator offers the opportunity to study and decrease variability in physician aggressiveness. The authors wish to understand how IMPACT’s prognostic calculations currently influence patient care and to better understand physician aggressiveness. The authors conducted an anonymous international, multidisciplinary survey of practitioners who provide care to patients with traumatic brain injury. Questions were designed to determine current use rates of the IMPACT prognostic calculator and thresholds of age and risk for death or poor outcome that might cause practitioners to consider withholding aggressive care. Correlations between physician aggressiveness, putative predictors of aggressiveness, and demographics were examined. One hundred fifty-four responses were received, half of which were from physicians who were familiar with the IMPACT calculator. The most frequent use of the calculator was to improve communication with patients and their families. On average, respondents indicated that in patients older than 76 years or those with a >85% chance of death or poor outcome it might be reasonable to pursue non-aggressive care. These thresholds were robust and were not influenced by provider or institutional characteristics. This study demonstrates the need to educate physicians about the IMPACT prognostic calculator. The consensus values for age and prognosis identified in our study may be explored in future studies aimed at reducing variability in physician aggressiveness and should not serve as a basis for withdrawing care.
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Affiliation(s)
- Joshua Letsinger
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States of America
| | - Casey Rommel
- Department of Biomedical Informatics, School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah, United States of America
| | - Gregory W. J. Hawryluk
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States of America
- * E-mail:
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Miller B, Keihani S, Smith BP, Reilly PM, Luo-Owen X, Mukherjee K, Morris BJ, Majercik S, Thomsen PB, Erickson BA, Breyer BN, Murphy G, Santucci RA, Hewitt T, Burks FN, DeSoucy ES, Zakaluzny SA, Allen L, Kocik JF, Nirula R, Myers JB. PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.2926] [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: 11/29/2022]
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Abstract
Rib fractures are a frequently identified injury in the trauma population. Not only are multiple rib fractures painful, but they are associated with an increased risk of adverse outcomes. Pneumonia in particular can be devastating, especially to an elderly patient, but other complications such as prolonged ventilation and increased intensive care and hospital durations of stay have a negative impact on the patient. Computed tomography scan is the best modality to diagnosis rib fractures but the treatment of fractures is still evolving. Currently patient care involves a multidisciplinary approach that includes pain control, aggressive pulmonary therapy, and possibly surgical fixation.
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Affiliation(s)
- Lara Senekjian
- Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
| | - Raminder Nirula
- Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
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Griffee MJ, Singleton A, Zimmerman JM, Morgan DE, Nirula R. The Effect of Perioperative Rescue Transesophageal Echocardiography on the Management of Trauma Patients. ACTA ACUST UNITED AC 2017; 6:387-90. [PMID: 27301053 DOI: 10.1213/xaa.0000000000000320] [Citation(s) in RCA: 7] [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: 11/05/2022]
Abstract
To evaluate the effect of rescue transesophageal echocardiography (TEE) on the management of trauma patients, we reviewed imaging and charts of unstable trauma patients at a level I trauma center. Critical rescue TEE findings included acute right ventricular failure, stress cardiomyopathy, type B aortic dissection, mediastinal air, and dynamic left ventricular outflow tract obstruction. Left ventricular filling was classified as low (underfilled) in 57% of all cases. Rescue TEE revealed a variety of new diagnoses and led to a change in resuscitation strategy about half of the time.
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Affiliation(s)
- Matthew J Griffee
- From the *Department of Anesthesiology, University of Utah, Salt Lake City, Utah; †Department of Surgery, University of Southern California, Los Angeles, California; and ‡Department of Surgery, University of Utah, Salt Lake City, Utah
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Somberg LB, Gutterman DD, Miura H, Nirula R, Hatoum OA. Shock associated with endothelial dysfunction in omental microvessels. Eur J Clin Invest 2017; 47:30-37. [PMID: 27809354 DOI: 10.1111/eci.12697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 10/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Impaired microvascular function leads to a poor outcome in a variety of medical conditions. Our aim was to determine whether vasodilator responses to acetylcholine (Ach) are impaired in human omental arterioles from patients with severe trauma. MATERIALS AND METHODS Patients with massive blood loss and severe shock requiring damage control procedures were included. Tissues were collected at the first (FEL) and the second explorative laparotomy (SEL). Control tissues were collected from nontrauma patients. Freshly isolated 50-200-μm-diameter omental arterioles were analysed using videomicroscopy. Dihydroethidine and DCF-DA fluorescence were used to assess reactive oxygen species (ROS) production. MnTBAP was used to determine the contribution of excess vascular superoxide contribution to endothelial dysfunction. RESULTS After constriction (30-50%) with endothelin-1, dilation to graded doses of Ach (10-9 -10-4 M) was greater in control vessels compared to FEL and SEL (max dilation at 10-4 M (MD) = 25 ± 3%, n = 8; and 59 ± 8%, n = 8, respectively, and controls MD = 93 ± 10%, n = 6, P < 0·05). Fluorescence imaging of ROS production showed significant increases in superoxide (225·46 ± 12·86; 215·77 ± 10·75 vs. 133·75 ± 7·26, arbitrary units; P < 0·05) and peroxide-related ROS (240·8 ± 20·42; 234·59 ± 28·86, vs. 150·78 ± 15·65, arbitrary units; P < 0·05), in FEL and SEL microvessels compared to control, respectively. FEL pretreated with MnTBAP demonstrated significant improvement in Ach-induced vasodilation (25·5 ± 3·0% vs. 79·5 ± 8·2%; P < 0·05). CONCLUSIONS Severe shock associated with microvascular endothelial dysfunction enhances production of ROS in human omental tissues. The altered flow regulation may contribute to a mismatch between local blood supply and demand, exacerbating abnormal tissue perfusion and function.
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Affiliation(s)
- Lewis B Somberg
- Division of Trauma/Critical Care, Departments of Medicine and Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David D Gutterman
- Division of Cardiovascular Medicine, Departments of Medicine and Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Hiroto Miura
- Division of Cardiovascular Medicine, Departments of Medicine and Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raminder Nirula
- Division of Trauma/Critical Care, Departments of Medicine and Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ossama A Hatoum
- Department of Surgery B, HaEmek Medical Center, Afula, Israel.,Faculty of Medicine, Technion-Israel Institute of Technology, Afula, Israel
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Chan J, Johnson C, Beran-Maryott G, Cortez J, Greene TH, Nirula R, Heilbrun M. Measuring the Impact of Whole-Body Computed Tomography on Hospital Length of Stay in Blunt Trauma. Acad Radiol 2016; 23:582-7. [PMID: 27085378 DOI: 10.1016/j.acra.2016.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 01/06/2016] [Accepted: 01/10/2016] [Indexed: 11/24/2022]
Abstract
RATIONALE AND OBJECTIVES Whole-body computed tomography (WBCT) imaging has become commonplace in some emergency departments (EDs) for trauma where management is dependent on rapid diagnosis achieved through comprehensive imaging. The purpose of this study was to assess the value that computed tomography (CT) imaging contributes to trauma patients by retrospectively comparing hospital length of stay (LOS) between WBCT and selective CT imaging, while controlling for hemodynamic stability and socio-economic considerations. MATERIALS AND METHODS This study was institutional review board approved. The institutional trauma registry database was cross-referenced with our radiology information system database to identify adult patients who sustained blunt trauma between July 2011 and June 2013 and received CT imaging. Propensity score weighting was utilized to achieve balance in baseline covariates, including demographics, hemodynamic stability, Glasgow Coma Scale, and socioeconomic factors. A generalized linear model was used to compare LOS between imaging types, and a multinomial logistic regression was utilized to analyze differences in discharge disposition. RESULTS A total of 2291 patients were identified of which 14.5% underwent WBCT imaging. WBCT patients had an insignificantly longer inpatient hospital LOS of 0.31 days (P = 0.54), and insignificantly higher odds of being discharged to a nursing home facility (versus home, odds ratio = 1.29 [P = 0.34]) when compared to those who received selective CT. CONCLUSION WBCT imaging did not have a statistically significant effect on inpatient hospital LOS or discharge disposition.
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Youngquist ST, Liao M, Hartsell S, Walker M, Kartchner NJ, Nirula R. Acute medical impairment among elderly patients involved in motor vehicle collisions. Injury 2015; 46:1497-502. [PMID: 25975765 DOI: 10.1016/j.injury.2015.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 10/10/2014] [Revised: 03/09/2015] [Accepted: 04/02/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The association between acute medical illness and motor vehicle collisions (MVCs) among elderly emergency department patients is unclear. We sought to determine the prevalence of acute medical conditions that might impair driving ability among the elderly involved in MVCs and determine if there was an increased risk of the driver having an acute medical condition compared to similarly aged passengers. METHODS We reviewed charts of patients aged 65 years or older whose emergency department visit was prompted by a motor vehicle collision between 1 July 2000 and 30 June 2010 at two Level 1 trauma centres. The exposure of interest was occupancy status (driver vs. passenger), and the outcome measure was the presence of any predefined acute medical illness that might impair driving ability. RESULTS Final analysis included 871 drivers (cases) and 307 passengers (controls). An acute medical illness was recorded in 107 patients (9%): 97 drivers (11%) and 10 passengers (3%). Compared to passengers, drivers had significantly higher odds of presenting with acute medical illness (OR 3.7, 95% CI 1.9-7.2). After controlling for potential confounders, the adjusted odds ratio was 5.5 (95% CI 2.3-13.0). CONCLUSION Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. A difference in the risk of finding an acute medical illness when comparing elderly drivers and passengers evaluated in the emergency department after a collision suggests the need for considering additional diagnostic investigation and post-discharge surveillance in this population.
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Affiliation(s)
- Scott T Youngquist
- Department of Surgery, Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States.
| | - Michael Liao
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States; Department of Emergency Medicine, North Suburban Medical Center, Thornton, CO, United States
| | - Sydney Hartsell
- Department of Surgery, Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Melissa Walker
- Department of Surgery, Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Nathan J Kartchner
- Department of Surgery, Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Raminder Nirula
- Department of Surgery, Section of Acute Care Surgery, University of Utah School of Medicine, Salt Lake City, UT, United States
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Lonardo NW, Mone MC, Nirula R, Kimball EJ, Ludwig K, Zhou X, Sauer BC, Nechodom K, Teng C, Barton RG. Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014; 189:1383-94. [PMID: 24720509 DOI: 10.1164/rccm.201312-2291oc] [Citation(s) in RCA: 76] [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: 01/27/2023] Open
Abstract
RATIONALE Mechanically ventilated intensive care unit (ICU) patients are frequently managed using a continuous-infusion sedative. Although recent guidelines suggest avoiding benzodiazepines for sedation, this class of drugs is still widely used. There are limited data comparing sedative agents in terms of clinical outcomes in an ICU setting. OBJECTIVES Comparison of propofol to midazolam and lorazepam in adult ICU patients. METHODS Data were obtained from a multicenter ICU database (2003-2009). Patient selection criteria included age greater than or equal to 18 years, single ICU admission with single ventilation event (>48 h), and treatment with continuously infused sedation (propofol, midazolam, or lorazepam). Propensity score analysis (1:1) was used and mortality measured. Cumulative incidence and competing risk methodology were used to examine time to ICU discharge and ventilator removal. MEASUREMENTS AND MAIN RESULTS There were 2,250 propofol-midazolam and 1,054 propofol-lorazepam matched patients. Hospital mortality was statistically lower in propofol-treated patients as compared with midazolam- or lorazepam-treated patients (risk ratio, 0.76; 95% confidence interval [CI], 0.69-0.82 and risk ratio, 0.78; 95% CI, 0.68-0.89, respectively). Competing risk analysis for 28-day ICU time period showed that propofol-treated patients had a statistically higher probability for ICU discharge (78.9% vs. 69.5%; 79.2% vs. 71.9%; P < 0.001) and earlier removal from the ventilator (84.4% vs. 75.1%; 84.3% vs. 78.8%; P < 0.001) when compared with midazolam- and lorazepam-treated patients, respectively. CONCLUSIONS In this large, propensity-matched ICU population, patients treated with propofol had a reduced risk of mortality and had both an increased likelihood of earlier ICU discharge and earlier discontinuation of mechanical ventilation.
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Shafi S, Barnes SA, Millar D, Sobrino J, Kudyakov R, Berryman C, Rayan N, Dubiel R, Coimbra R, Magnotti LJ, Vercruysse G, Scherer LA, Jurkovich GJ, Nirula R. Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries. J Neurosurg 2014; 120:773-7. [PMID: 24438538 DOI: 10.3171/2013.12.jns132151] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.
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Affiliation(s)
- Shahid Shafi
- Institute for Health Care Research and Improvement and
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Abstract
Esophageal perforation is uncommon but carries a high morbidity and mortality, particularly if the injury is not detected early before the onset of systemic signs of sepsis. The fact that it is an uncommon problem and it produces symptoms that can mimic other serious thoracic conditions, such as myocardial infarction, contributes to the delay in diagnosis. Patients at risk for iatrogenic perforations (esophageal malignancy) frequently have comorbidities that increase their perioperative morbidity and mortality. The optimal treatment of esophageal perforation varies with respect to the time of presentation, the extent of the perforation, and the underlying esophageal pathologic conditions.
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Affiliation(s)
- Raminder Nirula
- Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Abstract
The cause and management of gastroduodenal perforation have changed as a result of increasing use of nonsteroidal antiinflammatories and improved pharmacologic treatment of acid hypersecretion as well as the recognition and treatment of Helicobacter pylori. As a result of the reduction in ulcer recurrence with medical therapy, the surgical approach to patients with gastroduodenal perforation has also changed over the last 3 decades, with ulcer-reducing surgery being performed infrequently.
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Affiliation(s)
- Raminder Nirula
- Department of Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA.
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Byrge N, Barton RG, Enniss TM, Nirula R. Laparoscopic versus open repair of perforated gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis. Am J Surg 2013; 206:957-62; discussion 962-3. [PMID: 24112676 DOI: 10.1016/j.amjsurg.2013.08.014] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/23/2013] [Accepted: 08/21/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical repair of perforated gastroduodenal ulcers remains a common indication for emergent surgery. The aim of this study was to test the hypothesis that the laparoscopic approach (LA) would be associated with reduced length of stay compared to the open approach. METHODS Patients with acute, perforated gastroduodenal ulcer were identified in the National Surgical Quality Improvement Program database, of whom 50 had the LA. One-to-one case/control matching on the basis of age, American Society of Anesthesiologists class, gender, and cardiac disease was evaluated for outcome analysis. RESULTS After matching, the 2 groups had similar characteristics. The rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the LA by an average of 5.4 days. CONCLUSIONS The LA appears to be safe in mild to moderately ill patients with perforated peptic ulcer disease and is associated with reduced use of hospital resources.
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Affiliation(s)
- Nickolas Byrge
- Division of General Surgery, Section of Acute Care Surgery, University of Utah, School of Medicine, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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Hauschild TB, Fu KY, Hipwell RC, Baraghoshi G, Mone MC, Nirula R, Kimball EJ, Barton RG. Safe, timely, convenient, and cost-effective: a single-center experience with bedside placement of enteral feeding tubes by midlevel providers using fluoroscopic guidance. Am J Surg 2012; 204:958-62; discussion 962. [DOI: 10.1016/j.amjsurg.2012.07.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 06/11/2012] [Accepted: 07/02/2012] [Indexed: 01/30/2023]
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Al-Temimi MH, Griffee M, Enniss TM, Preston R, Vargo D, Overton S, Kimball E, Barton R, Nirula R. When is death inevitable after emergency laparotomy? Analysis of the American College of Surgeons National Surgical Quality Improvement Program database. J Am Coll Surg 2012; 215:503-11. [PMID: 22789546 DOI: 10.1016/j.jamcollsurg.2012.06.004] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/11/2012] [Accepted: 06/08/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND In an era of increasing demands to provide high-quality health care, surgeons need an accurate preoperative risk assessment tool to facilitate informed decision-making for themselves and their patients. Emergency laparotomy procedures have a high risk profile, but the currently available risk-assessment models for emergency laparotomy are either unreliable (eg, small sample size or single center study), difficult to calculate preoperatively, or are specific to the geriatric population. STUDY DESIGN The American College of Surgeons National Surgical Quality Improvement Program database (2005 to 2009) was used to develop logistic regression models for 30-day mortality after emergency laparotomy. Two models were created, one with the knowledge of the postoperative diagnosis and one without. Models' calibration and discrimination were judged using the receiver operating characteristics curves and the Hosmer-Lemeshow test. RESULTS There were 37,553 patients who had undergone emergency laparotomy, with a 14% mortality rate. The American Society of Anesthesiologists classification system, functional status, sepsis, and age were the variables most significantly associated with mortality. Patients older than 90 years of age, with an American Society of Anesthesiologists class V, septic shock, dependent functional status, and abnormal white blood cell count have a <10% probability of survival. CONCLUSIONS The models developed in this study have a high discriminative ability to stratify the operative risk in a broad range of acute abdominal emergencies. These data will assist surgeons, patients, and their families in making end-of-life decisions in the face of medical futility with greater certainty when emergency surgery is being contemplated.
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Affiliation(s)
- Mohammed H Al-Temimi
- Division of Public Health, Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84132, USA
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Hardee M, Stevens M, Nirula R, Lowrance W, Brant W, Gardner S, Leishman B, Myers J. 230 HIGH GRADE RENAL INJURIES: APPLICATION OF PARKLAND HOSPITAL'S PREDICTORS OF INTERVENTION FOR RENAL BLEEDING TO A LARGE SERIES OF PATIENTS WITH BLUNT RENAL TRAUMA. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.285] [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: 10/28/2022]
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Taylor M, Brant W, Wallis C, McFadden M, Stevens M, Bishoff J, Nirula R, Myers J. 97 EXTRAPERITONEAL BLADDER RUPTURES: COMPLICATIONS ASSOCIATED WITH OPERATIVE VERSUS NON-OPERATIVE MANAGEMENT AT THE TIME OF ANTERIOR PELVIC FIXATION OR ABDOMINAL EXPLORATION FOR OTHER INJURIES. J Urol 2011. [DOI: 10.1016/j.juro.2011.02.162] [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: 10/18/2022]
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Pierce DS, Sperry J, Nirula R. Cost-effective analysis of transjugular intrahepatic portosystemic shunt versus surgical portacaval shunt for variceal bleeding in early cirrhosis. Am Surg 2011; 77:169-173. [PMID: 21337874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.
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Pierce DS, Sperry J, Nirula R. Cost-Effective Analysis of Transjugular Intrahepatic Portosystemic Shunt versus Surgical Portacaval Shunt for Variceal Bleeding in Early Cirrhosis. Am Surg 2011. [DOI: 10.1177/000313481107700215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Upper gastrointestinal hemorrhage carries significant morbidity and mortality in patients with portal hypertension and cirrhosis. The optimal prevention strategy for rebleeding in these patients remains controversial with respect to the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) versus a portocaval surgical shunt (PC). We sought to determine the long-term cost-effectiveness of these two treatments. A Markov state transition decision analysis was created and Monte Carlo sensitivity analysis performed to follow patients with early cirrhosis who have an upper gastrointestinal bleed despite medical therapy into either TIPS or PC. Patients were followed throughout the transition states until either death or survival. Probabilities of gastrointestinal rebleed, hepatic encephalopathy, surgical and TIPS-related complications as well as death were obtained from an extensive literature review. Costs were derived from average Medicare reimbursements. The main outcome was dollars per life-year saved. For patients with mild to moderate cirrhosis with upper gastrointestinal variceal bleed, the average cost per life year saved was $17,771 (SD = 471) and $21,438 (SD = 308) for TIPS and PC, respectively. The average life expectancy was 5.0 years and 7.0 years for TIPS and PC, respectively. This yielded an incremental cost-effectiveness rate for portocaval shunt of $3,299 per life year saved. Compared with TIPS, surgical PC shunt resulted in improved survival with minimal increase in cost. Therefore, given the low incremental cost of PC, it should be adopted as a cost-effective strategy in managing this patient population.
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Affiliation(s)
| | - Jason Sperry
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, Utah
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Stuke LE, Nirula R, Gentilello LM, Shafi S. Protection against head injuries should not be optional: a case for mandatory installation of side-curtain air bags. Am J Surg 2010; 200:496-9. [DOI: 10.1016/j.amjsurg.2009.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 12/09/2009] [Accepted: 12/03/2009] [Indexed: 11/26/2022]
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Affiliation(s)
- B R Hill
- Department of Surgery, Division of General Surgery, Section of Burns/Trauma/Critical Care, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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