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Hochstetler LJ, Olney WJ, Bishop JM, Warriner ZD, VanHoose JD, Mynatt RP, Ali D, Schadler A, Parli SE. Antibiotics for Patients With a Planned Re-Laparotomy for Intra-Abdominal Infection. Surg Infect (Larchmt) 2024; 25:192-198. [PMID: 38407831 PMCID: PMC11001956 DOI: 10.1089/sur.2023.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Background: Appropriate antimicrobial therapy for the management of intra-abdominal infection (IAI) continues to evolve based on available literature. The Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial provided evidence to support four days of antibiotic agents in IAI post-source control but excluded patients with a planned re-laparotomy. This study aimed to determine the short- and long-term recurrent infection risk in this population. Patients and Methods: This is a single-center, retrospective, observational study of adult patients admitted to a quaternary medical center between January 1, 2016, and August 1, 2022, with IAI requiring planned laparotomy. Patients were designated as receiving five or less days of antibiotic agents (short course) or more than five days (long course) after source control. The primary outcome was IAI recurrence within 30 days. Results: Of the 104 patients who met inclusion criteria, 78 were included in analysis. Average age was 57 ± 13.3 years, 56% were male, 94% Caucasian, with a mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 17 ± 7.09. All other baseline characteristics and clinical severity markers were similar between the two groups. Regarding the primary outcome of IAI recurrence, there was no difference when comparing those who received short course versus those who received long course therapy (41.2% vs. 44.4%; p = 0.781). No differences were found between groups with respect to secondary outcomes. Conclusions: In patients admitted with IAI managed with planned re-laparotomy those who received short course antimicrobial therapy were not found to have an increase in IAI recurrence compared to those with longer courses of therapy.
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Affiliation(s)
- Lauren J. Hochstetler
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - William J. Olney
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Jacqueline M. Bishop
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | | | - Jeremy D. VanHoose
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Ryan P. Mynatt
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
| | - Dina Ali
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Aric Schadler
- Kentucky Children's Hospital, Lexington, Kentucky, USA
- University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
| | - Sara E. Parli
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA
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Levy BE, Castle JT, Virodov A, Wilt WS, Bumgardner C, Brim T, McAtee E, Schellenberg M, Inaba K, Warriner ZD. Artificial intelligence evaluation of focused assessment with sonography in trauma. J Trauma Acute Care Surg 2023; 95:706-712. [PMID: 37165477 DOI: 10.1097/ta.0000000000004021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/12/2023]
Abstract
BACKGROUND The focused assessment with sonography in trauma (FAST) is a widely used imaging modality to identify the location of life-threatening hemorrhage in a hemodynamically unstable trauma patient. This study evaluates the role of artificial intelligence in interpretation of the FAST examination abdominal views, as it pertains to adequacy of the view and accuracy of fluid survey positivity. METHODS Focused assessment with sonography for trauma examination images from 2015 to 2022, from trauma activations, were acquired from a quaternary care level 1 trauma center with more than 3,500 adult trauma evaluations, annually. Images pertaining to the right upper quadrant and left upper quadrant views were obtained and read by a surgeon or radiologist. Positivity was defined as fluid present in the hepatorenal or splenorenal fossa, while adequacy was defined by the presence of both the liver and kidney or the spleen and kidney for the right upper quadrant or left upper quadrant views, respectively. Four convolutional neural network architecture models (DenseNet121, InceptionV3, ResNet50, Vgg11bn) were evaluated. RESULTS A total of 6,608 images, representing 109 cases were included for analysis within the "adequate" and "positive" data sets. The models relayed 88.7% accuracy, 83.3% sensitivity, and 93.6% specificity for the adequate test cohort, while the positive cohort conferred 98.0% accuracy, 89.6% sensitivity, and 100.0% specificity against similar models. Augmentation improved the accuracy and sensitivity of the positive models to 95.1% accurate and 94.0% sensitive. DenseNet121 demonstrated the best accuracy across tasks. CONCLUSION Artificial intelligence can detect positivity and adequacy of FAST examinations with 94% and 97% accuracy, aiding in the standardization of care delivery with minimal expert clinician input. Artificial intelligence is a feasible modality to improve patient care imaging interpretation accuracy and should be pursued as a point-of-care clinical decision-making tool. LEVEL OF EVIDENCE Diagnostic Test/Criteria; Level III.
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Affiliation(s)
- Brittany E Levy
- From the Department of Surgery (B.E.L., J.T.C., W.S.W., E.M.), Institute for Biomedical Informatics (A.V.), Department of Pathology (C.B.), and Department of Radiology (T.B.), University of Kentucky, Lexington, Kentucky; Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery (M.S., K.I.), University of Southern California, Los Angeles, California; and Division of Trauma Critical Care and Acute Care Surgery, Department of Surgery (Z.D.W.), University of Kentucky, Lexington, Kentucky
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Bardes JM, Price BS, Bailey H, Quinn A, Warriner ZD, Bernard AC, LaRiccia A, Spalding MC, Linskey Dougherty MB, Armen SB, Wilson A. Prehospital shock index predicts outcomes after prolonged transport: A multicenter rural study. J Trauma Acute Care Surg 2023; 94:525-531. [PMID: 36728112 PMCID: PMC10038863 DOI: 10.1097/ta.0000000000003868] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Shock index (SI) predicts outcomes after trauma. Prior single-center work demonstrated that emergency medical services (EMSs) initial SI was the most accurate predictor of hospital outcomes in a rural environment. This study aimed to evaluate the predictive ability of SI in multiple rural trauma systems with prolonged transport times to a definitive care facility. METHODS This retrospective review was performed at four American College of Surgeons-verified level 1 trauma centers with large rural catchment basins. Adult trauma patients who were transferred and arrived >60 minutes from scene during 2018 were included. Patients who sustained blunt chest or abdominal trauma were analyzed. Subjects with missing data or severe head trauma (Abbreviated Injury Scale score, >2) were excluded. Poisson and binomial logistic regression were used to study the effect of SI and delta shock index (∆SI) on outcomes. RESULTS After applying the criteria, 789 patients were considered for analysis (502 scene patients and 287 transfers). The mean Injury Severity Score was 8 (interquartile range, 6) for scene and 8.9 (interquartile range, 5) for transfers. Initial EMSs SI was a significant predictor of the need for blood transfusion and intensive care unit care in both scene and transferred patients. An increase in ∆SI was predictive of the need for operative intervention ( p < 0.05). There were increased odds for mortality for every 0.1 change in EMSs SI; those changes were not deemed significant among both scene and transfer patients ( p < 0.1). CONCLUSION Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI is a significant predictor for use of blood and intensive care unit care, as well as mortality for scene patients. This highlights the importance of SI and ∆SI in rural trauma care. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- James M Bardes
- From the Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery (J.M.B., A.W.), West Virginia University, Morgantown, West Virginia; Department of Management Information Systems (B.S.P., H.B., A.Q.), West Virginia University, John Chambers College of Business and Economics, Morgantown, West; Department of Surgery, Division of Acute Care Surgery, Trauma and Surgical Critical Care (Z.D.W., A.C.B.), University of Kentucky Chandler Medical Center, Lexington; Department of Surgery, Division of Trauma (A.L., M.C.S.), OhioHealth Grant Medical Center, Columbus, Ohio; and Department of Surgery, Division of General Surgery, Surgical Critical Care, Trauma Surgery (M.B.L.C., S.B.A.), Penn State University College of Medicine/Penn State Health, Hershey, Pennsylvania
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Bardes JM, Grabo DJ, LaRiccia A, Spalding MC, Warriner ZD, Bernard AC, Dougherty MBL, Armen SB, Hudnall A, Stout C, Wilson A. A multicenter evaluation on the impact of non-therapeutic transfer in rural trauma. Injury 2023; 54:238-242. [PMID: 35931578 DOI: 10.1016/j.injury.2022.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma transfers are a common occurrence in rural areas, where critical access and lower-level trauma centers routinely transfer to tertiary care centers for specialized care. Transfers are non-therapeutic (NTT) when no specialist intervention occurs, leading to transfer that were futile (FT) or secondary overtriage (SOT). This study aimed to evaluate the prevalence of NTT among four trauma centers providing care to rural Appalachia. METHODS This retrospective review was performed at four, ACS verified, Level 1 trauma centers. All adult trauma patients, transferred during 2018 were included for analysis. Transfers were considered futile if in <48 h the patient died or was discharged to hospice, without operative intervention. SOT transfers were discharged in <48 h, without major intervention, with an ISS< 15. Cost analysis was performed to describe the impact of NTT on EMS use. RESULTS 4,189 patients were analyzed during the study period. 105 (2.5%) met criteria for futility. Futile patients had a median ISS of 25 (IQR 9-26), and 48% had an AIS head ≥4. These were significantly greater (p<0.001) than non-futile transfers, median ISS 5 (IQR 2-9), 3% severe head injury. SOT occurred in 1371 (33%), median ISS of 5, and lower AIS scores by region. Isolated facial injuries resulted in 165 transfers. 13% of FT+SOT were admitted to the ICU. Only 22% of FT+SOT came from a trauma center. 68% were transported by ALS and 13% transported by air transport. FT+SOT traveled on average 70 miles from their home to receive care. CONCLUSIONS Non-therapeutic transfers account for more than 1/3 of transfers in this rural environment. There was a significant use of advanced life support and aeromedical transport. The utility of these transfers should be questioned. With the recent increases in telehealth there is an opportunity for trauma systems to improve regional care and decrease transfers for futile cases.
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Affiliation(s)
- James M Bardes
- West Virginia University, Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, United States.
| | - Daniel J Grabo
- West Virginia University, Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, United States
| | | | | | | | | | | | - Scott B Armen
- Penn State University College of Medicine/Penn State Health, United States
| | - Aaron Hudnall
- West Virginia University, Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, United States
| | - Conley Stout
- West Virginia University, Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, United States
| | - Alison Wilson
- West Virginia University, Department of Surgery, Division of Trauma, Surgical Critical Care and Acute Care Surgery, United States
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Kumar S, Edmunds RW, Nisiewicz MJ, Warriner ZD, Chang YWW, Plymale MA, Davenport DL, Wade A, Roth JS. Totally extraperitoneal approach for open complex abdominal wall reconstruction. Surg Endosc 2020; 35:159-164. [PMID: 32030549 DOI: 10.1007/s00464-020-07374-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 01/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Ventral hernia repair is typically performed via a transabdominal approach and the peritoneal cavity is opened and explored. Totally extraperitoneal ventral hernia repair (TEVHR) facilitates dissection of the hernia sac without entering the peritoneal cavity. This study evaluates our experience of TEVHR, addressing technique, decision-making, and outcomes. METHODS This is an IRB-approved retrospective review of open TEVHR performed between January 2012 and December 2016. Medical records were reviewed for patient demographics, operative details, postoperative outcomes, hospital readmissions, and reoperations. RESULTS One hundred sixty-six patients underwent TEVHR (84 males, 82 females) with a mean BMI range of 30-39. Eighty-six percent of patients underwent repair for primary or first-time recurrent hernia, and 89% CDC wound class I. Median hernia defect size was 135 cm2. Hernia repair techniques included Rives-Stoppa (34%) or transversus abdominis release (57%). Median operative time was 175 min, median blood loss 100 mL, and median length of stay 4 days. There were no unplanned bowel resections or enterotomies. Four cases required intraperitoneal entry to explant prior mesh. Wound complication rate was 27%: 9% seroma drainage, 18% superficial surgical site infection (SSI), and 2% deep space SSI. Five patients (3%) required reoperation for wound or mesh complications. Over the study, four patients were hospitalized for postoperative small bowel obstruction and managed non-operatively. Of the 166 patients, 96%, 54%, and 44% were seen at 3-month, 6-month, and 12-month follow-ups, respectively. Recurrences were observed in 2% of patients at 12-month follow-up. One patient developed an enterocutaneous fistula 28 months postoperatively. CONCLUSIONS TEVHR is a safe alternative to traditional transabdominal approaches to ventral hernia repair. The extraperitoneal dissection facilitates hernia repair, avoiding peritoneal entry and adhesiolysis, resulting in decreased operative times. In our study, there was low risk for postoperative bowel obstruction and enterotomy. Future prospective studies with long-term follow-up are required to draw definitive conclusions.
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Affiliation(s)
- Shyanie Kumar
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - R Wesley Edmunds
- Plastic Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | | | - Zachary D Warriner
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - Yu-Wei Wayne Chang
- General Surgery Residency Program, University of Kentucky Graduate Medical Education, Lexington, KY, USA
| | - Margaret A Plymale
- Division of General Surgery, Department of Surgery, C 222, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA
| | | | - Alexander Wade
- University of Kentucky College of Medicine, Lexington, KY, USA
| | - John Scott Roth
- Division of General Surgery, Department of Surgery, C 222, Chandler Medical Center, University of Kentucky, 800 Rose Street, Lexington, KY, 40536, USA.
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Warriner ZD, Kim JS, Biswas S, Benjamin ER, Inaba K, Demetriades D. Impact of Alcohol on Seizures and Mortality after Isolated Blunt Traumatic Brain Injury. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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