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Ross SW, McCartt JC, Cunningham KW, Reinke CE, Thompson KJ, Green JM, Thomas BW, Jacobs DG, May AK, Christmas AB, Sing RF. Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center. Am J Surg 2022; 224:1409-1416. [PMID: 36372581 PMCID: PMC9575313 DOI: 10.1016/j.amjsurg.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 09/23/2022] [Accepted: 10/13/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.
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Affiliation(s)
- Samuel W. Ross
- Corresponding author. Atrium Health Carolinas Medical Center, Charlotte NC, 1000 Blythe Blvd, Suite 601 MEB, Charlotte, NC, 28203, USA
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2
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Ayuso SA, Elhage SA, Cunningham KW, Britton Christmas A, Sing RF, Thomas BW, May AK, Reinke CE, Ross SW. Emergency General Surgery Regionalization: Retrospective Cohort Study of Emergency General Surgery Patients at a Tertiary Care Center. Am Surg 2021:31348211038577. [PMID: 34397281 DOI: 10.1177/00031348211038577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) patients presenting at tertiary care hospitals may bypass local hospitals with adequate resources. However, many tertiary care hospitals frequently operate at capacity. We hypothesized that understanding patient geographic origin could identify opportunities for enhanced system triage and optimization and be an important first step for EGS regionalization and care coordination that could potentially lead to improved utilization of resources. METHODS We analyzed patient zip code and categorized EGS patients who were cared for at our tertiary care hospital as potentially divertible if the southern region hospital was geographically closer to their home, regional hospital admission (RHA) patients, or local admission (LA) patients if the tertiary care facility was closer. Baseline characteristics and outcomes were compared for RHA and LA patients. RESULTS Of 14 714 EGS patients presenting to the tertiary care hospital, 30.2% were categorized as RHA patients. Overall, 1526 (10.4%) patients required an operation including 527 (34.5%) patients who were potentially divertible. Appendectomy and cholecystectomy comprised 66% of the operations for potentially divertible patients. Length of stay was not significantly different (P = .06) for RHA patients, but they did have lower measured short-term and long-term mortality when compared to their LA counterparts (P < .05). CONCLUSIONS EGS diagnoses and patient geocode analysis can identify opportunities to optimize regional operating room and bed utilization. Understanding where EGS patients are cared for and factors that influenced care facility will be critical for next steps in developing EGS regionalization within our system.
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Affiliation(s)
- Sullivan A Ayuso
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Sharbel A Elhage
- Department of Surgery, 22442Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Addison K May
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Caroline E Reinke
- Division of Gastrointestinal and Minimally Invasive Surgery, 2351Atrium Health, Charlotte, NC, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, 2351Atrium Health, Charlotte, NC, USA
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Maloney SR, Reinke CE, Nimeri AA, Ayuso SA, Christmas AB, Hetherington T, Kowalkowski M, Sing RF, May AK, Ross SW. The Obesity Paradox in Emergency General Surgery Patients. Am Surg 2021; 88:852-858. [PMID: 33530738 DOI: 10.1177/0003134820968524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.
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Affiliation(s)
- Sean R Maloney
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Sullivan A Ayuso
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | | | | | - Marc Kowalkowski
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Addison K May
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| | - Samuel Wade Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
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Klima DA, Hanna EM, Christmas AB, Huynh TT, Etson KE, Fair BA, Green JM, Madjarov J, Sing RF. Endovascular Graft Repair for Blunt Traumatic Disruption of the Thoracic Aorta: Experience at a Nonuniversity Hospital. Am Surg 2020. [DOI: 10.1177/000313481307900620] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.
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Affiliation(s)
- David A. Klima
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin M. Hanna
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - A. Britton Christmas
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Toan T. Huynh
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kristina E. Etson
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Brett A. Fair
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John M. Green
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jeko Madjarov
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ronald F. Sing
- From the F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Abstract
It has been previously reported that trauma patients with cirrhosis undergoing emergency abdominal operations exhibit a fourfold increase in mortality independent of their Child's classification. We undertook this review to assess the impact of cirrhosis on trauma patients. We reviewed the records of patients from 1993 to 2003 with documented hepatic cirrhosis and compared them to a 2:1 control population without hepatic cirrhosis and matched for age, sex, Injury Severity Score (ISS), and Glasgow Coma Score (GCS). Demographic, severity of injury, and outcome data were recorded. Student's t test and χ2 were used for statistical analysis and a P < 0.05 was significant. Sixty-one patients had documented cirrhosis and were compared to 156 matched controls. Comparing the two groups demonstrates there was no difference in age, ISS, or GCS. Intensive care stay, hospital length of stay, blood requirements in the first 24 hours postinjury, and mortality (33% vs 1%) was significantly greater in the trauma patients with cirrhosis. Fifty-five per cent of deaths in the cirrhosis group was due to sepsis, and, as the Child's class increases, so does the mortality (Child's A, 15%; B, 37%; and C, 63%). In 64 per cent of cirrhotics without an emergent abdominal operation, mortality was 21 per cent. In the 36 per cent of cirrhotics who had emergent abdominal operation, mortality was 55 per cent. Hepatic cirrhosis in trauma patients, regardless of severity of injury or the need for an abdominal intervention, is a poor prognostic indicator. The necessity of an abdominal operative intervention further amplifies this effect. Trauma and cirrhosis is, in fact, a deadly duo.
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Affiliation(s)
| | - Ashley K. Wilson
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Glen A. Franklin
- Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Frank B. Miller
- Department of Surgery, University of Louisville, Louisville, Kentucky
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Arnold MR, Cunningham KW, Atkins TG, Haley OK, Bernard J, Seymour RB, Christmas AB, Sing RF. Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage. Am J Emerg Med 2020; 38:1097-1101. [DOI: 10.1016/j.ajem.2019.158379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022] Open
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Ross SW, Lauer CW, Miles WS, Green JM, Christmas AB, May AK, Matthews BD. Maximizing the Calm before the Storm: Tiered Surgical Response Plan for Novel Coronavirus (COVID-19). J Am Coll Surg 2020; 230:1080-1091.e3. [PMID: 32240770 PMCID: PMC7128345 DOI: 10.1016/j.jamcollsurg.2020.03.019] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 01/16/2023]
Abstract
The novel coronavirus (COVID-19) was first diagnosed in Wuhan, China in December 2019 and has now spread throughout the world, being verified by the World Health Organization as a pandemic on March 11. This had led to the calling of a national emergency on March 13 in the US. Many hospitals, healthcare networks, and specifically, departments of surgery, are asking the same questions about how to cope and plan for surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. Herein, we present a tiered plan for surgical department planning based on incident command levels. This includes acute care surgeon deployment (given their critical care training and vertically integrated position in the hospital), recommended infrastructure and transfer utilization, triage principles, and faculty, resident, and advanced care practitioner deployment.
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Affiliation(s)
- Samuel Wade Ross
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC.
| | - Cynthia W Lauer
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - William S Miles
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - John M Green
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - Addison K May
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
| | - Brent D Matthews
- Division of Acute Care Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC
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8
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Baimas-George M, Cunningham KW, Ross SW, Savell A, Monteruil K, Christmas AB, Sing RF. Filled to the brim: The characteristics of over-triage at a level I trauma center. Am J Surg 2019; 218:1074-1078. [PMID: 31540682 DOI: 10.1016/j.amjsurg.2019.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Interfacility transfers are necessary and valuable for the trauma system, but despite regional guidelines, many patients are inappropriately transferred. We evaluated over-triage at our Level I center and identified risk factors for over-triage. METHODS Retrospective analysis at our Level I urban trauma center assessed patients transferred from regional facilities during 2017. Over-triage was defined as patients discharged <48 h without procedures. Exclusion criteria were leaving against medical advice or no outside records. RESULTS Overall, 2352 patients met criteria. Nine hundred thirty (39.5%) with complete hospital records were discharged in <48 h; 498 (53.5%) received no procedural intervention and 909 (97.7%) were ultimately discharged home. CONCLUSION Many patients are inappropriately transferred to tertiary care centers without a definitive need for advanced services. Studies are needed to improve triage criteria without increasing under-triage.
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Affiliation(s)
- Maria Baimas-George
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Anita Savell
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Kelly Monteruil
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
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Arnold MR, Kao AM, Cunningham KW, Christmas AB, Thomas BW, Sing RF, Reinke CE, Ross SW. Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP. Am Surg 2019. [DOI: 10.1177/000313481908500943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11–1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.
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Affiliation(s)
- Michael R. Arnold
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Angela M. Kao
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle W. Cunningham
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - A. Britton Christmas
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Bradley W. Thomas
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ronald F. Sing
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Caroline E. Reinke
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Samuel W. Ross
- From the Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Arnold MR, Kao AM, Cunningham KW, Christmas AB, Thomas BW, Sing RF, Reinke CE, Ross SW. Not a Routine Case, Why Expect the Routine Outcome? Quantifying the Infectious Burden of Emergency General Surgery Using the NSQIP. Am Surg 2019; 85:1001-1009. [PMID: 31638514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Emergent surgeries have different causes and physiologic patient responses than the same elective surgery, many of which are due to infectious etiologies. Therefore, we hypothesized that emergency cases have a higher risk of postoperative SSI than their elective counterparts. The ACS NSQIP database was queried from 2005 to 2016 for all cholecystectomies, ventral hernia repairs, and partial colectomies to examine common emergency and elective general surgery operations. Thirty-day outcomes were compared by emergent status. Any SSI was the primary outcome. There were 863,164 surgeries: 416,497 cholecystectomies, 220,815 ventral hernia repairs, and 225,852 partial colectomies. SSIs developed in 38,865 (4.5%) patients. SSIs increased with emergencies (5.3% vs 3.6% for any SSI). Postoperative sepsis (5.8% vs 1.5%), septic shock (4.7% vs 0.6%), length of stay (8.1 vs 2.9 days), and mortality (3.6% vs 0.4%) were increased in emergent surgery; P < 0.001 for all. When controlling for age, gender, BMI, diabetes, smoking, wound classification, comorbidities, functional status, and procedure on multivariate analysis, emergency surgery (odds ratio 1.15, 95% confidence interval 1.11-1.19) was independently associated with the development of SSI. Patients undergoing emergency general surgery experience increased rates of SSI. Patients and their families should be appropriately counseled regarding these elevated risks when consenting for emergency surgery.
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Shenoy R, Cunningham KW, Ross SW, Christmas AB, Thomas BW, Avery MJ, Lessne ML, Prasad T, Sing RF. “Death Knell” for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline. Am Surg 2019. [DOI: 10.1177/000313481908500829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group ( P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.
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Affiliation(s)
- Rathna Shenoy
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Kyle W. Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Samuel Wade Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - A. Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Bradley W. Thomas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Michael J. Avery
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Mark L. Lessne
- Vascular and Interventional Specialists of Charlotte Radiology, Charlotte, North Carolina
| | - Tanushree Prasad
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
| | - Ronald F. Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina and
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Shenoy R, Cunningham KW, Ross SW, Christmas AB, Thomas BW, Avery MJ, Lessne ML, Prasad T, Sing RF. "Death Knell" for Prophylactic Vena Cava Filters? A 20-Year Experience with a Venous Thromboembolism Guideline. Am Surg 2019; 85:806-812. [PMID: 32051064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The role of prophylactic vena cava filters (pVCFs) in trauma patients remains controversial. After 20 years of data collection and experience, we reviewed our venous thromboembolism guideline for the efficacy of pVCFs in preventing pulmonary embolism (PE). A retrospective cohort study was performed using our Level I trauma center registry from January 1997 thru December 2016. This population was then divided by the presence of pVCFs. Univariate analysis was performed comparing the incidence of PEs, deep vein thrombosis, and mortality between those with and without a pVCF. There were 35,658 patients identified, of whom 2 per cent (n = 847) received pVCFs. The PE rate was 0.4 per cent in both groups. The deep vein thrombosis rate for pVCFs was 3.9 per cent compared with 0.6 per cent in the no-VCF group (P < 0.0001). Given that there was no difference in the rates of PEs between the cohorts, the subset of patients with a PE were analyzed by their risk factors. Only ventilator days > 3 were associated with a higher risk in the no-pVCF group (0.2 vs 1.5%, P = 0.033). pVCFs did not confer benefit reducing PE rate. In addition, despite their intended purpose, pVCFs cannot eliminate PEs in high-risk trauma patients, suggesting a lack of utility for prophylaxis in this population.
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13
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Motz BM, Baimas-George M, Barnes TE, Ragunanthan BV, Symanski JD, Christmas AB, Sing RF, Ross SW. Mitigating clinical waste in the trauma intensive care unit: Limited clinical utility of cardiac troponin testing for trauma patients with atrial fibrillation. Am J Surg 2019; 219:1050-1056. [PMID: 31371023 DOI: 10.1016/j.amjsurg.2019.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 04/08/2019] [Revised: 07/03/2019] [Accepted: 07/22/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The clinical significance of obtaining cardiac troponin (cTn) levels among trauma patients with new onset arrhythmias is unknown. We aimed to assess whether cTn levels actually influence clinical decision making or represent an inappropriate use of resources. METHODS Trauma patients admitted from 2013 to 2014 diagnosed with atrial fibrillation (AF) were retrospectively reviewed using the institutional trauma database. Demographics, cTn levels, and myocardial infarction (MI) diagnosis data were recorded. Standard univariate tests were used to compare data between patients with and without cTn. RESULTS There were 258 patients included of which 126 patients had cTn levels obtained (48.8%, TEST group). The remaining 132 patients (51.2%) were untested (noTEST group). Among TEST patients, use of echocardiography nearly doubled and cardiology consultations increased (all p < 0.05). No TEST patients suffered MI or PE. CONCLUSIONS Obtaining cTn values in trauma patients with new-onset AF resulted in increased resource utilization without clinical utility.
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Affiliation(s)
- Benjamin M Motz
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Maria Baimas-George
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - T Ellis Barnes
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Branavan V Ragunanthan
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - John D Symanski
- Sanger Heart & Vascular Institute, Department of Cardiology, Carolinas Medical Center, 1001 Blythe Blvd., Suite 300, Charlotte, NC, USA
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA
| | - Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd., MEB Suite 601, Charlotte, NC, 28203, USA.
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Ross SW, Christmas AB, Fischer PE, Holway H, Seymour R, Huntington CR, Heniford BT, Sing RF. Defining Dogma: Quantifying Crystalloid Hemodilution in a Prospective Randomized Control Trial with Blood Donation as a Model for Hemorrhage. J Am Coll Surg 2018; 227:321-331. [PMID: 29879520 DOI: 10.1016/j.jamcollsurg.2018.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 03/30/2018] [Accepted: 05/14/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The concept of hemodilution after blood loss and crystalloid infusion is a surgical maxim that remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for acute hemorrhage. STUDY DESIGN A prospective, randomized control trial was conducted in conjunction with community blood drives. Donors were randomized to receive no IV fluid (noIVF), 2 liters of normal saline (NS), or 2 liters lactated Ringer's (LR) after blood donation. Blood samples were taken before donation of 500 mL of blood, immediately after donation, and after IV fluid administration. Hemoglobin (Hgb) was measured at each time point. Hemoglobin measurements between time points were compared between groups using standard statistical tests and the Bonferroni correction for multiple comparisons. Statistical significance was set at p ≤ 0.0167. RESULTS Of 165 patients consented, 157 patients completed the study. Average pre-donation Hgb was 14.3 g/dL. There was no difference in the mean Hgb levels after blood donation between the 3 groups (p > 0.05). Compared with the control group, there was a significant drop in Hgb in the crystalloid infused groups from the post-donation level to post-resuscitation (13.2 vs 12.1 vs 12.2 g/dL, p < 0.0001). A formula was created to predict hemoglobin levels from a given estimated blood loss (EBL) and volume replacement (VR): Hemodilution Hgb = (mean pre-donation Hgb - hemorrhage Hgb drop - equilibration hemoglobin drop - resuscitation Hgb drop) = Mean pre-donation Hgb - [(EBL/TBV)*l] - [(EBL/TBV)*h] - [(VR/TBV)*r], l = 5.111g/dL = blood loss coefficient, h = 6.722 g/dL = equilibration coefficient, r = 2.617g/dL = resuscitation coefficient. CONCLUSIONS This study proves the concept of hemodilution and derived a mathematical relationship between blood loss and resuscitation. These data may help to estimate response of hemoglobin levels to blood loss and fluid resuscitation in clinical practice.
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Affiliation(s)
- Samuel Wade Ross
- Department of Surgery, Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, NC
| | - A Britton Christmas
- Department of Surgery, Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, NC
| | - Peter E Fischer
- Department of Surgery, Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, NC
| | - Haley Holway
- Department of Surgery, Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, NC
| | - Rachel Seymour
- Department of Orthopedic Surgery, Carolinas Medical Center, Charlotte, NC
| | - Ciara R Huntington
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC
| | - Ronald F Sing
- Department of Surgery, Division of Acute Care Surgery, Carolinas Medical Center, Charlotte, NC.
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Abstract
Conditions of systemic stress can lead to increased reactive oxygen species production, mitochondrial dysfunction, systemic inflammation, and multiorgan dysfunction. Triphenylphosphonium (TPP1) is a lipophilic cation used to target therapeutics to mitochondria. We sought to determine the effects of TPP1 on mitochondrial integrity. Male rats were anesthetized and TPP1 (5 mg/kg) or vehicle (saline) was administered intravenously 30-minutes after anesthesia initiation and intraperitoneally (20 mg/kg) 60-minutes later. Rats were exsanguinated 2-hours postinjection. Cardiac, pulmonary, hepatic, splenic, and renal tissues were analyzed for inflammation, lipid peroxidation, endogenous antioxidant activity, cytokine expression, and mitochondrial function. In vitro modeling was performed using freshly isolated hepatocytes subjected to 8-hours hypoxia/30-minutes reoxygenation in the absence or presence of TPP1. TPP1 increased lipid peroxidation in the liver, lung, and kidney as well as antioxidant activity in the liver, kidney, and spleen. Conversely, antioxidant activity decreased in the lung with TPP1. In addition, TPP1 altered hepatic inflammatory mediators. In vitro, TPP1 attenuated oxygen consumption and, when combined with hypoxic injury, depolarized mitochondrial membranes in hepatocytes. TPP1 induces systemic responses associated with oxidative stress and worsening pathologies in animals. Caution should be exercised when employing TPP1 for therapeutics.
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Affiliation(s)
- Rebecca D. Powell
- F.H. “Sammy” Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Donna A. Goodenow
- F.H. “Sammy” Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - A. Britton Christmas
- F.H. “Sammy” Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Iain H. Mckillop
- F.H. “Sammy” Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Susan L. Evans
- F.H. “Sammy” Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Powell RD, Goodenow DA, Christmas AB, Mckillop IH, Evans SL. Effect of Systemic Triphenylphosphonium on Organ Function and Oxidative Stress. Am Surg 2018; 84:36-42. [PMID: 29428024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Conditions of systemic stress can lead to increased reactive oxygen species production, mitochondrial dysfunction, systemic inflammation, and multiorgan dysfunction. Triphenylphosphonium (TPP+) is a lipophilic cation used to target therapeutics to mitochondria. We sought to determine the effects of TPP+ on mitochondrial integrity. Male rats were anesthetized and TPP+ (5 mg/kg) or vehicle (saline) was administered intravenously 30-minutes after anesthesia initiation and intraperitoneally (20 mg/kg) 60-minutes later. Rats were exsanguinated 2-hours postinjection. Cardiac, pulmonary, hepatic, splenic, and renal tissues were analyzed for inflammation, lipid peroxidation, endogenous antioxidant activity, cytokine expression, and mitochondrial function. In vitro modeling was performed using freshly isolated hepatocytes subjected to 8-hours hypoxia/30-minutes reoxygenation in the absence or presence of TPP+. TPP+ increased lipid peroxidation in the liver, lung, and kidney as well as antioxidant activity in the liver, kidney, and spleen. Conversely, antioxidant activity decreased in the lung with TPP+. In addition, TPP+ altered hepatic inflammatory mediators. In vitro, TPP+ attenuated oxygen consumption and, when combined with hypoxic injury, depolarized mitochondrial membranes in hepatocytes. TPP+ induces systemic responses associated with oxidative stress and worsening pathologies in animals. Caution should be exercised when employing TPP+ for therapeutics.
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Ross SW, Thomas BW, Christmas AB, Cunningham KW, Sing RF. Returning from the acidotic abyss: Mortality in trauma patients with a pH < 7.0. Am J Surg 2017; 214:1067-1072. [PMID: 29079021 DOI: 10.1016/j.amjsurg.2017.08.033] [Citation(s) in RCA: 5] [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: 03/11/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022]
Abstract
INTRODUCTION We hypothesized that a pH of <7.0 on presentation would correlate with almost universal mortality in trauma patients. METHODS A retrospective cohort study was performed on a Level I trauma center registry from 2013 to 2014. Hospital mortality was the primary outcome, which was compared by pH cohort (<7.0 or ≥7.0) using standard univariate statistics and multivariate logistic regression. RESULTS There were 593 patients included in the analysis: 66 in <7.0, 527 in ≥7.0. Mortality was 3× higher in the <7.0 pH cohort (62.1 vs. 20.3%; p < 0.0001), however there was no threshold for a pH below which there was 100% mortality. After controlling for these confounding variables, initial pH was found to be an independent predictor of inpatient mortality: pH < 7.0 (OR 6.33, 3.29-12.19; p < 0.0001). CONCLUSION This data indicates that while patients with severe acidosis are at increased risk for mortality, a pH < 7.0 is still recoverable in select cases.
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Affiliation(s)
- Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Bradley W Thomas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - A Britton Christmas
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Kyle W Cunningham
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Ronald F Sing
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Thomas BW, Avery MJ, Sachdev G, Christmas AB, Sing RF. Laparoscopic Repair of a Traumatic Bladder Rupture. Am Surg 2017; 83:e347-e348. [PMID: 30454346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Bradley W Thomas
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Affiliation(s)
- Bradley W. Thomas
- Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Michael J. Avery
- Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Gaurav Sachdev
- Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | | | - Ronald F. Sing
- Department of Surgery Carolinas Medical Center Charlotte, North Carolina
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Nunn A, Fischer P, Sing R, Templin M, Avery M, Christmas AB. Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience. Am Surg 2017. [DOI: 10.1177/000313481708300429] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004–2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.
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Affiliation(s)
- Andrew Nunn
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Peter Fischer
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Ronald Sing
- Division of Trauma and Surgical Critical Care, Department of Surgery, Carolinas HealthCare System, Charlotte, North Carolina
| | - Megan Templin
- Dickson Advanced Analytics, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael Avery
- Dickson Advanced Analytics, Carolinas Medical Center, Charlotte, North Carolina
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Nunn A, Fischer P, Sing R, Templin M, Avery M, Christmas AB. Improvement of Treatment Outcomes after Implementation of a Massive Transfusion Protocol: A Level I Trauma Center Experience. Am Surg 2017; 83:394-398. [PMID: 28424137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We assessed the effectiveness of the implementation of an institutional massive transfusion protocol (MTP) for resuscitation with a 1:1:1 transfusion ratio of packed red blood cell (PRBC), fresh frozen plasma, and platelet units. In a Level I trauma center database, all trauma admissions (2004-2012) that received massive transfusions (≥10 units PRBCs in the first 24 hours) were reviewed retrospectively. Demographic data, transfusion ratios, and outcomes were compared before (PRE) and after (POST) MTP implementation in May 2008. Age, sex, and mechanism of injury were similar between 239 PRE and 208 POST trauma patients requiring massive transfusion. Transfusion ratios of fresh frozen plasma:PRBC and platelet:PRBC increased after MTP implementation. Among survivors, MTP implementation shortened hospital length of stay from 31 to 26 days (P = 0.04) and intensive care unit length of stay from 31 to 26 days (P = 0.02). Linear regression identified treatment after (versus before) implementation of MTP as an independent predictor of decreased ventilator days after adjusting for age, Glasgow Coma Scale, and chest Abbreviated Injury Score (P < 0.0001). Modest improvement in ratios likely does not account for all significant improvements in outcomes. Implementing a standardized protocol likely impacts automation, efficiency, and/or timeliness of product delivery.
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22
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Affinati S, Patton D, Hansen L, Ranney M, Christmas AB, Violano P, Sodhi A, Robinson B, Crandall M. Hospital-based violence intervention programs targeting adult populations: an Eastern Association for the Surgery of Trauma evidence-based review. Trauma Surg Acute Care Open 2016; 1:e000024. [PMID: 29766064 PMCID: PMC5891700 DOI: 10.1136/tsaco-2016-000024] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [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: 06/22/2016] [Revised: 09/01/2016] [Accepted: 09/05/2016] [Indexed: 02/06/2023] Open
Abstract
Background Violent injury and reinjury take a devastating toll on distressed communities. Many trauma centers have created hospital-based violent injury prevention programs (HVIP) to address psychosocial, educational, and mental health needs of injured patients that may contribute to reinjury. Objectives To evaluate the overall effectiveness of HVIPs for violent injury prevention. We performed an evidence-based review to answer the following population, intervention, comparator, outcomes (PICO) question: Are HVIPs attending to adult patients (age 18+) treated for intentional injury more effective than the usual care at preventing: intentional violent reinjury and/or death; arrest and/or incarceration; substance abuse and/or mental issues; job and/or school attainment? Data sources PubMed, Web of Science, Google Scholar, and the Cochrane Library were queried for salient articles by a professional librarian on two separate occasions, and related articles were identified from references. Study eligibility criteria, participants, interventions Eligible studies examined adult patients treated for intentional injury in a hospital-based violence prevention program compared to a control group. Study appraisal and synthesis methods We used the Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the evidence. Results 71 articles were identified. After discarding duplicates, reviews, and those articles that did not address our PICO questions, we ultimately reviewed 10 articles. We found insufficient evidence to recommend adult-focused HVIP interventions. Limitations There was a relative paucity of data, and available studies were limited by self-selection bias and small sample sizes. Conclusions We make no recommendation with respect to adult-focused HVIP interventions.
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Affiliation(s)
- Steven Affinati
- The Family Institute at Northwestern University, Evanston, Illinois, USA
| | - Desmond Patton
- School of Social Work and School of Information, University of Michigan, Ann Arbor, Michigan, USA
| | - Luke Hansen
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Megan Ranney
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A Britton Christmas
- Department of Surgery, The F. H. 'Sammy' Ross, Jr Trauma Center, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Pina Violano
- Department of Injury Prevention, Community Outreach & Research, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Aparna Sodhi
- Northwestern University, Evanston, Illinois, USA
| | - Bryce Robinson
- Department of Surgery, University of Washington Harborview Medical Center, Seattle, Washington, USA
| | - Marie Crandall
- Department of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
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Ross SW, Bouchez JD, Fischer PE, Brintzenhoff RA, Sing RF, Christmas AB, Thomas BW. A Violation of Occam's Razor: Acute Appendicitis after Motor Vehicle Collision. Am Surg 2016; 82:e281-e283. [PMID: 27670549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Samuel W Ross
- Division of Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Ross SW, Bouchez JD, Fischer PE, Brintzenhoff RA, Sing RF, Christmas AB, Thomas BW. A Violation of Occam's Razor: Acute Appendicitis after Motor Vehicle Collision. Am Surg 2016. [DOI: 10.1177/000313481608200922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Samuel W. Ross
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Jonathan D. Bouchez
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Peter E. Fischer
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Rita A. Brintzenhoff
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Ronald F. Sing
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - A. Britton Christmas
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
| | - Bradley W. Thomas
- Division of Acute Care Surgery Department of Surgery Carolinas Medical Center Charlotte, North Carolina
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Ross SW, Oommen B, Wormer BA, Walters AL, Augenstein VA, Heniford BT, Sing RF, Christmas AB. Acute Colonic Pseudo-obstruction: Defining the Epidemiology, Treatment, and Adverse Outcomes of Ogilvie's Syndrome. Am Surg 2016; 82:102-11. [PMID: 26874130 DOI: 10.1177/000313481608200211] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute colonic pseudo-obstruction (ACPO) is a rare but often fatal disease. Herein, we present the largest study to date on ACPO. The National Inpatient Sample was queried for ACPO diagnoses from 1998 to 2011. Patients were analyzed by treatment into four groups: medical management (MM), colonoscopy alone [(endoscopy-only group) ENDO], surgery alone (SURG), or surgery and colonoscopy (SAC). Logistic regression was used to identify predictors of adverse outcomes by treatment group. There were 106,784 cases of ACPO: 96,657 (90.5%) MM, 2,915 (2.7%) ENDO, 6,731 (6.3%) SURG, and 481 (0.5%) SAC. The medical complication (45.7%), procedural complication (15.9%), and mortality rates (7.7%) were high. Increasing procedure invasiveness was independently associated with higher odds of medical complications, procedural complications, and death (P < 0.0125). The odds of death were significantly higher in the ENDO [odds ratio (OR) = 1.2], SURG (OR 1.4), and SAC (OR = 1.8) groups (P < 0.0125). Those who fail MM and require procedures have increasing morbidity and mortality with increasing invasiveness, likely reflecting the severity of their conditions.
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Affiliation(s)
- Samuel W Ross
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
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Sola R, Christmas AB, Thomas BW, Fischer PE, Eubanks GC, Raynor NE, Sing RF. Do not waste your time: straight to magnetic resonance imaging for pediatric burners and stingers. Am J Emerg Med 2016; 34:1442-5. [PMID: 27210728 DOI: 10.1016/j.ajem.2016.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Revised: 04/13/2016] [Accepted: 04/13/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Permanent neurologic injury in pediatric patients with burner and stinger syndrome (BSS) is unlikely. This study aims to assess the feasibility of clinical observation without extensive radiologic workup in this selective population. METHODS A retrospective study was conducted of patients aged younger than 18 years evaluated at a level I trauma center from 2012 to 2014. Patients were grouped according to positive deficit (PD) or negative deficit (ND) upon physical examination. Demographics, clinical findings, and outcomes were analyzed. RESULTS Thirty patients (ND, n = 14; PD, n = 16) were evaluated for BSS, most often as a result of injurious football tackle. Age and length of stay were similar between groups. Injury Severity Score was lower in the ND group than the PD group (1.6 ± 1.2 vs 3.8 ± 3.1, respectively; P< .05). Cervical computed tomography was performed on 11 patients (78.6%) in the ND group and 15 patients (93.8%) in the PD group at considerable added cost, with only 1 positive result in the ND group and none in the PD group. Magnetic resonance imaging (MRI) revealed 2 positive findings in each group, and no surgical interventions were indicated. Ten ND (71.4%) and 12 PD (75%) patients reported complete resolution of symptoms at discharge (P> .05). CONCLUSIONS Children presenting with BSS experience temporary symptoms that resolve without surgical intervention. Magnetic resonance imaging identified more injuries than computed tomographic imaging; therefore, we suggest that management for BSS should include observation, serial neurologic examinations, and MRI evaluation as appropriate.
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Affiliation(s)
- Richard Sola
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - A Britton Christmas
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Bradley W Thomas
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Peter E Fischer
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Grayson C Eubanks
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Nora E Raynor
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
| | - Ronald F Sing
- Division of Trauma and Acute Care Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
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Dahlquist RT, Fischer PE, Desai H, Rogers A, Christmas AB, Gibbs MA, Sing RF. Femur fractures should not be considered distracting injuries for cervical spine assessment. Am J Emerg Med 2015; 33:1750-4. [PMID: 26346048 DOI: 10.1016/j.ajem.2015.08.009] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 08/07/2015] [Accepted: 08/07/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION The National Emergency X-Radiography Utilization Study (NEXUS) clinical decision rule is extremely sensitive for clearance of cervical spine (C-spine) injury in blunt trauma patients with distracting injuries. OBJECTIVES We sought to determine whether the NEXUS criteria would maintain sensitivity for blunt trauma patients when femur fractures were not considered a distracting injury and an absolute indication for diagnostic imaging. METHODS We retrospectively analyzed blunt trauma patients with at least 1 femur fracture who presented to our emergency department as trauma activations from 2009 to 2011 and underwent C-spine injury evaluation. Presence of C-spine injury requiring surgical intervention was evaluated. RESULTS Of 566 trauma patients included, 77 (13.6%) were younger than 18 years. Cervical spine injury was diagnosed in 53 (9.4%) of 566. A total of 241 patients (42.6%) had positive NEXUS findings in addition to distracting injury; 51 (21.2%) of these had C-spine injuries. Of 325 patients (57.4%) with femur fractures who were otherwise NEXUS negative, only 2 (0.6%) had C-spine injuries (95% confidence interval [CI], 0.2%-2.2%); both were stable and required no operative intervention. Use of NEXUS criteria, excluding femur fracture as an indication for imaging, detected all significant injuries with a sensitivity for any C-spine injury of 96.2% (95% CI, 85.9%-99.3%) and negative predictive value of 99.4% (95% CI, 97.6%-99.9%). CONCLUSIONS In our patient population, all significant C-spine injuries were identified by NEXUS criteria without considering the femur fracture a distracting injury and indication for computed tomographic imaging. Reconsidering femur fracture in this context may decrease radiation exposure and health care expenditure with little risk of missed diagnoses.
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Affiliation(s)
| | - Peter E Fischer
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
| | - Harsh Desai
- University of Maryland School of Medicine, Baltimore, MD
| | - Amelia Rogers
- University of Maryland School of Medicine, Baltimore, MD
| | | | - Michael A Gibbs
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC
| | - Ronald F Sing
- Carolinas Medical Center, Carolinas HealthCare System, Charlotte, NC.
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Christmas AB, Honaker D. Incarcerated massive sliding hernia treated with bladder resection and mesh repair. Am Surg 2015; 81:E123-E124. [PMID: 25760189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- A Britton Christmas
- Division of Trauma/Surgical Critical Care, Department of General Surgery, Carolinas HealthCare System, Charlotte, North Carolina, USA
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Christmas AB, Honaker D. Incarcerated Massive Sliding Hernia Treated with Bladder Resection and Mesh Repair. Am Surg 2015. [DOI: 10.1177/000313481508100314] [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: 11/16/2022]
Affiliation(s)
- A. Britton Christmas
- Division of Trauma/Surgical Critical Care Department of General Surgery Carolinas HealthCare System Charlotte, North Carolina
| | - Drew Honaker
- Division of Trauma/Surgical Critical Care Department of General Surgery Carolinas HealthCare System Charlotte, North Carolina
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Fischer PE, Colavita PD, Fleming GP, Huynh TT, Christmas AB, Sing RF. Delays in transfer of elderly less-injured trauma patients can have deadly consequences. Am Surg 2014; 80:1132-1135. [PMID: 25347505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals' length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.
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Fischer PE, Colavita PD, Fleming GP, Huynh TT, Christmas AB, Sing RF. Delays in Transfer of Elderly Less-injured Trauma Patients Can Have Deadly Consequences. Am Surg 2014. [DOI: 10.1177/000313481408001130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Transfer of severely injured patients to regional trauma centers is often expedited; however, transfer of less-injured, older patients may not evoke the same urgency. We examined referring hospitals’ length of stay (LOS) and compared the subsequent outcomes in less-injured transfer patients (TP) with patients presenting directly (DP) to the trauma center. We reviewed the medical records of less-injured (Injury Severity Score [ISS] 9 or less), older (age older than 60 years) patients transferred to a regional Level 1 trauma center to determine the referring facility LOS, demographics, and injury information. Outcomes of the TP were then compared with similarly injured DP using local trauma registry data. In 2011, there were 1657 transfers; the referring facility LOS averaged greater than 3 hours. In the less-injured patients (ISS 9 or less), the average referring facility LOS was 3 hours 20 minutes compared with 2 hours 24 minutes in more severely injured patients (ISS 25 or greater, P < 0.05). The mortality was significantly lower in the DP patients (5.8% TP vs 2.6% DP, P = 0.035). Delays in transfer of less-injured, older trauma patients can result in poor outcomes including increased mortality. Geographic challenges do not allow for every patient to be transported directly to a trauma center. As a result, we propose further outreach efforts to identify potential causes for delay and to promote compliance with regional referral guidelines.
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Affiliation(s)
| | | | | | - Toan T. Huynh
- From Carolinas Medical Center, Charlotte, North Carolina
| | | | - Ronald F. Sing
- From Carolinas Medical Center, Charlotte, North Carolina
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Christmas AB, Freeman E, Chisolm A, Fischer PE, Sachdev G, Jacobs DG, Sing RF. Trauma intensive care unit 'bouncebacks': identifying risk factors for unexpected return admission to the intensive care unit. Am Surg 2014; 80:778-82. [PMID: 25105397 DOI: 10.1177/000313481408000827] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.
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Affiliation(s)
- A Britton Christmas
- The F.H. ''Sammy'' Ross, Jr. Trauma Center at Carolinas Medical Center, Department of Surgery, Charlotte, North Carolina, USA
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Ross SW, Christmas AB, Fischer PE, Holway HE, Seymour R, Heniford BT, Sing RF. Finally proving the maxim: quantifying the effect of hemodilution in prospective randomized control trial with blood donation as a model for hemorrhage. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.905] [Citation(s) in RCA: 1] [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] [Indexed: 10/24/2022]
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Sachdev G, Gesin G, Christmas AB, Sing RF. Failure of lorazepam to treat alprazolam withdrawal in a critically ill patient. World J Crit Care Med 2014; 3:42-44. [PMID: 24834401 PMCID: PMC4021153 DOI: 10.5492/wjccm.v3.i1.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/12/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Management of sedation in the critical care unit is an ongoing challenge. Benzodiazepines have been commonly used as sedatives in critically ill patients. The pharmacokinetic and pharmacodynamic properties that make benzodiazepines effective and safe in critical care sedation include rapid onset of action and decreased respiratory depression. Alprazolam is a commonly used benzodiazepine that is prescribed for anxiety and panic disorders. It is frequently prescribed in the outpatient setting. Its use has been reported to result in a relatively high rate of dependence and subsequent withdrawal symptoms. Symptoms of alprazolam withdrawal can be difficult to recognize and treat in the critical care setting. In addition, other benzodiazepines may also be ineffective in treating alprazolam withdrawal. We present a case of alprazolam withdrawal in a critically ill trauma patient who failed treatment with lorazepam and haloperidol. Subsequent replacement with alprazolam resulted in significant improvement in the patient’s medication use and clinical status.
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Schmelzer TM, Christmas AB, Norton HJ, Heniford BT, Sing RF. Vancomycin intermittent dosing versus continuous infusion for treatment of ventilator-associated pneumonia in trauma patients. Am Surg 2014; 79:1185-90. [PMID: 24165255 DOI: 10.1177/000313481307901123] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Current guidelines for the empiric treatment of ventilator-associated pneumonia (VAP) recommend that vancomycin is dosed 15 mg/kg and administered twice daily for a target trough level of 15 to 20 μg/mL. This study compared conventional intermittent vancomycin infusion (IVI) with continuous vancomycin infusion (CVI). Our prospective, randomized study compared CVI with IVI in trauma patients with suspected VAP. The primary outcome measure was a serum vancomycin level within the target level 48 hours after initiation of therapy. Treatment groups were compared using standard statistical methods. The study included 73 patients, 36 IVI and 37 CVI. Eighteen patients were withdrawn from the study as a result of discontinuation of the drug before 48 hours or failure to draw levels at the appropriate time, resulting in 27 IVI and 28 CVI study patients. There were no differences between treatment groups in gender (P = 0.97), Injury Severity Score (P = 0.70), total body weight (P = 0.36), or age (P = 0.81). The mean serum vancomycin level for the IVI group was 8.9 ± 3.9 μg/mL, and the CVI level was 19.8 ± 6.13 μg/mL (P < 0.0001). Two patients in the IVI group (7.4%) were in the therapeutic range compared with 16 (57.1%) in the CVI group (P < 0.0001). Six patients in the CVI group (21.4%) and none of the IVI patients had supratherapeutic levels. Four patients developed renal insufficiency, three IVI (11.1%) and one CVI (3.6%) (P = 0.36). The current American Trauma Society dosing recommendations for vancomycin for presumptive VAP treatment are inadequate. Continuous vancomycin infusion should be adopted as the standard dosing strategy.
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Affiliation(s)
- Thomas M Schmelzer
- F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina, USA
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Fischer PE, Nunn AM, Wormer BA, Christmas AB, Gibeault LA, Green JM, Sing RF. Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries. Am J Surg 2013; 206:900-3. [DOI: 10.1016/j.amjsurg.2013.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 07/14/2013] [Accepted: 07/14/2013] [Indexed: 11/26/2022]
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Klima DA, Hanna EM, Christmas AB, Huynh TT, Etson KE, Fair BA, Green JM, Madjarov J, Sing RF. Endovascular graft repair for blunt traumatic disruption of the thoracic aorta: experience at a nonuniversity hospital. Am Surg 2013; 79:594-600. [PMID: 23711269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Blunt thoracic aortic injury (BAI) represents the second leading cause of death from blunt trauma. Admission rates for BAI are extremely low because instant fatality occurs in nearly 75 per cent of patients. Management strategies have transitioned from the more invasive immediate thoracotomy to delayed endograft repair with strict hemodynamic management. In this study, we assess outcomes and complications of open versus endograft repair for BAI at a nonuniversity hospital. Retrospective chart review was conducted on 49 patients admitted to a Level I trauma center who incurred BAI from 2004 to 2011. Collected data points included demographics, mortality, complication rates, and intensive care unit and hospital length of stay (LOS). Twenty-one patients underwent open thoracotomy (OPEN), whereas 28 patients were managed with thoracic endovascular aortic repair (TEVAR). The overall 30-day mortality rate was significantly lower comparing TEVAR to OPEN (7.1 vs 50%, P = 0.028); seven deaths occurred in the OPEN group versus two with TEVAR. Overall complications, including mortality, acute respiratory distress syndrome, renal failure, pneumonia, pulmonary embolism, and cardiac arrest, were fewer after TEVAR (32.1 vs 81.0%, P < 0.001) despite similar injury severity. Survivor hospital LOS (26.0 ± 15.3 vs 27.7 ± 18.7 days, P = 0.79), intensive care unit LOS (13.5 ± 10.9 vs 12.7 ± 8.8 days, P = 0.94), and ventilator days (11.4 ± 13.4 vs 16.4 ± 14.5 days, P = 0.25) were similar. Early nonoperative management with TEVAR for BAIs is a feasible and effective management strategy. Improved patient outcomes over traditional open thoracotomy in the presence of similar injury severity can be seen after TEVAR in the nonuniversity hospital setting.
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Affiliation(s)
- David A Klima
- F.H. Sammy Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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Martin TR, Christmas AB, Gibeault LA, Heniford BT, Sing RF. Time for a relevant randomized controlled trial of vena cava filters. J Am Osteopath Assoc 2013; 113:11-12. [PMID: 23329800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Abstract
Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.
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Affiliation(s)
- Lindsay M. Fairfax
- From the F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina
| | - A. Britton Christmas
- From the F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina
| | - H. James Norton
- From the F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina
| | - David G. Jacobs
- From the F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina
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Fairfax LM, Christmas AB, Norton HJ, Jacobs DG. Breakdown of the consent process at a quaternary medical center: our full disclosure. Am Surg 2012; 78:855-863. [PMID: 22856492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.
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Affiliation(s)
- Lindsay M Fairfax
- F.H. Sammy Ross, Jr. Trauma Center, Carolinas Medical Center, Charlotte, North Carolina, USA
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Christmas AB, Bogart TA, Etson KE, Fair BA, Howe HR, Jacobs DG, Sing RF. The Reward is Worth the Wait: A Prospective Analysis of 100 Consecutive Organ Donors. Am Surg 2012. [DOI: 10.1177/000313481207800336] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor pre-procurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.
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Affiliation(s)
- A. Britton Christmas
- The F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tyson A. Bogart
- LifeShare of the Carolinas, Charlotte, North Carolina; the, North Carolina
| | - Kristina E. Etson
- University of South Carolina School of Medicine, Columbia, South Carolina; the, North Carolina
| | - Brett A. Fair
- University of North Carolina School of Medicine, Chapel Hill, North Carolina; and, North Carolina
| | - Harold R. Howe
- East Carolina University Brody School of Medicine, Greenville, North Carolina
| | - David G. Jacobs
- The F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ronald F Sing
- The F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Christmas AB, Bogart TA, Etson KE, Fair BA, Howe HR, Jacobs DG, Sing RF. The reward is worth the wait: a prospective analysis of 100 consecutive organ donors. Am Surg 2012; 78:296-299. [PMID: 22524766] [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: 05/31/2023]
Abstract
Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.
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Affiliation(s)
- A Britton Christmas
- The F.H. Sammy Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA.
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Abstract
Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ2 test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant ( P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant ( P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.
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Affiliation(s)
- A. Britton Christmas
- F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Rita A. Brintzenhoff
- F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Thomas M. Schmelzer
- F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Karen E. Head
- F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ronald F. Sing
- F.H. “Sammy” Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Christmas AB, Brintzenhoff RA, Schmelzer TM, Head KE, Sing RF. MOPEDS: Motorized Objects Propelling Ethanol Drinking Subjects. Am Surg 2011; 77:304-306. [PMID: 21375841] [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
Mopeds are not subject to the same laws and jurisdiction as cars or motorcycles, including the requirement of a driver's license. We undertook this study to examine the influence of alcohol (ETOH) on moped crashes. We retrospectively reviewed adult moped injuries compared with motor vehicle crashes (MVCs) and motorcycle crashes (MCCs) from 1995 through 2006. Demographics, severity of injury, mortality, and serum ETOH levels were recorded. Data were analyzed using the Student t test for continuous data and the χ² test for proportional data. Motor vehicle crashes accounted for 7186 admissions. MCC and moped crashes numbered 973 and 113, respectively. Although not statistically significant (P = 0.064), moped crashes yielded the highest mortality (9.7%) compared with MCCs (8.5%) and MVCs (6.7%). An increased association of blood ETOH levels with moped crashes, however, was statistically significant (P = 0.004). Serum ETOH levels above 0.05 g/dL were observed in 1681 MVCs (23.4%), 241 MCCs (24.8%), and 44 moped crashes (39%). In this study, we discovered that moped crashes demonstrate a significantly higher ETOH involvement than either MVCs or MCCs representing a previously unrecognized public safety risk.
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Affiliation(s)
- A Britton Christmas
- F.H. ''Sammy'' Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232, USA.
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Abstract
The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n = 16), vena cava thrombosis (n = 9), post-VCF pulmonary embolism (n = 2), and a ventricle perforation requiring operative repair (n = 1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe “landing zone” for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.
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Affiliation(s)
- Ronald F. Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Phuong H. Nguyen
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - David G. Jacobs
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Sing RF, Nguyen PH, Christmas AB, Jacobs DG, Heniford BT. Vena cava filter insertion and the general surgery armamentarium: a 13-year experience. Am Surg 2010; 76:713-717. [PMID: 20698376] [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: 05/29/2023]
Abstract
The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n=16), vena cava thrombosis (n=9), post-VCF pulmonary embolism (n=2), and a ventricle perforation requiring operative repair (n=1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe "landing zone" for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.
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Affiliation(s)
- Ronald F Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA.
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Fairfax LM, Christmas AB, Green JM, Miles WS, Sing RF. Operative Experience in the Era of Duty Hour Restrictions: Is Broad-Based General Surgery Training Coming to an End? Am Surg 2010. [DOI: 10.1177/000313481007600619] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site ( www.acgme.org ), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 ± 18 vs 911 ± 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 ± 7 vs 229 ± 3, P = 0.004), skin/soft tissue (31 ± 3 vs 36 ± 1, P = 0.01), and endocrine (26 ± 2 vs 31 ± 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 ± 0.3 vs 20 ± 0.3, P = 0.01), vascular (164 ± 29 vs 126 ± 5, P = 0.01), pediatric (41 ± 1 vs 37 ± 2, P = 0.006), genitourinary (10 ± 2 vs 7 ± 1, P = 0.004), gynecologic surgery (5 ± 1 vs 3 ± 0.6, P = 0.002), plastics (16 ± 0.3 vs 15 ± 0.7, P = 0.03), and endoscopy (91 ± 3 vs 82 ± 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?
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Affiliation(s)
- Lindsay M. Fairfax
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - John M. Green
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - William S. Miles
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ronald F. Sing
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Fairfax LM, Christmas AB, Green JM, Miles WS, Sing RF. Operative experience in the era of duty hour restrictions: is broad-based general surgery training coming to an end? Am Surg 2010; 76:578-582. [PMID: 20583511] [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: 05/29/2023]
Abstract
Since the institution of Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions, conflicting evidence exists regarding the impact on resident case volume with most data from single-institution studies. We examined the effect of restrictions on national resident operative experience. After permission from the ACGME, we reviewed the publicly available national resident case log data (1999 through 2008) maintained on the ACGME web site (www.acgme.org), including total major cases with subanalysis of the ACGME-specified categories. The mean cases per resident were compared before (1999 to 2003) and after (2003 to 2008) restrictions. After the implementation of duty hour restrictions, the mean number of total cases per resident significantly decreased (949 +/- 18 vs 911 +/- 14, P = 0.004). Subanalysis showed a significant increase in alimentary tract (217 +/- 7 vs 229 +/- 3, P = 0.004), skin/soft tissue (31 +/- 3 vs 36 +/- 1, P = 0.01), and endocrine (26 +/- 2 vs 31 +/- 2, P = 0.006) cases. However, we observed a significant decrease in head and neck (21 +/- 0.3 vs 20 +/- 0.3, P = 0.01), vascular (164 +/- 29 vs 126 +/- 5, P = 0.01), pediatric (41 +/- 1 vs 37 +/- 2, P = 0.006), genitourinary (10 +/- 2 vs 7 +/- 1, P = 0.004), gynecologic surgery (5 +/- 1 vs 3 +/- 0.6, P = 0.002), plastics (16 +/- 0.3 vs 15 +/- 0.7, P = 0.03), and endoscopy (91 +/- 3 vs 82 +/- 2, P < 0.001) procedures. Analysis of the ACGME-compiled national data confirms that duty hour restrictions have significantly impacted resident operative experience. Importantly, experience in specialty areas, including vascular and endoscopy, appears to have been sacrificed for consolidation of resources into general surgery services as indicated by the increase in alimentary tract and endocrine cases. These findings raise the following question: Is the era of truly broad-based general surgery training coming to an end?
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Affiliation(s)
- Lindsay M Fairfax
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina 28232-2861, USA
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Christmas AB, Camp SM, Barrett MC, Schmelzer TM, Norton HJ, Huynh TT, Thomason MH, Sing RF. Removal of erythropoietin from anaemia trauma practice guideline does not increase red blood cell transfusions and decreases hospital utilization costs. Injury 2009; 40:1330-5. [PMID: 19595325 DOI: 10.1016/j.injury.2009.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 06/03/2009] [Accepted: 06/03/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline. METHODS Electronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fisher's exact tests, and interval data were compared using ANOVA followed by Tukey's test where appropriate. Results were considered significant for P<0.05. RESULTS Over the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of $102,600. Group II (GUIDE) received a total of 410 doses at a cost of $184,500. Group III (POST) received 28 doses of r-EPO at a cost of $12,600. CONCLUSION Removal of erythropoietin from our trauma service anaemia practice management guideline did not result in increased blood utilization. However, it yielded a hospital acquisition cost savings of $171,900.
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Affiliation(s)
- A Britton Christmas
- The F.H. Sammy Ross, Jr. Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Christmas AB, Brintzenhoff RA, Sing RF, Schmelzer TM, Bolton SD, Miles WS, Thomason MH. Resident work hour restrictions impact chief resident operative experience. Am Surg 2009; 75:1065-1068. [PMID: 19927506] [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: 05/28/2023]
Abstract
Since the institution of the Accreditation Council for Graduate Medical Education resident work restrictions, much discussion has arisen regarding the potential effect on surgical resident training. We undertook this study to examine the effects on resident operative experience. We retrospectively analyzed chief residents' Accreditation Council for Graduate Medical Education case logs before (PRE) and after (POST) the 80-hour work restriction. Overall, 22 resident logs were evaluated, six PRE and 16 POST. Four case categories were examined: total major cases, total trauma operative cases, total chief cases, and total teaching assistant cases. Significance was defined as P < 0.05. Comparing the PRE and POST groups demonstrated a trend toward fewer total major cases (1061 vs 964, P = 0.38) and fewer total trauma operative cases (55 vs 47, P = 0.37). Teaching assistant cases increased from 67 to 91 but also failed to reach significance (P = 0.37). However, further comparison between the PRE and POST groups yielded a statistically significant decrease in the number of total chief cases (494 vs 333, P = 0.0092). The significant decrease in the number of total chief cases demonstrates that the work hour restriction most affected the chief year operative experience. Further evaluation of resident participation in nonoperative facets may reveal additional deficiencies of surgical training under work hour restrictions.
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