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Loudon AM, Rushing AP, Badrinathan A, Moorman ML. Benefit of balance? Odds of survival by unit transfused: Retrospective analysis of the ACS-TQIP database. Surgery 2024; 175:885-892. [PMID: 37852833 DOI: 10.1016/j.surg.2023.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/21/2023] [Accepted: 08/08/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The critical blood shortage in January 2022 threatened the availability of blood. Utility of transfusion per unit was reported in a previous study, revealing patients receiving balanced transfusion are more likely to die after 16 units of packed red blood cells. We aimed to validate this study using a larger database. METHODS Retrospective analysis utilizing the American College of Surgeons Trauma Quality Improvement Program was performed. Trauma patients aged ≥16 receiving transfusion within 4 hours of arrival were included and excluded if they died in the emergency department, received <2 units of packed red blood cells, did not receive fresh frozen plasma, or were missing data. Primary outcome was mortality. Subgroups were balanced transfusion if receiving ≤2:1 ratio of packed red blood cells:fresh frozen plasma, and unbalanced transfusion if >2:1 ratio. RESULTS A total of 17,047 patients were evaluated with 28% mortality (4,822/17,408). Multivariable logistic regression identified advancing age (odds ratio 1.03 95% confidence interval 1.03-1.04), higher ISS (odds ratio 1.04, 95% confidence interval 1.03-1.04), and lower GCS (odds ratio 0.82, 95% confidence interval 0.82-0.83) as risk factors for mortality. Protective factors were balanced transfusion (odds ratio 0.81 95% confidence interval 0.71-0.93), male sex (odds ratio 0.90, 95% confidence interval 0.81-0.99), and blunt mechanism (odds ratio 0.74, 95% confidence interval 0.67-0.81). At 11 units of packed red blood cells, balanced transfusion patients were more likely to die (odds ratio 0.88, 95% confidence interval 0.80-0.98). Balanced transfusion patients survived at a higher rate for each unit of packed red blood cells, between 6 and 23 units of packed red blood cells. CONCLUSION Mortality increases with each unit of packed red blood cell transfused. At 11 units of packed red blood cells, mortality is the more likely outcome. Balanced transfusion improves the chance of survival through 23 units of packed red blood cells.
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Affiliation(s)
- Andrew M Loudon
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Amy P Rushing
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Matthew L Moorman
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
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Towe CW, Bachman KC, Ho VP, Pieracci F, Worrell SG, Moorman ML, Linden PA, Badrinathan A. Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample. Medicina (Kaunas) 2024; 60:153. [PMID: 38256413 PMCID: PMC10819862 DOI: 10.3390/medicina60010153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/01/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.
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Affiliation(s)
- Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Vanessa P Ho
- MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH 44109, USA
| | - Fredric Pieracci
- Department of Surgery Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO 80045, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
| | - Avanti Badrinathan
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA
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Moorman ML, Loudon AM, Pronovost PJ. Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care. Popul Health Manag 2023; 26:353-355. [PMID: 37347932 DOI: 10.1089/pop.2023.0066] [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: 06/24/2023] Open
Affiliation(s)
- Matthew L Moorman
- Department of Surgery and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Departments of Surgery and Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Andrew M Loudon
- Department of Surgery and Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Departments of Surgery and Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter J Pronovost
- Departments of Surgery and Anesthesia, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Anesthesia, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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Loudon AM, Rushing AP, Hue JJ, Moorman ML. Response to Moore and Colleagues. J Trauma Acute Care Surg 2023; 95:e21-e22. [PMID: 37125947 DOI: 10.1097/ta.0000000000003986] [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: 05/02/2023]
Affiliation(s)
- Andrew M Loudon
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Zeineddin A, Tominaga GT, Crandall M, Almeida M, Schuster KM, Jawad G, Maqbool B, Sheffield AC, Dhillon NK, Radow BS, Moorman ML, Martin ND, Jacovides CL, Lowry D, Kaups K, Horwood CR, Werner NL, Proaño-Zamudio JA, Kaafarani HMA, Marshall WA, Haines LN, Schaffer KB, Staudenmayer KL, Kozar RA. Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale. J Trauma Acute Care Surg 2023; 95:213-219. [PMID: 37072893 DOI: 10.1097/ta.0000000000003969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
INTRODUCTION The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Ahmad Zeineddin
- From the Department of Surgery (A.Z.), Howard University Hospital, Washington, DC; Department of Surgery (A.Z., N.K.D., R.A.K.), Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (M.A., K.M.S.), Yale University, New Haven, Connecticut; Department of Surgery (G.J., B.M.), University of New Mexico Health Science Center, Albuquerque, New Mexico; Department of Surgery (M.C., A.C.S.), College of Medicine, University of Florida, Jacksonville, Florida; Department of Surgery (B.S.R., M.L.M.), University Hospitals Cleveland Medical Center, Cleveland, Ohio; Department of Surgery (N.D.M., C.L.J.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (D.L., K.K.), Community Regional Medical Center, UCSF Fresno, Fresno, California; Department of Surgery (C.R.H., N.L.W.), Denver Health, Denver, Colorado; Department of Surgery (J.A.P.-Z., H.M.A.K.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Department of Surgery (W.A.M., L.N.H.), University of California San Diego Health, San Diego; Department of Surgery (G.T.T., K.B.S.), Scripps Memorial Hospital, La Jolla; and Department of Surgery (K.L.S.), Stanford University, Stanford, California
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Badrinathan A, Sarode AL, Alvarado CE, Sinopoli J, Rice JD, Linden PA, Moorman ML, Towe CW. Surgical subspecialization is associated with higher rate of rib fracture stabilization: a retrospective database analysis. Trauma Surg Acute Care Open 2023; 8:e000994. [PMID: 37082302 PMCID: PMC10111909 DOI: 10.1136/tsaco-2022-000994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/07/2023] [Indexed: 04/05/2023] Open
Abstract
BackgroundSurgical stabilization of rib fractures (SSRF) is performed on only a small subset of patients who meet guideline-recommended indications for surgery. Although previous studies show that provider specialization was associated with SSRF procedural competency, little is known about the impact of provider specialization on SSRF performance frequency. We hypothesize that provider specialization would impact performance of SSRF.MethodsThe Premier Hospital Database was used to identify adult patients with rib fractures from 2015 and 2019. The outcome of interest was performance of SSRF, defined using International Classification of Diseases—10th Revision Procedure Coding System coding. Patients were categorized as receiving their procedures from a thoracic, general surgeon, or orthopedic surgeon. Patients with missing or other provider types were excluded. Multivariate modeling was performed to evaluate the effect of surgical specialization on outcomes of SSRF. Given a priori assumptions that trauma centers may have different practice patterns, a subgroup analysis was performed excluding patients with ‘trauma center’ admissions.ResultsAmong 39 733 patients admitted with rib fractures, 2865 (7.2%) received SSRF. Trauma center admission represented a minority (1034, 36%) of SSRF procedures relative to other admission types (1831, 64%, p=0.15). In a multivariable analysis, thoracic (OR 6.94, 95% CI 5.94–8.11) and orthopedic provider (OR 2.60, 95% CI 2.16–3.14) types were significantly more likely to perform SSRF. In further analyses of trauma center admissions versus non-trauma center admissions, this pattern of SSRF performance was found at non-trauma centers.ConclusionThe majority of SSRF procedures in the USA are being performed by general surgeons and at non-trauma centers. ‘Subspecialty’ providers in orthopedics and thoracic surgery are performing fewer total SSRF interventions, but are more likely to perform SSRF, especially at non-trauma centers. Provider specialization as a barrier to SSRF may be related to competence in the SSRF procedures and requires further study.TypeTherapeutic/care management.Level of evidenceIV
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Affiliation(s)
- Avanti Badrinathan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Anuja L Sarode
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christine E Alvarado
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jillian Sinopoli
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jonathan D Rice
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Matthew L Moorman
- Division of Trauma and Acute Care Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Wang N, Bachman KC, Linden PA, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age as a Barrier to Surgical Stabilization of Rib Fractures in Patients with Flail Chest. Am Surg 2023; 89:927-934. [PMID: 34732075 PMCID: PMC9061890 DOI: 10.1177/00031348211047490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Although randomized trials demonstrate a benefit to surgical stabilization of rib fractures (SSRF), SSRF is rarely performed. We hypothesized older patients were less likely to receive SSRF nationally. METHODS The 2016 National Inpatient Sample was used to identify adults with flail chest. Comorbidities and receipt of SSRF were categorized by ICD-10 code. Univariable testing and Multivariable regression were performed to determine the association of demographic characteristics and comorbidities to receipt of SSRF. RESULTS 1021 patients with flail chest were identified, including 244 (23.9%) who received SSRF. Patients ≥70 years were less likely to receive SSRF. (<70 yrs 201/774 [26.0%] vs ≥70 43/247 [17.4%], P = .006) and had higher risk of death (<70 yrs 39/774 [5.0%] vs ≥70 33/247 [13.4%], P < .001) In multivariable modeling, only age ≥70 years was associated with SSRF (OR .591, P = .005). CONCLUSION Despite guideline-based support of SSRF in flail chest, SSRF is performed in <25% of patients. Age ≥70 years is associated with lower rate of SSRF and higher risk of death. Future study should examine barriers to SSRF in older patients.
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Affiliation(s)
- Naomi Wang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Katelynn C Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Vanessa P Ho
- Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Loudon AM, Rushing AP, Hue JJ, Ziemak A, Sarode AL, Moorman ML. When is enough enough? Odds of survival by unit transfused. J Trauma Acute Care Surg 2023; 94:205-211. [PMID: 36694331 DOI: 10.1097/ta.0000000000003835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Balanced transfusion is lifesaving for hemorrhagic shock. The American Red Cross critical blood shortage in 2022 threatened the immediate availability of blood. To eliminate waste, we reviewed the utility of transfusions per unit to define expected mortality at various levels of balanced transfusion. METHODS A retrospective study of 296 patients receiving massive transfusion on presentation at a level 1 trauma center was performed from January 2018 to December 2021. Units of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets received in the first 4 hours were recorded. Patients were excluded if they died in the emergency department, died on arrival, received <2 U PRBCs or FFP, or received PRBC/FFP >2:1. Primary outcomes were mortality and odds of survival to discharge. Subgroups were defined as transfused if receiving 2 to 9 U PRBCs, massive transfusion for 10 to 19 U PRBCs, and ultramassive transfusion for ≥20 U PRBCs. RESULTS A total of 207 patients were included (median age, 32 years; median Injury Severity Score, 25; 67% with penetrating mechanism). Mortality was 29% (61 of 207 patients). Odds of survival is equal to odds of mortality at 11 U PRBCs (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.50-1.79). Beyond 16 U PRBCs, odds of mortality exceed survival (OR, 0.36; 95% CI, 0.16-0.82). Survival approaches zero >36 U PRBCs (OR, 0.09; 95% CI, 0.00-0.56). Subgroup mortality rates increased with unit transfused (16% transfused vs. 36% massive transfusion, p = 0.003; 36% massive transfusion vs. 67% ultramassive transfusion, p = 0.006). CONCLUSION Mortality increases with each unit balanced transfusion. Surgeons should view efforts heroic beyond 16 U PRBCs/4 hours and near futile beyond 36 U PRBCs/4 hours. While extreme outliers can survive, consider cessation of resuscitation beyond 36 U PRBCs. This is especially true if hemostasis has not been achieved or blood supplies are limited. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
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Affiliation(s)
- Andrew M Loudon
- From the Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Coffey MR, Bachman KC, Ho VP, Worrell SG, Moorman ML, Linden PA, Towe CW. Iatrogenic rib fractures and the associated risks of mortality. Eur J Trauma Emerg Surg 2022; 48:231-241. [PMID: 33496799 PMCID: PMC8310895 DOI: 10.1007/s00068-020-01598-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/27/2020] [Indexed: 02/03/2023]
Abstract
PURPOSE Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures. METHODS Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression. RESULTS 34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings. CONCLUSION IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.
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Affiliation(s)
- Max R. Coffey
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Katelynn C. Bachman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Vanessa P. Ho
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,MetroHealth Medical Center, Department of Surgery, Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Cleveland, OH, United States
| | - Stephanie G. Worrell
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Matthew L. Moorman
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Philip A. Linden
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
| | - Christopher W. Towe
- Case Western Reserve University School of Medicine, Cleveland, OH, United States,University Hospitals Cleveland Medical Center, Department of Surgery, Cleveland, OH, United States
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Moorman ML, Ustin JS, Drummond CK. Learning from the Customer: Biomedical Engineering Clinical Correlates Taught by Physicians. Proc North Cent Sect 2022; 2022:36056. [PMID: 36507924 PMCID: PMC9731400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Matthew L. Moorman
- Chief, Division of Trauma, Critical Care, and Acute Care Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio 44106
| | - Jeffrey S. Ustin
- Assistant Professor in Surgery, Adjunct Professor in Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio 44106
| | - Colin K. Drummond
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio 44106
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Bingmer KE, Ebertz DP, Violette AK, Radow BS, Rushing AP, Loudon AM, Moorman ML. Multi-System Inflammatory Syndrome Presenting as Non-Specific Colitis: A Medical Diagnosis with a Surgical Presentation. Am Surg 2021:31348211038572. [PMID: 34382433 DOI: 10.1177/00031348211038572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 20-year-old woman with previous COVID-19 diagnosis presented with abdominal pain and colitis on CT scan. She was admitted in septic shock, with etiology of colitis unclear. After resuscitation, antibiotics, and steroids, she clinically deteriorated. Worsening Clostridioides difficile infection was most likely and she was taken to the operating room. Intraoperatively, only a segment of transverse colon appeared abnormal on gross and endoscopic evaluation. Total colectomy was deferred in favor of segmental resection. Given her unusual disease pattern and recent COVID-19 infection, diagnosis of MIS-C was considered. Steroids were continued and treatment broadened to include heparin and IVIG. The patient returned to the operating room for planned reexploration, endoscopy, and end colostomy. On hospital day three, the patient had an acute mental status change. Computed tomography demonstrated acute cerebral edema with brainstem herniation. The family chose comfort-care measures. Final pathology from the transverse colon demonstrated COVID-19-associated vasculitis.
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Affiliation(s)
- Katherine E Bingmer
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David P Ebertz
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aisha K Violette
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Brandon S Radow
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Amy P Rushing
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Andrew M Loudon
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Matthew L Moorman
- Division of Trauma, Critical Care and Acute Care Surgery, Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Sarode AL, Ho VP, Chen L, Bachman KC, Linden PA, Lasinski AM, Moorman ML, Towe CW. Traffic stops do not prevent traffic deaths. J Trauma Acute Care Surg 2021; 91:141-147. [PMID: 34144561 PMCID: PMC8900371 DOI: 10.1097/ta.0000000000003163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Amid growing calls for police reform, it is imperative to reassess whether police actions designed to improve public safety are associated with injury prevention. This study aims to examine the relationship between the police traffic stops (PTSs) and motor vehicle crash (MVC) deaths at the state level. We hypothesize that increased PTSs would be associated with reduced MVC deaths. METHODS We retrospectively analyzed PTSs and MVC deaths at the state level from 2004 to 2016. Police traffic stops data were from 33 state patrols from the Stanford Open Policing Project. The MVC deaths data were collected from the National Highway Traffic Safety Administration. The vehicle miles traveled data were from the Federal Highway Administration Office of Highway Policy Information. All data were adjusted per 100 million vehicle miles traveled (100MVMT) and were analyzed as state-level time series cross-sectional data. The dependent variable was MVC deaths per 100MVMT, and the independent variable was number of PTSs per 100MVMT. We performed panel data analysis accounting for random and fixed state effects and changes over time. RESULTS Thirty-three state patrols with 235 combined years were analyzed, with a total of 161,153,248 PTSs. The PTS rate varied by state and year. Nebraska had the highest PTS rate (3,637/100MVMT in 2004), while Arizona had the lowest (0.17/100MVMT in 2009). Motor vehicle crash deaths varied by state and year, with the highest death rate occurring in South Carolina in 2005 (2.2/100MVMT) and the lowest in Rhode Island in 2015 (0.57/100MVMT). After accounting for year and state-level variability, no association was found between PTS and the MVC death rates. CONCLUSION State patrol traffic stops are not associated with reduced MVC deaths. Strategies to reduce death from MVC should consider alternative strategies, such as motor vehicle modifications, community-based safety initiatives, improved access to health care, or prioritizing trauma system. LEVEL OF EVIDENCE Retrospective epidemiological study, level IV.
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Affiliation(s)
- Anuja L Sarode
- From the Research in Surgical Outcomes and Effectiveness, Department of Surgery (A.L.S., L.C., K.C.B., P.A.L., M.L.M., C.W.T.), University Hospitals Cleveland Medical Center; Case Western Reserve University School of Medicine (V.P.H., L.C., K.C.B., P.A.L., A.M.L., M.L.M., C.W.T.); Division of Trauma, Critical Care, Burns, & Acute Care Surgery, Department of Surgery (V.P.H., A.M.L.), MetroHealth Medical Center, Cleveland, Ohio
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Bachman KC, Ho VP, Moorman ML, Worrell SG, Argote-Greene LM, Towe CW. Age Is a Barrier to Surgical Stabilization of Rib Fracture in Patients with Flail Chest. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Loudon A, Patil N, Adamski JH, Applegate G, Tinkoff G, Moorman ML, McQuay N, Younan D. Massive Transfusion is an Independent Predictor of Infectious Complications in Critically Ill Trauma Patients. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Spalding MC, Moorman ML, Holcomb JB. Use of ER-REBOA to Reverse Traumatic Arrest After Non-Truncal Bleeding. JEVTM 2018. [DOI: 10.26676/jevtm.v2i1.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We report a successful case of resuscitative endovascular balloon occlusion of the aorta (REBOA) to control hemorrhage in a patient with cardiac arrest secondary to non-truncal hemorrhage.
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Moorman ML, Capizzani TR, Feliciano MA, French JC. A competency-based simulation curriculum for surgical resident trauma resuscitation skills. Int J Crit Illn Inj Sci 2017; 7:241-247. [PMID: 29291178 PMCID: PMC5737067 DOI: 10.4103/ijciis.ijciis_12_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Evidence-based curricula for nonprocedural simulation training in general surgery are lacking. Residency programs are required to implement simulation training despite this shortcoming. The goal of this project was the development of a simulation curriculum that measurably improves milestone performance and replaces traditional experienced-based training with a competency-based model. Materials and Methods: SimMan 3G® (Laerdal Medical, Wappingers Falls, NY, USA) was utilized for simulation. Needs assessment targeted trauma and shock resuscitation. Scenario design applied deliberate practice methodology. Learner performance data included items such as identification of shock physiology, resuscitation products used, volume delivered, use of resuscitation end-points, and knowledge of massive transfusion. Characteristics essential for a successful program were tabulated. Results: Forty-eight residents in postgraduate year (PGY) 2–5 participated representing 100% of the 48 eligible for the training. Senior residents (PGY 4 and 5) demonstrated near universal improvement. Junior residents (PGY 2 and 3) improved in some areas but showed more skill decay between sessions. Overall, milestone performance improved with each training session, and resident feedback was universally positive. Conclusions: This prototype curriculum improved surgical resident competency in shock resuscitation in a simulated patient care environment. It can be modified to accommodate centers with fewer resources and can be implemented by clinical faculty. The essential characteristics of a successful program are identified.
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Affiliation(s)
- Matthew L Moorman
- Department of General Surgery, Section of Acute Care Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tony R Capizzani
- Department of General Surgery, Section of Acute Care Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michelle A Feliciano
- Department of General Surgery, Section of Acute Care Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Judith C French
- Department of General Surgery, Section of Acute Care Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Nash JE, O’Rourke C, Moorman ML. Transocular ultrasound measurement of the optic nerve sheath diameter can identify elevated intracranial pressure in trauma patients. Trauma 2015. [DOI: 10.1177/1460408615606752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Prompt identification of elevated intracranial pressure (eICP) is life-saving. Physical exam alone often fails to identify this problem and invasive monitoring is not always utilized appropriately. A non-invasive, rapid, reliable technique to detect eICP is needed and optic nerve sheath diameter (ONSD) is known to be a valid surrogate. Historically, ONSD in patients with eICP above 20 mmHg varied from 0.5 to 0.7 cm. Receiver operator curves predict that diameters below 0.5 to 0.58 cm correspond to normal pressures. Interobserver variability is low (0.01--0.03 cm). The learning curve was 25 and 10 procedures for novice and experienced sonographers, respectively. We report our initial experience using ultrasound to measure ONSD during initial trauma evaluation. Study design Transocular ultrasound was used to determine ONSD after traumatic brain injury. Data were correlated with CT and exam findings or measured ICP. Measurements were performed by a single trauma surgeon. Time to perform the measurement was recorded. Relevant literature from the past 15 years was reviewed. Results Physical exam was not a reliable indicator of eICP. In patients with eICP requiring surgery, ONSD averaged 0.62 cm. Normal pressures were ensured if the ONDS was <0.50 cm (95% CI 0.469–0.540 cm, p < 0.001). Intraobserver variability was low (0.01--0.02 cm). Average time to perform the exam was less than 2 min. Conclusions Determining ONSD with ultrasound is easy to learn, precise, and inexpensive. An ONSD of less than 5 mm ensures no eICP. This procedure can be added to the evaluation of trauma patients with no delay in care. Future prospective studies may validate and incorporate this technique into the trauma surgeon's armamentarium.
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Abstract
Outpatient colonoscopy has been proven safe but can rarely be associated with serious complications. The addition of polypectomy to the procedure increases the incidence of all complications with hemorrhage accounting for approximately half. The use of electrocautery for hot biopsy or polyp removal can result in a full-thickness burn without perforation in approximately 1 per cent of cases and typically presents as focal peritonitis without pneumoperitoneum. This so-called “postpolypectomy syndrome” or “serositis” is often successfully managed medically with resolution of symptoms in 24 to 48 hours. Bowel perforation occurs in less than 1 per cent of patients but requires emergent laparotomy. Appendicitis, both acute and perforated, has been reported as a rare complication of colonoscopy.
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Affiliation(s)
| | - Jerad P. Miller
- Department of Surgery, Mount Carmel Health System, Columbus, Ohio
| | | | - Phillip D. Price
- Department of Surgery, Mount Carmel Health System, Columbus, Ohio
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Moorman ML, Miller JP, Khanduja KS, Price PD. Postcolonoscopy appendicitis. Am Surg 2010; 76:892-895. [PMID: 20726424] [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
Outpatient colonoscopy has been proven safe but can rarely be associated with serious complications. The addition of polypectomy to the procedure increases the incidence of all complications with hemorrhage accounting for approximately half. The use of electrocautery for hot biopsy or polyp removal can result in a full-thickness burn without perforation in approximately 1 per cent of cases and typically presents as focal peritonitis without pneumoperitoneum. This so-called "postpolypectomy syndrome" or "serositis" is often successfully managed medically with resolution of symptoms in 24 to 48 hours. Bowel perforation occurs in less than 1 per cent of patients but requires emergent laparotomy. Appendicitis, both acute and perforated, has been reported as a rare complication of colonoscopy.
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Affiliation(s)
- Matthew L Moorman
- Department of Surgery, Mount Carmel Health System, Columbus, Ohio, USA.
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Moorman ML, Price PD. Migrating Mesh Plug: Complication of a Weil-Established Hernia Repair Technique. Am Surg 2004. [DOI: 10.1177/000313480407000405] [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: 11/29/2022]
Abstract
The mesh plug technique for repair of inguinal hernia has become one of the standard procedures in general surgery. The evolution of the technique of occluding the fascial defect with a foreign body has extensively been described in the surgical literature. The associated complications are also well described. We find only two published reports describing complications related to migration of a mesh plug. We present a case of a 50-year-old man with vague left lower quadrant pain approximately 18 months after left indirect inguinal hernia repair with the PerFix plug (Bard, Murray Hill, NJ) and overlay patch method. Laparoscopic exploration determined that the plug had migrated away from the left internal ring in the preperitoneal space and was involved with significant adhesions. The plug was removed, and his hernia was repaired laparoscopically with GORE-TEX mesh (W.L. Gore, Tempe, AZ). The patient's symptoms were relieved, and he remained pain free through follow-up at 6 months.
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Affiliation(s)
- Matthew L. Moorman
- From the Department of Surgery, Mount Carmel Health System, Columbus, Ohio
| | - Phillip D. Price
- From the Department of Surgery, Mount Carmel Health System, Columbus, Ohio
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Moorman ML, Price PD. Migrating mesh plug: complication of a well-established hernia repair technique. Am Surg 2004; 70:298-9. [PMID: 15098779] [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: 04/29/2023]
Abstract
The mesh plug technique for repair of inguinal hernia has become one of the standard procedures in general surgery. The evolution of the technique of occluding the fascial defect with a foreign body has extensively been described in the surgical literature. The associated complications are also well described. We find only two published reports describing complications related to migration of a mesh plug. We present a case of a 50-year-old man with vague left lower quadrant pain approximately 18 months after left indirect inguinal hernia repair with the PerFix plug (Bard, Murray Hill, NJ) and overlay patch method. Laparoscopic exploration determined that the plug had migrated away from the left internal ring in the preperitoneal space and was involved with significant adhesions. The plug was removed, and his hernia was repaired laparoscopically with GORE-TEX mesh (W.L. Gore, Tempe, AZ). The patient's symptoms were relieved, and he remained pain free through follow-up at 6 months.
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Affiliation(s)
- Matthew L Moorman
- Department of Surgery, Mount Carmel Health System, Columbus, Ohio, USA
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