4.13 The Anti-Cholinergic Pathway Protects Against Intestinal Barrier Dysfunction and DAMPs Release

Posted on December 22, 2014

M. E. Diebel1, D. M. Liberati1, L. N. Diebel1  1Wayne State University,Michael And Marian Ilitch Department Of Surgery,Detroit, MI, USA

Introduction: Intestinal barrier injury occurs following major trauma and leads to an  intestinal inflammatory response and subsequent remote organ dysfunction. This response may be modulated by either vagal nerve stimulation or pharmacologic stimulation of the alpha7-cholinergic receptor (nAChR) anti-inflammatory pathway. The downstream mediators in this pathway are relatively unknown. Gut injury is also associated with the release of endogenous damage associated molecular patterns (DAMPs) which may modulate shock induced organ dysfunction. The impact of stimulation of the intestinal cholinergic anti-inflammatory pathway on DAMPs release and resultant tissue injury was studied in vitro.

Methods: Intestinal epithelial cell (IEC-6) monolayers were subjected to hypoxia-reoxygenation (H/R) challenge. Cell subsets were treated after hypoxic challenge with nicotine or AR-R17779, a specific nAChR agonist. Nuclear factor kappa light-chain-enhancer of activated B cell (NFkB) activation was determined by ELISA and IEC monolayer integrity was indexed by permeability to an FITC-dextran probe (4,000 mw; FD-4). DAMPs production was indexed by high mobility group box 1 (HMGB-1) (western blot) and mitochondrial DNA (coxIII using RT-PCR) release. Human pulmonary microvascular endothelial cells (HMVEC) were then co cultured with IEC culture supernatants and monolayer permeability and ICAM-1 expression determined.

Results: mean ± S.D., N = 4 for each group

Conclusion: Pharmacologic stimulation of the nAChR pathway protected against H/R induced intestinal barrier derangement, NFkB activation and DAMPs release. Decreased IEC mediated DAMPs release was associated with protection against lung microvascular injury and ICAM-1 expression in this in vitro study. Modulation of this pathway may be helpful in the clinical setting.

 

36.09 The Cost of Secondary Trauma Overtriage in a Level I Trauma Center

Posted on December 22, 2014

D. A. Mateo De Acosta1, R. Asfour1, M. Gutierrez1, S. Carrie2, J. Marshall2  1University Of Illinois College Of Medicine At Peoria (UICOMP),Department Of Surgery,Peoria, IL, USA 2University Of Illinois College Of Medicine At Peoria,Division Of Trauma / Department Of Surgery,Chicago, IL, USA

Introduction:
The goal of regional trauma systems is to deliver adequate level of care to injured patients in a timely and cost effective manner. Inter-facility transfer of injured patients is the foundation of the United States trauma systems. Patients are commonly secondarily overtriaged delaying their definitive care and posing unnecessary burden on the receiving institution. Secondary overtriage ranges from 6.9 – 38%. The financial burden of secondary overtriaging that is placed on receiving institutions has been rarely studied. 

Methods:
We reviewed the EMR and trauma registry data of 1200 patients transferred to our institution due to traumatic injuries, during a three year period. Patients were divided in two groups. Group 1 included patients “secondarily overtriaged” and Group 2 (control) those appropriately triaged. Secondary overtriage was defined as patients transferred from another hospital emergency department to our trauma service with an injury severity score (ISS) < 10, did not require an operation, and were discharged home within 48 hours of admission.

Results:
We identified 399 adult patients secondarily overtriaged to our institution. These represented a 31.9% of those transferred to our institution during the study period. Common indications for transfer were trauma to the torso, neurological, facial or orthopedic trauma. Main reasons for transfer among those secondarily overtriaged were Traumatic Brain Injury (37.4%, p<0.05)  and Orthopedic Trauma (21.8 %, p<0.05), impacted by the unavailability of speialist physcians in the reffering institution. Average hospital cost and reimbursement per overtriaged patient were $19,301 and $7,356.83 respectively. Cost itemization was as follows: Trauma activation – $5,016.49, Observation boarding $1,7413, Radiology – $ $4,339.09, Laboratory – $1,836.68, Pharmacy – $1,256.1 and Supplies – $2,431.6.Transport was by ground in 85.95% of patients and via helicopter in 14.05%. Average cost helicopter transport was $19.535.78.

Conclusion:
Secondary trauma overtriage presents a significant burden on trauma centers with an average cost per patient of approximately $19,301. Major reasons for transfer to our institution were traumatic brain injury and orthopedic mainly due to the unavailability of subspecialty services in the transferring institution. Education of rural trauma triage staff must continue to intensify in order to minimize the secondary overtriage of patients, expediting their care and optimizing resource utilization
 

37.08 Emergency General Surgery in a Low-Middle Income Healthcare Setting – Determinants of Outcomes

Posted on December 22, 2014

A. A. Shah1,6, H. Zafar6, R. Riviello3, C. K. Zogg1, M. S. Halim7, S. Zafar5, A. Latif8, Z. Rehman6, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 3Harvard School Of Medicine,Center For Surgery And Public Health, Brigham And Women’s Hospital,Brookline, MA, USA 5Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 6Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 7Aga Khan University Medical College,Section Of Critical Care, Department Of Medicine,Karachi, Sindh, Pakistan 8Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA

Introduction:  The field of emergency general surgery (EGS) has rapidly evolved as a distinct component of acute care surgery. However, nuanced understandings of outcome predictors in EGS have been slow to emerge, particularly in resource-constrained parts of the world.  The objective of this study was to describe the disease spectrum and risk factors associated with outcomes of EGS among patients presenting to a tertiary care facility in Pakistan. 

Methods:  Discharge data from a university hospital were obtained for all adult patients (≥16 years) presenting between March 2009 and April 2014 with ICD-9-CM diagnosis codes consistent with an EGS condition, as described by the American Association for the Surgery of Trauma (AAST). Multivariate analyses, accounting for age, gender, year of admission, type of admission, admitting specialty, length of stay (LOS), major complications and Charlson Comorbidity Index, were used to assess potential associations between demographic/clinical factors and all-cause mortality and major complications (pneumonia, pulmonary emboli, urinary tract infections, cerebrovascular accidents, myocardial infarcts, cardiac arrest and systemic sepsis).

Results: Records for 13,893 patients were identified. Average age was 47.2 (±16.8) years, with a male preponderance (59.9%). The majority of patients presented with an admitting diagnosis of biliary disease (20.2%) followed by soft tissue disorders (15.7%), hernias (14.9%) and colorectal disease (14.3%). The crude rates of death and complications were 2.7% and 6.6%, respectively. Increasing age was an independent predictor of death and complications. Patients admitted for resuscitation (n=225) had the highest likelihood of mortality and complications (OR [95% CI]: 229.0 [169.8-308.8], 421.0 [244.8-724.3], respectively). The median length of hospital stay was 2 (IQR: 1-5) days. Examination of the proportion of deaths over a 30-day LOS revealed a tri-modal mortality distribution that peaked on days 20, 25 and 30.

Conclusion: Patients of advanced age and those requiring resuscitation are at greater risk of both mortality and complications. This study provides an important first step toward quantifying the burden of EGS conditions in a lower-middle-income country. Data presented here will help facilitate efforts to benchmark EGS in similar and, as yet, unexplored settings.

37.09 A propensity score based analysis of the impact of Decompressive Craniectomy on TBI in India

Posted on December 22, 2014

D. Agarwal1, V. K. Rajajee2, D. Schoubel2, M. C. Misra1, K. Raghavendran2  1All India Institute Of Medical Sciences,Apex Trauma Institute,New Delhi, , India 2University Of Michigan,Ann Arbor, MI, USA

Introduction:  Severe Traumatic Brain Injury (TBI) is a problem of epidemic proportion in the developing world. The use of Decompressive Craniectomy (DC) may decrease the subsequent need for resources directed at Intracranial Pressure (ICP) control and ICU length of stay, important considerations in resource-constrained environments. The impact of DC on outcomes, however, is unclear.The primary objective of the study was to  determine the impact of DC on in-hospital mortality and 6-month functional outcomes following severe TBI in a resource-constrained setting at the JPNATC, AIIMS, New Delhi, India.

Methods: During a 4-year period data was prospectively entered into a severe TBI registry. Patients aged >12-years meeting criteria for ICP monitoring (ICPM) were included. The registry was queried for known predictors of outcome in addition to use of ICPM and DC. Early DC (eDC) was defined as DC performed <48 hours from injury. Outcomes of interest were in-hospital mortality and poor 6-month functional outcome with Glasgow Outcome Scale (GOS)<3. A propensity-score based analysis was utilized to examine the impact of DC on outcomes.

Results: Of 1345 patients meeting study criteria, 589 (44%) underwent DC. Following propensity-score based analysis, DC was associated with a 9.2% increase (p=0.005) in mortality and a 13.2% increase (p=0.016) in poor 6-month outcome, while eDC was associated with a 15.0% (p<0.0001) increase in mortality but not significantly associated with poor 6-month outcome (p=0.15).

Conclusions: The use of DC following severe TBI was associated with an increased likelihood of in-hospital death and poor 6-month functional outcome in a high-volume resource-constrained setting. Clinical trials of DC in similar settings are warranted to determine the impact of DC in severe TBI.

35.07 Heart Rate in Pediatric Trauma: Rethink Your Strategy

Posted on December 22, 2014

J. Murry1, D. Hoang1, G. Barmparas1, A. Zaw1, M. Nuno1, K. Catchpole1, B. Gewertz1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:   The optimal heart rate (HR) for children after trauma is based on resting values for a given age, sometime with the use of a Broselow tape. Given the stages of shock are based in part on HR and blood pressure, treatment plan may vary if these values are abnormal.  Admission HRs for children after trauma were analyzed to determine which ranges were associated with lowest mortality.

Methods:   The NTDB (2007-2011) was queried for all injured patients ages 1 to 14 years admitted (n = 398,544). Age groups were analyzed at ranges to match those provided by the Broselow tape (1 year, 2-3 years, 4 years, 5-6 years, 7-8 years, 9-11 years, 12-13 years).  Exclusions included any Abbreviated Injury Scale=6, Injury Severity Score=75, ED demise, or missing information.  

Results:  After exclusions, admission HRs from 135,590 pediatric trauma patients were analyzed, overall mortality was 0.7% (table).  At 1 year the HR range with the lowest OR for mortality was 100 to 179. Starting at age 7 years lowest mortality was observed for HR range 80-99.

Conclusion:  The HR associated with lowest mortality after pediatric trauma frequently differs from current standards.  Starting at age 7 years, the HR range of 80 to 99 predicts lower mortality.  Our data indicates that at age 7 years a child with HR of 120 may be in stage III shock and treatment might include admission, intravenous fluids and probably blood products. Traditional HR ranges suggest that the normal HR for this child includes 120 and therefore aggressive treatment might not be considered.  Knowing when HR is critically high or low in the pediatric trauma population might guide treatment options such as ED observation, hospital admission, ICU admission and even emergent surgery.

 

35.08 The Impact of the American College of Surgeons Pediatric Trauma Center Verification on In-Hospital Mortality

Posted on December 22, 2014

B. C. Gulack1, J. E. Keenan1, D. P. Nussbaum1, B. R. Englum1, O. O. Adibe1, M. L. Shapiro1, J. E. Scarborough1  1Duke University Medical Center,Department Of Surgery,Durham, NC, USA

Introduction:  Previous studies have demonstrated improvement in the survival of pediatric trauma patients treated at American College of Surgeons (ACS) verified pediatric trauma centers.  However, it is not known whether the level of pediatric trauma center verification, Level 1 (PTC1) versus Level 2 (PTC2), has any effect on outcomes.

Methods: We performed a review of the research data set (RDS) from the National Trauma Data Bank (NTDB) from 2007-2011, including all pediatric patients less than 16 years of age who were treated at an ACS verified adult level I trauma center.  Patients were excluded if they were transferred to another facility.  Patients were subdivided on the basis of trauma center verification: PTC1, PTC2, or trauma center without a pediatric ACS verification. These groups were compared with regards to baseline demographics, injury severity, and outcomes.  Multivariable logistic regression was then performed to determine the independent association of ACS pediatric verification and in-hospital mortality.

Results: A total of 124,773 patients were included in the study, 63,746 (51.1%) of which presented to a PTC1 while 7,562 (6.1%) presented to a PTC2 and 53,465 (42.8%) presented to a trauma center with no pediatric ACS verification.  Unadjusted analysis demonstrated significant differences in in-hospital mortality at PTC1s (1.6%) compared to PTC2s (2.4%) and trauma centers without pediatric ACS verification (2.1%, p<0.001).  In multivariable logistic regression, compared to hospitals without pediatric ACS verification, PTC1s had a significantly reduced in-hospital mortality (Adjusted Odds Ratio [AOR] (95% Confidence Interval [CI]): 0.85 (0.73, 0.99), Figure) while PTC2s did not (AOR (95% CI): 1.07 (0.80, 1.42).

Conclusion: Pediatric patients treated at centers verified as a level I pediatric trauma center by the ACS have a significantly decreased odds of in-hospital mortality compared to those treated at non-verified centers, however this is not seen with regards to PTC2s.  Further investigation is necessary in order to determine if more stringent requirements are necessary for PTC2 verification.

35.09 Outcomes for Burns in Children: Volume Makes a Difference

Posted on December 22, 2014

T. L. Palmieri1,2, S. Sen1,2, D. G. Greenhalgh1,2  1University Of California – Davis,Sacramento, CA, USA 2Shriners Hospitals For Children Northern California,Sacramento, CA, USA

Introduction: The relationship between center volume and patient outcomes has been analyzed for multiple conditions, including burns, with variable results. To date, studies on burn volume and outcomes have primarily addressed adults. Burned children require age specific equipment and competencies in addition to burn wound care. We hypothesized that volume of patients treated would impact outcome for burned children.

Methods: We used the National Burn Repository (NBR) release from 2000-2009 to evaluate the influence of pediatric burn volume on outcomes using mixed effect logistic regression modeling. Of the 210,683 records in the NBR over that time span, 33,115 records for children ≤18 years of age met criteria for analysis.

Results: Of the 33,115 records, 26,280 had burn sizes smaller than 10%; only 32 of these children died. Volume of children treated varied greatly among facilities. Age, total body surface area (TBSA) burn, inhalation injury, and burn center volume influenced mortality (p<0.05) An increase in the median yearly admissions of 100 decreased the odds of mortality by approximately 40%. High volume centers (admitting >200 pediatric patients/year) had the lowest mortality when adjusting for age and injury characteristics (p<0.05).

Conclusion: Burn centers caring for a greater number of children had lower mortality rates.  The lower mortality of children a high volume centers could reflect greater experience, resource, and specialized expertise in treating pediatric patients.

 

35.10 Mechanism and Mortality of Pediatric Aortic Injuries.

Posted on December 22, 2014

J. Tashiro1, C. J. Allen1, J. Rey2, E. A. Perez1, C. M. Thorson1, B. Wang1, J. E. Sola1  1University Of Miami,Division Of Pediatric Surgery, DeWitt-Daughtry Department Of Surgery,Miami, FL, USA 2University Of Miami,Division Of Vascular And Endovascular Surgery, DeWitt-Daughtry Department Of Surgery,Miami, FL, USA

Introduction: Aortic injuries are rare, but have a high mortality rate in children and adolescents. We sought to investigate mechanisms of injury and predictors of survival.

Methods:  Kids’ Inpatient Database was used to identify cases of thoracic and abdominal aortic injury (ICD-9-CM 901.0, 902.0) in patients aged <20 yrs (1997-2009). Demographic and clinical characteristics were analyzed using standard and multivariate methods. Cases were limited to emergent or urgent admissions.

Results: Overall, 468 cases were identified. Survival was 65% for the cohort, 63% for boys, and 68% for girls. Average length of stay was 10.7±14.0 days with charges 105,110±121,838 USD. Adolescents (15-19 years) and males comprised the majority of the group (84% and 79%, respectively). Patients were predominantly Caucasian (45%) and privately insured (51%). Injuries tended to affect patients in the lowest income quartile (36%) and most presented to large (78%) or urban teaching (83%) hospitals. The most common mechanism of injury was motor vehicle-related (77%), followed by other penetrating trauma (10%) and firearm injury (8%). On logistic regression modeling, select diagnoses and procedures, along with gender, race group, payer / income status, and hospital type were found to be significant determinants of mortality. Boys (OR: 0.15 [95% CI: 0.05, 0.44]) and Hispanic children (OR: 0.14 [0.04, 0.55]) had lower associated mortality vs. girls and Caucasian patients, respectively. Self-pay patients (OR: 6.91 [2.01, 23.8]) had higher mortality vs. privately insured patients. Children in the lowest income quartile (OR: 15.5 [4.16, 57.6]) had higher mortality vs. highest income patients. Patients admitted to urban non-teaching hospitals (OR: 0.13 [0.03, 0.55]) had lower mortality vs. those admitted to urban teaching hospitals. Patients with traumatic shock (OR: 47.8 [12.4, 184]) or necessitating exploratory laparotomy (OR: 13.9 [2.12, 91.8]) had the lowest associated survival overall. Patients undergoing repair of vessel (OR: 0.25 [0.10, 0.62]) or resection of thoracic vessel with replacement (OR: 0.18 [0.04, 0.73]) had higher associated survival. Survival increased over the study period between 1997 and 2009, p<0.01.

Conclusion: Motor vehicle-related injuries are the predominant mechanism of aortic injury in the pediatric population. Gender, race, payer status, income quartile, and hospital type, along with associated procedures and diagnoses, are significant determinants of mortality on multivariate analysis.

36.05 Abandoning Daily Routine Chest X-rays in a Surgical Intensive Care Unit: A Strategy to Reduce Costs

Posted on December 22, 2014

S. A. Hennessy1, T. Hranjec2, K. A. Boateng1, M. L. Bowles1, S. L. Child1, M. P. Robertson1, R. G. Sawyer1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction:   Chest x-ray (CXR) remains the most commonly used imaging modality in the Surgical Intensive Care Unit (SICU), especially in mechanically ventilated patients.   The practice of daily, routine CXRs is associated with morbidity for the patient and significantly increased costs.  We hypothesized that elimination of routine daily CXRs in the SICU and integration of clinical on-demand CXRs would decrease cost without any changes in morbidity or mortality.

Methods:   A prospective comparative quality improvement project was performed over a 6 month period at a single institution.  From November 2013 through January 2014 critically ill patients underwent daily routine CXRs (group 1).  From February through April 2014 daily routine CXRs were eliminated (group 2); ICU patients only received a CXR based on the on-demand CXR strategy. This strategy advised imaging for significant clinical changes or post-procedure.  Patients before and after the on-demand CXR strategy were compared by univariate analysis.   Parametric and non-parametric univariate testing was used where appropriate.  A multivariate logistic regression was performed to identify independent predictors of mortality.

Results:  In total, 495 SICU admissions were evaluated:  256 (51.7%) in group 1 and 239 (48.3%) in group 2.   There was a significant difference in the number of CXRs, with 4.2 ± 0.7 in the daily CXR group versus 1.2 ± 0.1 in the on-demand group (p<0.0001).  The mean cost per admission was $394.8 ± 47.1 in the daily CXR group versus $129.9 ± 12.5 in the on-demand group (p<0.0001).  This was an estimated cost savings of $60,000 over a 3 month period for group 2 compared to group 1.  Decreased ICU length of stay (LOS), hospital LOS and mechanical ventilation (MV) was seen in group 2, while mortality and re-intubation rates were equivalent despite decreased imaging (Table 1).  After adjusting for age, gender, re-intubation rate, duration of MV and APACHE III score, no difference in mortality was seen between the two groups (OR 2.2, 95% CI 0.7-6.4, p=0.15).  To further adjust for severity of illness, patients with APACHE III score > 30 were analyzed separately.   Mortality and re-intubation rate, ICU LOS and hospital LOS were similar between the groups, while duration of MV was still decreased (Table 1).  In high APACHE III score patients there was also a reduction in number of CXR per admission from 4.5 ± 0.8 to 1.4 ± 0.2 with a cost savings of $316.6 per ICU admission.

Conclusion:  Use of a clinical on-demand CXR strategy lead to a large cost savings without associated increase in mechanical ventilation or mortality.  This is a safe and effective quality initiative that will reduce cost without increasing adverse outcomes. 

 

36.06 Factors Associated with Secondary Overtriage in a Statewide Rural Trauma System

Posted on December 22, 2014

J. Con1, D. M. Long1, G. Schaefer1, J. C. Knight1, K. J. Fawad1, A. Wilson1  1West Virginia University,Department Of Surgery / Division Of Trauma, Emergency Surgery And Surgical Critical Care,Morgantown, WV, USA

Introduction:
Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in infrastructure, human resources and operational goals.  “Secondary overtriage” is a term that has been used to describe the seemingly unnecessary transfers to another hospital, shortly after which the trauma patient is discharged home without requiring an operation.  An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole.  Few have addressed this phenomenom, and to our knowledge, we are the first to study it in the setting of a rural state's trauma system.

Methods:
Data was extracted from a statewide trauma registry from 2003-2013 to include those who were: 1) discharged home within 48h of arrival, and 2) did not undergo a surgical procedure.  We then identified those who arrived as a transfer prior to being discharged (secondary overtriage) from those who arrived from the scene.  Factors associated with transfers were analyzed using a logistic regression.  Injuries were classified based on the need for a specific consultant.  Time of arrival to ED was analyzed using 8-hour blocks, with 7AM-3PM as reference.

Results:
19,319 patients fit our inclusion criteria of which 1,897 (9.8%) arrived as transfers.  The mean ISS was 3.8 ± 3 for non-transfers and 6.6 ± 5 for transfers (p<0.0001).  Descriptive analysis showed various other differences between transfers and non-transfers due to our large sample size.  Thus, we examined variables that had more clinical significance using logistic regression controlling for age, ISS, the type of injury, blood products given, the time of arrival to the initial ER, and whether a CT scan was obtained initially.  Factors associated with being transferred were age>65, ISS>15, transfusion of PRBC’s, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries.  Orthopedic injuries were not associated with transfers.  Patients having a CT scan done at the initial facility were less likely to be transferred.  

Conclusion:
Although transferred patients were more severely injured, this was not the only factor driving the decision to transfer.  Other factors were related to the rural hospital’s limited resources, which included the availability of surgical specialists, blood products, and overall coverage during the graveyard-shift.  More liberal use of the CT scaner at the initial facility may prevent unnecessary transfers. 
 

35.02 Fateful or Fruitful? ICP Monitoring in Elderly Patients with TBI is Associated with Worse Outcomes

Posted on December 22, 2014

Q. N. Dang2, J. Simon2, J. Catino1,3, I. Puente1,3, F. Habib1,3, L. Zucker1, M. Bukur1,3  1Delray Regional Medical Center,Trauma And Surgical Critical Care,Delray Beach, FL, USA 2Larkin Community Hospital,Surgery,South Miami, FL, USA 3Broward General Hospital,Trauma And Surgical Critical Care,Fort Lauderdale, FL, USA

Introduction:  In an expanding elderly population, Traumatic Brain Injury (TBI) remains a significant cause of death and disability. Guidelines for management of TBI, according to the Brain Trauma Foundation (BTF) include intracranial pressure (ICP) monitoring. Whether or not ICP monitoring contributes to outcomes in the elderly patients with TBI has not been explored. 

Methods:  This is a retrospective study extracted from the National Trauma Database 2007-2008 Research Datasets. Patients were included if age > 55 and they met BTF indications for ICP monitoring. Patients that had non-survivable injuries (any body AIS = 6), were dead on arrival, had withdrawal of care, or LOS < 48 hours were excluded. Outcomes were then stratified based upon ICP monitoring. The primary outcomes were in-hospital mortality as well as favorable discharge (to home or rehab facility). Logistic regression was used to analyze the effect of ICP monitoring on outcomes. 

Results: A total of 4437 patients were included with 11.1% having an ICP monitor placed. Patients requiring an ICP monitor were younger overall, more likely to present hypertensive, had higher injury severity, and more likely to require operative intervention. Median GCS (3) and Head AIS (4) were similar between groups. Of those patients with ICP monitoring, overall mortality was significantly higher (table) and they were less likely to have favorable discharge status. Craniotomy itself was not associated with increased mortality (p = 0.450)

Conclusion: Our findings suggest that the use of ICP monitoring according to BTF Guidelines in elderly TBI patients does not provide outcomes superior to treatment without monitoring. The ideal group to benefit from ICP monitor placement remains to be elucidated. 

 

35.03 Increased Age Predicts Failure to Rescue

Posted on December 22, 2014

G. Barmparas1, J. Murry1, M. Martin2, D. A. Wiegmann3, K. R. Catchpole1, B. L. Gewertz1, E. Ley1  1Cedars-Sinai Medical Center,Division Of Acute Care Surgery And Surgical Critical Care / Department Of Surgery,Los Angeles, CA, USA 2Madigan Army Medical Center,Department Of Surgery,Tacoma, WA, USA 3University Of Wisconsin,Madison College Of Engineering,Madison, WI, USA

Introduction:   Failure to rescue (FTR), defined as any death following the development of in-hospital complications, has become an important quality measure. The purpose of this investigation was to examine whether older patients are at higher risk of FTR following traumatic injuries.

Methods:   National Trauma Databank (NTDB) datasets 2007-2011 were queried. Patients ≥ 16 years admitted to centers reporting ≥ 80% of AIS and/or ≥ 20% of comorbidities, with ≥ 200 subjects in the NTDB and who had any reported complication were reviewed. Those who survived (non-FTR) were compared to those who did not (FTR) using a forward logistic regression model.

Results: Of 3,313,117 eligible patients, 218,986 (6.6%) met inclusion criteria and had at least one complication reported. Of these, 201,358 (91.2%) survived their complication (non-FTR) and 17,628 (8.8%) died (FTR). A forward logistic regression identified 22 variables as predictors of FTR. Of those, age 65 to 89 years was the strongest predictor (AOR [95% CI]: 6.58 [6.11, 7.08], p<0.001), followed by the need for mechanical ventilation (AOR [95% CI]: 2.99 [2.81, 3.17], p<0.001) and ICU admission (AOR [95% CI]: 2.61 [2.40, 2.84], p<0.001). Using age group 16 to 45 years as the reference group, the adjusted risk for FTR increased with increasing age in a stepwise fashion [AOR [95% CI]: 1.94 [1.80, 2.09] for age 46 to 65 years, 6.78 [6.19, 7.42] for age 66 to 89 years and 27.58 [21.81, 34.87] for age ≥ 90 years]. The adjusted risk of FTR also increased in a stepwise fashion with increasing number of complications, reaching AOR (95% CI) of 2.25 (2.07, 2.45), p<0.001 for ≥ 4 complications.

Conclusion: The risk of failure to rescue increases with age and number of complications.  Strategies which track this quality measure to encourage early recognition and treatment of complications in the elderly are necessary.

35.04 The Impact of Preexisting Opioid Use on Injury Mechanism, Type, and Outcome

Posted on December 22, 2014

W. Wilson1, S. O’Mara1,2, J. Opalek2, U. Pandya1,2  1Ohio University,Heritage College Of Osteopathic Medicine,Athens, OH, USA 2Grant Medical Center,Trauma Services,Columbus, OH, USA

Introduction: The prevalence of prescription narcotic use in the U.S. is on the rise. Opioid use and its impact on the management of trauma patients has yet to be thoroughly studied. The aim of this study is to determine the prevalence of pre-injury opioid use and its influence on specific outcomes amongst the trauma patient population.  

Methods: A retrospective review of all trauma patients presenting to a Level I Trauma Center was performed from January 1, 2010 to December 31, 2010.  Patients who died within 24 hours of presentation and those with incomplete medication data were excluded.  Electronic medical record review of history and physical documentation and urine drug screen records were used to determine pre-injury opioid status.  Pre-existing narcotic use, demographic data, injury mechanism and severity, injury type, and outcome variables were analyzed.

Results:A total of 3953 patients met inclusion criteria.  Among our sample, 644 (16.3%) were positive for pre-injury opioid use. Patients in the pre-injury opioid group were older (48 years vs. 41 years) and more likely to be female (37.9% vs. 30.6%).  The mechanism of injury was more often falls (32.8% vs. 22.0%).  Patients on narcotics were more likely to be admitted (82.6% vs. 77.4 %) despite having overall lower injury severity.  Analysis of less severely injured patients (ISS < 15) found a significantly increased length of stay (3.7 days vs. 2.9 days) in the narcotics group.  Evaluation of injury type revealed that head injury, abdominal injury and lower extremity/pelvic injuries were predictive of increased length of stay in these patients. 

Conclusion:There is a considerable prevalence of pre-injury opioid use in the trauma population.  These patients have unique characteristics and causes of injury.   Pre injury opioid use is predictive of increased hospital admission rate and increased length of stay, with important ramifications for patient care and health care costs.
 

35.05 A Restrictive Transfusion Strategy is Safe in Patients with Isolated Traumatic Brain Injury

Posted on December 22, 2014

A. Nguyen2, D. Plurad1, A. Kaji3, S. Bricker1, A. Neville1, F. Bongard1, B. Putnam1, D. Kim1  1Harbor-UCLA Medical Center,Division Of Trauma/Acute Care Surgery/Surgical Critical Care,Torrance, CA, USA 2Harbor-UCLA Medical Center,Department Of Surgery,Torrance, CA, USA 3Harbor-UCLA Medical Center,Department Of Emergency Medicine,Torrance, C, USA

Introduction: The optimal transfusion threshold for patients with traumatic brain injury (TBI) is not well defined. The purpose of this study was to examine the impact of a liberal versus restrictive transfusion strategy (RTS) on outcomes in patients with TBI. We hypothesized that a RTS is not associated with mortality in TBI patients.

Methods: We performed a retrospective cohort analysis of adult patients with TBI over a 40-month period. Patients with an Abbreviated Injury Scale (AIS) ≥3 in 2 or more regions outside of the head and those patients who did not undergo transfusion were excluded. Liberal transfusion strategy (LTS) patients received packed red blood cells for a hemoglobin ≤10 mg/dL whereas as RTS patients were not transfused until their Hb was ≤7 mg/dL. Multivariate logistic regression analysis was performed to identify independent predictors of mortality.

Results: Of 103 patients, 61 patients (59%) underwent a LTS and 42 patients (41%) underwent a RTS. Both groups were similar in age, gender, injury severity, and head AIS scores. There was no difference in the number of patients with severe TBI between the RTS and LTS groups (50% vs. 46%, p=0.7). On unadjusted analysis, there was no difference in mortality (31% vs. 38%, p=0.5) or complications (20% vs. 18%, p=0.8) between groups. On multivariate logistic regression analysis, age (OR=1.03; 95%CI=1.00-1.05, p=0.02), head AIS (OR=2.4; 95%CI=1.2-5.1, p=0.02), and subarachnoid hemorrhage (OR=3.6; 95%CI=1.3-10.3, p=0.02) were the only independent predictors of mortality.

Conclusion: A restrictive transfusion strategy may be safe in patients following isolated TBI. Prospective multicenter studies are required before any definitive recommendations regarding a restrictive transfusion strategy can be set forth.

 

35.06 Outcomes of Supracondylar/Intercondylar Humerus Fractures in Adults

Posted on December 22, 2014

W. K. Roache1, A. Harris2  1Howard University College Of Medicine,Washington, DC, USA 2University Of Florida,Jacksonville,Gainesville, FL, USA

Introduction:
Distal humerus fractures in adults are rare (0.5-2% of all fractures) and are approximately 30% of all humeral fractures. Supracondylar/intercondylar fractures are even less common, having only a 0.31% incidence. These injuries often occur from high-energy trauma, particularly in the young adult, and often present as open fractures with complex fracture patterns. These fractures in adults can be debilitating and difficult injuries to treat and frequently require operative management to create a stable platform to allow for early range of motion (ROM).

Methods:
A retrospective analysis was completed on a consecutive series of skeletally mature adults treated at a Level I Trauma Center with a radiologically visible supracondylar/intercondylar humerus fracture during the period from Feb. 2006 to May 2013. Exclusion criteria were patients with still maturing epiphyseal plates, supracondylar humerus fractures that were not inter-articular, and patients treated non-operatively. Postoperative data such as date of union, status of infection, range of motion (ROM), further complications, subsequent surgeries, status of physical therapy or occupational therapy (PT/OT), and comorbidities was gathered from postoperative and clinic visit notes. Postoperative elbow ROM was measured by tracking the arc of the forearm from full extension to flexion.

Results:
High-energy mechanisms accounted for injuries in 81% of the cases treated. Using the AO/OTA classification, 42% had a C2 and 39% had a C3 fracture pattern, with 53% of the cases being open fractures and 50% of the cases being polytrauma. Operative management, however, is not without risks. Complications were seen in 57% of the cases, with the major issues being elbow stiffness (54% of all complications) and infection (17%), often related to a compromised soft tissue envelope. In cases of infection, all were associated with open fractures. In cases of post union stiff elbow, 54% were associated with an open fracture, while only 41% of functional elbow cases involved open fractures. However, all cases of frozen elbow involved open fractures. Mean time from injury to operative fixation was 28.8 hours sooner in cases resulting in functional elbows than stiff elbows. Of the patients who regained full ROM, 91% started aggressive PT/OT immediately after surgery.

Conclusion:
The combination of soft tissue damage and comminution may lead to arthrofibrosis and the formation of heterotopic bone. It appears clear however that the ability to regain functional range of motion or better is associated with early operative intervention and more importantly, immediate participation in therapy driven modalities. Aggressive physical/occupational therapy was extremely important in restoring ROM, while nearly all patients who achieved full ROM performed immediate therapy postoperatively. Secondary interventions (manipulation; HO excision) appear to prove beneficial in restoring functional motion if stiffness does occur.

31.01 Splenectomy is Associated with Hypercoagulable TEG Values and Increased Risk of Thromboembolism

Posted on December 22, 2014

M. J. Pommerening1, E. Rahbar1, K. M. Minei1, J. B. Holcomb1, M. A. Schreiber2, M. J. Cohen3, S. Underwood2, M. Nelson3, B. A. Cotton1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2Oregon Health And Science University,Portland, OR, USA 3University Of California – San Francisco,San Francisco, CA, USA

Introduction:  Previous investigators have demonstrated that post-injury thrombocytosis is associated with an increase in thromboembolic (TE) risk. Increased rates of thrombocytosis have been found specifically in patients following splenectomy for trauma. We hypothesized that patients undergoing splenectomy (1) would demonstrate a more hypercoagulable profile during their hospital stay and (2) that this hypercoagulable state would be associated with increased TE events. 

Methods:  A 14-month, prospective, observational trial evaluating serial rapid thrombelastography (rTEG) was conducted at three ACS-verified, level-1 trauma centers. Inclusion criteria: highest-level trauma activation, arrival within 6 hours of injury, 18 years of age or older. Serial rTEG (ACT, k-time, α-angle, mA, LY-30) and traditional coagulation testing (PT, PTT, fibrinogen and platelet count) was obtained at 0, 3, 6, 12, 24, 48, 72, 96 and 120 hours. Thromboembolic complications were defined as in-hospital DVT, PE, acute MI, or ischemic stroke. Patients were stratified into splenectomy versus non-splenectomy cohorts. Univariate analysis was perfomed, followed by longitudinal analysis using an adjusted generalized estimating equations (GEE) to evaluate the effects of time, splenectomy, and group-time interactions on changes in rTEG and traditional coagulation testing. For TE risk, we employed a multiple logistic regression. Both models controlled for age, gender, injury severity, and admission blood pressure, base deficit, and hemoglobin. 

Results: 1242 patients were enrolled. Of these, 605 patients had >24 hours of serial rTEG values post-admission and were analyzed (40 splenectomy, 565 non-splenectomy patients). Splenectomy patients were younger (median 30 vs. 38 years), more hypotensive (median systolic 100 vs. 130 mmHg) and more in shock on arrival (median base value -7 vs. -2); all p<0.001. While there was no difference in 24-hour (8 vs. 5%; p=0.348) or 30-day mortality (13 vs. 7%; p=0.129), splenectomy patients were more likely to develop TE events (17.5 vs. 7.5%; p=0.015). Logistic regression confirmed this risk, finding splenectomy was associated with an increased risk of TE events (OR 3.4, 95% C.I. 1.14-9.96, p=0.028).  GEE modeling demonstrated that rTEG values of α-angle and mA are significantly higher (more hypercoagulable) in splenectomy patients at 48, 72, 96 and 120-hours; all p<0.05. The GEE model also demonstrated that platelet counts were significantly higher in splenectomy patients beginning at 72 hours and continuing through 120 hours; p<0.05.

Conclusion: This multicenter study demonstrates that patients undergoing splenectomy are more hypercoagulable than other trauma patients. This hypercoagulable state (identified through higher TEG α-angle and mA values) begins at approximately 48 hours post-injury and continues through at least day 5. Moreover, this hypercoagulable state is associated with 3-fold increased risk of TE complications.

 

31.02 Prevalence and Impact of Admission Hyperfibrinolysis in Severely Injured Pediatric Trauma Pateints

Posted on December 22, 2014

I. N. Liras1, B. A. Cotton1, J. C. Cardenas1, M. T. Harting1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Hyperfibrinolysis (HF) on admission is associated with increased mortality in adult trauma patients. Several studies have demonstrated that 9% of severely injured adults present to the emergency department (ED) with HF. The purpose of the current study was to (1) define HF in pediatric patients and a relevant cut-point for therapeutic intervention (if any), (2) identify the prevalence of HF in severely injured pediatric patients, and (3) determine if HF on admission is as lethal a phenomenon as it is in adults. 

Methods:  Following IRB approval, we identified all pediatric trauma admissions (≤17 years old) that met highest-level trauma activation criteria between 01/2010 and 12/2013. Fibrinolysis rates were determined using LY-30 by rapid thrombelastography (rTEG),which represents the percent reduction of the maximal clot amplitude (fibrinolysis) 30 minutes after such amplitude is achieved. HF was defined a priori as initial LY-30 inflection point that translated to a doubling of mortality. Two previous studies in adults demonstrated an inflection point of ≥3%; where mortality doubled from 9 to 20%. We began by identifying a relevant inflection point to define HF and its prevalence, followed by univariate analysis to compare HF and non-HF patients. Finally, a purposeful logistic regression model was developed to evaluate predcitors of mortality in severely injured pediatric patients. 

Results: 819 patients met study criteria. LY-30 values were plotted against mortality. A distinct inflection point was noted at ≥3%, where mortality doubled from 6 to 14%. Of note, mortality continued to increase as the amount of lysis increased, with a 100% mortality demonstrated at an LY-30 ≥30% (compared to 77% in adults).  Using LY-30 ≥3%, patients were stratified into HF (n=197) and non-HF (n=622), with prevalence on admission of 24%. With the exception of HF patients being younger (median 11 vs. 15 years; p<0.001), there were no differences in demographics, scene vitals or injury severity scores between the groups.  On arrival to the ED, HF patients had a lower systolic blood pressure (median 118 vs. 124 mmHg) and lower hemoglobin (median 12.2 vs. 12.7 g/dL); both p<0.001). Controlling for age, arrival vital signs, admission hemoglobin and injury severity (ISS), logistic regression identified admission LY30 ≥3% (OR 6.2, 95% CI 2.47-16.27) as an independent predictor of mortality.

Conclusion: Similar to adults, admission HF appears to reach a critical threshold at LY30 ≥3% in pediatric patients. Admission HF in pediatric patients occurs more frequently than in adults (24 vs. 9%) but is similarly associated with a doubling in mortality (6 to 14%). Admission LY-30 ≥3% carries a 6-fold increased likelihood of mortality in severely injured pediatric patients. HF on admission may serve to rapidly identify those injured children and adolescents likely to benefit from hemostatic resuscitation efforts and to guide anti-fibrinolytic therapy.&nbsp

31.03 Predicting Progressive Hemorrhagic Injury from Isolated Traumatic Brain Injury and Coagulation

Posted on December 22, 2014

L. E. Folkerson1, D. Sloan1, B. A. Cotton1, J. B. Holcomb1, J. S. Tomasek1, C. E. Wade1  1University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction:  Traumatic brain injury (TBI) and acute coagulopathy of trauma have been the focus of much research as the combination leads to major disability and death. Progressive hemorrhagic injury (PHI) is associated with increased operative interventions and poor outcomes. Identifying which subset of patients will experience PHI based on initial head CT and laboratory coagulation data has proven difficult. We hypothesize that a subtype of TBI and coagulation status would be predictors of PHI. 

Methods:  This was a retrospective analysis from a single institution of adult patients who presented with the highest level of trauma activation between October 2010- May 2013, (n=1645). Patients (n=617) were identified who underwent at least 2 head CT scans within 24 hours of presentation. Patients with polytrauma (AIS ≥ 3 in all areas other than the head) and those on pre-hospital anticoagulants were excluded, leaving 279 patients in the study group with isolated TBI. Rapid thrombelastography (rTEG) was obtained on Emergency Department (ED) arrival and coagulopathy was defined as an ACT ≥128, MA ≤55, LY-30 ≥3.0 or platelet count ≤150 x 103/µL. Subtypes of TBI were categorized into the following groups: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), intraparenchymal contusion/hemorrhage (IPC/H), epidural hematoma (EDH) and combined (CD). PHI was defined as an increase in size of the intracranial hemorrhage from initial head CT as determined by a radiologist. Operative intervention and patient outcomes were recorded. Multivariable logistic regression was used to assess the effect of subtype and coagulation status on PHI. Data are reported as median (IQR).

Results: Of the 279 patients evaluated, 157 patients (56%) had PHI on repeat head CT and 122 (44%) were stable. There was no significant difference in admission GCS, systolic blood pressure or base deficit between groups; all p>0.3. Patients with PHI were older, 44 (27-58) vs 35 (25-52); had a greater incidence of platelet count ≤150 x 103/µL (13% vs 7%); greater incidence of IPC/H (34% vs 11%); a higher ISS, 21 (16-26) vs 17 (14-25); less hospital free days, 14 (0-23) vs 24 (14-27); higher mortality, (17% vs 4%); and higher likelihood of operative intervention (45% vs 34%, OR 1.8, 95% CI 1.0-3.0); all p <0.001. There were no differences in TEG parameters between groups or the incidence of coagulopathy (PHI 51% vs stable 42%; OR 0.6, 95% CI 0.33-0.92). When controlling for age, GCS, and coagulopathy, patients with an IPC/H were more likely to experience PHI than patients with other subtypes of TBI (OR 4.3 p <0.0001, 95% CI 2.2-8.4).

Conclusion: This retrospective analysis demonstrates that patients with IPC/H on initial head CT are more likely to experience PHI. TEG parameters and coagulopathy were not as strong predictors as IPC/H and age for PHI. Therefore, the presence of IPC/H in older patients should raise concern about the probability of PHI. 
 

31.04 Does Procedure Urgency Affect Outcomes in Colorectal Surgery?

Posted on December 22, 2014

B. T. Cain1, A. P. O’Rourke1, H. Jung1, A. E. Liepert1, S. K. Agarwal1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction:  Reimbursement for surgical care is based upon Current Procedural Terminology (CPT) codes for a ninety-day global period regardless of patient presentation: elective or acute.  It is generally accepted that care for acutely ill patients is more involved than that of their less emergently presenting counterparts; however, the long term ramifications of timing of surgical intervention is not considered by payers or hospital systems. Our objective was to characterize the preoperative condition, cost, and complexity of care for elective versus urgent/emergent patients.

Methods:  A retrospective chart review of patients who underwent colectomies at the University of Wisconsin Hospital and Clinics (UWHC) between February 2013 and February 2014 was performed. Patient comorbidities, insurance status, ASA score, and length of hospital stay (LOS) were recorded along with mortality, hospital readmissions, emergency room visits, physician charges, and negative postoperative events within a ninety-day postoperative period. Comparisons were made between patients undergoing elective procedures and those undergoing urgent/emergent operations.

Results: A total of 273 patients were included in this study. Of these, 183 underwent elective procedures while 90 required urgent/emergent operation. Emergent/urgent patients had a higher ASA score (2.73 vs. 2.17; p<0.001), longer LOS (12.66 days vs. 5.89 days; p<0.001), and greater number of negative postoperative events (4.79 vs. 1.63; p<0.001). Physician charges were found to be significantly less in urgent/emergent patients ($6865.00 vs. $7342.64; p<0.01), while no significant difference was observed in patient comorbidities between the two groups (Charlson comorbidity index score 4.26 vs. 4.47; p=0.554).

Conclusion: Emergent/urgent colectomy patients have a higher ASA score, a longer postoperative LOS, and experience more negative postoperative events. These patients require a greater investment of physician resources and time to optimally treat; however, physician charges associated with emergent/urgent colectomy patients are less.  This disconnect between acute care surgeon effort and compensation may negatively impact the field’s ability to recruit the most competitive residents and ultimately provide the best possible patient care.  Lobbying efforts aimed at rectifying the inequity in payment for amount of work performed should be initiated with the Center for Medicare and Medicaid Services, as well as with private insurers.

 

31.05 Utilizing Group-Based Trajectory Modeling to Understand Patterns of Hemorrhage and Resuscitation

Posted on December 22, 2014

S. A. Savage1, J. J. Sumislawski1, W. P. Dutton1, B. L. Zarzaur2  1University Of Tennessee Health Science Center Memphis,Memphis, TN, USA 2Indiana University-Purdue University Indianapolis,Indianapolis, IN, USA

Introduction:  Retrospective studies of traumatic hemorrhage have embraced the concept of massive transfusion, in which all patients reaching a set volume (commonly ten units over 24 hours) are included.  Patterns of hemorrhage vary, however, and massive transfusion definitions do little to describe these differences or their related outcomes.  The purpose of this study is to describe subpopulations of hemorrhage in a cohort of injured patients from an urban Level One trauma center.  We hypothesize that distinct group trajectories may be identified.

Methods:  Patients requiring at least one unit of packed red blood cells (PRBC) in the first 24 hours of admission, and not suffering isolated head injury, were identified from June 2012 to May 2013.  Time of blood transfusion, in minutes, was collected for each PRBC transfused in all patients.  These times were then aggregated into 30-minute blocks over the first day.  Group-based trajectory modeling was performed using Proc Traj (SAS, v. 9.3), with best model-fit determined using Bayesian Information Criterion (BIC) values.

Results: 318 patients met inclusion criteria for this study.  72% were male, the mean age was 39.5 years (SD 18), 39% suffered penetrating trauma, mean ISS was 17 (SD 11), mean 24 hour transfusion volume was 7 units PRBC (min 1u – max 50u) and overall mortality was 14%.  Transfusion patterns for patients receiving > 10 units PRBC/24 hours (n=71) are shown in Figure 1.  12% of massive transfusion patients (group 1) actually received intermittent PRBC transfusions throughout the first day.  All 318 patients were modeled to demonstrate 4 distinct trajectories for transfusion in figure 2.  20% of patients received negligible PRBC volumes over 24 hours (MIN- group1).  34% of patients received low but steady volumes of PRBC (LSV-group 2).  29% of patients received a moderate volume of PRBC only early in the hospital course (Early Bleeding (EB) – group 3).  Patients in group 4 represent the massively bleeding subpopulation and comprise 17% of patients (MB).  MB patients received large volumes of PRBC over the first seven hours and intermittently after that. 

Conclusion: Traditional definitions of massive transfusion encompass both rapidly hemorrhaging patients, as well as those who are transfused gradually for other indications.  These definitions are too broad.  In this study, group-based trajectory modeling was used to demonstrate subpopulations of hemorrhage that are more clinically relevant.  Understanding the trajectories of hemorrhage in injured subpopulations will allow more efficient allocation of clinical resources and concentrate research efforts on truly hemorrhaging subgroups.

 

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