55.02 Sex-Based Differences in Transfusion Need After Severe Injury: Findings of the PROPPR Study

Posted on January 18, 2018

M. McCrum2, B. Leroux1, T. Fang1, E. Bulger1, S. Arbabi1, C. E. Wade3, E. Fox3, J. B. Holcomb3, B. Robinson1  1University Of Washington,Surgery / General Surgery,Seattle, WA, USA 2University Of Utah,Surgery / General Surgery,Salt Lake City, UT, USA 3University Of Texas Health Science Center At Houston,Surgery / General Surgery,Houston, TX, USA

Introduction: Previous studies examining sex-based differences in outcomes after traumatic injury have revealed inconsistent findings, potentially due to heterogeneous study populations and variation in management strategies. We sought to evaluate if sex-based differences in outcomes exist for severely injured patients with hemorrhage who underwent protocolized damage control resuscitation. We hypothesized that female sex is protective against mortality in this setting, and that females would achieve hemostasis more rapidly than males.

Methods: We performed a secondary analysis of severely injured patients predicted to receive a massive transfusion who were randomized to 1:1:1 vs 1:1:2 plasma-platelet-red blood cells (RBCs) ratios at 12 level I North American trauma centers in the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial. We used Cox regression to evaluate the sex-based differences in time to hemostasis and mortality. Poisson regression with robust standard errors was used to evaluate differences in volume of blood products transfused in each phase of the study. Pre-randomization and randomization periods occurred prior to hemorrhage control, whereas the post-randomization period occurred after anatomic hemostasis was achieved. All analyses were adjusted for clinical site, age, race, height, base deficit, INR, mechanism of injury, AIS scores, and transfusion arm (1:1:1 vs 1:1:2).  

Results:We identified 134 females and 546 males in the study population. Female patients were older (age 40.5 [IQR 26-60] vs 33 [24-47], p<0.001), with higher ISS (29 [21-41] vs 26 [16-38], p=0.04), and with a higher proportion of blunt (76 vs 47%, p<0.001) and severe head injury (AIS ≥3, 33 vs 20%, p0.01); BMI did not differ by sex (p=0.50). There were no differences between the sexes in mortality over the first 24-hours (HR for female=1.08, 95% CI 0.66, 1.74; p=0.77), 30-days (HR=1.00, 95% CI 0.69, 1.45; p=0.99), or time to hemostasis (HR=1.02, 95% CI 0.82, 1.26; p=0.88). Differences by sex were not found in the volume of plasma, platelets or RBCs received in the pre-randomization or randomization periods. However, in the post-randomization period, females received 38% less plasma (95% CI 11%, 57%; p=0.01), 48% less platelets (95% CI 22%, 65%; p=0.001) and 48% less RBC (95% CI 20%, 67%; p=0.01) compared to males (Figure 1).

Conclusion:Mortality rates and time to hemostasis of severely injured trauma patients with hemorrhage did not differ by sex. Female sex appears to be protective against the need for “catch up” blood required after initial hemostasis. Further work is needed to elucidate sex-based differences in coagulopathy and hemostasis during and following damage control resuscitation.

54.17 Risk Factors for Prolonged Need for PEG Tube In Adult Trauma Patients: Experience of a Level I Trauma Center

Posted on January 18, 2018

B. K. Yorkgitis1, O. A. Olufajo2, L. Gurien1, E. Kelly2, A. Salim2, R. Askari2  1University Of Florida-Jacksonville,Acute Care Surgery,JAcksonville, FL, USA 2Brigham And Women’s Hospital,Trauma, Burns And Surgical Critical Care,Boston, MA, USA

Introduction: PEG tubes are a means of providing nutrition to patient that are unable to consume their caloric intake.  PEG tubes placed in trauma patients after the acute trauma differ from commonly studies malignancy patients.  Often, patients and/or care givers inquires about the length of time alternative means of nutrition will be required.  Our aim was to identify risk factors for prolong need for PEG tube (>90 days).

Methods: The trauma database of a Level I, urban trauma center was used to identify all trauma patients who had PEG tubes placed between January 1, 2009 to December 31, 2014.  Exclusions included age <18 years, pregnancy, patients without follow-up evaluations, and those with pre-existing PEG tubes. Variables examined included: age, sex, injury severity score (ISS), initial GCS, admission albumin, ventilator days, ICU days, hospital LOS, and Charlson Comorbidity Index (CCI). Multivariable logistic regression models were used to identify risk factors for having PEG tubes >90 days.

Results:

During the study period 9772 charts were reviewed for PEG tube placement.  Of these patients, 285 (2.9%) underwent attempted PEG tube, of which 281 (98.9%) were successful. Five attempts were aborted due inadequate visualization; one was able to be subsequently placed with an additional attempt. There were 9 (3.2%) in-hospital deaths in patients successfully receiving PEG tube placement during their index trauma admission; none were related to the procedure. There were 18 (6.2%) PEG tube related complications. Upon review of the living patients at discharge, 195 had adequate clinical documentation of PEG tube presence or decannulation status to allow for analysis.

Of these patients, 149 (76.4%) were male, the average age was 57.5 years with 80 (41.0%) being over 65 years.  The average admitting albumin was 3.7 g/dL and CCI was 1.1. First recorded mean GCS was 10.7 and ISS 23.2. The mean hospital LOS was 23.8 days, ICU LOS 16.5 days and ventilator days while in the hospital was 11.5 days. The mean CCI was 1.1.

The findings are summarized in Table 1. Of those requiring a PEG tube during their index admission, 77 (41.4%) required their PEG tube >90 days. Statistically significant characteristics identified upon univariate analysis include increasing age, age>65 years, higher CCI and longer in-hospital ventilator days.  Upon logistic regression, CCI>1 (OR1.27, CI 95% 1.03-1.56, p=0.02) and longer in-hospital ventilator days (OR 1.05 CI 95% 1.02-1.09, p<0.01) were predictive of need for prolonged PEG tube.

Conclusion:

Patients and their surrogates often inquire about the length of time a PEG tube may be needed after trauma.  This retrospective chart review identified CCI>1 and prolonged in-hospital ventilator days as risk factors for necessity of PEG tube >90 days. This may assist clinicians and patients or their surrogates in decision making when faced for the need for alternative routes for nutrition. 
 

54.19 A New Paradigm for the Acute Care Surgeon: The Active Cancer Patient Population

Posted on January 18, 2018

C. R. Horwood1, S. Byrd1, E. Schneider1, K. Woodling1, J. Wisler1, A. P. Rushing1  1Ohio State University,General Surgery,Columbus, OH, USA

Introduction:
With advances in cancer treatment, patients with active cancer are living longer and developing common conditions that fall outside the realm of oncologic treatment. There is little data describing the clinical decision-making and subsequent outcomes that occur in patients with cancer that present with an emergency general surgical diagnosis. The purpose of this study is to evaluate factors that determine operative management (OM) versus non-operative (NOM) management and subsequent outcomes of colonic emergencies within a cancer population.

Methods:
A single institution registry at a comprehensive cancer center was queried to identify patients with an active cancer diagnosis that had a surgical consult placed for one of three acute colonic surgical diagnoses between 2011 and 2016. The diagnoses included colitis (with or without peritonitis), bleeding diverticulosis, and diverticulitis. Records were retrospectively reviewed for patient demographics, baseline clinical characteristics, OM vs NOM interventions, and outcomes. Primary outcomes examined include hospital length of stay (LOS), 30-day mortality, disposition at discharge, and post-operative complications.

Results:
A total of 87 patients were evaluated of which 38 (43.7%) underwent OM vs 49 (56.3%) who underwent NOM. Differences in initial lab values included median white blood cell count (WBC) and median serum lactate. Median WBC was 8.1 in the OM group vs 4.6 in the NOM group, (p<0.001), and median serum lactate was 2.32 in the OM group vs 0.95 in the NOM group, (p<0.001). Thirteen patients had peritonitis at the time of surgical consult in the OM group vs zero in the NOM group, (p<0.001). With regard to post-operative outcomes, there was no difference in hospital LOS, but there was a difference in 30-day mortality and discharge to home between the groups. Median LOS in the OM group was 13.5 days vs 9 days in the NOM group (difference of 4.5 days, p=0.16). However, 30-day mortality was 32% in the OM group vs 6% in the NOM group (p=0.003) and discharge to home occurred in 35% of patients in the OM group compared to 80% in the NOM group (p<0.001). Within the OM group, 70% of patients had at least one post-operative complication.

Conclusion:
Not surprisingly, patients with higher WBCs, lactic acidosis, and peritonitis were more likely to undergo surgical intervention. Operative management was offered to sicker patients, and as a result, this group had a higher 30-day mortality and were less likely to be discharged home. While more work is needed to evaluate risk stratification for post-operative morbidity, particularly as it compares to non-cancer patients undergoing similar surgical procedures, these preliminary outcomes should be discussed with the active cancer patient prior to pursuing surgical intervention.
 

54.15 Surgeon-Placed Endoscopic Stent As Rescue Therapy For Failed Esophageal Repair After Trauma

Posted on January 18, 2018

K. Chow1, H. N. Mashbari1, M. Hemdi1, E. Smith-Singares1  1University Of Illinois At Chicago,Division Of Surgical Critical Care,Chicago, IL, USA

Introduction:
Esophageal trauma represents an uncommon but potentially catastrophic injury with a reported overall mortality of up to 20%. The management of iatrogenic and spontaneous perforations have been previously described with well-established guidelines which have been mirrored in the trauma setting. Esophageal leaks are the most feared complication after primary surgical management and present a challenge to salvage. There has been increasing reports in the literature supporting the use of removable covered metal stents to heal esophageal perforations and leaks in the non-trauma setting. We present the largest case series of four patients presenting with external trauma induced esophageal injuries, with failure of initial primary surgical repair with subsequent development of a leak successfully managed with esophageal stenting.

Methods:
A retrospective review of four patients who underwent endoscopically placed indwelling covered metal stents after leakage of primary esophageal repair was performed. Demographic information, hospital stay, additional interventions, complications, imaging studies, ISS scores, and outcomes were collected.

Results:
Our cohort consisted of 4 patients with penetrating injuries to the chest and neck with esophageal injuries (3 thoracic and 1 cervical esophageal injuries) managed with esophageal stenting after leaks were diagnosed following primary repair. Leaks were diagnosed on average post-operative day 9 with stents placed within 3 days after diagnosis. There was complete resolution of their esophageal fistulas with all patients resuming oral intake (averaging 72 days after stent placement). Three patients (75%) required further endoscopic interventions to adjust the stent due to migration or for dilations due to strictures. Mortality was 0%, all patients survived to be discharged from the hospital with average ICU length of stay of 30 days.

Conclusion:
The use of esophageal stenting has progressed over the last few years, with successful management of both post-operative upper gastrointestinal leaks as well as benign, spontaneous, or iatrogenic esophageal perforations. While the mainstay of traumatic esophageal injuries remains surgical exploration, debridement, and repair with perivisceral drainage; our case series illustrates that the use of esophageal stents is an attractive adjunct that can be effective in the management of post-operative leaks after attempted repair of external penetrating traumatic injuries to the esophagus.
 

54.16 Accelerometers as an adjunct to mobility assessment in the intensive care unit: a feasibility study

Posted on January 18, 2018

K. Ricci1, C. Horwood1, K. Castellon-Larios1, C. Byrd1, S. Steinberg1, D. Vazquez1  1The Ohio State Wexner Medical Center,Surgery,Columbus, OHIO, USA

Introduction:  

Early mobility of patients in the intensive care unit (ICU) has been associated with decreased complications and length of stay. We currently rely on subjective documentation by staff of the degree of activity among patients.   This is a report of a feasibility study of utilizing a wrist-worn accelerometer as an adjunct to developing an automated and objective mobility scoring system in a surgical ICU.

Methods:

 An IRB approved pilot project was conducted which involved placing an off-the-shelf activity tracking device (Fitbit Flex II) on six non-intubated surgical ICU patients.  The device was left on the patients for a total of 72 hours. The patients had similar demographics and acuity scores. Data on amount of steps, calories burnt and number of minutes of sleep was collected. Subjective mobility was also documented by nursing staff.

Results:
There was a large variation in results between patients.  The range of steps taken per day was 0 to 1962 with a mean of 489. The calories burnt per day ranged from 1543 to 2378 with a mean of 1625. Finally, sleep per day ranged from 0 to 1036 minutes, with a mean of 200 minutes.  The objective actimetry data for steps and calories appeared to correlate with the subjective daily nursing documentation of patient activity (see figure 1).  In contrast, the device did not appear to accurately reflect observed sleep.  This might be due to a limitation of the intrinsic sleep algorithm within the device, which requires an uninterrupted 60 minutes of no activity before it will reflect “sleep”.

Conclusion:
It is feasible to utilize wrist-worn accelerometers to objectively quantify activity in patients in the ICU.  However, the data obtained from the Fitbit Flex II appears to be at times inaccurate and unreliable particularly when assessing sleep patterns. Further work is needed testing other available devices prior to creating and validating an objective mobility scoring system.

54.14 ROTEM Guided Transfusion Reduces Incidence of Pelvic Packing in Patients who Sustain Pelvic Injury.

Posted on January 18, 2018

B. Zahoor1, S. Kent1, J. Piercey1, M. Randell1, K. Tetsworth1, D. Wall1  1Royal Brisbane & Women’s Hospital,Trauma,Brisbane, QLD, Australia

Introduction: ROTEM guided transfusion in the management of acutely injured patients has contributed significantly in their care especially when compared to earlier transfusion goals of standard ratio. Of particular interest, patients who sustain pelvic injury and require transfusion constitute a special and fragile population have the potential to benefit from ROTEM guided management. We introduced the use of ROTEM in our trauma service to guide our transfusion protocol and wanted to quantify any differences observed in the management of these critically ill patients.

Methods: We completed a retrospective review, at our Level 1 Trauma center, from 2011-2016. We selected for adult patients who sustained both a pelvic injury and required transfusion. We further classified this cohort according to whether transfusion goals were directed by ROTEM or Standard Ratio. Our primary outcome of interest was the need for pelvic packing, which is the primary surgical intervention of choice at our institution who present with severe pelvic injury and do not improve with conservative management.

Results: Our review yielded 46 patients who sustained both a pelvic injury and required transfusion. Our study population mean demographics were described as follows: mean age of 43 y.o, admission BP 99/63 mmHg, admission HR 124 bpm, admission SI 1.22, admission GCS 8 and admission ISS 31.2. Twenty-nine patients were managed with Standard Ratio (1:1:1) transfusion goals in reference; of these, 17 (59%) underwent pelvic packing in the management of their pelvic injury. Seventeen patients were managed with ROTEM guided transfusion; 7 (41%) of these patients underwent pelvic packing in the management of their pelvic injury. Of note, all patients survived at 30 days post admission.

Conclusion: At our institution, the introduction of ROTEM guided transfusion in patients who sustained pelvic injury was associated with a decrease in need for pelvic packing. This is in comparison to patients who were transfused using

traditional goals of standard ratio. Further study is warranted to look at additional variables in patient management to fully elaborate the benefit of using ROTEM guided transfusion in pelvic injury patients who from our limited experience seem to benefit from a reduced surgical intervention rate and risk.

54.13 Duodenal Stenting in the Management of Complex Pancreatic and Duodenal Trauma

Posted on January 18, 2018

H. N. Mashbari1, K. Chow1, M. Hemdi1, K. Danielson1, E. Smith-Singares1  1University Of Illinois At Chicago,Division Of Surgical Critical Care,Chicago, IL, USA

Introduction:

Complex pancreatic and duodenal injuries due to trauma continue to present a formidable challenge to the trauma surgeon. Duodenal trauma-related injuries have a described mortality of 5-30% and morbidity of 22-27%. Duodenal fistula formation subsequent to failure of attempted primary repair is associated with significant morbidity and mortality. No such data exists on the employment of duodenal stents as an adjunct in the management of complex duodenal injuries due to trauma, after failure of primary repair. The aim of this study is to document our experience with enteral stents in patients with complex duodenopancreatic traumatic injuries, and to determine if they are a viable option to treat duodenal fistulas in the hostile abdomen.

Methods:

A retrospective review of the trauma registry at a busy Academic Level I trauma center between 2010 and 2016 identified 4 patients who underwent endoscopically placed indwelling enteral covered metal stents after failure of primary duodenal repair in the form of high output duodenal fistulas. Drainage volumes were collected and classified according to source (i.e. drain data, laparostomy output data, and ileostomy output data) and phase of intervention (i.e. admission to fistula diagnosis, to stent insertion, upon removal, and until discharge). 

Results:

The overall mortality was 0%. All treated patients experienced complete resolution of their complex duodenal fistulas. There was no statistically significant change in mean or slopes of daily laparostomy output, combined surgical drain output or ileostomy output across phases. There was a clinically significant difference in the mean combined drain output of 497ml/day after stent placement.  When comparing the sum of all output sources, there was a statistically significant difference across phases (p=0.03) and “After Removal” was significantly less when compared to the reference phase (p=0.05). There was also a change in the directionality of the slope for the sum of all drain outputs with +13 ml/day2 prior to stent placement compared to -13ml/day2 after stent placement. 

Conclusion:

Indwelling enteral-coated stents appear to be an effective rescue method for an otherwise inaccessible duodenal fistula after failure of primary repair. In this cohort, our data showed that duodenal stents produced a significant and durable change in overall drainage outputs as well as obvious reversal in the rate of daily fistulous yield change as an indicator of duodenal leak healing. 

 

54.11 Understanding the Impact of Retained Bullets from the Perspective of the Injured: A Qualitative Study

Posted on January 18, 2018

R. Maduka1, S. Resnick1,2, V. Kumar1, S. Jacoby3, M. Seamon1,2, R. Smith4  1University Of Pennsylvania,The Perelman School Of Medicine,Philadelphia, PA, USA 2Hospital Of The University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA 3University Of Pennsylvania,School Of Nursing,Philadelphia, PA, USA 4Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA

Introduction:  Each year, over 70,000 individuals sustain non-fatal gunshot wounds and retained bullets are common after firearm injuries. We sought to qualitatively determine the signi?cance and impact of retained bullets on survivors of firearm injury. Our primary study objectives were: (1) to determine survivor desire for bullet extraction and; (2) to determine the effects of retained bullets on psychosocial health. 

Methods:  Nine subjects, age 18 years and older, with clinically or radiographically confirmed retained bullet fragments participated in semi-structured interviews. The encounters were transcribed and imported into NVivo 11 for analysis.  Independent coders systematically reviewed all transcripts and performed concept analysis to determine themes based on interview responses using Grounded Theory methodology. Themes and subthemes were coalesced to provide a consistent framework.

Results: Overall, participants communicated a desire to have retained bullet fragments removed, however, concerns regarding removal were linked to: (1) inconvenience and uncertainty regarding the procedure; (2) concern for subsequent healing, and (3) repeated appointments and exposure to the health care system. Of note, the few victims who did have the bullet removed at a later date expressed extreme relief. There were a variety of effects of retained bullets on the patient’s physical and psychosocial health. Themes that emerged included: (1) impact of retained bullets on daily life; (2) psychological stress and emotions; (3) physical pain and awareness, and; (4) medical care experience. 

Conclusion: Data revealed retained bullets significantly impact survivors of firearm injury.  While the long-term psychological ramifications related to retained bullets remains unknown, this study lays the foundation for universal guidelines for bullet extraction and management.  In addition, survivor narratives should inform appropriate allocation of mental health resources in this vulnerable patient population.
 

54.12 Analysis of Intensive Care Unit Admission Data in Urban Teaching Hospital in Maputo, Mozambique

Posted on January 18, 2018

J. Y. Valenzuela1, F. Urci3, L. Niquice3, M. Sidat3, R. G. Valenzuela2, K. McQueen1  1Vanderbilt University Medical Center,Nashville, TN, USA 2Stony Brook University Medical Center,Stony Brook, NY, USA 3Universidade Eduardo Mondlane,Maputo, ., Mozambique

Introduction:  An essential component to improve surgical capacity includes access to intensive care for pre and post operative management for the critically ill. Limited data exist regarding intensive care unit capacity, patient volume, case mix, and mortality rates in Mozambique and sub saharan Africa.

Methods:  Retrospective review of intensive care unit admissions at tertiary referral hospital in Maputo, Mozambique from January 2016 to December 2016.  Most common diagnoses were compiled along with respective mortality rates.

Results: The tertiary referral hospital has a 16 bed unit. In 2016, 1468 patients were evaluated by an intensivist with 965 ICU admissions.  Most common medical conditions requiring ICU care were Diabetes/CAD, stroke, pulmonary edema, hypertensive emergency, and malaria.  Most common surgical diagnoses admitted to ICU were head trauma/intracranial hemorrhage, polytrauma, GI bleed, and eclampsia. Of the surgical conditions, average mortality rate is 30.1%.  

Conclusion: Access to intensive care unit is an essential component of healthcare. Current capacity and demographics is unknown of ICUs in sub saharan Africa.  The primary tertiary hospital in Maputo admits a wide range of mixed medical and surgical conditions. We are in the process of calculating APACHE II scores to determine predicted deaths and compare to actual observed deaths.  Deaths due to surgical conditions warrant further investigation to determine how best to invest limited resources and to develop protocols to reduce mortality.

 

54.10 Are children who live near ski resorts at lower risk for injury compared to those from out of state?

Posted on January 18, 2018

F. Sheikh1, K. Tauber1, I. C. Bostock1, A. O. Crockett2, R. M. Baertschiger1  1Dartmouth Hitchcock Medical Center,Division Of Pediatric Surgery,Lebanon, NH, USA 2Dartmouth Hitchcock Medical Center,Division Of Trauma And Acute Care Surgery,Lebanon, NH, USA

Introduction:
Ski and snowboard crashes are frequent causes of injuries in children and teenagers.  Ski resorts will often attract visitors from out of state who may not be as familiar with winter sports as local residents.  The aim of our study was to retrospectively review cases of children who were victims of ski and snowboard injuries in a region of New England to determine if there are differences in the injury pattern between children who come from out of state vs. those who live in the region. 

Methods:
We queried the trauma registry at our ACS Level 1 Adult and ACS Level 2 Pediatric trauma center for all patients ages 0-18 years involved in a ski or snowboard accident between January 2005 and January 2016.  Data was reviewed for demographics, type of injury identified, reported use of protective gear, and injury severity score.  Children residing in New Hampshire and Vermont were considered in state and children from all other states of residence were deemed out of state.  A multivariate regression analysis was performed to assess for difference in injury patterns between out of state and local residents.

Results:
A total of 297 patients injured at 38 different ski areas were identified for review.  Fifty-eight percent had a primary residence out of the New Hampshire/Vermont area.  There was no difference in terms of age for either group as the mean age for each was 13 years (p=0.305).  Although there was no difference in the use of helmets (56% in state vs 47% out of state), children from out of state were more than 10% likely to sustain head injuries (32% in state vs. 49% out of state, OR 1.9, CI 1.226-3.204).  Beyond head trauma, the injury patterns were similar between both groups (Table 1).  No difference was found between the two groups in terms of injury severity score (mean in state 9 vs. 12 out of state, p=0.085).

Conclusion:
Compared to children who live in ski areas, children from out of state were more susceptible to head injuries despite wearing helmets.   Further education on safe ski and snowboarding techniques may be beneficial for children and their families who travel from a far prior to participation in winter sports.
 

54.08 Does Radial Nerve Exploration and Mobilization Reduce Risk of Nerve Injury in Humeral Shaft Repair?

Posted on January 18, 2018

R. Belayneh1,2, K. Broder1, D. Kugelman1, P. Leucht1, S. Konda1, K. A. Egol1  1New York University School Of Medicine,Orthopaedic Surgery,New York, NY, USA 2Howard University College Of Medicine,Washington, DC, USA

Introduction: There is currently no consensus in the orthopaedic community regarding efficacy of radial nerve exploration in humeral shaft fracture repairs. According to literature, incidence of radial nerve palsy subsequent to acute humeral shaft repair hovers between 10%-20%, but there is a paucity of definitive stances of whether radial nerve exploration reduces this frequency or makes no difference. The purpose of this study is to determine the incidence and resolution of secondary radial nerve palsy in the presence of radial nerve exploration, and compare it to the radial nerve palsy incidence rate reported in literature.

Methods: Fifty-five patients were identified who underwent acute or reconstructive humeral shaft repair with radial nerve exploration as part of the primary procedure for either humeral shaft fracture or nonunion. All patients exhibited intact radial nerve function pre-operatively. A retrospective chart review and analysis identified patients who developed a secondary radial nerve palsy post-operatively. Of the 55 procedures, 38 utilized an anterolateral approach, and 17 utilized a posterior approach. In each case the radial nerve was identified and mobilized for protection, regardless of whether the implant necessitated the extensile exposure.

Results: Of the 55 patients, 2 (3.6%) developed radial nerve palsy following surgery, 1 in each approach. One patient was male and the other female. Both patients exhibited complete recovery of radial nerve function by 6 months follow up. We compared age, gender, previous history of RNP, surgical approach, fracture type, and average follow-up time between both the radial nerve palsy group and the non-radial nerve palsy group and found no significant differences (p > 0.05) in all reported variables. 

Conclusion: Nerve exploration and protection in every case of humeral shaft fixation reduced the incidence of transient radial nerve palsy compared to the rate reported in the current literature (3.6% compared to 10-20%). Since nerve exploration is a relatively simple extension of the humeral shaft repair procedure and yields a significantly lower complication rate, radial nerve exploration and mobilization should be considered when approaching the humeral shaft for acute fracture and nonunion repairs.

 

54.09 Negative Impact of Sarcopenia on Postoperative Outcomes of Severely Burned Patients

Posted on January 18, 2018

B. Murray2, S. Deveraj2, A. Sanford2, T. Saclarides1, D. M. Hayden1  1Rush University Medical Center,Department Of General Surgery,Chicago, IL, USA 2Loyola University Medical Center,Department Of General Surgery,Maywood, IL, USA

Introduction: Loss of lean muscle mass has been associated with worse outcomes in cancer patients. Although there have been studies that have examined outcomes related to metabolic derangements in burn patients, the prevalence of sarcopenia and specifically sarcopenic obesity and their effects on the outcomes of severely burned patients has yet to be described.

Methods: Skeletal muscle mass index was measured for patients with at least 20% total surface area burn (partial or full thickness injury) admitted to the ICU with computed tomography scan performed between January 2007 and January 2017. Using Mimics® software (Belgium), skeletal muscle area was measured at the L3 level and then used to calculate the skeletal muscle mass index (cm2/m2). Sarcopenia was defined as two standard deviations below the index level defined in healthy adults. Statistical analysis using SPSS (Chicago, IL) evaluating demographics, co-morbidities and outcomes in relation to sarcopenia was performed.

Results: Of the nineteen patients included in the study, mean age was 43.2 (21-67) and 68.4% were male. Mean BMI was 29.3 (21.2-41.8). The mean percentage of total surface area burn was 43.9% (20-77.5). All patients underwent surgery; mean number of burn-specific operations per patient was 8.6 (1-27). 47.4% of skin grafts healed after the first attempt and overall healing was 73.7%. Mean length of stay (LOS) was 99.4 days (median 91, range 16-257). Sarcopenia was found in 68.4% of patients; 69.2% of males and 66.7% of females. Sarcopenia was significantly related to use of parenteral nutrition (p=0.045) and enteral supplementation (p=0.031). Sarcopenia was also associated with overall postoperative complications (p=0.007), superficial wound infections (p=0.012) and pneumonia (p=0.013). There were 6 (31.5%) patients categorized as having sarcopenic obesity.  These patients were more likely to use or have used alcohol (p=0.004, 0.009) and had increased number of overall and burn-specific operations (p=0.006 and 0.011, respectively). Although just trending toward significance for overall postoperative complications (p=0.057), they were more likely to have pulmonary embolism (p=0.028). Sarcopenia was not significantly associated with gender, race, co-morbidities, LOS, readmissions or mortality.

Conclusion: Our findings suggest that even in this small study population, decreased lean muscle mass at time of burn injury is associated with worse postoperative outcomes, especially if the patient is both sarcopenic and obese. Interestingly, co-morbidities, race and age were not associated with sarcopenia.  In these patients, it did appear that the ICU team recognized the risk of malnutrition since supplemental nutrition was started. However, it may require interventions targeting muscle strengthening, even during these lengthy hospitalizations to help improve operative outcomes in severely burned patients.

 

54.05 Timing Of VTE Chemoprophylaxis with Enoxaparin is Delayed in Traumatic Brain Injury Patients

Posted on January 18, 2018

G. Liao1, N. K. Dhillon1, G. Barmparas1, A. Yang1, R. Mason1, S. Lahiri1, G. M. Thomsen1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Early chemoprophylaxis is contraindicated in trauma patients with intracranial hemorrhage (ICH) despite the high risk for developing venous thromboembolism (VTE). We sought to determine if, and when, traumatic brain injury (TBI) patients received adequate VTE chemoprophylaxis with enoxaparin compared to trauma patients without brain injury.

Methods:  A retrospective study was conducted in which the medical records of trauma patients who received adequate enoxaparin dosing based on anti-factor Xa trough levels were reviewed between August 2014 and October 2016. Data collected included patient demographics, injury characteristics, length of stay (LOS), enoxaparin administration details, anti-factor Xa trough levels, and imaging results.

Results: A total of 163 patients were analyzed of which 41 (25.2%) had TBI. The cohorts were similar with respect to age and sex. Head AIS, ISS, ICU LOS, and hospital LOS were increased among TBI patients. TBI patients waited longer before enoxaparin was started (7.5 vs. 1.5 day, p<0.01) and to achieve adequate dosing (11 vs. 5 days, p<0.01), as determined by anti-factor Xa trough levels. VTE rates were higher among TBI patients (22% vs. 9%, p=0.03). Four patients (12.5%) had progression of their ICH prior to receiving enoxaparin although none progressed during the course of enoxaparin administration.

Conclusion: There is a delay in providing TBI patients with adequate enoxaparin for VTE chemoprophylaxis despite a high presence of VTE. Judicious early administration of enoxaparin titrated by anti-factor Xa trough levels may be indicated.

 

54.06 Utilization of a Massive Transfusion Protocol at a Single Pediatric Institution: a 5-Year Experience

Posted on January 18, 2018

J. D. Kauffman1, C. N. Litz1, S. A. Thiel1, L. K. Bingham2, P. D. Danielson1, N. M. Chandler1  1Johns Hopkins All Children’s Hospital,Division Of Pediatric Surgery,St. Petersburg, FLORIDA, USA 2Johns Hopkins All Children’s Hospital,Division Of Critical Care Medicine,St. Petersburg, FLORIDA, USA

Introduction: Massive transfusion protocols (MTP) have been shown to improve survival, decrease morbidity, and reduce unnecessary blood product use in adults. Studies comparing outcomes of pediatric cohorts before and after implementation of MTP have failed to demonstrate either a survival benefit or decrease in blood product utilization following MTP implementation. More studies are needed to clarify the utility of pediatric MTP and elucidate how it can be optimized in this population. The purpose of this study is to review our institutional experience with MTP since it was initiated in 2012.

Methods:  The institutional MTP registry and electronic medical records were retrospectively reviewed to identify all patients for whom MTP was initiated between January 1, 2012 and June 30, 2017. Data obtained included patient demographics, indication for transfusion, laboratory results, volume of blood products transfused (in ml/kg), and amount of blood products wasted. Outcomes such as intensive care unit (ICU) length of stay, duration of intubation, and mortality were assessed. MTP parameters, including time to initial transfusion, duration of MTP activation, and protocol documentation were also evaluated. Ordinal data was analyzed using Fisher’s exact test. Continuous data with dichotomous outcome variables was analyzed with multiple logistic regression. Statistical significance was set at p<0.05.

Results: Sixteen subjects were identified, two of which underwent MTP twice, for a total of 18 MTP activations over 5.5 years. The mean age was 11.8 years; 56% were male. The majority of activations occurred in either the ICU or operating room; the remaining two (11%) occurred in the emergency department. Five (31%) of those undergoing MTP were trauma patients. Overall mortality was 50%, whereas mortality among the trauma subgroup was only 20% (p=0.28). The mean time to transfusion following initiation of the protocol was 39 minutes (range 0 – 109 minutes); mean duration of activation was 78 minutes (range 13 – 232 minutes). The mean red blood cell/plasma/platelet transfusion ratio was more balanced following MTP initiation than prior to MTP activation (6:3:1 vs. 8:1:1). On multiple logistic regression there was no significant difference in mortality when considering age, weight, total volume of products transfused, volume infused in the first 24 hours, or relative ratio of products infused. Initial laboratory hemoglobin, platelet, and INR levels at time of MTP initiation likewise had no bearing on mortality.

Conclusion: Activation of the massive transfusion protocol at our institution is a rare event and is associated with 50% mortality. Those for whom MTP was initiated at our institution received more balanced proportions of blood products following the initiation of MTP.  Larger prospective studies are warranted to determine the factors related to survival of pediatric patients requiring massive transfusion of blood products.

54.07 Chest CT Associated with Improved Survival in Severe Trauma

Posted on January 18, 2018

J. Zhao1, W. A. Guo1  1State University Of New York At Buffalo,Buffalo, NY, USA

Introduction: Limited evidence and lack of expert consensus exist to guide clinicians on how to best image patients following chest trauma. This study aimed to compare outcomes for patients of similar trauma severity who underwent chest X-ray (CXR) versus chest computerized tomography (CCT).

Methods: The 2014 National Trauma Data Bank from the American College of Surgeons Trauma Quality Improvement Program (TQIP) was used for analysis. Only patients whose CXR or CCT took place within the first 24 hours of presentation were studied. Patients were stratified into two groups: those with CCT scans (standalone CCT +/- CXR) versus those only with CXR. Patients were further stratified by injury severity scores (ISS), revised trauma scores (RTS), and thorax-specific abbreviated injury scale (AIS). Hospital length of stay (LOS), mechanical ventilation (MV) and intensive care (ICU) need and duration, and mortality were calculated for each scoring stratification.

Results: A total of 45,165 (80%) patients underwent CCT, while 11,180 (20%) patients had CXR only. A higher percentage of patients who underwent CCT required ICU admission and MV (p<0.01). CCT patients required a longer hospital/ICU LOS, and MV duration compared to the CXR group. However, CCT was associated with lower mortality based on ISS and RTS, but not on AIS, than CXR alone (Figure 1).

Conclusion: Analysis of TQIP data showed that CCT, when undertaken within the first 24 hours of trauma presentation, was linked to longer hospitalizations, ICU LOS, and MV duration than CXR. However, these increases in hospital resource utilization appeared justified by the survival benefit associated with CCT.

54.04 The Predictive Value Of Early Lactate Area For Mortality In Elderly Patients With Septic Shock

Posted on January 18, 2018

H. Wang1, X. Chen1, D. Wu1  1Qilu Hospital Of Shandong University,Department Of Critical Care Medicine,Jinan, SHANDONG, China

Introduction: The mortality of septic shock among elderly people is very high, and the early detection of patients with high death risk is important. We aimed to determine the predictive value of early lactate area for mortality in elderly patients with septic shock.

Methods:  A prospective study was conducted from January 2012 to December 2013 in the intensive care unit of a chineses hospital with 3000 beds. A total of 115 septic shock patients with age ≥65 years were included in the study. Serum lactate was measured every 6 hours, the lactate indicators, including early lactate area, were recorded.

Results: The overall 28-day mortality rate was 67.0%. The top three primary infection sources were lung, abdominal cavity and bloodstream. When compared to survivors, non-survivors had significantly elevated early lactate area and APACHE II score and lowered lactate clearance, they were significantly more likely to have undergone mechanical ventilation, renal replacement therapy and inotropic or vasopressor support for ≥ 3d, and more frequently displayed signs of cardiovascular, respiratory, and renal and hepatic dysfunction (all P < 0.05). Receiver Operating Characteristic curves indicated the lactate area score displayed a strong predictive power for 28 day mortality as indicated by an AUC of 0.758 (P < 0.01) and had significantly greater predictive power when compared to the initial lactate or lactate clearance (all P < 0.05).

Conclusion:In geriatric patients with septic shock, the early lactate area is a useful predictor for early death and showed better predictive value than other lactate indicators.

 

54.03 Isolated Chest Wall Trauma in the Extremes of the Elderly: What to Expect.

Posted on January 18, 2018

A. X. Samayoa1, W. Alswealmeen1, R. Shadis1  1Abington Jefferson Health,Surgery,Abington, PA, USA

Introduction:  Chest wall trauma in the elderly can be a devastating injury. Pulmonary complications, prolonged hospitalization, and disposition challenges are expected. The aim of the study is to compare the hospital course in isolated chest wall injuries in the extremes of the elderly.

Methods:  We conducted a single institution retrospective review of prospectively collected data from 2000-2015.  All patients were admitted to our suburban Level II trauma center with isolated chest wall trauma (rib fractures, chest wall contusions). Patients were divided into two age groups: A [65-84yo] and B [≥ 85yo]. Patient characteristics and outcomes data were collected.

Results: Two hundred sixteen patients were identified with isolated chest wall trauma.  Of these, 134 were over 65 years of age, with 90 in Group A [age=76.9 ± 5.0y] and 44 in Group B [age=89.1±3.5y]. The most common mechanism of trauma was fall for both groups [Group A=71% vs Group B=84%] [p=0.135]. Rib fractures were the most common type of chest wall injury with 53% and 52% in Group A and B respectively [p=0.474]. Five percent of all patients required mechanical ventilation and no difference were found between groups [p=1.0]. The most common complications were pulmonary (pneumothorax, hemothorax, respiratory failure, pneumonia, etc.) and were present in 27% in Group A and 16% in Group B [P=0.195] (table1). Patients in Group A were more likely to be discharged home as compared to Group B [53% vs 30%] [P=0.010]. Group B patients were more likely to be discharged to a skilled nursing or rehabilitation facility as compared to Group A [59% vs 40%] [0.044] (Table 1). No difference was found in hospital mortality between groups [P=1.0] (table1).

Conclusion: Isolated chest wall trauma in the elderly confers significant morbidity. Most complications were pulmonary. Patients 85 years and older are more likely to be discharge to a skilled nurse facility. We feel that this study encompasses some important points on chest wall trauma in the elderly and a larger multicenter study would further validate these findings.

 

54.02 The Impact of Obesity on Outcomes in Geriatric Blunt Trauma.

Posted on January 18, 2018

R. Barry1, M. Modarresi1, R. Duran1, E. Thompson1, J. Sanabria1  1Marshall University Schoool Of Medicine,Department Of Surgery,Huntington, WV, USA

Introduction:
Trauma injuries still accounts for 10% of the deaths in the Western World. This mortality rate is believed to be even higher in older patients and subjects with multiple comorbidities. Due to the epidemic of obesity, trauma injuries are more common in obese patients. Obesity has been shown to be a factor for sub-optimal outcomes in adult patients, nonetheless, the impact of obesity in patients who undergo blunt injuries in the elderly still remains to be determined.

Methods:
The incidence, prevalence and mortality rates of blunt trauma by age, sex, cause, BMI, year, and geography were found using datasets from i) the Global Burden of Disease (GBD) group, where the epidemiological data obtained were modelled in DisMod-MR 2.1, a Bayesian meta-regression tool which pools data-points from different sources and adjusts for known sources of variability and ii) the local level II trauma registry where data was modelled by JMP methods. GBD data was extracted from 284 country-year and 976 subnational-year combinations from 27 countries in North America, Latin America, Europe, and New Zealand from 1990 to 2015. Outpatient encounter data was also available from the USA, Norway, Sweden, and Canada for 48 country-years. MU dataset was interrogated in patients ≥65yo admitted with blunt trauma between January 2014 and December 2016. Additional variables on patients who met inclusion criteria (n=1256) included vital signs at admission, exact mechanism of injury (MOI), Injury severity scores (ISS), major medical comorbidities, and length-of-stay (LOS). Variables were compared between obese (BMI≥30 kg/m2) and non-obese (BMI<30 kg/m2).

Results:
There was an increased change in the rate of blunt trauma from falls from 1990 to 2015 of 78.3%, 54.7% and 42.7% at a global, national and state level, respectively. It correlates with an increased change in the mortality rate of 5.7%, 102.6% and 89.3% at a global, national and state level, respectively. The local cohort showed no difference in the mortality of obese vs non-obese patients (n=320 and 4.8% vs n=926 and 4.4%, respectively, p<0.05).  The hospital LOS, Glasgow Coma Scale (GCS) score and systolic blood pressure on presentation were similar (4.13 vs 4.03days, 14.61 vs 14.46, and 146 vs 146mmHg for obese vs non-obese patients respectively, p<0.05). In addition, no differences were observed when the ISS was further subdivided based on severity and compared between the two groups. Major medical comorbidities were identified in 280 (87.5%) and 783 (84.6%) patients in the obese and non-obese groups, respectively.

Conclusion:

Although blunt trauma due to falls had increased in elderly patients with obesity, there was no difference in mortality when obese patients were compared to non-obese patients. This may be due to the similar rate of comorbidities between these groups.  

53.20 Outcomes of Abdominal Gunshot Wounds in Patients with Obesity

Posted on January 18, 2018

P. Patalano1, M. C. Smith2, T. Schwartz4, G. Sugiyama3, V. Roudnitsky4  1New York University School Of Medicine,Surgery,New York, NY, USA 2Vanderbilt University Medical Center,Surgery,Nashville, TN, USA 3North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA 4Kings County Hospital Center,Surgery,Brooklyn, NY, USA

Introduction:  Obesity is a public health crisis in the United States, as two thirds of the adult population is overweight or obese. Several studies have demonstrated differences in mortality and length of stay (LOS) according to body mass index (BMI) in blunt trauma, but none have examined this in penetrating trauma. We investigated the association between obesity and overall, as well as ICU LOS following admission for anterior abdominal gunshot wound (GSW).

Methods:  We performed a retrospective chart review of all patients admitted from January 1, 2013 to September 1, 2015 to our urban, Level I Trauma Center. Records were extracted from the trauma registry by mechanism of injury. Patients who were dead on arrival and pregnant patients were excluded.  Variables required to calculate Trauma and Injury Severity Score (TRISS), demographic information, BMI, and information on hospital course were extracted. The TRISS was used to control for injury severity. Our primary outcome was LOS; secondary outcomes were ICU LOS and mortality.

Results: 148 patients were included of which 45 were obese, 46 overweight, 56 normal weight and 1 underweight. There was no significant difference in ISS between obese and normal weight patients (22.38 vs. 22.91, p=0.775). There was a statistically significant increase in LOS for obese patients (21.4 vs. 13.1 days, p=0.032).  There was also an increased ICU LOS in obese patients (11.3 days vs. 5.1 days, p=0.020). Obesity was not associated with increased mortality (6.7 vs. 5.4%, p=0.562).

Conclusion: This data illustrates an association between obesity and increased hospital and ICU LOS in patients admitted with an abdominal GSW. Efforts to curb the epidemics of obesity and violence may lead to a reduced burden on the healthcare system as it relates to this issue. Further prospective studies are warranted to examine specific interventions aimed at decreasing length of stay in patients with obesity.

 

54.01 Predicting Mortality in Elective vs. Non-Elective Partial Colectomy: A Prognostic Decision Tree Model

Posted on January 18, 2018

M. Cheung1, R. LeDuc1, A. Cobb1, L. Gil1, H. Mundt1, R. P. Gonzalez1, M. J. Anstadt1  1Loyola University Chicago Stritch School Of Medicine,Department Of Surgery,Maywood, IL, USA

Introduction:  Partial colectomy is used to treat a variety of conditions. Studies have shown a greater risk of mortality in partial colectomy performed in emergent versus elective cases. While one large database study identified a variety of factors that were predictive of inpatient mortality in colon and rectal surgery, elective and non-elective (urgent and emergent) were not analyzed as separate groups. In addition, a smaller scale study identified preoperative hypotension and ASA score as risk factors that influence outcomes of emergent colectomy. Given the relatively small sample size of that study, the goal of our study was to use a large database to identify what specific factors contribute to the difference in outcomes in emergent/urgent versus non-emergent colectomy. Additionally, we aimed to identify the relative importance of the risk factors to guide the discussion for family decision making when possible and limit the incidence of unfavorable outcomes. 

Methods:  Using the HCUP-SID from California , Florida , Iowa, New York, and Washington between 2006-2013, patients who underwent partial colectomy were identified by ICD-9 code. These patients were divided into an elective and non-elective group, with the non-elective group being defined by admission type (elective, urgent, emergent) and meeting the criteria of less than 24 hours to operation following hospitalization. Three independent decision trees were carried out for the elective, non-elective, and overall partial colectomy groups, respectively, with comorbid conditions and patient characteristics as the independent variables and mortality as the primary outcome. The importance of each of the variables was then determined and weighted using a variable importance function.

Results: We identified 181,130 patients who underwent partial colectomy. Of these patients, 31,978 (17.65%) were classified as non-elective cases. The two groups exhibited no clinical difference in age, gender, or race. The non-elective group demonstrated a statistically significant greater inpatient mortality rate than the elective cohort (7.28% vs 4.96%; p<0.001). Following decision tree analysis, insurance status (relative importance, non-elective: 70.07; elective: 51.90), age (non-elective: 100; elective: 43.77), and presence of congestive heart failure (non-elective: 34.41; elective: 37.52) were the most important factors for both elective and non-elective groups. Obesity and tobacco use were much more predictive of inpatient mortality in non-elective cases compared to elective operations. 

Conclusion: The results of this study provide insight into what factors are predictive of inpatient mortality following partial colectomy in an elective and non-elective setting. These factors can be used as prognostic tools for predicting which patients will have better outcomes and in some cases may be useful in guiding the family discussion and decision making process in cases of emergent or urgent partial colectomy. 
 

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