19.08 Incoming Surgical Interns Benefit from Dedicated Opioid Education

Posted on January 31, 2019

K. A. Robinson1, K. Chhabra2, A. Gupta1, T. Kent1, M. M. Aner1, G. Brat1  1Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Surgery,Boston, MA, USA

Introduction:  Surgeons prescribe opioids at high rates. In academic centers, most of the frontline pain management and opioid prescribing is completed by residents. Yet recent recent research has shown that only 10-20% of surgical residents complete opioid education. Further, graduating medical students heading into their intern year (pre-interns) are expected to start residency with a knowledge base that allows them to write opioid prescriptions. The present study evaluated pre-intern comfort with opioid prescribing and baseline knowledge about opioids as treatment for acute pain.

Methods:  An opioid educational curriculum was designed to teach basic pain management skills to pre-interns. All pre-interns took a validated 11 question opioid knowledge assessment with a final question on their comfort in prescribing opioids. Pre-Interns rated their comfort with their own knowledge and readiness to prescribe opiates for acute pain on a scale of 1-10. The survey was presented prior to and after a 75 minute educational session. The post-survey included an additional question to understand if the participant felt that the training would impact their practice. Pre- and post- survey score results were analyzed using a paired t-test after confirming score normality.

Results: There were 58 pre-interns (all beginning a surgical internship) included in the study from April-June 2018 over 3 separate classes. 57 completed both surveys. Prior to the class, 28% of pre-interns could identify an opioid tolerant patient, 37% could identify when to use a long acting opioid, and 51% could correctly identify equianalgesic doses of IV opioids. These numbers rose to 72%, 74% and 86% respectively after the class. The mean percentage of correct answers increased significantly from a prior score of 54% to 69% after the class (p <0.0001 with non-overlapping confidence intervals at 95%). Comfort with opioid prescribing increased from an average score of 2.5 before the class to 4.7 (out of 10) after the class (Figure 1). 98.2% of participants said that the training would impact their practice.

Conclusion: Pre-interns have significant knowledge gaps when tested using a standardized opioid assessment tool. Further, they report feeling uncomfortable with prescribing opioids. Objective knowledge and subjective comfort level increased with a 75 minute educational session. This study demonstrates the need for more education on this topic. Opioids are one of the most common medication classes prescribed by interns; the important safety ramifications of opioid management should encourage educators to expand existing curricula.

 

19.07 QIC: An Interactive, Team-Based Quality Improvement Curriculum for Surgical Residents

Posted on January 31, 2019

J. S. Colvin1, X. Feng1, J. Lipman3, J. French1, V. Krishnamurthy2  1Cleveland Clinic,General Surgery,Cleveland, OH, USA 2Cleveland Clinic,Endocrine Surgery,Cleveland, OH, USA 3Cleveland Clinic,Colorectal Surgery,Cleveland, OH, USA

Introduction:  Incorporation of quality improvement (QI) training is essential to meet the milestones set forth by the Accreditation Council for Graduate Medical Education (ACGME). However, there is currently no standardized curriculum for delivering QI education to residents. With the current training system, educational time must be used efficiently to incorporate all essential components, creating a need for a concise and time-efficient QI curriculum. We aimed to create such a curriculum through the integration of formal didactics and team-based, hands-on learning via the completion of resident-led QI projects relevant to patient care.

 

Methods:  An IRB-approved QI curriculum consisting of four interactive workshops was developed at a surgical residency with 10 categorical graduates annually. The workshops were scheduled over an 11-week period, with each workshop lasting 1.5 hours. The curriculum introduced the various components of QI in a step-wise fashion, with a focus on Plan-Do-Study-Act (PDSA) cycles in the latter sessions. Anonymous and voluntary pre and post-curriculum surveys were administered. Univariate analysis of responses was performed using Fisher’s exact, chi square, and students’ t-tests for categorical and continuous variables when appropriate.

 

Results: Fifty surgical residents participated in the curriculum and four QI projects were completed, with 23 residents completing both pre- and post-curriculum surveys.  Following the curriculum, residents were more confident in their ability to design a QI project (5.7 ± 2.6 vs 7.1 ± 1.9, p=0.02), write a problem statement (6.7 ± 2.5 vs 7.8 ± 1.1, p=0.04), and write an AIM statement (6.7 ± 2.6 vs 7.8 ± 1.2, p=0.04). Residents also improved in their perceived ability to lead a QI project (5.6 ± 2.9 vs 6.9 ± 1.9, p=0.05), knowing the steps to complete a QI project (6.0 ± 2.8 vs 7.4 ± 1.7, p=0.04), and familiarity with basic QI terminology (5.6 ± 2.6 vs 7.0 ± 1.9, p=0.03). There was also a trend towards improvement in the ability to create a process map, how to do a root cause analysis, and how to use data to make improvements.

 

Conclusion: Overall, we found that the curriculum was a success—residents were able to complete QI projects through participation in the curriculum. In addition, there was an improvement in perceived competency and confidence surrounding some of the steps necessary to complete a QI endeavor. The curriculum was well received and the majority of residents who completed the curriculum found it useful. Future areas of investigation include trialing the curriculum over a longer timeline and making the transition to leadership roles for the senior residents. Additionally, the curriculum can be expanded to other institutions and specialties.

19.06 Screening Surgical Residents’ Laparoscopic Skills: Who Needs More Time in the Sim Lab?

Posted on January 31, 2019

K. H. Perrone1, H. Mohamadipanah1, J. Nathwani2, C. Parthiban2, K. Peterson2, B. Wise1, A. Garren2, C. Pugh1  1Stanford University,Palo Alto, CA, USA 2University Of Wisconsin,Madison, WI, USA

Introduction:
Laparoscopic surgery presents a unique set of technical challenges compared to open surgery and continues to account for an increasing proportion of modern surgical practice. As a result, laparoscopy is critical for trainees to master. This study investigated the possibility of using Virtual Reality (VR) perceptual-motor tasks as a screening tool for laparoscopic ability using Laparoscopic Ventral Hernia (LVH) repair as an archetypical procedure. We hypothesized that perceptual-motor skills assessed using VR will correlate with and contribute to LVH repair performance.

Methods:
Surgical residents (N=37), from seven mid-west programs, performed two perceptual-motor tasks: 1) force matching and 2) target tracking, using a haptic interface device and a VR environment. Perceptual-motor skills were quantified using motion metrics including “peak deflection on force release”, “summation of distance from sphere”, “path length” and “maximum distance from sphere”. The residents also performed a partial LVH repair on a benchtop simulator with previously demonstrated validity evidence in multiple contexts. Outcome metrics for the partial LVH repair included final product score and endoscopic visualization errors. A parametric correlational analysis was performed to assess the relationship between performance on VR tasks and LVH.

Results:
For the LVH metrics, residents with a higher number of endoscopic visualization errors had significantly lower final product scores (r = -0.52, p<0.01). When assessing the relationship between metrics in the force matching module in VR and LVH performance, residents with poor performance on “peak deflection on force release” (r = -0.344, p<0.05) and “summation of distance from sphere” (r = -0.359, p<0.05) in VR also had significantly lower final product scores. Likewise, poor performance metrics in the VR-based target tracking task including “path length” (r = -0.488, p<0.05) and “maximum distance” (r = -0.365, p<0.05) correlated significantly with lower final product scores. In addition, longer “path length” values (r = +0.375, p<0.05) had a significant correlation with endoscopic visualization errors. (Table 1)

Conclusion:
This study showed significant correlations between poor performance on VR-based perceptual-motor tasks and basic laparoscopic skills during a partial LVH repair thus supporting the notion that VR could be used as a screening tool for perceptual-motor skill among junior surgical trainees. For trainees identified as having poor perceptual-motor skill through VR, focused curricula could be created, allowing trainees to hone their personal areas of weakness and maximize technical skill to more efficiently prepare for basic and advanced laparoscopic procedures.
 

19.05 ACGME Duty Hour Compliance for General Surgery Residents: Finding Solutions in a Teaching Hospital

Posted on January 31, 2019

B. J. Goudreau1, D. F. Grabski1, A. G. Ramirez1, J. Gillen1, W. M. Novicoff2, P. W. Smith1, B. Schirmer1, C. M. Friel1  1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA 2University Of Virginia,Department Of Orthopaedic Surgery,Charlottesville, VA, USA

Introduction: The inception of work hour restrictions for resident physicians in 2003 created impactful and controversial change within surgery training programs. On a recent ACGME survey at our institution, we noted a discrepancy in low recorded duty hour violations and surgery residents' perception of poor duty hour compliance.  We sought to identify factors that lead to duty hour violations and encourage accurate reporting among surgical trainees.  We hypothesize that accurate reporting will permit program specific modifications that enhance educational and clinical opportunity while ensuring compliance with ACGME work hour limitations.

Methods: A3/Lean methodology, an industry derived systematic problem-solving approach, was used to investigate barriers to accurate duty hour reporting within the department of surgery at an academic institution.  In close partnership with our Graduate Medical Education office, we encouraged a 6-month trial period where residents were asked to accurately record duty hours and provide descriptive explanations of violations without consequence to the invididual or program.  Utilizing the A3/Lean session as the break point, we performed before and after analysis of duty hour violations. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation.  Qualitative evaluation by thematic area revealed resident attitudes and opinions about duty hour violations.  

Results:Through the A3/Lean process, residents reported fear of personal and programmatic punitive measures, desire to retain control of their surgical education, and frustration with the administrative burden following violations as deterrents to honest duty hour reporting.  The intervention was successful in changing logging behavior,10 total violations prior vs.179 violations after (p = 0.003) the A3/Lean evaluation. The increase was largely derived from Short Break violations (4 vs. 134, p = 0.021).   Analysis of violations revealed program-specific trends by post-graduate year (Table 1), rotation and weekend cross-coverage.  Systematic issues were identified and programmatic interventions were implemented.  Additional findings included lower than anticipated 80-hour work week violations despite high numbers of short break violations.  The ability to participate in cases/procedures and a sense of professional responsibility emerged as themes among residents describing violations.

Conclusion:Systematic evaluation of duty hour reporting within a surgical training program can identify structural and cultural barriers to accurate duty hour reporting.  Accurate reporting can identify program specific trends in duty hour violations that can be addressed through programmatic intervention.

 

19.04 Factors Associated with Burnout in Surgical Residents

Posted on January 31, 2019

F. Gleason1, S. Baker1, E. Malone1, R. Hollis1, K. Cofer1, J. Richman1, D. Chu1, B. Lindeman1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:   Surgical residents are a population at high risk for burnout.  Some studies have demonstrated a strong inverse relationship between burnout and both Emotional Intelligence (EI) and job resources .  We hypothesized that burnout among surgery residents at our institution would also be inversely related to EI and job resources, but directly related to experienced disruptive behavior.

Methods:   All general surgery residents at a single institution were invited to complete a survey in 2018 that included: the 22-item Maslach-Burnout Inventory (MBI), 30-item trait EI questionnaire (TEIQ-SF), as well as focused questions assessing disruptive behaviors (8 items), job resources (8 items), and demographic characteristics (4 items).  Burnout was defined as scoring high in Depersonalization (≥10 points) or Emotional Exhaustion (≥27 points).  Student’s t-tests and Wilcoxon tests were used to compare continuous variables; Chi-square and Fisher’s exact tests were used to compare categorical variables, as appropriate.

Results:  Surveys were completed by 60 residents (response rate 87%).  Median respondent age was 30 (IQR 28-32), 51.7% were female, and 48.3% single.  Thirty-five met criteria for burnout (58%).  Of female respondents, 68% were burned out compared to 48% of male respondents, however this difference was not statistically significant (p=0.13). There was no significant difference in burnout rates between married and non-married residents (55.6% vs. 65.5%, p=0.45). Among married respondents, 75% without children were burned out compared to 27% of those with children (p=0.03).  Residents with burnout had significantly lower scores for job resources compared to residents without burnout (19 vs. 26, p<0.01).  Job resources sub-domain scores for meaningful feedback and professional development were significantly associated with burnout (p<0.01 for both).  Having experienced any disruptive behavior was significantly associated with burnout (68% vs. 32%, p=0.01).  Mean EI scores were also lower for those with burnout (5.18 vs. 5.64, p<0.01).  Among EI sub-categories, burnout was significantly associated with well-being and emotionality (p<0.01 and p=0.02, respectively).

Conclusion:  Burnout is prevalent among surgery residents at our institution.  Experiencing disruptive behaviors was associated with higher burnout scores, while higher scores in emotional intelligence and perceptions of job resources were associated with lower burnout scores. Further research is needed to determine if increasing resident EI and perceptions of job resources could decrease burnout.

19.03 What makes the difference for Mindfulness-Based Interventions for medical trainees?

Posted on January 31, 2019

E. V. Guvva1, A. Desai1, C. Lebares1  1University Of California – San Francisco,Surgery,San Francisco, CA, USA

Introduction:  Burnout and distress are high stakes issues in medicine, affecting patient care, satisfaction, and physician well-being. Surgical trainees appear to be particularly high risk, as evidenced by alarming rates of burnout, depression and suicidal ideation. Few successful interventions exist for this complex problem, which has been framed as involving institutional, systemic and individual components. In regard to the latter, Mindfulness-Based Interventions (MBIs) have been shown to be highly feasible and acceptable as well as subjectively and objectively beneficial in surgical trainees. However, focused modification of MBIs could optimize them for dissemination across medical specialties. We explored cultural factors critical for successful implementation of MBIs among surgical and non-surgical trainees at our institution, identifying those factors universally important across groups versus those that were specialty- or training level- specific. 

Methods:  Using mixed methods, we conducted three different studies at a tertiary academic center: a longitudinal pilot RCT with surgery interns (n=40), a cohort study of mixed level urology residents (n=20), and a registered clinical trial of interns from surgical and non-surgical specialties (n=45).  Qualitative data from field observations, focus groups and key interviews were analyzed using grounded theory. Common concepts of perceived need, acceptability, and barriers to participation were identified and coded in an iterative fashion with consensus reached on major themes.

Results: Three influential factors emerged regarding successful implementation of MBIs across groups: motivation, relevance, and cultural norms. Framing MBI training as a discipline for the development of a discrete skill set was universally motivating, and contextualization of skills within familiar professional and personal situations conferred relevance. For example, using defined breathing techniques to transition from work to home or between patients; heightening focus in a code or in the operating room; or using objective self-awareness to observe thoughts when spiraling into self-doubt or when struggling with a new procedure. Cultural norms, while universally influential, showed the greatest variation across specialties and training levels. For instance, surgical specialties were the least willing to discuss personal struggles and feelings, which necessitated activities that approached these subjects in an oblique fashion. Interns, regardless of specialty, were found to be more receptive to the idea of MBIs conferring a professional skill set, whereas senior trainees required objective evidence of MBI effectiveness in other fields.

Conclusion: Wider dissemination of MBIs within medicine may require involving both a cultural insider and a flexible MBI instructor for each new setting. The former, to provide nuanced understanding for optimized motivation, relevance and acceptability, and the latter to adapt the MBI accordingly.

 

19.02 Surgical Resident Education Improves ACS NSQIP Outcomes

Posted on January 31, 2019

Z. Li1, J. Coleman1, D. Naanaa1, C. D’Adamo2, V. Ahuja1  1Sinai Hospital of Baltimore,Surgery,Baltimore, MD, USA 2University Of Maryland,Surgery,Baltimore, MD, USA

Purpose: The validity of outcomes data depends on the consistency of documentation of reported measures. Resident understanding of diagnostic criteria may influence correct documentation and quality outcomes.  This study aims to evaluate whether surgical resident education concerning definition and documentation of ACS NSQIP (American College of Surgeons- National Surgical Quality Improvement Program) cardiac occurrences affects the quality of data in the NSQIP database.

Methods: Data were obtained using NSQIP morbidity report for all elective general surgery and vascular surgery procedures at a single institution.  Post-operative myocardial infarction (MI) incidences were reviewed from the NSQIP semiannual report from January to June 2015. Individual cases from 2015 were independently reviewed by a hospital cardiologist to evaluate accuracy of diagnosis. Data from January to June 2017 was then reviewed and compared to data from 2015 using Fisher exact test to evaluate whether education leads to better documentation and improved accuracy of NSQIP data.

Results: Approximately 1,000 surgical procedures in 2015 and 2017 were examined. There were 12 post-operative MIs in the 2015 period and 3 post-operative MIs in the 2017 period. A hospital cardiologist review of documented 2015 postoperative MI cases by residents raised concerns as these cases were troponin rise which did not meet myocardial demand ischemia criteria. NSQIP definition allows MI occurrence to be based solely on physician documentation of MI, irrespective of the electrocardiogram changes.  A false elevation of MI due to physician’s documenting the diagnosis in their progress note incorrectly showed our hospital to be a high outlier in MI. Education was then provided to surgical residents regarding documentation of postoperative MI only by cardiologist or based on the NSQIP definition.  After education, Fisher exact test showed the odds of having documented post-operative MI within the NSQIP database in 2017 was significantly lower (Odds Ratio = 0.2, p = 0.0346, 95% CI = [0.072, 0.92]) than in 2015.

Conclusions: Correct diagnosis of post-operative MI by surgical residents may significantly impact quality of NSQIP data.  This study shows surgical residents’ education can improve correct diagnosis and documentation of post-operative MI leading to better hospital NSQIP outcomes.

19.01 Illegal Questions and Bias as Experienced by Applicants to General Surgery Residency Programs

Posted on January 31, 2019

L. Theiss1, G. McGwin3, H. Chen1, J. Porterfield1, S. Theiss2  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Orthopaedic Surgery,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA

Introduction: The National Resident Matching Program (NRMP) Code of Conduct stipulates that program directors shall refrain from asking applicants “illegal or coercive questions about age, gender, religion, sexual orientation and family status.” Despite this code, we hypothesize that applicants to general surgery residency programs are often asked illegal questions and that there is a bias against female applicants, who are asked illegal questions more often. Furthermore, we hypothesize these questions are more prevalent in general surgery interviews than other surgical subspecialties.

Methods: A survey was developed and sent to applicants to a university-based general surgery residency program. Applicants were asked questions about demographics and family status. The survey also asked applicants about the frequency of illegal questions about age, gender, religion, sexual orientation and family status. Data was analyzed using a Chi Square test.

Results: 1161 applicants were sent the survey, of which 309 responded. 40% of the applicants were female and 60% were male. Female general surgery residents were less likely to be married (p=0.03) and less likely to have children than their male colleagues (p=0.04). 19% of female applicants were asked questions relating to their gender, while 3% of males were asked about their gender (p<0.0001). 25% of female applicants and 13% of male applicants were asked about plans for pregnancy (p=0.02). There was a trend towards female applicants being asked about their age and marital status. 35% of female general surgery applicants stated that being asked an illegal question moved that program down their rank list, while only 14% of males said the same (p<0.0001).

Conclusion: In a survey of general surgery residency applicants, illegal questions as defined by the NRMP were frequently asked in a formal interview setting. More female applicants than male applicants were asked illegal questions. These findings do not only highlight the frequency of illegal questioning, it also highlights an inherit bias towards female applicants. This study will help programs become aware of the high prevalence of illegal questions during residency interviews and the gender bias of these questions related to women, particularly in general surgery.
 

18.21 Is Protocolized FFP Reversal truly inferior to the PCC for Patients with Warfarin associated ICH?

Posted on January 31, 2019

J. Butz1, Y. Shan1, R. Shadis1, T. Vu1, O. Kirton1  1Abington Hospital, Jefferson Health,Surgery,Abington, PA, USA

Introduction:  The Neurocritical Care Society and Society of Critical Care medicine are recommending the Prothrombin Complex Concentrate (PCC) as the preferred method of reversal for patient with warfarin related intracranial hemorrhage (ICH). The recommendation is based on studies, in which trauma patients are excluded. In trauma patients, protocol-based fresh frozen plasma (FFP) reversal may not be inferior.

Methods:  Our institution utilized a FFP reversal protocol for warfarin related traumatic ICH. The trauma registry (2010 – 2017) was surveyed for patients with ICH, who underwent warfarin reversal. Primary outcome was mortality. Secondary outcomes included ICH progression based on Stockholm score, neurological deterioration, need for surgical intervention, fluid overload, VTE complication, and re-admission. We compared the data to the previous published large population studies (n > 100) referenced in the Neurocritical Care Guideline.

Results: Total of 140 patients underwent FFP reversal protocol. Demographics were of the following: average age 80.8 ± 8.3 years, male 53.6%, female 46.4%, BMI 27.0 ± 6.0 kg/m2, fall 68%, Initial SBP 157 ± 32, Initial HR 80 ± 19, and Initial GCS of 13-15 96.4%. Average time to reversal (INR ≤ 1.5) was 6.1 ± 3.8 hours. Morality was 17.1%, ICH progression was 32.4%, and neurological deterioration was 18.6%. These were lower or comparable to previously published results after PCC reversal of 32-37% (1,2), 35.3% (3), and 20% (2) respectively. In these same studies, results from FFP reversal were 45.6-54%, 45.4%, and 11% respectively. Surgical intervention was done in 7.1% of patients. Fluid overload was 2.9%. VTE complication was 3.6%. Re-admission rate for ICH was 6.4%.

Conclusion: Studies on reversal of warfarin in hemorrhagic stroke patients may not be generalized to warfarin associated traumatic ICH patients. Dedicated studies on trauma patients are needed to evaluate the benefit of warfarin reversal with PCC.

1. Parry-Jones, AR. Napoli, MD. Goldstein, JN. et al. Reversal Strategies for Vitamin K Antagonists in Acute Intracerebral Hemorrhage. Annals of Neurology. 2015 78(1): 54-62

2. Majeed, A. Meijer, K. Larrazabal, R. et al. Mortality in Vitamin K antagonist-related intracerebral bleeding treated with plasma or 4-factor prothrombin complex concentrate. Thrombosis and Haemostasis. 2014; 111:233-239

3. Kuramatsu JB, Gerner ST, Schellinger PD, et al. Anticoagulant reversal, blood pressure levels, and anticoagulant resumption in patients with anticoagulation-related intracerebral hemorrhage. JAMA 2015; 313:824–836.

18.20 Central venous catheter-related DVT in the pediatric CVICU: causes and complications

Posted on January 31, 2019

E. H. Steen1, J. J. Lasa3, T. C. Nguyen3, S. G. Keswani2, P. A. Checchia3, M. M. Anders3  1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Section Of Critical Care Medicine, Department Of Pediatrics,Houston, TX, USA

Introduction: Central venous catheter (CVC) use is common in the management of critically ill children, especially those with congenital or acquired heart disease (CHD). Prior reports suggest that the presence of a CVC augments the risk of deep vein thrombosis (DVT). How CVC-associated DVTs contribute to morbidity and mortality in this high risk patient population is unknown. Taken together, the aim of this study is to identify the factors associated with DVT and thrombus propagation in the pediatric cardiovascular intensive care unit (CVICU) population.

Methods: The PC4 database and a radiologic imaging database for patients admitted to Texas Children’s Hospital were retrospectively reviewed. During the one year study period (January – December 2017), there were 1215 unique central lines placed in 851 admissions. Information gathered included demographics and outcomes of patients requiring central line placement in the TCH CVICU, as well as the incidence of DVT and complications. Data shown as OR [95% CI] by univariate linear regression; p value < 0.05 considered significant.

Results: DVT was diagnosed in 8% of admissions with a CVC. Almost 30% of these patients demonstrated thrombus extension into the inferior vena cava (IVC). The diagnosis of DVT is a highly significant risk factor for mortality in these patients (p=.0001, OR 6.1 [2.8, 13.1]). In a univariate regression model, the risk factors most significantly associated with DVT include the presence of more than one line and higher total line hours (defined as the sum of all lines multiplied by the number of hours each line was in place), as well as longer duration of intubation and extended CVICU admission times. A diagnosis of low cardiac output syndrome (LCOS), sepsis, UTI, CLABSI, and cardiac catheterization during admission are also significant risk factors. Of these, only longer catheter dwell times (p=.0001) and cardiac catheterization (p=.002) are significantly associated with the diagnosis of DVT on multivariate analysis. Interestingly, both LCOS and CLABSI (p<0.0001 in each) are significantly associated with propagation of the thrombus into the IVC. Of note, cardiac surgery with cardiopulmonary bypass appears to be protective of clot development (p=0.001, OR 0.38 [0.22, 0.67]). 

Conclusion: We have defined risk factors for CVC-associated DVT in the pediatric CVICU population, as well as specific factors associated with clot propagation into the IVC. CVC-associated DVTs impart a significant risk of morbidity and mortality in critically ill children, highlighting the need for well-designed studies to determine the best preventive and therapeutic strategies and to establish guidelines for appropriate monitoring and follow up of these patients.

18.19 Circumstances of Gunshot Injury: Understanding a Population

Posted on January 31, 2019

A. McGreal1, B. Tracy2, K. Williams2, R. Smith2,3  1Mercer University School of Medicine,Department Of Surgery,Savannah, GEORGIA, USA 2Emory University School of Medicine,Department Of Surgery,Atlanta, GEORGIA, USA 3Rollins School of Public Health,Atlanta, GEORGIA, USA

Introduction:  National surveillance provides data regarding the incidence and prevalence of gun-related injuries (GRIs), yet little is known about the circumstances surrounding these events.  We believe an understanding of how GRIs occur will better inform patient outreach and violence prevention. This study seeks to characterize the contexts and clinical impact of GRIs.

Methods:  In 2018, we performed a 4-month prospective review of patients who presented to our Level 1 trauma center because of a GRI.  We analyzed patient demographics, injury details, disposition, operations performed, and length of stay.  We then surveyed the patients regarding the context of the event, i.e. whether it was intentional, the immediate circumstances, or who was the owner of the gun.

Results: There were 186 patients sustaining GRIs during the study, of which 79 were included in analysis.  Most patients were black males in their third decade of life.  Patients presented with an average of 2.63 missile wounds with the most affected body region being the lower extremities.  Men had more missile wounds than females (2.76 vs 1.92, p= 0.05) and more retained ballistics (57 vs 7, p=0.03).  Sixty percent (n=47) of patients received an operation during their hospitalization with a mean of 5 procedures.  Most operations were orthopedic (53%, n=25), followed by general surgery interventions (45%, n=21).  Intentional injuries accounted for 76% (n=60) of GRIs, with 42% (n=25) of these events related to interpersonal altercations and 36% (n=22) related to robberies.  Unintentional injuries represented 24% (n=19) of GRIs of which the majority of patients (47%, n=9) were uninvolved bystanders.  Regarding gun ownership, 8 patients knew the owner, 9 owned the gun, and the remaining 62 were unknown.  

Conclusion: Our patient population largely sustained GRIs from intentional, interpersonal altercations and robberies.  These etiologies may shed light on the economic plight and desperation plaguing our city.  Interestingly, despite the number of intentional injuries, little is known or shared about ownership of the associated gun.  Furthermore, the volume of procedures per patient is high, which imparts a significant financial burden.  Ultimately, we still must better understand the circumstances that surround GRIs in order to effectively treat the survivors of these injuries and create effective outreach programs aimed at violence prevention.

18.18 Modifiable Risk Factors and Clinical Outcomes Associated with Augmented Renal Clearance in Trauma

Posted on January 31, 2019

M. B. Mulder1, M. S. Sussman1, S. A. Eidelson1, C. A. Karcutskie1, M. A. Cohen1, A. T. Vidalin1, G. A. Lama1, R. S. Iyengar1, P. M. Elias1, C. I. Schulman1, N. Namias1, K. G. Proctor1  1University Of Miami,Dewitt Daughtry Department Of Surgery: Division Of Trauma And Critical Care,Miami, FL, USA

Introduction:  

Augmented renal clearance ((ARC) defined as creatinine clearance (CLCr) > 130 mL/min) has a reported incidence from 14 to 80% in critically ill patients and is associated with therapy failures for renally-cleared drugs. While the awareness of ARC has increased, the clinical implications of this phenomenon are less defined. The objective of this study was to identify modifiable risk factors and clinical outcomes associated with ARC in severely injured trauma patients. 

Methods:  

In 199 trauma ICU patients with a Greenfield Risk Assessment Profile ≥  8, 24-hour CLCr was correlated with demographics, interventions (IV fluids, pressors, mechanical ventilation), clinical estimates of GFR (by Cockroft-Gault (CG), modification of diet in renal disease (MDRD), or chronic kidney disease epidemiology (CKD-EPI)), and clinical outcomes (infection, VTE, length of stay (LOS), and mortality). Patients with previous nephrectomy or renal transplant were excluded (n=6).  Univariate and multivariate analysis identified risk factors with significance defined at p≤0.05. Values are M±SD if parametric and median [interquartile range] if not. 

Results:

The population was 46±20 years, 68% male, BMI 28±6 kg/m2, 72% blunt mechanism of injury, and injury severity score (ISS) of 24±10. Admission SCr was 0.95 [0.78-1.2] mg/dL, CLCr was 152±74 ml/min, VTE incidence was 14%, ARC incidence was 57%, and mortality 11%. Clinical estimates of GFR by CG, MDRD, and CKD-EPI underestimated CLCr by 14%, 19%, and 18% respectively (all p≤0.001). CLCr was lower in patients receiving transfusions (123±74 v 167±67 ml/min, p≤0.001), pressors (117±71 v 162±73 ml/min, p≤0.001), with positive cultures (138±73 v 161±73 ml/min, p=0.041), and in those who expired (92±58 v 159±73 ml/min, p≤0.001).  Univariate analysis of over 15 risk factors and clinical outcomes were analyzed for ARC; values that were significant (p≤0.05) are shown in Table 1. On multivariate logistic regression male gender (OR 4.5 [1.8-11]), SCr (OR 0.17 [0.041-0.71]), age (OR 0.96 [0.94-0.99]) and transfusions (OR 0.24 [0.011-0.54) were independent predictors of ARC (all p≤0.01).  

Conclusion:
ARC occurs in half of all high-risk trauma ICU patients and is underestimated by standard clinical equations. ARC is associated with younger males, less transfusions, fewer infections, and reduced mortality. These clinical outcomes are counterintuitive.  Further investigations are warranted to delineate the implications and causality of ARC.

18.17 Superficial Surgical Infections in Operative Abdominal Trauma Patients: A TQIP Analysis

Posted on January 31, 2019

S. R. Durbin1, J. Peschman2, D. Milia2, T. Carver2, C. Dodgion2  1Medical College Of Wisconsin,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA

Introduction:
Surgical site infections (SSIs) have a substantial impact on economic and health indices for patients and healthcare institutions. The aim of this study was to identify risk factors for superficial surgical site infections in operative abdominal trauma patients using a national cohort.

Methods:
A retrospective analysis of all adult trauma patients treated within the Trauma Quality Improvement Database (TQIP) who underwent an abdominal operation from 2010-2015 was performed. Risk factors for infection were evaluated using χ2, Wilcoxon rank sum, and multivariate logistic regression.

Results:
There were 46,611 patients who underwent an exploratory laparotomy for trauma. The median age was 33 [24-50]; 36,337 (77.7%) were male and 24,968 (55.5%) were Caucasian. There were 20,750 (44.8%) penetrating injuries and the median injury severity score (ISS) was 21 [13-30]. 12,407 (26.5%) suffered a hollow viscus injury with one (9,457;20.2%), two (2,618;5.6%) or > three (354;0.7%) organs injured respectively.  Overall, 1,944 (4.2%) patients developed an SSI, with >15% of all colon and duodenal injuries developing an infection. On multivariate analysis, after controlling for gender, type of injury, shock on arrival, smoking status, diabetes, and steroid use or chemotherapy use, colonic injuries conferred the greatest independent risk for superficial SSIs (OR 2.91 [2.44-3.48]) followed by duodenal injuries (OR 1.92 [1.21-3.06]) small bowel injuries (OR 1.56 [1.30-1.87]) gastric injuries (OR 1.43 [1.07-1.91]), BMI >30 (1.33 [1.15-1.55]), African American race (OR 1.22 [1.03-1.47]), increasing ISS (OR 1.01 [1.01-1.02] and increasing age (OR 1.01 [1.002-1.01]. Additionally, an increasing number of hollow viscus injuries was associated with a greater risk for superficial SSI; one (OR 2.75 [2.32-3.26]), two (OR 3.81 [2.98-4.89]) or three (OR 6.85 [4.20-11.17]) organs injured respectively.

Conclusion:
The incidence of superficial SSI in operative abdominal trauma patients increases with higher ISS, increased BMI, increased age and an increasing number hollow viscus injuries. Colon and duodenal injuries, in particular, impart the greatest risk.  Consideration should be given to avoiding primary skin closure in patients with these risk factors as a way to mitigate SSIs in this patient population.

 

18.16 Blunt Esophageal Injuries: A 5-Year Review from the Trauma Quality Improvement Program (TQIP)

Posted on January 31, 2019

M. Osama1, M. Hamidi1, A. Northcutt1, E. Zakaria1, N. Kulvatunyou1, T. O’Keeffe1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Trauma And Acute Care Surgery,Tucson, AZ, USA

Introduction:
Blunt esophageal injuries are rare and their management is evolving. Diagnosis and management of these injuries remains a challenge. The aim of our study was to analyze the trends of operative intervention and mortality after blunt esophageal injuries.

Methods:
A 5-year (2010-2014) analysis of all trauma patients with esophageal injuries from the Trauma Quality Improvement Program (TQIP) was performed. All adult patients (>18 years) with blunt esophageal injuries were included. Patients were identified using ICD-9 codes and the following data points were obtained: demographics, admission vitals and procedures performed. Outcome measures were trends of operative intervention and mortality after esophageal injuries. Operative intervention was defined as any surgical procedure performed for the repair of esophagus (primary, secondary, diversion, and resection).  

Results:
808,196 trauma patients were analyzed of which 153 patients had blunt esophageal injuries. Mean age was 43 ± 25 years, 75.2% (115) were male, and 79.7% (122) were white. Median [IQR] ISS was 21[9-34]. 75.2% (115) of the injuries were from motor vehicle collisions while 15.7% (24) were from falls. Overall, mortality rate was 17% (26) of which 50% were within the first 24 hours of injury and 19.1% in the following 7-days. 19.6% (30) patients underwent surgical intervention for repair of esophageal injuries. 14 patients had primary repair of laceration while 1 patient had resection of esophagus. The rate of operative intervention has increased while the mortality has decreased over the 5-years study period (Figure 1). On regression analysis, SBP (OR= 0.85; 95% CI, 0.61-091; p=0.01), pulse (OR= 1.31; 95% CI, 1.2-1.9; p<0.001), ISS (OR= 1.8; 95% CI, 1.3-2.5; p<0.001), and treatment at a non-teaching hospital (OR= 2.5; 95% CI, 1.5-6.6; p<0.001) were independently associated with mortality.

Conclusion:
The rate of operative intervention of esophageal injuries has increased while the mortality rate has decreased over the study period. Teaching status of hospital was associated with decrease in hospital mortality. Understanding why teaching hospitals have better outcomes may help improve survival from this rare injury.
 

18.15 Heparin-Sparing Anticoagulation Strategies are Viable Options for Patients on Veno-venous ECMO

Posted on January 31, 2019

K. T. Carter3, R. Panchal3, J. A. Shake1, A. Panos1, R. P. Cochran1, L. Creswell1, M. E. Kutcher2, H. Copeland1  1University Of Mississippi,Cardiothoracic Surgery,Jackson, MS, USA 2University Of Mississippi,Trauma/Critical Care,Jackson, MS, USA 3University Of Mississippi,Surgery,Jackson, MS, USA

Introduction:  Extracorporeal membrane oxygenation (ECMO) is an option for severe pulmonary dysfunction, but has traditionally been limited by anticoagulation requirements.  Recently, the absolute requirement for anticoagulation has been challenged, potentially allowing inclusion of patients with high bleeding risk or other relative contraindications to anticoagulation.  We hypothesize that among veno-venous (VV) ECMO patients, there is no difference in mortality, bleeding, or thrombotic events between a heparin-sparing and a full therapeutic anticoagulation strategy.

Methods:  We conducted a single center retrospective review of all adult patients placed on VV ECMO from 10/2011 to 5/2018.  Beginning in October 2014, a heparin-sparing protocol was implemented.  VV ECMO was initiated without heparin or with low dose continuous intravenous (IV) heparin (activated clotting time goal 140-180) unless indications developed to start continuous therapeutic heparin.  We compared ECMO patients, pre and post protocol change.  The primary endpoint was survival; secondary endpoints were bleeding, thromboembolic events, and transfusion requirements.

Results: Forty adult patients were placed on VV ECMO during the study period: 17 patients (147 circuit-days) before and 23 patients (214 circuit-days) after an institutional change to a heparin-sparing protocol.  Prior to the protocol change, a heparin-sparing strategy was used during 27% of the total ECMO days compared with 89% after.  The post-protocol group had a lower mean body mass index (29 ± 8 vs. 38 ± 13, p=0.01), were cannulated earlier (median 1 vs. 5 day after ICU admission, p=0.03), and more commonly required inotropic support (87 vs. 41%, p=0.01), but were otherwise similar.  There were no significant differences between groups in survival to decannulation (61 vs. 82%, p=0.18 ) or discharge (52 vs. 71%, p=0.33).  Incidence of bleeding (41 vs. 45%, p=1.0) and thromboembolic events (18 vs. 36%, p=0.38) as well as need for transfusion (0.9 vs. 1 unit per circuit-day, p=0.87) were also similar in the pre vs. post groups.  After the protocol change, 75 circuit-days (35%) were completely heparin-free. Nine patients (39%) in the post-group had entirely heparin-free courses of ECMO (total 33 circuit-days); survival and the incidence of bleeding and thrombotic complications did not differ in this heparin-free subset.

Conclusion: There is no difference in survival, bleeding, thrombotic complications, or transfusion requirements between a heparin-sparing strategy and a full therapeutic heparin strategy in the management of VV ECMO.  VV ECMO can be an option in patients with traditional contraindications to anticoagulation, especially in trauma patients at high risk for bleeding.

 

18.14 “Brain Injury—Does it Matter if by Stroke or by Injury?”

Posted on January 31, 2019

E. Winford1, L. Tennakoon3, L. Knowlton3, M. Martin2, K. Staudenmayer3  1Meharry Medical College,School Of Medicine,Nashville, TN, USA 2Stanford University,Department Of Medicine,Palo Alto, CA, USA 3Stanford University,Department Of Surgery,Palo Alto, CA, USA

Introduction: Cerebrovascular accident (CVA) and traumatic brain injury (TBI) are leading causes of disability and are increasingly common in older adults. While both result in some form of brain injury, it is unknown whether the impact they have on outcomes is the same. We hypothesized that short-term outcomes and 6-month healthcare utilization would be worse for stroke.

Methods: The 2014 National Readmissions Database (NRD), a longitudinal, all-payer database was used. Patients were included in the study if they were ≥65 years and were admitted with a primary diagnosis of either CVA or TBI during the first half of the year. Patients were excluded if their primary diagnosis was “transient ischemic attack” for CVA; for TBI, patients with evidence of multiple injuries were excluded (AIS≥2 in any other body region). The primary outcome was mortality during index hospitalization. Secondary outcomes included rates of tracheostomy and gastrostomy, and 6-month inpatient hospitalization days and costs. Unadjusted and adjusted analyses were performed. Weighted numbers are reported.

Results: 175,415 patients met inclusion and exclusion criteria. Mortality during the index hospitalization was lower for CVA (8.8% vs 10.3% for CVA and TBI, respectively, p<0.001). After controlling for known confounders, CVA was associated with lower inpatient mortality (OR 0.92, 95% CI 0.86-0.98). Rates of gastrostomy and tracheostomy differed for both groups. For CVA vs. TBI, 4.9% vs. 2.8%, (p<0.001) of patients had a gastrostomy, whereas 0.9% vs. 1.3% had a tracheostomy (P=0.0002). This held true in adjusted analysis, where CVA was associated with a higher likelihood of gastrostomy and lower likelihood of tracheostomy vs. TBI (gastrostomy OR 1.95, 95% CI 1.75-2.17; tracheostomy OR 0.81, 95% CI 0.68-0.95). Despite these differences, 6-month inpatient costs and hospital days were similar. For CVA vs. TBI, 6-month costs were $15,507.77 vs. $15,945.47 (p=0.16) and hospital days were 7.0 days vs. 6.5 days (p<0.001). There was no difference when controlling for known confounders.

Conclusion: Brain injury is the final common pathway of CVA and TBI. Following CVA and TBI, healthcare costs and LOS are the same. Interestingly, rates of tracheostomy and gastrostomy are different for the two populations. This may be due to different needs, but also might be due to differences in patient management by different types of physicians. This suggests an opportunity for physicians caring for CVA and TBI patients to further explore and improve care by comparing management of patients who sustain brain injury by any mechanism.
 

18.13 Inpatient Rehabilitation Reduces the Likelihood of Chronic Pain After Injury: A Multi-Center Cohort Study

Posted on January 31, 2019

J. P. Herrera-Escobar1, R. Manzano-Nunez1, S. S. Al Rafai1, A. Toppo1, K. Han2, N. Bhulani1, G. Kasotakis3, G. Velmahos2, A. Salim4, A. H. Haider1,4, D. Nehra4  1Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 2Massachusetts General Hospital,Division Of Trauma, Emergency Surgery & Surgical Critical Care,Boston, MA, USA 3Boston University,Boston, MA, USA 4Brigham And Women’s Hospital,Division Of Trauma, Burn, And Surgical Critical Care,Boston, MA, USA

Introduction:  Most of the 96% of patients who survive traumatic injuries require ongoing rehabilitation after discharge. However, the long-term impact of post-discharge rehabilitation care remains poorly understood. In this study, we sought to compare the likelihood of persistent pain needing medication 6 to 12 months after traumatic injury between patients discharged to an inpatient rehabilitation facility (IRF) and a skilled nursing facility (SNF).

Methods:  Moderate to severe [Injury Severity Score (ISS) ≥ 9] trauma patients admitted to 1 of 3 Level-I trauma centers were interviewed between 6 and 12 months after injury from 2015 to 2018. During the interview, the presence of daily pain and need of pain medications were evaluated using the Trauma Quality of Life (T-QoL) questionnaire. This information was linked to the index hospitalization through the trauma registry. Inverse probability of treatment weighting (IPTW)–adjusted logistic regression analysis was performed to compare the likelihood of persistent pain requiring medication among patients who were discharged to IRF vs SNF. Factors used for the propensity score calculation included age, gender, insurance, comorbidities, injury type, polytrauma, ISS, head injury, extremities injury, intensive care unit admission, ventilator use, complications, length of stay, and hospital.

Results: A total of 519 patients were included in the analysis: 389 discharged to IRFs and 130 to SNFs respectively. Unweighted and weighted baseline characteristics are described in Table 1. In unweighted analysis, rates of pain needing medication were 29.1% for IRF vs 40.8% for SNF (P: .013). After IPTW adjustment, propensity score distribution between IRF vs SNF achieved adequate balance and standardized differences were less than 10% (Table 1), which indicated that patients of both groups were subsequently comparable. IPTW-adjusted rates of pain needing medication were 28.9% for IRF vs 47.5% for SNF. In the IPTW-adjusted logistic regression analysis, IRF was associated with a significant reduction in the likelihood of chronic pain after injury (OR 0.45; 95% CI, 0.23-0.90; P = .023).

Conclusion: IRFs may be associated with a reduction in the likelihood of chronic pain after trauma. The reasons for this difference are unknown, but it is likely to be multifactorial and perhaps we should consider IRF over SNF for patients at high risk for chronic pain after traumatic injury.

 

18.12 Efficacy of Platelet Transfusion for Antiplatelet Reversal in Traumatic Intracranial Hemorrhage

Posted on January 31, 2019

E. Baughman1,2, J. G. Hein1, M. Jackson1,3, T. W. Wolff1,4, M. L. Moorman1,2, U. Pandya1,2, M. C. Spalding1,2  1OhioHealth Grant Medical Center,Division Of Trauma And Acute Care Surgery,Columbus, OH, USA 2Ohio University Heritage College of Osteopathic Medicine,Athens, OH, USA 3Northeast Ohio Medical University,Rootstown, OH, USA 4OhioHealth Doctors Hospital,Department of Surgery,Columbus, OH, USA

Introduction: Increases in vascular disease prevalence have led to as many as half of all US adults aged 45 to 75 being prescribed antiplatelet agents. Patients on antiplatelet medication with traumatic intracranial hemorrhages (tICH) have been shown to have a 3 to 15 times higher rate of mortality. Some institutions adopted the practice of giving platelet transfusions to patients with tICH on pre-injury antiplatelet therapy. Although intuitive, there is little matched cohort data to justify this practice and many studies are biased by disease burden. The aim of our study is to understand the efficacy of platelet transfusion for patients with tICH on pre-injury antiplatelet medication.

Methods:  We identified patients on pre-injury antiplatelet medication admitted with a tICH to an urban, Level 1 trauma center between January 1, 2014 and June 30, 2018. Per institutional guidelines, patients admitted prior to September 2017 were transfused platelets, and those admitted after were not. The primary outcome was mortality. Secondary outcomes were: need for neurosurgical intervention, Intensive care unit length of stay, need for increased level of care, and discharge destination. Demographics, prehospital medications, comorbidities, injury characteristics, and hospitalization events were also evaluated. Chi squared analyses and t tests were used to compare the two groups.

Results: When comparing the platelet transfusion group (449) versus no transfusion group (102), demographics, prehospital medications, comorbidities, injury characteristics, and hospitalization events were not significant, including age (73.13 vs. 75.74, p=0.062), injury severity score (16.21 vs. 15.35, p=0.339), head abbreviated injury scale (7.10 vs. 6.93, p=0.890), Glasgow coma scale (11.9 vs. 11.5, p=0.354) and length of stay (5.39 vs. 5.55, p=0.772). The primary outcome of mortality was nonsignificant (p=0.193), with a 10% and 6% mortality in the transfused and non-transfused groups respectively. Secondary outcomes of neurosurgical intervention (11.6% vs. 7.8%, p=0.300), Intensive care unit length of stay (1.33 vs. 1.46 days, p=0.698), need for increased level of care (6.68% vs. 9.80%, p=0.273), and discharge destination (p=0.662) were also nonsignificant for transfused versus non-transfused groups. Subgroup analysis of patients with subarachnoid hemorrhage (SAH), a specific type of tICH, did reveal a significant difference in mortality (6.25% vs. 0%, p=0.022) and discharge destination (p=0.035) between the transfused versus non-transfused group.

Conclusion: This early analysis indicates that platelet transfusion may have a significant effect on mortality for patients with a SAH on pre-injury antiplatelet medication. Analysis of all tICH data agrees with previous literature supporting no empiric transfusion of platelets for tICH patients on pre-injury antiplatelet medication. Further study to validate this finding and to assess the impact on hematoma expansion should be undertaken.

18.11 What Are We Looking For: Frailty Scores Lacking Uniformity in Identifying Patients

Posted on January 31, 2019

H. K. Weiss1, B. Cook2, B. W. Stocker1, N. Weingarten1, K. E. Engelhardt3, J. Posluszny2  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Northwestern University,Department Of Surgery,Chicago, IL, USA 3The Medical University Of South Carolina,Department Of Surgery,Charleston, SC, USA

Introduction: Screening patients for frailty is traditionally done at the bedside. This process includes screening for comorbidities, physical activity, emotional health, and nutrition. However, recent studies have attempted to identify frailty using non-bedside, electronic medical record (EMR)-based, and primarily comorbidity-focused frailty assessments. Our objective is to determine how the bedside Trauma and Emergency General Surgery (TEGS) frailty index (FI) compares to non-bedside frailty assessments in uniformity of detecting patients.

Methods: We retrospectively reviewed our quality improvement (QI) project database consisting of geriatric ( ≥65 year old ) TEGS patients. Patients were screened with the TEGS FI, a literature validated, 15-question assessment performed at the bedside, including comorbidities, physical activity, emotional health, and nutrition. We reviewed the EMR to calculate non-bedside frailty scores: the Enterprise Data Warehouse (EDW) Frailty Assessment score, a 6-point score from an EMR-based database, the NSQIP mFI-11, and the NSQIP mFI-5 (see Table 1). Based on 31% of the patients being frail as defined by the TEGS FI, a score ≥ 3 on the mFI-11 and ≥ 2 on the mFI-5 was considered frail. We compared overlap of frailty diagnoses between the four different frail groups. We then compared illness and disease severity among groups (Charlson Age-Comorbidity Index (CCI), ASA, SOFA, APACHE II, and P-POSSUM).

Results: 71 geriatric TEGS patients were included, of which 22 (31%) were frail on the TEGS FI, 24 (33%) on the EDW FI, 25 (35.2%) on the mFI-11, and 29 (40.8%) on the mFI-5. Of the patients identified as frail on the TEGS FI, only 13 patients (59%) were frail on the EDW FI, 13 patients (59%) on the mFI-11, and 15 patients (68%) on the mFI-5. Only 7 (32%) patients of the 22 frail patients identified by the bedside TEGS FI were frail by all 4 frailty assessments. When compared to the TEGS FI, illness severity scores did not differ amongst groups (ex. CCI: TEGS, 5.4; EDW, 5.1 (p=0.55); mFI-11, 5.8 (p=0.41); mFI-5, 5.6 (p=0.67)).

Conclusion: There was minimal overlap between the bedside TEGS FI and the non-bedside FIs, suggesting these various frailty scoring systems are identifying different cohorts of patients. There was no difference in traditional illness-severity scores between frail patients identified on the bedside and non-bedside FIs, suggesting no difference in disease or comorbidity between groups. The bedside and non-beside frailty assessments are both assessing for frailty, yet they are resulting in markedly differing patient populations. Larger sample size and further study analyzing clinical outcomes will help to demonstrate if there is a superior approach to identifying frailty.

 

18.10 The Outcomes Of Severe Traumatic Brain Injury In The Elderly: Is It Age Or Is It Frailty, Or It Is Both??

Posted on January 31, 2019

A. Azim1, K. Prabhakaran1, D. Samson1, G. Lombardo1, J. Con1, A. El-Menyar1, R. Latifi1  1Westchester Medical Center,Surgery,Valhalla, NY, USA

Introduction:  Pneumonia, Acute Respiratory Distress Syndrome(ARDS) and  Acute Kidney Injury (AKI) are common in elderly trauma patients. Presence pf these comorbidities in severe Traumatic Brain Injury (sTBI) patients makes clinical course more complicated. The aim of this study was to review the factors that influence outcomes in patients with sTBI.

Methods: All trauma patients ≥ 65 years old with sTBI (GCS ≤8) identified in the trauma registry of our Level I ACS verified trauma center during 2011-2016 were studied. Data points including Injury characteristics, demographics, comorbidities were collected and analyzed. Previously validated 11 variable modified frailty index (mFI) as utilized to calculate frality status. Outcome variables included death and complications.

Results: There were 194 patients; 55.2% age 65-79 years (Group I) and 44.8% age >80(Group II). Modified Frailty Index(mFI) scores were ≥3 in 36 (18.6%). The injury severity score(ISS) was ≥25 in 56.7%. Older patients had abbreviated injury score (AIS) head > 3 (71.3% for ≥80 and 56.1% for 65-79, p=0.036), and cirrhosis of the liver (19.5% for ≥80 versus 4.7% for 65-79, p=0.001). 64.4% of patients ≥80  and 45.8%  of patients 65-79, (p=0.01) died. Patients with higher frailty score had an increased probability of experiencing acute kidney injury(AKI) (6.3% for mFI 0-2 versus 25% for mFI ≥3, p=0.002) as well as acute respiratory distress syndrome(ARDS) (22.8% for mFI 0-2 versus 38.9% for mFI ≥3, p=0.046). In subgroup analysis, mortality was significantly more likely in the mFI 0-2/age ≥80 group (68.1%) than in the mFI 0-2/age 65-79 group (45.1%, p=0.036). Older non-frail patients were less likely to experience AKI than younger more frail patients: 5.8% for mFI 0-2/age ≥80 versus 27.8% for mFI ≥3/age 65-79 (p=0.013) (see Table 1).

Conclusions: Age is associated with increased mortality, whereas frailty is associated with increased complications (particularly AKI) in this patient population. Identification of frailty status of the patient can help in risk startification and appropriate resource allocation in patients resulting in better outcomes in severe TBI patients

 

« Previous Page
Next Page »