79.03 Assessing Fatigue Recovery in Trauma Surgeons Utilizing Actigraphy Monitors

Posted on January 31, 2019

Z. C. Bernhard1,2, T. W. Wolff1,3, B. L. Lisjak1, I. Catanescu1, E. Baughman1,4, M. L. Moorman1,4, M. C. Spalding1,4  1OhioHealth Grant Medical Center,Division Of Trauma And Acute Care Surgery,Columbus, OHIO, USA 2West Virginia School of Osteopathic Medicine,Lewisburg, WEST VIRGINIA, USA 3OhioHealth Doctors Hospital,Department Of Surgery,Columbus, OHIO, USA 4Ohio University Heritage College of Osteopathic Medicine,Athens, OHIO, USA

Introduction: Mental fatigue is a psychobiological state caused by prolonged periods of demanding cognitive activity. For over 20 years, the relationship between mental fatigue and physical performance has been extensively researched by the US military, the transportation industry, and other high-risk occupations. This is a growing area of interest within the medical community, yet there remain relatively few investigations specifically pertaining to surgeons. This study sought to quantify and evaluate fatigue and recovery time following 24-hour call among trauma surgeons to serve as a starting point in optimizing staffing and scheduling. We expected more sleep both during and after call, prior to the next normal circadian sleep cycle, would lead to faster recovery times.

Methods:  This was a prospective analysis of trauma surgeons employed at an urban, Level 1 trauma center. Readiband actigraphy monitors (FatigueScience, Vancouver, BC) incorporating a validated Sleep, Activity, Fatigue, and Task Effectiveness Model, were used to track sleep/wake cycles over a 30-day period. Recovery time was measured as the time required during the post-call period for the surgeon to return to his/her pre-call 24-hour mean alertness level. Three groupings were identified based on recovery time: rapid (0-6 hours), intermediate (6-18 hours), and extended (>18 hours). Tri-linear regression analysis was performed to assess correlation between recovery time and on-call, post-call, and combined sleep quantities.

Results: Twenty-seven 24-hour call shifts among 8 trauma surgeons (6 males, 2 females) were identified and analyzed. Mean age was 41.0 ± 5.66. Mean work hours per week was 54.7 ± 13.5, mean caffeinated drinks per day was 3.19 ± 1.90, and mean hours of exercise per week was 4.0 ± 2.5. Six call shifts met rapid criteria, 11 shifts intermediate, and 10 shifts extended, with mean recovery times of 0.49 ± 0.68, 8.86 ± 2.32, and 24.93 ± 7.36 hours, respectively. Table 1 shows the mean alertness levels and sleep quantities for each group. Statistically significant and moderate positive correlations were found between recovery time and the amount of sleep achieved on-call (p=0.0001; R2=0.49), post-call (p=0.0013; R2=0.49) and combined (p<0.0001; R2=0.48).

Conclusion: This early analysis indicates that increased sleep quantities achieved on-call, post-call, and combined are partially indicative of quicker recovery time in surgeons following 24-hour call shifts, thus serving as a viable starting point to optimize trauma surgeon staffing and scheduling. Further studies to validate these findings and evaluate the impact of additional sleep components, such as number of awakenings, should be undertaken.

 

78.08 Variability of Radiological Grading of Blunt Cerebrovascular Injuries in Trauma Patients

Posted on January 31, 2019

A. K. LaRiccia1,2, T. W. Wolff1,2, M. O’Mara1, T. V. Nguyen1, J. Hill1, D. J. Magee4, R. Patel4, D. W. Hoenninger4, M. Spalding1,3  1Ohiohealth Grant Medical Center,Trauma And Acute Care Surgery,Columbus, OH, USA 2Ohiohealth Doctors Hospital,Surgery,Columbus, OH, USA 3Ohio University Heritage College of Osteopathic Medicine,Dublin, OH, USA 4Ohiohealth,Columbus Radiology,Columbus, OH, USA

Introduction:  Blunt cerebrovascular injury (BCVI) occurs in 1-2% of all blunt trauma patients. Computed tomographic angiography of the neck (CTAn) has become commonplace for diagnosis and severity determination of BCVIs. Management often escalates with injury grade and inaccurate grading can lead to both under- and over-treatment of these injuries. Several studies have investigated the sensitivity of CTAn, however, there remains a lack in understanding the inter-reader reliability. In this study, we determine the extent of variability in BCVI grades among neuro-radiologist interpretation of CTAn in traumatically injured patients.

Methods:  This was a retrospective review of trauma patients with a BCVI reported on initial CTAn imaging, admitted to an urban, Level I trauma center from January 2012 to December 2017. Patients were randomly assigned for CTAn re-evaluation by two of three blinded, independent neuro-radiologists. The evaluations were compared and the variability among the BCVI grades was measured using coefficient of unalikeability (u), which can quantify variability for categorical variables on a scale of 1-100 where the higher the value, the more unalike the data. Inter-reader reliability of the radiologists was calculated using weighted Cohen’s kappa (k).

Results: In total, 228 BCVIs in 217 patients were analyzed. Seventy-six (33%) involved the carotid vessels, 144 (63%) involved only vertebral vessels, and 8 (4%) involved both. The initial grades consisted of 71 (31%) grade 1, 74 (32%) grade 2, 26 (11%) grade 3, 57 (25%) grade 4, and 0 grade 5. Interpretation variability was present in 93 (41%) of all BCVIs. Initial grade 1 injuries had the lowest occurrence of uniform consensus (u = 1) with a mean of 31% among all interpretations (see figure). Grade 4 injuries had the highest consensus (92%). Grade 2 and 3 injuries had a mean consensus of 63% and 61%, respectively. Total variability of grade interpretations (u = 100) occurred most frequently with grade 3 BCVIs (21%). No significant differences were found between carotid and vertebral injuries. Weighted Cohen’s k calculations had a mean of 0.07, indicating poor reader agreement. Treatment recommendations would have been affected in 30% of these patients, with the treatment scope downgraded in 22% and upgraded in 8%.

Conclusion: Our study revealed BCVI variability of initial radiological grade interpretation in more than a third of patients and poor reader agreement. The reliability of CTAn interpretation of BCVI grades is not uniform, potentially leads to 8% under treatment and worse neurologic outcomes. Comparisons with variability in digital subtraction angiography may be beneficial to further understand the complexity of BVCI radiologic injury grading.

59.11 Analysis of Patient Outcomes Receiving a REBOA in the First 18 Months at a Level 1 Trauma Center

Posted on January 31, 2019

T. W. Wolff1,3, E. A. Naber1, M. L. Moorman1,2, M. C. Spalding1,2  1OhioHealth Grant Medical Center,Division Of Trauma And Acute Care Surgery,Columbus, OHIO, USA 2Ohio University Heritage College of Osteopathic Medicine,Athens, OHIO, USA 3OhioHealth Doctors Hospital,Department Of Surgery,Columbus, OHIO, USA

Introduction:  Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an emerging tool for trauma surgeons that serves as an alternative to open aortic occlusion in the acute resuscitation of patients in shock. Although placement is a team effort, program implementation is often surgeon-centric. We report our preparation and initial experience of a team-based REBOA program at an urban Level 1 trauma center in hopes to provide comparisons for similar centers initiating such programs.

Methods:  Two trauma surgeons attended the Basic Endovascular Skills in Trauma course and subsequently trained the remaining trauma surgeons, residents, advanced practice providers, nurses, emergency physicians, pharmacists, and medics. A nurse educator liaised with the emergency department (ED), operating room (OR), and intensive care unit (ICU) nursing staff. Training involved didactics, high-fidelity simulation, and structured debriefing in all three settings.

Results: Six trauma surgeons placed 27 REBOA catheters (mean ISS-36, GCS-6, HR-82, SBP-52) for penetrating (5, 19%) and blunt mechanisms (22, 82%). Patient physiology, indication, common femoral artery (CFA) access, and outcome differed significantly between months 1-9 and 10-18 (see Figure). REBOA was performed in the ED (22, 81.5%), ICU (1, 3.7%), OR (3, 11.1%), and interventional radiology (1, 3.7%). In-hospital mortality (55.6%) was significantly different between the first and second 9-month periods (75% vs. 40%, p<0.05). Complications consisted of inability to obtain arterial access in four cases and a CFA pseudoaneurysm that resolved with manual pressure.

Conclusion: We successfully implemented a REBOA program with little external assistance and placed 27 catheters in 18 months with no complications requiring intervention. During the 18-month initiation period, the patient selection differed significantly over time, more percutaneous access was acheieved, and survival was significantly different. This can assist newly established REBOA programs in predicting early outcomes, patient selection, and likely complications.

 

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.

18.08 The Association of ABO Blood Groups and Trauma Outcomes

Posted on January 31, 2019

M. W. Sauder1,2, T. Wolff1,3, M. C. Spalding1,2, U. B. Pandya1,2  3OhioHealth Doctors Hospital,Department Of Surgery,Columbus, OHIO, USA 1OhioHealth Grant Medical Center,Division Of Trauma And Acute Care Surgery,Columbus, OH, USA 2Ohio University,Heritage College Of Osteopathic Medicine,Dublin, OH, USA

Introduction:
Certain ABO blood types have been identified as risk factors for a variety of disease processes including acute respiratory distress syndrome, acute kidney injury, myocardial infarction, and venous thromboembolism. However, there is a relative paucity of literature regarding the implications of ABO blood type on characteristics and outcomes of traumatically injured patients. A recent study concluded that blood type O was associated with higher mortality in severely injured patients in Japan. The purpose of this study was to determine the association of ABO blood types with outcomes in traumatically injured patients in the United States.

Methods:
This retrospective study evaluated all category 1 and 2 trauma alerts at an urban, Level 1 trauma center from January 1, 2017 through December 31, 2017. Data was obtained from the institutional trauma database and electronic medical record. Patients were excluded if they were pregnant, less than 16 years old, or if blood type data was unavailable. Recorded outcomes included: ABO blood group, mortality, Injury Severity Score (ISS), race, ventilator days, transfusion requirements, massive transfusion protocol, injury type, mechanism of injury, and complications. Data analysis was performed using descriptive statistics including chi-squared and analysis of variance (ANOVA) calculations. 

Results:
A total of 3,779 patients met inclusion criteria. The proportions of ABO blood types represented by the patients in our sample data were not significantly different than published national averages. Likewise, no significant differences in age, gender, or ISS were present between blood types. Blood type AB was associated with a statistically significant increase in mortality rate in severely injured (ISS>15) Caucasian patients compared to non-AB blood types (39% vs. 16%; p=0.01). This relationship was not consistent among African-American patients (p=0.37). Neither race exhibited differences in hospital length of stay, intensive care unit length of stay, or ventilator days.

Conclusion:
Blood type AB is associated with increased mortality in severely injured Caucasian patients. This is in contrast to findings in Japanese and African American patients. Though this requires further validation, there is a potential correlation between ABO blood type, ethnicity, and trauma outcomes.