87.05 Intrahepatic Balloon Tamponade for Penetrating Liver Injury: Rarely Needed but Effective

Posted on January 26, 2017

L. M. Kodadek1, W. R. Leeper2, K. A. Stevens1, A. H. Haider3, D. T. Efron1, E. R. Haut1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Schulich School Of Medicine And Dentistry,Surgery,London, ONTARIO, Canada 3Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction:
Severe penetrating liver injuries are associated with high rates of morbidity and mortality. The objective of this study was to demonstrate the experience of a single urban, Level 1 trauma center with use of intrahepatic balloon tamponade for penetrating liver injuries.  

Methods:
This retrospective study queried the trauma registry for patients age 16 and older with traumatic liver injury (ICD-9 864.00-864.19) from penetrating injury undergoing exploratory laparotomy (procedure code 54.11, 54.12, 54.19) from 2000 through 2015. Operative notes were used to identify cases employing intrahepatic balloon tamponade. Charts were reviewed for patient characteristics, injury characteristics, morbidity, and in-hospital mortality. 

Results:
Of the 4,961 penetrating trauma patients admitted during the study period, 279 (5.6%) had liver injury and underwent exploratory laparotomy. Intrahepatic balloon tamponade was attempted in 9 patients (3.2%) for liver injury secondary to gunshot (8 patients) or stab wounds (1 patient). Seven cases (77.8%) utilized a penrose drain/red rubber catheter balloon and two cases utilized foley catheter balloon. One patient had the balloon immediately removed for increased hemorrhage after placement. Two of the 9 patients (22%) were in arrest at time of balloon placement and died during the index operation; both had retrohepatic IVC injury combined with cardiopulmonary injury. Among the 7 survivors, 2 had biliary injury requiring stent, 3 required hepatic angioembolization for definitive hemorrhage control, and 2 developed liver abscess. One patient, temporized with balloon tamponade, ultimately required left hepatectomy.  

Conclusion:
Although rarely needed, trauma surgeons must be prepared to use intrahepatic balloon tamponade as one surgical technique to control major hepatic injuries. This procedure can result in survival even after major penetrating liver injury. 
 

87.03 Eye-Tracking Devices: A Novel Communication Method for Mechanically Ventilated ICU Patients

Posted on January 26, 2017

E. Duffy1, J. Garry1, J. Vosswinkel1, D. Fitzgerald1, K. Grant1, C. Minardi1, M. Dookram1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  Mechanically ventilated patients cannot communicate verbally, creating challenges in addressing their needs. They must rely on alternative means for communication: writing, head nodding, communication boards (CB), etc. It has been suggested that this deficit may be addressed with eye-tracking devices (ETD), tablet-like devices that allow screen selection and enunciation of requests through eye gaze tracking. These devices have traditionally been used by patients with neurodegenerative diseases.  We hypothesized that ETDs would be useful in mechanically ventilated surgery/trauma intensive care unit (SICU) patients.

 

Method: A prospective pilot study was conducted in a tertiary care SICU.  A convenience sample was recruited over 5 weeks; the study was conducted Monday-Friday. All adult (age > 18) patients expected to continuously receive mechanical ventilation for > 48 hours, with a RASS score ≥-1 to ≤1 were evaluated. Exclusion criteria included TBI patients with GCS <15, stroke, eye injury, non-English speakers, and pregnant women. Patients were asked five basic needs questions (pain, temperature, position, suctioning) with the ETD and the CB, in random order. Patients were also prompted to communicate anything else they wished. Response accuracy was verified with head nod, hand movement, or blinking. An occupational therapist or SICU nurse served as an objective observer. Both the patient and the observer were surveyed at the end of the session regarding their experience.

 

Results: Of the 95 patients screened, 90 were excluded: mechanically ventilated <48 hours or not ventilated (n=62), TBI with GCS <15 (n=10), cognitive impairment (n=6), RASS score <-1 or >+1 (n=10), and eye impairment (n=2). Of the remaining 5 patients, 2 patients declined participation and 3 patients were enrolled. Accuracy to yes/no questions was equivalent between the ETD and the CB (Both accurate 10/12, 83% responses), but greater with the ETD for free response answers (2/2 responses for ETD and 2/3 responses for CB). Patient preference for communication was split evenly among the three options: ETD (1), CB (1), baseline form of communication (1). The observer preferred baseline communication (2/3 patients), to the CB (1/3 patients), and the ETD (0/3) for basic and complex communication.

 

Conclusions: Previous studies theorized that a substantial proportion of mechanically ventilated ICU patients can use ETDs. Our study found a limited proportion of eligible patients, likely due to strict inclusion/exclusion criteria.  The major criteria limiting participation were short duration of mechanical ventilation and low RASS score. In terms of optimal communication method, too few patients were enrolled to make any definitive conclusions. As such, the protocol has been being modified to include patients for whom mechanical ventilation is expected for >24 hours. Increased coordination with caregivers during sedation vacations will be pursued.

87.02 Pulse Waveform Analysis vs. Pulmonary Artery Catheterization in Orthotopic Liver Transplantation

Posted on January 26, 2017

J. M. Yee1, A. M. Strumwasser1, R. Hogen1, K. Dhanireddy2, S. Biswas1, P. J. Cobb1, D. H. Clark1  1University Of Southern California,Trauma, Acute Care Surgery, And Surgical Critical Care,Los Angeles, CA, USA 2University Of Southern California,Solid Organ Transplantation,Los Angeles, CA, USA

Introduction:
Hemodynamic monitoring in end-stage liver disease (ESLD) is controversial given difficulties in assessing volume responsiveness (VR) and cardiac function (CFx). Pulse waveform analysis (PWA) may supplant pulmonary artery catheterization (PAC) as a non-invasive modality. We hypothesize that PWA is equivalent to PAC for assessing VR and CFx post-orthotopic liver transplantation (OLT). Our specific aims were to determine if post-OLT PWA and PAC data are concordant for measures of VR and CFx, vary pre-and-post extubation, and impact cardiovascular management decisions.

Methods:
Between 2014-2015, (N=49) simultaneous PWA and PAC data (303 paired measurements) were obtained. Bland-Altman analysis determined variability and bias for CFx (cardiac index, CI), VR (stroke volume index, SVI), and vascular resistance (systemic vascular resistance index, SVRI). Reference ranges: CI 2.8-4.2 L/min/m2, SVI 33-47 ml/m2, SVRI 1200-2500 dynes/m2/cm5. Data were concordant if measurements agreed. For discordant data, cardiovascular management decisions (inotrope/pressor) were determined. Patients on post-OLT vasopressors, with vascular disease and/or ventilated < 8 ml/kg IBW.

Results:
Mean difference (ventilated) was 0.06 [-0.25,0.37] L/min/m2, 1.34 [-1.93,4.6] ml/m2, 736 [584,889] dynes/m2/cm5, and (extubated) was 0.17 [-0.2,0.54] L/min/m2, 2.67 [-2.19,7.52] ml/m2, 660 [416,904] dynes/m2/cm5 for CI, SVI, and SVRI respectively. 98.6%, 97.1%, 98% of ventilated patient data and 95.1%, 95.1%, 96.7% of extubated patient data for CI, SVI, and SVRI respectively, fell within 95% of these limits. For clinical interventions, PAC led to 5 unnecessary interventions whereas PWA led to 3.

Conclusion:
Comparing PAC and PWA, mean differences for CI and SVI fall within acceptable ranges of bias with high degree of concordance whereas SVRI data appears to have proportional variability outside of normal ranges. PWA may be used as an alternative to PAC post-OLT to assess VR and CFx.
 

86.20 Penetrating Gastric Trauma – Significance of Acid Suppression and Decompression

Posted on January 26, 2017

D. G. Davila1, A. Goldin1, B. Appel1, N. Kugler1, T. Neideen1  1Medical College Of Wisconsin,Trauma/Critical Care,Milwaukee, WI, USA

Introduction:
Penetrating gastric injuries comprise a small portion of traumatic injuries. A paucity of data exists regarding current management, including acid suppression and nasogastric (NG) decompression. 

Methods:
A single-institution retrospective of adult patients with penetrating gastric injuries between January 2004 and December 2014 was conducted. The primary study endpoint was 30-day mortality. Secondary endpoints included organ-space infections. Patients with >48 hours of proton pump inhibitor or H2 blocker were considered managed by acid suppression; >48 hours of NG management was considered decompressed.

Results:
A total of 167 patients were identified with the majority (77.2%) the result of a gunshot injury. The cohort was predominantly (90%) male at an average age of 30.4 years and ISS score of 16.5. Twenty-one patients died within 24-hours with four additional in-hospital deaths. The liver was the most common (42%) associated injury, followed by the diaphragm and the colon. Forty-five patients had two or more operations prior to closure. A single missed gastric injury was identified on second-look. There were no instances of gastric repair breakdown with no difference in complication rates between one or two layer repair (p=0.73). Organ-space infections were identified in 31 (21%) patients, most likely the result of an alternative source. Neither acid suppression nor NG tube was significantly associated with death (p=0.29 and p=0.64, respectively) or organ-space infection (p=0.89and p=0.11, respectively). 

Conclusion:
Neither acid suppression nor NG tube decompression appear to protect against death nor the infectious morbidity associated with penetrating gastric injuries. 
 

86.18 The Effect of Presence of a State Trauma System on Intentional Firearm-Related Mortality Rate

Posted on January 26, 2017

C. K. Cantrell1, R. Griffin1, T. Swain1, K. Hendershot1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  Firearm injury is one of the leading causes of death in individuals in the United States. Many factors play into mortality from firearm injuries. Two factors in mortality are time from injury to treatment and the quality of the treatment received. One recommendation that the ACS COT introduced in attempt to decrease firearm injury fatalities, as well as fatalities from other mechanisms of injury, was for each state to unify their trauma centers and create a statewide trauma system. Illinois, in 1971, was the first state to undergo this transition. Most of these transitions have been more recent, with the percent of states with a trauma system nearly doubling in the past 15 years while the rate of firearm incidents continues to rise.

Methods:  For this cross-sectional study, data on firearm-related intentional deaths (i.e., suicides and homicides excluding legal intervention) were collected by state for years 2000-2014 from the CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS). For each state, the presence of a state trauma system was determined by year as derived from state Public Health Department information. A General Estimating Equations negative binomial regression was used to estimate rate ratios (RRs) for the association between presence of a state trauma system and intentional mortality rate using the state’s population as an offset.

Results: The proportion of states with a state trauma system nearly doubled from 40% (n=20) in 2000 to 78% (n=39) in 2014 (see Graph 1). Overall, there was no association between presence of a state trauma system and intentional firearm-related mortality rate (RR 0.94, 95% CI 0.81-1.09). The lack of association remained for both firearm homicides (RR 0.83, 95% CI 0.63-1.07) and suicides (RR 0.98, 95% CI 0.82-1.16). The lack of association was observed across 5-year categories, though there was noted difference in the associations by year for firearm homicide, with 23% decrease in the rate observed among states with a trauma system in 2005-2009 (RR 0.77, 95% CI 0.58-1.03) while a near-null effect was observed for 2010-2014 (RR 0.91, 95% CI 0.62-1.32). Near-null associations were observed across the board for firearm suicide rate.

Conclusion: The lack of effect of trauma system presence on firearm suicide rate is not unexpected given the high case fatality rate of these injuries. Though presence of a state trauma system is not associated with the mortality rate, it would be of interest to determine whether the case fatality rate of intentional injury varies by presence of a trauma system.
 

86.16 Fecal Diversion in Traumatic Intraperitoneal Rectal Injuries: How much is too much?

Posted on January 26, 2017

P. S. Prakash1, D. Jafari2, R. N. Smith1, C. A. Sims1  1The Hospital Of The University Of Pennsylvania,Division Of Trauma, Surgical Critical Care, And Emergency Surgery,Philadelphia, PA, USA 2The Hospital Of The University Of Pennsylvania,Department Of Emergency Medicine,Philadelphi, PA, USA

Introduction:
Traumatic intraperitoneal rectal injuries can be managed with repair or resection and primary anastomosis similar to colonic injuries, yet controversy still exists at an institutional level on optimal management of such injuries during initial surgical intervention. We sought to characterize the incidence of fecal diversion and the associated morbidity in the management of intraperitoneal rectal injuries. 

Methods:
We conducted a retrospective cohort study at a level 1 trauma center using a prospective database from 2005-2015.  Adult patients with intraperitoneal rectal injuries after blunt and penetrating trauma were included. Operative procedures were determined after review of electronic reports and clinical characteristics and outcomes were compared between groups using appropriate statistical methods. Significance was defined as p < 0.05.

Results:
Overall, 24 patients were identified to have an intraperitoneal rectal injury in a 10 year period.  Mean age was 29.6 years (16-69 range). Twenty-one (87%) were male and 20 (83%) were due to penetrating injury. The mean AIS was 3.58 (SD=0.58) and TRISS 0.9 (SD=0.19). All patients survived to discharge. On presentation, mean GCS was 13.5 (SD=3.4), systolic pressure 129 (SD=27), and temperature 97F (SD=1.5). The mean red blood cells transfused on arrival in the trauma bay was 0.7 units (0-5 range).  Twenty-two (92%) had a fecal diversion (FD), while only 2 (8%) had a primary repair (PR). Of those who had FD, 18 (82%) received an end colostomy, 4 (18%) a diverting loop colostomy.  Overall, 7 (32%) of patients who underwent FD had a post-operative complication. Seventeen (77%) FDs had a colostomy reversal on separate admission.

Conclusion:
Although the treatment strategy for colorectal trauma has advanced during the last part of the twentieth century, complication rates are high and standard management for colorectal trauma remains a controversial issue. Though the literature suggests that intraperitoneal rectal injuries can effectively be managed by primary repair or resection with primary anastomosis, fecal diversion appears to still dominate management strategies, despite associated morbidity. 
 

86.14 Pulmonary Contusions In Elderly Blunt Trauma Are Infrequently Seen On CXR And Are Highly Morbid

Posted on January 26, 2017

A. Bader1, M. Morris1, J. A. Vosswinkel1, J. E. McCormack1, E. C. Huang1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction:  In patients with blunt chest trauma, pulmonary contusions are variably identified. However, there is limited research on the outcomes of elderly patients with pulmonary contusion.    

Methods:  We retrospectively reviewed the trauma registry for all admissions aged ≥65 years, admitted following blunt trauma with a thoracic injury.  Emergency Room deaths were excluded. The medical records of patients with pulmonary contusions were subsequently reviewed for additional details.

Results: There were 960 patients age ≥65 years admitted with thoracic trauma, of which 180 had  pulmonary contusions (PC) and 780 had no pulmonary contusion (NO). The major mechanisms of injury were MVC/MCC (52.22% PC, 35.64% NO, p<0.001) followed by falls (38.89% PC, 58.72% NO, p<0.001). Rib fractures were present in 80% of PC and 73.5% of NO patients, p=0.09. Hemothorax/pneumothorax was more prevalent in those with pulmonary contusions (44.44% PC vs 19.23% NO, p<0.001). While 98.3% of PC patients had chest AIS≥3, 41.9% of NO patients had chest AIS≥3, p<0.001. Hospitalization outcomes are presented in the table. Chart review of PC patients noted that pulmonary contusion was identified in only 34/180 patients on initial CXR. An additional 22 patients were noted to have pulmonary contusion on a subsequent CXR. A CT thorax was performed in 174 patients within 24 hours of admission. This CT scan identified the pulmonary contusion. Further, rib fractures were identified in 80% of PC patients.

Conclusion: Pulmonary contusions in the elderly blunt trauma population were infrequently identified on CXR.  They are associated with severe chest injury. Their presence is associated with substantial morbidity and mortality. The data suggest the need for increased vigilance for pulmonary contusion such as early chest CT scan performance in this population. Further study is warranted. 

86.08 Characterizing the Relationship Between Age and Venous Thromboembolism in Adult Trauma Patients

Posted on January 26, 2017

A. J. Nastasi1,2, J. K. Canner1, B. D. Lau1, M. B. Streiff3, J. K. Aboagye1, K. J. Van Arendonk1, P. S. Kraus6, D. B. Hobson5, D. Shaffer5, E. R. Haut1,4  1Johns Hopkins University,Surgery,Baltimore, MD, USA 2Johns Hopkins University,Epidemiology,Baltimore, MD, USA 3Johns Hopkins University,Hematology,Baltimore, MD, USA 4Johns Hopkins University,Health Policy And Management,Baltimore, MD, USA 5Johns Hopkins University,Nursing,Baltimore, MD, USA 6Johns Hopkins University,Pharmacy,Baltimore, MD, USA

Introduction:
Venous thromboembolism (VTE) is a great burden in trauma; however, current guidelines lack recommendations regarding the prevention of VTE in older adult trauma patients. Furthermore, the appropriate method of modeling age in VTE models is currently unclear.

Methods:
3,598,881 patients between the years 2008 and 2014 in the National Trauma Data Bank (NTDB) and 505,231 patients between 2009-2013 from the National Inpatient Sample (NIS) were analyzed. Multiple logistic regression of VTE on age was performed. Based on unadjusted VTE incidence, age was modeled as a linear spline with a knot at age 65.

Results:
In the NTDB, 34,202 (0.95%) patients were diagnosed with VTE while 1,709,881 (47.5%) patients were ≥65 years. In both the fully adjusted NTDB and NIS model, age was positively associated with VTE incidence until age 65 (NTDB: aOR 1.018, 95% CI 1.017 – 1.019, p < 0.001; NIS: aOR 1.025, 95% CI 1.022 – 1.027, p < 0.001). In patients ≥65 years, age was inversely associated with VTE in the NTDB model (aOR 0.995, 95% CI 0.992 – 0.999, p = 0.006) and not associated with VTE risk in the NIS model (aOR 0.998, 95% CI 0.994 – 1.002, p = 0.26).

Conclusion:
VTE risk in adult trauma patients appears to steadily increase with age until 65 years, after which risk appears to level off or even slightly decrease. These findings should be considered when creating standardized guidelines for VTE prevention in older adults as well when modeling age in VTE models of adult trauma patients.
 

 

 

 

86.07 BURDEN AND CHARACTERISTICS OF GLASS TABLE INJURIES

Posted on January 26, 2017

D. Chauhan1, C. Villegas1, R. Bueser1, S. Bonne1, D. Livingston1  1Rutgers – New Jersey Medical School,Department Of Trauma/critical Care,Newark, NJ, USA

Introduction:
Our trauma center has observed an increase in children with severe injuries from glass tables. This mechanism of injury is not well described. The goals of this study were to describe the burden of glass table injuries using the National Electronic Injury Surveillance System (NEISS) dataset and compare it to our data from a level 1 urban trauma center.

Methods:
The NEISS dataset from 2009 to 2015 was reviewed for glass table injuries. Data on demographics, injury severity, its description and outcomes were extracted. Cases were divided as they related to the glass shattering: definite, probable and not due to faulty glass. Similarly, our trauma registry was queried for all patients injured involving breaking glass tables from 2001 to 2016. An online search of 3 furniture websites was performed for details of the glass and safety information provided to consumers.  

Results:
3241 patients were reviewed in the NEISS data; 1151 definitely and 665 probably sustained injury due to the glass itself. Defined criteria (e.g. torso penetration or shock) to classify injury severity were developed and each injury was classified as mild or severe.  265 injuries were severe, 233 (88%) of which were due to faulty class.  There was a bimodal distribution in age with peaks at 2 and 22 years.  Demographics, injury pattern and disposition are shown in the Table and is compared to the 24 patients treated at our trauma center. No websites provided any safety instructions for glass tables. 113/300 (38%) tables examined had no information if the glass was tempered or on glass thickness. Currently there are no quality requirements for glass tables in the United States. 

Conclusion:
Glass table injuries are not uncommon, occasionally lethal and preventable. The burden is real, likely under reported and costly. Children are especially at risk. Warnings to consumers and enactment of glass standards by the Consumer Product Safety Commission is warranted. 
 

86.06 Current Practice Patterns and Burnout of Trauma and Acute Care Surgeons

Posted on January 26, 2017

N. Droz2, P. Parikh2, M. Whitmill2, K. M. Hendershot1  1University Of Alabama at Birmingham,Acute Care Surgery,Birmingham, Alabama, USA 2Wright State University,Trauma And Acute Care Surgery,Dayton, OH, USA

Introduction:

Providing 24/7 care for our patients and supervision for our residents/fellows is a cornerstone in the Trauma/Acute Care Surgeons (T/ACS) work-life.  Our previous work defined what the T/ACS current practice pattern is (majority in a group practice with shared responsibilities; majority take in-house call in 24 hour shifts and 3-7 calls per month; majority staying part or all of post-call day).

The purpose of our current study is to look at the T/ACS attitudes regarding their practice patterns, specifically related to their call schedule and post-call day.  Issues such as post-call fatigue and burnout related to their work schedule are also explored.

Methods:

An IRB-approved electronic survey was distributed nationally to Eastern Association for the Surgery of Trauma members.  Participants were asked about attitudes related to their call schedule and coverage they provide while on call.  They were also asked about fatigue and burnout related to their work schedule.

Results:

A total of 274 participants were analyzed (response rate 20%).  The majority like their call schedule structure and length of their call shifts (62% and 66%, respectively).  The scope of practice was liked by 77% with 14% not liking the elective surgery aspect of the practice.  The majority (86%) covers all trauma, emergency general surgery (EGS), and surgical critical care while on call and 75% feel this is an adequate amount of work to cover while on call.  The majority (83%) think they should get paid for trauma/EGS call.

 

Although 75% state they are able to get some rest while on call, 56% are “very tired” post-call and 29% have fallen asleep while driving post-call.  The majority (71%) is concerned about fatigue post-call; 67% are concerned about being over-worked, and 72% are concerned about burnout.  A change in their practice pattern could help with fatigue and feelings of being overworked according to 72% of participants.

Conclusion:

Despite the majority of T/ACS expressing concern about post-call fatigue, being overworked, and feelings of burnout, less than 20% have developed or implemented any innovative strategies to change the call structure and post-call day.  Change is often difficult, so trying to think outside the box and develop novel approaches to attendings’ practice patterns should be encouraged and shared with the larger trauma community.

 

86.04 Time to Surgical Source Control in Intra-Abdominal Infections

Posted on January 26, 2017

R. Chang1, M. Scerbo1, L. Moore1, A. Macaluso1, C. Wade1, J. Holcomb1  1University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA

Background: Although many infections can be treated with antibiotic therapy alone, intra-abdominal infections (IAI) often require surgical intervention to achieve adequate source control. Time to initiation of appropriate antibiotic therapy is a well-described quality metric in the treatment of life-threatening infections (sepsis), but time to operation for source control has not been amply investigated for surgical sources of infection. We hypothesized that decreased time to laparotomy (TTL) to achieve surgical source control was associated with improved outcomes in patients presenting with IAI.

Methods: Billing codes were used to identify adult patients who underwent laparotomy from 2011-2015 at a single center. These were screened to identify patients who presented to the emergency department (ED) with IAI, underwent laparotomy for source control, and had hospital stay >24 hours. TTL was defined as the time from ED triage to initiation of laparotomy. The SOFA score was calculated using parameters obtained in the ED. The primary outcome was survival to hospital discharge; the secondary outcome was ICU-free days. Using SOFA score as a covariate, we constructed multivariable logistic and linear regression models to test the hypothesis that decreased TTL was associated with increased survival and increased ICU-free days respectively.

Results: Of the 54 patients included for analysis, 46 (85%) survived to hospital discharge. Overall incidence of sepsis (defined as change in baseline SOFA ≥2) was 57%. Median ICU-free days was 26 with interquartile range of 15 to 30. Survivors had lower SOFA scores (median 2 vs 7, p<0.01) but similar TTL (median 16 vs 17 hours, p>0.05) compared to non-survivors. For patients with sepsis, TTL was also similar between survivors and non-survivors (median 15 vs 17 hours, p>0.05). Perforated hollow viscus accounted for 54% of infectious sources (colorectal 20%, small bowel 17%, stomach 17%), and intra-abdominal abscess accounted for 46%.

Decreased TTL was not associated with improved survival (odds ratio 1.00, 95% confidence interval [CI] 0.98 – 1.02) on multivariable logistic regression, but was significantly associated with increased ICU-free days (relative risk -0.05, 95% CI -0.10 to -0.01) on multivariable linear regression.

Conclusion: Although there was no difference in mortality, decreased TTL was associated with increased ICU-free days in patients presenting with IAI requiring laparotomy. Despite the emphasis on time to initiation of antibiotic therapy, comparatively little attention has been paid to time to surgical source control, even though both are needed to treat certain cases of IAI.

86.03 Laboratory versus clinically-evident coagulopathy: results from PROHS

Posted on January 26, 2017

R. Chang1, E. Fox1, T. Greene1, M. Swartz1, S. DeSantis1, D. Stein6, E. Bulger4, S. Melton8, M. Goodman2, M. Schreiber5, M. Zielinski3, T. O’Keeffe9, K. Inaba7, J. Tomasek1, J. Podbielski1, C. Wade1, J. Holcomb1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2University Of Cincinnati,Cincinnati, OH, USA 3Mayo Clinic,Rochester, MN, USA 4University Of Washington,Seattle, WA, USA 5Oregon Health And Science University,Portland, OR, USA 6University Of Maryland,Baltimore, MD, USA 7University Of Southern California,Los Angeles, CA, USA 8University Of Alabama At Birmingham,Birmingham, AL, USA 9University Of Arizona Medical Center,Tuscon, AZ, USA

Introduction: Laboratory evidence of coagulopathy is observed in 25% of severely injured trauma patients, but clinically-evident coagulopathy (CC) is not well-described. This study investigates the characteristics of CC and seeks to identify any potentially modifiable prehospital risk factors of CC.

 

Methods: The Prehospital Resuscitation on Helicopters Study (PROHS) was a prospective observational study of adult trauma patients transported by helicopter from the scene to one of nine Level 1 trauma centers in 2015. Predefined highest-risk criteria were any of the following during helicopter transport: heart rate >120 bpm, SBP ≤90 mmHg, penetrating truncal injury, tourniquet application, pelvic binder application, or intubation. Patients meeting any highest-risk criteria were divided into 2 groups based on presence of CC, defined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by normal means (e.g. sutures). Purposeful multiple logistic regression was performed to identify potentially modifiable prehospital risk factors of CC.

 

Results: Of the 2341 patients enrolled, 1058 (45%) met highest risk criteria and were divided into CC (n=43, 4%) and not CC (n=1015, 96%) groups. CC patients were older (median age 50 vs 38), more severely injured (median ISS 30 vs 17), and were more likely to have had penetrating trauma (33% vs 19%), prehospital RBCs and/or plasma (56% vs 12%), and laboratory evidence of coagulopathy on admission (86% vs 46%) (all p<0.05). Prehospital crystalloid volumes were similar (median 200 vs 250ml), and transfusion ratios were balanced. CC patients had increased mortality at 30 days (60% vs 15%, p<0.01); although the leading cause of death was TBI in both groups (54% vs 66%), exsanguination was increased in CC patients (38% vs 18%, p<0.01). Transport time, prehospital RBC or plasma units, and crystalloid volume were not significant predictors of CC on multiple logistic regression after controlling for age, ISS, mechanism, admission GCS, and availability of prehospital blood products.

 

Conclusion:

Despite the relatively common finding of laboratory evidence of coagulopathy, CC was rare (4%) but associated with substantial mortality. No obvious modifiable prehospital risk factors of CC were identified.

86.02 Do Traffic Law Violators Have Differing Attitudes About Their Driving Behaviors?

Posted on January 26, 2017

J. A. Vosswinkel1, K. L. Ladowski1, J. E. McCormack1, R. S. Jawa1  1Stony Brook University Medical Center,Stony Brook, NY, USA

Introduction: Despite advances in engineering, motor vehicle crashes remain a leading cause of injury morbidity and mortality, due in great part to driver behaviors such as speeding and inattention.

Methods: In 2015, the County’s Traffic & Parking Violation Agency began offering a 3 hour traffic violator course as part of a plea deal to reduce points/fines. Course instructors include representatives from agencies with a vested interest in traffic safety; county police department, defense lawyer and/or judge, trauma center, and a local human service agency. The course is divided into 2 sections based on type of violation received: Dangerous Driver (DD) program for speeding and/or aggressive driving and Inattentive Driver (ID) program for cell phone violations. Both courses cover similar content including traffic laws, judicial consequences of unsafe driving, and emotional/physical consequences of unsafe driving. After the course, participants are given an anonymous post-then-pre survey about their driving behavior. The Likert-type answers are coded numerically (1=Not At All, 2=A little, 3=somewhat, 4=A lot). Retrospective data analysis was performed using Student’s t-test.

Results: There were 214 surveys (139DD, 75 ID) collected from 11 classes (7DD, 4ID). We analyzed 5 key questions about their driving behavior: 1.Worried it could result in legal consequences; 2.Worried it could cause injury; 3.Want to change driving behavior to avoid legal consequences; 4.Want to change driving behavior to avoid causing injury; 5.Believe can improve driving behavior. Results presented below. Of note, the final 3 columns compare the mean change in attitudes between the DD and ID program. Furthermore, the DD overall scores were significantly higher both pre (DD=14.5±3.2, ID=12.7±3.1) and post (DD=17.4±3.4, ID=16.0±3.5)(p <.001), but there was no significant difference in the overall score increases between groups (DD=2.6±4.4, ID=2.9±3.8, p=0.60).

Conclusion: On course completion, both groups were more likely to agree with statements that worried about their driving behavior and more likely wanted to change their driving behavior. Although both group’s overall scores increased similarly, there were underlying differences in the attitudes of driving behavior between the DD and ID groups.  Overall, ID were less likely to worry about their driving behavior and less strongly felt they needed to change their driving behavior compared to the DD both before and after the class. These findings are similar to other studies that have concluded that drivers who operate cell phones tend to overestimate their driving ability and underestimate the demands of driving.  Further study is warranted.

85.17 Primary Non-Hodgkin Lymphoma of the Gallbladder: Characteristics and Outcomes of 106 Patients

Posted on January 26, 2017

A. Ayub1, S. Rehmani1, A. Al Ayoubi1, W. Raad1, J. McGinty2, G. Kim2, F. Y. Bhora1  1Mount Sinai School Of Medicine,Division Of Thoracic Surgery / Department Of Surgery / Mount Sinai West,New York, NY, USA 2Mount Sinai School Of Medicine,Department Of Surgery / Mount Sinai West,New York, NY, USA

Introduction:  Primary Non-Hodgkin lymphoma of the gallbladder (PNHLGB) is extremely rare with limited available data. In this study, we sought to evaluate the clinical features and outcomes of patients with PNHLGB utilizing a population-based database.

Methods:  Surveillance, Epidemiology, and End Results (SEER) database was queried for patients with gallbladder cancer between 1973 and 2013. Only patients with histologically proven PNHLGB were included.  Demographics, tumor characteristics, and outcomes were assessed. 

Results: Of 150 gallbladder lymphomas in the SEER database, 106 cases had PNHLGB and were included in the study. The mean age at diagnosis was 71 (±15) years. PNHLGB primarily afflicted whites (92%) with a male: female of 1.03: 1. Diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype (33%); majority (61%) had loco-regional disease. Surgical resection was performed in 85% cases. Median overall survival of the whole cohort was 41 months with a 5-year survival rate of 40%. In multivariate analysis, increasing age at diagnosis (p<0.001) was associated with increased hazards of death, surgical resection had a protective effect (p=0.007), while gender, race, tumor histology and disease stage were not associated with overall survival (Figure). 

Conclusion: This study represents the largest series of PNHLGB to be reported. Compared to other gastrointestinal lymphomas reported in the literature, PNHLGB appears to have worse prognosis and surgical resection provides survival benefit. Further studies with information regarding adjunctive therapies are warranted.  

 

85.16 Outcomes of Cholecystectomy in Patients with End Stage Renal Disease

Posted on January 26, 2017

I. Olorundare1, S. DiBrito1, C. Holscher1, C. Haugen1, D. Segev1  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  Patients diagnosed with End Stage Renal Disease (ESRD) are a growing population who are at risk of cholelithiasis and cholecystitis and may require surgical management. Despite this, previous studies of outcomes in this population have been limited by small sample size and a lack of generalizability. We studied outcomes of ESRD patients following cholecystectomy in a large nationally representative database

Methods: We used the Nationwide Inpatient Sample to study 40,765 ESRD and 5.4 million non-ESRD patients who underwent cholecystectomy from 2000-2011. Postoperative complications were defined by ICD-9 codes. Mortality, complication rates, LOS, and hospital costs were compared using hierarchical logistic regression, hierarchical negative binomial regression, and mixed effects log-linear models respectively.

Results:ESRD patients had significantly higher mortality and postoperative complication rates than non-ESRD peers (5.0% vs 0.7%, p<0.001) and (23.1% vs 12.8%, p<0.001) respectively on primary admission. After accounting for patient and hospital level factors, ESRD patients had a greater risk of mortality (OR 4.03, 95% CI 3.08 – 5.26) and postoperative complications (OR 2.42, 95% CI 2.09 – 2.81). In particular, they were at a greater risk of infectious (OR 2.98, 95% CI 2.68 – 3.32), mechanical wound (OR 2.21, 95% CI 1.82 – 2.69), and intraoperative complications (OR 1.53, 95% CI 1.32 – 1.78). Median length of stay (LOS) was longer in ESRD patients (8 vs 3 days, p<0.001) as were median hospital costs ($17169 vs $8762, p<0.001). In adjusted analysis, ESRD patients were at significantly greater risk of extended LOS (RR 1.48, 95% CI 1.45 – 1.50) and higher costs (Ratio 1.36, 95% CI 1.34 – 1.39).

Conclusion:ESRD patients experience higher postoperative mortality, complication rates, hospital costs and an extended length of stay following cholecystectomy when compared to non-ESRD peers. Interventions targeting better control of postoperative wound and infectious complications may allow for improvement in overall outcomes of ESRD patients following cholecystectomy. 

 

84.20 Ventral hernia repair and mesh infection survey.

Posted on January 26, 2017

L. Knaapen1, O. Buyne1, S. Feaman4, P. Frisella4, N. Slater2, B. Matthews3, H. Van Goor1  1Radboud University Medical Center,Department Of Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboud University Medical Center,Department Of Plastic And Reconstructive Surgery,Nijmegen, , Netherlands 3Carolinas Hernia Institute,Charlotte, SOUTH CAROLINA, USA 4Washington University,Department Of Surgery, Section Of Minimally Invasive Surgery,St. Louis, MISSOURI, USA

Introduction:
Choice of mesh and surgical technique in ventral hernia repair represent major surgical challenge, especially under contaminated conditions. Aim of this survey was to present international overview of current practice concerning ventral hernia repair in clean or contaminated condition.

Methods:
A survey (2013-2015) was send to surgeons worldwide performing ventral hernia repair. This survey was designed to compare differences in ventral hernia repair concerning life style/pre-operative work-up, antibiotic prophylaxis, hernia repair in clean/contaminated environment, recurrence and mesh infection. 

Results:
Responders (n=417) were male (92%;n=381), aged 36-65 (84%;n=351) and practicing inNorth- America (56%;n=234). Open repair was performed by 99% (20% expert level). Laparoscopic repair by 77% (15% expert level).
The majority agrees on benefit of pre-operative work-up/lifestyle changes like smoking cessation (80%;n=319) and weight-loss (64%;n=254)). Not reaching target(s) does not change decision on whether to operate or not.
Common practice is administer antibiotics at least one hour preoperatively (71%;n=295).
Synthetic (43%;n=180) and biologic (42%;n=175) mesh are used as often in contaminated primary hernia repair.
Concerning recurrent hernia repair, synthetic mesh (87%;n=359) is used in clean environment, biological (53%;n=215) or no mesh (28%;n=112) in contaminated environment. American surgeons prefer biologic mesh over  synthetic mesh in contaminated environment. 
Generally, percutaneous drainage and antibiotics is the first step regarding mesh abscess, independent of type of repair or mesh used. Concerning synthetic mesh infection with sepsis most explant the mesh and repair with biologic mesh (54%;n=217). There is no agreement on mesh infection without sepsis on when to explant  and how to repair.

Conclusion:
The majority agrees on the benefit of pre-operative work-up however not always with consequences. Both synthetic and biologic meshes are used for primary hernia repair in contaminated environment. Concerning recurrent hernia repair, synthetic mesh is used in clean environment and biologic mesh or no mesh in contaminated environment. 

83.19 Using Adenoma Weight and Volume to Predict Multigland Disease in Primary Hyperparathyroidism

Posted on January 26, 2017

J. Lee1, M. B. Albuja-Cruz1, C. Burton1, C. D. Raeburn1, R. McIntyre1  1University Of Colorado School Of Medicne,GI, Tumor And Endocrine Surgery,Denver, CO, USA

Introduction:
Intraoperative parathyroid hormone (ioPTH) monitoring is the current gold-standard for intraoperative determination of multi-gland disease (MGD) in patient with primary hyperparathyroidism (PHPT).   A prior study found that the risk of persistent disease after minimally invasive parathyroidectomy (MIP) is higher if the weight of the resected gland is ≤ 200mg.  The purpose of this study is to determine if the volume and weight of first resected adenoma is a reliable predictor of MGD. This would provide surgeons immediate and inexpensive information to assist with the decision of conversion from a MIP to bilateral neck exploration (BNE). 

Methods:
Retrospective review of prospectively collected data of 469 consecutive patients who underwent initial parathyroidectomy for PHPT at a single tertiary medical center from 2010 to June 2015 was performed.  Intraoperative parathyroid hormone was used in all cases and intraoperative cure was defined by a >50% drop of the preoperative PTH at 10 minutes and within normal limits.  One hundred eighty-five patients met criteria for inclusion in this study.  Data was analyzed for patient demographics, operative procedure, first resected adenoma weight and volume, presence of MGD, complications, cure and persistence disease.

Results:
Of the 185 patients, 74% had a single adenoma and 26% had MGD. The mean weight for the single adenoma group was 846 mg compared to 461mg for the MGD group (P< 0.05).  A weight of ≥200mg was used as a cutoff to distinguish a single adenoma from MGD (sensitivity 87%, specificity 28%, PPV 76%, NPV 45% and accuracy 71%; P= 0.73). 
The mean volume for the single adenoma group was 1.13 compared to 0.5cm3 for the MGD group (P< 0.05). A volume of ≥0.2cm3 was used as cutoff to differentiate a single adenoma from MGD (sensitivity 83%, specificity 35%, PPV 78%, NPV 44% and accuracy 71%; P= 0.82).
Final cure rate for PHPT was achieved in 97% of the patients included in the study.  Then median follow up was 25 months.

Conclusions:
The weight and volume of the first resected adenoma are not accurate measures to determine the presence of multigland disease in patients with PHPT, despite significant difference in mean weight and volume between the single adenoma vs. MGD groups.  Surgeon judgment and ioPTH remains paramount in the in the operative management of this patient population.
 

 

83.11 Optimal Timing of Surgical Intervention for Patients with Gastroschisis and Atresia

Posted on January 26, 2017

H. E. Arnold1, H. Short1, K. Baxter1, C. D. Travers2, A. M. Bhatia1, M. M. Durham1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  Gastroschisis complicated by atresia represents a clinical challenge. In addition to the initial abdominal wall defect repair, these children require subsequent interventions to establish bowel continuity. After definitive abdominal closure, the second surgery is often delayed to enhance bowel recovery. The optimal timing of the second intervention has not been fully investigated. The purpose of this study was to determine if early intervention for patients with gastroschisis and atresia results in improved outcomes compared to late intervention. 

Methods:  Retrospective chart review of patients who underwent surgical repair of gastroschisis between January 1, 2009 and December 31, 2012 was performed at a quaternary children’s hospital. We identified a subset of patients who had gastroschisis complicated by atresia and compared those who had early intervention (<4 weeks) versus late intervention (>4 weeks) to manage the atresia.

Results: Of 143 gastroschisis patients identified, 13 (9.1%) had atresia including 5 (38.5%) primary abdominal wall closures and 8 (61.5%) that were delayed closures using a silo. From definitive closure to subsequent intervention for the atresia, 7 were considered early (<4 weeks, median 9 days), and 6 were considered delayed (>4 weeks, median 49 days). All patients in the early intervention group received ostomies, while patients in the late intervention group underwent primary anastomosis. Overall, 5 patients had major complications including 1 with volvulus, 1 with intestinal necrosis, and 3 with perforations. Of these, only one major complication occurred in the delayed group, which was the case of the volvulus. Excluding those patients with emergent complications (1 patient with necrosis, 1 patient with perforation) that forced earlier than planned intervention, overall length of stay trended toward shorter stays for early intervention patients (66 vs. 98 median days, p=0.30). Early intervention was associated with shorter time to enteral feeds (28 vs. 60 median days of life, p=0.02). 

Conclusion: In this single-center, retrospective review, patients undergoing early intervention for atresia after definitive gastroschisis closure trended toward shorter length of stay and earlier initiation of feeds despite uniformly receiving ostomies. The optimal timing of surgical intervention in this complex patient population warrants further investigation. 

 

83.07 Pressure Ulcer Formation in Pediatric Patients on Extracorporeal Membranous Oxygenation

Posted on January 26, 2017

S. Tam1, A. Mobargha2, J. Tobias3, C. Schad4, S. Okochi1, A. Shakoor1, W. Middlesworth1, V. Duron1  1New York Presbyterian Hospital,New York, NY, USA 2Copenhagen University Hospital,Copenhagen, -, Denmark 3Columbia University College Of Physicians And Surgeons,New York, NY, USA 4Morgan Stanley Children’s Hospital of New York,New York, NY, USA

Introduction:
Critically ill pediatric patients have been shown to be at risk for pressure ulcers similar to adult patients. Associated with this are increased morbidity and length of stay, decreased quality of life, and increased hospital costs. While the incidence of pressure ulcers in patients in pediatric intensive care unit patients has been studied, there are virtually no studies addressing pressure ulcers in pediatric patients on extracorporeal membraneous oxygenation (ECMO).

Methods:
The charts of patients 21 years and younger who underwent ECMO from November 2009 to November 2015 at our Tertiary Care Children’s Hospital were analyzed. All patients developed a pressure ulcer either during their ECMO run or within 7 days of decannulation according to nursing documentation. All data was collected and de-identified from the institution’s electronic medical record. Variables of interest included type of ECMO – venovenous (VV) or venoarterial (VA), amount volume of crystalloid and blood products received during the first 7 days or during the length of the ECMO run, albumin and lactate levels on the day of ulcer formation, and whether patients were on vasopressor supportreceived steroids.

Results:
From November 2009 to November 2015, 204 patients were placed on ECMO and 10% (20) developed a pressure ulcer during their ECMO run or within 7 days of decannulation. The average age of patients was 110 ± 86 months and 60% were male. The average body surface area was 1.1 ± 0.8 m2. Most patients were placed on venoarterial (VA) ECMO (85%) and the average length of the ECMO run was 460 ± 360 hours. A majority of the decubitus ulcers were stage I (40%) and stage II (35%). Patients received a mean of 4337 ± 2609 mL of crystalloid and 4337 ± 4727 mL of blood products during the first 7 days of their ECMO run. Mean albumin on the day of ulcer formation was 3.3 ± 0.5 g/dL and lactate was 1.1 ± 0.5 mmol/L. A majority of patients were on vasopressor support during their ECMO run (70%). 

Conclusion:
This is the only observational study to date evaluating pressure ulcer formation in pediatric patients receiving ECMO. These patients are at risk of pressure ulcer formation due to their prolonged immobility and critical illness. This baseline analysis emphasizes the need for further studies identifying which risk factors are associated with ulcer development in pediatric patients on ECMO. 
 

82.05 A Comparison of Specialty-based Surgical Approaches and Attitudes to Adrenalectomy

Posted on January 26, 2017

S. C. Oltmann3, D. M. Elfenbein2, R. S. Sippel4, H. Chen1, J. L. Rabaglia3, A. P. Dackiw3, F. E. Nwariaku3, S. A. Holt3, D. F. Schneider4  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 2University Of California – Irvine,Surgery,Orange, CA, USA 3University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 4University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:
Adrenalectomy is an infrequent surgical procedure performed by multiple specialties, with multiple technical approaches. The hypothesis of this study is surgical approaches and contraindications are consistent regardless of surgical specialty.

Methods:
Members of the American Association of Endocrine Surgeons (AAES) and of the Endourological Society (EUS) were surveyed using an internet based questionnaire, regarding current practice and attitudes toward adrenalectomy.

Results:

109 AAES members and 146 EUS members completed the survey. AAES performed more adrenalectomies annually, and reported familiarity with a greater number of adrenalectomy techniques (Table). EUS used the robot more frequently, and considered themselves high volume laparoscopic surgeons more often.

Laparoscopic transabdominal adrenalectomy was the top preferred approach for both. AAES preferred retroperitoneoscopic more, and robotic transabdominal approach less.

Contra-indications for transabdominal laparoscopic adrenalectomy varied. AAES was more likely to view known adrenal malignancy(69% vs. 10%, p<0.01), and suspected malignancy(43% vs. 9%, p<0.01) as contraindications, and less likely to view a hostile abdomen(39% vs. 58%, p<0.01) or co-morbidities(4% vs. 18%, p<0.01) as contraindications. Tumor size(45% vs. 52%), and location(35% vs. 27%) were equally considered.

For retroperitoneoscopy, known adrenal malignancy(89% vs. 16%, p<0.01), suspected adrenal malignancy(66% vs. 10%, p<0.01) and BMI(36% vs. 15%, p<0.01) were more often considered a contraindication by AAES. Tumor size(76% vs. 71%), and location(35% vs. 43%) were equally viewed. 

Conclusion:
Both surgical specialties perform adrenalectomy with frequency. Attitudes regarding contraindication to a minimally invasive approach vary greatly between AAES and EUS members, most notably regarding malignancy. 

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