34.07 Palliative Care Assessment for Injured Patients: Perspectives from Trauma and Palliative Care Teams

Posted on January 25, 2017

M. J. Keating1, N. D. Patel1, M. Nishtala1, C. W. Towe1, C. S. Koniaris2, J. George2, V. P. Ho1  1Case Western Reserve University School Of Medicine,Surgery,Cleveland, OH, USA 2Case Western Reserve University School Of Medicine,Medicine,Cleveland, OH, USA

Introduction:
Palliative care is a medical specialty focused on improving quality of life and alleviating symptoms for patients facing life-threatening illness. Barriers to the integration of Palliative Care team (PCT) services into the care of trauma patients have not been clearly defined. We sought to prospectively evaluate whether trauma team (TT) and PCT members differed regarding perceived benefit of PCT (PBP) consultation in trauma patient care.

Methods:
TT and PCT clinicians attended weekday trauma service sign out for 12 weeks. Based on verbal report, each member of the TT and PCT independently assessed whether patients might benefit from a PCT consultation.  TT included trauma surgeons (TS), advance practice providers (APPs), and residents. Sign out typically involved 4-6 TT members. PCT included physicians and APPs; sign out typically involved 1-2 PCT members. Data were prospectively collected regarding assessments, demographics, injury severity, and outcomes. Patients who received a PCT consult were excluded from subsequent assessments. PBP between the TT and PCT clinicians was compared. Secondarily, we sought to identify clinical outcomes associated with PBP. Chi-square and Student’s t-test were used to compare groups (p<0.05 considered significant).

Results:
186 patients (median age 47.6, SD 23.9) had 2013 assessments performed by TT members and 522 assessments by PCT members. Mean injury severity score was 11.9 (SD 9.9). Mean length of stay was 5 days (SD 10.9). There were 5 deaths. TT members identified 76 patients (41%) as having PBP at least once during the hospital stay, compared with 59 patients (32%) identified by PCT (p<0.001), with 78% concordance. TS identified fewer patients with PBP than PCT (22% vs 32%, p<0.001), with 49% concordance with PCT. Eight (5%) patients received a formal PCT consult.  Patients identified as having PBP by any clinician were significantly more likely to change code status to “Do Not Resuscitate,” and were more likely to be discharged to a destination other than home.

Conclusion:
TT and PCT providers identify a high proportion of trauma patients who might benefit from PCT evaluation. Despite this, consultations are rarely requested. Further exploration should be performed to determine barriers to PCT consultation.

34.06 Outcomes Of Patients with Traumatic Brain Injury in Skilled Nursing Facilities

Posted on January 25, 2017

S. N. Lueckel1,2, D. S. Heffernan1,3, T. Kheirbek1,3, M. D. Connolly1,3, S. F. Monaghan1,3, C. A. Adams1,3, W. G. Cioffi1,3, K. Thomas2  3Brown University,School Of Medicine,Providence, RI`, USA 1Rhode Island Hospital,Department Of Surgery Division Of Trauma Surgery And Critical Care,Providence, RI, USA 2Brown Universtiy,School Of Public Health,Providence, RI, USA

Introduction:
Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. In 2010, 2.5 million people suffered TBI at a cost of $76.5 billion. Within the survivors, TBI remains a leading contributor to long term disability. It is estimated that 5.3 million people are living with physical, emotional, cognitive and behavioral disabilities attributable to TBI, many of whom require placement in long term skilled nursing (SNFs). Despite this very large population of TBI patients, very little is known about the long term outcomes of TBI survivors, including rates of discharge to home or risk of death in long term nursing facilities.

Methods:
This is a retrospective review of the prospectively maintained Federal Minimum Data Set (MDS) combined with the CMS Vital Status database from 2012-2013. Records were reviewed for clinical characteristics upon admission to the SNF including cognitive function (CFS), ability to communicate, and motor function. Activities of daily living were reassessed at 30 days post SNF admission to calculate Functional Improvement at 30 and 60 days and 1 year (FI). Records were also reviewed for discharge to home, readmission rates and death at 30 and 60 days and 1 year. For analysis we used robust Poisson regression to estimate relative risk (RR).

Results:
Overall, 65,099 individuals were admitted to SNFs with a TBI diagnosis in the US. The mean age was 71.6 years with 26% over the age of 85yrs. Overall, poor cognitive or functional status upon presentation to a SNF was associated with increased risk for poorer outcomes. Patients who were unable to communicate upon presentation to the SNF had a 42% lower risk of showing any FI at 30 days compared to those who could communicate. Patients with motor dysfunction had a 17% lower risk of showing any FI. Patients with communication impairment and patients with motor impairment had lower risk of being discharged to home, 86% and 85% respectively. Overall, older patients (> 65yrs) with TBI had a 3.6 times higher risk of death at 30 days in SNF compared to younger patients with TBI (RR=3.6, 95%CI=2.9,4.3). The risk of death was higher in patients with poor cognitive function was (RR=8.9, 95%CI=7.4, 10.6) significant motor impairment (RR=5 95%CI=4.5, 5.6) and in patients with impairment in communication (RR=5.5, 95%CI=5.0, 6.0) compared to those without the respective deficits.

Conclusion:
Our results further suggest that among a population with TBI admitted to SNFs, the likelihood of adverse outcomes varies significantly by key clinical and demographic characteristics. Understanding this can help set expectations to patients, families, as well as providers.  Moreover, this data might help guide future therapies and calls for dedicated TBI rehabilitation facilities. 
 

34.05 The “Lethal Triad” in Blunt Traumatic Hemorrhagic Shock: What is Contributing to “Lethal?”

Posted on January 25, 2017

J. O. Hwabejire1, C. E. Nembhard1, T. A. Oyetunji3, W. R. Greene2, M. Williams1, E. E. Cornwell III1, S. M. Siram1  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Emory University Hospital,Surgery,Atlanta, GEORGIA, USA 3Northwestern University Feinberg School Of Medicine,Surgery,Chicago, ILLINOIS, USA

Introduction:  The combination of acidosis, coagulopathy and hypothermia in a trauma patient is a harbinger of death. Resuscitation and control of bleeding are two key tenets of trauma care designed to halt this vicious cycle. We examine clinical variables that contribute to mortality in blunt traumatic shock patients presenting with this triad.   

Methods:  The Inflammation and the Host Response to Injury database was analyzed. Patients who, on presentation to the emergency room (ER), had the triple combination of severe hyperlactatemia (serum lactate >4 mg/dL), coagulopathy (INR >1.5) and hypothermia (body temperature ≤ 36 °C) were included. Univariate analyses were used to compare survivors and non-survivors while multivariable analysis was used to determine predictors of mortality.

Results: A total of 172 patients met all three criteria. The mean age of the cohort was 39 years, 70% were male, and 90% were White. Their overall mortality was 30.8%. There was no difference in pre-injury comorbidities, body mass index, Injury Severity Score, multiple organ dysfunction score, ER systolic BP, ER heart rate, ER body temperature, crystalloid volume administered within 12 hours, WBC count, and platelet count between survivors and non-survivors. Compared to survivors, non-survivors were older (46±22 vs. 37±18 years, p=0.005), more coagulopathic (ER INR 2.6±1.5 vs. 2.1±1.2, p=0.021), had higher ER lactate (7.8±3.2 vs. 6.5±2.2 mg/dL, p=0.002), higher APACHE II score (37±6 vs. 31±5, p<0.001), larger volume of transfused blood within 12 hours (6848±5574 vs. 3232±2779 mL, p<0.001) and were more likely to have a cardiac arrest (50.9% vs. 2.5%, p<0.001) or myocardial infarction (7.5% vs. 0.8%, p=0.032).  Non-survivors were more likely to undergo angiographic embolization (37.7% vs. 14.3%, p=0.001) or an operative thoracic procedure (thoracotomy, sternotomy, or VATS, 26.4% vs. 7.6%, p=0.01), although they had similar laparotomy rates (52.8 % vs. 49.6%, p=0.694). Independent predictors of mortality in this cohort include APACHE II score (OR: 1.15, CI: 1.04-1.28, p=0.005), cardiac arrest (OR: 21.21, CI: 5.06-88.87, p<0.001), and angioembolization (OR: 4.31, CI: 1.45-12.83, p=0.009). For patients who underwent angiographic embolization, mortality was 54.1%, and for those who suffered a cardiac arrest, mortality was 90%. 

Conclusion: In blunt trauma patients with hemorrhagic shock who met criteria for the lethal triad on presentation to the ER, angiographic embolization, APACHE II score, and cardiac arrest independently predict mortality. The exact role of angiographic embolization, which should be a life-saving procedure, deserves further study.

 

34.04 Complications in the Morbidly Obese After ORIF of Isolated Open Tibia Fractures

Posted on January 25, 2017

N. N. Branch1, R. Wilson1  1Howard University College Of Medicine,Washington, DC, USA

Introduction: Obesity is known to be associated with postoperative complications. Few articles investigate the association between obesity and isolated open tibia fractures {IOTF), thus understanding how this condition will affect patient outcomes is critical. We aim to determine perioperative complications after open reduction and internal fixation (ORIF) of IOTF in morbidly obese (MO) patients using a large national sample.

Methods: Using ICD-9 codes we reviewed the National Trauma Data Bank (NTDB) from 2007- 2010. Patients 18 years and older with open IOTF who underwent ORIF at level I or II trauma centers were identified. Multivariate logistic regression and univariate analyses were used to investigate postoperative complications. The NTDB defines obesity as a body mass index (BMI) of 40 or greater, which for the purposes of this study is reference as morbid obesity.

Results: 7,201 cases met inclusion criteria. The majority were white males ages 25-44 with private insurance injured in motor vehicle collisions. 248 (3.44%) of those patients were MO. On multivariate analysis morbidly obese patients had a 40% increased odds (OR: 1.41 CI: 1.07-1.84 p=0.014) of undergoing ORIF after hospital day 2 and were two times more likely to develop acute respiratory distress syndrome (OR: 2.0 Cl: 1.08-3.71 p=0.028). MO patients were more likely to develop superficial (OR: 3.19 Cl: 1.17-8.74 p=0.024), organ/space (OR: 1.75 Cl: 1.08-2.85 p=0.024), or any surgical site infection (OR: 1.93 Cl: 1.23-3.03 p=0.004). MO patients were two times more likely to have at least one complication (OR: 2.01 Cl: 1.35-2.99 p=0.001), and more than four times more likely to develop cardiac arrest (OR: 4.28 Cl: 1.31-13.71 p=0.014). Mortality and length of stay were not associated with being MO (Table 1).

Conclusion: Morbid obesity was found to be associated with increased perioperative complications in IOTF. These patients are at greater risk of infectious complications, most notably superficial surgical site infections. Delays in time to surgical fixation may be secondary to concurrent trauma related injuries while optimizing the patient for surgery. Despite having a significantly higher risk of cardiopulmonary complications, morbidly obese patients did not have an increased mortality.

34.03 Can We Truly Impact The Incidence Of Post-Traumatic Seizures Using Anti-Epileptic Drug Prophylaxis?

Posted on January 25, 2017

M. B. Singer1, B. Zangbar1, K. Williams1, B. Joseph1, A. Tang1, N. Kulvatunyou1, P. Rhee1, T. O’Keeffe1  1University Of Arizona,Division Of Trauma, Critical Care, Burns, And Emergency Surgery,Tucson, AZ, USA

Introduction:  Patients who sustain traumatic brain injury (TBI) are at risk for post-traumatic seizures (PTS). The reported incidence of early PTS varies widely from 2% to 14% but there is disagreement over which patients are at highest risk. We hypothesize that the PTS rate is lower than previously reported and that specific types of brain injury are not predictive of PTS.

Methods:  We conducted a retrospective cohort analysis of all TBI patients admitted to our level one academic trauma center over a nine year period (January 1, 2006 to December 31, 2015). Demographic and injury data including ISS, head AIS, TBI type, history of seizure disorder, time of seizure and prophylactic AED use were collected for all patients who experienced PTS. Seizures were defined by clinical criteria due to the fact that electroencephalography is not routinely performed at our institution. Multivariate logistic regression was used to identify independent predictors of PTS.

Results: 10,001 TBI patients were evaluated at our institution during the nine-year study period, 180 (1.8%) of whom experienced PTS. 63 (34.8%) of these patients seized in the field or in the trauma bay and 23 (12.7%) had a prior history of seizure disorder. Of the 118 patients who seized after hospital admission, 28 (23.7%) were receiving AED prophylaxis at the time of PTS.  Head abbreviated injury scale (AIS) ?  3, injury severity score, and subdural hematoma were independent predictors of PTS (Table 1). PTS did not independently predict mortality.

Conclusion: The rate of PTS at our institution is significantly lower than other published reports. This may reflect a change in the natural history of PTS or changes in intensive care unit management. In light of the high rates of pre-admission and breakthrough PTS (approximately 50%), we question the effectiveness of routine AED prophylaxis in reducing early PTS. Specific risk factors for PTS remain elusive.
 

34.02 Concussion Among The Elderly: A Silent Epidemic

Posted on January 25, 2017

A. Caiado1, S. Armen1, R. Staszak1, J. Chandler1, K. Fitzgerald1, S. Allen1  1Penn State Hershey Medical Center,Hershey, PA, USA

Introduction: A significant amount of attention has been given to the identification and consequences related to mild traumatic brain injury (mTBI) or concussion among young athletes and combat veterans. The interest in concussion is the result of the insidious yet devastating long-term sequelae of these seemingly minor head injuries. The effects of concussion among the elderly are largely unstudied; furthermore, the incidence and identification of concussions in this age group is not well delineated. The goal of this study was to investigate the incidence of the diagnosis of concussion among the elderly population as compared to an injury matched younger cohort. We hypothesized that elderly patients who meet criteria for the diagnosis of a concussion are under-diagnosed compared to a younger, injury matched cohort.

Methods: The trauma registry of an academic Level 1 trauma center was retrospectively queried over a 2 year study period. Adult patients (>18 years of age) with an abbreviated injury score (AIS) head of 1-2 from a blunt mechanism of injury and who met criteria for mTBI as set forth by the American Association of Neurosurgeons (AANS) were evaluated. Demographic information, as well as Glasgow coma score (GCS), the GCS motor score (MS), injury severity score (ISS), blood alcohol concentration (BAC), ICU length of stay, and hospital length of stay were studied. The charts of all patients were queried for the specific diagnoses of mTBI or concussion (n=618). An older cohort (>65 years of age) (n=231) was then compared to a younger cohort (18-64 years) (n=387) matched on MS, GCS and ISS. The difference in the incidence of the diagnosis of concussion was calculated. Chi-squared tests as well as student’s t-tests were used for statistical analysis as appropriate.

Results:There was a steady and statistically significant decrease in the incidence of the diagnosis of concussion across the older decades of life. Nearly 90% of patients 18-24 years of age were diagnosed with concussion as compared to just over 50% of those over the age of 75 years and is inversely related to the incidence pre-existing dementia. There were no differences in ISS, MS and GCS among the two study groups. Concussion was formally diagnosed significantly less in older patients as compared to the injury matched younger group.

Conclusion:Mild traumatic brain injuries are common among patients who sustain blunt injuries. However, while younger patients are frequently diagnosed with concussion, only 50% of elderly adults who meet criteria for mTBI are formally diagnosed with concussion. The failure to recognize this ubiquitous injury among the elderly may lead to less interventions and significantly poorer long-term outcomes, especially in those with a prior history of dementia. Future studies should focus on early and aggressive interventions for concussion in the elderly in an effort to mitigate the negative sequelae of these injuries and improve quality of life.

 

34.01 Bile Leak After Operative AAST Grade III-V Liver Injuries, Risk Factors and Management

Posted on January 25, 2017

R. J. Miskimins1, A. A. Greenbaum1, P. Kilen2, R. Preda1, S. W. Lu1, T. R. Howdieshell1, S. D. West1  1University Of New Mexico HSC,Department Of Surgery,Albuquerque, NM, USA 2University Of New Mexico HSC,School Of Medicine,Albuquerque, NM, USA

Introduction: Bile leak from the intrahepatic biliary tree is a major cause of morbidity after high grade liver injury. The rate of bile leak after hepatic trauma ranges from 0.5-21%. The risk of a bile leak increases with higher grade injury, however other risk factors have not been characterized. The aim of our study was to clarify the incidence, risk factors and management of intrahepatic bile leak following laparotomy for high grade liver injury.

Methods:  A retrospective review of patients with complex liver injuries, defined as AAST grade III-V, who underwent laparotomy from Jan 2008 to July 2015 at an ACS-verified Level I trauma center was performed. Patients who died within 72 hours or under the age of 14 were excluded. Bile leak was defined as bilious output lasting more than 14 days from a surgically or interventional radiology percutaneous drain (IRPD). The grade of liver injury, number of laparotomies, operative techniques, use of hepatic angioembolization (HAE), placement of surgical drains, reason for laparotomy, number of readmissions, and interventions for management of bile leak were recorded. The institutional trauma database was used to obtain demographics, initial vital signs, ISS, length of stay (LOS), ICU LOS, and mechanism of injury (MOI). Statistical analyses were performed using Chi-squared and Fisher exact tests for categorical data, and the Mann–Whitney U-test for continuous variables. P-values < 0.05 were significant.

Results: 117 patients met inclusion criteria, 29 (25%) developed a bile leak (BLG) and 88 (75%) had no leak (NLG).  There was no significant difference between the groups in age, sex, MOI, initial vitals, ISS, ICU LOS or reason for laparotomy. The BLG had higher grades of injury (Grade 5: 45% vs 10%, Grade 4: 41% vs 31%, Grade 3: 14% vs 60%,  P <0.01), longer hospital LOS (29 vs 21 days, p <0.01) and were more likely to be readmitted (41% vs 15%, P<0.01). No significant difference in the rates of perihepatic packing, argon beam hepatorrhaphy, gelfoam packing, or suture hepatorrhaphy was observed. The BLG required more laparotomies (3.5 vs 2.2, p<0.01), were more likely to have excisional debridement (38% vs 9%, p<0.01), and HAE (38% vs 6%, P=0.03). Ninety-seven percent (n=28) in the BLG had perihepatic drains placed prior to abdominal closure, and 65% (n=19) of bile leaks were managed entirely with these drains. Seventeen percent (n=5) required IRPD, 14% (n=4) underwent ERCP and insertion of biliary stent in addition to the perihepatic surgical drains, and 3% (n=1) underwent both IRPD and ERCP.

Conclusion: In patients with AAST Grade III-V liver injury who require laparotomy, the grade of injury, use of hepatic embolization and excisional debridement are assoicated with development of bile leak.Those who develop a bile leak have longer hospital LOS and are more likely to be readmitted. The majority of bile leaks can be managed conservatively with perihepatic drain placement prior to definitive abdominal closure.

33.05 Abnormal Platelet Function Contributes to Hypercoagulability After Trauma

Posted on January 25, 2017

S. A. Eidelson1, C. A. Karcutskie1, C. I. Schulman1, N. Namias1, K. G. Proctor1  1University Of Miami,Department Of Surgery,Miami, FL, USA

Introduction:

Thomboelastography (TEG) has had an increasingly useful role in critical care.  It has been postulated that platelets may contribute to hypercoagulability after trauma.  There is not yet definitive data on when these patients become hypercoagulable, or how long this persists.  We hypothesize that patients will gradually develop abnormal platelet function after trauma.

Methods:
Prospective study of patients sustaining blunt or penetrating trauma admitted to the intensive care unit from 8/2011-4/2015.  Patients were all deemed high risk for venous thromboembolism with a Greenfield Risk Assessment Profile Score of 10 or greater.  All patients received bilateral lower extremity duplex ultrasounds and TEGs on admission and then weekly afterwards.  Additionally, all patients received mechanical and chemical thromboprophylaxis.

Results:
One hundred patients received TEGs on both admission and at one week.  The cohort was aged 47±20 years, with 76% blunt trauma and 24% penetrating trauma.  The deep venous thrombosis rate was 22%.  The maximum amplitude (MA) TEG value, which indicates platelet function, was in the hypercoagulable range in 7 patients (7.0%) on admission.  At week 1, MA was in the hypercoagulable range in 62 patients (62%), significantly higher compared to admission (p<0.001).  Fifty-five of these patients also received TEGs at week 2.  In this subgroup, hypercoagulable MA values were seen in 5 (9.1%), 36 (65.5%), and 37 (67.3%) patients at admission, week 1, and week 2, respectively.  Again, there were significantly more hypercoagulable patients at week 1 than admission (p<0.001).  There was no difference in hypercoagulability at weeks 1 and 2.

Conclusion:
Despite the use of chemical thromboprophylaxis, trauma patients appear to exhibit abnormal platelet function as early as week 1.  This hypercoagulability seems to persist to at least week 2.  Antiplatelet therapy may play a significant role in thromboprophylaxis after trauma.
 

33.04 Platelet ADP Receptor Inhibition Predicts Need for Platelet Transfusion but not Massive Transfusion

Posted on January 25, 2017

G. R. Stettler1, H. B. Moore1, G. R. Nunns1, A. Sauaia1, A. Ghasabyan2, C. C. Silliman1,3,4, A. Banerjee1, E. E. Moore1,2  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA 2Denver Health Medical Center,Department Of Surgery,Aurora, CO, USA 3Bonfils Blood Center,Denver, CO, USA 4Children’s Hospital Colorado,Aurora, CO, USA

Introduction: Platelet dysfunction has been documented early after trauma, but the impact on outcome has not been determined. A recent randomized trial of blood component therapy did not document a survival advantage of early platelet transfusion. Our experimental work suggests metabolites generated during shock inhibit platelet function. Our previous clinical work suggested inhibition to adenosine diphosphate (ADP) was a more sensitive marker of trauma induced platelet dysfunction than arachidonic acid. We hypothesize that platelet function assessment via the ADP response will be associated with platelet transfusion but platelet count will be a superior predictor of massive transfusion.

Methods: Subjects without coagulation-related comorbidities or medications were enrolled from 2014-16. Thromboelastography (TEG) Platelet Mapping was assessed in trauma activation patients (TAP, n=270, field or ED arrival blood samples) and healthy volunteers (n=89). Values of MA-ADP (mm) and ADP receptor inhibition (%ADP-INH) presented as median, IQR or n,%. The results of the platelet assessment was not known to the physicians managing the patient, who based their decision for platelet transfusion based on rTEG MA.

Results:Compared to controls, TAP patients showed early low MA-ADP [59, 53-65, vs. 36, 17-50] and higher %ADP-INH [40, 23-69, vs. 4, 0-14] (p<0.0001). MA-ADP and %ADP-INH were both significantly (all p<0.05) correlated with NISS (Spearman Rho: -0.37, +0.26), temperature (Rho=+0.18, -0.14), GCS (Rho=+0.24, -0.20), and platelet count (Rho=+0.21, -0.16). %ADP-INH was higher in blunt trauma compared to penetrating (47, 23-81 vs. 36, 22-60; p=0.03). Adjusted for platelet count, MA-ADP predicted massive transfusion (MT=>10PRBC or death/6hrs, p=0.02), while %ADP-INH did not (p=0.16). Adjusted for platelet count, MA-ADP and %ADP-INH predicted platelet transfusion requirements. Platelet count remained a powerful predictor of MT (p<0.0001).  Platelet count is a powerful predictor of MT or death within 6 hours (AUC 0.84), ventilator free days <3 (AUC 0.69), ICU free days <6 (AUC 0.63), death within 24 hours (AUC 0.82), and requirements for platelet transfusions (AUC 0.75). Platelet count was a better predictor of need for MT or death in the first 6 hours compared to %ADP-INH (AUC 0.66; p=0.037) (Fig).

Conclusion:%ADP-INH predicts the need for platelet transfusion, but not for massive transfusion. Compared to platelet function, platelet count is consistently a better predictor of post injury outcomes. The predictive value of dysfunction at the ADP receptor is improved by adjustment for total platelet count.

33.03 Safety of Early Venous Thromboembolism Prophylaxis for Isolated Blunt Splenic Injury: A TQIP Study

Posted on January 25, 2017

B. Lin1, K. Matsushima1, L. De Leon1, G. Recinos1, A. Piccinini1, E. Benjamin1, K. Inaba1, D. Demetriades1  1University Of Southern California,Acute Care Surgery,Los Angeles, CALIFORNIA, USA

Introduction:

Non-operative management (NOM) has become the standard of care in hemodynamically stable patients with blunt splenic injury. Due to the potential risk of bleeding, there are no widely accepted guidelines for an optimal and safe timeframe for the initiation of venous thromboembolism (VTE) prophylaxis in patients undergoing NOM. The purpose of this study was to explore the association between the timing of VTE prophylaxis initiation and NOM failure rate in isolated blunt splenic injury. 

Methods:

After approval by the institutional review board, we utilized the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) database (2013-2014) to identify adult patients (≥18 years) who underwent NOM for isolated blunt splenic injuries (Grade III/IV/V). Patients were excluded if they expired within 24 hours of admission or required surgical management of splenic injury within 12 hours after admission. Failure of NOM was defined as any splenic surgeries after 12 hours of admission. The incidence of overall NOM failure was compared between two groups: 1) VTE prophylaxis <48 hours after admission (early prophylaxis group), and 2) VTE prophylaxis ≥48 hours (late prophylaxis group). Similarly, we compared the incidence of NOM failure after the initiation of VTE prophylaxis between the early and late prophylaxis group. Multiple logistic regression analysis was performed for NOM failure adjusting for clinically important covariates including the timing of VTE prophylaxis initiation. 

Results:

A total of 816 patients met the inclusion criteria; median age: 34 years (IQR 23-52), 67% male gender, median ISS: 13 (IQR 10-17), 679 patients (83.2%) with severe splenic injury (Grade IV/V). Of the patients who met the inclusion criteria, VTE prophylaxis was not administered in 525 patients (64.3%), whereas VTE prophylaxis was given < 48 hours and ≥48 hours after admission in 144 and 147 patients, respectively. Among patients who received VTE prophylaxis, angioembolization of the spleen was performed in 30 patients (10.3%). Overall NOM failure rate was 13.4% (39/291). While overall NOM failure rate was significantly lower in the early group compared to late prophylaxis group (4.9% vs. 21.8%, p<0.001), there was no significant difference in the NOM failure rate after the initiation of VTE prophylaxis between two groups (3.5% vs. 3.4%, p=1.00). In the multiple logistic regression analysis, early initiation of VTE prophylaxis was not significantly associated with NOM failure (OR: 1.19, 95% CI 0.31-4.51, p=0.80).

Conclusion:

Our results suggest that early initiation of VTE prophylaxis (<48 hours) does not increase the risk of NOM failure in patients with isolated splenic injury. Further prospective study to validate the safety of early VTE prophylaxis is warranted.   
 

33.02 An Analysis of Trauma Intubations Performed by Emergency Physicians at a Level 1 Trauma Center

Posted on January 25, 2017

K. N. Williams1, P. Rhee1, T. O’Keeffe1, B. Joseph1, M. Singer1, A. Tang1, G. Vercruysse1, N. Kulvatunyou1, J. Sakles1  1University Of Arizona,Division Of Trauma,Tucson, AZ, USA

Introduction:  There is variability amongst trauma centers as to who primarily manages the airway of trauma patients, with some utilizing anesthesia personnel and others emergency department physicians.  It is not known if this impacts the success rates for intubation in trauma patients. The aim of this study was to examine success rates and complications from a prospectively collected database. Our hypothesis was that ED physicians can effectively intubate trauma patients with few complications.

Methods:  An analysis of a prospectively collected database of all adult (≥18 years old) trauma patients requiring intubation at a level I trauma center over a 6 year period (2009-2015) was performed. The database was a quality improvement database collected in the trauma bays and was matched to the institutional trauma registry for additional data.  All initial intubation attempts were performed by an emergency physician.  After intubation, the physician that performed the intubation completed a structured data collection form that included: demographics, complications, and the presence of difficult airway characteristics (DACs). Our primary outcome was first pass success of intubations. Secondary outcomes were number of attempts, success in patients with DACs and immediate complications. 

Results: 972 patients met analysis criteria. The successful intubation rate by emergency medicine physicians was 98%. An Anesthesiologist was called for 7 patients (0.7%) and a surgical airway was required in only 12 (1.2%) patients. Five were for failed intubations, four for cardiac arrest and three for primary surgical airway. First attempt success rate was 80% and the second attempt success rate was 95%. The first emergency physician was successful in intubating the patient 93% of the time and only 7% needed rescue by a senior resident or attending. PGY1 residents (n=126) had a first attempt success rate of 69% and complication rate of 26.2%, compared to PGY3 residents (n=393) with an 82% (p=.019) first attempt success rate and an 18.8% (p=.082) complication rate. The overall complication rate was 21%. Complications included, desaturation (14%), esophageal intubation (2%), cardiac arrest (0.9%), aspiration (0.8%), hypotension (0.5%), dysrhythmia (0.5%), dental/airway trauma (0.3%) and laryngospasm (0.1%). When comparing the first three years of the study period to the latter three years, the first pass success rate was 74% during the first half of the study period, compared to 86% (p=.001) during the second half (when GlideScope Videolaryngoscopy (GVL) was increasingly utilized).  There was no difference in overall complication rates between the first and second half of the study period (p=0.84).

Conclusion: The overall rate of successful intubation in trauma patients is high and the need for emergency rescue is very low; Emergency Department physicians can safely intubate trauma patients with high success rates comparable to those reported in the anesthesiology literature.

 

 

33.01 Fractured Care and Outcomes After Injury: National Estimates of 30-day Hospital Readmissions and Mortality

Posted on January 25, 2017

B. P. Smith1, C. E. Fick2, D. N. Holena1  1University Of Pennsylvania,Surgery,Philadelphia, PA, USA 2Georgetown University Medical Center,Washington, DC, USA

Introduction:  Hospital readmissions data is a critical aspect of patient care as it is directly related to patient outcomes and healthcare expenditures. Data suggest some patients experience improved outcomes with readmission to their index hospital versus another hospital. Much of the information known about re-admission for injured patients is based on single center or state level data sets, which report unplanned 30 day readmission rates between 2 and 7%. The purpose of this study was to define national estimates for trauma readmissions and compare outcomes of patients re-admitted to index hospitals compared to non-index hospitals.

Methods:  We performed a retrospective cohort study using the 2013 National Readmission Database.  Inclusion criteria were primary ICD-9CM diagnosis codes indicating injury (800.00-959.9, excluding 905-909, 910-924, 930-939), age≥18years, maximum Abbreviated Injury Score≥3, and non-elective admission.  The index hospital was defined as the center of first injury admission, and readmission was defined as any non-elective re-admission within 30 days of discharge.  The proportion of discharges readmitted to the index vs. non-index hospital were tabulated, and discharge weights and hospital strata were used to generate national estimates.

Results: After weighting, there were 350,102 trauma admissions meeting inclusion criteria (60% male, mean age 58 (SD 22) years, median Injury Severity Score 13 (IQR9-17)).  Median index length of stay was 4 (IQR2-9) days.  Of these, 31,558 (9%) had ≥ 1 30-day readmission of which only 22,372 (71%) were ever readmitted to the index hospital. Complications related to intracranial injuries, septicemia, and procedural outcomes accounted for nearly 25% of re-admission diagnoses. After adjusting for age, index length of stay, mechanism of injury, and injury severity score, diagnoses most strongly associated with re-admission to the index hospital included complications of surgery (OR 3.3, 95% CI 2.6-4.1), complications of devices (1.9, 1.5-2.4) and acute cerebrovascular accident (1.7, 1.4-2.1). Overall mortality for patients readmitted in 30 days was 4.83% and did not vary between those readmitted to index vs. other centers (4.81% vs. 4.89%, p =0.84). The most common admitting diagnosis resulting mortality in readmitted patients was sepsis, accounting for 36% of 30 day-readmission deaths.

Conclusion: Using a nationally representative dataset, we show the unplanned 30 day re-admission rate for injured patients is 9.0%, which far exceeds most single center and state reports. Most striking is that nearly 1/3 of injured patients are re-admitted to hospitals that differ from the index hospital. Although we are unable to demonstrate a mortality difference between re-admission locations, we do add crucial data to patient centered outcomes such as recovery from brain injury, and outcomes related to procedural and operative intervention for injury.

 

32.08 Trends in Firearm Related Injuries in Children and Young Adults Admitted to US Hospitals

Posted on January 25, 2017

M. Nuno1, M. K. Srour1, A. V. Lewis1, R. F. Alban1  1Cedars-Sinai Medical Center,Trauma And Critical Care Surgery,Los Angeles, CA, USA

Introduction:
Firearm violence in the USA results in the injury and death of thousands of individuals annually. In an effort to curtail this public health concern, firearm prevention strategies such as the Brady handgun violence prevention act – the Brady law have been proposed. Given the gaps inherent is some of these laws, these prevention strategies have resulted in limited success.  The objective of this study was to evaluate the role of state-level gun laws, age and race on firearm related injuries and mortality among children and young adults admitted to US hospitals.

Methods:
A total of 27,566 children and young adults were identified using the Kids’ Inpatient Sample (KID) database (2000, 2003, 2006, and 2009). Data was obtained from the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ) and all statistical analyses were conducted in SAS 9.2. Trends of injuries were explored in terms of state-level gun laws, age, and race. Admitting hospitals were stratified into 5 categories (A, B, C, D and F, with A representing states with the most strict and F states with the least strict laws) based on the Brady Campaign to prevent Gun Violence that assigns scorecards for every state. Descriptive statistics were provided and multivariate logistic regression was applied to evaluate factors associated with in-hospital mortality.

Results:
A total of 27,566 children and young adults were analyzed in this study. Most patients were young adults of age 15-19 years (87.3%), male (89.7%), black (53.7%), and admitted as emergent/urgent cases (85.0%). Most patients were discharged from teaching (81.9%) hospitals with large bedsize (70.9%), and located in southern states (34.2%). States with weaker gun laws had an increased rate in accidents while more assaults were documented in states with stronger gun laws. Accidents were significantly more common in children age 0-4 while assaults were prevalent in younger adults. Whites experienced more firearm related accidents while Black and Hispanics were victims of more assaults. Overall mortality was 6.4%; after adjusting for multiple factors we found that race (p=0.009), age (p<0.0001), and the type of firearm related injury (p=0.0011) were associated with mortality. Hispanics compared to Whites (OR 1.36, 95% CI: 1.03-1.78), children age 5-9 (OR 2.03, 95% CI: 1.30-3.17) compared to young adults (15-19), and suicides (OR 15.6, 95% CI: 11.6-20.9) in comparison to accidents had an increased risk of in-hospital mortality.

Conclusion:
Firearm related injury type was strongly correlated with state-level gun laws, age and race of victim. Accidents were most prevalent in states with weak gun laws, young children and Whites while assaults prevailed in states with stricter gun laws, young adults, and Black and Hispanics. Further disparities in mortality were found by race, age, and type of injury.
 

32.07 The Impact Of Gcs-age Prognosis (Gap) Score On Geriatric Tbi Outcomes

Posted on January 25, 2017

M. Khan1, A. Azim1, T. O’Keeffe1, L. Gries1, K. Ibraheem1, A. Tang1, G. Vercruysse1, R. Friese1, B. Joseph1  1University Of Arizona,Trauma And Surgical Critical Care/Department Of Surgery,Tucson, AZ, USA

Introduction:
As the population ages, increasing number of elderly patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information plays a crucial role in informed decision making for these patients. The aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients

Methods:
One-year (2011) retrospective analysis of geriatric TBI patients (h-AIS≥3 and age≥65) in the National Trauma Data Bank was performed and patients dead on arrival were excluded. We defined and calculated a GCS and Age Prognosis (GAP) score (Age/GCS score) for all patients. Our outcome measures were mortality and discharge disposition (Home versus Rehab/SNiF). ROC analysis was performed to determine the discriminatory power of GAP score.

Results:
A total of 8,750 geriatric patients with TBI were included. Mean age was 77.8± 7.1 years, median [IQR] GCS was 15 [14-15], and median [IQR] head-AIS was 4[3-4]. Overall mortality rate was 14.1% and 42.7% patients were discharged home. As the GAP score increased, mortality rate increased and discharge to home decreased. ROC analysis revealed excellent an discriminatory power for mortality (AUC: 0.826). Above a GAP score of 12, mortality rate was greater than 60%, more than 35% patients were discharged to Rehab/SNif and less than 5% of patients were discharged home.

Conclusion:
For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in drastic increase in mortality and adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patient families.
 

32.05 Asymptomatic Screening in Trauma Patients Reduces Risk for Pulmonary Embolism

Posted on January 25, 2017

D. Koganti1, A. Johnson1, S. Stake1, A. Wallace1, S. Cowan1, J. Marks1, M. Cohen1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA

Introduction:
Now that deep vein thrombosis (DVT) is linked to reimbursement and publicly reported metrics, hospitals are pressuring trauma programs to discourage lower extremity (LE) venous duplex ultrasounds (VDUS) in asymptomatic patients. Current evidence is ambiguous and controversial. We aimed to evaluate LE VDUS screening practices at our institution for risk reduction for pulmonary embolism (PE).

Methods:
Patients admitted to an urban level-1 trauma center between 2005 and 2015 were retrospectively reviewed, excluding patients with a length of stay (LOS) <4 days. We performed propensity-matching of screened to unscreened patients based on gender, transfer, spinal procedure, spinal cord injury, or spinous, femur, pelvis, tibia and upper extremity fracture. In our matched samples, we performed a chi-squared analysis to determine association of screening with PE, absolute risk reduction and number needed to treat.

Results:
Of the 11,280 trauma patients admitted, 5,611 met LOS criteria. Of these patients, 2,687 (48%) underwent asymptomatic LE VDUS screening. Propensity matching identified 1,915 unscreened patients with a similar risk profile. The rate of PE was significantly higher in our matched unscreened sample [1.72% (n=33) vs 0.45% (n=12), p<0.001, Figure]. The absolute risk reduction was 1.28%, suggesting that the number needed to screen to prevent one PE is 78 high-risk patients.

Conclusion:
The data demonstrate significant risk reduction for pulmonary embolism in propensity-matched patients at our institution over a 10-year period. The screened patients still have a higher risk factor profile than the matched cohort suggesting that the actual risk reduction might even be greater than 1.28%. This data can help define the best population for routine screening and determine the cost-effectiveness of screening programs.
 

32.02 Effectiveness of ATOMAC Guideline for Blunt Pediatric Injury: A 3-Year 10-Center Prospective Study

Posted on January 25, 2017

D. M. Notrica1,11,12, C. S. Langlais1, M. E. Linnaus1,11, K. A. Lawson2, J. W. Eubanks6, A. C. Alder3, N. M. Garcia2, R. W. Letton5, D. W. Tuggle2, T. Ponsky8, D. Ostlie1, A. Bhatia10, S. D. St. Peter9, C. Leys7, R. T. Maxson4, D. M. Notrica1,11,12  1Phoenix Children’s Hospital,Phoenix, AZ, USA 2Dell Children’s Medical Center,Austin, TX, USA 3Children’s Medical Center Dallas, Part Of Children’s Health,Dallas, TX, USA 4Arkansas Children’s Hospital,Little Rock, AR, USA 5The Children’s Hospital At OU Medical Center,Oklahoma City, OK, USA 6LeBonheur Children’s Hospital,Memphis, TN, USA 7American Family Children’s Hospital,Madison, WI, USA 8Akron Children’s Hospital,Akron, OH, USA 9Children’s Mercy Hospital,Kansas City, MO, USA 10Children’s Healthcare Of Atlanta,Atlanta, GA, USA 11Mayo Clinic,Phoenix, AZ, USA 12University Of Arizona College Of Medicine – Phoenix,Phoenix, AZ, USA

Introduction: Prior guidelines had required bedrest equal to the grade of injury +1 day. The ATOMAC guideline is an evidence-based published guideline for management of pediatric blunt liver and spleen injury (BLSI). The guideline allows for an abbreviated period of bedrest, and provides a detailed algorithm for management. The purpose of this study was to prospectively evaluate the effectiveness of the algorithm to safely guide care and confirm the safety of the abbreviated bedrest included in the algorithm.

Methods: After IRB approval, data was prospectively collected on patients ≤18 years of age admitted with a BLSI identified by Computed Tomography. Data collected included injury details, hospital details, and clinical outcomes. The algorithm was amended during the study to make early recurrent hypotension a failure point. Descriptive statistics are reported. Length of stay (LOS) was compared to a LOS equal to grade + 1 day.

Results: A total of 1008 children were included; 499 liver injuries (50%), 410 spleen injuries (41%), and 99 with both (10%).  Median age was 10.3 years [IQR 5.9, 14.2]. At initial presentation, 286 (28%) had recent or ongoing bleeding and were assigned to the bleeding pathway; 242 (24%) were tachycardic and 129 (13%) were hypotensive. Concomitant traumatic brain injury was present in 189 (19%).  There were 23 in-hospital deaths (2.5%), 2 due to bleeding. Of the 717 patients clinically assessed and started on the stable pathway, 10 (1.5%) crossed over to the algorithm’s unstable pathway. While minor deviations were common, only 1 patient (0.1%) was at risk of a negative outcome if they followed the original algorithm, resulting in the algorithm amendment. In patients with isolated injuries, median [IQR] lengths of stay by grade of injury (in days) were 0.94 [0.75, 2.17], 1.21 [0.83, 1.89], 1.65 [1.17, 2.08], 2.00 [1.46, 3.29], and 3.23 [2.35, 4.88] for isolated injuries grade 1-5, respectively, totaling 678 days, compared to an expected LOS of 1,211days.

Conclusion:The original ATOMAC guideline was safely applied to 99.9% of 1008 children with BLSI.  With the modification for recurrent hypotension in the guideline published last year, the guideline could have safely guided care for 100% of the children with BLSI. Ninety-one (9%) patients reached the algorithm endpoint where continued NOM could no longer be recommended; 22 (24%) of these were still managed nonoperatively at the surgeon’s discretion. Ten patients (1.5%) crossed over from the stable to the unstable pathway. The algorithm saved 533 hospital days over the prior guideline. In the largest prospective study ever conducted of pediatric BLSI, the ATOMAC guideline performed well in guiding non-operative management of patients with BLSI.

 

31.08 Pre-Operative Native TEG Maximum Amplitude Predicts Massive Transfusion in Liver Transplantation

Posted on January 25, 2017

P. J. Lawson1, H. B. Moore1, G. R. Stettler1, T. J. Pshak1, T. L. Nydam1  1University Of Colorado Denver,Aurora, CO, USA

Introduction:
Pre-operative laboratory values to assess liver transplant patients coagulation status is based off of plasma based assays, such as INR. These assays partition coagulation and violate the current understanding of cell the based hemostasis. Whole blood viscoelastic assays such as thrombelastography (TEG) have been used for decades in liver transplant surgery but have not been utilized for perioperative coagulation assessment. We hypothesize that TEG is a superior predictor of perioperative blood products transfused during liver transplant surgery than INR.

Methods:
Liver transplant had blood drawn prior to surgical incision and assayed with citrated native TEG. Pre-operative labs including liver function test, coagulation assays, and complete blood counts were collected as part of the standard of care. Initial blood samples were collected on patients before surgical incision. TEG variables including R-Time, Angle, MA, and LY30 were correlated to red blood cell (RBC), plasma (FFP), cryoprecipitate (Cryo), and platelets (Plts) during the intra operative period in addition to INR, platelet count, and MELD score. Massive transfusion (MT) was defined as >10 units of RBC during surgery. A receiver operator curve (ROC) was generated to identify which pre-operative value had the greatest predictability of identifying a patient requiring a MT during surgery.

Results:
Eighteen patients were included in the analysis. The median MELD score was 29.0 (20.5-37.0). The median INR was 1.4 (1.3-2.8). The median RBC transfused was 3.5 (0.8-11.3). The median Platelet Count was 91 (50-111). Pre-Op TEG values were: R-Time (12.3 min, 7.4-12.3), Angle (52.2 degrees, 38.6-56.9), MA (51.8 mm, 36.5-60.8), and LY30 (0.1 %, 0.0-1.3). 33% of patients required a massive transfusion. Spearman’s Rho correlations for RBC transfusion and variables of interest included: R-Time (0.1583, p=0.530), Angle (-0.4623, p=0.534), MA (-0.6268, p=0.005), LY30 (0.1184, p=0.640), INR (0.5013, p=0.422), Plts (0.5053, p=0.040), MELD (0.4974, p=0.036). Correlation to FFP utilization was significant for MA (p=0.0081), INR (p=0.006), and Plts (p=0.044), but not other variables. This correlation persisted for MA for Cryo (p=0.003) and Plts (p<0.001), but not INR. Pre-Op lab and TEG variable correlation to RBC use were ROC curve with AUC (p=0.013). When performing a ROC curve, MA had an AUC of 0.941 (p<0.001) superior to INR AUC of 0.618 (p=0.235).

Conclusion:
Preoperative assessment of predicted blood product utilization in liver transplant surgery remains poorly defined. The INR which drives preemptive plasma transfusion before surgery was not a good predictor of massive transfusion. The maximum clot strength measured by TEG has superior predictability and may help guide more cost effective blood bank preparation for this procedure as only a third of patients required a massive transfusion.

31.06 Early Post-transplant Clinical Outcomes for Liver Allografts with Any Steatosis

Posted on January 25, 2017

J. P. Davis1, C. A. Kubal1, B. Ekser1, J. A. Fridell1, K. A. Thatch1, R. S. Mangus1  1Indiana University School Of Medicine,Indianapolis, IN, USA

Introduction:
Deceased donor liver transplant allografts with steatosis have an increased risk of post-transplant primary non-function and early allograft dysfunction. The degree of allograft steatosis which results in these negative outcomes is not clearly defined, largely because there is significant variability in grading graft steatosis. This study reviews a large number of liver transplants at a single center. The percent of total graft steatosis from the permanent reperfusion biopsy is recorded. Early clinical outcomes are then measured with increasing severity of steatosis.

Methods:
The records of all liver transplants (LTs) performed over a 15-year period were reviewed. Reperfusion biopsy reports were reviewed and recorded in the transplant center research database. All biopsies were read by experienced liver pathologists, from permanent sections taken at transplant. Total steatosis included both micro- and macrovesicular and was categorized into four study groups, (1) none (0%), (2) mild (1-10%), (3) moderate (11-20%) and (4) severe (>20%). Outcomes included early allograft dysfunction (EAD) and graft loss, peak alanine aminotransferase (ALT) and total bilirubin (TB) values, length of hospital stay, and change in renal function.

Results:
Data were available for 1864 adult LT recipients, 40% of whom had some liver allograft steatosis.  Donor factors associated with increasing graft steatosis included White race, older age, and chronic alcohol abuse. Pre-procurement donor peak ALT and TB levels were no different for livers with or without steatosis. Recipient post-transplant peak ALT levels were similar to non-steatotic livers when there was <10% steatosis. However, above 10% steatosis, there was an incremental increase (p<0.001). Peak TB did not differ among the groups. EAD was similarly seen only in livers with > 10% steatosis, reaching 42% in the 11-20% steatosis group and 54% in the >20% steatosis group (p<0.001). There was a significant risk of graft loss, but this was only seen in grafts with >20% steatosis (p<0.01 at 7 days and p=0.02 at 30 days). Steatosis >20% was associated with an acute decrease in glomerular filtration rate (>20%) which persisted through day 30.

Conclusion:
Initial liver function is delayed in grafts with more than 10% steatosis, being demonstrated by high peak ALT and a 40-50% risk of early allograft dysfunction.  There is a significant risk of graft loss when total steatosis is greater than 20%. Severe steatosis is also associated with acute kidney dysfunction early post transplant. The early graft losses seen in livers with > 20% steatosis lead to a 10% reduction in survival at 10-years compared to non-steatotic grafts.
 

31.05 Incidence and impact of adverse drug events leading to hospitalization in kidney transplantion

Posted on January 25, 2017

M. Arms1, J. W. McGillicuddy1, S. N. Nadig1, D. J. Taber1  1Medical University Of South Carolina,Transplant Surgery,Charleston, SC, USA

Introduction: Long-term graft survival in kidney transplant recipients remains sub-optimal.  The impact of adverse drug events (ADEs) contributing to hospitalization and as a predominant risk factor for late graft loss has not been well-studied in this population.

Methods:  This was a retrospective longitudinal cohort study of adult solitary kidney recipients transplanted between 2005 and 2010 with follow up through May 2016.  Patients were divided into three cohorts: no readmissions, readmissions not due to an ADE, and ADEs contributing to readmissions.  Medication regimens and progress notes were utilized to assess for ADE contribution to hospitalization using validated methodology.   The rationale of the ADE contribution to the readmission was categorized in terms of probability, preventability, and severity.  Predominant readmission etiologies across time, from 2005 to 2013 were compared to assess for temporal trends.

Results: 837 patients with 963 hospital readmissions were included in the study with a total follow up of 3,734 patient years (26 admissions per 100 patient years).   Of the 837 patients, 47.9% had at least one hospital readmission during follow up; 65.0% of readmissions were deemed as having an ADE contribute to the readmission.  The predominant causes of readmissions related to ADEs included non-opportunistic infections (39.6%), opportunistic infections (10.5%), acute rejection (18.1%) and acute kidney injury not related to rejection or infection (11.8%).  From 2005 to 2013, readmissions over time due to under-immunosuppression significantly decreased at a rate of -1.6% per year, while readmission due to over-immunosuppression, as indicated by infection, cancer or cytopenias, significantly increased at a rate of 2.1% increase per year (difference 3.7%, p=0.026, see Figure 1).  Significant risk factors for readmission related to an ADE included African American race, increased time on dialysis, increased time on waitlist and increased kidney donor profile index (KDPI). Protective factors included only being the recipient of a living donor kidney.  Delayed graft function, acute rejection, serum creatinine, graft loss and death were all significantly higher in those with an ADE that contributed to a readmission, as compared to those with a readmission not due to an ADE or those that did not have a readmission during follow-up (p<0.05, see Table 1). 

Conclusion: These results provide novel evidence demonstrating that ADEs contribute to a substantial number of readmissions after kidney transplant, which significantly increases the risk of graft loss and death, as compared to those readmitted for other causes or those without readmissions after transplant. 

31.01 Neutrophil–lymphocyte Ratio Reflects Cancer Recurrence After Liver Transplantation

Posted on January 25, 2017

T. Motomura1, T. Yoshizumi1, A. Nagatsu1, S. Itoh1, N. Harada1, N. Harimoto1, T. Ikegami1, Y. Soejima1, Y. Maehara1  1Kyushu University,Department Of Surgery And Sciences,Fukuoka, , Japan

Introduction:

Although the Milan criteria (MC) have been used to select liver transplantation candidates among patients with hepatocellular carcinoma (HCC), many patients exceeding the MC have shown good prognosis. Recently, inflammation-based scores such as Preoperative neutrophil–lymphocyte ratio (NLR) or platelet-lymphocyte ratio (PLR) are received attention as predictors of patient prognosis in various malignant cancers, but it has yet to be clarified which is better criteria for liver transplantation with HCC. 

Methods:
We assessed outcomes in 202 patients who had undergone living-donor liver transplantation (LDLT) for HCC (1999.Jul-2015.Sep). Recurrence-free survival (RFS) was determined in patients with high (≥4) and low (<4) NLR, or with high (≥150) and low (<150) PLR. The cut-off values were determined according to the previous reports. Next, the levels of expression of vascular endothelial growth factor (VEGF), interleukin (IL)-8, IL-17, CD68 and CD163 were measured.

Results:
The 5-year RFS rate was significantly lower in patients with high (n=29) than with low (n=172) NLR (52.8% versus 88.9%, P<0.0001), both in patients with high (n=17) than with low (n=185) PLR (55.9% versus 86.8%, P<0.05). Multivariate analysis showed both NLR and MC significantly correlated with HCC recurrence (p=0.0009 and p=0.0001, respectively), whereas PLR was not significant (p=0.71). Combined with NLR and MC, the 5-year RFS rate was significantly lower in patients with high (n=11) than with low (n=57) NLR who exceeded the MC (19.5% versus 76.8%, P=0.0002). Tumor expression of VEGF, IL8, IL-17, CD68 and CD163 was similar in the high and low NLR groups, but serum and peritumoral IL-17 were significantly higher in the high-NLR group (P=0.01 each). The peritumoral CD163 correlated with the peritumoral IL-17-producing cells (P=0.04) and was significantly higher in the high-NLR group (P=0.005). 

Conclusion:
NLR predicts outcomes after LDLT for HCC via inflammatory tumor microenvironment. Combined with the MC, NLR may be a new criterion for LDLT candidates with HCC.
 

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