12.04 Patient Reported Outcomes Following Splenectomy for Hematological Disorders

Posted on January 25, 2017

M. O. Mohamed1, D. Laan1, C. A. Thiels1, J. Bingener1  1Mayo Clinic,Surgery,Rochester, MN, USA

Introduction:
Splenectomy for hematologic malignancy is a high risk procedure, performed to improve patients’ quality of life (QOL). It is not well known which role underlying diseases play in the patient reported outcomes for these patients postoperatively.

Methods:
Patients who underwent elective splenectomy for hematological causes at our institute between the years 2009 and 2015 were identified retrospectively. Our institution routinely collects the validated LASA (Linear Analog Self-Assessment) to assess the patients’ fatigue, pain and overall QOL preoperatively (baseline) and at 1 month, 3 months, 6 months and 12 months after surgery. Demographic, operative approach, complications and one-year survival were abstracted. T-test and ANOVA were used to compare outcomes.

Results:

QOL data was available for 115 splenectomy patients including 82 patients with lymphoma, 16 patients with leukemia and 17 patients with myelofibrosis. Mean age was 62 years and 40 patients (31%) were women. Operative approach, spleen weight and complications are depicted in table 1. Thirty day mortality was zero, one year survival was 79% in the lymphoma group, 62%  in the leukemia group, and 65%  in patients with myelofibrosis.

Overall QOL did not markedly improve in general; only MF patients had improved QOL at one year postoperatively (0.55+3.35). Fatigue and pain showed clinically significant improvement from baseline for all groups during the follow-up period after splenectomy, more significantly for MF patients. 

Increased preoperative fatigue correlated with a decreased one year survival for the leukemia group p=0.023.

Conclusion:
Splenectomy significantly improved the fatigue for lymphoma and leukemia patients over the follow up duration, overall QOL did not change markedly. More PRO data are necessary to help patients and surgeons select the appropriate timing and indication for splenectomy in hematologic malignancies.

12.03 Patient Perceptions and Quality of Life after Colon and Rectal Surgery

Posted on January 25, 2017

S. M. Wrenn1, D. Ramos-Valadez2, A. Cepeda-Benito3, P. Cataldo1  1University Of Vermont College Of Medicine,Department Of Surgery,Burlington, VT, USA 2Sanford Health,Surgery,Thief River Falls, MINNESOTA, USA 3University Of Vermont,Department Of Psychological Sciences,Burlington, VT VERMONT, USA

Introduction: As healthcare payment models shift increasingly toward value-based incentives, it is imperative that postoperative outcomes are both accurately assessed and correctly aligned with patient priorities regarding their recovery and care. In particular, the assessment of patient quality of life as it pertains to both laparoscopic and open colorectal surgery remains understudied. 

Methods: Patients who underwent a colon or rectal surgical resection at a single academic medical center between 2009-2015 were identified and contacted via traditional mail.  Subjects were offered to complete a voluntary hand-written 36-question survey regarding their perioperative and postoperative quality of life. Responders who enrolled in the study were stratified into subcategories (including laparoscopic vs. open groups, benign vs. malignant groups). Analysis was performed via both subjective reported data and objective data from the electronic medical record regarding their clinical course. Statistical analysis was performed for categorical variables via chi squared test, and unpaired t test for interval variables. Statistical significance was defined as p<.05. 

Results:A total of 626 patients were queried, and 167 patients responded to the survey (27% response rate). 25% of patients reported their surgery was laparoscopic, 63.5% reported their surgery was open, and the rest did not respond or were unsure. 92.2% of responders were satisfied with their surgical recovery. Factors deemed most important to all responders included being cured of colorectal cancer (91%), not having a permanent ostomy or stoma (84%), and not having any complications after surgery (74%).  Patients who underwent laparoscopic surgery reported a shorter hospital length of stay (p<.001), quicker return to full strength (p<.05), and smaller incision (p<.001) with greater satisfaction with the appearance of their scar (p<0.05). 

Conclusion:Regardless of surgical technique or indication, patients in our study reported high levels of satisfaction with their surgical care. Laparoscopic colorectal resections do appear to have some significant advantages over traditional open procedures, however not in the categories deemed most important to patients.  This research helps elucidate the quality outcomes that are truly considered most valuable to patients during their perioperative and postoperative colorectal surgical care.   

 

12.02 A Critical Analysis of Feeding Jejunostomy Following Esophagectomy Versus Gastrectomy

Posted on January 25, 2017

R. E. Sargent1, A. M. Blakely1, T. Ng1, T. J. Miner1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction:  Adequate nutrition following major upper gastrointestinal cancer resection is critical in order to achieve optimal recovery from the operation and to facilitate initiation of adjuvant therapy when indicated. Feeding jejunostomy tubes (FJT) are often placed at time of resection in order to secure enteral access. FJT utilization rates and need for parenteral nutrition (PN) were assessed.

Methods:  Retrospective review of prospectively-maintained database was performed of adult patients who underwent esophagectomy or gastrectomy (subtotal or total) for cancer with curative intent, January 2001 to June 2014. Esophagectomy approach, extent of gastrectomy, FJT placement and utilization at discharge, administration of PN, and complications were evaluated.

Results: 287 patients underwent resection, comprised of 182 esophagectomy (n=107 transhiatal, 58.7%; n=56 Ivor-Lewis, 30.7%) and 105 gastrectomy (n=63 subtotal [SG], 60.0%; n=42 total [TG], 40.0%). 181 of 182 esophagectomy patients underwent FJT, compared with 47 of 105 gastrectomy patients (99.5% vs. 44.8%, p<0.0001), of whom most had undergone TG (n=39, 92.9% vs. n=8 SG, 12.9%, p<0.0001). Median length of stay was similar between esophagectomy and gastrectomy groups (14.7 days vs. 17.1, p=0.076). Upon discharge, 81 esophagectomy patients (48.6%) were taking enteral feeds, with 53 (29.3%) fully and 28 (15.4%) partially dependent. Meanwhile, 20 of 39 TG patients (51.3%) were either fully (n=3, 15.0%) or partially (n=17, 85.0%) dependent on tube feeds, compared with 5 of 8 SG (62.5%) patients, all of whom were partially dependent. Gastrectomy patients were significantly less likely to be fully dependent on tube feeds at discharge compared to esophagectomy patients (6.4% vs. 29.3%, p=0.0006). PN was administered despite FJT placement more often following gastrectomy than esophagectomy (n=11, 23.4% vs. n=7, 3.9%, p=0.0001). Four esophagectomy patients required PN due to chylothorax. FJT-specific complications requiring reoperation within 30 days of resection occurred more commonly in the gastrectomy group (n=6), all after TG, compared to 1 esophagectomy patient (12.8% vs. 0.6%, p=0.0003). Six of 7 patients (85.7%) who experienced tube-related complications required PN.

Conclusion: Esophageal and gastric malignancies are distinct pathologies, and resection of each is associated with a unique complication profile. Such complications may preclude feeding jejunostomy use and therefore require parenteral nutrition. Reliance on tube feeds was more common following esophagectomy, while major tube-related complications occurred more frequently following gastrectomy. The type of upper gastrointestinal resection should inform the decision to place a feeding jejunostomy tube, considering potential resection- and tube-related complications, in order to optimize postoperative utilization rates. 

 

 

12.01 Outcomes Significantly Differ by Indication for Surgery in Elective Colectomies

Posted on January 25, 2017

A. A. Gullick1,2, L. E. Goss1,2, D. I. Chu1,2, C. Balentine1,2, M. S. Morris1,2  1University Of Alabama at Birmingham,Gastrointestinal Surgery,Birmingham, Alabama, USA 2VA AL Healthcare System,Surgery,Birmingham, AL, USA

Introduction:   Patients have high complication rates following Colorectal surgery and some of these outcomes are publically reported. Outcomes following colectomy are extensively reported but most studies fail to consider surgical indication or are performed on a cohort with a single indication such as colorectal cancer. We aim to examine our hypothesis that postoperative outcomes vary based on surgical indication in non-emergent colorectal procedures.

Methods:   We queried the 2011-2014 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) colectomy procedure targeted database for non-emergency cases and stratified patients by primary indication for surgery. Patient and operative characteristics were compared.  Primary outcomes are30 day all-cause readmission rates and post-surgical length of stay (poLOS). Secondary outcomes included post-operative complications. Chi-square and Wilcoxon Rank Sums tests were used to determine differences among categorical and continuous variables, respectively. Backwards linear regression was performed to identify risk factors for poLOS and backwards logistic regression was used to identify 30 day readmission risk factors.

Results: Of 52,617 patients who underwent elective colectomies, the indications included colorectal cancer (CRC)  (46.97%),diverticular disease (DV) (23.05%), other benign disease (OBD) (21.10%) and inflammatory bowel disease (IBD) (8.88%). Overall, 52.2% were female, the majority white (78.9%) and had a median age of 62.0 (52-72.0). IBD patients were more likely to be underweight, and most were on steroid medications, while those with diverticular disease were more likely to have diabetes, smoke and have hypertension When examining post-operative complications, IBD patients experienced the greatest proportion of organ space infections (6.65%), while those with colorectal cancer  experienced the greatest proportion of post-operative bleeding (11.37%).  30 day mortality was highest in those presenting with other benign disease (1.77%) and lowest in IBD patients (.30%). Readmission rates were significantly higher in those with IBD (13.97% vs  10.14%, 8.56% and 10.1% , p<0.001).  On adjusted comparisons, IBD patients had longer poLOS compared to other benign disease, diverticular disease and colorectal cancer (6.91 vs 6.86, 5.74 and 6.68, p<0.001) and was a significant predictor of readmission (OR: 1.18(1.03-1.36)).

Conclusion:  For patients undergoing colorectal surgery, the indication for surgery needs to be considered when reporting rates of readmission, surgical site infections and length of stay. Patients with IBD are at particular high-risk for post-operative complications including 30-day readmission and total number of complications. As financial penalties are tied to these outcomes, hospitals who serve higher proportions of IBD patients will be disproportionally affected.

11.20 Radiographic Evaluation of the Pregnant Trauma Patient: What Are We Willing to Miss?

Posted on January 25, 2017

E. Herfel1, E. Buggie2, M. Lieber2, J. Hill2  1OhioHealth Doctors Hospital,Obstetrics And Gynecology,Columbus, OH, USA 2OhioHealth Grant Medical Center,Trauma Services,Columbus, OHIO, USA

Introduction:  Trauma is the leading cause of non-obstetrical causes of death in pregnant patients. The use of radiographic imaging for evaluation of a pregnant trauma patient in the trauma bay is controversial, considering research has linked radiation exposure to inappropriate development in some children. However, in critical cases the benefits of using radiographic imaging to ensure maternal survival outweigh the risks of radiation exposure to the fetus. This study explored whether sparing fetal exposure to radiation by minimizing use of radiographic imaging put the mother at risk for a delayed diagnosis of injury. We hypothesize that minimizing the use of radiographic imaging in the initial assessment of pregnant trauma patients will not lead to a higher incidence of a delayed diagnosis or missed injury.

Methods:  We performed a seven year retrospective chart review at an urban level 1 trauma center reviewing pregnant patients and a 2:1 cohort of non pregnant patients matched for age, injury severity score (ISS) and injury type, all involved in blunt trauma. Collected data points include: number and type of imaging studies performed on initial presentation and those images that were delayed. Delayed imaging was defined as any imaging study obtained two hours or more after arrival in the trauma bay. A delayed diagnosis was defined as any injury identified by delayed imaging. The primary outcome was incidence of delayed diagnosis in the pregnant trauma patient compared to the non-pregnant patient.

Results: A total of 83 pregnant patients and 167 non-pregnant patients were examined. Average age was 23.7 years and average ISS was 2.7 in both groups. 95.2% of the pregnant population had at least one imaging study done versus 100% of the control group (p=0.004).  The pregnant population had an average of 4.3 images performed compared with an average of 6.8 images in the non pregnant cohort (p=<0.001). 18 (21.7 %) pregnant patients had delayed imaging and 58 (34.7%) control patients had delayed imaging (p=0.03). Only 1/18 of pregnant patients had a delayed diagnosis of a traumatic injury (transverse process fracture of the lumbar spine). 9/58 control patients had a delayed injury (p=0.17).

Conclusion: Our study demonstrates that bluntly injured pregnant trauma patients receive significantly fewer radiographic images upon presentation than their non-pregnant counterparts. However, only 1% of those pregnant patients had a delayed injury diagnosed. This was not significantly different from non-pregnant patients when matched for age and ISS. Though the ISS was low for both patient cohorts, this study suggests that mitigated radiographic imaging in the pregnant trauma patient is safe and does not result in delayed diagnosis of injury. 

11.19 Identification of Organ Failure Patterns for Early Stratification of Trauma Patients

Posted on January 25, 2017

D. Liu1, R. A. Namas1, Q. Mi1, O. Abdul-Malak1, J. Guardado1, B. Zuckerbraun1, J. Sperry1, M. Rosengart1, Y. Vodovotz1, B. Timothy1  1University Of Pittsburgh,General Surgery,Pittsburgh, PA, USA

Introduction: Multiple organ dysfunction syndrome (MODS) typically peaks within 5 days of injury and is associated with a complicated clinical course. However, the number of distinct organ failure patterns following injury in humans is unknown. Using MODScore parameter optimized to correlate with adverse in-hospital outcomes, we sought to establish the number of distinct pattern-specific patient clusters present in a highly characterized cohort of blunt trauma patients admitted to the ICU. Inflammatory networks based on measurements of 31 circulating inflammation biomarkers were characterized.

Methods: 376 patients admitted to the ICU and with sequential Marshall MODScores from days (D) 2-5 post-injury were studied. MODScores from D2-D5 were subjected to Fuzzy Clustering Analysis (FCA) to suggest trauma patient sub-groups. Eight widely accepted internal quality indices were calculated to determine the optimal number of trauma patient sub-groups using R. Inflammation biomarkers (31 cytokines and chemokines) were assayed (by Luminex™) in serial blood samples (3 samples within the first 24 h and then daily up to day 5 post-injury). Biomarkers were analyzed using Two-Way ANOVA (p<0.05). Dynamic network analysis (DyNA) was used to suggest dynamic connectivity and complexity among the inflammatory mediators.

Results: Six (75%) of the eight indices suggested that the optimal number of  clusters was 4: Group 1 (n=199, age=49 ± 1, male/female [M/F]=134/65, average MODScore=0.3); Group 2 (n=99, age=48 ± 2, M/F=70/29, average MODScore=2); Group 3 (n=53, age=47 ± 3, M/F=36/17, average MODScore=4); and Group 4 (n=25, age=46 ± 4, M/F=20/5, average MODScore=7). There were statistically significant differences among the four groups with regards to ICU LOS, total LOS, and days on mechanical ventilation being all greatest in Group 4, which in turn exhibited a higher incidence of nosocomial infection (76%) when compared to Groups 1, 2, and 3 (16%, 41%, and 49% respectively). Of the 31 circulating biomarkers measured, IL-6, MCP-1, IL-10, IL-8, IP-10, sST2, and MIG were differentially elevated upon presentation and over time among the groups. DyNA suggested a higher sustained degree of systemic interconnectivity in Group 4, which persisted up to D5 post-injury when compared to the other groups.

Conclusion: These results suggest that blunt trauma leads to 4 distinct organ failure patterns in patients who are admitted to the ICU and survive to discharge. The organ failure patterns are preceded by distinct patterns of inflammation biomarkers and followed by severity-specific differences in patients’ in-hospital outcomes.

11.18 The Impact of Severe Head Trauma on the Management of Isolated Open Tibia Fractures

Posted on January 25, 2017

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

Introduction: A consensus has yet to be established for the ideal timing of definitive fixation of open tibia fractures in the setting of traumatic brain injury (TIB).  Data regarding definitive fixation in patients with severe TBI has been inconclusive in studies of closed long bone fractures, however little is known regarding outcomes in the open fracture setting.  Therefore we sought to outline the perioperative complications in patients with severe head trauma who have undergone open reduction and internal fixation (ORIF) for isolated open tibia fractures (IOTF).

Methods: A retrospective analysis of the National Trauma Data Bank from 2007-2010 utilizing ICD-9 codes (823.10, 823.30, and 823.90) was conducted.  Cases > 18 years old with IOTF who underwent ORIF at a level I or level II trauma center were included.  Using Glasgow Coma Scale (GCS) totals patients were stratified by score (severe head injury < 8; minor head injury 8 >), with minor head injuries serving as the reference group.  Multivariate logistic regression was used to investigate postoperative complications.

Results: 9,331 isolated open tibia fractures during the study period underwent ORIF, of which 7,201 cases met inclusion criteria.  The majority were white (67%), males (74%), between 25-44 years old (42%) with private insurance (23%) and injured via motor vehicle collisions (25%). Mean days to ORIF was 2.98 sd. 7.4.  GCS mean 14.05 sd. 2.9 6.9% (n = 496) of cases had severe head injuries.  On multivariate analysis patients with severe head injuries 88% more likely to have fixation after hospital day 2, 81% increased odds of requiring transfusion, and more than three times more likely to develop acute respiratory distress syndrome (ARDS).  Odds of most infectious complications more than doubled. Development of any complication and perioperative cardiac arrest requiring CPR were also increased more than two fold, and patients had an increased relative risk for a longer than average length of stay. There was no additional risk of death. (Table 1).

Conclusion: Determining the timing of definitive fixation in IOTB in patients with severe head injuries remains a challenge.  These patients are at risk for infectious complications and an increased need for transfusion.  Notably these patients have more than threefold risk of ARDS possibly due to the severity of their head injury and requirements for prolonged ventilation.  While their management does not demonstrate an increased odds of death the risk of cardiac arrest or development of any complication warrants additional investigation for ways to reduce morbidity this small yet vulnerable population, and the role of GCS as a predictor of perioperative patient outcomes.

11.17 Troponin I in the Evaluation of Blunt Cardiac Injury Following Sternal Fracture

Posted on January 25, 2017

P. Hu1, R. Uhlich1, A. Witcher1, J. Kerby1, P. Bosarge1  1UAB,Acute Care Surgery/Surgery,Birmingham, AL, USA

Introduction:
Blunt cardiac injury (BCI) is often identified in the presence of sternal fractures in blunt trauma. Full evaluation and management of this injury remains controversial. Electrocardiogram (ECG) is the current standard in diagnosis and is recommended for any patient with possible BCI. The utility of troponins are less clear. It remains a matter of debate as to the type of troponin to be measured, the ideal timing, and required duration of monitoring.  We sought to determine the role of troponin I measurement in the evaluation of BCI following sternal fracture.

Methods:
Trauma patients admitted to an American College of Surgeons verified level I trauma center from 2011-2013 with a diagnosis of sternal fracture were identified from the trauma registry. A retrospective review of the medical record was performed to determine patient age, gender, length of stay, results of ECG, echocardiography, troponin I values, patient cardiac morbidity and mortality. The first three Troponin I levels collected during hospitalization were recorded. BCI was diagnosed by newly identified ECG abnormalities.

Results:
203 trauma patients were admitted with sternal fracture following blunt trauma. BCI was diagnosed in 89 patients by ECG. 101 patients had at least one troponin I level measured. Troponin I levels were undetectable in 15 patients with BCI compared to 14 without BCI. Mean troponin I levels were 0.328 ng/mL in patients with BCI compared to 0.055 ng/mL without. Troponin I greater than 0.1 ng/mL on admission has a positive predictive value of 89%. Negative predictive value of undetectable troponin I levels for BCI is 48%. Twelve  patients died within 30 days of hospital admission, however no deaths were due to acute heart failure, myocardial infarction, or cardiogenic shock.

Conclusion:
Troponin I levels offer little benefit following sternal fracture in excluding the possibility of blunt cardiac injury. While the presence of elevated troponins increases the likelihood of BCI, it does not appear to correlate with cardiac related morbidity or mortality.
 

11.16 Hemodynamically Abnormal Thoracoabdominal Trauma Should Undergo CT Prior To Definitive Therapy

Posted on January 25, 2017

J. Carney1, A. Strumwasser1, K. Matsushima1, D. Grabo1, D. Clark1, K. Inaba1, E. Benjamin1, L. Lam1, D. Demetriades1  1University Of Southern California,Surgery – Trauma/Acute Care Surgery,Los Angeles, CA, USA

Introduction:  The triage of hemodynamically abnormal trauma patients is debated. Controversial data suggests that hemodynamically abnormal patients can safely undergo CT prior to definitive therapy. We wished to investigate outcomes for hemodynamically abnormal thoracoabdominal trauma undergoing CT.  

Methods:  All hemodynamically abnormal (HR≥120, SBP<90 mmHg) patients arriving at our Level I trauma center in 2014 were reviewed.  Inclusion criteria were thoracoabdominal trauma patients that achieved hemodynamic normalization (SBP≥90 mmHg) and were eligible for CT.  Pregnant patients, pediatric patients (age<18), patients undergoing resuscitative thoracotomy, and isolated head, neck and extremity injuries were excluded.  Variables abstracted from the registry included patient demographics, injury mechanism, injury severity score (ISS), physical exam, E-FAST results, laboratory data, CT scan findings and operative details.  Primary outcomes included hospital length-of-stay (HLOS), ICU LOS, ventilator days and mortality.  Secondary outcomes included intraoperative data (procedure duration, fluids, blood loss), transfusion burden, incidence of venous thromboembolism (VTE), infectious complications, need for additional procedures, and total hospital cost.  Data was analyzed by unpaired Student’s t-test for continuous variables and Chi Square analysis for categorical variables with significance denoted at a p value of 0.05 or less.

Results:  A total of 201 patients met inclusion criteria. Thirty-five (17%) went directly to the OR at triage, 117 (59%) went to CT, and 49 (24%) were spared an operation. The CT and non-CT groups were well matched at baseline for age (34±2.0 vs. 38±1.2 years, p=0.1), injury burden (mean ISS-CT=18±2.7 vs. ISS-non-CT=18±0.9) and total resuscitation time (81±43.0 vs. 67±9.4 minutes, p=0.7).    No difference in time-to-normalization of lactate, HLOS, ICU LOS or mortality was observed (p>0.1 for each).  Patients undergoing CT prior to OR had increased recognition of intraabdominal injuries (89 vs. 74%, p=0.05), a significant reduction in negative explorations (2.3 vs. 8.6%, p<0.01) and a decreased need for PRBCs (2±0.6 vs. 7±2.5 units, p<0.01), FFP (1±0.3 vs. 4±1.3, p<0.01) and platelets (0.3±0.1 vs. 1±0.4 units, p=0.03) throughout admission.  Moreover, patients in the non-CT group had an increased need for surgical procedures (37.1 vs. 12.1%, p<0.01) after the index operation.  No differences were noted in any secondary outcome (p>0.1 for each).

Conclusion: Hemodynamically abnormal thoracoabdominal trauma achieving a SBP≥90 during resuscitation should undergo CT scanning prior to definitive therapy.  Imaging increases the identification of intraabdominal injuries, decreases negative explorations, decreases transfusion burden and decreases the need for additional surgical procedures without affecting morbidity, mortality or hospital cost.

 

11.15 Use of Routine Head CT After Initiation of Chemoprophylaxis in Patients with Intracranial Hemorrhage

Posted on January 25, 2017

C. L. Shelley1, P. M. Arnold2, K. Udobi1, J. Green1, A. W. Bennett1, S. Berry1, J. M. Howard1, T. McDonald1, M. Moncure1, R. Winfield1  1University Of Kansas Medical Center,Trauma Surgery,Kansas City, KS, USA 2University Of Kansas Medical Center,Neurosurgery,Kansas City, KS, USA

Introduction: Traumatic brain injury (TBI) is a risk factor for the development of venous thromboembolism (VTE). Administration of low dose unfractionated heparin (LDUH) or low molecular weight heparin (LMWH) is an effective preventive strategy for this problem, but must be weighed against the risk of progression of intracranial hemorrhage. Studies have documented safety of VTE prophylaxis in TBI; however, no series has included routine follow up head CT after chemoprophylaxis initiation. The purpose of this study was to assess progression of intracranial hemorrhage after VTE prophylaxis using routine 24-hour head CT, which is standard practice at our institution.

Methods: A retrospective review of our level 1 trauma center’s registry from January 1, 2010 to December 31, 2015 was performed. Adult patients with head CT demonstrating TBI, subsequent initiation of VTE chemoprophylaxis, and repeat head CT obtained within 24 hours of initiation of chemoprophylaxis were included. Patients with history of coagulopathy were excluded.

Results: 1,120 records were reviewed. 255 met inclusion and exclusion criteria. Median post-injury start date for chemoprophylaxis was 4 days, with 159 patients receiving LDUH and 96 receiving LMWH. No patient had neurologic decline prior to scheduled 24-hour scan. Progression of hemorrhage occurred in 9 patients (3.5%); 7 had hemorrhage at a prior intervention site, 1 had a new lesion identified, and 1 had increase in an existing injury. Progression was not significantly different between patients receiving LDUH (n=7) and LMWH (n=2) (x ²=0.95, p=0.33). No patient required surgical intervention as a result of progression.

Conclusion: There is a low rate of progression of TBI seen on routine CT after initiation of VTE prophylaxis. There is no difference in progression rates between patients receiving LDUH or LMWH, but progression is more likely if patients undergo neurosurgical intervention. Intervention for progression of TBI is unlikely after VTE prophylaxis is initiated.

 

11.14 Tachycardia Is As Bad As Bradycardia In Traumatic Brain Injury

Posted on January 25, 2017

A. Azim1, P. Rhee2, K. Ibraheem1, T. O’Keeffe1, N. Kulvatunyou1, G. Vercruysse1, A. Tang1, L. Gries1, B. Joseph1  1University Of Arizona,Trauma And Surgical Critical Care/Department Of Surgery,Tucson, AZ, USA 2Grady Memorial Hospital,Trauma And Surgical Critical Care/Department Of Surgery,Atlanta, GA, USA

Introduction:
Heart rate (HR) at initial presentation is an important indicator of hemodynamic status of the patient. However, systolic blood pressure (SBP) often takes precedence over heart rate in clinical decision-making. The aim of this study was to assess the independent effect of admission HR on mortality in traumatic brain injury (TBI) patients. 

Methods:
A one-year (2011) analysis of the National Trauma Data Bank (NTDB) was performed. Patients with TBI (head abbreviated injury scale (AIS) score ≥3) were included. Transferred patients, patients dead on arrival, and those missing vitals on presentation were excluded. Patients were stratified into groups based on admission HR. Outcome of mortality was compared for different HR groups in reference to HR range of 90-100. The association of HR groups with mortality was assessed using multivariate regression analysis after controlling for age, head AIS, gender, ISS, vital parameters, admission GCS.

Results:
A total of 48,359 patients with isolated TBI were included with mean age 41 ± 37 years, median [Range] GCS score of 15 [3-15], mean (SD) SBP of 132 (40) mm of Hg, and mean HR of 88 ± 29 bpm. The overall mortality rate was 8.9% (n=4,321). Patients with HR >100 were 25% more likely to die compared to patients with HR between 90-100 (OR: [95% CI]: 1.253 [1.117-1.404], p<0.001).  Mortality in patients with heart rate <90 was 23% higher than patients with HR between 90-100 (OR: [95% CI]: 1.23 [1.103-1.371], p<0.001). Patients with HR in the range of 80-90 bpm had the lowest mortality rate among the groups (p<0.001). With every 10 bpm increase or decrease from HR range of 90-100, mortality increases.

Conclusion:
Admission heart rate is independently associated with mortality in TBI patients regardless of their presenting SBP and GCS. The results of our study demonstrate a curvilinear association towards both extremes of heart rate. Patients who are either tachycardic or bradycardic have an associated increased mortality and warrant careful evaluation.

11.13 Mortality Rates of Severe Traumatic Brain Injury Patients: Impact of Direct vs. Non-direct Transfers

Posted on January 25, 2017

K. Prabhakaran1, P. Petrone1, G. Lombardo1, C. Stoller1, A. Betancourt1, A. Policastro1, C. P. Marini1  1Westchester Medical Center University Hospital,Trauma/Surgery/New York Medical College,Valhalla, NY, USA

Introduction: Direct transport of patients with severe traumatic brain injury (STBI) to trauma centers (TCs) that can provide definitive care results in lower mortality rates. Secondary transfers are required when patients with STBI are originally transported to non-trauma centers (NTCs) lacking in neurosurgical expertise, and thus resulting in delay of care. This study investigated the impact of direct versus non-direct transfers on the mortality rates of patients with STBI.

Methods: Data on patients with TBI admitted between 1/1/2012 to 12/31/2013 to our Level I TC were obtained from the trauma registry. Data included patient age, sex, mechanism and type of injury, co-morbidities, Glasgow Coma Scale (GCS), Injury Severity scores, pre-hospital time (PHT), time to request and to transfer, time to initiation of multimodality monitoring and goal-directed therapy protocol (MM&GDTP), dwell time in the emergency department (EDT), and mortality. Data, reported in means ± SD, were analyzed with the student t-test and chi-square. Statistical significance was accepted at a p value < 0.05.

Results:

STBI Direct transfer to TC vs. transfer from NTC: Of the 1,187 patients with TBI admitted to our TC, 768 (64.7%) were directly from the scene while 419 (35.3%) were after secondary transfer. 171 (22.2%) of the direct transfers had GCS < 8 (STBI) and 92 (21.9%) of the secondary transfers had STBI.

Transfer time: Time from scene to arrival to the ED was significantly shorter for TC vs. NTCs 43 ± 14 vs. 77 ± 26 minutes, respectively (p < 0.05). ED dwell time before transfer and time from injury to arrival to TC were 4.2 ± 2.1 and 6.2 ± 8.3 hr, respectively.

MM&GDTP: Time to initiation of MM&GDTP including craniotomy for patients with STBI was 3.1 ± 1.2 vs. 12.4 ± 2.2 hr, for patients arriving from scene to TC as opposed to patients transferred from NTC (p<0.05).

Mortality: There was a statistically significant lower mortality for patients with STBI transferred directly from the scene to TCs as opposed to patients transferred from NTCs, 33/171 (19.3%) vs. 28/92 (30.4%), respectively (p<0.05).

Conclusion: To decrease TBI-related mortality, patients with suspected STBI should be taken directly to a Level I or II TC unless they require life-saving stabilization at NTCs.

 

11.12 Non-Alcoholic Fatty Liver Disease (NAFLD) Is Associated With Increased Post-Traumatic Pneumonia

Posted on January 25, 2017

J. A. Bailey1, L. Brown1, A. Y. Parikh2, R. H. Wachsberg1, A. Kunac1, B. Koneru1, D. H. Livingston1  1New Jersey Medical School,Newark, NJ, USA 2Morristown Medical Center,Morristown, NJ, USA

Introduction:  Non-alcoholic fatty liver disease (NAFLD) has become epidemic in the US and has been associated with pulmonary complications following elective surgery and liver transplantation, but has not been considered as a comorbidity after trauma. Abdominal CT scanning can detect moderate-to-severe fatty infiltration of the liver. We hypothesized that trauma patients with pulmonary complications would have an increased incidence of pre-existing NAFLD compared to the trauma population at-large. 

Methods:  Data on adult ICU trauma patients with the diagnosis of ventilator-associated pneumonia (VAP) (N=147) were extracted from a prospective ICU respiratory database. Presence of NAFLD was identified using defined metrics comparing liver-to-spleen density on their admission abdominal CT. Analysis included demographics, ventilator and ICU days, respiratory failure, recurrent pneumonia, bacteriology, and mortality. To determine the baseline prevalence of NAFLD in the trauma population, 130 additional consecutive trauma patients who underwent abdominal CT on admission were analyzed.  

Results: The prevalence of NAFLD in the general trauma population was 27%. In contrast, NAFLD was present in 50% of trauma ICU patients who went on to develop VAP (p=0.001).  Known risk factors for VAP were similar in patients with and without NAFLD:  age (43 vs 49 years), BMI (28 vs 28), emergent intubation (68% vs 65%), TBI with head AIS ≥3 (31% vs 32%), and ISS (30 vs 33).  There were no differences in bacteriology, ventilator days or ICU stay.   

Conclusion: The presence of NAFLD on admission CT was significantly higher in ICU patients with post-traumatic VAP compared to the baseline trauma population. Given other risk factors were equal, we postulate that NAFLD may represent a pre-existing inflammatory focus that may alter the immune response to injury and represent an independent risk factor for post traumatic VAP.  The mechanisms for the increase in VAP remain speculative but this novel observation requires further prospective study, which might provide potential avenues of intervention to decrease the incidence of post-traumatic VAP. 

11.11 The Role of Cardiopulmonary Resuscitation Following Traumatic Arrest

Posted on January 25, 2017

P. Hu1, R. Uhlich1, J. Kerby1, P. Bosarge1  1UAB,Acute Care Surgery/Surgery,Birmingham, AL, USA

Introduction:
Cardiac arrest following traumatic injury is almost universally fatal. Resuscitation strategies vary depending on mechanism of injury and length of arrest. While little evidence has been published to support its use following traumatic arrest, cardiopulmonary resuscitation (CPR) remains recommended as definitive therapy following injury. We sought to evaluate the outcomes of patients suffering traumatic arrest following CPR.

Methods:
All adult trauma patients that presented to an American College of Surgeons verified level I trauma center with cardiac arrest from June 1, 2014 to August 1, 2016 were identified. Patients in arrest secondary to obvious traumatic brain injury, anoxic brain injury, burn inhalation injury or any patient undergoing resuscitative thoracotomy were excluded. Data including mechanism of injury, demographics, duration of pre and in hospital CPR, initial cardiac rhythm, any identified procedures, blood product utilization, mortality data, and disposition from hospital were collected. 

Results:
183 cases of CPR following traumatic arrest were identified. Of those, 87 were identified as meeting inclusion criteria. The majority of patients were male (78.2%) and the mean age was 47.1 years. Patients suffered mainly blunt injury (75.9%) compared to penetrating trauma (24.1%). 42 patients received CPR upon arrival in the emergency department, compared to 8 patients with isolated prehospital CPR and 37 patients receiving both. Mean prehospital CPR duration was 21.9 (0-60) minutes whereas mean isolated ED CPR time was 18.0 (0-80) minutes.  Of those receiving CPR, return of spontaneous circulation (ROSC) occurred in only 8 patients (9.2%), none of whom received prehospital CPR. All underwent attempted operative intervention following ROSC. Mean CPR time was 3.6 (2-5) minutes with one lone survivor receiving 2 minutes of CPR while en route to the operating room. Overall, patients received on average 10.2 units of blood products. No patient presenting with asystole (39) and only one with PEA (35) survived to attempted operative intervention.

Conclusion:
For patients suffering traumatic cardiac arrest, short duration CPR may be beneficial as a bridge to immediate hemorrhage control. Prolonged periods of CPR without hemorrhage control are likely futile and unlikely to result in survival. 
 

11.10 Effects of Missed or Off-Schedule Doses of Antibiotics on Patient Outcomes

Posted on January 25, 2017

C. Patel1, M. Swartz1, J. Tomasek1, L. Vincent1, W. Hallum2, J. Holcomb1  1University Of Texas Health Science Center At Houston,Houston, TX, USA 2Memorial Hermann Hospital,Houston, TX, USA

Introduction: When delivered according to the appropriate schedule, antibiotics (Abs) improve outcomes. Missing doses of Abs is a well described but an inadequately recognized issue. We hypothesized that missing doses of Abs decreases quality of care.

Methods: A retrospective study on all patients admitted to the Shock Trauma ICU from February to June 2015 was performed. Patients prescribed a course of Abs were evaluated, those given prophylactic or one dose were excluded.  A missed Ab dose was one planned but never given (a completely missed dose) or a dose that was not given within an hour before or after the planned time (an off-schedule missed dose). Abs given ± one hour is the standard ICU guideline. There were valid and non-valid reasons for completely missing a dose. Valid examples included a change in the order, doses held by an MD, high drug levels or dosing conflict. Non-valid examples included patient off unit and unknown. Patient outcomes included a positive culture, sepsis, ventilator, ICU and hospital days and mortality. Multiple statistical methods were used as appropriate, significance was set as p<0.05.

Results: 280 patients were admitted, 200 met inclusion criteria and 8167 doses of Abs were ordered. 8% of patients (16/200) did not miss any Ab doses, 38% (77/200) had off-schedule missed doses, 43% (86/200) missed a dose for non-valid reasons and 10% (21/200) missed doses for valid reasons. The median Ab doses ordered for those who did not miss doses was 4 (3, 6), while 26 (9, 53) were ordered for those who did miss doses (p<0.0001). All demographic data (age, BMI, ISS) were similar between patients who did and did not miss doses of Abs.
8167 total doses of Abs were ordered and 25% were missed. 21% of doses (1729/8167) were off-schedule, 2.3% (189/8167) were completely missed for non-valid reasons, and 1.3% (113/8167) were completely missed for valid reasons. Among off-schedule doses (1729/8167), the median number of hours off-schedule was 2 (2, 2) for both late doses and early doses.
Unadjusted analysis showed that patients who missed Abs had a higher rate of sepsis (p=0.01), while those who missed a dose of Abs for non-valid reasons spent more days on a ventilator (p=0.03) and in the hospital (p<0.0001) than patients who did not miss any doses.
Adjusting for age, gender, BMI, ISS and doses of Abs showed that those who completely missed a dose for non-valid reasons spent 50% more days in the hospital (p=0.01) than patients who did not miss any doses of Abs, while patients who only had off-schedule missed doses spent 54% more days in the hospital (p=0.004). Sepsis, mortality, days on ventilator, and days in the STICU were not significant when adjusted for covariates.

Conclusion: Missing doses of antibiotics (both completely and off-schedule) correlated with a substantial increase in length of hospital stay. To optimize quality of care, methods to improve compliance with antibiotic dosing schedules should be investigated. 

 

11.09 Validation of a Field Spinal Motion Restriction Protocol

Posted on January 25, 2017

J. M. Tatum1, N. Melo1, A. Ko1, N. K. Dhillon1, M. W. Choi1, E. J. Smith1, D. A. Yim1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Division Of Trauma And Critical Care, Department Of Surgery,Los Angeles, CA, USA

Introduction: Routine spinal motion restriction after traumatic injury has been a mainstay of pre-hospital trauma care for over three decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met.

Methods: In January, 2014 the Department of Health Services of the City of Los Angeles, California implemented revised guidelines for cervical spinal motion restriction after blunt mechanism trauma. Adult patients (≥18 years old) with an initial GCS of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following one-year period were retrospectively reviewed. Demographics, injury data, and pre-hospital data were collected. Cervical spine injury (CSI) was identified by ICD-9 codes.

Results: 1,111 patients were presented to the trauma center by emergency medical services after sustaining blunt mechanism trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients with a documented evaluation were included in our analysis. Spinal motion restrictions were not implemented in 172 (17.2%) in accordance with the protocol. The rate of spinal cord injury among all patients was 2.2% (22/997) and 1.2% (2/172) in patients without spinal motion restrictions. The sensitivity and specificity of the protocol is 90.9% (95% CI: 69.4-98.4) and 17.4% (95% CI: 15.1-20.0), respectively, for cervical spine injury. Two patients with CSI (9.1%) arrived without immobilization, having met field clearance guidelines. Both were managed non-operatively and had no neurological compromise.

Conclusion: New guidelines for cervical spinal motion restriction have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions there were no negative clinical outcomes. A pre-hospital selective approach to implementing cervical spinal motion restriction is safe.

11.08 Institutional Experience with Suspected Non-Accidental Trauma

Posted on January 25, 2017

C. N. Litz1, P. D. Danielson1, N. M. Chandler1  1Johns Hopkins All Children’s Hospital,Division Of Pediatric Surgery,St. Petersburg, FL, USA

Introduction: Suspected non-accidental trauma (NAT) victims comprise a significant portion of the pediatric trauma population. There is no gold standard method of confirming NAT; instead, the diagnosis is made after a comprehensive evaluation by a child protective services (CPS) team. The purpose of this study was to compare the clinical and social outcomes between patients with suspected NAT (SUSP) and confirmed NAT (CONF).

Methods: Following IRB approval (No. 00082930), our institutional trauma registry was retrospectively reviewed for patients aged 0-18 years presenting from 2007 to 2012. Patients with traumatic injuries suspicious for NAT were included. NAT was diagnosed after evaluation by our CPS team. Patients with suspected and confirmed NAT were compared. General admission and outcome data were collected and analyzed.

Results: There were 281 patients with traumatic injuries suspicious for NAT; 170 were CONF and 111 SUSP. The groups did not differ in age (CONF 0.9 ± 1.1 vs SUSP 1.2 ± 2 years, p=0.16). CONF patients presented with a higher heart rate (142 ± 27 vs 128 ± 23 bpm, p<0.0001), lower systolic blood pressure (100 ± 18 vs 105 ± 16 mm Hg, p < 0.05), lower Glasgow Coma Score (12 ± 4 vs 15 ± 1, p <0.0001), and a higher Injury Severity Score (15 ± 11 vs 9 ± 5, p<0.0001). A significantly greater percentage of CONF patients were admitted to the intensive care unit (42% vs 8%, p<0.0001). CONF patients had significantly higher mortality (8.2% vs 0%, p<0.0001). CONF patients had a significantly longer overall length of stay (LOS) (7.8 ± 9.8 vs 1.6 ± 1.3 days, p <0.001), as well as a longer LOS after being medically cleared for discharge (1.2 ± 1.7 vs 0.2 ± 0.4 days, p<0.0001). Significantly fewer CONF patients were discharged with parents or other family members (54% vs 100%, P<0.0001) (Table 1).

Conclusion: Patients with a confirmed diagnosis of NAT present with more severe injuries and arrive less hemodynamically stable compared to patients in whom NAT is suspected and ruled out. In addition, patients with confirmed NAT require increased hospital resources and are less likely to be discharged to the care of parents or family members. This study emphasizes the fact that NAT patients are a high-risk subset of the pediatric trauma population, and suggests that providers should have an increased suspicion for true non-accidental trauma in patients being evaluated for possible NAT who present with more severe injuries.

11.07 EARLY POSITIVE PRESSURE VENTILATION IN TRAUMA PATIENTS WITH FACIAL AND SKULL BASE FRACTURES

Posted on January 25, 2017

M. C. Spalding1,2, D. E. Leshikar1,3, C. Hester1, C. T. Minshall1  1Parkland, UT Southwestern,Burn/Trauma/Critical Care Surgery,Dallas, TEXAS, USA 2Grant Medical Center, Ohio University College Of Osteopathic Medicine,Trauma And Acute Care Surgery,Columbus, OHIO, USA 3UC Davis,Trauma, Acute Care Surgery And Surgical Critical Care,Sacramento, CA, USA

Introduction: There are over 1.7 million traumatic brain injuries annually. Thirty percent of these patients present with associated skull fractures and maxillofacial fractures (SMXFX). Despite a paucity of evidence, consulting services ENT, OMFS, Plastic Surgery and Neurosurgery will restrict pulmonary recruitment techniques: incentive spirometer or bi-level positive airway pressure (BiPAP) secondary to the alleged risk of post-traumatic meningitis. These imposed limitations are not evidence-based and are potentially dangerous in patients with marginal pulmonary effort. We initiated an aggressive noninvasive respiratory protocol (NRP) to improve pulmonary recruitment for all patients with SMXFX and minimal pulmonary reserve. We prospectively evaluated the effect of therapy on the incidence of meningitis, pneumothorax, pneumocephalus or need for re-intubation on patients with SMXFX.

Methods: This is a prospective evaluation of all trauma patients with SMXFX admitted to the SICU of a Level I Trauma Center from 1/2015 to 12/2015. Patients with SMXFX were required to perform incentive spirometer (IS) every 4hrs under direction of respiratory therapy after 48 hours from time of injury. Patients that were not capable of achieving > 30% of predicted volume (PV) using IS were also started on BiPAP treatment every 4 hrs. Liberation from BiPAP therapy occurred when patients achieved > 50% PV on IS for two consecutive treatment sessions.  We tracked the incidence of new or worsening pneumocephalus, worsening pulmonary failure, pneumothorax, SICU readmission, meningitis, and deviations from protocol.

Results:Seventy five patients with complex SMXFX were admitted to the SICU during the study period. Eighty two percent of these patients received IS therapy every 4 hours with a mean start time of 48 hours from admission. The mean inspiratory capacity for patients who progressed to BIPAP was 32% of PV. The average number of BIPAP treatments per patient in this group was 39 and these treatments achieved a mean volume of 1345 ml. One patient was intubated after initiation of the NRP for progressive respiratory failure. There were no cases of meningitis, pneumothorax, need for re-intubation or pneumocephalus

Conclusion:Early implementation of the proposed NRP is safe for patients with complex SMXFX within 48 hour injury or closure of a CSF leak. Since these results we have advanced our volume recruitment strategies for complex SMXFX patients to be implemented in the first 24 hours after admission for those without a cerebral spinal fluid (CSF) leak, or 24 hours after documented closure of the CSF leak.

 

11.06 State Trauma Alert Criteria Versus Paramedic Judgment: A Comparative Analysis

Posted on January 25, 2017

T. Husty1, M. Crandall1, D. Chesire1, D. Ebler1  1University Of Florida,Surgery,Jacksonville, FL, USA

Introduction: The State of Florida Adult Trauma Triage Criteria defines specific parameters that prompt paramedics to initiate a trauma alert, including injury mechanism and vital signs. In addition to these predefined criteria, paramedics may initiate an alert based on their own judgment. This activation is known as an alert based on Paramedic Discretion (PD). Our aim was to identify predictors of PD activations and to compare the outcomes of trauma patients who met objective alert criteria versus PD. 

Methods:  This is a retrospective observational study which included all trauma patients 18 years and older evaluated in our trauma center from January 1, 2007 to December 31, 2014. Demographic and injury severity variables were obtained from our trauma registry and outcomes were compared between patients who met state alert criteria and those who were brought by PD.  We performed bivariate and multivariate statistics using SPSS and STATA.

Results: There were 13,305 patients who met state alert criteria and 1,188 alerted due to PD during the study period. Patients who were activated by state criteria had lower mean Glasgow Coma Scores [12 vs 14, p<0.001] and systolic blood pressures [126 vs 133, p<0.001].  On initial evaluation, 822 (6.4%) who met alert criteria and 14 (1.2%) activated via PD died [OR 3.7, 95% CI 2.5-5.5, p<0.001].  Admission rates were similar for both groups, as were lengths of stay.  Regression modeling was unable to find independent or combinations of vital signs or demographics that would predict PD alerts [OR 1.4, 95% CI 0.74-2.62, p=0.31].  On multivariate modeling, PD was not an independent predictor of mortality or length of stay after controlling for injury severity and demographics.

Conclusion: As expected in an established trauma triage protocol, the mortality was higher for patients who met TA criteria but crude admission and discharge rates were similar. Though regression analysis could not elucidate predictors of PD, these results suggest PD may identify a subset of patients that benefit from trauma center evaluation.  However, PD itself does not appear to be an independent predictor of mortality or length of stay after controlling for injury severity.  In summary, PD remains a reasonable adjunct to state activation criteria, but further research into PD would help refine and codify these criteria.

 

11.05 Tranexamic Acid is Associated with Increased Mortality in Patients with Physiologic Levels of Fibrinolysis

Posted on January 25, 2017

H. B. Moore1, B. Huebner1, T. L. Nydam1, G. Settler1, G. Nunns1, C. C. Silliman1, A. Sauaia1, E. E. Moore1  1University Of Colorado Denver,Surgery,Aurora, CO, USA

Introduction: Utilization of tranexamic acid (TXA) in trauma remains debated.  While European guidelines recommend empiric TXA in hypotensive trauma patients, many trauma centers in the United States question this practice.  Recent appreciation of the spectrum of fibrinolysis acutely after injury has identified an associated protective effect of a moderate level of fibrinolysis.  There are concerns that TXA may harm this patient population.  TXA administration at our trauma center is goal directed on rapid thrombelastography (rTEG) LY30 results, although clinicians can empirically administer TXA if they believe it is indicated.   We hypothesize that this is a futile intervention and poses the risk of increased mortality in patients with physiologic fibrinolysis levels.

 

Methods: Trauma activations from 2015-2016 with blood samples obtained in the ambulance or emergency department were analyzed with rTEG.  Patients included in the analysis had an LY30 between 0.8 and 2.9 (previously defined as physiologic fibrinolysis).  Demographics, clinical variables, and blood product utilization were collected by prospectively by trained research assistants.  The primary outcome of interest was in hospital mortality contrasted between patients who received TXA and no TXA. Confounders(age, NISS, systolic blood pressure(SBP), Glasgow Coma Score(GCS), RBC transfusion in the first 2 hours from injury) were adjusted with multivariate logistic regression and cox regression analysis.

 

Results:  Fourtny nine percent of patients (141/291) were identified to have physiologic levels of fibrinolysis  The median NISS was 27 and mortality rate was 6% (significantly less than hyperfibrinolysis 20% and shutdown 16% p=0.004). Patients with physiologic phenotype were given TXA 5% of the time and delayed delivery(>3 hours) occurred in 38% of patients. NISS was higher but not significant in patients given TXA (48 vs 27p=0.334), while SBP (108 vs 118 p=0.325) and GCS were similar (15 vs 15 p=0.779). TXA patients received more RBC units at hour 1 and 2 during resuscitation (1 vs 0 p<0.001 and 2 vs 0 p=0.001). Mortality was significantly higher in the TXA group 38% vs 4% (p=0.004). After adjusting for confounders TXA was significantly associated with increased mortality in logistic regression analysis (p=0.024) and cox regression (HR 14.5 p=0.042). In patients with hyperfibrinolysis there was no differnce in survival with TXA use before (p=0.521) and after adjustment (p=0.531).

 

Conclusion:Patient's with physiologic levels of fibrinolysis that receive TXA have increased mortality compared to patients who did not receive this medication.  While the TXA patients had an overall higher requirement of blood products and were given this medication based on clinician gestalt, there was no observed benefit. These data support the continued concerns of empiric utilization of TXA, and has identified a potential danger of giving this medication to patients who present to the hospital with physiologic levels of fibrinolysis. 

 

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