85.13 Personalized Massive Transfusions: A Primer for Rural and Critical Access Hospitals

Posted on January 26, 2017

J. Tung1, K. A. Hollenbach1, S. Desjardins1, B. S. Prato1, T. E. Hayes1, R. S. Kramer1, J. F. Rappold1  1Maine Medical Center,Acute Care Surgery,Portland, ME, USA

Introduction: Recent evidence supports the use of a 1:1:1 ratio of packed red blood cells (pRBC)/fresh frozen plasma (FFP)/platelets (Plts) for trauma patients undergoing massive transfusions (MT). For many rural and critical access hospitals (RCAH) this is not feasible. Additionally, new evidence supports altering the definition of MT from ≥ 10units pRBC/24 hrs to ≥ 3 units pRBC/h which seems to better predict injury severity and mortality. The purpose of this study was to evaluate a personalized MT process coordinated and run by a single dedicated transfusion medicine specialist in a resource constrained rural Level I trauma center.

Methods: A retrospective review of all trauma patients admitted to our rural Level I trauma center was conducted from 1 January 2014 to 31 December 2015. Data on the amount of blood products transfused, mechanism of injury, injury severity score (ISS), patient outcomes and standard demographic data were collected. Additionally, a MT algorithm was developed and employed by the dedicated transfusion specialist allowing for a consistent approach to all institutional MTs.

Results: see Table.

Conclusion: In this small retrospective study of a rural trauma center the addition of a dedicated transfusion medicine specialist appears to result in improved survival among trauma patients requiring MT despite not being able to support a 1:1:1 transfusion ratio. Whether this is related to increased use of cryoprecipitate and/or the evolving experience of the transfusion specialist remains to be determined. This methodology has broad implications for RCAH facilities and warrants additional study for validation. Further, the use of fresh whole blood (FWB) may offer a solution for facilities unable to support a dedicated transfusion specialist and who are unable to meet the preferred 1:1:1 transfusion ratio

 

85.12 Assessment of Hemodynamic Response to Fluid Resuscitation Of Patients With Intra-abdominal Sepsis in LMICS.

Posted on January 26, 2017

E. ABAHUJE1, R. RIVIELLO2, F. NTIRENGANYA1  1National University Of Rwanda,SURGERY,Butare, , Rwanda 2Brigham And Women’s Hospital,Boston, MA, USA

Introduction:
Management of patients with severe sepsis and septic shock due to intra-abdominal infection includes resuscitation with intravenous fluids, anti-microbial therapy and timely control of the source of infection. These patients need to achieve adequate hemodynamic status before being taken to the operating room. Several parameters (urinary output, vital signs, inferior vena cava collapsibility index, and central venous pressure) are being used to assess hemodynamic response to fluids resuscitation, but the options are still few in limited resource settings. This study aimed at assessing if a bedside performed ultrasound to assess the inferior vena cava collapsibility index is superior to urinary output in assessing hemodynamic response to fluid resuscitation.

Methods:
This study was carried out on patients of 18 years and above who presented with intra-abdominal infection and who needed intravenous fluid resuscitation prior to being taken to the operating room. At admission, before intravenous fluids (IVF) administration, the baseline inferior vena cava collapsibility index (IVC-CI) and vital parameters were recorded. After initiation of resuscitation with IVF, serial measurement of IVC-CI and urinary output were recorded every two hours until the decision was made to take the patient to the operating room.

Results:

24 patients were enrolled, 79.2% were male . Time from onset of the symptoms to time of admission to our hospital ranged from 1 to 21 days with a mean duration of symptoms of 4.7 days. 4 patients (16%) had altered mental status as a result of septic shock.

 50% off all the patients had generalized peritonitis due to gangrenous bowel as the clinical diagnosis.

 

The mean of difference between time of hemodynamic response based on IVC-CI versus urinary output was 2 hours. Mean time from admission to time of fluid response based on inferior vena cava collapsibility index was 0.708 (0.39-1.03) while the mean time from admission to time of hemodynamic response based on urinary output was 2.708 (1.85-3.57) with a p-value less than 0.05 (0.000)

Conclusion:
This study suggests that measurement of the inferior vena cava collapsibility index can provide early detection of hemodynamic response to fluid therapy in patients with intra-abdominal infection with spontaneous breathing compared to urinary output.

85.11 Worsening head bleeds in the anticoagulated elderly: delayed CT head fails to change management

Posted on January 26, 2017

D. Scantling1, R. Gruner1, R. Kucejko1, S. Reid1, B. McCracken1  1Hahnemann University Hospital,Surgery,Philadelphia, PA, USA

Introduction:

Increases in active lifespan have created a new generation of elderly trauma patients. The majority of these

patients suffer blunt trauma and many are anticoagulated. The literature regarding routine use of repeat

head CT in elderly patients with an initial ICH on CT is varied when no clinical change has occurred. We

hypothesized that routine delayed CT-head (D-CTH) in elderly blunt trauma victims would not change clinical

management.

Methods:

A retrospective chart review using our institutional trauma registry of patients ≥65 years sustaining blunt

head injuries from 2010-2012 was performed. Patients on anticoagulation who had an ICH present on initial

CT who received routine D-CTH were included. Of 268 anticoagulated elderly patients admitted for blunt

head injury, 25 met inclusion criteria. 9 patients were excluded for clinical deterioration before second CTH.

Demographics, injuries, medications, laboratory values, LOS, GCS, and management were analyzed.

Results:

Of the 25 patients who met inclusion criteria, 4/25 (16%) asymptomatic patients had a worsened ICH on D-

CTH. One had a change in management due to D-CTH (4%, p=0.16) and underwent craniotomy. The

median GCS of all included patients was 15. Patients who were found to have a worsening ICH had a median

GCS of 14. The single patient, who received a craniotomy as a result of an early repeat CTH, had an

admitting GCS of 9. 3 of 4 patients with worsened incidental D-CTH required no intervention. One patient

was found to have a worsening bleed on 2 nd D-CTH with a stable 3 rd D-CTH. After developing neurologic

changes (aphasia), a 4 th CTH resulted in hematoma evacuation after identifying a worsened ICH.

Conclusion:

Elderly trauma patients taking anticoagulants with an ICH on initial CTH, who have an adequate baseline

mental status and are clinically asymptomatic, do not necessitate routine D-CTH and may over utilize

healthcare resources. D-CTH in patients with a stable, unchanged neurologic exam does not alter clinical

management. In patients with diminished GCS or unreliable neurologic examination obscuring clinical

changes, it may be reasonable to routinely obtain repeat CTH.

85.10 Deadliest Catch: The Epidemiology of Fishing Related Injuries Presenting to US Emergency Departments

Posted on January 26, 2017

A. Talukder1, C. J. Mentzer3, P. Martinez-Quinones1, S. B. Holsten1, J. R. Yon2  1Augusta University,Department Of General Surgery, Medical College Of Georgia,Augusta, GA, USA 2Swedish Medical Center,Acute Care Surgery,Englewood, CO, USA 3University Of Miami,Trauma And Critical Care, Surgery,Miami, FL, USA

Introduction: Recreational fishing is a pastime undertaken by an estimated 35.2-57.9 million Americans. Traditionally viewed as a low risk activity, the equipment and environmental aspects of fishing pose some inherent risk.

Methods: Fishing related injuries captured by the US Consumer Product Safety Commission National Electronic Injury Surveillance System (NEISS) from 2010 to 2014 that presented to US Emergency Departments were reviewed. Injury context, severity and outcomes were examined.

Results: 6,673 patients were included in the NEISS from 2010 to 2014. 80.44% of the patients were male and Caucasian, 58.76% of injuries occurred primarily in two distinct age groups 11-20 (1,214) and 41-50 (1,021). The most common reported injury was related to the presence of a foreign body (3,726) and affected primarily the extremities (3,055). Distribution of extremity injury was as follows: Finger (1,734), Toe (69), Foot (213), Hand (435), Upper Leg (61), Upper Arm (46), Ankle (17), Lower Leg (176), Knee (37), Wrist (26), Lower Arm (202) and elbow (18). The majority, 96.5%, of all patients were treated and released while 2.7% of all patients were admitted. Further analysis of injury patterns and disposition was completed.

Conclusion: The most commonly injured body part was the upper extremity, primarily the finger due to laceration, puncture, or foreign body–usually a fishing hook. Inpatient admission most frequently occurred following presentation of acute onset chest pain, head injuries, syncope, and drowning. The identification of specific activity related injury patterns will allow for the development of identifiable preventive measures.

 

85.08 Evaluation and Management of Metacarpal and Phalanx Fractures at a Community Hospital

Posted on January 26, 2017

D. S. Urias1, E. Lotton1, K. Shayesteh1  1Conemaugh Memorial Medical Center,Surgery,Johnstown, PA, USA

Introduction:

Hand fractures are the second most common fracture in the upper extremity and can be missed in the setting of life threatening injuries. These fractures contribute to a loss in millions of dollars in days off work and billions in healthcare annually. The associated loss of function/pain, and high estimated health care/productivity costs have encouraged us to investigate fracture patterns of the hand in the trauma population to determine if a link was present. Thus help trauma services decrease morbidity by decreasing the time to intervention and decrease the economic burden.

Methods:

We conducted a retrospective, observational study, at Duke Life Point-Conemaugh Memorial Medical Center a rural Level 1 Trauma center in Johnstown, PA, to investigate the mechanism, patterns of injury and management for fractures of the phalanges/metacarpals encountered in trauma patients. The study period was January 2011 – October 2014 and included all patients evaluated and admitted by the trauma department with hand fractures.

Results:

During the four year period, 4,378 trauma patients were evaluated and admitted, of which 2% experienced 107 fractures of the hand. The most common mechanism of injury was motor vehicle accident (MVA) occurring 59% of the time. Metacarpal fractures accounted for the majority of the fractures at 61% with phalangeal fractures accounting for 39%. The little metacarpal was the most commonly fractured bone contributing to 21% of all fractures. When categorized by mechanism of injury the most common fracture for those involved in an MVA was the little metacarpal at 22% and the thumb metacarpal was the second most common at 19%.

Conclusion:

The fracture pattern identified in our study is an adjunct to the National Hospital Ambulatory Medical Care Survey of 1998 of all emergency room visits, where they reported on both hand and forearm fractures. They found falls to be the most common mechanism at 47% (MVA ranked fourth at 7%), with the metacarpals accounting for 18% of all hand and forearm fractures. Thus, our study provides additional data for evaluating the trauma patient in the acute setting to decrease the likelihood of missed injuries.

85.07 Repeat CT Scan Improves Accuracy in Evaluating for Delayed Exploration after Blunt Abdominal Trauma

Posted on January 26, 2017

M. A. Brooke1, G. P. Victorino1  1University Of California – San Francisco,General Surgery,San Francisco, CA, USA

Introduction: Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed non-operatively. Our hypothesis was that repeat CT would accurately identify the need for an exploratory laparotomy in this clinical situation.

Methods: From 2005-2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified 52 patients who underwent repeat CT of the abdomen within 72 hours for the documented, specific purpose of re-evaluating potential intra-abdominal injuries. CT findings were categorized into either presence or absence of an indication for exploration based on the CT, allowing a sensitivity analysis.

Results: Of the 52 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 43 did not. Three of the explorations were negative for significant intra-abdominal injuries. Admission clinical indicators such as GCS, ISS, and AIS were not statistically different between the operative and non-operative groups. The second CT was performed significantly earlier after the first scan in patients who received an operation compared to the non-operative group (10.3 vs. 33.2 hours, p=0.003). Compared with initial abdominal CT scan, repeat CT scan was found to increase the sensitivity for the detection of an operative indication from 67 to 100%, while also improving the specificity, positive predictive value (PPV) and negative predictive value (NPV)(Table 1).

Conclusions: Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed non-operatively for delayed operative intervention. The second CT scan improves the sensitivity of CT evaluation to 100% while also increasing the specificity, PPV, and NPV. Repeat CT can help guide decision-making in those patients lacking clinical signs mandating exploration.

 

85.05 Hip Fracture Patients Exhibit Improved Outcomes Compared To Uninjured Patients After A Fall

Posted on January 26, 2017

R. Lindborg1, A. Jambhekar1, V. Chan1, B. Fahoum1, J. Rucinski1  1New York Methodist Hospital,Brooklyn, NY, USA

Introduction:
Falls are the leading cause of injury, death, and disability in senior citizens. Up to 1% of falls lead to hip fractures which are associated with significant morbidity and decreased functional outcomes. In contrast the population of patients who fall and do not suffer any traumatic injuries has not been well studied.  The objective of this study was to determine if falls in elderly patients result in similar hospitalization outcomes.

Methods:

Data was prospectively collected on 153 patients who fell from July 1, 2015 to February 29, 2016. All patients over the age of 65 who were also evaluated by Trauma Surgery were included. Patients were divided into those with hip fractures (n = 123) and those with no injuries (n = 25). Length of stay (LOS), mortality, discharge disposition, and 30 day readmission rate were analyzed using the student’s unpaired T-test and chi square tests.

Results:
LOS was similar between the groups with an average of 5.08 +/- 1.99 days for uninjured patients compared to 6.06 +/- 1.14 days for patients with hip fractures (p = 0.25). The two groups had equal mortality rates (4% vs. 4.1%, p = 1.0). Hip fracture patients were more likely to be discharged to subacute rehabilitation facilities (74.8% vs. 32%, p < 0.0001). Additionally, 30 day readmission rates were significantly lower for patients with hip fractures (0.8% vs. 16%; p<0.0001).

Conclusion:
Falls in the elderly are associated with significant morbidity. In the current study, patients with hip fractures and those with no injuries had similar lengths of stay and mortality rates. Hip fracture patients were more likely to be discharged to a rehabilitation facility and less likely to be readmitted within 30 days in part due to established systems of care. All elderly patients who fall require multidisciplinary care to improve outcomes regardless of the injury sustained.
 

85.04 A Very Unhappy Birthday

Posted on January 26, 2017

P. P. Patel1, E. Clark1, K. Cerasoli1, C. F. McNicoll1, C. W. Katona1, P. R. McGrew1, P. J. Chestovich1  1University Of Nevada,School Of Medicine,Las Vegas, NV, USA

Introduction:

Experience has shown the incidence of traumatic injuries spikes during the summer, holidays, and weekends.  Many epidemiology studies have demonstrated deviations from expected mortality rates with peaks on birthdays. We hypothesized that there was an increased incidence of traumatic injuries on one's birthday, which may be linked to risky behavior resulting in increased mortality

Methods:

We retrospectively reviewed all patients admitted to our Level 1 trauma center during a 10-year period from January 1, 2006, to December 31, 2015. Demographic and resuscitation data were obtained from our trauma registry.  A cohort of patients that were injured on their birthday were selected and further analyzed.  Data points included gender, mechanism of injury, and injury severity score (ISS).  Additional points linked to behavior assessed if the patient was visiting the city as tourist, if there was suspicion for alcohol or drug use, and if proper safety equipment was utilized. Patients entered as a Doe were excluded.

Results:
A total of 29,657 patients were seen during this 10 year span of which 339 (1.14%) patients were injured on their birthday.  Within this cohort, 248 (73%) patients were male, average ISS was 18, 91 (27%) cases were due to a penetrating mechanism and 103 (30%) died.  Tourists accounted for 10% of cases, while risky behavior as defined by suspicion of substance use or improper safety precautions was present in over two-thirds of cases (68%). Self-inflicted trauma resulted in 16 injuries.

Conclusion:

There is an increased incidence of traumatic injuries on birthdays.  The cause of this added injury burden is unclear, however our data shows that risky behavior is suspected in over half of these cases. Additional research could clarify the strength of that relationship, any potential causality, and the impact of behavioral interventions to prevent injury.

 

85.03 The Utilization of Continuous Renal Replacement Therapy for Malignant Hypervolemia

Posted on January 26, 2017

M. Choi1, N. K. Dhillon1, E. J. Smith1, J. M. Tatum1, G. Barmparas1, H. Rodriguez1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Continuous renal replacement therapy (CRRT) is utilized primarily in patients with renal failure and hemodynamic instability. The role of CRRT in patients without renal failure who have malignant hypervolemia has not been studied.

Methods:  A review of all patients receiving CRRT in the surgical intensive care unit from February 2013 to February 2015 was performed. Patients undergoing CRRT for hypervolemia without a prior diagnosis of chronic kidney injury and creatinine of 1.5 or less were identified. The group was analyzed for patient characteristics including diagnosis, ICU length of stay (LOS), hospital LOS, APACHE II scores, CRRT duration, volume removed with CRRT, and mortality.

Results: Fifty-nine patients underwent CRRT during the study period. Of the 59, 21 (35.6%) had undergone CRRT for hypervolemia without presence or history of renal failure. Mean age was 61.2 ± 15.2 years, 15 (71%) were male, and median APACHE II score was 28.5 (4.5-47.2). The median ICU and Hospital LOS were 16 (7.5-22) and 29.9 ± 14.2 days, respectively. Mean creatinine prior to the initiation of CRRT in the study population was 1.1 ± 0.3. Patients underwent CRRT for a median of 6 (4-13) days with a total median volume of 15.9 (9.6-3.8) liters removed. A mean of 2.8 ± 1.1 liters was removed per day. The mortality rate for this group was 33%.

Conclusion: CRRT can be utilized to remove volume from critically ill patients with malignant hypervolemia in the setting of normal renal function. Further investigation is warranted on how to best use this therapy for patients without renal failure.

85.02 Cirrhosis and Splenic Trauma: Case Series and Systematic Review

Posted on January 26, 2017

R. A. Rasheed1, E. A. Rogers-Delmas1, A. H. Tyroch1, B. R. Davis1  1Texas Tech University Health Sciences Center In El Paso,Department Of Surgery,El Paso, TX, USA

Introduction:
The purpose of this paper is to analyze the effect of cirrhosis on morbidity and mortality incurred by patients that have sustained splenic injuries due to non-penetrating abdominal trauma.

Methods:

CPT codes for “cirrhosis” and “injury to spleen” were submitted to the UMC Trauma Data Bank as search criteria for patient selection. The period of evaluation spanned from January 01 2009 to August 31 2014. Over this period of time, 266 patients suffered splenic trauma. Multiple points of demographic data were obtained, the most important of which was grade of splenic injury and procedures undergone during hospitalization.

Of these 266 patients, 11 patients carried a diagnosis of cirrhosis due to any etiology. Once this pool of patients was obtained, we used laboratory parameters to calculate a MELD score for each patient. We then searched for evidence of non-operative management and subsequent conversion to procedural management, which was either indicated by the presence of an operative report for laparotomy and splenectomy, or a procedure report for splenic artery embolization.

We then analyzed the data, and attempted to sort patients into subsets of splenic injury grading and determine the threshold MELD that predicted the need for operative management.

Results:
In patients with Grade I & II splenic injury, MELD did not seem to predict failure of non-operative management. In patients with Grade III splenic injury, a MELD > 18 predicted failure of non-operative management. In patients with Grade IV injury, failure of non-operative management occurred, regardless of MELD.

Conclusion:

This correlative data could be used to predict failure rates of non-operative management, and may allow surgeons to better prepare for operative management in this subset of challenging trauma patients.

Due to the limited data, the power of this analysis is limited. However, this limited series does seem to suggest that greater severity of cirrhosis portends a higher failure rate of non-operative management in the setting of blunt splenic injury. This is consistent with the findings of larger studies that demonstrate cirrhosis is an independent risk factor for failure of non-operative management in this unique subset of trauma patients. The published literature will be reviewed during the course of the presentation. Further plans for this study include pooling data from other trauma centers in the state in an attempt to power the study and reach statistical significance.

85.01 The Impact of Trauma Centers on Statewide Organ Donation Rate

Posted on January 26, 2017

C. Santino1, K. Ibraheem1, N. Kulvatunyou1, A. Azim1, G. Vercruysse1, A. Tang1, R. Friese1, L. Gries1, T. O’Keeffe1, B. Joseph1  1University Of Arizona,Division Of Trauma, Critical Care, Burns & Emergency Surgery,Tucson, AZ, USA

Introduction:

Trauma care has evolved with several studies demonstrating that patients treated at trauma centers have better outcomes. Trauma patients also form the major pool of organ donors in the United States. However, it is unknown if the distribution of trauma centers has affected organ donation. The aim of this study was to assess the association between trauma center distribution across states and organ donation rates.

Methods:

We performed a one year analysis (2013) of the CDC WISQARS database for all injury related deaths in a state. Number of organ donors after trauma-related death were obtained from the UNOS database. Number of trauma centers and their level of verification (Level I, II, III) in each state were obtained from American College of Surgeons’ (ACS) trauma center registry. Only states with data available for organ donation were included. States were divided into two groups based on the trauma center distribution per million population: high density states (HDS) where trauma center density was greater than the national average and low density states (LDS) where trauma center density was less than the national average. Stepwise linear regression analysis was performed for the predictors of organ donors per million population and organ donors per 100,000 trauma deaths.

Results:

A total of 40 states were included in the analysis with mean trauma center distribution of 5.7 trauma centers per one million population and an organ donation rate of 16.8±12.8 organ donors per one million population. 30 states were included in LDS and 10 in HDS. HDS states had a higher number of total adult trauma centers (5 [2-11] vs. 2 [1-7]; p=0.02), a higher number of level 1 and 2 trauma centers (5 [1-10] vs. 2 [1-5]; p=0.02), and a lower area of coverage per trauma center (p=0.001). HDS states had a higher rate of organ donors per one million population (24.8±21.9 vs. 14.2±6.5;p=0.022) and a higher rate of organ donors per 100,000 trauma deaths (32.2±22.1 vs. 17.4±7.8;p=0.025). On stepwise linear regression analysis, trauma center distribution per million population was independently associated with higher rate of organ donors per one million population (β [95% CI]: 0.38 [0.01-0.49]; p=0.04) and organ donors per trauma death (β [95% CI]: 0.40 [0.03 – 0.59]; p=0.03).                 

Conclusion:

Regional variability of ACS verified trauma centers significantly impact statewide trauma-related organ donation rate. The findings of this study highlight a correlation between statewide organ donation rates and ACS verified trauma center density.

 

84.20 Ventral hernia repair and mesh infection survey.

Posted on January 26, 2017

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

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

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

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

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

84.19 Trends in CIRP Levels and Wound Healing

Posted on January 26, 2017

A. Baig1, A. Jacob1,3, S. Kaplan1, M. Akerman3, P. Wang1,2,3, A. Oropallo1,2  1Northwell Health,Surgery,Manhasset, NY, USA 2Hofstra Northwell School Of Medicine,Hempstead, NY, USA 3The Feinstein Institute For Medical Research,Manhasset, NY, USA 4Hofstra Northwell School Of Medicine,Hempstead, NY, USA

Introduction:  It has been well established that many factors affect how quickly and effectively different wounds heal. We evaluated cold inducible RNA binding protein (CIRP), an inflammatory mediator that has been shown to be increased in patients with sepsis and suggested to be an outcome predictor in sepsis. We hypothesize that circulating levels of CIRP are associated with wound size and healing rates. There are no published data regarding the relationship of CIRP levels and wound healing

Methods:  This study is a prospective study of individuals with venous stasis ulcers of at least 1 cm at the start of the study, with adequate vascular perfusion as measured by ankle brachial index (ABI).  Exclusion criteria included: diabetes, suspicion of wound infection or osteomyelitis, immunosuppressants, and autoimmune connective tissue disorders. Patients were enrolled in the study for a total of 12 weeks. Patients’ blood was drawn weekly and CIRP level was measured using Western blot with wound measurements taken as well. 

Results: Patients in our case series that met the exclusion and inclusion criteria, the CIRP levels decreased over time (n=4). We noticed a correlation between average primary wound size and average CIRP level. Multiple patients developed new wounds during the course of the 12 week period, and we noticed an increase in CIRP levels of those patients that correlated to the discovery of a new, separate wound. CIRP is a potential systemic inflammatory marker and the rise in CIRP levels in patients who developed a second wound is in accordance with our hypothesis. Using a mixed model repeated measures ANOVA, our sample size of four patients yielded a trend showing a decrease in CIRP across week 0 to week 11, but was not statistically significant (p=0.052). The data was also suggestive of a positive association between CIRP levels and wound size; as the wound size decreased over the weeks, the CIRP levels correspondingly decreased as well. 

Conclusion: Although the results need to be further explored with a well-structured study using a larger sample size, initial results of using CIRP demonstrate a promising correlation between CIRP and wound measurement.
 

84.18 Frailty as a Predictor of Complications in Plastics

Posted on January 26, 2017

O. Trofymenko1, H. Aziz1, B. Joseph1  1University Of Arizona,General Surgery,Tucson, AZ, USA

Introduction:

Frailty has emerged as an important patient-specific characteristic that has been show to positively correlate with various surgical and medical complications encompassing a broad range of surgical practices.

Methods:
National Surgical Quality Improvement Program (NSQIP) was quarried to select all of the cased from 2011-2012 of non-emergency elective outpatient and inpatient plastic surgery procedures. The data was separated into inpatient and outpatient procedures and analyzed separately for each cohort. Modified frailty (mFI), previously described measure of frailty, was used as a proxy for frailty.

Results:
Out of 23,661 cases quarried, 63.48% (n=16,440) were inpatient and 30.52% (n=7,221) – outpatient. For outpatient cohort, 73.29% of patients had mFI of 0 (non-frail), 20.10% were ASA class 3 or above, 3.30% had postoperative complication(s), and 2.11% were readmitted within 30 days. For outpatient sample, 63.99% of patients were non-frail, 34.10% were ASA class 3 or above, 15.51% had postoperative complication(s), and 6.62% were readmitted within 30 days. On univariate analysis, higher mFI positively correlated with outpatient (p=0.017) and inpatient (p<0.001) overall complication rates; as well as outpatient (p<0.001) and inpatient (p<0.001) unplanned readmission rates. Multivariate CC model showed mFI to independently correlated with outpatient unplanned readmission rate (Odds Ratio (OR): 18.657; p=0.020) and inpatient overall complication rate (OR: 26.107; p=0.001). MICE model indicated mFI to be independently predictive of outpatient unplanned readmission rate (OR: 69.059; p<0.001), inpatient overall complications rate (OR: 28.553; p<0.001), and inpatient unplanned readmission rate (OR: 20.358; p=0.013).

Conclusion:
Our findings suggest that frailty, as a patient-specific characteristic, may add value to stratification of operative risks, preoperative planning, and implementation of a more effective post-operative management.
 

84.17 Long Term Results In Abdominal Wall Reconstruction

Posted on January 26, 2017

J. Zakhary1,2, C. A. Sedano1, C. D. Killingsworth1, L. O. Vásconez2, J. I. De La Torre1,2  1University Of Alabama At Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction: Incisional hernias are a common problem for which the optimal surgical technique has yet to be established.  Several key advances in the mangement of incisional hernias have contributed to a decrease in recurrence rates, including the use of mesh for tension free colsure, laparoscopic approaches, component separation and acellular dermal matrix.  The published recurrence rates for primary repair of hernias (25-60%) open componenet separation (14-27%) and laparoscopic repair (4-19%) do not usually include long term outcomes.

Methods: A retropsective chart review was perfromed for a abdominal wall reconstructive procedures utilizing component separation by a single surgeon over a six year period.  Data abstraction was perfromed by review of patient electronic health records for preoperative risk factors, hernia characteristics and postoperative course.  Operative notes were reviewed for specific technical details.  In addition, patients completed a phone interview and survey to establish long term outcomes.  All patients had a minimum follow-up time of three years or until recurrence.

Results: A total of 81 consecutive patients were evaluated.  Thirteen patients were excluded for insufficient follow-up   Of the remaining patients, all underwent reconstruction using a component separation and in most cases had acellular demal matric reinfrocement.  The median followup time was 40 months.  The average hernia size was 223 cm2.  Factors associated with recurrence included the inability to establish myofacial continuity (p= 0.018), contaminated field (p= 0.07) and prior failed hernia reconstruction (p= 0.10).  Of the patients in whom successful components separation with myofascial continuty was perfromed, the recurrence rate was 10%. 

Conclusion: The inability to restore myofascial continuity is a critical risk factor for recurrence.  Long term recurrence rate seen in this patient population is well within the range of published outcomes.  Incisional hernia reconstruction in a contaminated field is a risk factor for recurrence even with the use of acellular dermal matrix for reinfrocement.  Postoperative wound complicatins, most commonly seroma or skin ischemia occured at a significant rate, These complications may be avoided by minimally invasive approaches and require further evaluation.

 

84.16 Evolution of Abdominal Wall Reconstruction for Incisional Hernia Repair

Posted on January 26, 2017

J. Zakhary1,2, B. D. Denny1, A. Kilic1, J. I. De La Torre1,2  1University Of Alabama At Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction: Abdominal wall reconstruction with mobilization of autologous tissue has continued to evolve as a safe and reliable option for patients with large ventral wall hernias.?

Methods: With the goal of evaluating how the application of components separation has evolved in our practice, morbidity and recurrence rates in patients who underwent reconstruction for incisional ventral hernia, were retrospectively reviewed. The charts of 284 patients treated by a single surgeon between 1999 and 2016 were reviewed and patients with a minimum of two-year follow-up were included.  Two data groups, an early group (1999-2004) and a late group (2009-2014) were evaluated, each over a five-year period. Outcomes from the data collection period were compared and significant changes in technique were noted.

Results: In the early group, the recurrence rate was 13% and primary approximation of the fascial defect was achieved in 77% of the patients. Overall morbidity rate was 38%, with significant complications occurring in 17% of patients, wound healing problems occurring in 13% and seromas occurring in 3%.  In the late group, the recurrence rate was 7% and and primary approximation of the fascial defect was achieved in 92% of the patients. Overall morbidity was 46%, with significant complications occurring in 17% wound healing problems occurring in 14% and seromas occurring in 17%.

Conclusions: In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates. Refinements in techniques have led to decreased recurrence rate.

84.15 Cleft Care in the Medically Complex Patient

Posted on January 26, 2017

F. Fallahian1, M. Tracy1, A. Kaye1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Plastic Surgery,Kansas City, MO, USA

Introduction:  Direct causality of congenital cleft conditions is often not known and is currently considered to represent a combination of complex environmental and genetic factors and interactions. There are numerous syndromes which can be associated with cleft lip and/or palate as well as unique patients with multiple medical problems without an over-arching diagnosis. This provides us with a number of patients for whom highly individualized treatment plans must be devised. Safety and appropriateness for surgery or the need to prioritize other necessary surgeries are factors that may preclude following typical cleft treatment protocols. This study aims to determine the prevalence of children in our Cleft Team population who also carry concomitant complex medical diagnoses in order to assess the challenges of this population and the alterations in their ultimate cleft-related care.

Methods:  This study is a retrospective review of patients presenting to the Cleft Team for cleft care with a history of multiple medical issues in addition to a diagnosis of cleft lip and/or palate.

Results: 133 patients were identified with a variety of cleft conditions: incomplete cleft lip (CL) = 7, cleft lip and palate (CL/P) = 51, isolated cleft palate (CP) = 53, and submucous cleft palate (SMCP) = 22. A numerous variety of concomitant diagnoses were seen including 37 named syndromes, 20 unique chromosomal abnormalities, and 17 unidentified constellations of anomalies. Diagnoses were made by a combination of clinical assessment (30.7%), specific gene studies (25.0%), high resolution chromosome (18.3%) or CGH microarray analysis (16.3%). 51.9% of patients have congenital heart disease, 40.6% of which required surgery to treat. 36.8% of patients have brain abnormalities. 23.3% have congenital hearing loss. 63.9% have developmental delays. 81.2% of patients are cared for by 3 or more subspecialty teams aside from the Cleft Team, most commonly: ENT, Cardiology, Ophthalmology and Orthopedic Surgery. 54.1% of these patients have surgical feeding tubes and 15.0% have tracheostomies. 6.7% of these patient have died prematurely related to their condition. Average age at cleft lip repair when performed in this group is 7.29 months (SD 2.65). Average age at primary palate repair in this group is 23.13 months (SD 20.56). One third of patients have delayed or missed cleft-related surgeries. 60.9% of these patients have global developmental delays. More than half have speech-language delays, 59.4% of which are severe or profound.

Conclusion: Patients with congenital cleft conditions and concomitant complex medical presentations present unique situations for coordinated cleft team care. These patient have frequent delays in the timing of their cleft-related surgeries resulting from poor health condition, need for other surgery, or significant speech/developmental delays.  
 

84.14 Disparities in Management of Below Elbow Injuries at a Single, Level 1 Trauma Center

Posted on January 26, 2017

C. Kerby1, K. E. Leibl3, E. K. Awad2, T. A. Swain1, R. L. Griffin1, T. W. King1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA 2University Of South Alabama,Mobile, AL, USA 3University Of Wisconsin,Madison, WI, USA

Introduction:  It has been shown previously that disparities exist in treatment and access to care by race, insurance coverage, and age in the United States. Our objective was to evaluate if treatment and time to treatment disparities exist in patients sustaining injuries below the elbow managed at a single level 1 trauma center in the United States. 

Methods:  The number of upper limb injuries below the elbow seen at a level 1 trauma center from 2010-2014 were determined using the trauma registry. Injuries were defined as any injury in the upper extremity below the elbow and were identified by anatomical region using the abbreviated injury scale (AIS). Only anatomical regions clearly defined by AIS which were below the elbow were used; therefore, whole limb categories were excluded as well as injuries specific to vessels, nerves, and skin since AIS does not specify anatomical regions for these structures below the elbow. ICD-9 procedural codes for amputation on the upper limb were used to identify patients undergoing amputation. Patient demographic, injury, and clinical variables were compared by amputation procedure status using the chi-square and t-test for categorical and continuous variables, respectively. 

Results: There were 2059 patients from 2010 to 2014, which had an upper extremity injury below the elbow. Of these patients, 77 (3.7%) required an amputation. Injury severity score was significantly higher (p<0.0001) for those who did not undergo amputation (14.8) when compared to those who did (6.0). Time to admission from injury was also longer for those not undergoing amputation (0.3 days) compared to those undergoing amputation (0.1 days) (p=0.0005). Those who underwent amputation were more likely to be male (80.5%) (p=0.0244). There was no difference for race (p=0.7326), age (p=0.8724), hospital LOS (p=0.0834), ICU LOS (p=0.1463), or time to admission from injury (p=0.4501). Payment type differed significantly by amputation procedure status (p<0.0001), with 23.4% of those amputated paying through workers’ compensation, compared with only 4.6% among those not amputated.

Conclusion: Amputation is uncommon following upper extremity injury below the elbow. Ironically, the ISS was lower for patients receiving amputations. This likely implies, but can not be absolutely concluded, that the below elbow amputation injury was an isolated injury   Those requiring amputation were more likely male, presented for treatment sooner, and were more often associated with a work-related injury.  This data does not support previous studies’ findings of racial or age disparities. However, this analysis is limited by being at a single center and the limitations associated with the AIS.  Further investigations utilizing a multicenter, nationwide database should be performed to verify and validate these results.

 

84.13 DIEP Flap Breast Reconstruction: Predictive Factors for Perioperative Blood Loss and Transfusion

Posted on January 26, 2017

E. Conci1, M. Khatib2, F. Barakat3, P. Forouhi4, C. M. Malata2,5  1Cambridge University Medical School,Cambridge, , United Kingdom 2Cambridge University Hospitals NHS Trust,Plastic Surgery,Cambridge, , United Kingdom 3Barnet General Hospital,London, , United Kingdom 4Cambridge University Hospitals NHS Trust,Cambridge Breast Unit,Cambridge, , United Kingdom 5Anglia Ruskin University,Faculty Of Health Sciences,Cambridge, , United Kingdom

Introduction: Peri-operative blood loss contributes to the morbidity of patients undergoing immediate and delayed autologous free flap breast reconstruction post-mastectomy. The study aims to develop predictors for blood loss and transfusion requirements in microvascular breast reconstruction.

Methods:

A retrospective cohort study of autologous free flap breast reconstructions by a single plastic surgeon performed from January 2010 – December 2015 was conducted. Data from patient medical records were input into databases of electronic health records (EMR and EPIC).  Data analysis was performed using STATA software. 

Outcomes collected include haemoglobin drop (preoperative Hb – lowest Hb following surgery), estimated blood loss (EBL) and the total units of blood transfused (intra-operative and perioperative). Estimated blood loss (EBL) was the total weight of the swabs used during surgery minus their weigth prior to surgery while the estimated blood volume (EBV) was calculated using a validated formula [InBV= 70/√(BMI/22 )]. lnBV represents the indexed blood volume in ml/kg.

Variables studied pertain to the patient, namely age, BMI and chemotherapy status; the operation, namely timing, duration and extent (laterality, axillary clearance, mastectomy weight); and the flap transferred, namely its weight, number of pedicles and ischaemia time. 

Results:

Of the 163 microvascular procedures, 133 were unilateral and 30 were bilateral.

The median estimated blood loss (EBL) was 640ml (IQR=407-1000) and the mean haemoglobin drop was 29.9g/L (±11.1). 44% of patients required a transfusion.

Multivariable linear regression analysis showed that immediate timing of reconstruction (p=0.016), concomitant lymph node dissection (p=0.01), increased duration of surgery (p<0.001) and higher mastectomy weight (p<0.001) were significantly associated with higher EBL.

Independent predictors of the likelihood of blood transfusion were bilateral reconstruction (p=0.02), lower estimated total blood volume (p=0.04) and higher mastectomy weight (p<0.001).

Haemoglobin drop was predicted by chemotherapy (including tamoxifen) within six months prior to surgery (p=0.006) and the duration of the operation (p=0.04).     

Conclusion:

A significant association between higher EBL and transfusion requirements was found with several variables that denote the extent of the operation. This has provided empirical information to our unit in predicting perioperative blood loss and preoperative patient counselling. It has also enabled us to design measures to restrict blood loss in these “high-risk” patients and hence reduce patient morbidity and length of stay. 

84.12 Superomedial Pedicle Reduction Mammaplasty: Increased Resection Weight Does Not Increase Nipple Necrosis

Posted on January 26, 2017

P. Brownlee1, D. Chesire1, M. Crandall1, J. Murray1  1University Of Florida,Jacksonville, FL, USA

Introduction:  Nipple-areola complex (NAC) necrosis is a dreaded complication of reduction mammaplasty that results from tissue ischemia. Multiple breast reduction techniques have been designed, each with the goal of minimizing complications and optimizing aesthetic outcomes. The superomedial pedicle (SMP) reduction mammaplasty offers several advantages over more traditional operative techniques, such as improved preservation of long-term breast shape. However, many surgeons believe that using the superior and superomedial pedicles cause an increase in NAC necrosis rates up to 7.0-10.0% as the degree of macromastia increases. The aim of this paper is to show that the superomedial pedicle has comparable NAC necrosis rates to other breast reduction techniques and can be used in any size reduction without a significant risk to the NAC.

Methods:  We performed a retrospective study of patients who underwent breast reduction surgery by a single surgeon between May 1, 2013 and May 1, 2015. We reviewed patient demographics, operative details, the weight of the breast tissue removed per pathology report, and post-operative findings up to six months after the date of their operation. Patients were excluded from this study if they were converted to free nipple grafting intra-operatively prior to completion of their initial operation (n=3). Each breast was counted as an individual data point and then divided into subgroups based on the weight of the tissue removed. Using SPSS version 23 and chi-square analysis, the subgroups were compared against each other to look for a significant difference in rates of NAC necrosis. The overall rate of NAC necrosis in this study was also determined and compared to those of previously reported rates for alternative pedicle techniques.

Results: 70 patients (130 breasts) met inclusion criteria for this study. The average age at time of reduction was 38 years old, and the patients had a mean body mass index (BMI) of 36.6 kg/m2. The mean resection weight per breast was 1016.7 grams (± 478.3). The mean pre-operative sternal notch to nipple distance was 36.3 cm (± 5.3). The overall NAC necrosis rate was 0.7%, with 0% in the groups where less than 1200 grams of tissue were removed and 2.3% in the group where 1200 grams or more of tissue were removed. There was no significant difference with respect to the number of patients developing NAC necrosis across these groups.

Conclusion: The superomedial pedicle breast reduction has an overall rate of NAC necrosis which compares favorably to other more popular techniques, and this study shows no significant increase in NAC necrosis with larger volume tissue reductions. Given the benefits of this technique when compared to alternative pedicles, such as preservation of breast shape and nipple sensitivity, it should be considered a safe choice for any size breast reduction.

 

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