59.12 Does Admission TEG Predict the Need for Dose Adjustment of Venous Thromboembolism Chemoprophylaxis?

Posted on January 31, 2019

H. V. Lewis1, C. Furnish2, C. A. Droege3,4, M. E. Droege3,4, N. E. Ernst3,4, M. D. Goodman1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Colorado Denver,Skaggs School Of Pharmacy And Pharmaceutical Sciences,Aurora, CO, USA 3University Of Cincinnati,Department Of Pharmacy Services,Cincinnati, OH, USA 4University Of Cincinnati,Division Of Pharmacy Practice And Administrative Sciences, University Of Cincinnati James L. Winkle College Of Pharmacy,Cincinnati, OH, USA

Introduction:  Venous thromboembolism (VTE) contributes to significant morbidity and mortality in trauma patients, with enoxaparin chemoprophylaxis preferred in high risk patients. Early thrombelastography (TEG) following injury has been shown to predict the incidence of posttraumatic VTE; however, TEG-adjusted enoxaparin dosing has not adequately guided chemoprophylaxis as reliably as serum anti-factor Xa (aXa) concentrations. We hypothesized that the TEG obtained during initial trauma evaluation could facilitate earlier identification of the need for enoxaparin dose adjustment based on subprophylactic aXa.

Methods:  This single-center, retrospective chart review evaluated patients admitted to an urban level I trauma center over a nine month period. Patients were included if they underwent rapid TEG testing upon emergency department arrival and received a dose of enoxaparin with at least one serum trough anti-Xa concentration drawn during admission. Patients were stratified into dose adjusted (DAE) or single dose (SDE) groups based upon final enoxaparin dose received. Demographics including injury, VTE incidence, and chemoprophylaxis dosing and timing were analyzed. The primary aim was to compare TEG parameters between SDE and DAE groups. Secondary aims included VTE incidence and time to chemoprophylaxis initiation. Multivariate logistic regression analyses were performed to identify laboratory-associated and injury-specific independent risk factors for enoxaparin dose adjustment.

Results: 204 patients were included in the analysis with the majority (n=140, 69%) receiving dose-adjusted enoxaparin. Baseline differences between groups included age (SDE, 48.5 [29.3-72] vs. DAE, 38.5 [25-55.7] years; p=0.005), admission creatinine clearance (SDE, 92.9 [67.4-113.4] vs. DAE, 102.1 [83.8-129.2] mL/min; ­p=0.02), and time to VTE prophylaxis initiation (SDE, 23.8 [11.2-36.4] vs. DAE, 34.5 [18.3-52.7] hours; p<0.005). There was no difference in any TEG parameter, including MA:R ratio (SDE, 1.59 [1.18-1.87] vs. DAE, 1.43 [1.06-1.80]; p=0.13), or VTE incidence (SDE, 17.2% vs DAE, 11.4%; p=0.37) between groups. No independent laboratory value risk factors for enoxaparin dose adjustment were identified. Risk Assessment Profile score above 10 was an independent risk factor for VTE development.

Conclusion: Admission TEG did not predict the need for subsequent enoxaparin dose adjustment in trauma patients. Multicenter trials are needed to further explore the utility of TEG in guiding enoxaparin chemoprophylaxis in trauma patients.

 

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

Posted on January 31, 2019

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

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

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

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

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

 

59.10 Contrast Induced Nephropathy in Patients with Kidney Trauma

Posted on January 31, 2019

J. Saluck1,2, A. A. Fokin2, J. Wycech2,3, A. Tymchak1,2,3, M. Gomez3, M. Crawford2, I. Puente1,2,3,4  1Florida Atlantic University,College Of Medicine,Boca Raton, FL, USA 2Delray Medical Center,Trauma Services,Delray Beach, FL, USA 3Broward Health Medical Center,Trauma Services,Fort Lauderdale, FL, USA 4Florida International University,College Of Medicine,Miami, FL, USA

Introduction:
Incidence of contrast-induced nephropathy (CIN) has been reported in 1.9%-9.8% among different subgroups of trauma patients. However, the consequences of serial administration of contrast medium during angiography and repeat contrast computed tomography (CT) in patients with kidney trauma (KT) have not been sufficiently studied. The purpose of this study was to evaluate the incidence and predictors of contrast induced nephropathy (CIN) in patients with KT and to assess the effect of CIN on clinical outcomes.

Methods:

This IRB approved retrospective cohort study included adult patients, admitted to a level 1 trauma center between 2012 and 2017 who received contrast, 86 patients with a KT, and 224 with abdominal organ injuries (AOI), other than the kidney.

In the KT cohort, 10 (11.6%) developed CIN (CIN KT Group), while 76 (88.4%) did not (No-CIN KT Group). In our AOI cohort, 21 (9.4%) developed CIN and 203 (91.6%) did not. CIN was defined as relative (≥25%) or absolute (≥0.5 mg/dL) increase in serum creatinine within 72 hours of contrast administration. Age, Injury Severity Score (ISS), Kidney Organ Injury Scale (KOIS) Grade, rates of transfusion of blood products, angiography, embolization, repeat abdominal CT, hemoperitoneum, intensive care unit length of stay (ICULOS), hospital LOS (HLOS) and mortality were compared between CIN KT and No-CIN KT Groups.

Results:

Of the patients who developed CIN in KT cohort, 60.0% had an absolute increase in serum creatinine within 72 hours of contrast administration and 40.0% had a relative increase.

CIN KT and No-CIN KT Groups showed no significant difference in age (50.0 vs 44.8 years. p=0.6), ISS (27.4 vs 21.4, p=0.4), and KOIS Grade (2.4 vs 2.1, p=0.2). Both Groups, also had comparable rates of angiography (20.0% vs 17.1%, p=0.8), embolization (10.0% vs 3.9%, p=0.4), and repeat CT (40.0% vs 39.5%, p=1.0). With 100.0% of patients in CIN KT Group and 68.4% in No-CIN KT Group requiring a stay in the ICU, the difference in ICULOS between the two Groups did not reached statistical difference (9.8 vs 6.6 days, p=0.05).

CIN KT compared to No-CIN KT Group, had statistically higher rate of blood product transfusions (80.0% vs 46.1%, p=0.04) and detection of hemoperitoneum on CT (100.0% vs 55.3%, p=0.007). CIN KT patients had a statistically longer HLOS (14.2 vs 9.6 days, p=0.04), but mortality was not statistically different (20.0% vs 10.5%, p=0.4).

Conclusion:

Low grade kidney trauma did not increase incidence of CIN in patients with abdominal injuries. Higher rates of blood transfusions and hemoperitoneum detected on CT were risk factors associated with the occurrence of CIN in patients with kidney injury. Patients that developed CIN had longer HLOS, but not higher mortality.

59.09 Safety and Efficacy of Angioembolization in Combined Traumatic Brain Injury/Blunt Splenic Injury

Posted on January 31, 2019

B. Choi1, E. Warnack1, C. DiMaggio1, S. Frangos1, M. Bukur1, H. L. Pachter1, M. Klein1  1New York University School Of Medicine,Department Of Surgery,New York, NY, USA

Introduction: There is limited data regarding the safety and efficacy of nonoperative management for blunt splenic injury (BSI) with concomitant traumatic brain injury (TBI) despite its increased use over time. We studied trends in the treatment of combined TBI/BSI, hypothesizing that angioembolization would not lead to increased mortality.

Methods:  Data were obtained from NIS-HCUP for 2004 to 2011, using ICD-9 codes to identify BSI, TBI, and treatment. Injury severity was assessed using International Classification of Injury Severity Scores (ICISS). In-hospital mortality for splenectomy and embolization groups was analyzed using logistic regression after controlling for year, age, gender, hospital teaching status, Charlson score, ICISS, and hypotension or shock at the time of presentation.

Results: Of 179,446 patients with BSI, 13,247 patients had associated TBI. The US population-based rate of TBI/BSI decreased by 0.02 injuries per 100,000 per year (P=0.09). 12.3% of TBI/BSI patients required splenectomy, while 6.1% underwent angioembolization. The rate of splenectomy decreased over the study period, from 16.6% to 8.0% (P<0.05) while the rate of embolization increased from 3.9% to 7.2% (P=0.22). Overall mortality in TBI/BSI patients was 17.1%, and did not change significantly over the study period (P=0.28). Mortality rate was lower in embolized patients (15.9%) than splenectomized patients (40.7%). Splenectomized patients had 2.75 times higher odds of death than all other TBI/BSI patients (95% CI 2.02-3.75, P<0.01), while embolized patients had no increased odds of death (OR 0.70, 95% CI 0.46-1.08, P=0.46).

Conclusion: Patients with combined BSI/TBI undergoing splenectomy carry a high mortality. For select patients, angioembolization has proven to be a safe and effective treatment option.

 

59.08 Skin Closure Techniques Following Trauma Laparotomy: Is Secondary Closure as Beneficial as We Think?

Posted on January 31, 2019

C. A. Fitzgerald1, B. C. Morse1, R. N. Smith1, J. Nguyen2, O. Danner2, R. B. Gelbard1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Morehouse School of Medicine,Surgery,Atlanta, GA, USA

Introduction:

Trauma laparotomy incisions are often left open in the setting of enteric injuries to reduce the risk of wound infection, but there are limited data to support this practice. The purpose of this study was to determine if primary or delayed skin closure after trauma laparotomy is associated with an increased incidence of surgical site infections (SSI) and other wound complications.  

Methods:

Retrospective review of all patients who underwent a trauma laparotomy at a Level I trauma center from 2015-2017. Patients were separated into three groups: Group 1: fascia and skin both closed, Group 2: fascia closed, skin open for secondary closure, Group 3: delayed primary skin closure.

Results:

A total of 819 patients were included. Most patients were male (81.8%) and had penetrating injuries (66.4%). There were 556 (67.9%) patients in Group 1, 244 (29.8%) in Group 2 and 19 (2.3%) in Group 3. The incidence of hollow viscus injury (HVI) was 256 (46%), 222 (90.9%) and 18 (94.7%) in Groups 1, 2 and 3, respectively. There were 25 (4.5%) damage control laparotomies in Group 1, 57 (23.4%) in Group 2, and 1 (5.2%) in Group 3. Group 2 had longer ICU and hospital lengths of stay (10.4±14.8 vs. 5.8±9.3 vs. 6.2±12.0, p<0.001, and 25.1±24.1 vs. 15.2±14.5 vs. 17.8±12.2, p<0.001). Group 2 had a higher rate of organ space infections compared to Groups 1 and 3 (40/244, 16.4% vs. 35/556, 6.3%, vs. 1/19, 5.2%, p=0.0003) while Group 3 was associated with a significantly higher rate of fascial dehiscence and enterocutaneous fistula (ECF) among patients with HVI. There was no difference in the incidence of superficial or deep SSI or overall mortality between groups (Table 1).

Conclusion:
Leaving skin incisions open following trauma laparotomy appears to be associated with higher morbidity without reducing the rate of surgical site infections. Closing skin at the time of initial laparotomy should be considered to reduce hospital stays and lower the risk of fascial dehiscence and ECF.
 

59.07 High Rate of Fibrinolytic Shutdown and Venous Thromboembolism in Severely Injured Pelvic Fracture Patients.

Posted on January 31, 2019

J. T. Nelson1, J. R. Coleman2, H. Carmichael2, C. Mauffrey3, D. Rojas Vintimilla3, J. M. Samuels2, C. C. Silliman4, A. Banerjee2, A. Sauaia2, E. E. Moore5  1Rosalind Franklin University of Medicine and Science,Chicago Medical School,North Chicago, IL, USA 2University Of Colorado Denver,Surgery,Aurora, CO, USA 3Denver Health Medical Center,Orthopedics,Aurora, CO, USA 4Children’s Hospital Colorado,Hematology,Aurora, CO, USA 5Denver Health Medical Center,Surgery,Aurora, CO, USA

Introduction:   Trauma patients with severe pelvic fractures have a uniquely high rate of venous thromboembolic events (VTE), ranging from 3.5-8.8% in the orthopedic trauma literature.  The reason for this high morbidity risk is unknown.  In other trauma patients fibrinolytic shutdown (SD) is strongly associated with VTE. Thus, we hypothesize that the observed increase in VTE in patients with severe pelvic fractures is due to their state of fibrinolysis, specifically shutdown.

Methods:   Data was solicitated from the trauma registry of a single, urban, Level-1 trauma center for all trauma patients who presented with pelvic fracture from 2007-2017. The inclusion criteria were severely injured patients (injury severity score [ISS] > 15) with a severe pelvic fracture (abbreviated injury score [AIS] > 2) who presented after blunt mechanism and had an initial citrated rapid thrombelastography (CR-TEG). Fibrinolytic phenotypes were examined and defined as fibrinolytic shutdown (LY30 [lysis 30 minutes after maximum amplitude on CR-TEG] < 0.9%), physiologic lysis (0.9-2.9%) and hyperfibrinolysis (≥ 3.0%).  Outcomes including surgical fixation and VTE were also examined.  Chi-square tests were used for proportional comparisons, and Mann-Whitney U-test was used for comparison of non-normally distributed continuous variables.

Results:  This study included 210 patients with a median age was 44.0 years and the majority (64%) were male.  The median ISS was 34.0.  The majority of patients (59%, n=123) presented in fibrinolytic shutdown (SD) compared to 21% (n=45) in physiologic fibrinolysis (PL) and 20% (n=42) in hyperfibrinolysis (HF).  The VTE incidence was 11.0% (n=23).  The median LY30 in VTE patients was 0.5% versus 0.0% in non-VTE patients (p=0.38).  There was also no difference in injury severity, degree of shock (systolic blood pressure), traumatic brain injury, concomitant orthopedic injuries, other TEG measurements or fibrinolytic phenotypes of patients who developed a VTE compared to those who did not (Table 1).  Patients with VTE had longer length of stay (19 days vs. 16 days, p=0.02) and intensive care unit days (11.39 vs. 5.44, p=0.001). Patients who underwent pelvic fixation had a trend toward higher rate of VTE (15.8% versus 6.0% in patients who didn’t undergo fixation, p=0.08).

Conclusion:  In this population severely injured pelvic fracture patients had a high rate of VTE at 11.0%, higher than what has been described for these patients, and the majority (59%) presented in fibrinolytic shutdown.  However, in this prospective study, we were unable to identify unique factors predictive of VTE in severe pelvic fractures.  This supports the concept of implementing VTE chemoprophylaxis measures as soon as hemostasis is achieved.  

59.06 Platelet Dysfunction Not Corrected by Platelet Transfusion in Traumatic Brain Injury Patients

Posted on January 31, 2019

R. D. Rodriguez1, B. W. Carr1, A. L. Patterson1, S. A. Savage1  1Indiana University,General Surgery,Indianapolis, IN, USA

Introduction:  Platelet dysfunction is common in traumatic brain injury. While platelet transfusion is used to reverse dysfunction, there is not an established dose-response to measure effectiveness. Thromboelastogram Platelet Mapping (TEG-PM) quantifies dysfunction in the arachidonic acid (AA) and adenosine diphosphate (ADP) pathways. The purpose of this study was to examine the effect of platelet transfusion on TEG-PM in TBI patients on antiplatelet agents.

Methods:  This retrospective observational study included trauma patients admitted to a Level 1 Trauma Center with TBI from 2014 through 2017. Inclusion criteria was transfusion of at least one unit of platelets, use of antiplatelet agent prior to admission, and TEG-PM measured before and after transfusion. Repeated measures analysis of variance (ANOVA) was used to define change in ADP and AA inhibition over time in light of platelet transfusions.

Results:  Twenty-eight patients met screening criteria. Mean age was 74.6 with a median ISS of 25.  26 patients were on ASA, 12 on Plavix, 3 on ticargrelor, and 1 on dipyramidole. The median initial ADP inhibition was 66.6% and AA inhibition was 83.3%. Units of platelets transfused ranged from 1 to 6 with median 2. The change in inhibition over time, controlling for units of platelets transfused, was not statistically significant for ADP (p = 0.76) or AA (p = 0.09), see Table 1. Nine patients had expansion of hemorrhage, with 3 requiring operative intervention and 3 transitioned to hospice.

Conclusion:  Transfusion of platelets to restore platelet function was not effective for patients on antiplatelet agents as measured by TEG-PM, potentially exposing patients to unnecessary risk. This may be attributed to insufficient transfusion dosing or dysfunction in stored platelets. Further work is ongoing to identify the best way to define dysfunction, determine if correction of dysfunction is possible with platelet transfusion, and establish effective dosing.

 

59.05 Midline Catheters: An Underutilized, Cost-Effective Means of Decreasing Central Venous Catheter Use

Posted on January 31, 2019

X. Shanja-Grabarz1, L. Santoriello1, G. Ritter1, V. Patel1, J. Nicastro1, R. Barrera1  1North Shore University And Long Island Jewish Medical Center,Department Of Surgery/Zucker School Of Medicine At Hofstra/Northwell,Manhasset, NY, USA

Introduction:  Central line associated blood stream infections (CLABSI) remain a significant source of morbidity and
increased healthcare costs in patients in ICU’s and other hospital areas. In this study we aimed to show
that by having a midline dedicated team of physician assistants for the placement and monitoring of
midline catheters, the number of central lines placed on medical and surgical wards could be decreased.
Patients with and without CVCs with difficult peripheral access were instead given midline catheters,
decreasing the overall cost of line placement as well as the number of CVC associated complications.

Methods: Data regarding central line days and CLABSI were collected from 2009 to 2017. In that time period, system changes including designated CVC monitoring and midline placment teams were implemented. Data from Jan 2016 through December 2017 pertaining to patients in the SICU, CTICU, NSICU and surgical wards was reviewed, comparing the overall number of CVC and midline catheters placed. Our primary endpoint was decrease in the number of central line days and consequently the number of associated complications in ICU and Non-ICU settings.

Results: Midline catheters were used more often than CVC’s in both years included in the study and in both the ICU and floor setting. There was an appreciable decrease in the number of central-line days and CLABSI that corresponded to various hospital system changes including utilizing a team of trained designated housestaff and PAs to monitor central lines and place midline catheters sterilely in patients with difficult peripheral access.

Conclusion: 

Our data show that with the implementation of teams to monitor CVC's and place midline catheters, the number of midline catheters placed increase and patients have fewer central line days and fewer central line associated complications. Staff members that are already proficient in ultrasound guided placement of central lines can easily be taught the placement of midline catheter, as both procedures require a similar skill set. In a patient with difficult IV access, midline catheter placement is a safer and more cost-effective way to provide acess without resorting to unceccesary central line use.

59.04 Optimal Time of Abdominal Radiography after Gastrografin Administration for Small Bowel Obstruction

Posted on January 31, 2019

M. D. Ray-Zack1, O. Alnachoukati2, J. Dunn2, S. Godin2, B. Smoot2, M. Zielinski1  1Mayo Clinic,Rochester, MN, USA 2UCHealth North Medical Center of the Rockies,Loveland, CO, USA

Introduction:
Gastrografin (GG) is a commonly administered contrast to evaluate and treat adhesive small bowel obstruction (SBO).  Resolution of SBO can be confirmed by identifying GG contrast in the colon either via a single abdominal x-ray (AXR), i.e. GG Challenge (GGC); or via a series of AXRs until the contrast reaches the colon, i.e. small bowel follow-through (SBFT). In this study, we aimed to determine the optimal time of the first AXR following GG administration for SBFT.

Methods:
A retrospective review included patients with SBO undergoing SBFT at one institution vs. GGC at another institution from Mar 2015 –Jan 2018.  Patient characteristics and medical history were recorded to calculate Charlson Age-Comorbidity Index (CACI). SBO severity was graded according to the American Association for the Surgery of Trauma imaging criteria. The primary outcome was the time of noting GG contrast in the colon on AXR. Additional outcomes following GG administration were also analyzed. Time intervals were described as median hours/days [interquartile range]. Multivariable regression model controlled for patients’ age, sex, BMI, CACI, previous SBO admissions, abdominal surgeries, and SBO severity grade.

Results:
A total of 255 patients were included: SBFT= 128; GGC=127. No significant difference in patients’ age, sex, prior SBO admissions, or SBO severity grade was noted (Table 1). SBO resolved following GG administration for 103 (80.5%) of SBFT patients, and 100 (78.7%) of GGC patients. GG in colon was confirmed on AXR earlier among SBFT patients compared to GGC patients:  4 [2-6] vs. 8.5 [8-9] hrs, p <0.001. However, SBFT patients underwent imaging more often: 3 [2-4] vs. 1 [1-1] AXRs, p <0.001. Time from hospital admission to operative exploration for SBFT was not significantly different: 34 [20-94] vs. 47 [21-105] hrs, p=0.70. SBFT patients were not significantly different from GGC patients in terms of GG aspiration: 0.8% vs. 1.6%, p =0.3127; time to soft diet toleration: 2 [1-4] vs. 1 [1-3] days, p =0.05; and hospital length of stay: 2 [3-5] vs. 2 [1-5] days, p=0.10.

Conclusion:
SBFT and GGC are effective approaches for managing SBO. Earlier imaging confirmation of SBO resolution was not associated with earlier operative exploration or shorter hospital stay. Practice guidelines to confirm GG in colon at 4 hrs & 8 hrs AXRs may be more efficient for non-operative SBO management.
 

59.03 A Selective Approach for the Evaluation of Bladder Injuries in Patients with Pelvic Fractures.

Posted on January 31, 2019

T. J. Herron1, J. Chipko1, S. Dosal1, S. Lorch1, D. J. Ciesla1  1University Of South Florida College Of Medicine,Division Of Trauma & Acute Care Surgery,Tampa, FL, USA

Introduction:  Bladder injury is a rare but serious complication of pelvic fractures.  Diagnosis usually requires CT cystography, however, scanning all patients with pelvic fractures is inefficient and increases radiation exposure. The purpose of this study was to identify associated clinical findings to guide a selective approach to diagnostic imaging in blunt trauma patients with pelvic fractures.  

Methods:  Adult (Age>18) Trauma patients with pelvic fractures at a Level 1, academic medical center were retrospectively reviewed from a prospective database over a three-year period. All patients underwent an initial CT of the abdomen and pelvis as well as a microscopic urinalysis as part of their initial trauma evaluation. An arbitrary cut off of microscopic hematuria was designated as >100 RBC per high power field (HPF).  Patients who had a penetrating mechanism as well as those who did not have both components of the aforementioned evaluation were excluded.   

Results: A total of 434 patients were reviewed.  Of these, 120 patients met exclusion criteria, for a sample size of 314 patients. There were no identified bladder injuries in the 231 patients with microscopic hematuria <100 RBC per HPF (NPV=100%). Nine bladder injuries (2.87%) were identified in the 83 patients with microscopic hematuria >100 RBC per HPF; two of the 83 patients with microscopic hematuria >100 RBC per HPF, but without gross hematuria, had bladder injuries (NPV=96%). Six of the bladder injuries were extraperitoneal and treated with bladder decompression alone. Three of the bladder injuries were intraperitoneal ruptures requiring operative intervention.  All patients with bladder injuries had high energy transfer mechanisms with anteroposterior compression and lateral compression fracture patterns being most common.  The mean ISS of patients without a bladder injury [n=305] was 18.24 vs. 27.44 in patients with a bladder injury [n=9] (p=0.029) 95% CI [0.91, 17.51]   

Conclusion: In trauma patients presenting with pelvic fractures, a microscopic hematuria of <100 RBC per HPF excludes bladder injury (NPV=100%).  In patients without gross hematuria, a selective use of CT cystogram in the evaluation of bladder injury can be applied to patients with higher energy transfer mechanisms resulting in pelvic fractures.
 

59.02 Maintaining Optimal Trauma Outcomes: Resilience in the Midst of a Ransomware Attack

Posted on January 31, 2019

J. F. Narvaez1, J. Zhao1, J. Pugh2, W. Guo1  1University at Buffalo,Department Of Surgery,Buffalo, NY, USA 2University at Buffalo,Department Of Emergency Medicine,Buffalo, NY, USA

Introduction: On April 9, 2017, Erie County Medical Center, Western New York’s sole level I trauma center was under cyberattack. The perpetrators utilized ransomware that gained access to the hospital’s web server and encrypted hospital data, forcing a system-wide downtime for nearly 2 months. Electronic medical records, imaging, and interdepartmental communication were severely affected, forcing the hospital to temporarily return to pre-EMR era operations. We examined the impact of this cyber disaster on the outcomes of trauma care.

Methods:  Hospital trauma registry data and operating room case logs from April 9th through June 9th, 2017 were examined and compared to the previous year. Baseline characteristics were examined using the chi-square test for categorical variables and the Student’s t-test for continuous variables that were normally distributed.

Results: There were 427 trauma admissions with patients aged 50.91 ± 22.4 from April 9th – June 9th, 2017 (n=417, aged 50.57 ± 21.95 during the same period in 2016). Blunt to penetrating ratio was 8:1 in both years. The mean injury severity score was 10.33 ± 8.33 in 2017 vs 9.86 ± 6.52 in 2016, and revised trauma score was 7.40 ± 1.32 vs 7.56 ± 0.92. There were 504 trauma/acute care operations in 2017 compared to 565 in 2016. Mean ICU length of stay (LOS) was 5.08 ± 4.59 days and hospital LOS was 6.95 ± 6.63 days in 2017 vs 4.79 ± 4.45 and 6.65 ± 7.34 days, respectively, in 2016. The in-hospital mortality was 4.92% in 2017 compared to 2.9% in 2016. Of these discharges in 2017, 34.3% went to a rehabilitation facility, 64.4% were discharged home and 0.5% were transferred to a different hospital, compared with 37.2%, 60.6% and 0.7%, respectively, in 2016. There were no statistically significant differences in all reported covariates.

Conclusion: Our results suggest that trauma patient outcomes have remained optimal despite the temporary loss of electronic health records and computer functionality. This is likely due to operational back-ups in place, increased communication between providers and staff, prioritization of patient care over documentation/ electronic tasks, and increased resilience of surgical care providers. With cyber security threats increasing in healthcare, proper preparedness should be included at different levels in hospital operations.  It is important to have policies, processes, and procedures in place for the hospital administration, information technology department, and clinical staff in order to continue to provide optimal care during such downtimes of unprecedented scale.

 

59.01 Chronic Alcohol Consumption And Risk Of Deep Venous Thrombosis: A Propensity-Matched Analysis

Posted on January 31, 2019

K. Hanna1, M. Zeeshan1, T. O’Keeffe1, N. Kulvatunyou1, A. Tang1, E. Zakaria1, L. Gries1, A. Northcutt1, B. Joseph1  1University Of Arizona,Trauma And Acute Care Surgery,Tucson, AZ, USA

Introduction:
Alcohol consumption is associated with a decrease in coagulation factors. The relationship between chronic alcoholism and occurrence of venous thromboembolic (VTE) events in trauma patients in unknown. The aim of our study was to analyze the association between chronic alcohol consumption and risk of VTE in trauma patients.

Methods:
We performed a two-year (2013-14) analysis of all patients in the TQIP. All trauma patients with ISS>16 were included. Patients with acute alcohol intoxication, hematological disorders, and cancer were excluded. Patients were divided into two groups (alcoholic and non-alcoholic) and were matched in a 1:1 ratio using propensity score matching for demographics, injury severity, injury location, and admission vitals. Outcomes measures were the prevalence of VTE (DVT and PE) in each group.

Results:
A total of 91,066 trauma patients were included in our analysis of which 35,460 patients (alcoholics: 17,730, non-alcoholics: 17,730) were matched. Mean age 45±18y, and 81% were males. Matched groups were similar in age (p=0.32), HR (p=0.31), SBP (p=0.46), location of injury (p=0.85), ISS (p=0.76) and GCS (p=0.38). Prevalence of DVT was lower in alcoholics compared non-alcoholics (2.34% vs. 5.12%, p=0.01).  Overall Incidence of PE was 1.2% and there was no difference between the two groups (1.1% vs.1.3%, p=0.22). Similarly, there was no difference in mortality (14.8% vs 15.4%, p=0.32) between the two groups.

Conclusion:
Chronic alcohol consumption is associated with a low risk of DVT in trauma patients. This association warrants further investigation of the possible physiological effects of alcohol in trauma patients.
 

58.20 Characteristics and Complications of G-Tube Placement Among Surgical and Non-Surgical Services.

Posted on January 31, 2019

P. M. Alvarez1, J. Herb2, A. Vijay1, C. Cunningham1, K. Anderson1, S. Francois1, K. Herbert1, N. Bartl1, E. Hoke2, J. Jadi1, N. Rodriguez-Ormaza2,3, R. Maine2, E. Dreesen2, A. Charles2, T. Reid2  1University Of North Carolina At Chapel Hill,School Of Medicine,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of General Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Department Of Epidemiology,Chapel Hill, NC, USA

Introduction:  While surgical and non-surgical services routinely place gastrostomy tubes, few investigations have examined the procedure’s outcomes based on performing service. This study describes baseline characteristics, complications, and mortality among patients who had gastrostomy tubes placed by either a surgical or non-surgical service.

Methods:  This is a retrospective study of all adult patients who underwent gastrostomy tube placement at UNC from March 2014 to July 2017. Baseline characteristics included age, sex, BMI, substance abuse, comorbidities, previous abdominal surgery, and prior gastrostomy tube. We compared placement by surgical versus non-surgical services outcomes, including severe and minor complications, and mortality, overall and gastrostomy tube related.

Results: Of the 1,339 adults who underwent gastrostomy tube placement, 45%(n=626) were placed by surgical services and 55% (n=713) were placed by non-surgical services. Baseline characteristics were similar although non-surgical services had higher rates of congestive heart failure (p=0.004) and COPD (p=0.05). Non-surgical services placed all gastrostomy tubes percutaneously, while surgical services placed 52.6% percutaneously, 37.3% laparoscopically, and 10.1% open. Mortality related to gastrostomy tube placement was similar (surgical 0.6% vs nonsurgical 0.5%, p=1.0), however overall mortality was higher among non-surgical services (23.7% vs 16.5%, p=0.004). There was no difference in major or minor complication rate (27.3% surgical vs 27.2% non-surgical, p=0.88).

Conclusion: Surgical and non-surgical service placement of gastrostomy tubes had equivalent gastrostomy tube related mortality and complication rates, although patients with gastrostomy tubes placed by non-surgical services experienced higher overall hospital mortality. The high in-hospital mortality and complication rates underscore the need for thoughtful patient selection for this procedure.

58.19 Pancreatic Cancer: A Topic Related Bibliometric Analysis

Posted on January 31, 2019

Q. D. Gibson1, H. Chen1, J. B. Rose1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction:
While there is ongoing controversy regarding the utility of bibliometric indices such as impact factor, h-index, and eigenfactor in the evaluation of academic journals and author productivity, there is generally agreement that such factors have value when used appropriately. The current study aims to perform a topic related bibliometric analysis on journal articles about pancreatic cancer.

Methods:
A Scopus database search relating to pancreatic cancer was performed. The search parameters included the keyword “Pancreatic Cancer” in the subject area of “Medicine”. The search was further limited to English language articles from academic journals published after 1993. Publication and citation counts with varying measures of centricity were used to calculate a modified topic specific impact factor

Results:
The search yielded 21,710 articles from 1,690 journals. The article with the most citations dealing solely with pancreatic cancer appeared in the Journal of Clinical Oncology.  The journal with the most publications over the past 25 years is Pancreas. The journal with the most pancreatic cancer related publications per year is Oncotarget with 78.43 articles per year for its 7 years of existence. Six of the top twenty articles were surgery related articles and all six detailed experiences with pancreaticoduodenectomies at a single institution. Of the top 30 journals by article count, the Journal of Clinical Oncology had the highest median citation count.

Conclusion:
Topic related bibliometric analysis provides unique insights into a field of interest.  This analysis demonstrates the value in relating institutional experiences with surgical procedures which is supported by the fact that 30% of the top twenty articles reported institutional experiences with the Whipple procedure. Topic related bibliometric analyses also allow institutions and individuals to target journal submissions, journal subscriptions and literature research.
 

58.17 Assessment of Post-Trauma Care Provided by Primary Care Providers in the Rural Nebraska Setting.

Posted on January 31, 2019

R. Muehling1, M. R. Goede1, J. I. Summers1, P. J. Schenarts1  1University Of Nebraska College Of Medicine,Department Of Surgery,Omaha, NE, USA

Introduction:   Management of trauma patients in both the pre-hospital and rural hospital setting has been studied extensively.  However, studies evaluating follow-up care by rural primary care providers are nonexistent.  This study aims to answer questions regarding the availability of follow-up and comfort level in rural providers managing discharged trauma patients in the rural setting in Nebraska.

Methods:   The survey was sent to providers in rural Nebraska, which were obtained via the University of Nebraska Medical Center Health Professions Tracking Service. The survey inquired about individual communities and general, orthopedic, and neurosurgeon access, followed by a Likert scale assessing providers’ comfort level treating various trauma conditions.

Results:  The table illustrates the results of the survey, which had a 4.51% response rate.  51.95% of rural hospitals transfer over half of trauma patients, even with surgeon access in the community.  74.71%, 80.46% and 39.08% of communities report general, orthopedic and neurosurgeon access, respectively.  In follow-up, the results demonstrate overall comfort in treating patients after discharge from a trauma center by primary care providers.  Write-in responses mention that continued medical education and communication of discharge plans were important to improve post-discharge care.

Conclusion:  The majority of primary care providers polled are comfortable in handling follow-up care of trauma patients, with the exception being chest, spine, and traumatic brain injuries.  Trauma surgeons can assist providers by supplying educational opportunities and improving communication at discharge between trauma centers and the rural provider.  Future efforts are to survey trauma surgeons in urban areas to determine how comfortable they believe rural providers are with follow-up care to compare perceptions with reality.

 

58.16 Influence Of The Opioid Epidemic On Firearm Violence.

Posted on January 31, 2019

S. Dittmer1, S. Slavova1, D. Davenport1, D. Oyler1, A. Bernard1  1University Of Kentucky,College Of Medicine,Lexington, KY, USA

Introduction:
The opioid crisis is a major public health emergency, killing more Americans than motor vehicle collisions and firearms combined. However, current data likely underestimates the full impact on mortality due to limitations in reporting and toxicology screening that have been previously described. Given the established relationship between illicit drug use and gun-related behaviors, we aimed to explore the relationship between opioid overdose ED visits (ODED) and firearm-associated ED visits (FAED).

Methods:
For the years 2010 to 2017 we analyzed county-level emergency department visits in Kentucky for ODED (per 1,000) and FAED (per 10,000) using Office of Health Policy and US Census Bureau data. Additional variables analyzed included: insurance status, ethnicity, median household earnings, unemployment rate, and education level.

Results:
ODED and FAED visits were correlated (Rho = .178, p < .001) and both increased over the study period, remarkably so after 2013 (p < .001 for increase, Figure 1). FAED visits were higher in rural compared to urban counties (p < .001), while ODED visits were not. In multivariable analysis, FAED visits were associated with ODED visits (B= 0.17, p=.001), rural status (B = 0.33, p = .012), white race rate (B = -2.4, p = .012), and high school diploma rate (-6.45, p < .001) after adjustment for year. Unemployment and earnings were univariate correlates with FAED visits (rho = .19, p < .001 and -.15, p < .001 resp.) but were not significant in the multivariable model.

Conclusion:
In addition to existing nonfatal consequences of the opioid crisis (e.g,. neonatal abstinence, burden on the criminal justice & foster care systems, incidence of opioid use disorder, etc.), firearm violence appears to be a corollary impact, particularly in rural counties. Future analyses should examine opioid use characteristics (e.g., prescription vs. illicit) as well as the impact of interventional models to reduce associated harm.
 

58.15 A System Dynamics Model of Violent Trauma and the Role of Violence Recovery Programs

Posted on January 31, 2019

J. Cirone1, P. Bendix1, G. An1  1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:

Prior exposure to violence is a known predictor for subsequent interpersonal violence (IPV). Violence recovery programs (VRPs) reduce IPV among high-risk individuals using multifactorial, case management approaches (1), however, little is known of the contribution of the individual VRP components. System dynamics models (SDMs) are a type of dynamic computational modeling that has shown utility in understanding other complex healthcare processes (2). SDMs represent systems as a series of “stocks” (populations) that are linked by interconnected “flows” (transitions) that can be configured as complex feedback loops. Running a SDM produces changes in the various population levels due to programmed transition rates linking one population type to another. Here, we model the general epidemiologic dynamics of IPV and how a VRP may influence IPV risk and recovery.

 

Methods:

A SDM was created based on an abstract process model of IPV. The model initially simulates flow between low- and high-risk populations, then through IPV and hospitalization events, a potential for death, and a return to the at-risk population. Risk factors such as prior exposure to violence, gang membership, and education were included in IPV risk and event calculations. We included points at which the interventions of a VRP could influence the transition from high-risk to low-risk populations. Model outputs include: trajectories of population distributions, number of IPV events, hospitalizations, and deaths.

Results: 

The VRP SDM was successfully implemented using the System Dynamics Modeler in NetLogo and incorporated the features noted above. Simulation experiments involved parameter sweeps of initial population levels, IPV event likelihood and population transition rates. Initial validation of the VRP SDM was achieved by observing output behaviors consistent with known patterns of IPV. Simulation runs converged to stable steady states with the greatest effect on IPV produced by varying the transition propensity between high- and low-risk populations. The VRP also functioned in a recognizable fashion, producing the greatest effect in reducing IPV events by increasing the shift from high- to low-risk populations.

Conclusion: 

This initial implementation of the VRP SDM produced recognizable baseline behavior while incorporating the possible effects of a VRP. The VRP SDM will allow us to compare hypotheses of the epidemiology of IPV and evaluate the components of a VRP intervention. Future work will emphasize adding complexity to the VRP SDM and identifying real-world metrics to aid in testing, validation and prediction of the model.

 

References:

1. Cooper C, Eslinger DM, Stolley PD. Hospital-based violence intervention programs work. Journal of Trauma. 2006;61(3):534-537.

2. Homer JB, Hirsch GB. System Dynamics Modeling for Public Health: Background and Opportunities. American Journal of Public Health. 2006;96(3):452-458.

58.14 Cholecystectomy: Exploring the Interplay Between Access to Care and Emergent Presentation

Posted on January 31, 2019

A. Moore1, H. Carmichael1, L. Steward1, C. G. Velopulos1  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:
The burden of Emergency General Surgery (EGS) leads to higher cost and less compensation to institutions. A recent study quantified the top 7 conditions contributing to 80% of the burden of EGS; cholecystectomy accounted for >150,000 cases/yr, the highest number of EGS cases that have a potentially elective course. Implications of variation in demographics and access at the local level are unclear, preventing clear strategy formation. We sought to study this more specifically in our population. We hypothesized that our cholecystectomy patient pool would have unique characteristics informing healthcare access in our area.

Methods:
We identified cholecystectomy patients at our academic hospital over a 6-month period from January to June of 2018 and classified them as emergent or elective.  We excluded pregnant patients, patients <18, and patients who had undergone another major procedure concurrently. Cases that initially presented emergently, with interval elective surgery were also excluded from the study. We abstracted patient demographics and clinical course from the EMR.

Results:
Of 289 patients who underwent cholecystectomy, 267 met inclusion criteria. There were no differences in age, sex or BMI between the two groups. Most patients (n=196, 73.4%) had surgery emergently. Emergent patients were more likely to be minorities (65.8% vs. 40.8%, p < 0.001), less likely to have insurance or a primary care physician, and notably 25% of them required an interpreter (see Table). While patients in the elective setting had higher prevalence of chronic symptoms (more than one-month duration), many patients in the emergent setting had duration of symptoms of months to years (n=107 patients, 56.3%). Most patients in the emergent group had acute cholecystitis (n=94, 48%), choledocholithiasis (n=27, 14%) or pancreatitis (13.3%). Elective patients most commonly had symptomatic cholelithiasis (n=43, 61%). Emergent patients had a longer length of stay (2 vs. 0 days, p<0.001). Overall, rates of conversion to an open procedure or other complication were low, without significant differences in emergent versus elective (7.1% vs. 4.2%, p=0.56).

Conclusion:
Significant differences in insurance status and utilizing primary care in our EGS population compared to elective patients indicates several targets for gallbladder disease at our institution. There was also a trend towards increased use of interpreters in this population. The majority of patients in the emergent group experienced chronic symptoms, indicating an opportunity to prevent the necessity of emergency surgery as treatment. This study provides local population characterization for improvements in access to care which can lead to decreases in emergency gallbladder.
 

58.13 A Comparison between Pediatric and Adult Patients Transported to a Rural Trauma Center by Helicopter

Posted on January 31, 2019

E. C. Gray1, M. A. Quinn1, S. Brown1, J. B. Yarger1, J. B. Burns1  1East Tennesse State University,Quillen College Of Medicine Department Of Surgery,Johnson City, TN, USA

Introduction: Helicopter Emergency Medical Services (HEMS) allow rapid transport of trauma patients over long distances which is beneficial in a rural trauma setting. However this rapid transit comes with an increase in monetary cost and risk to both crew and patient. We compared pediatric and adult trauma patients who were transported via HEMS to determine if pediatric patients would have a lower Injury Severity Score (ISS) and be more likely to be discharged home from the emergency department (ED).

Methods: Retrospective data was collected from January 1, 2010 to December 31, 2016 from the trauma registry data for an Appalachian Level 1 adult and pediatric general referral center. All trauma patients arriving via helicopter were included. A chi-square test was used to compare ISS for pediatric and adult patients. Patient disposition was also compared to explore rate of discharge from the ED. Pediatric patients were considered those younger than 16 years of age.

Results: Of 1,604 trauma patients transported by HEMS, 9.8% were pediatric patients and 90.2% were adults. A statistically higher percent of pediatric patients had an ISS of 0-15 versus adults (72.1% versus 59.4% p=0.002) and fewer pediatric patients had an ISS of 16-75 compared to adults (27.9% versus 40.6% p=0.002).  Additionally, pediatric patients were more likely to be discharged to home from the ED (33.1% versus 23.2%)

Conclusion: Pediatric patients transported via HEMS were significantly more likely to have a lower ISS and to be discharged to home. Currently there is no standardized system to triage pediatric patients to HEMS versus ground transport. Based on the data it would appear that EMS providers may benefit from standardization to reduce cost and risk associated with HEMS usage.

 

58.12 The Readability of Patient Discharge Education Materials Among Gastrointestinal Surgery

Posted on January 31, 2019

E. R. Kaplan1, K. Perkins1, A. Liwo1, I. Marques1, J. A. Cannon1, G. D. Kennedy1, M. Morris1, J. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Health literacy is a key determinant of health outcomes. Printed material, such as discharge instructions, are commonly utilized in healthcare, but it is unclear if these materials are health literate by readability/understandability standards. According to the American Medical Association (AMA) and National Institute of Health (NIH), a readable document is at or below the 6thgrade reading level. It is unclear whether discharge materials in surgery are at this recommended level. We hypothesized that discharge instructions on a gastrointestinal surgical division are written above a 6thgrade reading level and lack readability. 

Methods: Patient discharge materials were collected from a single-institution surgical service line. Four instruments were used to assess the readability and understandability of the materials: (i) the Flesch-Kincaid Grade Level instrument, (ii) SMOG (Simple Measure of Gobbledygook), (iii) PEMAT (Patient Education Materials Assessment Tool), and (iv) Print Communication Rating (PCR) from the Health Literacy Environment of Hospitals and Health Centers (HLEHH). Two independent observers rated these education materials.

Results:We collected 42 printed education materials from the gastrointestinal surgical service line. Of these, 24 were pre-operative and 18 were post-operative instructions. The overall average FKGL for all materials was 6.90 (standard deviation [SD] ± 0.82), with 90% of the documents scoring higher than a 6thgrade reading level. Material describing vacuum-assisted closure therapy was the most readable (FKGL = 5.3), while the most unreadable material explained general anesthesia and wound care after surgery (FKGL =9. 7). None of the materials were at or below a 6thgrade reading level when analyzed with SMOG. The average SMOG reading grade level of all printed education materials was 10.79 ± 1.34 SD, exceeding the recommended reading grade level by an average of 4.79 grade levels. 40 out of the 42 materials collected were at or greater than a high school reading level. The average PEMAT understandability and actionability score was 57.96% ± 6.28 and 49.13% ± 14.35, respectively, both having a total possible score of 100%. For both understandability and actionability, all but two documents scored lower than 70%, which is unacceptable. The average PCR score was 49.38 ± 1.49 out of a possible 72 points. 

Conclusion:The readability of patient discharge instructions on a surgical service deviates significantly from AMA/NIH recommendations. The majority of material was not at the recommended 6thgrade level. Additionally, all materials lacked understandability and tools for engagement for overall decision making. Increased efforts are needed to eliminate literacy-related barriers of discharge materials. 

 

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