Multidisciplinary Limb Salvage Service Reduces Major Amputations in Diabetic Foot Infections.

BACKGROUND: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS). METHODS: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed. RESULTS: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort. CONCLUSIONS: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.

The impact of intracranial pressure monitoring on mortality after severe traumatic brain injury.

BACKGROUND: The effect of intracranial pressure (ICP) monitoring on mortality after severe traumatic brain injury (sTBI) remains unclear. We hypothesized that ICP monitoring would not be associated with improved survival in patients with sTBI. METHODS: A retrospective analysis was performed on sTBI patients, defined as admission Glasgow Coma Scale score of 8 or less with intracranial hemorrhage. Patients who underwent ICP monitoring were compared with patients who did not. The primary outcome measure was inhospital mortality. RESULTS: Of 123 sTBI patients meeting inclusion criteria, 40 (32.5%) underwent ICP monitoring. On bivariate and multivariate regression analyses, ICP monitoring was associated with decreased mortality (odds ratio = .32, 95% confidence interval = .10 to .99, P = .049). This finding persisted on propensity-adjusted analysis. CONCLUSIONS: ICP monitoring is associated with improved survival in adult patients with sTBI. In addition, significant variability exists in the use of ICP monitoring among patients with sTBI.

General Surgery Residents can Be a Reliable Resource in the Evaluation of Residency Applications.

OBJECTIVE: Surgical residents' ability to screen general surgery (GS) applicants has not been previously investigated. The objective of this study was to compare surgical residents' evaluation of Electronic Residency Application Service (ERAS) applicants to that of faculty using a standardized assessment instrument. DESIGN: A prospective analysis of ERAS applications using a standardized assessment tool. SETTING: A university-affiliated, academic, county GS residency program. PARTICIPANTS: Before the interview day, 51 ERAS (2013-2014) applications were reviewed by 10 different assessors (6 GS faculty, including the program director, and 4 GS residents), who evaluated applicants on 10 characteristics (subjective and objective) using a 5-point Likert scale, a total score, and a Global Rating Scale that ranked candidates into deciles. RESULTS: There were a total of 510 assessments. In 8 of 10 individual domains the interrater reliability (IRR) between residents and faculty was good. The IRRs of the total score and global score were excellent. The Spearman ρ between the total score and final rank list were similar for faculty (-0.558) and residents (-0.592). CONCLUSIONS: The excellent IRR score between the total and global scores of faculty and residents demonstrates the reliability of GS residents in evaluating ERAS applications. The low correlations between the total score and final rank are consistent with those in previous studies, in which the interview has been demonstrated to be the most important factor in determining final selection.

The impact of a massive transfusion protocol on outcomes among patients with abdominal aortic injuries.

BACKGROUND: Injuries of the abdominal aorta are uncommon and associated with a high mortality. The purpose of this study was to examine the impact of an institutional massive transfusion protocol (MTP) on outcomes in patients with injuries of the abdominal aorta. METHODS: A 12.5-year retrospective analysis of a Level 1 trauma center database to identify patients with abdominal aortic injuries was conducted. Demographics, associated injuries and severity, operative procedures, resuscitation requirements, and outcomes were compared among patients before and after implementation of an MTP. RESULTS: Of the 46 patients with abdominal aortic injuries, 29 (63%) were in the pre-MTP group and 17 (37%) were in the post-MTP group. The mean age of the entire cohort was 32 ± 17 years and the two most common mechanisms of injury were gunshot wounds (63%) followed by motor vehicle collisions (24%). Thirteen patients (28%) underwent an emergency department thoracotomy and 11 patients (24%) sustained concomitant inferior vena cava injuries. There was a significant reduction in the volume of pre- and intraoperative crystalloids administered between the pre- and post-MTP groups. Intraoperatively, the use of tranexamic acid was increased in the post-MTP group (P < 0.001). A statistically significant difference in achievement of a low packed red blood cells to fresh frozen plasma ratio was observed for the post- versus the pre-MTP group (88% vs. 30%, P = 0.015). Overall survival was improved among post- versus pre-MTP patients (47% vs. 14%, P = 0.03). CONCLUSIONS: Abdominal aortic injuries continue to represent a challenge and remain associated with a high mortality. Modern improvements in damage control resuscitation techniques including implementation of an institutional MTP may improve outcomes in patients with these injuries.

The Effect of Platelet and Desmopressin Administration on Early Radiographic Progression of Traumatic Intracranial Hemorrhage.

Limited data exist regarding the use of hemostatic adjuncts on the progression of traumatic intracranial hemorrhage (tICH). The objective of this study was to examine the impact of platelet transfusion and desmopressin (DDAVP) administration on hemorrhage progression following tICH. We hypothesized that platelet and DDAVP administration would not result in decreased early hemorrhagic progression. We performed a three-year retrospective analysis of a Level 1 trauma center database to identify all adult patents with blunt tICH. The primary outcome was early (≤4 hours) radiographic hemorrhagic progression. Secondary outcomes included mortality, frequency of operative interventions, and complications. Multiple logistic regression analysis was performed to identify predictors for hemorrhage progression and mortality. A propensity score analysis also was performed to minimize differences and improve comparability between patients who received platelets and DDAVP and those who did not. Of 408 patients with tICH meeting the inclusion criteria, 126 received platelets and DDAVP (P/D [+]) and 282 did not (P/D [-]). Overall, 37% of patients demonstrated early radiographic hemorrhage progression. On univariate analysis, there was no difference in the incidence of hemorrhage progression between groups (43.7% [P/D (+)] vs. 34.2% [P/D (-)]; p = 0.07). On multivariate analyses, platelet and DDAVP administration was not associated with either a decreased risk of hemorrhage progression (odds ratio [OR] = 1.40, confidence interval [CI] = 0.80-2.40; p = 0.2) or mortality (OR = 1.50, CI = 0.60-4.30; p = 0.4). The administration of platelets and DDAVP is not associated with a decreased risk for early radiographic hemorrhage progression in patients with tICH. Further prospective study of these potentially hemostatic adjuncts in patients with tICH is potentially warranted.

Abdominal hollow viscus injuries are associated with spine and neurologic infections after penetrating spinal cord injuries.

Penetrating spinal cord injuries are rare but potentially devastating injuries that are associated with significant morbidity. The objective of this study was to assess the impact of abdominal hollow viscus injuries (HVIs) on neurologic and spinal infectious complications in patients sustaining penetrating spinal cord injuries. We performed a 13-year retrospective review of a Level I trauma center database. Variables analyzed included demographics, injury patterns and severity, spine operations, and outcomes. Spine and neurologic infections (SNIs) were defined as paraspinal or spinal abscess, osteomyelitis, and meningitis. Multivariate analysis was performed to identify factors associated with SNI. Of 137 patients, there were 126 males (92%) with a mean age of 27 ± 10 years. Eight patients (6%) underwent operative stabilization of their spine. Fifteen patients (11%) developed SNI. There was a higher incidence of SNI among patients with abdominal HVI compared with those without (eight [26%] vs six [6%], P < 0.001). On multivariate analysis, after controlling for injury severity, solid abdominal injury and HVI, vascular injury, and spine operation, abdominal HVIs were independently associated with an increased risk for SNI (odds ratio, 6.88; 95% confidence interval, 2.14 to 22.09; P = 0.001). Further studies are required to determine the optimal management strategy to prevent and successfully treat these infections.

Effect of marijuana use on outcomes in traumatic brain injury.

Traumatic brain injury (TBI) is associated with significant morbidity and mortality. Several studies have demonstrated neuroprotective effects of cannabinoids. The objective of this study was to establish a relationship between the presence of a positive toxicology screen for tetrahydrocannabinol (THC) and mortality after TBI. A 3-year retrospective review of registry data at a Level I center of patients sustaining TBI having a toxicology screen was performed. Pediatric patients (younger than 15 years) and patients with a suspected nonsurvivable injury were excluded. The THC(+) group was compared with the THC(-) group with respect to injury mechanism, severity, disposition, and mortality. Logistic regression was used to determine independent associations with mortality. There were 446 cases meeting all inclusion criteria. The incidence of a positive THC screen was 18.4 per cent (82). Overall mortality was 9.9 per cent (44); however, mortality in the THC(+) group (2.4% [two]) was significantly decreased compared with the THC(-) group (11.5% [42]; P = 0.012). After adjusting for differences between the study cohorts on logistic regression, a THC(+) screen was independently associated with survival after TBI (odds ratio, 0.224; 95% confidence interval, 0.051 to 0.991; P = 0.049). A positive THC screen is associated with decreased mortality in adult patients sustaining TBI.

Surgical malpractice in California: res judicata.

Medical negligence claims are of increasing concern to surgeons. Although noneconomic damage awards in California are limited by the Medical Injury Compensation Reform Act (MICRA) law to $250,000, the total amount of such settlements can increase significantly based on claims for economic damages. We reviewed negligence litigation involving California surgeons to determine outcomes and monetary awards through retrospective review of surgical malpractice cases published in a legal journal. This review was limited to actions involving general surgeons. Such litigation was voluntarily reported by either defense's or plaintiff's counsel at the conclusion of the litigation. Data reviewed included alleged damages incurred by the plaintiff; plaintiff's pretrial settlement demand, plaintiff or defense verdict, use of alternate means of resolution such as arbitration or mediation, and total monetary award to the plaintiff. A total of 69 cases were reported over a 20-month period: 32 (46%) were plaintiffs' verdicts, whereas 37 (54%) were in favor of the surgeon. Only 10 (31%) of the plaintiff verdicts were by jury trial, whereas the rest were settled by pretrial agreement, mediation, or arbitration. Of cases settled by alternate dispute resolution, the median settlement was $820,000 (n = 22) compared with a median jury trial award of $300,000 (n = 10).

Flat or fat? Inferior vena cava ratio is a marker for occult shock in trauma patients.

BACKGROUND: Identification of occult shock (OS) or hypoperfusion is critical in the initial management of trauma patients. Analysis of inferior vena cava (IVC) ratio on computed tomography (CT) scan has shown promise in predicting intravascular volume. We hypothesized that a flat IVC is a predictor of OS and associated with worse outcomes in major trauma patients. MATERIALS AND METHODS: We performed a 1-y retrospective analysis of our level 1 trauma center database to identify all major trauma activations that underwent evaluation with a CT scan of the torso, arterial blood gas, and serum lactate. A flat IVC was defined as a transverse-to-anteroposterior ratio ≥2.5 at the level of the suprarenal IVC. OS was defined as a base deficit ≥4.0 in the absence of hypotension (systolic blood pressure ≤90 mm Hg). RESULTS: Two hundred sixty-four patients were included, of which 52 had a flat IVC. Patients with a flat IVC were found to have a higher injury severity score, lactate, and base deficit compared with patients with a fat IVC. Flat IVC patients also required greater amounts of fluids (P < 0.04) and blood (P < 0.01). On multivariate analysis, a flat IVC was independently associated with an increased risk for OS (odds ratio = 2.87, P < 0.007) and overall complications (odds ratio = 2.26, P = 0.05). The area under the receiver operating characteristic curve for a flat IVC to predict OS was 0.74. CONCLUSIONS: A flat IVC on CT is an accurate marker for OS in major trauma victims and may help stratify patients who require more aggressive resuscitation, monitoring, and support.

Use of recombinant factor VIIa for adjunctive hemorrhage control in trauma and surgical patients.

Recombinant factor VIIa (rFVIIa) has recently been described for patients with ongoing massive bleeding in a number of different clinical scenarios. A retrospective chart review was conducted at a public level I trauma center in order to describe the use of rFVIIa in trauma and surgical patients with massive bleeding despite surgical control. Fifteen trauma and general surgical patients underwent major operative procedures and developed coagulopathy requiring massive blood product transfusion. All patients had continued life-threatening hemorrhage despite surgical control of bleeding. The mean base deficit was 6 and arterial lactate was 9.0 mmol/L. An initial dose of rFVIIa was given intravenously, followed by a second dose if there was evidence of at least a partial response. Twelve of 15 patients who had been expected to die from hemorrhage survived for greater than 48 hours, and 7 survived to hospital discharge. A partial or complete hemostatic response to rFVIIa was noted in 12 of 15 patients. The number of blood products received after administration of rFVIIa was significantly reduced and the International Normalized Ratio (INR) decreased. Our experience demonstrates that rFVIIa may reduce or completely arrest coagulopathic bleeding in trauma and surgical patients after vascular control.