A Novel Approach to Limb Salvage: Healing Transmetatarsal Amputations without a Viable Plantar Flap.

BACKGROUND: The lack of a viable plantar flap in patients undergoing transmetatarsal amputation has been considered an indication for below-knee amputation (BKA). In an effort to reduce limb loss in this patient population, we sought to review our experience with transmetatarsal amputation salvage in patients with an open, guillotine transmetatarsal amputation. We hypothesized that performing a transmetatarsal amputation without a viable flap would extend time of independent ambulation and improve limb salvage. METHODS: This is a retrospective review of 27 consecutive patients who did not have a viable plantar flap and who underwent an open, guillotine transmetatarsal amputation. Patients presented with a nonviable plantar flap due to either extensive tissue loss on initial presentation, or secondary transmetatarsal amputation (TMA) flap necrosis. Patients initially underwent an open, guillotine TMA for control of infection and debridement of nonviable tissue. To achieve best results, during procedure, the metatarsals were resected to be as flush with soft tissue as possible. Once infection was resolved and all nonviable tissue debrided, negative pressure wound therapy (NPWT) was applied to the open wound. NPWT was continued until a base of granulation tissue covered the previously exposed bone. Wound closure was obtained by either the application of a split-thickness skin graft (STSG) or through continued NPWT allowing the wound to heal by secondary intention. RESULTS: Between January 2016 and December 2018, there were 27 open TMAs performed in 27 patients. Two patients did not granulate sufficiently and underwent BKA. Fourteen patients underwent STSG for closure, whereas 11 patients continued with NPWT. In the STSG group, 12 (86%) of the patients are healed, with a median time to complete healing of 75 days (range 28-330 days); the remaining 2 are ambulatory and undergoing continued wound care. In the 11 patients who did not receive STSG, 7 (64%) are healed with a median time to heal of 165 days. Of the remaining 4 patients in this group, 3 are ambulatory and still undergoing wound care, one was lost to follow-up. Overall, 19 patients (70%) have completely healed with a median time to heal of 82 days. CONCLUSIONS: Limb salvage in patients with a nonviable plantar flap for TMA is possible and should be a considered procedure. This technique has the potential to improve functional outcomes and limb salvage in patients who might otherwise undergo BKA.

Trends in organ donor management: 2002 to 2012.

BACKGROUND: Refinements in donor management have resulted in increased numbers and quality of grafts after neurologic death. We hypothesize that the increased use of hormone replacement therapy (HRT) has been accompanied by improved outcomes over time. STUDY DESIGN: Using the Organ Procurement and Transplant Network donor database, all brain-dead donors procured from July 1, 2001 to June 30, 2012 were studied. Hormone replacement therapy was identified by an infusion of thyroid hormone. An expanded criteria donor was defined as age 60 years or older. Incidence of HRT administration and number of donors and organs recovered were calculated. Using the Organ Procurement and Transplant Network thoracic recipient database transplant list, wait times were examined. RESULTS: There were 74,180 brain-dead donors studied. Hormone replacement therapy use increased substantially from 25.6% to 72.3% of donors. However, mean number of organs procured per donor remained static (3.51 to 3.50; p = 0.083), and the rate of high-yield donors decreased (46.4% to 43.1%; p < 0.001). Incidence of traumatic brain injury donors decreased (42.1% to 33.9%; p < 0.001) relative to an increased number of expanded criteria donors (22.1% to 26%). Despite this, there has been an increase in the raw number of donors (20,558 to 24,308; p < 0.001) and organs (5,857 to 6,945; p < 0.001). There has been an increase in organs per traumatic brain injury donor (4.02 to 4.12; p = 0.002) and a decrease in days on the waiting list (462.2 to 170.4 days; p < 0.001) for a thoracic transplant recipient. CONCLUSIONS: The marked increase in the use of HRT in the management of brain-dead donors has been accompanied by increased organ availability overall. Potential mechanisms might include successful conversion of previously unacceptable donors and improved recovery in certain subsets of donors.

Insurance status predicts survival for trauma patients undergoing urgent intervention.

BACKGROUND: The purpose of this study was to investigate the relationship between insurance status and outcomes for trauma patients presenting without vital signs undergoing urgent intervention. MATERIALS AND METHODS: The National Trauma Data Bank was queried for patients presenting with a systolic blood pressure equal to zero and a Glasgow Coma Scale score of three ("clinically dead"), who underwent urgent thoracotomy and-or laparotomy (UTL). Insured patients were compared with uninsured (INS [-]) patients. RESULTS: There were 18,171 patients presenting clinically dead having a payment source documented. INS (-) patients were more likely to undergo UTL (5.4% [416-7704] versus 2.7% [285-10,467], 1.481 [1.390-1.577], <0.001). Out of 689 patients who underwent UTL and meeting inclusion criteria, 416 (60.4%) were INS (-). Patients with insurance demonstrated a significantly greater survival (9.9% [27-273] versus 1.7% [7-416], 5.878 [2.596-13.307] P < 0.001). Adjusting for mechanism, race, age, injury severity, and comorbidities, insured status was independently associated with survival. CONCLUSIONS: The presence of health insurance is independently associated with survival in trauma patients presenting with cardiovascular collapse who undergo urgent surgical intervention.

The effect of arginine vasopressin on organ donor procurement and lung function.

BACKGROUND: Hormone replacement therapy (HRT) is becoming more common when managing brain-dead donors. Arginine vasopressin (AVP) is associated with benefits but is not consistently used. We hypothesize that AVP is associated with the maintenance of lung function and successful recovery in donors and enhanced lung graft performance in recipients. METHODS: The Organ Procurement and Transplantation Network database was used. Study donors were those treated with HRT and procured from January 1, 2009 to June 30, 2011. AVP (+) and AVP (-) donors were compared. Donor lung function, the rate of successful lung procurement, and the incidence of graft failure in recipients were studied. RESULTS: There were 12,322 donors included, of which 7686 received AVP (62.4%). Cerebrovascular accident (4722 [38.3%]) was the most common cause of donor death. There was a significant increase in high yield (≥4 organs) (51.0% versus 39.3%, <0.001), mean number of organs (3.75 versus 3.33, <0.001), and rate of successful lung recovery (26.3% versus 20.5%, <0.001) with AVP. Lung function was preserved to a greater degree in donors receiving AVP. Adjusting the significant factors, AVP was independently associated with lung procurement (1.220 [1.114-1.336], <0.001). The incidence of early graft failure was not changed. CONCLUSIONS: AVP with HRT is associated with the maintenance of lung function and a significant increase in successful organ recovery in donors without untoward effects in the recipient. AVP should be universally adopted as a component of HRT in the management of donors with neurologic death.

The impact of age on mortality in patients in extremis undergoing urgent intervention.

Trauma patients admitted without vital signs have little hope of survival even with extreme interventions. We performed this study to determine the effect of age on survival in patients in extremis undergoing urgent thoracotomy. The National Trauma Database was searched for patients presenting without a systolic blood pressure (0), a Glasgow Coma Scale score less than 8, and underwent an urgent thoracotomy. Mortality was determined for pediatric (younger than 16 years) and older patients (older than 60 years) and compared. Of 708 patients, 32 (4.5%) were pediatric and 57 (8.1%) were elderly. Pediatric mortality was 93.8 per cent (30) versus 95.6 per cent (646) for patients older than 16 years (P = 0.981). Mortality in the older patients was 94.7 per cent (54) versus 95.5 per cent (622) in patients younger than 60 years (P = 0.778). Race and blunt injury were independently associated with death. However, neither pediatric (P = 0.418) nor older status (P = 0.184) was predictive. Age does not significantly impact mortality in patients in extremis who undergo urgent thoracotomy. Age should not be a contributing factor in determining who should undergo more extreme maneuvers if they present as a reasonable candidate using other criteria.

Penetrating cardiac injury and the significance of chest computed tomography findings.

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

Ventilator-associated pneumonia in severe traumatic brain injury: the clinical significance of admission chest computed tomography findings.

BACKGROUND: Ventilator-associated pneumonia (VAP) in severe traumatic brain injury (STBI) is a significant morbidity. Bilateral dependent consolidation (BDC) can be seen on admission chest computed tomography (CCT) in STBI. We hypothesize that this finding may be associated with VAP. MATERIALS AND METHODS: We retrospectively studied patients who sustained STBI after blunt injury and survived >48 h, who were admitted over a 40-mo period. We defined STBI as an admission Glasgow Coma Scale Score ≤ 8. We identified VAP by an elevated white blood cell count, a new infiltrate on chest x-ray, and a positive respiratory culture in a ventilated patient. Variables included demographics, injury, admission CCT, and culture data. We compared BDC-positive and BDC-negative patients. RESULTS: There were 33 cases of VAP in 94 study patients (35.1%), in whom the incidence of intracranial pressure (ICP) monitoring (66.7% versus 39.3%; P = 0.011) was significantly increased. Ventilator-associated pneumonia was significantly increased in the 28 patients (29.8%) in the BDC-positive group (16 [57.1%] versus 17 (25.6%); P = 0.004). Bilateral dependent consolidation independently predicted VAP. In the 33 VAP cases, gram-negative organisms were present in 27 patients (81.8%), with a predominance of Enterobacteriaceae (16 patients [48.5%]). Culture results did not significantly differ between the early (<4 d) versus late or BDC-positive versus BDC-negative VAP groups. CONCLUSIONS: Ventilator-associated pneumonia is common after STBI, and BDC is independently associated; however, there is no predilection for specific organisms. Admission CCT findings may prove useful in identifying a group of STBI patients at higher risk for VAP.

Arginine vasopressin significantly increases the rate of successful organ procurement in potential donors.

BACKGROUND: Hormone replacement therapy increases the number and quality of grafts recovered from brain-dead organ donors. Arginine vasopressin (AVP) has also been shown to have beneficial effects. The aim of this study was to determine the effect of AVP on recovery rates. METHODS: The Organ Procurement and Transplantation Network database was used. Donors treated with hormone replacement therapy and vasopressor agents who were successfully procured between January 1, 2009, and June 30, 2011, were studied. AVP-positive and AVP-negative donors were compared. The primary study end point was the rate of high-yield procurement (≥4 organs). RESULTS: A total of 10,431 donors were included. AVP was infused in 7,873 (75.5%) and was associated with an increased rate of high-yield procurement (50.5% vs 35.6%, P < .001). There was less overall graft refusal due to poor function (38.9% vs 45.6%, P < .001). AVP independently predicted high yield procurement. CONCLUSIONS: The use of AVP with hormone replacement therapy is independently associated with an increased rate of organ recovery. This strategy should be universally adopted in the management of donors progressing to neurologic death.

Donor hormone and vasopressor therapy: closing the gap in a transplant organ shortage.

BACKGROUND: Hormone replacement therapy (HRT) use for donors with hemodynamic instability is common. The purpose of this study was to determine the effect of HRT in donors without significant cardiovascular dysfunction and examine outcomes according to vasopressor exposure. METHODS: All successfully procured donors admitted between January 1, 2006, and March 31, 2011, were included. HRT group I were donors without significant hemodynamic instability at the initiation of HRT. Comparison was made to all other donors receiving HRT (HRT group II). Vasopressor use was also examined and compared. High-yield procurement was the successful recovery of ≥ 4 organs. RESULTS: Forty-seven donors were studied. Most were male (36 [76.6%]) and trauma (41% [87.2%]) predominated. Twenty-two (46.8%) patients were in HRT group I. There were no differences in gender, admission diagnosis, or complications; however, HRT group I had a significantly greater number of organs recovered (4.73 ± 1.42 vs. 3.08 ± 1.19, p < 0.001). Differences in rates for the heart (68.2% vs. 24%, p = 0.002) and lung (40.9% vs. 8.0%, p = 0.008) were marked. HRT group I was more likely managed on a single agent (45.5% vs. 8.0%, p = 0.003). Norepinephrine was associated with a decreased rate of high-yield procurement (48.0% vs. 77.3%, p = 0.039), while vasopressin exposure was associated with an absolute increase (72.0% vs. 59.1%, p = 0.351). After adjusting for differences between groups (particularly age), HRT group I status was independently associated with high-yield procurement. CONCLUSION: A more liberal strategy of HRT seems to significantly increase procurement rates. Vasopressor selection favoring vasopressin as opposed to norepinephrine may also play a role. LEVEL OF EVIDENCE: Therapeutic study, level III.

The correlation of near-infrared spectroscopy with changes in oxygen delivery in a controlled model of altered perfusion.

Alterations in regional tissue perfusion may precede global indications of shock. This study compared regional tissue oxygenation saturation (StO2) using near-infrared spectroscopy with standard hemodynamic and biochemical variables in 40 patients undergoing cardiopulmonary bypass (CPB). Mean arterial pressure, cardiac output, oxygen delivery, arterial blood gases, and lactate were recorded at specific intervals during surgery. Data were organized by stage of procedure, and the relationship of StO2 to established parameters was investigated. With initiation of CPB, StO2 declined by 12.9 per cent (standard deviation +/- 14.75%) with a delayed increase in lactate from 0.9 (interquartile range [IQR], 0.6-1.5) mmol/L to 2.3 (IQR, 1.8-2.5) mmol/L. The minimum StO2 value preceded the maximum lactate level by an average time of 93.9 (standard deviation +/- 86.3) minutes. Additionally, a decrease in StO2 corresponded with an increase in base deficit of 4.84 (standard deviation +/- 2.37) mEq/L over the same period. Calculated oxygen delivery decreased from a baseline value of 754 (IQR, 560-950) mL/min to 472 (IQR, 396-600) mL/min with initiation and maintenance of CPB. For patients undergoing CPB, StO2 is a reliable, noninvasive monitor of perfusion, which correlates well with oxygen delivery and identifies perfusion deficits earlier than lactate or base deficit.

Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department.

BACKGROUND: To determine whether prehospital hypotension predicts the need for an emergent, therapeutic operation in trauma patients who present to the emergency department (ED) with normal systolic blood pressure (SBP). METHODS: An observational, cohort study was conducted at a Level I, urban, county trauma center. Consecutive trauma patients not in cardiopulmonary arrest and transported to the ED by emergency medical services during a one-year period were studied. Data on prehospital and ED vital signs, subsequent hospital course, and surgical procedures were collected. The occurrence of an emergent, therapeutic operation, which was defined based on the types of injuries found or repaired within 6 hours of arrival, was determined from operative and hospital records. RESULTS: Of the 1,227 total trauma patients, 160 were excluded because of cardiopulmonary arrest or inadequate documentation, leaving 1,067 study patients. Of those, 1,028 were normotensive on arrival to the ED. Seventy-one of the 1,028 patients (7%) were hypotensive in the field; 37% of these patients received an emergent, therapeutic operation and 6% died. Of the 1,028 patients, 957 (93%) were normotensive in the field; 11% of these patients received an emergent, therapeutic operation and 3% died. Thus, in trauma patients who were normotensive on arrival to the ED, the need for an emergent, therapeutic operation was more than three times more likely compared with those who had normal SBP in the field (odds ratio 4.5, 95% confidence interval 2.7-7.6). Mortality was also higher in the prehospital hypotension group (odds ratio 2.3, 95% confidence interval 0.8-6.9). CONCLUSION: Prehospital hypotension is a strong predictor of the need for an emergent, therapeutic operation in trauma patients with normal SBP on arrival to the ED.

Iliac vessel injuries.

Trauma to the iliac vasculature continues to pose a significant challenge to management. In several large series, mortality for penetrating injuries is reported as approaching 40%. Uncontrollable hemorrhage originating from an anatomically inaccessible source and multiple associated injuries often contribute to this high mortality rate. This article discusses the current existing management strategies and the controversial role of PTFE in vascular reconstruction within a contaminated field. Concomitant injuries to the enteric viscera and genitourinary system are also addressed. Postoperative management including anticoagulation and the complications of liberal fasciotomy are mentioned. The evolving role of endovascular therapy as an adjunctive modality in the armamentarium of the trauma surgeon is also presented briefly.