Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury.

OBJECTIVES: Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. METHODS: The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. RESULTS: The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). CONCLUSIONS: In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Decreased Length of Stay After Laparoscopic Diaphragm Repair for Isolated Diaphragm Injury After Penetrating Trauma.

BACKGROUND: Isolated diaphragm injury (IDI) occurs in up to 30% of penetrating left thoracoabdominal injuries. Laparoscopic abdominal procedures have demonstrated improved outcome including decreased postoperative pain and length of stay (LOS) compared to open surgery. However, there is a paucity of data on this topic for penetrating IDI. The aim of this study was to examine the prevalence and outcome of laparoscopic diaphragmatic repair versus open diaphragmatic repair (LDR vs ODR) of IDI. METHODS: The Trauma Quality Improvement Program (2010-2016) was queried for patients with IDI who underwent ODR versus LDR. A bivariate analysis using Pearson chi-square and Mann-Whitney test was performed to determine LOS among the two groups. RESULTS: From 2039 diaphragm injuries, 368 patients had IDI; 281 patients (76.4%) underwent ODR and 87 (23.6%) underwent LDR. Compared to LDR, the ODR patients were older (median, 31 vs 25 years, P < .001) and had a higher injury severity score (mean, 11.2 vs 9.6, P = .03) but had similar rates of intensive care unit LOS, unplanned return to the operating room, ventilator days, and complications (P > .05). Patients undergoing ODR had a longer LOS (5 vs 4 days, P = .01), compared to LDR. There were no deaths in either group. CONCLUSIONS: Trauma patients presenting with IDI undergoing ODR had a longer hospital LOS compared to patients undergoing LDR with no difference in complications or mortality. Therefore, we recommend when possible an LDR should be employed to decrease hospital LOS. Further research is needed to examine other benefits of laparoscopy such as postoperative pain, incisional hernia, and wound-related complications.

Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days.

OBJECTIVES: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN: Retrospective cohort analysis. SETTING: The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. CONCLUSION: Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. ARTICLE TWEET: Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

Early Versus Late Pulmonary Embolism in Trauma Patients: Not All Pulmonary Embolisms are Created Similarly.

BACKGROUND: Pulmonary embolism (PE) is an uncommon complication occurring in up to 5% of trauma patients. In small previous studies, patients with long-bone fractures were associated with a higher risk of early PE while those with severe head injuries were at higher risk for late PE. MATERIALS AND METHODS: This was a retrospective analysis at a single level I trauma center from 2010 to 2017. Patients with early PE (≤4 d) were compared to those with late PE (>4 d) using bivariate analysis and multivariable logistic regression analysis. We sought to confirm risk factors for early and late PE, hypothesizing that early PE is associated with long-bone fractures and late PE is associated with above-the-knee deep venous thrombosis (DVT). RESULTS: From 12,833 trauma admissions, 76 patients (0.6%) had a PE. Of these, 33 (43.4%) had an early PE and 43 (54.6%) were diagnosed with late PE. After adjusting for covariates, independent risk factors for late PE included above-the-knee DVT (odds ratio [OR] = 12.01, confidence interval [CI] = 1.34-107.52, P = 0.03), blood transfusion (OR = 8.99, CI = 1.75-46.22, P = 0.009), and craniotomy (OR = 8.82, CI = 1.03-75.97, P = 0.04), while the only independent risk factor for early PE was smoking (OR = 4.56, CI 1.06-19.66, P = 0.04). Severe head injury and long-bone fractures were not risk factors for early or late PE (P > 0.05) CONCLUSIONS: The strongest risk factor for late PE is above-the-knee DVT. Contrary to previous reports, long-bone extremity fractures and severe head injuries are not associated with early or late PE. The only risk factor for early PE was a history of smoking.

Early Outcome of Treatment of Chronic Mesenteric Ischemia.

There are limited data regarding long-term outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment outcomes of CMI. The NIS database was used to identify patients admitted for the diagnosis of CMI between 2002 and 2012. Multivariate analysis using logistic regression was performed to quantify outcomes of CMI. A total of 160,889 patients were admitted for chronic vascular insufficiency of intestine; of which 7,906 patients underwent surgical/endovascular treatment for CMI. Among patients who underwent surgery 62 per cent had endovascular treatment and 38 per cent had open vascular treatment. Need of open surgery (adjusted odds ratio (AOR): 5.13, P < 0.01) and age ≥70 years (AOR: 3.41, P < 0.01) had strong associations with mortality of patients. Open vascular treatment has higher mortality (AOR: 5.07, P < 0.01) and morbidity (AOR: 2.14, P < 0.01). However, endovascular treatment had higher risk of postoperative wound hematoma (AOR: 2.81, P < 0.01). Most patients admitted for CMI are treated with endovascular treatment. Endovascular treatment has the advantage of lower mortality and morbidity. Need to open surgery and age ≥70 years have strong associations with mortality of patients.

Even modest hypoalbuminemia affects outcomes of colorectal surgery patients.

BACKGROUND: A small decrease in the serum albumin from the normal level is a common condition in preoperative laboratory tests of colorectal surgery patients; however, there is limited data examining these patients. We sought to identify outcomes of such patients. METHODS: The National Surgical Quality Improvement Program database was used to evaluate all patients who had modest levels of hypoalbuminemia (3 ≤ serum albumin < 3.5 g/dL) before colorectal resection from 2005 to 2012. Multivariate analysis using logistic regression was performed to quantify complications associated with modest hypoalbuminemia. RESULTS: A total of 108,898 patients undergoing colorectal resection were identified, of which 16,962 (15.6%) had modest levels of preoperative hypoalbuminemia. Postsurgical complications significantly associated (P < .05) with modest hypoalbuminemia were as follows: hospitalization more than 30 days (adjusted odds ratio [AOR], 1.77), deep vein thrombosis (AOR, 1.64), unplanned intubation (AOR, 1.42), ventilator dependency for more than 48 hours (AOR, 1.30), and wound disruption (AOR, 1.22). CONCLUSIONS: Modest hypoalbuminemia is a common preoperative condition in patients undergoing colorectal resection. Our analysis demonstrates that modest hypoalbuminemia has associations with increased postoperative complications, especially pulmonary complications.

Laparoscopic appendectomy trends and outcomes in the United States: data from the Nationwide Inpatient Sample (NIS), 2004-2011.

Laparoscopic appendectomy (LA) is becoming the standard procedure of choice for appendicitis. We aimed to evaluate the frequency and trends of LA for acute appendicitis in the United States and to compare outcomes of LA with open appendectomy (OA). Using the Nationwide Inpatient Sample database, we examined patients who underwent appendectomy for acute appendicitis from 2004 to 2011. A total of 2,593,786 patients underwent appendectomy during this period. Overall, the rate of LA was 60.5 per cent (children: 58.1%; adults: 63%; elderly: 48.7%). LA rate significantly increased from 43.3 per cent in 2004 to 75 per cent in 2011. LA use increased 66 per cent in nonperforated appendicitis versus 100 per cent increase in LA use for perforated appendicitis. The LA rate increased in all age groups. The increased LA use was more significant in male patients (84%) compared with female patients (62%). The overall conversion rate of LA to OA was 6.3 per cent. Compared with OA, LA had a significantly lower complication rate, a lower mortality rate, a shorter mean hospital stay, and lower mean total hospital charges in both nonperforated and perforated appendices. LA has become an established procedure for appendectomy in nonperforated and perforated appendicitis in all rates exceeding OA. Conversion rate is relatively low (6.3%).

The current role of magnetic resonance imaging for diagnosing cervical spine injury in blunt trauma patients with negative computed tomography scan.

Clearance of cervical spine (CS) precautions in the neurologically altered blunt trauma patient can be difficult. Physical examination is not reliable, and although computed tomography (CT) may reveal no evidence of fracture, it is generally believed to be an inferior modality for assessing ligamentous and cord injuries. However, magnetic resonance imaging (MRI) is expensive and may be risky in critically ill patients. Conversely, prolonged rigid collar use is associated with pressure ulceration and other complications. Multidetector CT raises the possibility of clearing CS on the basis of CT alone. We performed a retrospective review at our Level I trauma center of all blunt trauma patients with Glasgow Coma Scale Score 14 or less who underwent both CT and MRI CS with negative CT. One hundred fourteen patients met inclusion criteria, of which 23 had MRI findings. Seven (6%) of these had neurologic deficits and/or a change in management on the basis of MRI findings. Although use of the single-slice scanner was significantly associated with MRI findings (odds ratio, 2.62; P=0.023), no significant clinical risk factors were identified. Patients with MRI findings were heterogeneous in terms of age, mechanism, and Injury Severity Score. We conclude that CS MRI continues play a vital role in the workup of neurologically altered patients.

Predictive factors of in-hospital mortality in colon and rectal surgery.

BACKGROUND: Knowledge of the independent risk factors for mortality in colon and rectal surgery can aid surgeons in surgical decision making and in providing patients with appropriate information about the risks of surgery. This study endeavors to identify the risk factors for mortality that are associated with colon and rectal surgery. STUDY DESIGN: Using the Nationwide Inpatient Sample database, we examined the clinical data of patients who underwent colon and rectal resection from 2006 to 2008. Multivariate regression analysis was performed to identify factors predictive of in-hospital mortality. RESULTS: A total of 975,825 patients underwent colon and rectal resection during this period. Overall, the rate of in-hospital mortality was 4.50% (elective surgery, 1.42% vs emergent surgery, 8.76%; p < 0.01). Mortality was lower after laparoscopic compared with open operation (1.43% vs 4.74%; p < 0.01). Using multivariate regression analysis, significant risk factors for in-hospital mortality were emergent surgery (adjusted odds ratio [AOR] = 3.53), liver disease (AOR = 3.02), age older than 65 years (AOR = 2.92), total colectomy (AOR = 2.88), chronic renal failure (AOR = 2.37), malignant tumor (AOR = 2.0), open operation (AOR = 1.85), peripheral vascular disease (AOR = 1.81), diverticulitis (AOR = 1.77), transverse colectomy (AOR = 1.43), chronic lung disease (AOR = 1.41), ulcerative colitis (AOR = 1.40), left colectomy (AOR = 1.31), alcohol abuse (AOR = 1.21), male sex (AOR = 1.12), nonteaching hospital (AOR = 1.11), and African-American race (AOR = 1.09). There was no association between hypertension, diabetes, congestive heart failure, obesity, smoking, proctectomy, sigmoidectomy, or Crohn disease and in-hospital mortality. CONCLUSIONS: In patients undergoing colorectal surgery, emergent surgery, liver disease, total colectomy, age older than 65 years, chronic renal failure, and malignant tumor are the major risk factors for in-hospital mortality.

Does laparoscopic appendectomy impart an advantage over open appendectomy in elderly patients?

BACKGROUND: The use of laparoscopy in the elderly has been increasing in recent years. The data comparing laparoscopic (LA) with open appendectomy (OA) in elderly patients are minimal. We evaluated outcomes of LA versus OA in perforated and nonperforated appendicitis in elderly patients (aged ≥ 65 years). METHODS: Using the Nationwide Inpatient Sample database, clinical data of elderly patients who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008. RESULTS: A total of 65,464 elderly patients underwent urgent appendectomy during this period. The rate of perforated appendicitis was twice as high in elderly patients (50 vs. 25%, p < 0.01) and rate of LA in elderly patients was lower (52 vs. 63%, p < 0.01) compared with patients younger than aged 65 years. Utilization of LA increased 24% from 46.5% in 2006 to 57.8% in 2008 (p < 0.01). In elderly patients with acute nonperforated appendicitis, LA had lower overall complication rate (15.82 vs. 23.49%, p < 0.01), in-hospital mortality (0.39 vs. 1.31%, p < 0.01), hospital charges ($30,414 vs. $34,095, p < 0.01), and mean length of stay (3.0 vs. 4.8 days, p < 0.01) compared with OA. Additionally, in perforated appendicitis in elderly patients, LA was associated with lower overall complication rate (36.27 vs. 46.92%, p < 0.01), in-hospital mortality (1.4 vs. 2.63%, p < 0.01), mean hospital charges ($43,339 vs. $57,943, p < 0.01), and shorter mean LOS (5.8 vs. 8.7 days, p < 0.01). CONCLUSIONS: Laparoscopic appendectomy can be performed safely with significant advantages compared with open appendectomy in the elderly and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Comparison of outcomes of laparoscopic versus open appendectomy in children: data from the Nationwide Inpatient Sample (NIS), 2006-2008.

BACKGROUND: The benefits of laparoscopic appendectomy (LA) remain undefined as compared to open appendectomy (OA) in children, particularly in cases of perforated appendicitis. The purpose of the present study was to evaluate the outcomes of LA versus OA in perforated and nonperforated appendicitis in children. METHODS: Using the Nationwide Inpatient Sample database, we evaluated the clinical data of children (<18 years old) who underwent LA and OA from 2006 to 2008. Incidental and elective appendectomies were excluded. RESULTS: A total of 212,958 children underwent urgent appendectomy in the United States during these years. The overall rate of perforated appendicitis was 27.7, and 56.9% of all cases were performed laparoscopically. In nonperforated cases, LA was associated with comparable overall complication rate (LA: 2.56 vs. OA: 2.66%; p = 0.26), shorter length of hospital stay (LOS, LA: 1.6 vs. OA: 2.0 days; p < 0.01), comparable mortality (LA: 0.01 vs. OA: 0.02%; p = 0.25); and higher hospital charges (LA: $20,328 vs. OA: $16,830; p < 0.01) compared to OA. In perforated cases, LA had a lower overall complication rate (LA: 16.03 vs. OA: 18.07%; p < 0.01), shorter LOS (LA: 5.1 vs. OA: 5.8 days; p < 0.01), lower mortality (LA: 0.0% versus OA: 0.06%; p < 0.01), and similar hospital charges (LA: $33,361 versus OA: $33, 662; p = 0.71) compared to OA. CONCLUSIONS: LA is safe in children with acute perforated and nonperforated appendicitis, and is associated with shorter hospital stay than OA. The laparoscopic approach is associated with lower morbidity and mortality in perforated cases. However, in nonperforated cases, these benefits are modest and are associated with higher hospital charges.

Prospective correlation of arterial vs venous blood gas measurements in trauma patients.

OBJECTIVE: The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients. METHODS: We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients. RESULTS: We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE. CONCLUSION: Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required.

Predictive factors of splenic injury in colorectal surgery: data from the Nationwide Inpatient Sample, 2006-2008.

OBJECTIVES: To determine frequency of splenic injury and to evaluate predictive risk factors of splenic injury during colorectal surgery. DESIGN: Retrospective database analysis. SETTING: The National Inpatient Sample database. PATIENTS: Patients who underwent a colorectal resection during the period from 2006 to 2008 in the United States. MAIN OUTCOME MEASURES: Patient characteristics, patient comorbidities, type of pathology, type of resection, surgical technique used, type of admission, and teaching hospital status were evaluated for splenic injury during colorectal surgery. RESULTS: A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of splenic injury was 0.96%, of which 84.75% were treated with complete splenectomy (splenorrhaphy, 13.55%; partial splenectomy, 1.70%). The most common procedure associated with splenic injury was transverse colectomy (3.40%). Using multivariate regression analysis, we found that transverse colectomy (adjusted odds ratio [AOR], 5.30), left colectomy (AOR, 5.08), total colectomy (AOR, 2.85), open operation (AOR, 2.68), malignant tumor (AOR, 2.11), diverticulitis (AOR, 1.93), teaching hospital (AOR, 1.73), male sex (AOR 1.20), peripheral vascular disease (AOR, 1.14), and emergent admission (AOR, 1.06) were associated with a higher risk of splenic injury. There was no association between age, race, hypertension, diabetes, chronic lung disease, congestive heart failure, renal failure, liver disease, obesity, sigmoidectomy, proctectomy, ulcerative colitis, or Crohn disease and splenic injury. CONCLUSIONS: Type of resection (transverse, total, or left colectomy), type of pathology (malignancy or diverticulitis), open operation, and teaching hospital are potent independent predictors of splenic injury. Male sex, peripheral vascular disease, and emergent admission are less effective predictors. Surgeons should be aware of these risk factors and inform patients accordingly. In higher-risk circumstances, it may be appropriate to consider prophylactic vaccination.

Outcomes of laparoscopic and open appendectomy for acute appendicitis in patients with acquired immunodeficiency syndrome.

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.

Comparison of laparoscopic versus open appendectomy for acute nonperforated and perforated appendicitis in the obese population.

BACKGROUND: Use of laparoscopic appendectomy (LA) has been increasing in obese patients. We evaluated the outcomes of LA compared with open appendectomy (OA) in obese patients. METHODS: By using the Nationwide Inpatient Sample database, clinical data of obese patients who underwent LA and OA for suspected acute appendicitis (perforated or nonperforated) from 2006 to 2008 were examined. RESULTS: A total of 42,426 obese patients underwent an appendectomy during this period. In acute nonperforated cases, LA had a lower overall complication rate (7.17% vs 11.72%; P < .01), mortality rate (.09% vs .23%; P < .01), mean hospital charges ($25,193 vs $26,380; P = .04), and shorter mean length of stay (2.0 vs 3.1 d; P < .01) compared with OA. Similarly, in perforated cases, LA was associated with a lower overall complication rate (22.34% vs 34.65%; P < .01), mortality rate (.0% vs .50%; P < .01), mean hospital charges ($36,843 vs $43,901; P < .01), and a shorter mean length of stay (4.4 vs 6.5 d; P < .01) compared with OA. CONCLUSIONS: LA can be performed safely with superior outcomes compared with OA in obese patients and should be considered the procedure of choice for perforated and nonperforated appendicitis in these patients.

Comparison of outcomes of laparoscopic versus open appendectomy in adults: data from the Nationwide Inpatient Sample (NIS), 2006-2008.

INTRODUCTION: Although laparoscopic appendectomy (LA) is being performed with increased frequency, the utilization of laparoscopy in the management of acute appendicitis remains controversial, and it continues to be used selectively. OBJECTIVES: This study aims to evaluate outcomes of LA vs. open appendectomy (OA) in perforated and non-perforated appendicitis in adults. METHODS: Using the Nationwide Inpatient Sample database, clinical data of adults who underwent LA and OA for suspected acute appendicitis were evaluated from 2006 to 2008. Incidental and elective appendectomies were excluded. RESULTS: A total of 573,244 adults underwent urgent appendectomy during these 3 years. Overall, 65.2% of all appendectomies were performed laparoscopically. Utilization of LA increased 23.7% from 58.2% in 2006 to 72.0% in 2008. In acute non-perforated appendicitis, LA had a lower overall complication rate (4.13% vs. 6.39%, p < 0.01), lower in-hospital mortality (0.03% vs. 0.05%, p < 0.01), and shorter mean length of hospital stay (LOS; 1.7 vs. 2.4 days, p < 0.01) compared with OA; however, hospital charges were higher in the LA group ($22,948 vs. $20,944, p < 0.01). Similarly, in perforated appendicitis, LA was associated with a lower overall complication rate (18.75% vs. 26.76%, p < 0.01), lower in-hospital mortality (0.06% vs. 0.31%, p < 0.01), lower mean hospital charges ($32,487 vs. $38,503, p < 0.01), and shorter mean LOS (4.0 vs. 6.0 days, p < 0.01) compared with OA. CONCLUSION: LA is safe and associated with lower morbidity, lower mortality, and shorter hospital stay with acute perforated and non-perforated appendicitis. Also, in perforated cases, LA had an advantage over OA in hospital charges. LA should be considered the procedure of choice for perforated and non-perforated appendicitis in adults.

Risk factors for traumatic injury findings on thoracic computed tomography among patients with blunt trauma having a normal chest radiograph.

HYPOTHESIS: We sought to identify risk factors that might predict acute traumatic injury findings on thoracic computed tomography (TCT) among patients having a normal initial chest radiograph (CR). DESIGN: In this retrospective analysis, Abbreviated Injury Score cutoffs were chosen to correspond with obvious physical examination findings. Multivariate logistic regression analysis was performed to identify risk factors predicting acute traumatic injury findings. SETTING: Urban level I trauma center. PATIENTS: All patients with blunt trauma having both CR and TCT between July 1, 2005, and June 30, 2007. Patients with abnormalities on their CR were excluded. MAIN OUTCOME MEASURE: Finding of any acute traumatic abnormality on TCT, despite a normal CR. RESULTS: A total of 2435 patients with blunt trauma were identified; 1744 (71.6%) had a normal initial CR, and 394 (22.6%) of these had acute traumatic findings on TCT. Multivariate logistic regression demonstrated that an abdominal Abbreviated Injury Score of 3 or higher (P = .001; odds ratio, 2.6), a pelvic or extremity Abbreviated Injury Score of 2 or higher (P < .001; odds ratio, 2.0), age older than 30 years (P = .004; odds ratio, 1.4), and male sex (P = .04; odds ratio, 1.3) were significantly associated with traumatic findings on TCT. No aortic injuries were diagnosed in patients with a normal CR. Limiting TCT to patients with 1 or more risk factors predicting acute traumatic injury findings would have resulted in reduced radiation exposure and in a cost savings of almost $250,000 over the 2-year period. Limiting TCT to this degree would not have missed any clinically significant vertebral fractures or vascular injuries. CONCLUSION: Among patients with a normal screening CR, reserving TCT for older male patients with abdominal or extremity blunt trauma seems safe and cost-effective.

A multidisciplinary organ donor council and performance improvement initiative can improve donation outcomes.

The shortage of organs available for transplantation has become a national crisis. The Department of Health and Human Services established performance benchmarks for timely notification, donation after cardiac death (DCD), and conversion rates (total donors/eligible deaths) to guide organ procurement organizations and donor hospitals in their attempts to increase the number of transplantable organs. In January 2007, an organ donor council (ODC) with an ongoing performance improvement case review process was created at a Level I trauma center. A critical care devastating brain injury protocol and a DCD policy were instituted. Best performance benchmarks were evaluated before and after establishment of the ODC. At our center, the total number of referrals increased from 96 in 2006 to 139 in 2007 and 143 in 2008. Timely notification rate increased from 64 per cent in 2006 to 83 per cent in 2007 and 2008 (P < 0.01). DCD rate increased from 0 per cent in 2006 to 13 per cent in 2007 (P = 0.06) and 10 per cent in 2008 (P = 0.09). Conversion rate increased from 53 per cent in 2007 to 78 per cent in 2008 (P = 0.05) and 73 per cent in 2009 (P = 0.16). Organs transplanted per eligible death trended upward from 1.80 in 2007 to 2.54 in 2009 (P = 0.20). As a consequence, the establishment of a multidisciplinary ODC and performance improvement initiative demonstrated improved donation outcomes.

Standard prophylactic enoxaparin dosing leads to inadequate anti-Xa levels and increased deep venous thrombosis rates in critically ill trauma and surgical patients.

BACKGROUND: Deep venous thromboses (DVT) continue to cause significant morbidity in critically ill patients. Standard prophylaxis for high risk patients includes twice-daily dosing with 30 mg enoxaparin. Despite prophylaxis, DVT rates still exceed 10% to 15%. Anti-Xa levels are used to measure the activity of enoxaparin and 12-hour trough levels

Elevated serum pancreatic enzyme levels after hemorrhagic shock predict organ failure and death.

BACKGROUND: Intraluminal pancreatic enzymes have been shown in animal models to be associated with multiple organ failure after hemorrhagic shock, independent of pancreatitis. The translocation of these enzymes into the circulation may serve as a marker of hemorrhagic shock-induced gut ischemia in critically injured trauma patients. We hypothesized that serum amylase and lipase would be significantly elevated in patients presenting in hemorrhagic shock and in those who develop organ failure. METHODS: : Review of a prospective database at a level-1 trauma center from 2000 to 2005. Two thousand seven hundred eleven critically injured trauma patients without pancreatic injuries were evaluated for shock (systolic pressure <90 mm Hg in the emergency department), massive transfusion (10 units of packed red blood cells within the first 24 hours), and organ failure (standard criteria for acute pulmonary, cardiovascular, renal, and hepatic system failure were used). Serum levels >2 times the upper limit of normal for amylase (30-130 U/L) and lipase (7-60 U/L) were defined as elevated. Univariate analyses were performed with the Pearson's chi, and binary logistic regression was used to determine significant risk factors for organ failure. Results with a p value <0.05 were considered significant and are reported. RESULTS: : Patients with elevated amylase (n = 481, 18%) were more likely to present in shock (16% vs. 8%), require massive transfusion (19% vs. 9%), develop organ failure (34% vs. 16%), and die (23% vs. 13%). Patients with elevated lipase (n = 288, 11%) were more likely to require massive transfusion (18% vs. 10%) and develop organ failure (43% vs. 16%). Independent predictors of organ failure were age (odds ratio [OR] = 1.016), Injury Severity Score (OR = 1.02), massive transfusion (OR = 3.1), elevated amylase (OR = 1.9), and elevated lipase (OR = 3.2). Elevated amylase was also an independent predictor of mortality (OR = 1.3). CONCLUSIONS: : Serum levels of pancreatic enzymes are elevated in patients who present in shock or require a massive transfusion and are independent predictors of organ failure. Whether these elevations are caused by ischemic pancreatitis or the translocation of intraluminal enteric pancreatic enzymes is uncertain and future studies are needed. Trauma patients with elevated pancreatic enzymes in the absence of a pancreatic injury have an increased risk of morbidity and mortality.