Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

What's a trauma surgeon worth? A salary survey of the Eastern Association for the Surgery of Trauma.

BACKGROUND: Professional compensation is an important consideration for all physicians. Few objective data specific to trauma surgery are available to those seeking employment or contract renegotiation in the United States. National benchmark salary data should assist trauma surgeons in securing fair and equitable compensation. The purpose of this study was to survey trauma surgeons who are members of the Eastern Association for the Surgery of Trauma regarding current salary levels, benefits, contract arrangements, practice descriptors, and opinions on professional reimbursement. METHODS: Anonymous self-report questionnaires were mailed to active members of the Eastern Association for the Surgery of Trauma. Only general surgeons practicing in the United States were included. Data were maintained in a confidential database. RESULTS: Of 385 surveys mailed, 207 (53.7%) were returned. There were 172 usable questionnaires, for an overall response rate of 44.6%. Nearly 93% of respondents worked in states east of the Mississippi River. Mean age was 42.4 years (range, 33-50 years) and 94.7% were male. Over 66% of the surgeons were fellowship trained in trauma, and 44% were chiefs of trauma services. The mean years of experience was 8.8 years (range, 1-17 years). Most respondents worked at teaching institutions (88%) and Level I centers (66%). The mean annual compensation was $229,142+/-$78,045 (range, $90,000-$528,000). These salaries were comparable to ranges from academic surveys of general surgeons. Few surgeons had professional guidance negotiating their compensation. Survey respondents were aware of few objective data specific to trauma surgery. CONCLUSION: This preliminary survey provides a unique benchmark for trauma surgeon salaries. Trauma surgeons should benefit from a more informed and structured approach to salary negotiations. Detailed trauma surgeon-specific data obtained periodically are essential to ensuring fair and equitable compensation in this specialty.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma.

BACKGROUND: Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults. METHODS: A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant. RESULTS: A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum. CONCLUSION: In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

Billing, coding, and documentation in the critical care environment.

Optimal conduct of modern-day physician practices involves a thorough understanding and application of the principles of documentation, coding, and billing. Physicians' role in these activities can no longer be secondary. Surgeons practicing critical care must be well versed in these concepts and their effective application to ensure that they are competitive in an increasingly difficult and demanding environment. Health care policies and regulations continue to evolve, mandating constant education of practicing physicians and their staffs and surgical residents who also will have to function in this environment. Close, collaborative relationships between physicians and individuals well versed in the concepts of documentation, coding, and billing are indispensable. Similarly, ongoing educational and review processes (whether internal or consultative from outside sources) not only can decrease the possibility of unfavorable outcomes from audit but also will likely enhance practice efficiency and cash flow. A financially viable practice is certainly a prerequisite for a surgical critical care practice to achieve its primary goal of excellence in patient care.

Acinetobacter calcoaceticus pneumonia and the formation of pneumatoceles.

Pneumatoceles are cystic lesions of the lungs often seen in children with staphylococcal pneumonia and positive-pressure ventilation. Acinetobacter calcoaceticus is an aerobic, short immobile gram-negative rod, or coccobacillus, which is an omnipresent saprophyte. The variant anitratus is the most clinically significant pathogen in this family, usually presenting as a lower respiratory tract infection. Acinetobacter has been demonstrated to be one of the most common organisms found in the ICU. We present three critically ill surgery patients with Acinetobacter pneumonia, high inspiratory pressures, and the subsequent development of pneumatoceles. One of these patients died from a ruptured pneumatocele, resulting in tension pneumothorax. Treatment of pneumatoceles should center on appropriate intravenous antimicrobial therapy. This should be culture directed but is most often accomplished with Imipenem. Percutaneous, computed tomographic-guided catheter placement or direct tube thoracostomy decompression of the pneumatocele may prevent subsequent rupture and potentially lethal tension pneumothorax.

Diagnosis and management of blunt small bowel injury: a survey of the membership of the American Association for the Surgery of Trauma.

BACKGROUND: Blunt small bowel injury (SBI) may be difficult to diagnose accurately. Diagnostic delays are associated with increased morbidity and mortality. METHODS: A cross-sectional survey of members of the American Association for the Surgery of Trauma was conducted. A Likert-type multiple-choice scale was used to evaluate use and usefulness of diagnostic and laboratory tests. Data were analyzed by using univariate and multivariate techniques. RESULTS: A total of 461 of the 702 members (68%) surveyed responded, of which 133 members (29%) were excluded because they did not currently manage adult SBI. Of the remaining 328 respondents, 244 members (74%) reported prior experience as the most important influence on their current practice of diagnosing blunt SBI. None of the standard laboratory tests were reported as useful. Seventy-seven percent of respondents use computed tomographic (CT) scan most or all of the time for diagnosis (p < 0.05 compared with other modalities). Most respondents estimated their annual incidence of SBI at 5% with a >15% frequency of delay in diagnosis. Forty-four percent of the respondents estimated the mortality associated with a delay in diagnosis at < or =5%. Respondents varied significantly in their management of the patient with an unreliable abdominal exam and a CT scan finding of isolated free fluid. In patients with head injuries, 28% observe, 12% repeat the CT scan, 42% perform diagnostic peritoneal lavage, and 16% operate. For intoxicated patients, 51% observe, 11% repeat the CT scan, 26% perform diagnostic peritoneal lavage, and 10% operate. A more aggressive approach with diagnostic and operative intervention was significantly (p < 0.05) advocated by respondents practicing without residents, more than 15 years out from residency, or by those with a perception of higher morbidity and mortality from delays in diagnosis. CONCLUSION: There is significant variation in the diagnostic approach to the patient with suspected SBI. The perceived mortality of delayed diagnosis is much less than reported. Those surgeons with more experience or perception of greater morbidity and mortality from a delayed diagnosis are more aggressive. Further investigation into the diagnosis and treatment of this injury is needed.

Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience.

OBJECTIVE: Blunt small bowel injury (SBI) is uncommon, and its timely diagnosis may be difficult. The impact of operative delays on morbidity and mortality has been unclear. The purpose of this study was to determine the relationship of diagnostic delays to morbidity and mortality in blunt SBI. METHODS: Patients with blunt SBI with perforation were identified from the registries of eight trauma centers (1989-1997). Patients with duodenal injuries were excluded. Data were extracted by individual chart review. Patients were classified as multi-trauma (group 1) or near-isolated SBI (group 2 with Abbreviated Injury Scale score < 2 for other body areas). Time to operation and its impact on mortality and morbidity was determined for each patient. RESULTS: A total of 198 patients met inclusion criteria: 66.2% were male, mean age was 35.2 years (range, 1-90 years) and mean Injury Severity Score was 16.7 (range, 9-47). 100 patients had multiple injuries (group 1). There were 21 deaths (10.6%) with 9 (4.5%) attributable to delay in operation for SBI. In patients with near-isolated SBI, the incidence of mortality increased with time to operative intervention (within 8 hours: 2%; 8-16 hours: 9.1%; 16-24 hours: 16.7%; greater than 24 hours: 30.8%, p = 0.009) as did the incidence of complications. Delays as short as 8 hours 5 minutes and 11 hours 15 minutes were associated with mortality attributable to SBI. The rates of delay in diagnosis were not significantly associated with age, gender, intoxication, transfer status, or presence of associated injuries. CONCLUSION: Delays in the diagnosis of SBI are directly responsible for almost half the deaths in this series. Even relatively brief delays (as little as 8 hours) result in morbidity and mortality directly attributable to "missed" SBI. Further investigation into the prompt diagnosis of this injury is needed.

Accuracy of administrative data in trauma.

BACKGROUND: Accurate data are needed to evaluate outcomes, therapeutics, and quality of care. This study assesses the accuracy of administrative databases in recording information about trauma patients. METHODS: Patients with thoracic aorta injury were identified with a state trauma registry, and the medical records were reviewed. Data collected were compared to administrative data on patients with thoracic aorta injuries, at the same hospitals in the same time period. RESULTS: Fifteen patients (16.3%) with thoracic aorta injury were not recorded in the administrative database, and 23 patients (18.7%) were misdiagnosed. Ninety-one patients were found in both data sources. The administrative database significantly (P < .05) underrecorded abdominal injuries (50 vs 35), orthopedic injuries (117 vs 75), and chest injuries (77 vs 48). The number of aortograms (78 vs 8), type of operative procedures (use of graft; 70 vs 30), use of bypass (35 vs 16), and complications (77 vs 33) were underreported (P < .05). The Injury Severity Score was underestimated by the administrative database (38.65 +/- 12.41 vs 25.66 +/- 9.53; P < .05). CONCLUSIONS: Administrative data lack accuracy in the recording of associated injury, injury severity, diagnostic, and procedural data. Whether these data should be used to evaluate treatment or quality of care in trauma is questionable.

The utility of traditional prehospital interventions in maintaining thermostasis.

OBJECTIVE: Hypothermia can have a negative effect on the metabolic and hemostatic functions of patients with traumatic injuries. Multiple methods of rewarming are currently used in the prehospital arena, but little objective evidence for their effectiveness in this setting exists. The purpose of this study was to assess the relative effectiveness of traditional prehospital measures in maintaining thermostasis in trauma patients. METHODS: Participating helicopter and ground ambulance ALS units were prospectively randomized to provide either routine care only (passive or no warming) or routine care (passive warming) in conjunction with active warming (either reflective blankets, hot pack rewarming, or warmed IV fluids). A total of 174 trauma code patients, aged >14 years, who met inclusion criteria were prospectively enrolled by prehospital providers. Patients who received a non-assigned intervention or who had incomplete temperature data were dropped from the analysis. A total of 134 patients were included in the final analysis. RESULTS: Patients who received hot pack rewarming showed a mean increase in body temperature during transport (+1.36 degrees F/0.74 degrees C), while all other groups (no intervention, passive rewarming, reflective blankets, warmed IV fluids, warmed IV fluid plus reflective blanket) showed a mean decrease in temperature during transport [-0.34 to -0.61 degrees F (-0.2 to -0.4 degrees C); p<0.01]. In addition, the hot pack group was consistent, with every patient who received hot pack warming showing an increase in body temperature during transport, while in all other groups there were patients who had both increases and decreases in temperature. The intervention groups did not differ significantly on exposure to precipitation, transport unit temperature, total prehospital time, initial vital signs, amount of fluid administered, Injury Severity Score, or Glasgow Coma Score. CONCLUSIONS: Most traditional methods of maintaining trauma patient temperature during prehospital transport appear to be inadequate. Aggressive use of hot packs, a simple, inexpensive intervention to maintain thermostasis, deserves further study as a potential basic intervention for trauma patients.

Immediate endoscopic injection therapy of bleeding oesophageal varices: a prospective comparative evaluation of injecting materials in Egyptian patients with portal hypertension.

The present study was conducted to compare usual sclerosants: polidocanol 1%, ethanolamine oleate 5% and the tissue adhesive: cyanoacrylate in the control of oesophageal variceal bleeding in Egyptian patients with portal hypertension in a prospective comparative trial. Sixty patients with portal hypertension due to schistosomal hepatic fibrosis and/or posthepatitic liver cirrhosis who had presented with acute oesophageal variceal bleeding were enrolled. Patients received balloon tamponade prior to injection were excluded. Resuscitation had been done before or during emergency endoscopy. Emergency endoscopy was conducted within 2 hours from the onset of hematemesis. Patients were immediately randomized during emergency endoscopy to receive polidocanol 1%, ethanolamine oleate 5% or tissue adhesive. Variceal rebleeding was managed by reinjection. The three groups were comparable for age, sex, etiology of portal hypertension, Child-Pugh class and findings at emergency endoscopy. No active bleeding was observed at the end of all injection sessions. Rebleeding had been occurred within the first 24 hours in 2 (10%) patients in polidocanol group and 3 (15%) patients in ethanolamine group (P > 0.05). Reinjection did control rebleeding in 2 (10%) patients in ethanolamine group with a total success rate of 95%. Exsanguinating rebleeding occurred in 2 (10%) patients in polidocanol group and one (5%) patient in ethanolamine group (P > 0.05). Postinjection large ulcers were diagnosed either in polidocanol (15%) or ethanolamine (10%) groups (P > 0.05). Other complications were minor and showed no significant differences between the three groups. In coclusion, polidocanol, ethanolamine and cyanoacrylate are equally safe and effective. For immediate endoscopic injection therapy an experienced team must be available.

The conundrum of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow verbal score from the Glasgow eye and motor scores.

BACKGROUND: The Glasgow Coma Scale (GCS), which is the foundation of the Trauma Score, Trauma and Injury Severity Score, and the Acute Physiology and Chronic Health Evaluation scoring systems, requires a verbal response. In some series, up to 50% of injured patients must be excluded from analysis because of lack of a verbal component for the GCS. The present study extends previous work evaluating derivation of the verbal score from the eye and motor components of the GCS. METHODS: Data were obtained from a state trauma registry for 24,565 unintubated patients. The eye and motor scores were used in a previously published regression model to predict the verbal score: Derived Verbal Score = -0.3756 + Motor Score * (0.5713) + Eye Score * (0.4233). The correlation of the actual and derived verbal and GCS scales were assessed. In addition the ability of the actual and derived GCS to predict patient survival in a logistic regression model were analyzed using the PC SAS system for statistical analysis. The predictive power of the actual and the predicted GCS were compared using the area under the receiver operator characteristic curve and Hosmer-Lemeshow goodness-of-fit testing. RESULTS: A total of 24,085 patients were available for analysis. The mean actual verbal score was 4.4 +/- 1.3 versus a predicted verbal score of 4.3 +/- 1.2 (r = 0.90, p = 0.0001). The actual GCS was 13.6 + 3.5 versus a predicted GCS of 13.7 +/- 3.4 (r = 0.97, p = 0.0001). The results of the comparison of the prediction of survival in patients based on the actual GCS and the derived GCS show that the mean actual GCS was 13.5 + 3.5 versus 13.7 + 3.4 in the regression predicted model. The area under the receiver operator characteristic curve for predicting survival of the two values was similar at 0.868 for the actual GCS compared with 0.850 for the predicted GCS. CONCLUSIONS: The previously derived method of calculating the verbal score from the eye and motor scores is an excellent predictor of the actual verbal score. Furthermore, the derived GCS performed better than the actual GCS by several measures. The present study confirms previous work that a very accurate GCS can be derived in the absence of the verbal component.

Statewide, population-based, time-series analysis of the frequency and outcome of pulmonary embolus in 318,554 trauma patients.

UNLABELLED: The low occurrence, nonspecific signs and symptoms, and high rate of associated morbidity and mortality of pulmonary embolus (PE) create major problems in the prevention, diagnosis, and treatment of PE. The purpose of this study was to analyze the frequency and outcome of PE in an entire state's trauma population using a large, population-based, hospital discharge data base. With the inclusion of an entire population, the reported incidence, high risk groups of patients, and specific risk factors regarding PE were assessed. A multivariate, logistic regression model was created from the data to determine predictive power of selected risk factors in patients at risk. METHODS: The data source was a statewide, hospital discharge data base that includes data on all hospitalized patients for all of the hospitals in North Carolina. Data were available from 1988 to 1993. Using primary discharge diagnosis and nine additional ICD-9 coded diagnoses from the discharge abstract, patients were selected by presence of diagnostic codes for traumatic injury (800-959.9) and PE (415.1). Statistical analysis was performed using univariate and multivariate analysis to determine significant risk factors and to create a candidate model for the prediction of risk in the study population. RESULTS: Of 318,554 patients, 952 (0.30%) had a recorded diagnosis of PE. The mortality rate for patients with PE (26%) was 10 times higher than the mortality rate in patients without PE (2.6%). In evaluating specific risk factors, age was a significant predictor of the risk of PE: 0.05% for patients under age 55 and 0.7% in those 55 years and over. The rate of PE, 0.3%, was low for the entire study population, but was highest in patients with injuries of the extremities, 0.53%. Increasing Injury Severity Score and Abbreviated Injury Scale score for determined body systems were also found to correlate with an increasing risk of PE. Over the course of the study, the incidence of PE among patients discharged from non-trauma centers showed a significant decrease. There was also a decrease in the mortality in non-trauma centers for PE. This finding cannot be due to coding changes coincident with the advent of diagnosis related groups because it would be associated with more vigorous combing of charts for diagnoses? It may well be that the use of prophylactic measures in injured patients initially used at trauma centers was adopted by the physicians at non-trauma centers over this time with the resultant decline in PE and associated mortality. From the univariate linear regression models, a logistic regression model was created that confirmed age as the most significant risk factor, followed by Injury Severity Score and Abbreviated Injury Scale score for soft tissue, extremity, and chest. The calculated area under the receiver operator characteristic curve was 0.72. CONCLUSION: Using a large, population-based data base, we were able to determine the reported incidence of PE among trauma patients and establish specific risk factors. The reported incidence of PE in this population is low, 0.30%. The mortality among those with PE, however, is significant at 26%. In this study, age, Injury Severity Score, and injury to specific body regions (soft tissue, extremity, chest) were associated with an increased risk of PE. The investigation of prophylaxis of PE and the general management of injured patients may be influenced by the overall low reported frequency of PE and the specific high risk populations described in this study. In light of the low incidence of PE in patients without specific risk factors, prophylactic interventions cannot be routinely recommended unless their benefits clearly outweigh their risks.

Survival, quality of life, and charges in critically III surgical patients requiring prolonged ICU stays.

UNLABELLED: Critical care consumes a significant portion of health care costs. Although there are currently increasing pressures to limit expenditures, data are not always available to allow physicians and patients to make informed therapeutic or triage decisions regarding prolonged intensive care unit (ICU) stays. The purpose of this study was to evaluate long-term outcome, quality of life, and charges in surgical patients requiring prolonged ICU stays (> 14 days). METHODS: Adults requiring over 14 days of surgical ICU care from January 1991 to September 1993 were selected from our ICU data base. Survivors to hospital discharge were evaluated for outcome and quality of life by mail survey and/or telephone interview in addition to chart review. RESULTS: Eighty-three patients spent over 14 days in the surgical ICU during the study period. Fifty-two patients (62.6%) survived to hospital discharge. Average age was 53 years, average ICU length of stay was 26 days, and average hospital length of stay was 50 days. Complete follow-up data were available for 39 patients (75%). Thirty of the 39 patients (77%) were alive at an average follow-up of 18 months. Long-term survival in patients over 65 years old was 67% compared with 83% for younger patients (p < 0.05). Seventy percent reported less than 50% functional recovery. Seventy percent wer living at home and 23% were on disability. Of 11 patients employed before discharge, five had returned to work. Eighty percent of respondents reported good to fair quality of life, and 81% stated that they would undergo critical care again. The average ICU charge was $51,512 per patient, and the average hospital charge was $164,019 per patient. The average charge to achieve one long-term survivor was $247,812. CONCLUSIONS: In this population, prolonged ICU stays resulted in acceptable quality of life and a relatively high survival rate despite significant economic investment. This study does not support withdrawal of therapy or triage decisions based solely or primarily on age or length of ICU stay.

Management and outcome of splenic injury: the results of a five-year statewide population-based study.

Although splenectomy was the preferred method of treating the injured spleen in the past, the methods of splenorrhaphy and nonoperative management have appeared to gain in popularity. The purpose of this study was to determine whether the management of splenic injuries has changed over the course of time and if there has been any differences in the morbidity and mortality associated with different methods of treatment. We retrospectively examined the discharge records from 2627 patients with splenic injuries from the North Carolina Discharge Database. There were 2258 adults and 369 pediatric patients for evaluation. The rate of nonoperative therapy increased from 33.9 per cent to 46.3 per cent over the 5 years of the study, whereas the rate of splenectomy decreased from 52.9 per cent to 43.4 per cent over the same time period. Splenorrhaphy was used in approximately 10 per cent of the injuries over the course of the entire study period. Adults treated nonoperatively required late operation 6.0 per cent (49/811) of the time. The pediatric late operation rate for nonoperative management was 0.4 per cent(1/231). Reoperation after splenorrhaphy was 2.9 per cent (7/240) for adult patients and 4.3 per cent (2/47) for pediatric patients. The majority of adults (57.2%) with an Injury Severity Score (ISS) < or = 15 were able to be cared for via nonoperative methods, whereas the majority of adults (66.4%) with an ISS > 15 required splenectomy. The majority of pediatric patients were able to be cared for in a nonoperative fashion in both the ISS < or = 15 (83.4%) and ISS > 15 (45.5%).

The impact of laparoscopic cholecystectomy on the management and outcome of biliary tract disease in North Carolina: a statewide, population-based, time-series analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) has had a major impact on the treatment of patients with biliary tract disease, but the magnitude and the details of its effects on biliary surgery remain incompletely described. The purpose of this study was to perform a statewide, population-based, time-series analysis of the effects of LC on biliary surgery. STUDY DESIGN: Patient data were obtained from the statewide hospital discharge database that collects data from all 157 hospitals in the state of North Carolina. All patients with hospital admissions for biliary tract disease from 1988 through 1993 were selected for analysis. RESULTS: The use of open cholecystectomy (OC) dropped from 100 percent of all cholecystectomies in 1988 to 32.3 percent in 1993, while LC increased from eight cases in 1988 to over 7,800 per year in 1993. The increase in the rate of LC was not associated with an increase in the overall rate of cholecystectomy. Bile duct (BD) repairs increased from 13 in 1988 to a high of 36 in 1992. There was a strong, statistically significant correlation between the rate of LCs and the rate of BD repairs (R = 0.89, p = 0.0001). Hospital charges and component charges were lower for patients having elective LC compared to those having elective OC (p = 0.001). This remained true after stratification by age and type of gallbladder disease. Hospital stays were shorter for patients having LC than for those having OC (p = 0.001 for all). Surgeons in smaller hospitals were slower at adopting LC. Younger and board certified surgeons adopted LC more rapidly than older and non-board certified surgeons. CONCLUSIONS: In North Carolina, LCs progressed from nonexistent to the dominant approach for managing patients with cholelithiasis in a matter of a few years. Associated with this change were shorter hospitalizations and lower charges. Contrary to other published reports, North Carolina did not experience an increase in the overall rate of cholecystectomy with the adoption of LC. There was a highly correlated increase in the rate of bile duct repairs in the first years of the study.

A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury.

UNLABELLED: Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS: Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS: During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS: This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.

Prospective analysis of outcome after cardiopulmonary resuscitation in critically ill surgical patients.

BACKGROUND: This study was done to examine the outcome of cardiopulmonary resuscitation (CPR) in the surgical intensive care unit (SICU) and to identify factors preceding cardiopulmonary arrest that could predict survival. STUDY DESIGN: We prospectively collected demographic, laboratory, diagnostic, and complications data in our SICU database on 5,237 consecutive patients and reviewed the charts of all patients receiving CPR. RESULTS: Cardiopulmonary resuscitation was performed upon 1.1 percent (55 of 5,237 patients) of patients in the SICU. Twenty-nine percent (16 of 55 patients) survived greater than 24 hours but died in the hospital, and 13 percent (seven of 55 patients) survived to discharge. No patient with a worsening Glasgow Coma Scale (GCS) score, acute physiology score (APS), or any acute organ failure who had cardiopulmonary arrest survived. Survival after CPR for patients with a stable or improving APS was 32 percent (p < 0.01). CONCLUSIONS: Patients in the SICU who survived CPR had a stable or improving clinical course as determined by APS and GCS score, and had not had acute organ failure. Patients who were critically ill with a declining clinical course did not survive after CPR.

Regional and institutional variation in burn care.

In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the American Burn Association to determine how burn care is currently administered in the United States and Canada. Responses were obtained from 83 hospitals (60%). The survey addressed resuscitation, operative and nonoperative wound care, medications, antimicrobial agents, and pain control. The major influence on care appeared to be the experience of the director (considered "very influential" in 85%) compared with the literature ("very influential" in 12%) and habit/what works for us ("very influential" in 48%). The Parkland formula was used "always" or "often" by 78%, and the Brooke formula "never" by 81% of respondents. Lactated Ringer's solution was the most popular initial fluid, and most (78%) respondents changed fluids after 24 hours. However, the fluids used in the second 24 hours varied equally among several choices. The use of colloids also varied without a set pattern. Furosemide (Lasix) and nonsteroidal antiinflammatory drugs were used "rarely" or "never" by 67% of centers in the acute stage. H2 blockers were used for gastritis prophylaxis "always" or "often" in 60% (vs 53% for antacids and 20% for sucralfate [Carafate]). Tube feedings were started on day 1 after burn injury "always" by less than 30% of centers. Total parenteral nutrition was not commonly used. Most centers use of silver sulfadiazine on the body and hands, but facial topical antimicrobial therapy varied.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients.

The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138 of 1447). The presence of inhalation injury, increasing burn size, and advancing age were all associated with an increased mortality (p < 0.01). The incidence of inhalation injury was 19.6% (284 of 1447) and correlated with increasing percent total body surface area (%TBSA) burn (r = 0.41, p < 0.01) and advancing age (r = 0.15, p < 0.01). The overall mortality for patients with inhalation injury was 31% (88 of 284) compared with 4.3% (50 of 1163) for those without inhalation injury. Using multivariate analysis inhalation injury was found to be an important variable in determining outcome, but the most important factor in predicting mortality was %TBSA burn (accuracy = 92.8%) or a combination of %TBSA burn and patient age (accuracy = 93.0%). Adding inhalation injury only slightly improved the ability to predict mortality (accuracy = 93.3%). The presence of inhalation injury is significantly associated with mortality after thermal injury but adds little to the prediction of mortality using %TBSA and age alone.