Has the trauma surgeon become house staff for the surgical subspecialist?

BACKGROUND: The role of the trauma surgeon is perceived to be mostly supportive of other procedure-oriented specialties. We designed this study to characterize the surgical and nonsurgical responsibilities of the contemporary trauma surgeon. METHODS: Trauma patients admitted to an urban academic level I trauma center were studied using trauma registry data for 2004. RESULTS: The large majority of patients admitted to trauma service has mild single-system injuries to 1 or 2 anatomic regions. Most (57%) did not have injuries to the neck, chest, or abdomen. Head and extremity injuries were present in 45% and 46% of patients, respectively. Surgeries were performed by orthopedists in 28%, trauma surgeons in 11%, and neurosurgeons in 6% of patients. CONCLUSIONS: The contemporary trauma surgeon has little surgical opportunity and provides a disproportionate amount of nonsurgical care in support of consultant specialists. This is a major deterrent to general surgeon interest in trauma care and must be addressed as the acute-care surgeon evolves.

Obesity increases risk of organ failure after severe trauma.

BACKGROUND: Obesity is an independent risk factor for a variety of diseases, including postinjury morbidity and mortality. Obesity is associated with a proinflammatory state that could affect the postinjury inflammatory response and increase risk of organ dysfunction. The purpose of this study was to determine the relationship between obesity and postinjury multiple organ failure (MOF). STUDY DESIGN: A prospective observational study of patients at risk for postinjury MOF. Inclusion criteria were age older than 15 years, Injury Severity Score > 15, ICU admission within 24 hours of injury, and survival longer than 48 hours after injury. Isolated head injuries were excluded. Organ dysfunction was assessed using the Denver multiple organ failure score. RESULTS: Data were collected on 716 severely injured patients, 70% were men and 83% were victims of blunt trauma. There was no relationship between body mass index and injury severity or the amount of blood transfused within 12 hours of injury. Postinjury MOF was observed in 123 of 564 (22%) nonobese patients and 56 of 152 (37%) obese patients. Obesity was independently associated with MOF (odds ratio, 1.8; 95% CI, 1.2-2.7) after adjusting for patient age, injury severity, and amount of blood transfused during resuscitation. In this study population, obesity was also associated with increased length of ICU and hospital stay but not death. CONCLUSIONS: Obese patients are at increased risk of postinjury MOF. Study of the obesity-related inflammatory profile could provide additional insight into the pathogenesis of organ dysfunction and identify therapeutic targets for both obese and nonobese patients. Increased morbidity and length of stay in obese trauma patients implies greater resource allocation for this population.

Intravesicular pressure monitoring does not cause urinary tract infection.

OBJECTIVE: To determine whether intravesicular pressure monitoring using a closed system increases the risk of nosocomial urinary tract infection. DESIGN: Retrospective chart and database review. SETTING: Surgical/trauma intensive care units of a regional level-I trauma center. PATIENTS: 3108 critically ill patients of which 122 patients underwent intravesicular pressure monitoring. INTERVENTIONS: Severity-adjusted urinary tract infection rates were compared among patients with and without intravesicular pressure monitoring. MEASUREMENTS AND RESULTS: Over a 24-month period, 122 consecutive patients had 2202 intravesicular pressure measurements performed. During 1448 urinary catheter days, 15 patients who required intravesicular pressure monitoring developed a urinary tract infection with a severity-adjusted device-related infection rate of 7.9 infections per 1000 catheter days. Of the 2986 patients who did not require such monitoring, 98 patients developed a urinary tract infection with an infection rate of 6.5 infections per 1000 catheter days (p=0.56). CONCLUSIONS: Intravesicular pressure monitoring using the closed transducer technique is safe and does not increase the risk of urinary tract infection.

Biodegradable cisplatin polymer in limb-sparing surgery for canine osteosarcoma.

BACKGROUND: The rate of local recurrence of osteosarcoma after limb-sparing surgery in dogs and humans has been reported up to 28%. The primary purpose of this study was to determine whether a biodegradable cisplatin-containing implant (OPLA-Pt), inserted into the limb-sparing surgery site at the time of surgery, would decrease the rate of local recurrence. Secondary aims included evaluation of systemic toxicity associated with the release of cisplatin from the implant and identification of prognostic factors associated with limb-sparing surgery for osteosarcoma in dogs. METHODS: Eighty dogs with spontaneously occurring osteosarcoma were treated with limb-sparing surgery. They were randomized to receive the biodegradable implant either without cisplatin (control group) or with cisplatin (OPLA-Pt group) and were targeted to receive four doses of an adjuvant cisplatin chemotherapy protocol. RESULTS: Although this was not statistically significant (P =.071), dogs in the OPLA-Pt group were 53.5% less likely to develop local recurrence than dogs in the control group. There were no significant differences in systemic toxicity between treatment arms. Incomplete surgical resection, absence of infection, and fewer than four doses of adjuvant chemotherapy had a significant correlation with local recurrence and survival according to univariate analyses, although only incomplete surgical resection remained significant for local recurrence after multivariate analysis. CONCLUSIONS: Local tumor recurrence may be decreased after limb-sparing surgery by use of biodegradable implants impregnated with chemotherapeutic agents.