Surgical Site Infections in Trauma Exploratory Laparotomies Preoperative Ceftriaxone and Metronidazole Versus Cefoxitin.

Surgical site infections (SSIs) remain a significant cause of morbidity and mortality in patients undergoing traumatic exploratory laparotomy. The goal of this study was to compare antibiotic usage and subsequent outcomes in patients undergoing traumatic exploratory laparotomy. A retrospective chart analysis and a chi-square test of independence were performed to examine the relation between preoperative cefoxitin versus ceftriaxone and metronidazole and the rate of SSI development. 323 patients were analyzed, 111 patients receiving cefoxitin and 212 patients receiving ceftriaxone and metronidazole. The proportion of patients who developed SSI was 16.2% for the cefoxitin group and 9.9% for the ceftriaxone and metronidazole group, X2 (1, N = 323) = 2.7, P = .098, thus displaying no statistical difference in the development of SSIs between patients in the cefoxitin group when compared to the ceftriaxone and metronidazole group.

Incisional Negative Pressure Wound Therapy to Decrease the Incidence of Surgical Site Infections in Trauma Laparotomy Wounds.

BACKGROUND: Surgical site infection (SSI) is a common post-operative complication, especially in trauma laparotomies. Incisional negative pressure wound therapy (iNPWT) is a novel technique in reducing SSIs. We aim to study the rate of wound complications in trauma laparotomy with standard primary closure with staples vs iNPWT. METHODS: We had 152 patients meeting inclusion criteria who underwent emergent trauma laparotomies performed at Sentara Norfolk General from 2017 to 2020. We had 79 patients in the standard staple group and 73 patients in the iNWPT group. We then analyzed surgical site infection rates and wound complication rates in both groups within a 30-day period. RESULTS: The wound infection rate in the staple vs staple plus iNPWT was 10.0% vs 3.8%, respectively (P = .13). Wound dehiscence rates were 24.1% vs 10.13%, respectively (P = .02). When looking at a subset of patients with hollow viscous injury, the rate of SSIs was statistically lower in the iNPWT group. Prior to the introduction of the incisional vacuum-assisted closure (VAC) to our practice compared to after its introduction, 39.25% of wounds were left open vs 19.51%, respectively (P = .001). CONCLUSION: Our data identified a trend toward a decrease in overall SSIs in trauma laparotomies closed with iNPWT. The use of iNPWT demonstrated a decrease in superficial wound dehiscence and a decrease in SSIs in patients with associated full thickness bowel injury. With iNPWT, we are more aggressive with primarily closing trauma laparotomy wounds. This shows promise for increasing primary closure rates while simultaneously decreasing overall superficial surgical site infection rate.

Utility of Thromboelastography in Detecting NOAC-Related Coagulopathy in Traumatic Brain Injury.

INTRODUCTION: Novel oral anticoagulants (NOACs) have gained popularity as a vitamin K antagonist alternative without regular monitoring. There has been an increase in elderly patients on NOACs admitted for traumatic brain injury (TBI). The aim of this study is to determine the efficacy of thromboelastography (TEG) in detecting NOAC-related coagulopathy among TBI patients. METHODS: A retrospective chart review of 456 TBI patients admitted to Sentara Norfolk General Hospital from 2015 to 2020 was performed. Inclusion criteria comprised patients on NOACs with a TEG performed at presentation (66 patients). Analysis included TEG values, use of prothrombin complex concentrate factor 4 (PCC4), increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission, and mortality. RESULTS: TEG results showed 0% elevated reaction time, 1.5% elevated kinetics time, 1.5% low alpha angle, 4.5% low max amplitude, and 3.0% elevated clot lysis percent at 30 min in our cohort. Despite overwhelmingly normal TEG results, 42.42% of patients received PCC4. A subset analysis of these patients compared to those who did not receive PCC4, revealed a higher frequency of increased intracranial hemorrhage on repeat head computed tomography within 24 h of admission (42.86% versus 18.42%, P = 0.03), and increased mortality (25.0% versus 5.26%, P = 0.0219). Patients who did not receive PCC4 had no increased frequency of operative intervention or worsening of Glasgow Coma Score. CONCLUSIONS: Results suggest that TEG does not reliably assess NOAC-related coagulopathy in TBI patients. Caution must be used when interpreting TEG data to determine reversal strategies in TBI patients on NOACs.

Medical therapy in type B aortic intramural hematoma is associated with a high failure rate.

OBJECTIVE: Intramural hematoma (IMH) is on the spectrum of acute aortic syndrome, but optimal management is poorly understood. The aim of this study was to evaluate outcomes of patients with type B IMH (TBIMH) after best medical therapy (BMT) and to assess for risk factors associated with failure of BMT. METHODS: This is a single-institution retrospective chart review of all patients with TBIMH between January 2008 and December 2017. Failure of BMT was defined as any of the following end points: aortic rupture, aorta-related death, aortic enlargement to at least 55 mm or growth of >10 mm within 12 months, or need for surgical aortic intervention for failed BMT. RESULTS: We identified 92 patients, of whom 25 received emergent thoracic endovascular aortic repair; 67 patients were initially managed with BMT, and of these, 32 underwent thoracic endovascular aortic repair within 14 days for early BMT failure. Two additional patients had early BMT failure; one died of aortic rupture due to retrograde type A dissection, and one patient was advised to undergo repair but did not comply and was lost to follow-up. Fourteen patients (20.9%) received endovascular therapy for late failure of BMT after the initial hospitalization. Medical management was successful in 19 patients (28.4%), although 5 patients had aortic enlargement but below the threshold for elective repair (maximal aortic diameter of 55 mm). On univariate analysis, presenting IMH thickness and growth of IMH thickness were risk factors for BMT failure. On multivariate analysis, presenting IMH thickness was the sole predictive risk factor for medical therapy failure (odds ratio, 1.083; 95% confidence interval, 1.021-1.149; P = .008), with an odds ratio of 6.810 (95% confidence interval, 1.921-24.146; P = .002) with a presenting IMH thickness of ≥8.0 mm, which was the calculated IMH thickness cutoff value with highest sensitivity and specificity to predict failure of BMT (area under the receiver operating characteristic curve = 0.795; P = .001; J = 0.62). CONCLUSIONS: BMT for TBIMH is associated with a high failure rate and need for interventions. IMH thickness on admission is the most reliable factor to predict failure of BMT.

Inpatient Peripherally Inserted Central Venous Catheter Complications: Should Peripherally Inserted Central Catheter Lines Be Placed in the Intensive Care Unit Setting?

Peripherally inserted central venous catheters (PICCs) are now commonly used for central access in the intensive care unit (ICU) setting; however, there is a paucity of data evaluating the complication rates associated with these lines. We performed a retrospective review of all PICCs placed in the inpatient setting at our institution during a 1-year period from January 2013 to December 2013. These were divided into two groups: those placed at the bedside in the ICU and those placed by interventional radiology in non-ICU patients. Data regarding infectious and thrombotic complications were collected and evaluated. During the study period, 1209 PICC line placements met inclusion criteria and were evaluated; 1038 were placed by interventional radiology in non-ICU patients, and 171 were placed at the bedside in ICU patients. The combined thrombotic and central line associated blood stream infection rate was 6.17 per cent in the non-ICU group and 10.53 per cent in the ICU group (P = 0.035). The thrombotic complication rate was 5.88 per cent in the non-ICU group and 7.60 per cent in the ICU group (P = 0.38), whereas the central line associated blood stream infection rate was 0.29 per cent in the non-ICU group and 2.92 per cent in the ICU group (P = 0.002). This study seems to suggest that PICC lines placed at the bedside in the ICU setting are associated with higher complication rates, in particular infectious complications, than those placed by interventional radiology in non-ICU patients. The routine placement of PICC lines in the ICU settings needs to be reevaluated given these findings.

Kratom: A New Product in an Expanding Substance Abuse Market.

Kratom, a drug that produces similar adverse effects like those produced by opioids in patients who have overdosed or are going through withdrawal, has grown in popularity and availability.