Does saline resuscitation affect mechanisms of coagulopathy in critically ill trauma patients? An exploratory analysis.

Metabolic acidosis has been implicated in the development of coagulopathy, although the specific mechanisms have not been well characterized. We sought to explore whether resuscitation of injured patients with a balanced crystalloid solution affects coagulation, as measured by endogenous thrombin potential (ETP) and thromboelastography (TEG). We performed an exploratory analysis of a subset of subjects enrolled in a randomized trial comparing the effect of resuscitation with isotonic saline versus Plasma-Lyte A (PLA) on acidosis and electrolyte abnormalities. We collected plasma at admission and 6 h later for subsequent ETP and TEG analysis and compared subjects receiving isotonic saline to those receiving PLA. Among 18 evaluated subjects, baseline characteristics, including ETP and TEG parameters, were similar between the two arms. At 6 h, subjects receiving isotonic saline were more acidemic. At 6 h, there were no differences in ETP parameters between groups; however, TEG results showed the time from initial clot formation to an amplitude of 20 mm (K) was shorter (3.8 ±â€Š2.1 vs. 7.2 ±â€Š2.8 s) and the rapidity of fibrin build-up and cross-linking (α angle) was significantly greater (41 ±â€Š8 vs. 24 ±â€Š15 deg) for the PLA group than in the isotonic saline group. Relative to PLA, isotonic saline does not alter thrombin generation, but isotonic saline and PLA may differentially impact clotting factor availability. The shorter time to reach prespecified clot amplitude and the increased rate of fibrin generation imply faster amplification of clotting factors with PLA without effect on latency time or clot strength.

Bariatric surgery and the changing current scope of general surgery practice: implications for general surgery residency training.

IMPORTANCE: The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. OBJECTIVE: To evaluate the current scope of academic general surgery and its implications on surgical residency. DESIGN, SETTING, AND PARTICIPANTS: The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90,000 physicians who practice at 95 institutions across the United States. MAIN OUTCOMES AND MEASURES: The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. RESULTS: During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). CONCLUSIONS AND RELEVANCE: A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery.

Cost-minimization analysis of two fluid products for resuscitation of critically injured trauma patients.

PURPOSE: Results of a study to determine potential cost benefits of substituting an alternative electrolyte solution for 0.9% sodium chloride injection for the initial fluid resuscitation of trauma patients are presented. METHODS: Using data from a randomized clinical trial that compared 24-hour fluid resuscitation outcomes in critically injured trauma patients treated with 0.9% sodium chloride injection and those who received a balanced electrolyte solution (Plasma-Lyte A, Baxter Healthcare), a cost-minimization analysis was performed at a large medical center. The outcomes evaluated included fluid and drug acquisition costs, materials and nurse labor costs, and costs associated with electrolyte replacement. RESULTS: The use of Plasma-Lyte A was associated with a relatively higher fluid acquisition cost but a reduced need for magnesium replacement. During the first 24 hours of hospitalization, 4 of 24 patients (17%) treated with 0.9% sodium chloride injection and none of the patients who received the comparator product (n = 22) required supplemental magnesium. Patients treated with 0.9% sodium chloride injection received a median of 4 g of magnesium (interquartile range [IQR], 2.5-4.0 g), compared with a median of 0 g (IQR 0-2 g) in the comparator group. Taking into account the costs of consumable supplies and nursing labor, the cost-minimization analysis indicated a 24-hour cost differential of $12.35 in favor of Plasma-Lyte A. CONCLUSION: Substitution of Plasma-Lyte A for 0.9% sodium chloride injection for fluid resuscitation during the first 24 hours after traumatic injury was associated with decreased magnesium replacement requirements and a net cost benefit to the institution.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

BACKGROUND: Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH. METHODS: Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls. RESULTS: There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher. CONCLUSION: Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries.

OBJECT: Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS: This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS: The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS: Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

The utility of laparoscopic evaluation of the parietal peritoneum in the management of anterior abdominal stab wounds.

BACKGROUND: Trauma centres vary in their approaches to managing stable patients with anterior abdominal stab wounds (AASWs), with no approach yet proven superior. We sought to evaluate the performance of screening laparoscopy (i.e., parietal peritoneal penetration or not) in determining which patients should undergo laparotomy. METHODS: We conducted a retrospective case series study, including all patients with an AASW who presented to U.C. Davis Medical Center from January 2003 through March 2009. We collected data from medical records using a standardised, pre-tested instrument. Among laparoscopically screened cases, we determined the test characteristics of peritoneal penetration for detecting intra-abdominal injury. We sub-classified injuries as "requiring treatment" (e.g., full-thickness enterotomy or active haemorrhage) or not. RESULTS: Of 358 patients with AASWs, 163 underwent screening laparoscopy. Seventy-eight of the 163 (48%) had no peritoneal penetration and six (4%) had peritoneal penetration but a low-risk wound; none of these 84 underwent laparotomy nor had a missed injury. Of 79 patients with peritoneal penetration who underwent laparotomy, 61 had an intra-abdominal injury, of whom 42 were treated intraoperatively. Among these 42, 30 had an injury "requiring treatment." The PPV of peritoneal penetration for an injury requiring treatment was 38% (30/79) (95% CI 27-50%), NPV 100% (84/84) (95% CI 95-100%), sensitivity 100% (30/30) (95% CI 88-100%), and specificity 63% (84/133) (95% CI 54-71%). The negative and positive likelihood ratios were 0 (95% CI 0-0.4) and 2.7 (95% CI 2.2-3.4), respectively. CONCLUSIONS: Screening laparoscopic evaluation of the parietal peritoneum results in a negligible rate of missed injury and an approximately 40% rate of finding an injury requiring treatment.

Saline versus Plasma-Lyte A in initial resuscitation of trauma patients: a randomized trial.

OBJECTIVE: We sought to compare resuscitation with 0.9% NaCl versus Plasma-Lyte A, a calcium-free balanced crystalloid solution, hypothesizing that Plasma-Lyte A would better correct the base deficit 24 hours after injury. BACKGROUND: Sodium chloride (0.9%) (0.9% NaCl), though often used for resuscitation of trauma patients, may exacerbate the metabolic acidosis that occurs with injury, and this acidosis may have detrimental clinical effects. METHODS: We conducted a randomized, double-blind, parallel-group trial (NCT01270854) of adult trauma patients requiring blood transfusion, intubation, or operation within 60 minutes of arrival at the University of California Davis Medical Center. Based on a computer-generated, blocked sequence, subjects received either 0.9% NaCl or Plasma-Lyte A for resuscitation during the first 24 hours after injury. The primary outcome was mean change in base excess from 0 to 24 hours. Secondary outcomes included 24-hour arterial pH, serum electrolytes, fluid balance, resource utilization, and in-hospital mortality. RESULTS: Of 46 evaluable subjects (among 65 randomized), 43% had penetrating injuries, injury severity score was 23 ± 16, 20% had admission systolic blood pressure less than 90 mm Hg, and 78% required an operation within 60 minutes of arrival. The baseline pH was 7.27 ± 0.11 and base excess -5.9 ± 5.0 mmol/L. The mean improvement in base excess from 0 to 24 hours was significantly greater with Plasma-Lyte A than with 0.9% NaCl {7.5 ± 4.7 vs 4.4 ± 3.9 mmol/L; difference: 3.1 [95% confidence interval (CI): 0.5-5.6]}. At 24 hours, arterial pH was greater [7.41 ± 0.06 vs 7.37 ± 0.07; difference: 0.05 (95% CI: 0.01-0.09)] and serum chloride was lower [104 ± 4 vs 111 ± 8 mEq/L; difference: -7 (95% CI: -10 to -3)] with Plasma-Lyte A than with 0.9% NaCl. Volumes of study fluid administered, 24-hour urine output, measures of resource utilization, and mortality did not significantly differ between the 2 arms. CONCLUSIONS: Compared with 0.9% NaCl, resuscitation of trauma patients with Plasma-Lyte A resulted in improved acid-base status and less hyperchloremia at 24 hours postinjury. Further studies are warranted to evaluate whether resuscitation with Plasma-Lyte A improves clinical outcomes.

Identification of barriers to adaptation of battlefield technologies into civilian trauma in California.

OBJECTIVE: To characterize the adoption of routine battlefield medical techniques (tourniquets, hemostatic agents, and tactical combat casualty care into civilian prehospital trauma care and to identify the barriers to their use in the state of California through anonymous electronic survey of local emergency medical services agency (LEMSA) directors. RESULTS: The response rate for this survey was 50% (14/28). The majority of LEMSA directors (86%) were emergency medicine physicians. Tourniquets were used by 57% of respondents. The top three reasons cited for not using tourniquets included different injury patterns in civilian trauma, no proven benefit of use, and increased risk of complications. Hemostatic agents were used even less frequently in civilian practice (7%) but had similar barriers to use. Only 36% of LEMSA directors use tactical combat casualty care with tactical emergency medical services, but when used, respondents had higher usage of tourniquets. Overall lack of training, no proven benefit, and expense were the reasons cited for not incorporating military medical techniques. CONCLUSIONS: Tourniquets, hemostatic agents, and tactical medical care are the integral components of battlefield medicine and have been lifesaving in these settings. The barriers to this transition are multifactorial. Physicians familiar with these technologies should become advocates for their integration in civilian trauma patient care.

The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span.

BACKGROUND: Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies. OBJECTIVE: The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this. METHODS: We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program. RESULTS: Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns. CONCLUSIONS: Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.

Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.

OBJECTIVE: To assess the association of 0.9% saline use versus a calcium-free physiologically balanced crystalloid solution with major morbidity and clinical resource use after abdominal surgery. BACKGROUND: 0.9% saline, which results in a hyperchloremic acidosis after infusion, is frequently used to replace volume losses after major surgery. METHODS: An observational study using the Premier Perspective Comparative Database was performed to evaluate adult patients undergoing major open abdominal surgery who received either 0.9% saline (30,994 patients) or a balanced crystalloid solution (926 patients) on the day of surgery. The primary outcome was major morbidity and secondary outcomes included minor complications and acidosis-related interventions. Outcomes were evaluated using multivariable logistic regression and propensity scoring models. RESULTS: For the entire cohort, the in-hospital mortality was 5.6% in the saline group and 2.9% in the balanced group (P < 0.001). One or more major complications occurred in 33.7% of the saline group and 23% of the balanced group (P < 0.001). In the 3:1 propensity-matched sample, treatment with balanced fluid was associated with fewer complications (odds ratio 0.79; 95% confidence interval 0.66-0.97). Postoperative infection (P = 0.006), renal failure requiring dialysis (P < 0.001), blood transfusion (P < 0.001), electrolyte disturbance (P = 0.046), acidosis investigation (P < 0.001), and intervention (P = 0.02) were all more frequent in patients receiving 0.9% saline. CONCLUSIONS: Among hospitals in the Premier Perspective Database, the use of a calcium-free balanced crystalloid for replacement of fluid losses on the day of major surgery was associated with less postoperative morbidity than 0.9% saline.

Laparoscopic transdiaphragmatic pericardial window: getting to the heart of the matter.

BACKGROUND: Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. STUDY DESIGN: At our Level I trauma center we reviewed consecutive patients who underwent evaluation of pericardial fluid after trauma between 2001 and 2008 and identified those patients in whom laparoscopic pericardial window was performed. We collected data on demographics, technique, findings, complications, and follow-up. RESULTS: There were 393 patients who underwent diagnostic laparoscopy. Of those, 38 patients received laparoscopic transdiaphragmatic pericardial window. Six cardiac injuries (15.8%) were identified with 5 penetrating injuries to the right ventricle and 1 myocardial contusion. All 5 right ventricular injuries required median sternotomy for injury repair. None of the patients had significant hemodynamic compromise during operation. The pericardial window was left open in all patients, with no morbidity. The average length of stay for patients without chest tubes and a negative window was less than 24 hours. For patients with chest tubes, length of stay was 4.6 days. The interquartile range for follow-up was 21.5 to 315 days. CONCLUSIONS: Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.

Trauma and emergency surgery: an evolutionary direction for trauma surgeons.

BACKGROUND: The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons. METHODS: We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period. RESULTS: TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex. CONCLUSION: Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

Videotape review leads to rapid and sustained learning.

BACKGROUND: Performance review using videotapes is a strategy employed to improve future performance. We postulated that videotape review of trauma resuscitations would improve compliance with a treatment algorithm. METHODS: Trauma resuscitations were taped and reviewed during a 6-month period. For 3 months, team members were given verbal feedback regarding performance. During the next 3 months, new teams attended videotape reviews of their performance. Data on targeted behaviors were compared between the two groups. RESULTS: Behavior did not change after 3 months of verbal feedback; however, behavior improved after 1 month of videotape feedback (P <0.05) and total time to disposition was reduced by 50% (P <0.01). This response was sustained for the remainder of the study. CONCLUSIONS: Videotape review can be an important learning tool as it was more effective than verbal feedback in achieving behavioral changes and algorithm compliance. Videotape review can be an important quality assurance adjunct, as improved algorithm compliance should be associated with improved patient care.

Improving ventricular-arterial coupling during resuscitation from shock: effects on cardiovascular function and systemic perfusion.

BACKGROUND: Efficacy of circulation depends on interactions between the heart and the vascular system. Ventricular-arterial coupling (VAC) has been described as an important determinant of cardiovascular function during resuscitation from shock. However, no prospective studies examining VAC and systemic perfusion have been performed. VAC is measured by the ratio of afterload (aortic input impedance [E ]) to contractility (end-systolic elastance [E ]). Lowering E /E is associated with better VAC and improved myocardial work efficiency. Our hypothesis was that optimizing VAC during resuscitation results in improved myocardial work efficiency while simultaneously improving systemic perfusion. METHODS: This was a prospective study in a consecutive series of critically injured patients. Hemodynamic variables, including E, E, and myocardial work efficiency were evaluated by constructing ventricular pressure-volume loops at the bedside during resuscitation. After pulmonary artery catheterization and adequate fluid resuscitation, left ventricular power output and E /E were optimized with inotropic agents and/or afterload reduction. Efficiency was calculated as stroke work/total left ventricular energy expenditure. Tissue perfusion was estimated by calculating base deficit clearance per hour. RESULTS: Twenty-three patients were studied over a 9-month period. Fifteen patients required inotropic support or afterload reduction. Improvements were seen in E /E (from 1.0 +/- 0.4 to 0.6 +/- 0.2 mm Hg/mL/m, p = 0.0004), and left ventricular power output (from 280 +/- 77 to 350 +/- 81 L/min/m. mm Hg, p = 0.003) with resuscitation. A concomitant improvement in myocardial efficiency (from 70% +/- 8.0% to 77% +/- 5.0%, p = 0.0001) and base deficit clearance (from 0.1 +/- 0.4 to -0.2 +/- 0.1 mEq/L/h, p = 0.006) was seen. CONCLUSION: Improved ventricular-arterial coupling during resuscitation is associated with improved myocardial efficiency and systemic tissue perfusion. Perfusion can be improved at lower energy cost to the heart by focusing on thermodynamic principles during resuscitation.

The vacuum assisted closure device: a method of securing skin grafts and improving graft survival.

HYPOTHESIS: Use of the vacuum assisted closure device (VAC) for securing split-thickness skin grafts (STSGs) is associated with improved wound outcomes compared with bolster dressings. DESIGN: Consecutive case series. PATIENTS AND SETTING: Consecutive patients at a level I trauma center requiring STSG due to traumatic or thermal tissue loss during an 18-month period. MAIN OUTCOME MEASURE: Repeated skin grafting due to failure of the initial graft. Secondary outcome measures included dressing-associated complications, percentage of graft take, and length of hospital stay. RESULTS: Sixty-one patients underwent STSG placement. Indications for STSG were burn injury (n = 32), soft tissue loss (n = 27), and fasciotomy-site coverage (n = 2). Patients were treated with the VAC (n = 34) or the bolster dressing (n = 27). The VAC group required significantly fewer repeated STSGs (1 [3%] vs 5 [19%]; P =.04). Two additional graft failures occurred in the no-VAC group, but repeated STSGs were refused by these patients. No difference was seen between the groups in age, percentage of graft take, or hospital length of stay. The no-VAC group had significantly larger grafts (mean +/- SD, 984 +/- 996 vs 386 +/- 573 cm(2); P =.006). The patients requiring repeated STSGs (n = 6) did not have significantly larger grafts than those not requiring repeated STSGs (mean +/- SD, 617 +/- 717 vs 658 +/- 857 cm(2); P =.62). No dressing-associated complications occurred in the VAC group. CONCLUSIONS: The VAC provides a safe and effective method for securing STSGs and is associated with improved graft survival as measured by a reduction in number of repeated STSGs.