Narcotic Consumption Analysis among Severely Injured and Advanced Aged Trauma Patients.

BACKGROUND: Multimodal pain management has been shown to be effective in treating pain in acutely injured trauma patients. Our community-based, level 1 trauma center previously published in 2022 the efficacy of implementing multimodal pain control (MMPC) protocol in our inpatient trauma population which decreased the use of opioids while maintaining similar pain control. The MMPC group had a trend toward higher age and was significantly less injured. We hypothesize MMPC will reduce opioid consumption in both the advanced aged and more severely injured trauma populations while still providing adequate pain control. METHODS: Defined by the year of admission, MMPC and physician managed pain control (PMPC) were compared in both advanced age groups and between the severely injured groups. The advanced age group included patients ≥55 years old. The severely injured group included ≥18 years old with ≥15 ISS. Primary outcomes were total opioid utilization per day, calculated in morphine milliequivalents (MME), and median daily pain scores. RESULTS: For the severely injured population, the MMPC group showed a 3-fold decrease in opioid use (30 MME/d vs 90.3 MME/d, P < .001) and lower pain scores (5/10 vs 6/10, P < .001) than the PMPC group. In the advance age group, there was no significant difference between MMPC and PMPC groups in opioid use (P = .974) or pain scores (P = .553). CONCLUSION: MMPC effectively reduces opioid consumption in a severely injured patient population while simultaneously improving pain control. Advanced age trauma patients can require complex pain management solutions and future research to determine their needs is recommended.

Cost Savings of Whole Blood Versus Component Therapy at a Community Level 1 Trauma Center.

BACKGROUND: Blood product component-only resuscitation (CORe) has been the standard of practice in both military and civilian trauma care with a 1:1:1 ratio used in attempt to recreate whole blood (WB) until recent data demonstrated WB to confer a survival advantage, leading to the emergence of WB as the contemporary resuscitation strategy of choice. Little is known about the cost and waste reduction associated with WB vs CORe. METHODS: This study is a retrospective single-center review of adult trauma patients admitted to a community trauma center who received WB or CORe as part of their massive transfusion protocol (MTP) resuscitation from 2017 to 2021. The WB group received a minimum of one unit WB while CORe received no WB. Univariate and multivariate analyses were completed. Statistical analysis was conducted using a 95% confidence level. Non-normally distributed, continuous data were analyzed using the Wilcoxon rank sum test. RESULTS: 576 patients were included (201 in WB and 375 in CORe). Whole blood conveyed a survival benefit vs CORe (OR 1.49 P < .05, 1.02-2.17). Whole blood use resulted in an overall reduction in products prepared (25.8%), volumes transfused (16.5%), product waste (38.7%), and MTP activation (56.3%). Cost savings were $849 923 annually and $3 399 693 over the study period. DISCUSSION: Despite increased patient volumes over the study period (43.7%), the utilization of WB as compared to CORe resulted in an overall $3.39 million cost savings while improving mortality. As such, we propose WB should be utilized in all resuscitation strategies for the exsanguinating trauma patient.

Double Superior Vena Cava Due to Persistent Left Superior Vena Cava Incidentally Identified on Central Venous Catheterization: A Case Report.

BACKGROUND Persistent left superior vena cava (PLSVC) results in a double superior vena cava (SVC), and although it is rare, this is the most common venous anomaly of the thorax. PSLVC arises from the junction of the left subclavian and internal jugular veins. It is identified on the left side of the mediastinum adjacent to the aortic arch, and it usually drains into the right atrium through the coronary sinus. This report presents the case of a 40-year-old man with an incidental finding of double SVC due to PSLVC identified on hospital admission following a motor vehicle collision. CASE REPORT A 40-year-old man was found to have a double SVC due to PLSVC upon chest radiography during hospital admission for injuries related to motor vehicle trauma. The discovery was made following placement of a central venous catheter (CVC) down the left-sided SVC and into the coronary sinus. The patient suffered no harm as a result. The diagnosis was made by chest radiography and confirmed by computed tomography angiography. CONCLUSIONS PSLVC is an uncommon condition that can complicate common procedures and therefore must be well-understood by physicians across many medical and surgical specialties. Although PLSVC may be asymptomatic, as in this case, in some patients PLSVC presents as atrial fibrillation or with nonspecific cardiac symptoms. Therefore, all patients identified with PLSVC should be investigated to exclude associated cardiac abnormalities and arrythmias, and before the placement of central venous access devices.

Multi-modal Pain Control Protocol Decreases Narcotic Consumption in an Inpatient Trauma Population.

INTRODUCTION: Opioid use after surgery or trauma has been implicated as a contributing factor to opioid dependence. The Acute Care Surgery (ACS) service at our community-based trauma center instituted an opioid-minimizing, multi-modal pain control (MMPC) protocol. The classes of pain medication included a non-opioid analgesic, a non-steroidal anti-inflammatory drug, a gabapentinoid, a skeletal muscle relaxant, and a topical anesthetic. We hypothesize that the MMPC will result in lower opioid consumption compared with the prior STP as evidenced by lower morphine milligram equivalents (MME) per day. METHODS: All adult patients (≥18 years) admitted to the ACS service from Jan 2014 to Dec 2015 and Jan 2018 to Dec 2019 were screened for inclusion. The standard pain control group (STP) and MMPC groups were defined by the year of admission. The primary outcome is opioid use per day, calculated in MME received. Secondary outcomes of the study include daily pain scores, incidence of opioid-related complications, death, ventilator days, intensive care unit length of stay, and hospital length of stay (HLOS) days. RESULTS: Multi-modal pain control protocol group was older and less injured than STP group. Daily opioid utilization was significantly less in the MMPC group (22.5 MMEs/d vs 60MMEs/d in the STP group, P < .0001). Additionally, daily pain scores were not different between groups. Secondary outcomes did not vary between the two groups. CONCLUSION: This study shows that implementation of a MMPC protocol resulted in lower opioid consumption in injured patients. Pain was equivalently controlled during the MMPC protocol period as demonstrated by similar pain scores.

Safety and Outcome of Intracranial Pressure Monitor Placement Performed by Trauma Critical Care Surgeons.

INTRODUCTION: The Brain Trauma Foundation advises intracranial pressure monitor placement (ICPM) following traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score ≤8 and an abnormal head computed tomographic scan (CT) finding. Prior studies demonstrated that ICPMs could be placed by non-neurosurgeons. We hypothesized that ICPM placement by trauma critical care surgeons (TCCS) would increase appropriate utilization (AU), decrease time to placement (TTP), and have equivalent complications to those placed by neurosurgeons. METHODS: We retrospectively reviewed medical records of adult trauma patients admitted with a TBI in a historical control group (HCG) and practice change group (PCG). Demographics, Injury Severity Score (ISS), outcomes, ICPM placement by provider type, and time to placement were identified. Complications and appropriate utilization were recorded. RESULTS: 70 patients in the HCG and 84 patients in the PCG met criteria for inclusion. Demographics, arrival GCS, ICU GCS, ISS, and admission APACHE II scores were not statistically significant. AU was 7/70 for HCG vs 19/84 in the PCG (P = .04036). Median TTP was 6.5 hours for HCG vs 5.25 for PCG (P = .9308). Interquartile range showed the data clustered around an earlier placement time, 2.3-14.0 hours, in the PCG. Complications between the 2 groups were not statistically significant, 0/7 for HCG vs 5/19 for PCG (P = .2782). DISCUSSION: This study confirms that ICPMs can be safely placed by TCCS. Our results demonstrate that placement of ICPMs by TCCS improves AU and possibly improves TTP.

Measurement of Anticoagulation in Patients on Dabigatran, Rivaroxaban, and Apixaban Therapy by Novel Automated Thrombelastography.

Background Direct-acting oral anticoagulants (DOACs) do not require monitoring. Measurement of DOAC effect would be useful in the event of bleeding, trauma, and thromboembolism while on anticoagulation. We evaluated the effectiveness of the investigational DOAC assays on the TEG®6s Hemostasis Analyzer to assess the anticoagulant effect of DOACs in patients treated for atrial fibrillation or deep vein thrombosis (DVT). Methods Patients on treatment for a minimum of 7 days with standard doses of dabigatran, rivaroxaban, and apixaban were included. DOAC plasma concentrations and TEG®6s Reaction (R)-time were measured and correlated. The sensitivity, specificity, and negative predictive value (NPV) of R-time to detect DOAC concentrations of ≥30, ≥50, and ≥100 ng/mL were calculated. Results A total of 189 patients were included, ( n = 50) on apixaban, ( n = 62) on rivaroxaban, ( n = 53) on dabigatran, and ( n = 24) on no DOAC were studied. Using the direct thrombin inhibitor (DTI) channel, R-time demonstrated strong linear correlation with dabigatran levels (r = 0.93, p < 0.0001). Using the antifactor Xa (AFXa) channel, R-time demonstrated strong nonlinear correlation with rivaroxaban and apixaban levels ( r s = 0.92 and 0.84, respectively, p < 0.0001 for both). R-time revealed strong sensitivity and NPV in detecting low DOAC levels for the predefined concentrations. Conclusion R-time measured by TEG®6s DOAC-specific cartridge has a strong correlation with concentrations of the most commonly used DOACs with high sensitivity and NPV for detecting lower drug levels that are considered clinically relevant for patients in need of antidote, or prior to urgent surgery. Further studies to determine the relation of R-time to clinical outcomes are warranted.

Rapid point-of-care detection and classification of direct-acting oral anticoagulants with the TEG 6s: Implications for trauma and acute care surgery.

BACKGROUND: The trauma patient on direct oral anticoagulant (DOAC) therapy preinjury presents a challenge in trauma and acute care surgery. Our understanding of these patients is extrapolated from vitamin K antagonists. However, DOACs have different mechanisms of action, effects on laboratory coagulation assays, and reversal strategies. Rapid identification of DOACs in the blood will allow timely reversal of factor Xa inhibitors and direct thrombin inhibitors when necessary. The present study evaluated viscoelastic testing to detect and classify DOACs in patient blood samples. METHODS: This observational, prospective, open-label, multicenter study used point-of-care viscoelastic testing to analyze blood samples taken from patients with and without DOAC treatment, and healthy volunteers. Antifactor Xa and direct thrombin inhibition (DTI) assays were used to establish reference ranges for viscoelastic testing parameters on the TEG 6s system. These ranges were applied to produce a DOAC identification algorithm for patient blood samples. Internal consistency of the measurements, as well as algorithm sensitivity and specificity, was evaluated. RESULTS: Using the TEG 6s system, the R parameter reference range was 0.6 minutes to 1.5 minutes for the Antifactor Xa assay and 1.6 minutes to 2.5 minutes for the DTI assay. Our identification algorithm using these ranges for 2.5 minutes or less has sensitives of 98.3% and 100% for factor Xa inhibitor and direct thrombin inhibitor detection, respectively. Specificity was 100%. Both classes of DOAC were detectable, even when samples were collected during the "trough" between doses of medication. CONCLUSION: Point-of-care viscoelastic testing with TEG 6s can detect and classify DOACs with high sensitivity and specificity. This tool can be used to better determine the need for reversal in trauma and acute care surgery patients and guide optimal surgical timing in the acute setting. LEVEL OF EVIDENCE: Prognostic and epidemiological study, level II.

A rare malignant Brenner tumor of the ovary in a 77-year-old woman: a case report.

BACKGROUND: A malignant Brenner tumor is a rare form of invasive epithelial ovarian cancer and is extremely uncommon in women > 65 years of age. We present a case of an invasive Brenner tumor of the ovary in a woman greater than age 70. CASE: A 77-year-old woman presented with a rare, invasive Brenner tumor of the ovary. She was referred for evaluation of a complex pelvic mass and elevated serum CA-125. Treatment included complete surgical resection and staging procedure. Pathology revealed a malignant Brenner tumor. Immunohistochemical staining with cytokeratin 7 was positive, with cytokeratin 20 was negative, and was positive for uroplakin III and thrombomodulin. CONCLUSION: The histologic appearance of malignant Brenner tumor is similar to that of transitional cell cancer of the ovary and transitional epithelium of the urinary bladder. Immunohistochemical staining of malignant Brenner tumor often demonstrates positivity for uroplakin III, thrombomodulin and cytokeratin 7 and negativity to cytokeratin 20. The mainstay of treatment is surgical resection, but the exact regimen and benefit of adjuvant therapy remain unknown.