Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities.

BACKGROUND: Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma. METHODS: All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated. RESULTS: During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Talk and Die: A Descriptive Analysis of Penetrating Trauma Patients.

INTRODUCTION: "Talk and die" traditionally described occult presentations of fatal intracranial injuries, but we broaden its definition to victims of penetrating trauma. METHODS: We conducted a descriptive analysis of patients with penetrating torso trauma who presented with a Glasgow Coma Scale verbal score ≥3 and died within 48 h of arrival from 2008 to 2018. RESULTS: Sixty patients were identified. Eighteen (30.0%) required resuscitative thoracotomy with 7 (11.7%) dying in the trauma bay. Fifty-three (86.9%) patients went to the operating room, and 35 (66.0%) required multicavitary exploration. The most common injuries were hollow viscous (58.5%), intra-abdominal vascular (49.0%), liver (28.3%), pulmonary (26.4%), intrathoracic vascular (18.9%), and cardiac (15.75) injuries. Twenty-three (43.4%) patients survived their initial operation, but died in the first 48 h postoperatively. CONCLUSIONS: Patients who "talk and die" most frequently have intra-abdominal vascular injures and require multicavitary exploration.

The changing epidemiology of interpersonal firearm violence during the COVID-19 pandemic in Philadelphia, PA.

Recent increases in firearm violence in U.S. cities are well-documented, however dynamic changes in the people, places and intensity of this public health threat during the COVID-19 pandemic are relatively unexplored. This descriptive epidemiologic study spanning from January 1, 2015 - March 31, 2021 utilizes the Philadelphia Police Department's registry of shooting victims, a database which includes all individuals shot and/or killed due to interpersonal firearm violence in the city of Philadelphia. We compared victim and event characteristics prior to the pandemic with those following implementation of pandemic containment measures. In this study, containment began on March 16, 2020, when non-essential businesses were ordered to close in Philadelphia. There were 331 (SE = 13.9) individuals shot/quarter pre-containment vs. 545 (SE = 66.4) individuals shot/quarter post-containment (p = 0.031). Post-containment, the proportion of women shot increased by 39% (95% CI: 1.21, 1.59), and the proportion of children shot increased by 17% (95% CI: 1.00, 1.35). Black women and children were more likely to be shot post-containment (RR 1.11, 95% CI: 1.02, 1.20 and RR 1.08, 95% CI: 1.03, 1.14, respectively). The proportion of mass shootings (≥4 individuals shot within 100 m within 1 h) increased by 53% post-containment (95% CI: 1.25, 1.88). Geographic analysis revealed relative increases in all shootings and mass shootings in specific city locations post-containment. The observed changes in firearm injury epidemiology following COVID-19 containment in Philadelphia demonstrate an intensification in firearm violence, which is increasingly impacting people who are likely made more vulnerable by existing social and structural disadvantage. These findings support existing knowledge about structural causes of interpersonal firearm violence and suggest structural solutions are required to address this public health threat.

Trends in General Surgery Resident Experience with Colorectal Surgery: An Analysis of the Accreditation Council for Graduate Medical Education Case Logs.

OBJECTIVE: Colorectal surgery is a core component of general surgery. The volume of colorectal surgery performed by general surgery residents throughout training has not been studied. This study aims to analyze trends observed in colorectal-specific case numbers logged by general surgery residents over 16 years. DESIGN: Case number data for general surgery residents was extracted from the publicly available, annually published Accreditation Council for Graduate Medical Education (ACGME) database from 2003 to 2019. Cases were categorized as open or laparoscopic colectomy/proctectomy, colectomy with ileoanal pull-thru, abdomino-perineal resection (APR), transanal rectal tumor excision (TRE), anorectal procedure, colonoscopy, and total colorectal cases. The average case numbers per category was calculated for each year. Linear regression analyzed trends in case categories for all residents and those logged as surgeon chief and junior residents. SETTING: ACGME accredited general surgery residency programs. PARTICIPANTS: Not applicable. RESULTS: General surgery residents reported increased numbers of all, chief, and junior resident colorectal cases over the study period (124.5-173.7 cases/yr; 38.4-53.0 cases/yr; 86.4-120.6 cases/yr, all p = 0.00). Average cases for all, chief, and junior residents have increased for laparoscopic colectomy/proctectomy (4.6-26.4 cases/year; 2.7-12.9 cases/year; 2.0-13.5 cases/year, all p = 0.00), anorectal surgeries (26.7-37.7 cases/year; 5.4-9.9 cases/year; 21.3-27.8 cases/year, all p = 0.00), and colonoscopies (35.9-70.6 cases/year, p = 0.00; 6.6-14.1 cases/year, p = 0.01; 29.4-56.5 cases/year, p = 0.00). Average cases for all, chief, and junior residents have decreased for open colectomy/proctectomy (52.0-34.9 cases/year; 21.2-14.3 cases/year; 30.9-20.6 cases/year, all p = 0.00), APR (3.3-2.7 cases/year, p = 0.00; 1.8-1.3 cases/year, p = 0.00; 1.5-1.4 cases/year, p = 0.02), TRE (1.9-1.1 cases/year; 0.7-0.4 cases/year; 1.2-0.6 cases/year, all p = 0.00). Ileoanal pull-thru did not demonstrate a linear trend. CONCLUSIONS: The increase in exposure to colectomies/proctectomies, anorectal procedures and colonoscopies is encouraging, as these common colorectal operations will be encountered in general surgery practice. The observed low case numbers for TRE, APR, and ileoanal pull-thru suggest a need for specialized training.

Procedural-based Specialties Benefit from a Formal Informed Consent and Disclosures Educational Program.

OBJECTIVE: At our tertiary academic center, residents undergo formalized training in obtaining informed consent and disclosing a complication. The informed consent portion has previously been shown to benefit a group of surgical and emergency medicine residents. We aimed to determine if the benefits from training persist across a larger number of procedural-based specialties and to ascertain the benefit of training in disclosing complications. DESIGN: This retrospective cohort study examined first-year residents from seven procedural-based specialties who participated in a formal informed consent and disclosures training program, consisting of a didactic lecture and two-part simulation. Two years after the start of the program, the disclosure scenario was added. Participants were given pre- and post-surveys assessing comfort and confidence in the informed consent and disclosure scenarios. Survey results were compared using the signed-rank test and Kruskal-Wallis test as appropriate. SETTING: This study occurred at Temple University Hospital, a tertiary academic institution in Philadelphia, PA. PARTICIPANTS: First-year residents from 2014 to 2020 in seven procedural-based specialties, including general surgery, orthopedic surgery, otolaryngology, obstetrics and gynecology, emergency medicine, radiology, and anesthesia, participated in this study. One hundred and ninety-three residents completed the program and surveys. RESULTS: Residents reported improved confidence in filling out an informed consent form (p = 0.036) and more comfortable in obtaining informed consent (p = 0.041), as well as more confidence (p = 0.018) and comfort (p = 0.001) in disclosing a complication. Surgical residents demonstrated greater confidence in obtaining informed consent (p = 0.009) and disclosing a complication (p = 0.0002) after training than non-surgical residents. CONCLUSIONS: Across multiple procedural-based specialties, formal training in informed consent and disclosure of complications increases resident ability to perform these tasks. A formal training program is valuable for residents who are expected to perform these tasks across various specialties.

Formal Training Improves Resident Understanding and Communication Regarding Brain Death/Death by Neurologic Criteria.

OBJECTIVE: Residents often are involved in discussions with families regarding brain death/death by neurologic criteria (BD/DNC); however, they receive no standardized training on this topic. We hypothesized that residents are uncomfortable with explaining BD/DNC and that formal didactic and simulated training will improve residents' comfort and skill in discussions surrounding BD/DNC. DESIGN: We partnered with our organ procurement organization (OPO) to create an educational program regarding BD/DNC consisting of a didactic component, and role-play scenarios with immediate individualized feedback. Residents completed pre- and post-training surveys. SETTING: This study included participants from 16 academic and community institutions across New Jersey, Pennsylvania, and Delaware that are within our OPO's region. PARTICIPANTS: Subjects were recruited using convenience sampling based on the institution and training programs' willingness to participate. A total of 1422 residents at participated in the training from 2009 to 2020.  1389 (97.7%) participants competed the pre-intervention survey, while 1361 (95.7%) completed the post-intervention survey. RESULTS: Prior to the training, only 56% of residents correctly identified BD/DNC as synonymous with death. Additionally, 40% of residents had explained BD/DNC to families at least once, but 41% of residents reported never having been taught how to do so. The biggest fear reported in discussing BD/DNC with families was being uncomfortable in explaining BD/DNC (48%). After participating in the training, 99% of residents understood the definition of BD/DNC and 92% of residents felt comfortable discussing BD/DNC with families. CONCLUSIONS: Participation in a standardized curriculum improves residents' understanding of BD/DNC and their comfort in discussing BD/DNC with families.

Handoffs and transitions in critical care-understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial.

BACKGROUND: The implementation of evidence-based practices in critical care faces specific challenges, including intense time pressure and patient acuity. These challenges result in evidence-to-practice gaps that diminish the impact of proven-effective interventions for patients requiring intensive care unit support. Research is needed to understand and address implementation determinants in critical care settings. METHODS: The Handoffs and Transitions in Critical Care-Understanding Scalability (HATRICC-US) study is a Type 2 hybrid effectiveness-implementation trial of standardized operating room (OR) to intensive care unit (ICU) handoffs. This mixed methods study will use a stepped wedge design with randomized roll out to test the effectiveness of a customized protocol for structuring communication between clinicians in the OR and the ICU. The study will be conducted in twelve ICUs (10 adult, 2 pediatric) based in five United States academic health systems. Contextual inquiry incorporating implementation science, systems engineering, and human factors engineering approaches will guide both protocol customization and identification of protocol implementation determinants. Implementation mapping will be used to select appropriate implementation strategies for each setting. Human-centered design will be used to create a digital toolkit for dissemination of study findings. The primary implementation outcome will be fidelity to the customized handoff protocol (unit of analysis: handoff). The primary effectiveness outcome will be a composite measure of new-onset organ failure cases (unit of analysis: ICU). DISCUSSION: The HATRICC-US study will customize, implement, and evaluate standardized procedures for OR to ICU handoffs in a heterogenous group of United States academic medical center intensive care units. Findings from this study have the potential to improve postsurgical communication, decrease adverse clinical outcomes, and inform the implementation of other evidence-based practices in critical care settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04571749 . Date of registration: October 1, 2020.

Police transport of firearm-injured patients-more often and more injured.

BACKGROUND: Police transport (PT) of penetrating trauma patients decreases the time between injury and trauma center arrival. Our study objective was to characterize trends in the rate of PT and its impact on mortality. We hypothesized that PT is increasing and that these patients are more injured. METHODS: We conducted a single-center, retrospective cohort study of adult (≥18 years) patients presenting with gunshot wounds (GSWs) to a level 1 center from 2012 to 2018. Patients transported by police or ambulance (emergency medical service [EMS]) were included. The association between mode of transport (PT vs. EMS) and mortality was evaluated using χ2, t tests, Mann-Whitney U tests, and logistic regression. RESULTS: Of 2,007 patients, there were 1,357 PT patients and 650 EMS patients. Overall in-hospital mortality was 23.7%. The rate of GSW patients arriving by PT increased from 48.9% to 78.5% over the study period (p < 0.001). Compared with EMS patients, PT patients were sicker on presentation with lower initial systolic blood pressure (98 vs. 110, p < 0.001), higher Injury Severity Score (median [interquartile range], 10 [2-75] vs. 9 [1-17]; p < 0.001) and more bullet wounds (3.5 vs. 2.9, p < 0.001). Police-transported patients more frequently underwent resuscitative thoracotomy (19.2% vs. 10.0%, p < 0.001) and immediate surgical exploration (31.3% vs. 22.6%, p < 0.001). There was no difference in adjusted in-hospital mortality between transport groups. Of patients surviving to discharge, PT patients had higher Injury Severity Score (9.6 vs. 8.3, p = 0.004) and lower systolic blood pressure on arrival (126 vs. 130, p = 0.013) than EMS patients. CONCLUSION: Police transport of GSW patients is increasing at our urban level 1 center. Compared with EMS patients, PT patients are more severely injured but have similar in-hospital mortality. Further study is necessary to understand the impact of PT on outcomes in specific subsets in penetrating trauma patients. LEVEL OF EVIDENCE: Epidemiological, level III.

Major venous injury and large volume crystalloid resuscitation: A limb threatening combination.

INTRODUCTION: Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not. METHODS: We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015 at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation. RESULTS: 478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(p < 0.001), combined arterial/venous injury (p = 0.001), and associated fracture (p = 0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (p = 0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); p < 0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); p = 0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); p = 0.004) were more likely to require amputation. CONCLUSION: Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation.

Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project.

BACKGROUND: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE: Epidemiological study with one negative criterion, level III.

Outcomes in Trauma Patients With Behavioral Health Disorders.

BACKGROUND: The relationship between behavioral health disorders (BHDs) and outcomes after traumatic injury is not well understood. The objective of this study was to evaluate the association between BHDs and outcomes in the trauma patient population. MATERIALS AND METHODS: We performed a review of the Trauma Quality Improvement Program database from 2013 to 2016 comparing patients with and without a BHD, which was defined as a psychiatric disorder, alcohol or drug use disorders, dementia, or attention deficit hyperactivity disorder. Outcomes of interest were mortality, length of stay (LOS), and inpatient complications. RESULTS: In the study population, 254,882 patients (25%) had a BHD. Of these, psychiatric disorders comprised 38.3% (n = 97,668) followed by alcohol (33.3%, n = 84,845) and drug (26.4%, n = 67,199) use disorders, dementia (20.2%, n = 51,553), and attention deficit hyperactivity disorder (1.7%, n = 4301). On multivariable analysis, overall mortality was lower in the BHD group (odds ratio [OR] 0.83, confidence interval [CI] 0.79-0.83; P < 0.001). Patients with dementia had higher mortality when controlling for other risk factors (OR 1.62, CI 1.56-1.69; P < 0.001). LOS was 8.5 d (s = 0.02) for patients with a BHD versus 7.4 d (s = 0.01) for patients without a BHD (P < 0.001). Comorbid BHD was associated with any inpatient complication (OR 1.19, CI 1.18-1.20; P < 0.001). CONCLUSIONS: Trauma patients with a BHD had lower overall mortality compared with those without a BHD. However, on subgroup analysis, those with dementia had increased mortality. BHDs increased risk for any inpatient complication and prolonged LOS. Trauma patients with BHDs represent a vulnerable population and warrant special attention to minimize harm and improve outcomes.

Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis.

BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Venous thromboembolism after major venous injuries: Competing priorities.

BACKGROUND: Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. METHODS: A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). RESULTS: The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). CONCLUSION: Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Systemic intraoperative anticoagulation during arterial injury repair: Implications for patency and bleeding.

BACKGROUND: The role of systemic intraoperative anticoagulation (SIAC) during surgical repair of major arterial injuries is controversial. Any potential improvement in arterial patency must be weighed against the risk of hemorrhage in these critically injured patients. We hypothesized that SIAC would increase arterial patency without increasing bleeding complications. METHODS: We conducted a multi-institution, retrospective cohort study of trauma patients with major vascular injury from 2005 to 2013 in three Level I centers. Arterial injuries of the neck, torso, and proximal extremities requiring operative management were included. Our primary endpoint was maintenance of arterial patency during index hospitalization. Complications related to bleeding were assessed. The association between SIAC and arterial patency was evaluated using chi-square, t test, and multiple logistic regression modeling. RESULTS: Of 323 study patients, most were male (88%) and injured by gunshot wounds (69%). Patients repaired with SIAC (n = 154) were compared to those repaired without SIAC (n = 169). No difference in age, gender, mechanism, admission heart rate, or concomitant injury was detected between the groups (all p > 0.05). SIAC use was associated with greater arterial patency rates (93% vs. 85%, p = 0.02) without increasing return to OR for bleeding (4% vs. 6%, p = 0.29). After controlling for gender, admission hemodynamics, ISS, injury location, and postoperative anticoagulation, multivariable regression determined that SIAC patients were 2.6 times more likely (OR 2.6, 95% CI 1.1-6.2, p = 0.03) to maintain patency. Patients who maintained arterial patency were then less likely to return to the OR (9% vs. 78%, p < 0.001) with shorter intensive care unit (median 3 vs. 9 days, p < 0.01) and hospital length of stay (median 13 vs. 21 days, p < 0.01). CONCLUSION: Patients who underwent operative repair of arterial injuries utilizing SIAC experienced better arterial patency without additional bleeding complications as compared to those repaired without SIAC. Our data suggest that SIAC may improve arterial patency rates after repair and the attributable bleeding risk of SIAC may be overstated. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Comparing open gastrostomy tube to percutaneous endoscopic gastrostomy tube in heart transplant patients.

INTRODUCTION: Impaired wound healing due to immunosuppression has led some surgeons to preferentially use open gastrostomy tube (OGT) over percutaneous gastrostomy tube (PEG) in heart transplant patients when long-term enteral access is deemed necessary. METHODS: The National Inpatient Sample (NIS) database (2005-2010) was queried for all heart transplant patients. Those receiving OGT were compared to those treated with PEG tube. RESULTS: There were 498 patients requiring long-term enteral access treated with a gastrostomy tube, with 424 (85.2%) receiving a PEG and 74 (14.8%) an OGT. The PEG cohort had higher Charlson comorbidity Index (4.1 vs. 2.0, p = 0.002) and a higher incidence of post-operative acute renal failure (31.5 vs. 12.7%, p = 0.001). Post-operative mortality was not different when comparing the two groups (13.8 vs. 6.1%, p = 0.06). On multivariate analysis, while both PEG (OR: 7.87, 95%C.I: 5.88-10.52, p < 0.001) and OGT (OR 5.87, 95%CI: 2.19-15.75, p < 0.001) were independently associated with mortality, PEG conferred a higher mortality risk. CONCLUSIONS: This is the largest reported study to date comparing outcomes between PEG and OGT in heart transplant patients. PEG does not confer any advantage over OGT in this patient population with respect to morbidity, mortality, and length of stay.

Noncardiac Surgical Procedures After Left Ventricular Assist Device Implantation.

As left ventricular assist devices (LVADs) are increasingly used for patients with end-stage heart failure, the need for noncardiac surgical procedures (NCSs) in these patients will continue to rise. We examined the various types of NCS required and its outcomes in LVAD patients requiring NCS. The National Inpatient Sample Database was examined for all patients implanted with an LVAD from 2007 to 2010. Patients requiring NCS after LVAD implantation were compared to all other patients receiving an LVAD. There were 1,397 patients undergoing LVAD implantation. Of these, 298 (21.3%) required 459 NCS after LVAD implantation. There were 153 (33.3%) general surgery procedures, with abdominal/bowel procedures (n = 76, 16.6%) being most common. Thoracic (n = 141, 30.7%) and vascular (n = 140, 30.5%) procedures were also common. Patients requiring NCS developed more wound infections (9.1 vs. 4.6%, p = 0.004), greater bleeding complications (44.0 vs. 24.8%, p < 0.001) and were more likely to develop any complication (87.2 vs. 82.0%, p = 0.001). On multivariate analysis, the requirement of NCSs (odds ratio: 1.45, 95% confidence interval: 0.95-2.20, p = 0.08) was not associated with mortality. Noncardiac surgical procedures are commonly required after LVAD implantation, and the incidence of complications after NCS is high. This suggests that patients undergoing even low-risk NCS should be cared at centers with treating surgeons and LVAD specialists.

Comparison of open gastrostomy tube to percutaneous endoscopic gastrostomy tube in lung transplant patients.

INTRODUCTION: Lung transplant patients require a high degree of immunosuppression, which can impair wound healing when surgical procedures are required. We hypothesized that because of impaired healing, lung transplant patients requiring gastrostomy tubes would have better outcomes with open gastrostomy tube (OGT) as compared to percutaneous endoscopic gastrostomy tube (PEG). METHODS: The National Inpatient Sample (NIS) Database (2005-2010) was queried for all lung transplant recipients requiring OGT or PEG. RESULTS: There were 215 patients requiring gastrostomy tube, with 44 OGT and 171 PEG. The two groups were not different with respect to age (52.0 vs. 56.9 years, p = 0.40) and Charlson Comorbidity Index (3.3 vs. 3.5, p = 0.75). Incidence of acute renal failure was higher in the PEG group (35.2 vs. 11.8%, p = 0.003). Post-operative pneumonia, myocardial infarction, surgical site infection, DVT/PE, and urinary tract infection were not different. Post-operative mortality was higher in the PEG group (11.2 vs. 0.0%, p = 0.02). Using multiple variable analysis, PEG tube was independently associated with mortality (HR: 1.94, 95%C.I: 1.45-2.58). Variables associated with survival included age, female gender, white race, and larger hospital bed capacity. DISCUSSION: OGT may be the preferred method of gastric access for lung transplant recipients. CONCLUSIONS: In lung transplant recipients, OGT results in decreased morbidity and mortality when compared to PEG.

The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment.

BACKGROUND: Controversy remains over the ideal way to transport penetrating trauma victims in an urban environment. Both advance life support (ALS) and basic life support (BLS) transports are used in most urban centers. METHODS: A retrospective cohort study was conducted at an urban Level I trauma center. Victims of penetrating trauma transported by ALS, BLS, or police from January 1, 2008, to November 31, 2013, were identified. Patient survival by mode of transport and by level of care received was analyzed using logistic regression. RESULTS: During the study period, 1,490 penetrating trauma patients were transported by ALS (44.8%), BLS (15.6%), or police (39.6%) personnel. The majority of injuries were gunshot wounds (72.9% for ALS, 66.8% for BLS, 90% for police). Median transport minutes were significantly longer for ALS (16 minutes) than for BLS (14.5 minutes) transports (p = 0.012). After adjusting for transport time and Injury Severity Score (ISS), among victims with an ISS of 0 to 30, there was a 2.4-fold increased odds of death (95% confidence interval [CI], 1.3-4.4) if transported by ALS as compared with BLS. With an ISS of greater than 30, this relationship did not exist (odds ratio, 0.9; 95% CI, 0.3-2.7). When examined by type of care provided, patients with an ISS of 0 to 30 given ALS support were 3.7 times more likely to die than those who received BLS support (95% CI, 2.0-6.8). Among those with an ISS of greater than 30, no relationship was evident (odds ratio, 0.9; 95% CI, 0.3-2.7). CONCLUSION: Among penetrating trauma victims with an ISS of 30 or lower, an increased odds of death was identified for those treated and/or transported by ALS personnel. For those with an ISS of greater than 30, no survival advantage was identified with ALS transport or care. Results suggest that rapid transport may be more important than increased interventions. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.