Combination of Lactate and Base Deficit Levels at Admission to Predict Mortality in Blunt Trauma Patients.

INTRODUCTION: Elevated lactate levels are associated with increased mortality in both trauma and non-trauma patients. The relation between base deficit (BD) and mortality is less clear. Traumatologists debate the utility of elevated lactate (EL) versus BD in predicting mortality. We hypothesized that EL (2mmol/L to 5mmol/L) and BD (≤-2mmol/L) in combination could predict mortality in blunt trauma patients.  Methods: This is a retrospective analysis of the trauma registry from 2012 to 2021 at a level 1 trauma center. Blunt trauma patients with admission lactate and BD values were included in the analysis. Exclusion criteria were age <18, penetrating trauma, unknown mortality, and unknown lactate or BD. Logistics regression of the total 5153 charts showed 93% of the patients presented with lactate levels <5mmol/L, therefore patients with lactate >5mmol/L were excluded as outliers. The primary outcome was mortality. RESULTS: A total of 4794 patients (151 non-survivors) were included in the analysis. Non-survivors had higher rates of EL + BD (35.8% vs. 14.4%, p <0.001). When comparing survivors and non-survivors, EL + BD (OR 5.69), age >65 (5.17), injury severity score (ISS) >25 (8.87), Glasgow coma scale <8 (8.51), systolic blood pressure (SBP) <90 (4.2), and ICU admission (2.61) were significant predictors of mortality. Other than GCS <8 and ISS >25, EL + BD had the highest odds of predicting mortality. CONCLUSION: Elevated lactate + BD on admission in combination represents a 5.6-fold increase in mortality in blunt trauma patients and can be used to predict a patient's outcome on admission. This combination variable provides an additional early data point to identify patients at elevated risk of mortality at the moment of admission.

Laparoscopic Cholecystectomy in the Time of Coronavirus: A Level-1 Trauma Center's Experience.

INTRODUCTION: Laparoscopic cholecystectomy (LC), one of the most common surgical procedures performed in the U.S., offers a window into the effects of the COVID-19 pandemic on routine surgical care. The purpose of our study was to analyze the effects of the COVID-19 pandemic at a Level-1 trauma center on the performance rate of non-elective LC over time. METHODS: A retrospective chart review from July 2019 to December 2020 identified all non-elective LC cases performed at a level-1 trauma center. Patients were categorized into 4 temporal phases along the course of the pandemic based on statewide incidence data on COVID-19: pre-pandemic, peak 1, recovery, and peak 2. We compared the phases based on demographic information and outcomes. RESULTS: In total, 176 patients were reviewed. The performance rate in cases/day varied as follows: pre-pandemic .61, 1st peak .34, recovery .44, and 2nd peak .53. The complication rate was highest in the 2nd peak (16%) (P < .05). Compared to the pre-pandemic period, the intra-pandemic period had a higher incidence of complicated gallbladder disease (P < .05). In the non-elderly subgroup, complicated gallbladder disease was significantly more prevalent in the intra-pandemic period compared to the pre-pandemic period (25% vs 10%, P < .05). CONCLUSIONS: Our data suggests a learning curve throughout the course of the pandemic, reflecting a stepwise increase in the performance rate of LC. The higher incidence of complicated gallbladder disease in the intra-pandemic period may imply patient hesitancy to seek routine surgical care, especially among younger patients.

More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care.

BACKGROUND: As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers' endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers' understanding of the scope of palliative medicine is necessary to direct further training and development efforts. METHOD: A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network. RESULTS: 30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009). CONCLUSIONS: Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.

Impact of Repeat Head Computed Tomography on Mild Traumatic Brain Injury Patients With Abbreviated Injury Score 1-2 Injuries.

BACKGROUND: Patients presenting with traumatic intracranial hemorrhage (ICH) routinely undergo repeat head Computed Tomography (CT) scans with the goal of identifying progressing hemorrhage early and providing timely intervention. Glasgow Coma Scale (GCS) score and Abbreviated Injury Score (AIS) are typically used to grade the severity of traumatic brain injury (TBI) and triage subsequent management. However, most patients receive a repeat head CT scan within 6 hours of the initial insult, regardless of these clinical scores. We investigated the yield of a repeat CT scan for mild blunt TBI (GCS 13-15, AIS 1-2). METHODS: This was a single-center retrospective chart review at a level 1 trauma center between 2009 and 2019. Our primary outcome was medical or surgical intervention directly resulted from change in CT head findings. We used multivariate regression to identify predictors of surgical and medical intervention. RESULTS: 234 mild TBI patients met inclusion criteria. 33.7% of all patients had worsening ICH. 7.7% of patients required a surgical intervention, and 27.4% received a medical intervention. Multivariate analysis found that a decline in GCS (OR 8.64), and polytrauma (Injury Severity Score >15; OR 3.32) predicted surgical intervention. Worsening ICH did not predict surgical or medical intervention. Patients requiring medical intervention were more likely to have a decline in GCS (OR 2.53, P = .02) and be older (age >65, OR 2.06, P = .02). CONCLUSION: In the population of blunt traumatic injury, worsening ICH did not predict surgical or medical intervention. Routine repeat imaging for this population is low yield, and clinical exam should guide the decision to reimage.

Insurance Status Impacts Hospital Discharge for Penetrating Trauma Survivors.

BACKGROUND: Despite equalized acute care in trauma, disparities exist in the long-term outcomes of trauma survivors. Prior studies have revealed insurance status plays a role in the discharge destination of blunt trauma survivors. This is yet to be described in patients with penetrating traumatic injury. METHODS: A retrospective chart review from 2009 to 2019 from an urban Level 1 trauma center identified adult patients who survived penetrating trauma to discharge. Patients were categorized by insurance status. Patient demographics, discharge destination, and hospital length of stay (LOS) were analyzed using the t-test and ANOVA. RESULTS: 1806 patients were identified with 1410 survivors to hospital discharge. Among the survivors, 26.8% were uninsured, 13.1% were privately insured, and 60.0% had Medicare/Medicaid. The uninsured patients were significantly less likely to be discharged to a rehabilitation facility or skilled nursing facility (OR = .49, 95% CI .35-.71) compared to the insured patients. Uninsured survivors had shorter LOS compared to the other groups (5.8 vs. 7.3, P < .01.) Severity of injury did not significantly influence the discharge destination or LOS between the groups. CONCLUSION: Despite recent health care reform, many trauma patients remain uninsured. Our study shows that uninsured penetrating trauma survivors are less likely to be discharged to rehabilitation and skilled nursing facilities. This may contribute to uninsured trauma survivors not receiving appropriate post-traumatic care and could lead to the accrual of undue disability, long-term complications, and increased societal burdens.

Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): Does it matter?

BACKGROUND: Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. METHODS: A retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. RESULTS: One hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). CONCLUSION: Gastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.