Umbilical Fascial Defects are Common and Predict Trocar Site Hernias After Laparoscopic Appendectomy.

INTRODUCTION: Investigations have demonstrated that trocar site hernia (TSH) is an under-appreciated complication of laparoscopic surgery, occurring in as many as 31%. We determined the incidence of fascial defects prior to laparoscopic appendectomy and its impact relative to other risk factors upon the development of TSH. METHODS: TSH was defined as a fascial separation of ≥ 1 cm in the abdominal wall umbilical region on abdominal computerized tomography scan (CT) following laparoscopic appendectomy. Patients admitted to our medical center who had both a preoperative CT and postoperative CT for any reason (greater than 30 days after surgery) were reviewed for the presence of TSH from May 2010 to December 2018. CT scans were measured for fascial defects, while investigators were blinded to film timing (preoperative or postoperative) and patient identity. Demographic information was collected. RESULTS: 241 patients undergoing laparoscopic appendectomy had both preoperative and late postoperative CT. TSH was identified in 49 (20.3%) patients. Mean preoperative fascial gap was 3.3 ± 4.3 mm in those not developing a postoperative hernia versus 14.8 ± 7.3 mm in those with a postoperative hernia (P < .0001). Preoperative fascial defect on CT was predictive of TSH (P < .001, OR = 1.44), with an Area Under the Curve (AUC) of .921 (95%CI: .88-.92). Other major risk factors for TSH were: age greater than 59 years (P < .031, OR = 2.48); and obesity, BMI > 30 (P < .012, OR = 2.14). CONCLUSIONS: The incidence of trocar site hernia was one in five following laparoscopic appendectomy. The presence of a pre-existing fascial defect, advanced age, and obesity were strong predictors for the development of trocar site hernia.

Treatment of Acute Delirium in a Patient with Parkinson's Disease by Transfer to the Intensive Care Unit and Administration of Dexmedetomidine.

The treatment of delirium or psychosis in patients with Parkinson's disease (PD) can be complicated by the limited number of pharmacological agents that can be used in this population. Typical and atypical antipsychotics are contraindicated, as they can worsen motor symptoms. The treatment of acute delirium is even more complicated in the hospital setting, as many medications deemed safer in this population are only available in oral form. We present a case of acute delirium in a patient with PD, likely precipitated by a polypharmacy interaction of new medications, that was successfully managed by transferring the patient to the intensive care unit and administering dexmedetomidine for 72 hours.

Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.