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American Association for the Surgery of Trauma (AAST): Annual Meeting
Hemorrhage control after pelvic fracture: Methods vary widely
LAS VEGAS – Methods for controlling hemorrhage from severe pelvic fractures vary widely across institutions, according to findings from a prospective observational study.
In particular, the findings from the 2-year multicenter study of 1,339 patients show that resuscitative endovascular balloon occlusion of the aorta (REBOA) is rarely used, despite its inclusion in recent management algorithms, Dr. Todd W. Costantini reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
The most common methods used for hemorrhage control were angioembolization alone and external fixator placement alone, used in 55 (4.1%) and 78 (5.8%) patients, respectively. These methods were also used in 19 (10.7%) and 17 (9.6%) of the 178 patients of the overall study population who presented in shock, said Dr. Costantini of the University of California San Diego Health System.
Other methods included preperitoneal pelvic packing alone in 20 patients overall and 6 patients in shock, embolization plus external fixator in 11 patients overall and 6 patients in shock, embolization and pelvic packing in 6 patients overall and 2 patients in shock, external fixator plus pelvic packing in 6 patients overall and 1 patient in shock, embolization plus external fixator plus pelvic packing in 5 patients overall and 1 patient in shock.
“As most pelvic fracture algorithms suggest the use of preperitoneal packing prior to embolization in patients who present with hemodynamic instability, we were interested to find that only two patients [in shock] were treated with this method,” Dr. Costantini said.
Further, REBOA with or without any other method was used in only five patients overall (0.4%) and five patients in shock (2.8%), and all of these were from only 1 of the 11 participating centers, he noted.
Study subjects were adults with a mean age of 47 years with pelvic fracture from blunt trauma, and 57% were men. The mean Injury Severity Score was high at 19.2 on a scale of 75. Associated injury was common; 32% had an abbreviated injury scale (AIS) score of 3 or higher (out of 6) for chest injury.
The average intensive care unit length of stay was 8.2 days, and the average hospital length of stay was 10.9 days. In-hospital mortality was 9%.
“Pelvic fractures are associated with significant disability, demonstrated by the fact that only 43% of patients were discharged home from the hospital after admission for pelvic fractures. The remainder required ongoing care in either skilled nursing facilities or acute rehab facilities,” he said.
Of the patients who met criteria for shock, the mean age was 44 years, 59% were men, and the mean ISS was 28.2, with nearly half having a chest AIS of 3 or greater, nearly 39% having a head AIS of 3 or greater, and 32% having an abdominal AIS of 3 or greater. The mean ICU stay was 11.6 days, and the mean hospital stay, 19.3 days. In-hospital mortality among those presenting in shock was 32%.
Most patients underwent computed tomography, and arterial blush was noted in 10% of cases. Angiography was used in 148 patients, and half of those were noted to have contrast extravasation.
Therapeutic angioembolization was used in 79 patients (5.9%) overall, and in 60% of those undergoing angiography. The most common indication for angiography was ongoing hemorrhage, hemodynamic instability, and blush on CT scan.
The findings demonstrate significant variability in the approach to hemorrhage control across participating institutions.
“We found that there is currently limited use of REBOA in the treatment of hemorrhage associated with pelvic fracture. However, this may change as management strategies evolve with advances in training and technology,” Dr. Costantini concluded.
As a discussant for Dr. Costantini’s paper, Dr. Walter Biffl of the University of Colorado, Denver, expressed concern regarding the lack of adherence to management algorithms, saying that the data suggest a lack of standardization and orderly application of principles that have been shown to reduce mortality.
“Only 19% had pelvic binding. In our algorithm, 100% get that. And 85% of those in shock had CT scans. In our algorithm that comes after all these other interventions,” he said. “This study clearly opens the door for further research. If we could start with a pelvic binder and hemostatic resuscitation and maybe add REBOA for the severely hypertensive patients, maybe we can begin to determine the goals and efficacy of more interventions,” he said.
Dr. Costantini’s study was supported by the AAST Multi-Institutional Trials Committee. He reported having no disclosures.
LAS VEGAS – Methods for controlling hemorrhage from severe pelvic fractures vary widely across institutions, according to findings from a prospective observational study.
In particular, the findings from the 2-year multicenter study of 1,339 patients show that resuscitative endovascular balloon occlusion of the aorta (REBOA) is rarely used, despite its inclusion in recent management algorithms, Dr. Todd W. Costantini reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
The most common methods used for hemorrhage control were angioembolization alone and external fixator placement alone, used in 55 (4.1%) and 78 (5.8%) patients, respectively. These methods were also used in 19 (10.7%) and 17 (9.6%) of the 178 patients of the overall study population who presented in shock, said Dr. Costantini of the University of California San Diego Health System.
Other methods included preperitoneal pelvic packing alone in 20 patients overall and 6 patients in shock, embolization plus external fixator in 11 patients overall and 6 patients in shock, embolization and pelvic packing in 6 patients overall and 2 patients in shock, external fixator plus pelvic packing in 6 patients overall and 1 patient in shock, embolization plus external fixator plus pelvic packing in 5 patients overall and 1 patient in shock.
“As most pelvic fracture algorithms suggest the use of preperitoneal packing prior to embolization in patients who present with hemodynamic instability, we were interested to find that only two patients [in shock] were treated with this method,” Dr. Costantini said.
Further, REBOA with or without any other method was used in only five patients overall (0.4%) and five patients in shock (2.8%), and all of these were from only 1 of the 11 participating centers, he noted.
Study subjects were adults with a mean age of 47 years with pelvic fracture from blunt trauma, and 57% were men. The mean Injury Severity Score was high at 19.2 on a scale of 75. Associated injury was common; 32% had an abbreviated injury scale (AIS) score of 3 or higher (out of 6) for chest injury.
The average intensive care unit length of stay was 8.2 days, and the average hospital length of stay was 10.9 days. In-hospital mortality was 9%.
“Pelvic fractures are associated with significant disability, demonstrated by the fact that only 43% of patients were discharged home from the hospital after admission for pelvic fractures. The remainder required ongoing care in either skilled nursing facilities or acute rehab facilities,” he said.
Of the patients who met criteria for shock, the mean age was 44 years, 59% were men, and the mean ISS was 28.2, with nearly half having a chest AIS of 3 or greater, nearly 39% having a head AIS of 3 or greater, and 32% having an abdominal AIS of 3 or greater. The mean ICU stay was 11.6 days, and the mean hospital stay, 19.3 days. In-hospital mortality among those presenting in shock was 32%.
Most patients underwent computed tomography, and arterial blush was noted in 10% of cases. Angiography was used in 148 patients, and half of those were noted to have contrast extravasation.
Therapeutic angioembolization was used in 79 patients (5.9%) overall, and in 60% of those undergoing angiography. The most common indication for angiography was ongoing hemorrhage, hemodynamic instability, and blush on CT scan.
The findings demonstrate significant variability in the approach to hemorrhage control across participating institutions.
“We found that there is currently limited use of REBOA in the treatment of hemorrhage associated with pelvic fracture. However, this may change as management strategies evolve with advances in training and technology,” Dr. Costantini concluded.
As a discussant for Dr. Costantini’s paper, Dr. Walter Biffl of the University of Colorado, Denver, expressed concern regarding the lack of adherence to management algorithms, saying that the data suggest a lack of standardization and orderly application of principles that have been shown to reduce mortality.
“Only 19% had pelvic binding. In our algorithm, 100% get that. And 85% of those in shock had CT scans. In our algorithm that comes after all these other interventions,” he said. “This study clearly opens the door for further research. If we could start with a pelvic binder and hemostatic resuscitation and maybe add REBOA for the severely hypertensive patients, maybe we can begin to determine the goals and efficacy of more interventions,” he said.
Dr. Costantini’s study was supported by the AAST Multi-Institutional Trials Committee. He reported having no disclosures.
LAS VEGAS – Methods for controlling hemorrhage from severe pelvic fractures vary widely across institutions, according to findings from a prospective observational study.
In particular, the findings from the 2-year multicenter study of 1,339 patients show that resuscitative endovascular balloon occlusion of the aorta (REBOA) is rarely used, despite its inclusion in recent management algorithms, Dr. Todd W. Costantini reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
The most common methods used for hemorrhage control were angioembolization alone and external fixator placement alone, used in 55 (4.1%) and 78 (5.8%) patients, respectively. These methods were also used in 19 (10.7%) and 17 (9.6%) of the 178 patients of the overall study population who presented in shock, said Dr. Costantini of the University of California San Diego Health System.
Other methods included preperitoneal pelvic packing alone in 20 patients overall and 6 patients in shock, embolization plus external fixator in 11 patients overall and 6 patients in shock, embolization and pelvic packing in 6 patients overall and 2 patients in shock, external fixator plus pelvic packing in 6 patients overall and 1 patient in shock, embolization plus external fixator plus pelvic packing in 5 patients overall and 1 patient in shock.
“As most pelvic fracture algorithms suggest the use of preperitoneal packing prior to embolization in patients who present with hemodynamic instability, we were interested to find that only two patients [in shock] were treated with this method,” Dr. Costantini said.
Further, REBOA with or without any other method was used in only five patients overall (0.4%) and five patients in shock (2.8%), and all of these were from only 1 of the 11 participating centers, he noted.
Study subjects were adults with a mean age of 47 years with pelvic fracture from blunt trauma, and 57% were men. The mean Injury Severity Score was high at 19.2 on a scale of 75. Associated injury was common; 32% had an abbreviated injury scale (AIS) score of 3 or higher (out of 6) for chest injury.
The average intensive care unit length of stay was 8.2 days, and the average hospital length of stay was 10.9 days. In-hospital mortality was 9%.
“Pelvic fractures are associated with significant disability, demonstrated by the fact that only 43% of patients were discharged home from the hospital after admission for pelvic fractures. The remainder required ongoing care in either skilled nursing facilities or acute rehab facilities,” he said.
Of the patients who met criteria for shock, the mean age was 44 years, 59% were men, and the mean ISS was 28.2, with nearly half having a chest AIS of 3 or greater, nearly 39% having a head AIS of 3 or greater, and 32% having an abdominal AIS of 3 or greater. The mean ICU stay was 11.6 days, and the mean hospital stay, 19.3 days. In-hospital mortality among those presenting in shock was 32%.
Most patients underwent computed tomography, and arterial blush was noted in 10% of cases. Angiography was used in 148 patients, and half of those were noted to have contrast extravasation.
Therapeutic angioembolization was used in 79 patients (5.9%) overall, and in 60% of those undergoing angiography. The most common indication for angiography was ongoing hemorrhage, hemodynamic instability, and blush on CT scan.
The findings demonstrate significant variability in the approach to hemorrhage control across participating institutions.
“We found that there is currently limited use of REBOA in the treatment of hemorrhage associated with pelvic fracture. However, this may change as management strategies evolve with advances in training and technology,” Dr. Costantini concluded.
As a discussant for Dr. Costantini’s paper, Dr. Walter Biffl of the University of Colorado, Denver, expressed concern regarding the lack of adherence to management algorithms, saying that the data suggest a lack of standardization and orderly application of principles that have been shown to reduce mortality.
“Only 19% had pelvic binding. In our algorithm, 100% get that. And 85% of those in shock had CT scans. In our algorithm that comes after all these other interventions,” he said. “This study clearly opens the door for further research. If we could start with a pelvic binder and hemostatic resuscitation and maybe add REBOA for the severely hypertensive patients, maybe we can begin to determine the goals and efficacy of more interventions,” he said.
Dr. Costantini’s study was supported by the AAST Multi-Institutional Trials Committee. He reported having no disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Methods for controlling hemorrhage from severe pelvic fractures vary widely across institutions, according to findings from a prospective observational study.
Major finding: REBOA was used in five patients overall (0.4%) and five patients in shock (2.8%), all from 1 of the 11 participating centers.
Data source: A prospective, multicenter, observational study of 1,339 patients.
Disclosures: Dr. Costantini’s study was supported by the AAST Multi-Institutional Trials Committee. He reported having no disclosures.
BCVI: Screen with CT angiography, confirm with DSA
LAS VEGAS – Management of blunt cerebrovascular injuries using 64-channel computed tomographic angiography screening coupled with digital subtraction angiography for a definitive diagnosis is safe and effective for identifying clinically significant injury and for maintaining a low stroke rate, according to a review of 228 cases.
The computed tomographic angiography (CTA) screening was positive in 189 patients (83%), and digital subtraction angiography (DSA) confirmed injury in 104 (55%) of those. The remaining 39 patients were found to have no injury on DSA, Dr. Charles P. Shahan of the University of Tennessee, Memphis reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
Stroke related to blunt cerebrovascular injury (BCVI) occurred in five patients (4.8%); three of those patients were symptomatic at the time of presentation, and two became symptomatic while on therapy for a known lesion. None of the patients who had a negative screening CTA, including three with injuries missed on CTA, had a stroke, Dr. Shahan said.
The current study follows a prior study reported at the 2013 AAST annual meeting that suggested that 64-channel multidetector CTA could be the primary screening tool for BCVI. The previously used 32-channel multidetector CTA was found to be inadequate, with a sensitivity of only 52%. Sensitivity increased to 68% with the 64-channel CTA, but the positive predictive value remained remarkably low at 36%, he said.
That study led to a change in the screening algorithm, replacing DSA with CTA for screening, and reserving DSA for definitive BCVI diagnosis following a positive CTA or unexplained neurologic findings, he explained, noting that the rationale was that most injuries missed were low-grade injuries less likely to result in further injury, and that with CTA alone, about two-thirds of patients would be treated unnecessarily because of the false-positive rate.
The purpose of the current study was to evaluate outcomes in the wake of the algorithm change and to assess the potential for missed, clinically significant BCVI.
Study subjects were patients who underwent DSA over an 18-month period after implementation of the algorithm change. Most (64%) were men with a mean age of 43 years and a mean injury severity score of 22 out of 75, indicating moderate or severe injury.
The stroke rate was statistically unchanged in the second study, compared with the first. The findings demonstrate the safety and efficacy of the current management algorithm for BCVI, as well as the value of using DSA to identify false-positive CTA findings. In fact, definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients, with no increase in the incidence of strokes resulting from injuries missed by CTA, Dr. Shahan said.
“Considering there were 85 false-positive CTAs, and also considering that our average length of heparin time is approximately 7 days prior to reevaluation, we’ve extrapolated this to nearly 600 heparin infusion days that were avoided by confirmatory DSA testing,” he said, concluding that “CTA with 64-channel multidetector technology with experienced radiology staff in a high-volume center can be safe and effective for BCVI screening.”
He added, however, that false-positive rates with CTA continue to necessitate DSA confirmation to avoid overtreatment.
“We feel that CTA screening with DSA confirmation has allowed us to maintain an acceptably low stroke rate and prevented a tremendous amount of unnecessary anticoagulation in these patients,” he said.
Dr. Clay Cothren Burlew, who was an invited discussant for Dr. Shahan’s paper, applauded Dr. Shahan and his colleagues for “continuing to question the validity of CTA as our primary diagnostic modality for BCVI,” and said the findings made her “stop and think, should we all be doing confirmatory angiography? … Are CTAs actually overcalling 45% of the injuries that we identify?”
Dr. Burlew of the University of Colorado, Denver, questioned whether the high rate of false positives is a result of radiologists who “overcall” questionable findings knowing that a confirmatory angiogram will quickly follow.
“I think this evaluation should be a model for others. Each institution should critically review their individual rates and methods of BCVI diagnosis,” she said, adding that “for centers with a marked increase in the identification of BCVI following institution of CTA as their screening tool, consideration of confirmatory angiography is recommended due to the potential false-positive rate of up to 45%.”
However, confirmatory angiography may not be warranted at centers whose screen yields remain the same with no missed injuries, she said.
“All programs should evaluate their injuries, appropriateness of diagnosis, and impact of subsequent treatment. Only then will we have optimal outcomes,” she concluded.
Dr. Shahan and Dr. Burlew reported having no relevant financial disclosures.
LAS VEGAS – Management of blunt cerebrovascular injuries using 64-channel computed tomographic angiography screening coupled with digital subtraction angiography for a definitive diagnosis is safe and effective for identifying clinically significant injury and for maintaining a low stroke rate, according to a review of 228 cases.
The computed tomographic angiography (CTA) screening was positive in 189 patients (83%), and digital subtraction angiography (DSA) confirmed injury in 104 (55%) of those. The remaining 39 patients were found to have no injury on DSA, Dr. Charles P. Shahan of the University of Tennessee, Memphis reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
Stroke related to blunt cerebrovascular injury (BCVI) occurred in five patients (4.8%); three of those patients were symptomatic at the time of presentation, and two became symptomatic while on therapy for a known lesion. None of the patients who had a negative screening CTA, including three with injuries missed on CTA, had a stroke, Dr. Shahan said.
The current study follows a prior study reported at the 2013 AAST annual meeting that suggested that 64-channel multidetector CTA could be the primary screening tool for BCVI. The previously used 32-channel multidetector CTA was found to be inadequate, with a sensitivity of only 52%. Sensitivity increased to 68% with the 64-channel CTA, but the positive predictive value remained remarkably low at 36%, he said.
That study led to a change in the screening algorithm, replacing DSA with CTA for screening, and reserving DSA for definitive BCVI diagnosis following a positive CTA or unexplained neurologic findings, he explained, noting that the rationale was that most injuries missed were low-grade injuries less likely to result in further injury, and that with CTA alone, about two-thirds of patients would be treated unnecessarily because of the false-positive rate.
The purpose of the current study was to evaluate outcomes in the wake of the algorithm change and to assess the potential for missed, clinically significant BCVI.
Study subjects were patients who underwent DSA over an 18-month period after implementation of the algorithm change. Most (64%) were men with a mean age of 43 years and a mean injury severity score of 22 out of 75, indicating moderate or severe injury.
The stroke rate was statistically unchanged in the second study, compared with the first. The findings demonstrate the safety and efficacy of the current management algorithm for BCVI, as well as the value of using DSA to identify false-positive CTA findings. In fact, definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients, with no increase in the incidence of strokes resulting from injuries missed by CTA, Dr. Shahan said.
“Considering there were 85 false-positive CTAs, and also considering that our average length of heparin time is approximately 7 days prior to reevaluation, we’ve extrapolated this to nearly 600 heparin infusion days that were avoided by confirmatory DSA testing,” he said, concluding that “CTA with 64-channel multidetector technology with experienced radiology staff in a high-volume center can be safe and effective for BCVI screening.”
He added, however, that false-positive rates with CTA continue to necessitate DSA confirmation to avoid overtreatment.
“We feel that CTA screening with DSA confirmation has allowed us to maintain an acceptably low stroke rate and prevented a tremendous amount of unnecessary anticoagulation in these patients,” he said.
Dr. Clay Cothren Burlew, who was an invited discussant for Dr. Shahan’s paper, applauded Dr. Shahan and his colleagues for “continuing to question the validity of CTA as our primary diagnostic modality for BCVI,” and said the findings made her “stop and think, should we all be doing confirmatory angiography? … Are CTAs actually overcalling 45% of the injuries that we identify?”
Dr. Burlew of the University of Colorado, Denver, questioned whether the high rate of false positives is a result of radiologists who “overcall” questionable findings knowing that a confirmatory angiogram will quickly follow.
“I think this evaluation should be a model for others. Each institution should critically review their individual rates and methods of BCVI diagnosis,” she said, adding that “for centers with a marked increase in the identification of BCVI following institution of CTA as their screening tool, consideration of confirmatory angiography is recommended due to the potential false-positive rate of up to 45%.”
However, confirmatory angiography may not be warranted at centers whose screen yields remain the same with no missed injuries, she said.
“All programs should evaluate their injuries, appropriateness of diagnosis, and impact of subsequent treatment. Only then will we have optimal outcomes,” she concluded.
Dr. Shahan and Dr. Burlew reported having no relevant financial disclosures.
LAS VEGAS – Management of blunt cerebrovascular injuries using 64-channel computed tomographic angiography screening coupled with digital subtraction angiography for a definitive diagnosis is safe and effective for identifying clinically significant injury and for maintaining a low stroke rate, according to a review of 228 cases.
The computed tomographic angiography (CTA) screening was positive in 189 patients (83%), and digital subtraction angiography (DSA) confirmed injury in 104 (55%) of those. The remaining 39 patients were found to have no injury on DSA, Dr. Charles P. Shahan of the University of Tennessee, Memphis reported at the annual meeting of the American Association for the Surgery of Trauma (AAST).
Stroke related to blunt cerebrovascular injury (BCVI) occurred in five patients (4.8%); three of those patients were symptomatic at the time of presentation, and two became symptomatic while on therapy for a known lesion. None of the patients who had a negative screening CTA, including three with injuries missed on CTA, had a stroke, Dr. Shahan said.
The current study follows a prior study reported at the 2013 AAST annual meeting that suggested that 64-channel multidetector CTA could be the primary screening tool for BCVI. The previously used 32-channel multidetector CTA was found to be inadequate, with a sensitivity of only 52%. Sensitivity increased to 68% with the 64-channel CTA, but the positive predictive value remained remarkably low at 36%, he said.
That study led to a change in the screening algorithm, replacing DSA with CTA for screening, and reserving DSA for definitive BCVI diagnosis following a positive CTA or unexplained neurologic findings, he explained, noting that the rationale was that most injuries missed were low-grade injuries less likely to result in further injury, and that with CTA alone, about two-thirds of patients would be treated unnecessarily because of the false-positive rate.
The purpose of the current study was to evaluate outcomes in the wake of the algorithm change and to assess the potential for missed, clinically significant BCVI.
Study subjects were patients who underwent DSA over an 18-month period after implementation of the algorithm change. Most (64%) were men with a mean age of 43 years and a mean injury severity score of 22 out of 75, indicating moderate or severe injury.
The stroke rate was statistically unchanged in the second study, compared with the first. The findings demonstrate the safety and efficacy of the current management algorithm for BCVI, as well as the value of using DSA to identify false-positive CTA findings. In fact, definitive diagnosis by DSA led to avoidance of potentially harmful anticoagulation in 45% of CTA-positive patients, with no increase in the incidence of strokes resulting from injuries missed by CTA, Dr. Shahan said.
“Considering there were 85 false-positive CTAs, and also considering that our average length of heparin time is approximately 7 days prior to reevaluation, we’ve extrapolated this to nearly 600 heparin infusion days that were avoided by confirmatory DSA testing,” he said, concluding that “CTA with 64-channel multidetector technology with experienced radiology staff in a high-volume center can be safe and effective for BCVI screening.”
He added, however, that false-positive rates with CTA continue to necessitate DSA confirmation to avoid overtreatment.
“We feel that CTA screening with DSA confirmation has allowed us to maintain an acceptably low stroke rate and prevented a tremendous amount of unnecessary anticoagulation in these patients,” he said.
Dr. Clay Cothren Burlew, who was an invited discussant for Dr. Shahan’s paper, applauded Dr. Shahan and his colleagues for “continuing to question the validity of CTA as our primary diagnostic modality for BCVI,” and said the findings made her “stop and think, should we all be doing confirmatory angiography? … Are CTAs actually overcalling 45% of the injuries that we identify?”
Dr. Burlew of the University of Colorado, Denver, questioned whether the high rate of false positives is a result of radiologists who “overcall” questionable findings knowing that a confirmatory angiogram will quickly follow.
“I think this evaluation should be a model for others. Each institution should critically review their individual rates and methods of BCVI diagnosis,” she said, adding that “for centers with a marked increase in the identification of BCVI following institution of CTA as their screening tool, consideration of confirmatory angiography is recommended due to the potential false-positive rate of up to 45%.”
However, confirmatory angiography may not be warranted at centers whose screen yields remain the same with no missed injuries, she said.
“All programs should evaluate their injuries, appropriateness of diagnosis, and impact of subsequent treatment. Only then will we have optimal outcomes,” she concluded.
Dr. Shahan and Dr. Burlew reported having no relevant financial disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Use of 64-channel CT angiography screening coupled with digital subtraction angiography for a definitive diagnosis of blunt cerebrovascular injury is safe and effective for identifying clinically significant injury and for maintaining a low stroke rate.
Major finding: None of the patients who had a negative screening CTA, including three with injuries missed on CTA, had a stroke.
Data source: A review of 228 patients with possible BCVI.
Disclosures: Dr. Shahan and Dr. Burlew reported having no relevant financial disclosures.
Study reveals higher than expected post-discharge mortality after trauma
LAS VEGAS – A higher-than-expected proportion of trauma-related deaths occur in the months and years after hospital discharge, according to findings from a prospective cohort study.
In 908 trauma patients followed for up to 9.8 years (median, 1.7 years), overall mortality was 27%, and in 509 patients followed for at least 2 years, overall mortality was 38%. Mortality was highest among those who were severely injured (43% at 5 years), Dr. Rachael A. Callcut reported at the annual meeting of the American Association for the Surgery of Trauma.
The median Injury Severity Scale score was 18, but for all ISS groups, survival was significantly worse than predicted actuarial survival for that group – even after exclusion of deaths that occurred within 30 days, she said.
For example, at 5 years, predicted actuarial survival was greater than 95%, but actual survival was about 90% for those with ISS less than 15, about 85% for those with ISS of 15-24, and about 57% for those with ISS greater than 24. This dose-response–like relationship between injury severity and mortality demonstrates that the deaths are not just occurring in “patients who are old and would have died from a heart attack anyway” she explained.
The 30-day mortality in the cohort was 22%, and in-hospital mortality was 22.9%, as eight patients who died after the first 30 days did so in the hospital. Forty-five of the 245 deaths (18%) occurred after 30 days, and 36 of those (80%) occurred after hospital discharge, meaning the out-of-hospital mortality rate was 5.3% overall, and 10% for the most severely injured (hazard ratio, 2.7 for the most severe vs. the least severe injuries).
“I personally found this quite striking given that when a patient leaves the hospital, we feel, to some degree, that we won – only to find out that at least 5% of these patients will go on to subsequently die,” said Dr. Callcut of the University of California San Francisco, adding that “if you look at it slightly differently, which is even more concerning, 37 of the out-of-hospital deaths of the total of 245 deaths, mean that out-of-hospital deaths account for 15% of the total mortality following trauma.”
Further, of the deaths that occurred after 30 days, 53% occurred between 31 days and 1 year after trauma, and trauma was the leading cause of postdischarge death, accounting for 41% of the late deaths, she said.
The patients included in this analysis were all highest level trauma activation patients enrolled in the ongoing study between 2005 and 2012. Comprehensive prospective data were collected, and patients were followed throughout their hospitalization and after discharge. Institutional medical records or death certificates were used to determine timing and cause of death, and survival status was determined based on the last date of care in the institution or by query of the National Death Index for 2013.
These findings provide a rare glimpse of trauma-related outcomes among patients discharged from the hospital. Most prior studies focused on 30-day outcomes, with a few extended out to 90 days, but very few studies have looked at long-term outcomes, Dr. Callcut noted.
“You could say that despite having survived to leave the hospital alive, long-term survival is actually worse than predicted actuarial survival, and this suggests to us that successful hospital discharge does not mean success for your patient,” she concluded.
Dr. Callcut was supported in part by a National Institutes of Health award.
LAS VEGAS – A higher-than-expected proportion of trauma-related deaths occur in the months and years after hospital discharge, according to findings from a prospective cohort study.
In 908 trauma patients followed for up to 9.8 years (median, 1.7 years), overall mortality was 27%, and in 509 patients followed for at least 2 years, overall mortality was 38%. Mortality was highest among those who were severely injured (43% at 5 years), Dr. Rachael A. Callcut reported at the annual meeting of the American Association for the Surgery of Trauma.
The median Injury Severity Scale score was 18, but for all ISS groups, survival was significantly worse than predicted actuarial survival for that group – even after exclusion of deaths that occurred within 30 days, she said.
For example, at 5 years, predicted actuarial survival was greater than 95%, but actual survival was about 90% for those with ISS less than 15, about 85% for those with ISS of 15-24, and about 57% for those with ISS greater than 24. This dose-response–like relationship between injury severity and mortality demonstrates that the deaths are not just occurring in “patients who are old and would have died from a heart attack anyway” she explained.
The 30-day mortality in the cohort was 22%, and in-hospital mortality was 22.9%, as eight patients who died after the first 30 days did so in the hospital. Forty-five of the 245 deaths (18%) occurred after 30 days, and 36 of those (80%) occurred after hospital discharge, meaning the out-of-hospital mortality rate was 5.3% overall, and 10% for the most severely injured (hazard ratio, 2.7 for the most severe vs. the least severe injuries).
“I personally found this quite striking given that when a patient leaves the hospital, we feel, to some degree, that we won – only to find out that at least 5% of these patients will go on to subsequently die,” said Dr. Callcut of the University of California San Francisco, adding that “if you look at it slightly differently, which is even more concerning, 37 of the out-of-hospital deaths of the total of 245 deaths, mean that out-of-hospital deaths account for 15% of the total mortality following trauma.”
Further, of the deaths that occurred after 30 days, 53% occurred between 31 days and 1 year after trauma, and trauma was the leading cause of postdischarge death, accounting for 41% of the late deaths, she said.
The patients included in this analysis were all highest level trauma activation patients enrolled in the ongoing study between 2005 and 2012. Comprehensive prospective data were collected, and patients were followed throughout their hospitalization and after discharge. Institutional medical records or death certificates were used to determine timing and cause of death, and survival status was determined based on the last date of care in the institution or by query of the National Death Index for 2013.
These findings provide a rare glimpse of trauma-related outcomes among patients discharged from the hospital. Most prior studies focused on 30-day outcomes, with a few extended out to 90 days, but very few studies have looked at long-term outcomes, Dr. Callcut noted.
“You could say that despite having survived to leave the hospital alive, long-term survival is actually worse than predicted actuarial survival, and this suggests to us that successful hospital discharge does not mean success for your patient,” she concluded.
Dr. Callcut was supported in part by a National Institutes of Health award.
LAS VEGAS – A higher-than-expected proportion of trauma-related deaths occur in the months and years after hospital discharge, according to findings from a prospective cohort study.
In 908 trauma patients followed for up to 9.8 years (median, 1.7 years), overall mortality was 27%, and in 509 patients followed for at least 2 years, overall mortality was 38%. Mortality was highest among those who were severely injured (43% at 5 years), Dr. Rachael A. Callcut reported at the annual meeting of the American Association for the Surgery of Trauma.
The median Injury Severity Scale score was 18, but for all ISS groups, survival was significantly worse than predicted actuarial survival for that group – even after exclusion of deaths that occurred within 30 days, she said.
For example, at 5 years, predicted actuarial survival was greater than 95%, but actual survival was about 90% for those with ISS less than 15, about 85% for those with ISS of 15-24, and about 57% for those with ISS greater than 24. This dose-response–like relationship between injury severity and mortality demonstrates that the deaths are not just occurring in “patients who are old and would have died from a heart attack anyway” she explained.
The 30-day mortality in the cohort was 22%, and in-hospital mortality was 22.9%, as eight patients who died after the first 30 days did so in the hospital. Forty-five of the 245 deaths (18%) occurred after 30 days, and 36 of those (80%) occurred after hospital discharge, meaning the out-of-hospital mortality rate was 5.3% overall, and 10% for the most severely injured (hazard ratio, 2.7 for the most severe vs. the least severe injuries).
“I personally found this quite striking given that when a patient leaves the hospital, we feel, to some degree, that we won – only to find out that at least 5% of these patients will go on to subsequently die,” said Dr. Callcut of the University of California San Francisco, adding that “if you look at it slightly differently, which is even more concerning, 37 of the out-of-hospital deaths of the total of 245 deaths, mean that out-of-hospital deaths account for 15% of the total mortality following trauma.”
Further, of the deaths that occurred after 30 days, 53% occurred between 31 days and 1 year after trauma, and trauma was the leading cause of postdischarge death, accounting for 41% of the late deaths, she said.
The patients included in this analysis were all highest level trauma activation patients enrolled in the ongoing study between 2005 and 2012. Comprehensive prospective data were collected, and patients were followed throughout their hospitalization and after discharge. Institutional medical records or death certificates were used to determine timing and cause of death, and survival status was determined based on the last date of care in the institution or by query of the National Death Index for 2013.
These findings provide a rare glimpse of trauma-related outcomes among patients discharged from the hospital. Most prior studies focused on 30-day outcomes, with a few extended out to 90 days, but very few studies have looked at long-term outcomes, Dr. Callcut noted.
“You could say that despite having survived to leave the hospital alive, long-term survival is actually worse than predicted actuarial survival, and this suggests to us that successful hospital discharge does not mean success for your patient,” she concluded.
Dr. Callcut was supported in part by a National Institutes of Health award.
AT THE AAST ANNUAL MEETING
Key clinical point: A concerning proportion of trauma-related deaths occur after hospital discharge, according to findings from a prospective cohort study.
Major finding: The out-of-hospital mortality rate was 5.3% overall, and 10% for the most severely injured (hazard ratio, 2.7 for the most vs. least severely injured).
Data source: A prospective cohort study involving 908 patients.
Disclosures: Dr. Callcut was supported in part by a National Institutes of Health award.
Readmissions for C. difficile infections high among elderly
LAS VEGAS – More than one in 10 patients with Clostridium difficile infection at the time of hospital discharge are readmitted for C. difficile infection within 90 days, according to findings from a review of Medicare data from 2009 to 2011.
Of a random sample of nearly 900,000 Part A inpatients and Part D prescription drug claimants during the study period, about 8,500 were hospitalized with a primary or secondary diagnosis of C. difficile infection, and of 7,042 of those who were discharged alive and who were eligible for the study, 945 (13.4%) were readmitted within 90 days, Dr. Charles M. Psoinos reported at the annual meeting of the American Association for the Surgery of Trauma.
Compared with 1,900 patients not readmitted for any reason, those who were readmitted had more baseline comorbidities (average Elixhauser index, 5.9 vs. 4.7), and a significantly shorter length of stay during the index hospitalization (9.2 vs. 11.8 days), and those older than 95 years were twice as likely as those aged 65-70 years to be readmitted, as were those with an emergent vs. nonemergent index hospitalization, said Dr. Psoinos of the University of Massachusetts, Worcester.
Further, the readmission rate was lower in the 39% of patients discharged on oral metronidazole (19%), and in the 12% discharged on oral vancomycin (28%), than among the 38% discharged with no ongoing treatment (48%), while those discharged on both oral metronidazole and vancomycin were at increased risk for readmission (odds ratio, 1.29), he said.
The 90-day all cause mortality rate was nearly doubled in those who were readmitted, compared with those who were not (17.8% vs. 8.9%; OR, 1.77), he said.
Patients who were and were not readmitted did not differ significantly with respect to age (mean of about 80 years) and race distribution, and the outcomes were adjusted for the differences in baseline comorbidities and other confounding factors.
The findings could have important implications for reducing readmissions among Medicare beneficiaries, Dr. Psoinos said.
The incidence of C. difficile infections has increased nearly eightfold in the elderly population over the last several decades, and the elderly now account for more than 70% of hospitalized patients with such infections. Recurrence rates range from 5% to 31% after cessation of therapy, and readmission rates are similar, he explained, noting that treatment recommendations for C. difficile infections are commonly based on symptoms and their severity, with oral metronidazole recommended for mild and moderate disease, vancomycin only for severe disease, and dual therapy for complicated severe disease.
Though limited by the retrospective design of the study, the findings suggest that C. difficile patients discharged from the hospital may benefit from ongoing monotherapy treatment to reduce subclinical infections and induce long-term eradication, and that elderly patients on dual therapy may benefit from continued hospitalization until they are appropriate for discharge on monotherapy.
These strategies could reduce the rate of readmissions, Dr. Psoinos concluded.
Dr. Psoinos reported having no relevant financial conflicts.
LAS VEGAS – More than one in 10 patients with Clostridium difficile infection at the time of hospital discharge are readmitted for C. difficile infection within 90 days, according to findings from a review of Medicare data from 2009 to 2011.
Of a random sample of nearly 900,000 Part A inpatients and Part D prescription drug claimants during the study period, about 8,500 were hospitalized with a primary or secondary diagnosis of C. difficile infection, and of 7,042 of those who were discharged alive and who were eligible for the study, 945 (13.4%) were readmitted within 90 days, Dr. Charles M. Psoinos reported at the annual meeting of the American Association for the Surgery of Trauma.
Compared with 1,900 patients not readmitted for any reason, those who were readmitted had more baseline comorbidities (average Elixhauser index, 5.9 vs. 4.7), and a significantly shorter length of stay during the index hospitalization (9.2 vs. 11.8 days), and those older than 95 years were twice as likely as those aged 65-70 years to be readmitted, as were those with an emergent vs. nonemergent index hospitalization, said Dr. Psoinos of the University of Massachusetts, Worcester.
Further, the readmission rate was lower in the 39% of patients discharged on oral metronidazole (19%), and in the 12% discharged on oral vancomycin (28%), than among the 38% discharged with no ongoing treatment (48%), while those discharged on both oral metronidazole and vancomycin were at increased risk for readmission (odds ratio, 1.29), he said.
The 90-day all cause mortality rate was nearly doubled in those who were readmitted, compared with those who were not (17.8% vs. 8.9%; OR, 1.77), he said.
Patients who were and were not readmitted did not differ significantly with respect to age (mean of about 80 years) and race distribution, and the outcomes were adjusted for the differences in baseline comorbidities and other confounding factors.
The findings could have important implications for reducing readmissions among Medicare beneficiaries, Dr. Psoinos said.
The incidence of C. difficile infections has increased nearly eightfold in the elderly population over the last several decades, and the elderly now account for more than 70% of hospitalized patients with such infections. Recurrence rates range from 5% to 31% after cessation of therapy, and readmission rates are similar, he explained, noting that treatment recommendations for C. difficile infections are commonly based on symptoms and their severity, with oral metronidazole recommended for mild and moderate disease, vancomycin only for severe disease, and dual therapy for complicated severe disease.
Though limited by the retrospective design of the study, the findings suggest that C. difficile patients discharged from the hospital may benefit from ongoing monotherapy treatment to reduce subclinical infections and induce long-term eradication, and that elderly patients on dual therapy may benefit from continued hospitalization until they are appropriate for discharge on monotherapy.
These strategies could reduce the rate of readmissions, Dr. Psoinos concluded.
Dr. Psoinos reported having no relevant financial conflicts.
LAS VEGAS – More than one in 10 patients with Clostridium difficile infection at the time of hospital discharge are readmitted for C. difficile infection within 90 days, according to findings from a review of Medicare data from 2009 to 2011.
Of a random sample of nearly 900,000 Part A inpatients and Part D prescription drug claimants during the study period, about 8,500 were hospitalized with a primary or secondary diagnosis of C. difficile infection, and of 7,042 of those who were discharged alive and who were eligible for the study, 945 (13.4%) were readmitted within 90 days, Dr. Charles M. Psoinos reported at the annual meeting of the American Association for the Surgery of Trauma.
Compared with 1,900 patients not readmitted for any reason, those who were readmitted had more baseline comorbidities (average Elixhauser index, 5.9 vs. 4.7), and a significantly shorter length of stay during the index hospitalization (9.2 vs. 11.8 days), and those older than 95 years were twice as likely as those aged 65-70 years to be readmitted, as were those with an emergent vs. nonemergent index hospitalization, said Dr. Psoinos of the University of Massachusetts, Worcester.
Further, the readmission rate was lower in the 39% of patients discharged on oral metronidazole (19%), and in the 12% discharged on oral vancomycin (28%), than among the 38% discharged with no ongoing treatment (48%), while those discharged on both oral metronidazole and vancomycin were at increased risk for readmission (odds ratio, 1.29), he said.
The 90-day all cause mortality rate was nearly doubled in those who were readmitted, compared with those who were not (17.8% vs. 8.9%; OR, 1.77), he said.
Patients who were and were not readmitted did not differ significantly with respect to age (mean of about 80 years) and race distribution, and the outcomes were adjusted for the differences in baseline comorbidities and other confounding factors.
The findings could have important implications for reducing readmissions among Medicare beneficiaries, Dr. Psoinos said.
The incidence of C. difficile infections has increased nearly eightfold in the elderly population over the last several decades, and the elderly now account for more than 70% of hospitalized patients with such infections. Recurrence rates range from 5% to 31% after cessation of therapy, and readmission rates are similar, he explained, noting that treatment recommendations for C. difficile infections are commonly based on symptoms and their severity, with oral metronidazole recommended for mild and moderate disease, vancomycin only for severe disease, and dual therapy for complicated severe disease.
Though limited by the retrospective design of the study, the findings suggest that C. difficile patients discharged from the hospital may benefit from ongoing monotherapy treatment to reduce subclinical infections and induce long-term eradication, and that elderly patients on dual therapy may benefit from continued hospitalization until they are appropriate for discharge on monotherapy.
These strategies could reduce the rate of readmissions, Dr. Psoinos concluded.
Dr. Psoinos reported having no relevant financial conflicts.
AT THE AAST ANNUAL MEETING
Key clinical point: More than 1 in 10 patients with Clostridium difficile infection at the time of hospital discharge are readmitted for C. difficile infection within 90 days, according to findings from a review of Medicare data from 2009 to 2011.
Major finding: Of 7,042 discharged patients, 945 (13.4%) were readmitted within 90 days.
Data source: A retrospective cohort study of about 900,000 Medicare beneficiaries.
Disclosures: Dr. Psoinos reported having no relevant financial disclosures.
Damage control laparotomy an option for nontrauma secondary peritonitis
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
LAS VEGAS – Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
For example, the deferred ostomy rate was 16.7% among 72 patients who underwent damage control laparotomy (DCL), which was significantly lower than the primary ostomy rate of 53.6% in 110 patients who underwent a definitive surgical procedure (DSP), Dr. Maria P. Garcia-Garcia reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the fistula rate was lower among 60 DCL patients who underwent delayed anastomosis, compared with 51 DSP patients who underwent primary anastomosis (26.7% vs. 37.2%), and the mortality rate was lower in the DCL vs. DSP patients (16.7% vs. 24.5%). These differences did not meet statistical significance due to the sample size. Deaths in the DCL group all occurred in those who underwent delayed anastomosis; deaths in the DSP group occurred in 14 ostomy patients and 13 anastomosis patients, said Dr. Garcia-Garcia of Fundacion Valle del Lili, Cali, Colombia.
Disease severity, as measured by APACHE II scores, was similar in the two groups (mean of about 17 for each group). Septic shock was present in 37% at the time of admission. Mean hospital length of stay and mean intensive care unit length of stay did not differ significantly between the groups, nor did the systemic complication rate, or the rates of multiple organ failure and acute respiratory distress syndrome.
Small-bowel perforation occurred in 77 (42.3%), and colon perforation occurred in 105 (57.7%).
The patients included teens and adults aged 16 years or older (mean of 60.3 years) with severe nontrauma secondary peritonitis (NSPT) who were undergoing bowel resection after enteric perforations between 2003 and 2013. The DSP patients underwent either primary anastomosis or primary ostomy, and the DCL patients underwent segmental bowel resection, temporary abdominal closure, and subsequent delayed anastomosis or deferred ostomy.
DCL is a recognized strategy for managing bowel injuries in trauma patients. It was developed in response to the poor outcomes associated with attempting definitive repair, but evidence regarding the role and timing of anastomosis in DCL in NTSP – a condition associated with high morbidity and a 30% in-hospital mortality rate – is lacking, Dr. Garcia-Garcia said, noting that the current findings suggest it is the preferred approach.
“When a definite surgical repair is chosen, there is a 50/50 chance of performing anastomosis or ostomy. However, when a damage control abbreviated laparotomy is performed, there is a high bowel reconstruction success rate of about 80%. Therefore, damage control abbreviated laparotomy is a reliable and safe option in critically ill nontrauma secondary peritonitis patients. At the end of the day it’s your choice: Would you rather leave your patient with an ostomy or tube, or would you give your patient a chance of successful reconstruction without an ostomy?” she said.
Dr. Garcia-Garcia reported having no disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Damage control laparotomy is a safe and reliable approach to the surgical management of patients with severe nontrauma secondary peritonitis who require bowel resection, according a review of 182 cases.
Major finding: The ostomy rate was 16.7% vs. 53.6% with DCL vs. DSP.
Data source: A review of 182 cases.
Disclosures: Dr. Garcia-Garcia reported having no disclosures.
Surgical stabilization bests medical management for rib fractures
LAS VEGAS – Surgical stabilization of severe rib fractures leads to better outcomes than does the best medical management in critically ill trauma patients, findings from a 2-year, single-center, clinical trial suggest.
For example, the likelihood of respiratory failure was significantly lower in 35 patients who underwent surgical stabilization of severe rib fractures (SSRF) than among 35 who received optimal medical management (odds ratio, 0.22), and the likelihood of tracheostomy was also significantly lower with SSRF (OR, 0.20). These findings remained significant after controlling for a significantly higher RibScore – a radiographically derived score that predicts pulmonary outcomes in rib fracture patients – in the surgery group (score of 4 vs. 3 on a 0-6 scale), and for a significantly lower incidence of intracranial hemorrhage in the surgery group (5.7% vs. 28.6%), Dr. Fredric Pieracci reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the average daily spirometry value was 280 mL higher in the operative group, and there were nonsignificant trends toward a decreased likelihood of pneumonia (20.1% vs. 31.5%, respectively), decreased number of ventilator days (6.4 vs. 10.6), decreased ICU length of stay (8.3 vs. 10.4 days), and decreased hospital length of stay (15.2 vs. 25.3 days).
Narcotic requirements were similar in the groups, and no deaths occurred, said Dr. Pieracci, of Denver Health Medical Center.
The study, which was conducted at a level 1 trauma center from 2013 to 2014, enrolled adult patients with various rib fracture patterns, including flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. Only those who presented within 72 hours of their injury were included.
All eligible patients were managed nonoperatively in the first year of the study, and all were managed operatively in the second year using a standardized technique described recently in the Journal of Trauma and Acute Care Surgery. The nonoperative and operative patient groups were well matched with respect to age, gender, mechanism of injury, preexisting lung pathology, and tobacco use, Dr. Pieracci noted.
“In conclusion, we found that surgical stabilization of severe rib fractures was independently associated with improved pulmonary outcomes, specifically respiratory failure, tracheostomy, duration of mechanical ventilation, and spirometry, and based on this we recommend consideration of surgical stabilization in trauma patients who meet one or more of our inclusion criteria,” he said.
Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.
LAS VEGAS – Surgical stabilization of severe rib fractures leads to better outcomes than does the best medical management in critically ill trauma patients, findings from a 2-year, single-center, clinical trial suggest.
For example, the likelihood of respiratory failure was significantly lower in 35 patients who underwent surgical stabilization of severe rib fractures (SSRF) than among 35 who received optimal medical management (odds ratio, 0.22), and the likelihood of tracheostomy was also significantly lower with SSRF (OR, 0.20). These findings remained significant after controlling for a significantly higher RibScore – a radiographically derived score that predicts pulmonary outcomes in rib fracture patients – in the surgery group (score of 4 vs. 3 on a 0-6 scale), and for a significantly lower incidence of intracranial hemorrhage in the surgery group (5.7% vs. 28.6%), Dr. Fredric Pieracci reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the average daily spirometry value was 280 mL higher in the operative group, and there were nonsignificant trends toward a decreased likelihood of pneumonia (20.1% vs. 31.5%, respectively), decreased number of ventilator days (6.4 vs. 10.6), decreased ICU length of stay (8.3 vs. 10.4 days), and decreased hospital length of stay (15.2 vs. 25.3 days).
Narcotic requirements were similar in the groups, and no deaths occurred, said Dr. Pieracci, of Denver Health Medical Center.
The study, which was conducted at a level 1 trauma center from 2013 to 2014, enrolled adult patients with various rib fracture patterns, including flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. Only those who presented within 72 hours of their injury were included.
All eligible patients were managed nonoperatively in the first year of the study, and all were managed operatively in the second year using a standardized technique described recently in the Journal of Trauma and Acute Care Surgery. The nonoperative and operative patient groups were well matched with respect to age, gender, mechanism of injury, preexisting lung pathology, and tobacco use, Dr. Pieracci noted.
“In conclusion, we found that surgical stabilization of severe rib fractures was independently associated with improved pulmonary outcomes, specifically respiratory failure, tracheostomy, duration of mechanical ventilation, and spirometry, and based on this we recommend consideration of surgical stabilization in trauma patients who meet one or more of our inclusion criteria,” he said.
Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.
LAS VEGAS – Surgical stabilization of severe rib fractures leads to better outcomes than does the best medical management in critically ill trauma patients, findings from a 2-year, single-center, clinical trial suggest.
For example, the likelihood of respiratory failure was significantly lower in 35 patients who underwent surgical stabilization of severe rib fractures (SSRF) than among 35 who received optimal medical management (odds ratio, 0.22), and the likelihood of tracheostomy was also significantly lower with SSRF (OR, 0.20). These findings remained significant after controlling for a significantly higher RibScore – a radiographically derived score that predicts pulmonary outcomes in rib fracture patients – in the surgery group (score of 4 vs. 3 on a 0-6 scale), and for a significantly lower incidence of intracranial hemorrhage in the surgery group (5.7% vs. 28.6%), Dr. Fredric Pieracci reported at the annual meeting of the American Association for the Surgery of Trauma.
Further, the average daily spirometry value was 280 mL higher in the operative group, and there were nonsignificant trends toward a decreased likelihood of pneumonia (20.1% vs. 31.5%, respectively), decreased number of ventilator days (6.4 vs. 10.6), decreased ICU length of stay (8.3 vs. 10.4 days), and decreased hospital length of stay (15.2 vs. 25.3 days).
Narcotic requirements were similar in the groups, and no deaths occurred, said Dr. Pieracci, of Denver Health Medical Center.
The study, which was conducted at a level 1 trauma center from 2013 to 2014, enrolled adult patients with various rib fracture patterns, including flail chest, three or more fractures with bicortical displacement, 30% or greater hemithorax volume loss, and either severe pain or respiratory failure despite optimal medical management. Only those who presented within 72 hours of their injury were included.
All eligible patients were managed nonoperatively in the first year of the study, and all were managed operatively in the second year using a standardized technique described recently in the Journal of Trauma and Acute Care Surgery. The nonoperative and operative patient groups were well matched with respect to age, gender, mechanism of injury, preexisting lung pathology, and tobacco use, Dr. Pieracci noted.
“In conclusion, we found that surgical stabilization of severe rib fractures was independently associated with improved pulmonary outcomes, specifically respiratory failure, tracheostomy, duration of mechanical ventilation, and spirometry, and based on this we recommend consideration of surgical stabilization in trauma patients who meet one or more of our inclusion criteria,” he said.
Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.
AT THE AAST ANNUAL MEETING
Key clinical point: Surgical stabilization of severe rib fractures leads to better outcomes than does best medical management in critically ill trauma patients.
Major finding: Surgery patients were significantly less likely than medically managed patients to experience respiratory failure and tracheotomy (OR, 0.22 and 0.20, respectively).
Data source: A prospective, controlled clinical trial involving 70 patients.
Disclosures: Dr. Pieracci reported serving as a speaker for, and receiving research funding and honorarium from DePuy Synthes.
PROPPR finds resuscitation strategy had no effect on laparotomy outcomes
LAS VEGAS – Choice of damage control resuscitation – plasma-platelet-red blood cell ratio of either 1:1:1 or 1:1:2 – did not affect whether severely injured patients required an emergency laparotomy, nor did it affect time to laparotomy or survival following laparotomy, according to findings from the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial.
“We were unable to detect significant effects of damage control resuscitation on the frequency and time to emergency laparotomy, outcomes, disposition at 30 days, or main endpoint survival,” said Dr. Vicente J. Undurraga Perl of the Oregon Health and Science University, Portland. The lack of a difference between the treatment groups with respect to emergency laparotomy and 30-day survival may be a result of the low overall mortality of 23% and to the study being underpowered to detect a difference between the groups.
The PROPPR trial demonstrated that damage control resuscitation, defined as “a massive transfusion strategy targeting a balanced delivery of plasma-platelet-RBC in a ratio of 1:1:1,” allows earlier achievement of hemostasis in a greater number of severely injured patients than does a 1:1:2 ratio. A corresponding reduction in deaths because of exsanguination was observed in the study subjects, who were enrolled from 12 level-1 trauma centers in North America, where they presented with severe injuries.
Of 680 patients who had severe injuries and were predicted to require massive transfusions, 613 underwent a surgical procedure and 397 underwent a laparotomy. Of the latter, 346 were emergency laparotomies. Of those who received damage control resuscitation using the 1:1:1 ratio, 52% underwent emergency laparotomy (defined as laparotomy within 90 minutes of arrival at a trauma center). Of those who received the 1:1:2 ratio, 50% underwent emergency laparotomy. The difference between the groups was not statistically significant, Dr. Perl reported at the annual meeting of the American Association for the Surgery of Trauma.
The median time to laparotomy was 28 minutes in both groups, and the proportions of patients who survived to 3 hours, 6 hours, 24 hours, and 30 days also were similar in the two groups. For example, 88% and 85% of those in the 1:1:1 and 1:1:2 groups, respectively, survived to 24 hours; 82% and 77%, respectively, survived to 30 days, he said.
There was no overall difference in mortality between the groups (hazard ratio, 0.78), nor was there a difference in survival by study site, he noted.
Dr. Perl reported having no disclosures.
LAS VEGAS – Choice of damage control resuscitation – plasma-platelet-red blood cell ratio of either 1:1:1 or 1:1:2 – did not affect whether severely injured patients required an emergency laparotomy, nor did it affect time to laparotomy or survival following laparotomy, according to findings from the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial.
“We were unable to detect significant effects of damage control resuscitation on the frequency and time to emergency laparotomy, outcomes, disposition at 30 days, or main endpoint survival,” said Dr. Vicente J. Undurraga Perl of the Oregon Health and Science University, Portland. The lack of a difference between the treatment groups with respect to emergency laparotomy and 30-day survival may be a result of the low overall mortality of 23% and to the study being underpowered to detect a difference between the groups.
The PROPPR trial demonstrated that damage control resuscitation, defined as “a massive transfusion strategy targeting a balanced delivery of plasma-platelet-RBC in a ratio of 1:1:1,” allows earlier achievement of hemostasis in a greater number of severely injured patients than does a 1:1:2 ratio. A corresponding reduction in deaths because of exsanguination was observed in the study subjects, who were enrolled from 12 level-1 trauma centers in North America, where they presented with severe injuries.
Of 680 patients who had severe injuries and were predicted to require massive transfusions, 613 underwent a surgical procedure and 397 underwent a laparotomy. Of the latter, 346 were emergency laparotomies. Of those who received damage control resuscitation using the 1:1:1 ratio, 52% underwent emergency laparotomy (defined as laparotomy within 90 minutes of arrival at a trauma center). Of those who received the 1:1:2 ratio, 50% underwent emergency laparotomy. The difference between the groups was not statistically significant, Dr. Perl reported at the annual meeting of the American Association for the Surgery of Trauma.
The median time to laparotomy was 28 minutes in both groups, and the proportions of patients who survived to 3 hours, 6 hours, 24 hours, and 30 days also were similar in the two groups. For example, 88% and 85% of those in the 1:1:1 and 1:1:2 groups, respectively, survived to 24 hours; 82% and 77%, respectively, survived to 30 days, he said.
There was no overall difference in mortality between the groups (hazard ratio, 0.78), nor was there a difference in survival by study site, he noted.
Dr. Perl reported having no disclosures.
LAS VEGAS – Choice of damage control resuscitation – plasma-platelet-red blood cell ratio of either 1:1:1 or 1:1:2 – did not affect whether severely injured patients required an emergency laparotomy, nor did it affect time to laparotomy or survival following laparotomy, according to findings from the Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial.
“We were unable to detect significant effects of damage control resuscitation on the frequency and time to emergency laparotomy, outcomes, disposition at 30 days, or main endpoint survival,” said Dr. Vicente J. Undurraga Perl of the Oregon Health and Science University, Portland. The lack of a difference between the treatment groups with respect to emergency laparotomy and 30-day survival may be a result of the low overall mortality of 23% and to the study being underpowered to detect a difference between the groups.
The PROPPR trial demonstrated that damage control resuscitation, defined as “a massive transfusion strategy targeting a balanced delivery of plasma-platelet-RBC in a ratio of 1:1:1,” allows earlier achievement of hemostasis in a greater number of severely injured patients than does a 1:1:2 ratio. A corresponding reduction in deaths because of exsanguination was observed in the study subjects, who were enrolled from 12 level-1 trauma centers in North America, where they presented with severe injuries.
Of 680 patients who had severe injuries and were predicted to require massive transfusions, 613 underwent a surgical procedure and 397 underwent a laparotomy. Of the latter, 346 were emergency laparotomies. Of those who received damage control resuscitation using the 1:1:1 ratio, 52% underwent emergency laparotomy (defined as laparotomy within 90 minutes of arrival at a trauma center). Of those who received the 1:1:2 ratio, 50% underwent emergency laparotomy. The difference between the groups was not statistically significant, Dr. Perl reported at the annual meeting of the American Association for the Surgery of Trauma.
The median time to laparotomy was 28 minutes in both groups, and the proportions of patients who survived to 3 hours, 6 hours, 24 hours, and 30 days also were similar in the two groups. For example, 88% and 85% of those in the 1:1:1 and 1:1:2 groups, respectively, survived to 24 hours; 82% and 77%, respectively, survived to 30 days, he said.
There was no overall difference in mortality between the groups (hazard ratio, 0.78), nor was there a difference in survival by study site, he noted.
Dr. Perl reported having no disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Choice of damage control resuscitation – plasma-platelet-red blood cell ratio of either 1:1:1 or 1:1:2 – does not affect whether severely injured patients require an emergency laparotomy, time to laparotomy, or survival following laparotomy.
Major finding: 52% of patients in the 1:1:1-ratio emergency resuscitation group and 50% in the 1:1:2-ratio group underwent emergency laparotomy, and 30-day survival was 82% and 77%, respectively.
Data source: An analysis of data for 680 patients from the PROPPR trial.
Disclosures: Dr. Perl reported having no disclosures.
HIT risk rises with obesity
LAS VEGAS – High body mass index is strongly associated with increased rates of heparin-induced thrombocytopenia, based on findings from a review of prospectively collected data from surgical and cardiac intensive care unit patients presumed to have the condition.
Of 304 patients included in the review, 36 (12%) were positive for heparin-induced thrombocytopenia (HIT). The rates increased in tandem with BMI. For example, the rate was 0% among 9 underweight individuals (BMI less than 18.5 kg/m2), 8% among 119 normal-weight individuals (BMI of 18.5-24.9 kg/m2), 11% among 98 overweight individuals (BMI of 25-29.9 kg/m2), 18% among 67 obese individuals (BMI of 30-39.9 kg/m2), and 36% among 11 morbidly obese individuals (BMI of 40 kg/m2 or greater), Dr. Matthew B. Bloom reported at the annual meeting of the American Association for the Surgery of Trauma.
The odds of HIT were 170% greater among obese patients, compared with normal-weight patients (odds ratio, 2.67), and 600% greater among morbidly obese patients, compared with normal-weight patient (odds ratio, 6.98), said Dr. Bloom of Cedars-Sinai Medical Center, Los Angeles.
Logistic regression showed that each 1 unit increase in BMI was associated with a 7.7% increase in the odds of developing HIT, he noted.
Additionally, an anti-heparin/PF4 (platelet factor 4) antibody OD (optical density) value of 2.0 or greater, but not of 0.4 or greater or 0.8 or greater, was also significantly increased with BMI, and in-hospital mortality increased significantly with BMI above normal, he said.
Warkentin 4T scores used to differentiate HIT from other types of thrombocytopenia were not found to correlate with changes in BMI in this study, nor were deep vein thrombosis, pulmonary embolism, or stroke.
The increase in PF4 with increasing BMI may be a marker for overall increasing levels of circulating antibodies in the obese ICU population, but more biochemical studies are needed to tease this out, he said.
Patients included in the review were all those admitted to the surgical and cardiac ICUs at Cedars-Sinai over a more than 7 year period. They had a mean age of 62.1 years, 59% were men, and their mean BMI was 27 kg/m2.
The findings are among the first to show a strong association between BMI and HIT in ICU patients, Dr. Bloom said, noting that several other studies have shown that obesity is linked with increased incidence and increased severity of immune-mediated diseases, including rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease.
“And HIT is an immune-mediated disease,” he added.
“BMI may be an important new clinical variable for estimating the pre-test probability of HIT, and perhaps, in the future, patient ‘thickness’ could be considered a new ‘T’ in the 4T score, he concluded.
Dr. Bloom reported having no disclosures.
LAS VEGAS – High body mass index is strongly associated with increased rates of heparin-induced thrombocytopenia, based on findings from a review of prospectively collected data from surgical and cardiac intensive care unit patients presumed to have the condition.
Of 304 patients included in the review, 36 (12%) were positive for heparin-induced thrombocytopenia (HIT). The rates increased in tandem with BMI. For example, the rate was 0% among 9 underweight individuals (BMI less than 18.5 kg/m2), 8% among 119 normal-weight individuals (BMI of 18.5-24.9 kg/m2), 11% among 98 overweight individuals (BMI of 25-29.9 kg/m2), 18% among 67 obese individuals (BMI of 30-39.9 kg/m2), and 36% among 11 morbidly obese individuals (BMI of 40 kg/m2 or greater), Dr. Matthew B. Bloom reported at the annual meeting of the American Association for the Surgery of Trauma.
The odds of HIT were 170% greater among obese patients, compared with normal-weight patients (odds ratio, 2.67), and 600% greater among morbidly obese patients, compared with normal-weight patient (odds ratio, 6.98), said Dr. Bloom of Cedars-Sinai Medical Center, Los Angeles.
Logistic regression showed that each 1 unit increase in BMI was associated with a 7.7% increase in the odds of developing HIT, he noted.
Additionally, an anti-heparin/PF4 (platelet factor 4) antibody OD (optical density) value of 2.0 or greater, but not of 0.4 or greater or 0.8 or greater, was also significantly increased with BMI, and in-hospital mortality increased significantly with BMI above normal, he said.
Warkentin 4T scores used to differentiate HIT from other types of thrombocytopenia were not found to correlate with changes in BMI in this study, nor were deep vein thrombosis, pulmonary embolism, or stroke.
The increase in PF4 with increasing BMI may be a marker for overall increasing levels of circulating antibodies in the obese ICU population, but more biochemical studies are needed to tease this out, he said.
Patients included in the review were all those admitted to the surgical and cardiac ICUs at Cedars-Sinai over a more than 7 year period. They had a mean age of 62.1 years, 59% were men, and their mean BMI was 27 kg/m2.
The findings are among the first to show a strong association between BMI and HIT in ICU patients, Dr. Bloom said, noting that several other studies have shown that obesity is linked with increased incidence and increased severity of immune-mediated diseases, including rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease.
“And HIT is an immune-mediated disease,” he added.
“BMI may be an important new clinical variable for estimating the pre-test probability of HIT, and perhaps, in the future, patient ‘thickness’ could be considered a new ‘T’ in the 4T score, he concluded.
Dr. Bloom reported having no disclosures.
LAS VEGAS – High body mass index is strongly associated with increased rates of heparin-induced thrombocytopenia, based on findings from a review of prospectively collected data from surgical and cardiac intensive care unit patients presumed to have the condition.
Of 304 patients included in the review, 36 (12%) were positive for heparin-induced thrombocytopenia (HIT). The rates increased in tandem with BMI. For example, the rate was 0% among 9 underweight individuals (BMI less than 18.5 kg/m2), 8% among 119 normal-weight individuals (BMI of 18.5-24.9 kg/m2), 11% among 98 overweight individuals (BMI of 25-29.9 kg/m2), 18% among 67 obese individuals (BMI of 30-39.9 kg/m2), and 36% among 11 morbidly obese individuals (BMI of 40 kg/m2 or greater), Dr. Matthew B. Bloom reported at the annual meeting of the American Association for the Surgery of Trauma.
The odds of HIT were 170% greater among obese patients, compared with normal-weight patients (odds ratio, 2.67), and 600% greater among morbidly obese patients, compared with normal-weight patient (odds ratio, 6.98), said Dr. Bloom of Cedars-Sinai Medical Center, Los Angeles.
Logistic regression showed that each 1 unit increase in BMI was associated with a 7.7% increase in the odds of developing HIT, he noted.
Additionally, an anti-heparin/PF4 (platelet factor 4) antibody OD (optical density) value of 2.0 or greater, but not of 0.4 or greater or 0.8 or greater, was also significantly increased with BMI, and in-hospital mortality increased significantly with BMI above normal, he said.
Warkentin 4T scores used to differentiate HIT from other types of thrombocytopenia were not found to correlate with changes in BMI in this study, nor were deep vein thrombosis, pulmonary embolism, or stroke.
The increase in PF4 with increasing BMI may be a marker for overall increasing levels of circulating antibodies in the obese ICU population, but more biochemical studies are needed to tease this out, he said.
Patients included in the review were all those admitted to the surgical and cardiac ICUs at Cedars-Sinai over a more than 7 year period. They had a mean age of 62.1 years, 59% were men, and their mean BMI was 27 kg/m2.
The findings are among the first to show a strong association between BMI and HIT in ICU patients, Dr. Bloom said, noting that several other studies have shown that obesity is linked with increased incidence and increased severity of immune-mediated diseases, including rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease.
“And HIT is an immune-mediated disease,” he added.
“BMI may be an important new clinical variable for estimating the pre-test probability of HIT, and perhaps, in the future, patient ‘thickness’ could be considered a new ‘T’ in the 4T score, he concluded.
Dr. Bloom reported having no disclosures.
AT THE AAST ANNUAL MEETING
Key clinical point: Higher body mass index is strongly associated with increased rates of heparin-induced thrombocytopenia.
Major finding: The HIT rate was 0%, 8%, 11%, 18,%, and 36% among underweight, normal-weight, overweight, obese, and morbidly obese individuals, respectively.
Data source: A review of prospectively collected data for 304 patients.
Disclosures: Dr. Bloom reported having no disclosures.
